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Thora Y Chai,1– 3 Karen Byth,2,4 Jacob George,2,5,6 Dharmintra Pasupathy,3 N Wah Cheung1– 3 1Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, Australia; 2Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; 3Reproduction and Perinatal Centre, The University of Sydney, Sydney, NSW, Australia; 4Western Sydney Local Health District Research Education Network, Westmead, NSW, Australia; 5Storr Liver Centre, Westmead Millennium Institute for Medical Research, Westmead, NSW, Australia; 6Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, NSW, AustraliaCorrespondence: Thora Y Chai, Email thora.chai@sydney.edu.auObjective: To determine whether an elevated hepatic steatosis index (HSI), a non-invasive test for possible metabolic dysfunction-associated fatty liver disease (MAFLD), is associated with the development of adverse pregnancy outcomes.Material and Methods: A retrospective cohort study was conducted on adult women with singleton pregnancies who delivered at two tertiary hospitals from August 2014 to December 2017. Aspartate aminotransaminase (AST) and alanine aminotransaminase (ALT) levels obtained 12 months pre-gravid, or during pregnancy but prior to screening for gestational diabetes mellitus (GDM), were extracted and linked with oral glucose tolerance test results. The HSI was calculated using the following equation: 8 × (ALT/AST ratio) + BMI (+2 if female; +2 if diabetes mellitus present) and considered elevated if > 36. Multiple logistic regression analysis was used to quantify the association between elevated HSI and each composite adverse pregnancy outcome after adjusting for independent maternal risk factors.Results: Over 40-months, 11929 women were eligible and of these, 1885 had liver enzymes collected. Women with an elevated HSI (> 36) were more likely multiparous and overweight/obese compared to those women with a non–elevated HSI (≤ 36). Elevated HSI was significantly associated with a composite of adverse maternal outcomes (adjusted odds ratio (aOR) 1.55 95% CI 1.11– 2.17, p=0.01), although a non-significant increased risk of a composite of adverse neonatal outcomes occurred after multivariable adjustment (aOR 1.17, 95% CI 0.94– 1.45, p=0.17).Conclusion: Over and above known maternal risk factors, women with elevated HSI were more likely to develop adverse maternal, but not adverse neonatal outcomes.Keywords: liver steatosis, pregnancy outcomes, liver function tests, maternal health, neonatal health

Issue Addressed: This study aimed to examine the participation of Australian Chinese in cardiovascular risk factor and cancer screening.Methods: A telephone survey of a random sample of Chinese in New South Wales, Australia, was conducted. The presence of, and participation in screening for, hypertension, hyperlipidaemia and diabetes were ascertained. Additionally, women were surveyed regarding breast cancer and cervical cancer screening.Results: Five hundred and fifty-five subjects were interviewed. Generally, Australian Chinese were as likely to participate in health screening activities as the general population. However, Chinese with poor English-speaking ability were less likely to have had recent lipid testing (85.4% vs 91.2%, p=0.01) or mammography (63.2% vs 92.6%, p=0.01) than those who were proficient in English (adjusted for age and gender). Those not in employment were less likely to have had lipid testing (86.9% vs 88.4%, p=0.04), mammography (61.1% vs 93.5%, p=0.04) or Pap tests (64.7% vs 85.0%, p<0.01) than those in employment. Chinese who had been in Australia for less than 10 years were also less likely to undergo Pap tests (68.7% vs 79%, p=0.03).Conclusions: Overall, participation of Australian Chinese in health screening is within the community norm. However, those with poor English-speaking skills, who are not employed, or who had been resident in Australia for a shorter duration are less likely to undergo some of these health activities. [ABSTRACT FROM AUTHOR]

PURPOSE: This study investigated postpartum dietary behaviors among women with recent gestational diabetes mellitus (GDM), the cognitive and social factors related to these, and preferred types of lifestyle support, in order improve the development of diabetes prevention strategies for this group. METHODS: Participants were a random sample of 226 women diagnosed with GDM in the prior 6 to 24 months. Telephone surveys were used to evaluate dietary behaviors, self-efficacy, social support, perceived barriers to healthy eating, and preferred methods of lifestyle support. RESULTS: Only 5% of the respondents consumed 5 servings/day of vegetables and 44% consumed 2 or more servings/day of fruit. Fried food was eaten at least twice per week by 26% of women and 50% usually consumed full-fat milk. Higher vegetable consumption was associated with self-efficacy to cook healthy foods, reporting that a healthy diet is not a difficult change and that dislike of healthy foods by other household members is not a barrier. Fruit consumption was positively related to self-efficacy when busy and when not reporting a dislike of healthy foods by others at home. Advice from a dietitian and telephone support from a health educator were the most preferred forms of health assistance. CONCLUSIONS: Dietary risks factors are prevalent among women with recent GDM. Confidence and skills in cooking healthy foods, along with family food preferences and time pressures, are important influences on eating habits. Dietary change programs, informed by the beliefs and circumstances of this high-risk population, need to be developed. [ABSTRACT FROM AUTHOR]

