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Context The optimal 50 g-glucose challenge test (GCT) cutoff for the diagnosis of gestational diabetes mellitus (GDM) in twin pregnancies is unknown. Objective This work aimed to explore the screening accuracy of the 50 g-GCT and its correlation with the risk of large for gestational age (LGA) newborn in twin compared to singleton pregnancies. A population-based retrospective cohort study (2007-2017) was conducted in Ontario, Canada. Participants included patients with a singleton (n = 546 892 [98.4%]) or twin (n = 8832 [1.6%]) birth who underwent screening for GDM using the 50 g-GCT. Methods We compared the screening accuracy, risk of GDM, and risk of LGA between twin and singleton pregnancies using various 50 g-GCT cutoffs. Results For any given 50 g-GCT result, the probability of GDM was higher (P = .0.007), whereas the probability of LGA was considerably lower in the twin compared with the singleton group, even when a twin-specific growth chart was used to diagnose LGA in the twin group (P Conclusion The screening performance of the 50 g-GCT for GDM and its correlation with LGA differ between twin and singleton pregnancies.

Electronic health records (EHRs) allow standardized data capture for robust quality and performance assessments, but data quality issues may exist. This study compared extracted structured EHR data with chart review from endocrinologists' health-care records at a large, academic ambulatory hospital in Toronto, Ontario.Consecutive chart review for the first 10 patients with either type 1 or type 2 diabetes seen between January 1, 2015 and March 1, 2016 was sampled for each of the 10 endocrinologists within the diabetes program, and electronic data extraction was also completed for a core set of structured diabetes care elements. Fisher exact test was used to determine differences in data availability between extracted EHR data and chart review.Out of 100 charts, there was significant under-representation of care elements using EHR extraction compared with chart review for glycated hemoglobin (45% vs 100%; p0.0001), low-density lipoprotein (36% vs 89%; p0.0001), urine albumin to creatinine ratio (38% vs 86%; p0.0001), insulin use (20% vs 72%; p0.0001), glomerular filtration rate (42% vs 87%, p0.0001) and use of oral hypoglycemic agent (14% vs 64%; p0.0001), respectively. EHR data extraction could not be obtained for driving status, hypoglycemia and driving counselling, smoking cessation counselling, family planning counselling and eye examination documentation.There is poor accuracy of using EHR data extraction during the early adoption phase to understand diabetes care, limiting EHR-based quality assessments.

This article is the third and final installment in our diabetes quality improvement primer series. It summarizes how to interpret real-time data with run charts and highlights 4 key rules that can be applied to understand whether improvement is statistically significant. We also review the importance of outlining a family of measures, including outcome, process and balancing measures. Finally, we discuss strategies for sustaining change.

There is a large evidence-to-clinical practice gap in diabetes care. Application of quality improvement (QI) strategies can be used to improve gaps in care delivery. In this first of 3 articles in the diabetes QI primer series, we introduce the steps required to plan a QI project by using a case example for improving foot screening of people with diabetes. We review how to select an appropriate QI project, conduct a baseline gap analysis to clarify the QI problem and engage stakeholders to ensure successful implementation. The next 2 articles in the series will focus on root-cause analysis, selection of change ideas to improve care gaps, execution of the QI project using rapid-cycle testing and monitoring to sustain improvement over time.

In this second article of our diabetes quality improvement primer series, readers will become familiar with various diagnostic tools used to understand the root causes of a quality problem. We discuss change concepts, and specific change ideas are developed to match the root causes. We review the application of a plan-do-study-act cycle from the Model for Improvement quality improvement framework to test 1 change idea and measure for the intended improvements.