Objective: There is conflicting evidence regarding the benefit of intravenous insulin therapy on mortality following acute myocardial infarction (AMI). The goal of the current study was to determine whether improved glycemic control, achieved through an insulin/dextrose infusion with a variable rate of insulin, reduces mortality among hyperglycemic patients with AMI.Research Design and Methods: Subjects suffering AMI with either known diabetes or without diabetes but blood glucose level (BGL) > or =7.8 mmol/l were randomized to receive insulin/dextrose infusion therapy for at least 24 h to maintain a BGL <10 mmol/l or conventional therapy.Results: A total of 240 subjects were recruited. Insulin/dextrose infusion did not reduce mortality at the inpatient stage (4.8 vs. conventional 3.5%, P = 0.75), 3 months (7.1 vs 4.4%, P = 0.42), or 6 months (7.9 vs. 6.1%, P = 0.62). There was, however, a lower incidence of cardiac failure (12.7 vs. 22.8%, P = 0.04) and reinfarction within 3 months (2.4 vs. 6.1%, P = 0.05). When analyzed by mean BGL achieved during the first 24 h, mortality was lower among subjects with a mean BGL < or =8 mmol/l, compared with subjects with a mean BGL >8 mmol/l (2 vs. 11% at 6 months, P = 0.02).Conclusions: We did not find a reduction in mortality among patients who received insulin/dextrose infusion therapy. However, it remains possible that tight glycemic control with insulin therapy following AMI improves outcomes. [ABSTRACT FROM AUTHOR]

Objective: Postpartum testing with a 75-g 2-h oral glucose tolerance test or fasting plasma glucose (FPG) alone is often not performed among women with histories of gestational diabetes mellitus (GDM). Use of hemoglobin A(1c) (A1C) might increase testing. The association between A1C and glucose has not been examined in women with histories of GDM.Research Design and Methods: We assessed the association of A1C ≥5.7% with FPG ≥100 mg/dL and 2-h glucose ≥140 mg/dL among 54 women with histories of GDM between 6 weeks and 36 months postpartum.Results: A1C ≥5.7% had 65% sensitivity and 68% specificity for identifying elevated FPG or 2-h glucose and 75% sensitivity and 62% specificity for elevated FPG alone. The area under the receiver operating characteristic curve for A1C was 0.76 for elevated FPG or 2-h glucose and 0.77 for elevated FPG alone.Conclusions: The agreement between A1C and glucose levels is fair for detection of abnormal glucose tolerance among women with histories of GDM. [ABSTRACT FROM AUTHOR]

For many years, the diagnosis of diabetes has been made through the laboratory-based measurement of fasting or random blood glucose levels, or using the oral glucose tolerance test. A glycated haemoglobin (HbA(1c)) level ≥ 6.5% (48 mmol/mol) is now also acceptable for diagnosing diabetes. Caution is needed in interpreting HbA(1c) test results in the presence of conditions affecting red blood cells or their survival time, such as haemoglobinopathies or anaemia. [ABSTRACT FROM AUTHOR]