Background People with type 2 diabetes mellitus (T2DM) are at increased risk for depression. Both conditions are associated with disturbances in polyunsaturated fatty acids. Omega-3 and omega-6 fatty acids can be converted into bioactive epoxides by cytochrome P450s (CYP450), which play pro-resolving roles in the inflammatory response; however, soluble epoxide hydrolase (sEH) metabolizes epoxides into diols, which lack pro-resolving functions and can be cytotoxic. Here, we survey serum CYP450- and sEH-derived metabolite concentrations in people with T2DM with and without a major depressive episode. Methods Sunnybrook Type 2 Diabetes Study (NCT04455867) participants experiencing a major depressive episode (research version of the Structured Clinical Interview for DSM-5 criteria) were matched 1:1 for gender, glycosylated hemoglobin A1c and body mass index to participants without a current depressive episode. Depression severity was assessed using the Beck Depression Inventory 2nd Edition (BDI-II). From fasting morning blood, unesterified serum oxylipins were quantified by ultra-high-performance liquid chromatography tandem mass spectrometry following solid phase extraction, and interleukin-6 (IL-6) by enzyme-linked immunosorbent assay. Results Between 20 depressed and 20 non-depressed participants (mean age 58.9 ± 8.5 years, 65% women) with T2DM, several sEH-derived fatty acid diols, but not IL-6, were higher among those with a depressive episode (effect sizes up to d = 0.796 for 17,18-DiHETE, a metabolite of eicosapentaenoic acid [EPA]; t = 2.516, p = 0.016). Among people with a depressive episode, two epoxides were correlated with lower BDI-II scores: 12(13)-EpOME (ρ = −0.541, p = 0.014) and 10(11)-EpDPE (ρ = −0.444, p = 0.049), metabolites of linoleic acid and docosahexaenoic acid (DHA), respectively, while the ratio of 12,13-DiHOME/12(13)-EpOME was correlated with higher BDI-II scores (ρ = 0.513, p = 0.021). Conclusions In people with T2DM, major depressive episodes and depressive symptom severity were associated with an oxylipin profile consistent with elimination of pro-resolving lipid mediators by sEH.

Objectives The goal of this quality initiative was to develop consensus standards for glycemic management of patients with diabetes who undergo surgical procedures in Canada. Methods A modified Delphi method was used to gather broad stakeholder input and arrive at a consensus for perioperative/periprocedure diabetes management. Results Glycemic management standards were developed for the following categories: Organization of Care; Preoperative Assessment; Immediate Preoperative and Intraoperative; Postanesthesia Care Unit or Recovery Room; Postoperative Period; and Transition to Outpatient Care. Conclusions It is anticipated these standards will serve as a basis to develop clinical tools to support the recommendations.

Objective As part of a larger project to develop quality standards in perioperative diabetes management, the goal of this project was to assess self-reported management of surgical patients with diabetes across healthcare institutions and specialties in Canada. Methods Current practice of perioperative management of patients with diabetes was assessed using multiple-choice questions based on commonly encountered clinical scenarios involving patients with type 1 and type 2 diabetes. The survey was sent to a broad stakeholder group of individuals involved in perioperative medicine in academic and community settings across Canada. Results Responses to clinical case scenarios demonstrated more consistent approaches for patients with type 1 diabetes undergoing cardiac surgery, possibly reflecting more robust evidence. There was more variability in the management of noninsulin antihyperglycemic agents and hyperglycemia in patients with type 2 diabetes undergoing noncardiac surgery. Conclusions Given the variability in clinical practice, standards and clinical tools are required for perioperative and periprocedural glycemic management in Canada to inform practice, improve the experience and outcomes for people with diabetes and provide a foundation for quality improvement initiatives and benchmarking.