Aim: We aimed to determine if hospital admission hyperglycaemia and hypoglycaemia are associated with increased long-term mortality., Methods: A post-hoc analysis of data from a trial of glucose screening in the emergency department was conducted. Data were linked with a death registry up to 5 years after admission. The relationship between admission glucose and mortality was examined by cox regression. Further analyses of people who survived the admission and subsequent 28 days was performed., Results: There were 131,322 patients, of whom 38,712 (29.5 %) died. Mean follow-up was 3·3 ± 1·5 years. Compared to the reference glucose band of 6·1-8·0 mmol/L, there was increased mortality in higher bands, reaching a hazard ratio (HR) of 1·44 (95 %CI 1·34-1·55, p < 0·001) for people with glucose > 20·0 mmol/L. The HR was 1·56 (95 %CI 1·46-1·68, p < 0·001) for people with glucose ≤ 4·0 mmol/L. Similar relationships were observed among 28-day survivors. The relationships were attenuated among people with known diabetes. Among 4867 subjects with glucose ≥ 14·0 mmol/L, those diagnosed with diabetes during the admission had lower mortality compared to subjects where the diagnosis was not made (HR 0·53, 95 %CI 0·40-0·72, p < 0·001). This was attenuated among 28-day survivors., Conclusion: Hyperglycaemia and hypoglycaemia on hospital admission are associated with increased long-term mortality., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: The Quality in Acute Stroke Care (QASC) Trial demonstrated that assistance to implement protocols to manage Fever, hyperglycaemia (Sugar) and Swallowing (FeSS) post-stroke reduced death and disability. In 2017, a 'Strong Recommendation' for use of FeSS Protocols was included in the Australian Clinical Guidelines for Stroke Management. We aimed to: i) compare adherence to FeSS Protocols pre- and post-guideline inclusion; ii) determine if adherence varied with prior participation in a treatment arm of a FeSS Intervention study, or receiving treatment in a stroke unit; and compare findings with our previous studies., Methods: Pre-test post-test study using Australian acute stroke service audit data comparing 2015/2017 (pre-guideline) versus 2019/2021 (post-guideline) adherence. Primary outcome was adherence to all six FeSS indicators (composite), with mixed-effects logistic regression adjusting for age, sex, stroke type and severity (ability to walk on admission), stroke unit care, hospital prior participation in a FeSS Intervention study, and correlation of outcomes within hospital. Additional analysis examined interaction effects., Results: Overall, 112 hospitals contributed data to ≥1 one Audit cycle for both periods (pre=7011, post=7195 cases); 42 hospitals had participated in any treatment arm of a FeSS Intervention study. Adherence to FeSS Protocols post-guideline increased (pre: composite measure 35% vs post: composite measure 40 %, aOR:1.2 95 %CI: 1.2, 1.3). Prior participation in a FeSS Intervention study (aOR:1.6, 95 %CI: 1.2, 2.0) and stroke unit care (aOR 2.3, 95 %CI: 2.0, 2.5) were independently associated with greater adherence to FeSS Protocols. There was no change in adherence over time based on prior participation in a FeSS Intervention study ( p = 0.93 interaction), or stroke unit care ( p = 0.07 interaction)., Conclusions: There is evidence of improved adherence to FeSS Protocols following a 'strong recommendation' for their use in the Australian stroke guidelines. Change in adherence was similar independent of hospital prior participation in a FeSS Intervention study, or stroke unit care. However, maintenance of higher pre-guideline adherence for hospitals prior participation in a FeSS Intervention study suggests that research participation can facilitate greater guideline adherence; and confirms superior care received in stroke units. Nevertheless, less than half of Australian patients are being cared for according to the FeSS Protocols, providing impetus for additional strategies to increase uptake., Competing Interests: KH (National Manager Stroke treatment, Stroke Foundation) MK, MR, TP and DC are responsible for the independent and alloy analysis of National Stroke Audit data on behalf of the Stroke Foundation MK (member of the Research Advisory Committee at the Stroke Foundation) SM, CL, DAC, SD, NWC, JG, CDE, EM, KC, OF, BM (Investigators QASC Research Program: QASC QASCIP,T3 and QASC Europe Studies)The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Professor Sandy Middleton reports financial support was provided by National Health and Medical Research Council Investigator Grant. Kelly Coughlan reports financial support was provided by Australian Government Research Training Program Scholarship. Monique Kilkenny reports financial support was provided by National Heart Foundation of Australia fellowship. Kelly Coughlan reports financial support was provided by St Vincent's Hospital (Melbourne) Limited. Kelvin Hill reports a relationship with Stroke Foundation Australia that includes: employment. Co-author Monique Kilkenny is a member of the Research Advisory Committee at Stroke Foundation Australia Co-authors Monique Kilkenny, Megan Reyneke, Tara Purvis and Dominique Cadilhac are responsible for the independent and alloy analysis of National Stroke Audit data on behalf of the Stroke Foundation Corresponding author and co-authors Sandy Middleton, Christopher Levi, Dominique Cadilhac, Simeon Dale, N Wah Cheung, Jeremy Grimshaw, Cate DEste, Elizabeth McInnes, Kelly Coughlan, Oyebola Fasugba, are investigators for the QASC Research Program (QASC QASCIP,T3 and QASC Europe Studies) If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Objective: To identify factors associated with neonatal respiratory distress (NRD) in early Gestational diabetes mellitus (eGDM)., Design: Nested case-control analysis of the TOBOGM trial., Setting: Seventeen hospitals: Australia, Sweden, Austria and India., Population: Pregnant women, <20 weeks' gestation, singleton, GDM risk factors., Methods: Women with GDM risk factors completed an oral glucose tolerance test (OGTT) before 20 weeks: those with eGDM (WHO-2013 criteria) were randomised to immediate or deferred GDM treatment. Logistic regression compared pregnancies with/without NRD, and in pregnancies with NRD, those with/without high-dependency nursery admission for ≤24 h with those admitted for >24 h. Comparisons were adjusted for age, pre-pregnancy body mass index, ethnicity, smoking, primigravity, education and site. Adjusted odds ratios (95% CI) are reported., Main Outcome Measures: NRD definition: ≥4 h of respiratory support (supplemental oxygen or supported ventilation) postpartum. Respiratory distress syndrome (RDS): Supported ventilation and ≥24 h nursery stay., Results: Ninety-nine (12.5%) of 793 infants had NRD; incidence halved (0.50, 0.31-0.79) if GDM treatment was started early. NRD was associated with Caesarean section (2.31, 1.42-3.76), large for gestational age (LGA) (1.83, 1.09-3.08) and shorter gestation (0.95, 0.93-0.97 per day longer). Among NRD infants, >24 h nursery-stay was associated with higher OGTT 1-h glucose (1.38, 1.08-1.76 per mmol/L). Fifteen (2.0%) infants had RDS., Conclusions: Identifying and treating eGDM reduces NRD risk. NRD is more likely with Caesarean section, LGA and shorter gestation. Further studies are needed to understand the mechanisms behind this eGDM complication and any long-term effects., (© 2024 The Author(s). BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)