Summary Background Although metformin is increasingly being used in women with type 2 diabetes during pregnancy, little data exist on the benefits and harms of metformin use on pregnancy outcomes in these women. We aimed to investigate the effects of the addition of metformin to a standard regimen of insulin on neonatal morbidity and mortality in pregnant women with type 2 diabetes. Methods In this prospective, multicentre, international, randomised, parallel, double-masked, placebo-controlled trial, women with type 2 diabetes during pregnancy were randomly assigned from 25 centres in Canada and four in Australia to receive either metformin 1000 mg twice daily or placebo, added to insulin. Randomisation was done via a web-based computerised randomisation service and stratified by centre and pre-pregnancy BMI ( ClinicalTrials.gov , NCT01353391 . Findings Between May 25, 2011, and Oct 11, 2018, we randomly assigned 502 women, 253 (50%) to metformin and 249 (50%) to placebo. Complete data were available for 233 (92%) participants in the metformin group and 240 (96%) in the placebo group for the primary outcome. We found no significant difference in the primary composite neonatal outcome between the two groups (40% vs 40%; p=0·86; relative risk [RR] 1·02 [0·83 to 1·26]). Compared with women in the placebo group, metformin-treated women achieved better glycaemic control (HbA1c at 34 weeks' gestation 41·0 mmol/mol [SD 8·5] vs 43·2 mmol/mol [–10]; 5·90% vs 6·10%; p=0·015; mean glucose 6·05 [0·93] vs 6·27 [0·90]; difference −0·2 [–0·4 to 0·0]), required less insulin (1·1 units per kg per day vs 1·5 units per kg per day; difference −0·4 [95% CI −0·5 to −0·2]; p Interpretation We found several maternal glycaemic and neonatal adiposity benefits in the metformin group. Along with reduced maternal weight gain and insulin dosage and improved glycaemic control, the lower adiposity and infant size measurements resulted in fewer large infants but a higher proportion of small-for-gestational-age infants. Understanding the implications of these effects on infants will be important to properly advise patients who are contemplating the use of metformin during pregnancy. Funding Canadian Institutes of Health Research, Lunenfeld-Tanenbaum Research Institute, University of Toronto.

Introduction: Memory decline is accelerated in type 2 diabetes mellitus (T2DM), and it is thought that microvascular disease may be a contributor. Oxylipins, bioactive lipid species derived from polyunsaturated free fatty acids such as linoleic acid, can act on small vessels. Cytochrome p450 derived epoxides may be immunologically active, whereas their hydrolysis into diols by soluble epoxide hydrolase (sEH) may render them inactive or cytotoxic. We examine linoleic acid epoxide and diol concentrations in peripheral blood and their associations with memory performance and retinal microvascular disease in patients with T2DM or prediabetes. Methods: Patients with T2DM or prediabetes were recruited from 3 sites. Memory was assessed via California Verbal Learning Test 2nd Edition (CVLT-II). Patient history of retinopathy was recorded. Serum oxylipin concentrations were measured via ultra-high-performance liquid chromatography tandem mass-spectrometry. Results: In people with T2DM or prediabetes (n=76, 55% women, 63±9 years old, HbA1C=7.4±1.2% mmol/mol, duration of diabetes 8±10 years), 9.2% had retinopathy, and the mean CVLT-II was -0.07±1.01 Z-score units (indicating generally average performance). The linoleic acid derived epoxide 12(13)-epoxyoctadecenoic acid concentration was negatively correlated with CVLT-II performance (β=-0.298, p=0.003), whereas the diol derived from that species (12,13-dihydroxyoctadecenoic acid) was elevated in people with retinopathy (9.1±4.1 nM vs. 6.5±11.5 nM, U=72.0, p=0.008). Discussion: Oxylipins generated by cytochrome p450 and sEH should be explored as potential biomarkers for cognitive complications and microvascular disease in T2DM. The observed relationships might suggest the presence of a cytochrome p450-mediated response that may generate differential response and lack benefit in T2DM, possibly due to sEH-mediated conversion of epoxides into diols, warranting further study. Disclosure S.K. Wong: None. M.M. Nguyen: None. C. Major-Orfao: None. K.L. Lanctôt: None. N. Herrmann: None. P. Oh: None. B.R. Shah: None. J. Gilbert: Speaker’s Bureau; Self; Abbott, Amgen, Ascensia Diabetes Care. Other Relationship; Self; AstraZeneca, Boehringer Ingelheim (Canada) Ltd., Dexcom, Inc., Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Merck & Co., Inc., Novo Nordisk Inc., Sanofi. A. Assal: None. I. Halperin: Advisory Panel; Self; Tandem Diabetes Care. Speaker’s Bureau; Self; Abbott, Boehringer Ingelheim (Canada) Ltd., Dexcom, Inc., Novo Nordisk Inc., Sanofi. P. Yang: None. T. Pedersen: None. A. Taha: None. W. Swardfager: None. Funding Canadian Institutes of Health Research (410010992)