Objective: We evaluated associations between early-pregnancy oral glucose tolerance test (OGTT) glucose and complications in the Treatment of Booking Gestational Diabetes Mellitus (TOBOGM) cohort to inform prognostic OGTT thresholds., Research Design and Methods: Individuals with risk factors for hyperglycemia were recruited for an international, multicenter, randomized controlled gestational diabetes mellitus (GDM) (World Health Organization 2013 criteria) treatment trial. A 2-h 75-g OGTT was performed at <20 weeks' gestation. Individuals with early treated hyperglycemia in pregnancy were excluded from the primary analysis. Early OGTT glucose concentrations were analyzed continuously and in glycemic categories (normal, low band, and high band)., Results: Overall, 3,645 individuals had an OGTT at (mean ± SD) 15.6 ± 2.5 weeks. For each 1-SD increase in fasting, 1-h, and 2-h glucose values, there were continuous positive associations with late GDM: adjusted odds ratio (aOR) 2.04 (95% CI 1.82-2.27), 3.05 (2.72-3.43), and 2.21 (1.99-2.45), respectively. There were continuous positive associations between 1-h and 2-h glucose and the perinatal composite (birth <37 + 0 weeks, birth trauma, birth weight ≥4,500 g, respiratory distress, phototherapy requirement, stillbirth/neonatal death, and shoulder dystocia), with aOR 1.15 (95% CI 1.04-1.26) and 1.14 (1.04-1.25), respectively, and with large-for-gestational-age offspring, with aOR 1.18 (1.06-1.31) and 1.26 (1.01-1.25), respectively. Significant associations were also observed between 1-h glucose and cesarean section and between fasting and 2-h glucose and neonatal hypoglycemia. In categorical analysis, only the high-band 1-h glucose (≥10.6 mmol/L [191 mg/dL]) predicted the perinatal composite., Conclusions: There is a continuous positive association between early-pregnancy OGTT glucose and complications. In individuals with hyperglycemia risk factors, only the high-glycemic-band 1-h glucose corresponded to increased risk of major perinatal complications., (© 2024 by the American Diabetes Association.)

Background: A recently undertaken multicenter randomized controlled trial (RCT) " Treatment Of BOoking Gestational diabetes Mellitus" (TOBOGM: 2017-2022) found that the diagnosis and treatment of pregnant women with early gestational diabetes mellitus (GDM) improved pregnancy outcomes. Based on data from the trial, this study aimed to assess the cost-effectiveness of diagnosis and treatment of early GDM (from <20 weeks') among women with risk factors for hyperglycemia in pregnancy compared with usual care (no treatment until 24-28 weeks') from a healthcare perspective., Methods: Participants' healthcare resource utilization data were collected from their self-reported questionnaires and hospital records, and valued using the unit costs obtained from standard Australian national sources. Costs were reported in US dollars ($) using the purchasing power parity (PPP) estimates to facilitate comparison of costs across countries. Intention-to-treat (ITT) principle was followed. Missing cost data were replaced using multiple imputations. Bootstrapping method was used to estimate the uncertainty around mean cost difference and cost-effectiveness results. Bootstrapped cost-effect pairs were used to plot the cost-effectiveness (CE) plane and cost-effectiveness acceptability curve (CEAC)., Findings: Diagnosis and treatment of early GDM was more effective and tended to be less costly, i.e., dominant (cost-saving) [-5.6% composite adverse pregnancy outcome (95% CI: -10.1%, -1.2%), -$1373 (95% CI: -$3,749, $642)] compared with usual care. Our findings were confirmed by both the CE plane (88% of the bootstrapped cost-effect pairs fall in the south-west quadrant), and CEAC (the probability of the intervention being cost-effective ranged from 84% at a willingness-to-pay (WTP) threshold value of $10,000-99% at a WTP threshold value of $100,000 per composite adverse pregnancy outcome prevented). Sub-group analyses demonstrated that diagnosis and treatment of early GDM among women in the higher glycemic range (fasting blood glucose 95-109 mg/dl [5.3-6.0 mmol/L], 1-h blood glucose ≥191 mg/dl [10.6 mmol/L] and/or 2-h blood glucose 162-199 mg/dl [9.0-11.0 mmol/L]) was more effective and less costly (dominant) [ - 7.8% composite adverse pregnancy outcome (95% CI: -14.6%, -0.9%), -$2795 (95% CI: -$6,638, -$533)]; the intervention was more effective and tended to be less costly [ - 8.9% composite adverse pregnancy outcome (95% CI: -15.1%, -2.6%), -$5548 (95% CI: -$16,740, $1547)] among women diagnosed before 14 weeks' gestation as well., Interpretation: Our findings highlight the potential health and economic benefits from the diagnosis and treatment of early GDM among women with risk factors for hyperglycemia in pregnancy and supports its implementation. Long-term follow-up studies are recommended as a key future area of research to assess the potential long-term health benefits and economic consequences of the intervention., Funding: National Health and Medical Research Council (grants 1104231 and 2009326), Region O¨rebro Research Committee (grants Dnr OLL-970566 and OLL-942177), Medical Scientific Fund of the Mayor of Vienna (project 15,205 and project 23,026), South Western Sydney Local Health District Academic Unit (grant 2016), and Western Sydney University Ainsworth Trust Grant (2019)., Competing Interests: WHH reports participation on Merck Sharp & Dohme Board and Rivus Pharmaceuticals Board. DS reports Presidency of the Australasian Diabetes in Pregnancy Society. All otherauthor(s) have no potential conflict of interests to report., (© 2024 The Author(s).)

Objective: To compare pregnancy outcomes among women with a normal oral glucose tolerance test (OGTT) before 20 weeks' gestation (early) and at 24-28 weeks' gestation (late) (no gestational diabetes mellitus, or No-GDM), those with early GDM randomized to observation with a subsequent normal OGTT (GDM-Regression), and those with GDM on both occasions (GDM-Maintained)., Research Design and Methods: Women at <20 weeks' gestation with GDM risk factors who were recruited for a randomized controlled early GDM treatment trial were included. Women with treated early GDM and late GDM (according to the World Health Organization's 2013 criteria) were excluded from this analysis. Logistic regression compared pregnancy outcomes., Results: GDM-Regression (n = 121) group risk factor profiles and OGTT results generally fell between the No-GDM (n = 2,218) and GDM-Maintained (n = 254) groups, with adjusted incidences of pregnancy complications similar between the GDM-Regression and No-GDM groups., Conclusions: Women with early GDM but normal OGTT at 24-28 weeks' gestation had pregnancy outcomes that were similar to those of individuals without GDM. Identifying early GDM likely to regress would allow treatment to be avoided., (© 2024 by the American Diabetes Association.)

Gestational diabetes (GDM) is associated with a long-term risk of diabetes. We aimed to determine whether a text-messaging-based lifestyle support program would improve diabetes risk factors following GDM. Women with GDM were randomised following delivery to receive four text messages per week supporting a healthy lifestyle and parenting for 6 months, with feedback from an activity monitor (intervention), or to receive the activity monitor only (control). The primary outcome was a composite of weight, physical activity and dietary goals. There were 177 women randomised, with 88 intervention and 89 control participants. All the participants experienced COVID-19 lockdowns during the study. Six-month primary outcome data were obtained for 57 intervention participants and 56 controls. There were 7/57 (12%) intervention and 6/56 (11%) control participants who met the primary outcome (relative risk, 1.08; 95%CI, 0.63-1.85; p = 0.79). Two intervention participants met the dietary goals compared to none of the control participants ( p = NS). The intervention participants were more likely to record >1000 steps/day (on 102 ± 59 vs. 81 ± 59 days, p = 0.03). When analysed monthly, this was not initially different but became significant 3-6 months post-partum. Interviews and surveys indicated that with the Intervention, healthier choices were made, but these were negatively impacted by COVID-19 restrictions. Participants found the messages motivational (74%) and the activity monitor useful (71%). In conclusion, no improvement in the diabetes risk factors occurred among the women receiving the text messaging intervention when affected by COVID-19 restrictions.

Objective: In most gestational diabetes mellitus (GDM) studies, cohorts have included women combined into study populations without regard to whether hyperglycemia was present earlier in pregnancy. In this study we sought to compare perinatal outcomes between groups: women with early GDM (EGDM group: diagnosis before 20 weeks but no treatment until 24-28 weeks if GDM still present), with late GDM (LGDM group: present only at 24-28 weeks), and with normoglycemia at 24-28 weeks (control subjects)., Research Design and Methods: This is a secondary analysis of a randomized controlled treatment trial where we studied, among women with risk factors, early (<20 weeks' gestation) GDM defined according to World Health Organization 2013 criteria. Those receiving early treatment for GDM treatment were excluded. GDM was treated if present at 24-28 weeks. The primary outcome was a composite of birth before 37 weeks' gestation, birth weight ≥4,500 g, birth trauma, neonatal respiratory distress, phototherapy, stillbirth/neonatal death, and shoulder dystocia. Comparisons included adjustment for age, ethnicity, BMI, site, smoking, primigravity, and education., Results: Women with EGDM (n = 254) and LGDM (n = 467) had shorter pregnancy duration than control subjects (n = 2,339). BMI was lowest with LGDM. The composite was increased with EGDM (odds ratio [OR] 1.59, 95% CI 1.18-2.12)) but not LGDM (OR 1.19, 95% CI 0.94-1.50). Induction of labor was higher in both GDM groups. In comparisons with control subjects there were higher birth centile, higher preterm birth rate, and higher rate of neonatal jaundice for the EGDM group (but not the LGDM group). The greatest need for insulin and/or metformin was with EGDM., Conclusions: Adverse perinatal outcomes were increased with EGDM despite treatment from 24-28 weeks' gestation, suggesting the need to initiate treatment early, and more aggressively, to reduce the effects of exposure to the more severe maternal hyperglycemia from early pregnancy., (© 2024 by the American Diabetes Association.)