Serum osteocalcin is emerging as a potential marker of glucose homeostasis and risk of type 2 diabetes mellitus (T2DM). In mice, osteocalcin knockouts exhibit depressive-like behaviours but knockouts of a putative osteocalcin receptor, GPR158, are resistant to chronic unpredictable mild stress. Recently, osteocalcin release from bone has been suggested to mediate some aspects of the acute stress response. Here, we assess relationships between serum osteocalcin, depression and perceived stress in people with T2DM. Participants with T2DM were assessed for whether they met the DSM-5 criteria for Major Depressive Disorder using the research version of the Structured Clinical Interview for DSM-5 depression criteria (SCID-5RV). Subjective stress was assessed using the Perceived Stress Scale (PSS) with higher scores indicating greater subjective stress. Serum carboxylated (cOCN) and uncarboxylated (unOCN) osteocalcin were assayed from fasting morning blood by commercial ELISA. Among 87 participants (mean age 62.9±9.5, 52% women), 18 (26%) were experiencing a depressive episode (7 men, 11 women). Both serum unOCN and cOCN were associated with higher PSS scores in participants with depression (unOCN, r=0.566, p=0.014; cOCN, r=0.564, p=0.015) but not in those without depression (unOCN, r=0.002, p=0.985; cOCN, r=0.090, p=0.463). A significant interaction was found between depression and PSS scores predicting serum unOCN in a linear model adjusted for age, sex, body mass index, antidepressant use and HbA1c (F=6.225, p=0.015). The results are consistent with reports that osteocalcin release from bone may be a mediator of stress perception; however, among people with T2DM, this relationship was observed only among those currently experiencing a depressive episode.

Objectives To gather patient perspectives on quality of care provided in diabetes clinics within the framework of the Institute of Medicine's 6 domains of quality. Methods A qualitative study including semi-structured interviews was conducted at 5 academic hospital sites. Transcripts were analyzed using a direct content approach for themes and subthemes with saturation of themes achieved. Purposive sampling was conducted at 5 diabetes clinics (n=47 interviews). Results The median age of participants was 50 years with a mean duration of diabetes of 14 years; 53% of participants were male, 57% had type 2 diabetes and 81% were using insulin. Patients ranked safety as the most important Institute of Medicine domain, followed by the domains effective, patient-centred, timely, equitable and efficient. Their expectations spanned the first 4 Institute of Medicine domains. They expressed a desire for a knowledgeable, caring, available and communicative team that assist with self-management and overall control of diabetes (effective, patient-centred and timely). They wanted to avoid diabetes complications, including hypoglycemia (safe and effective). They wanted to share in care planning and achieve personalized goals (patient-centred). Efficient and equitable care were not prioritized as highly, but many patients expressed concerns about the costs of medications and insulin supplies. Conclusion Patients' views of high-quality diabetes care include all 6 domains of quality with a stronger emphasis on safe, effective and patient-centred care. Future evaluation of diabetes programs should incorporate a comprehensive and patient-informed approach to consideration of what constitutes high-quality care.

Objectives Gestational diabetes mellitus (GDM) increases the risk of pregnancy complications. South Asian immigrant women have among the highest rates of GDM in Canada and they also have the highest lifelong risk of developing type 2 diabetes after a GDM pregnancy. Diabetes Canada has been developing diabetes education material that accounts for the cultural preferences of South Asians. However, there is uncertainty to whether South Asian immigrants are aware of these resources or trust them, or if other factors influence their uptake of advice. Methods In this study, we conducted qualitative interviews to explore, among South Asian immigrant women with GDM: 1) their awareness of diabetes education resources, 2) their attitudes toward information from different resources and varying health-care providers and 3) their barriers and facilitators for GDM management recommendations. Gender theory is embedded in this study, as culturally specific gender roles regarding motherhood have been shown to be important to South Asian immigrant women and their perceptions of health. Results There was an emergence of 3 main themes. First, awareness of culturally tailored educational resources is low. Second, there is an overabundance of GDM management information, which leads to variability among participants of how they rank accuracy of informational sources. Finally, there is a gender role reversal present, where women are being taken care of by their families instead of being the providers of care. Conclusions These results indicate that better dissemination strategies for GDM educational material are needed for health-care providers and patients, and may require additional consideration of family involvement during GDM education sessions.