Background: Women with a history of gestational diabetes (GD) have a high risk of developing diabetes and subsequent cardiovascular disease (CVD)., Aim: To assess whether diabetes screening and CVD risk screening occurred in general practice (GP) among postpartum women with GD., Methods: This is a retrospective study of clinical record data of women with GD, under active GP management, from the MedicineInsight programme, run by Australia's National Prescribing Service MedicineWise, with GP sites located in Australia from January 2015 to March 2021. Documentation of screening for diabetes, assessment of lipids and measurement of blood pressure (BP) was assessed using proportions and mixed-effects logistic regression with a log follow-up time offset., Results: There were 10 413 women, with a mean age of 37.9 years (standard deviation, 7.6), from 406 clinics with a mean follow-up of 4.6 years (interquartile range, 1.8-6.2 years) A total of 29.41% (3062/10 413; 95% confidence interval [CI], 28.53-30.28) had not been assessed for diabetes, 37.40% (3894/10 413; 95% CI, 36.47-38.32) were not assessed for lipids and 2.19% (228/10 413; 95% CI, 1.91-2.47) had no BP documented. In total, 51.82% (5396/10 413; 95% CI, 50.86-52.78) were screened for all three (diabetes + lipids + BP) at least once. Obesity, comorbidities and dyslipidaemia were associated with increased likelihood of screening. New diabetes diagnosis was documented in 5.73% (597/10 413; 95% CI, 5.29-6.18) of the cohort., Conclusion: Screening for diabetes and hyperlipidaemia was suboptimal in this high-risk cohort of women with prior GD. Improved messaging that women with a GD diagnosis are at high cardiovascular risk may improve subsequent screening., (© 2023 The Authors. Internal Medicine Journal published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Physicians.)

Breastfeeding is associated with reduced lifetime cardiometabolic risk, but little is known regarding the metabolic benefit in a subsequent pregnancy. The primary aim of this study was to investigate the association between breastfeeding duration and intensity and next pregnancy oral glucose tolerance test (OGTT) results. A retrospective cohort study was conducted from March 2020 to October 2022. All multiparous women who met inclusion criteria and gave birth during the study period were eligible for inclusion. Analysis was stratified by risk for gestational diabetes (GDM). High GDM risk criteria included previous GDM and BMI > 35 kg/m 2 . The association between breastfeeding duration and high-intensity breastfeeding (HIBF) and subsequent pregnancy OGTT were assessed with multivariate logistic models adjusted for statistically and clinically relevant covariables. There were 5374 multiparous participants who met the inclusion criteria for analysis. Of these, 61.7% had previously breastfed for >6 months, and 43.4% were at high risk for GDM. HIBF was associated with 47% reduced odds of an abnormal fasting glucose in a subsequent pregnancy OGTT (aOR 0.53; 95%CI 0.38-0.75; p < 0.01). There was no association between HIBF and other glucose results on the OGTT. Women who smoked were least likely to breastfeed at high intensity (aOR 0.31; 95%CI 0.21-0.47; p < 0.01). South Asian women had 65% higher odds of HIBF than women who identified as White/European (aOR 1.65; 1.36-2.00; p < 0.01). This study highlights the importance of exclusive breastfeeding to potentially reduce the prevalence of GDM and may also translate into long-term reduction of cardiometabolic risk.

Aims: Blood glucose control is central to the management of diabetes, and continuous glucose monitoring (CGM) improves glycemic control. We aimed to describe the perspectives of people with diabetes using CGM., Materials and Methods: We performed a systematic review of qualitative studies., Results: Fifty-four studies involving 1845 participants were included. Six themes were identified: gaining control and convenience (reducing pain and time, safeguarding against complications, achieving stricter glucose levels, and sharing responsibility with family); motivating self-management (fostering ownership, and increasing awareness of glycemic control); providing reassurance and freedom (attaining peace of mind, and restoring social participation); developing confidence (encouraged by the endorsement of others, gaining operational skills, customizing settings for ease of use, and trust in the device); burdened with device complexities (bewildered by unfamiliar technology, reluctant to rely on algorithms, overwhelmed by data, frustrated with malfunctioning and inaccuracy, distressed by alerts, and bulkiness of machines interfering with lifestyle); and excluded by barriers to access (constrained by cost, lack of suppliers)., Conclusions: CGM can improve self-management and confidence in patients managing diabetes. However, the technical issues, uncertainty in readings, and cost may limit the uptake. Education and training from the health professionals may help to reduce the practical and psychological burden for better patient outcomes., (© 2023 The Authors. Journal of Diabetes published by Ruijin Hospital, Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd.)