Objectives Our aims in this study were to: 1) review diabetes apps available in Canada using the Mobile App Rating Scale tool and generate usability scores for each, 2) characterize availability of features across all apps, 3) evaluate the clinical safety of bolus insulin calculators and 4) evaluate the quality of exportable blood glucose reports meant for use by health-care providers. Methods Two primary reviewers searched for, screened and evaluated diabetes apps from the Android Play Store and iOS App Store, resulting from the search terms “glucose” and “diabetes.” Results Overall Mobile App Rating Scale quality rating score was 3.1 out of 5. The Functionality subsection scored the highest (3.9 out of 5) and Information scored the lowest (2.0 out of 5). The majority of apps have the ability to track carbohydrate intake (54 of 75, 72%), send reminders (46 of 75, 61%) and can generate blood glucose reports (53 of 75, 71%), but few have bolus insulin calculators (6 of 75, 9%) and remote diabetes support (10 of 75, 13%). Conclusion Despite the widespread availability of many iOS and Android diabetes management apps, few are of high quality.

Objectives Although metformin has traditionally been avoided in pregnancy, evidence now supports its safety and efficacy for management of gestational diabetes mellitus (GDM). The primary objective of this study was to evaluate the clinical impact of a metformin-based approach for GDM management through assessment of pregnancy outcomes, clinic efficiency and patient satisfaction. Methods A retrospective chart review was conducted of new GDM patients seen before (January to July 2015) and after (January to September 2016) implementation of the “Metformin First” (MF) protocol. A prospective patient survey was also administered and responses were compared with a similar survey from 2013 (acting as a historical control). Results Of the 264 patients included in the chart review, 90 were seen in the pre-MF period and 174 in the post-MF period. There were no significant differences in rates of pregnancy complications (obstructed labour, infants born large for gestational age, neonatal intensive care unit admissions and infant hypoglycemia) between the 2 study periods. Blood glucose control was also comparable and satisfactory across both time periods. Of the 65 patients initially started on metformin, 18 (28%) required supplemental insulin therapy. Nonetheless, overall percentage of patients started on insulin dropped significantly (33% in 2015 vs 17% in 2016, p=0.003). Patient satisfaction scores at the clinic also increased following implementation of the MF protocol (4.68/5 in 2016 vs 4.3/5 in 2013, p=0.014). Conclusions Introduction of the MF protocol, which gave patients an informed choice between insulin and metformin, was associated with similar glycemic control and pregnancy outcomes, but improved patient satisfaction and clinic efficiency.

Gestational diabetes (GDM) is defined as hyperglycemia that is first recognized during pregnancy. It affects 5% of pregnancies, and higher rates occur in certain ethnic minorities (1). GDM increases the risk for the development of type 2 diabetes and other metabolic complications later in life. Of women with GDM, 4% will be diagnosed with type 2 diabetes, and 20% of womenwith GDMwill have developed type 2 diabetes within 10 years postpartum (2). Within the first 6 months after delivery, upwards of 25% of women will have persistent abnormalities in their postpartum glucose levels in the form of impaired glucose tolerance (IGT), which is detectable only by a formal 2-hour 75 g oral glucose tolerance test (OGTT) (3). Identification of IGT prior to a subsequent pregnancy is important because these women experience dysglycemia with the onset of pregnancy and require ongoing monitoring and treatment. The Canadian Diabetes Association guidelines recommend a 75 g OGTT 6 weeks to 6 months postpartum; however, the rates of compliance with this guideline are less than 20% (4). Diabetes and its complications are a major financial burden on the healthcare system and are associated with major morbidity for patients. Screening programs in this population have been shown to be cost saving and to improve quality of life (5). There is high-level evidence that intensive lifestyle interventions can prevent the development of diabetes in patients with impaired glucose tolerance (6). The diabetes-prevention program showed