Introduction: The aim of this study was to determine the prevalence of diabetic retinopathy (DR) in a low socioeconomic region of a high-income country, as well as determine the diagnostic utility of point-of-care screening for high-risk populations in tertiary care settings., Research Design and Methods: This was a cross-sectional study of patients with diabetes attending foot ulcer or integrated care diabetes clinics at two Western Sydney hospitals (n=273). DR was assessed using portable, two-field, non-mydriatic fundus photography and combined electroretinogram/ pupillometry (ERG). With mydriatic photographs used as the reference standard, sensitivity and specificity of the devices were determined. Prevalence of DR and vision-threatening diabetic retinopathy (VTDR) were reported, with multivariate logistic regression used to identify predictors of DR., Results: Among 273 patients, 39.6% had any DR, while 15.8% had VTDR, of whom 59.3% and 62.8% were previously undiagnosed, respectively. Non-mydriatic photography demonstrated 20.2% sensitivity and 99.5% specificity for any DR, with a 56.7% screening failure rate. Meanwhile, mydriatic photography produced high-quality images with a 7.6% failure rate. ERG demonstrated 72.5% sensitivity and 70.1% specificity, with a 15.0% failure rate. The RETeval ERG was noted to have an optimal DR cut-off score at 22. Multivariate logistic regression identified an eGFR of ≤29 mL/min/1.73 m 2 , HbA1c of ≥7.0%, pupil size of <4 mm diameter, diabetes duration of 5-24 years and RETeval score of ≥22 as strong predictors of DR., Conclusion: There is a high prevalence of vision-threatening and undiagnosed DR among patients attending high-risk tertiary clinics in Western Sydney. Point-of-care DR screening using portable, mydriatic photography demonstrates potential as a model of care which is easily accessible, targeted for high-risk populations and substantially enhances DR detection., Competing Interests: Competing interests: Similarly, Welch Allyn loaned equipment for data collection, with no involvement in study design, data analysis, interpretation, manuscript preparation, nor the decision to submit the report for publication. Duality of Interest: Welch Allyn provided financial support for another clinical study run in the Department of Ophthalmology, Westmead Hospital. The authors received no personal financial support., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Both obesity and sleep disorders are common among women during pregnancy. Although prior research has identified a relationship between obesity and sleep disorders, those findings are from women later in pregnancy., Objective: To explore the relationships between self-reported sleep duration, insufficient sleep and snoring with body mass index (BMI) among multiethnic women at risk of gestational diabetes mellitus (GDM)in early pregnancy., Methods: Cross-sectional study of baseline data from women at risk of GDM enrolled in the Treatment of BOoking Gestational diabetes Mellitus (TOBOGM) multicentre trial across 12 Australian/Austrian sites. Participants completed a questionnaire before 20 weeks' gestation to evaluate sleep. BMI <25 kg/m 2 served as the reference group in multivariable logistic regression., Results: Among the 2865 women included, the prevalence of overweight and obesity classes I-III was 28%, 19%, 11% and 12%, respectively. There was no relationship between sleep duration and BMI. The risk of insufficient sleep >5 days/month was higher in class II and class III obesity (1.38 (1.03-1.85) and 1.34 (1.01-1.80), respectively), and the risk of snoring increased as BMI increased (1.59 (1.25-2.02), 2.68 (2.07-3.48), 4.35 (3.21-5.88) to 4.96 (3.65-6.74), respectively))., Conclusions: Obesity is associated with insufficient sleep among pregnant women at risk of GDM. Snoring is more prevalent with increasing BMI., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article., (© 2023 The Authors. Obesity Science & Practice published by World Obesity and The Obesity Society and John Wiley & Sons Ltd.)

Background: Maintaining engagement and support for patients with chronic diseases is challenging. SMS text messaging programs have complemented patient care in a variety of situations. However, such programs have not been widely translated into routine care., Objective: We aimed to examine the implementation and utility of a customized SMS text message-based support program for patients with type 2 diabetes (T2D), coronary heart disease, or both within a chronic disease integrated care program., Methods: We conducted a 6-month pragmatic parallel-group, single-blind randomized controlled trial that recruited people with T2D or coronary heart disease. Intervention participants received 4 semipersonalized SMS text messages per week providing self-management support to supplement standard care. Preprogrammed algorithms customized content based on participant characteristics, and the messages were sent at random times of the day and in random order by a fully automated SMS text messaging engine. Control participants received standard care and only administrative SMS text messages. The primary outcome was systolic blood pressure. Evaluations were conducted face to face whenever possible by researchers blinded to randomization. Participants with T2D were evaluated for glycated hemoglobin level. Participant-reported experience measures were evaluated using questionnaires and focus groups and summarized using proportions and thematic analysis., Results: A total of 902 participants were randomized (n=448, 49.7% to the intervention group and n=454, 50.3% to the control group). Primary outcome data were available for 89.5% (807/902) of the participants. At 6 months, there was no difference in systolic blood pressure between the intervention and control arms (adjusted mean difference=0.9 mm Hg, 95% CI -1.1 to 2.1; P=.38). Of 642 participants with T2D, there was no difference in glycated hemoglobin (adjusted mean difference=0.1%, 95% CI -0.1% to 0.3%; P=.35). Self-reported medication adherence was better in the intervention group (relative risk=0.82, 95% CI 0.68-1.00; P=.045). Participants reported that the SMS text messages were useful (298/344, 86.6%) and easily understood (336/344, 97.7%) and motivated change (217/344, 63.1%). The lack of bidirectional messaging was identified as a barrier., Conclusions: The intervention did not improve blood pressure in this cohort, possibly because of high clinician commitment to improved routine patient care as part of the chronic disease management program as well as favorable baseline metrics. There was high program engagement, acceptability, and perceived value. Feasibility as part of an integrated care program was demonstrated. SMS text messaging programs may supplement chronic disease management and support self-care., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616001689460; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371769&isReview=true., International Registered Report Identifier (irrid): RR2-10.1136/bmjopen-2018-025923., (©Ngai Wah Cheung, Julie Redfern, Aravinda Thiagalingam, Tien-Ming Hng, Simone Marschner, Rabbia Haider, Sonia Faruquie, Amy Von Huben, Shelley She, Daniel McIntyre, Jin-Gun Cho, Clara K Chow, The SupportMe Investigators. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 16.06.2023.)

Background: As a COVID-19 risk mitigation measure, Australia closed its international borders for two years with significant socioeconomic disruption including impacting approximately 30% of the Australian population who are migrants. Migrant populations during the peripartum often rely on overseas relatives visiting for social support. High quality social support is known to lead to improved health outcomes with disruption to support a recognised health risk., Aim: To explore women's experience of peripartum social support during the COVID-19 pandemic in a high migrant population. To quantify type and frequency of support to identify characteristics of vulnerable perinatal populations for future pandemic preparedness., Methods: A mixed methods study with semi-structured interviews and a quantitative survey was conducted from October 2020 to April 2021. A thematic approach was used for analysis., Results: There were 24 participants interviewed both antenatally and postnatally (22 antenatal; 18 postnatal). Fourteen women were migrants and 10 Australian born. Main themes included; 'Significant disruption and loss of peripartum support during the COVID-19 pandemic and ongoing impact for migrant women'; 'Husbands/partners filling the support gap' and 'Holding on by a virtual thread'. Half of the participants felt unsupported antenatally. For Australian born women, this dissipated postnatally, but migrants continued to feel unsupported. Migrant women discussed partners stepped into traditional roles and duties of absent mothers and mothers-in-law who were only available virtually., Conclusion: This study identified disrupted social support for migrant women during the pandemic, providing further evidence that the pandemic has disproportionately impacted migrant populations. However, the benefits identified in this study included high use of virtual support, which could be leveraged for improving clinical care in the present and in future pandemics. The COVID-19 pandemic impacted most women's peripartum social support with migrant families having ongoing disruption. Gains in the pandemic included greater gender equity for domestic work as husbands/partners increased their contribution to domestic work and childcare., (© 2023. Crown.)

Background: Whether treatment of gestational diabetes before 20 weeks' gestation improves maternal and infant health is unclear., Methods: We randomly assigned, in a 1:1 ratio, women between 4 weeks' and 19 weeks 6 days' gestation who had a risk factor for hyperglycemia and a diagnosis of gestational diabetes (World Health Organization 2013 criteria) to receive immediate treatment for gestational diabetes or deferred or no treatment, depending on the results of a repeat oral glucose-tolerance test [OGTT] at 24 to 28 weeks' gestation (control). The trial included three primary outcomes: a composite of adverse neonatal outcomes (birth at <37 weeks' gestation, birth trauma, birth weight of ≥4500 g, respiratory distress, phototherapy, stillbirth or neonatal death, or shoulder dystocia), pregnancy-related hypertension (preeclampsia, eclampsia, or gestational hypertension), and neonatal lean body mass., Results: A total of 802 women underwent randomization; 406 were assigned to the immediate-treatment group and 396 to the control group; follow-up data were available for 793 women (98.9%). An initial OGTT was performed at a mean (±SD) gestation of 15.6±2.5 weeks. An adverse neonatal outcome event occurred in 94 of 378 women (24.9%) in the immediate-treatment group and in 113 of 370 women (30.5%) in the control group (adjusted risk difference, -5.6 percentage points; 95% confidence interval [CI], -10.1 to -1.2). Pregnancy-related hypertension occurred in 40 of 378 women (10.6%) in the immediate-treatment group and in 37 of 372 women (9.9%) in the control group (adjusted risk difference, 0.7 percentage points; 95% CI, -1.6 to 2.9). The mean neonatal lean body mass was 2.86 kg in the immediate-treatment group and 2.91 kg in the control group (adjusted mean difference, -0.04 kg; 95% CI, -0.09 to 0.02). No between-group differences were observed with respect to serious adverse events associated with screening and treatment., Conclusions: Immediate treatment of gestational diabetes before 20 weeks' gestation led to a modestly lower incidence of a composite of adverse neonatal outcomes than no immediate treatment; no material differences were observed for pregnancy-related hypertension or neonatal lean body mass. (Funded by the National Health and Medical Research Council and others; TOBOGM Australian New Zealand Clinical Trials Registry number, ACTRN12616000924459.)., (Copyright © 2023 Massachusetts Medical Society.)

Background: The COVID-19 pandemic has had indirect effects on pregnancy outcomes. There is limited data on the impact on gestational diabetes (GDM) in diverse populations and the possible underlying mediators. This study aimed to assess the risk of GDM pre-COVID-19 and in two distinct pandemic exposure periods, and to determine the potential factors contributing to increased risk in a multiethnic population., Methods: A multicentre, retrospective cohort study was performed of women with singleton pregnancy receiving antenatal care at three hospitals two years pre-COVID-19 (January 2018 - January 2020), first year of COVID-19 with limited pandemic-mitigating restrictions (February 2020 - January 2021) and second year of COVID-19 with stringent restrictions (February 2021 - January 2022). Baseline maternal characteristics and gestational weight gain (GWG) were compared between cohorts. The primary outcome was GDM, assessed using univariate and multivariate generalised estimating equations models., Results: 28,207 pregnancies met the inclusion criteria, 14,663 pregnancies two years pre-COVID-19, 6,890 in COVID-19 Year 1 and 6,654 in COVID-19 Year 2. Maternal age increased across exposure periods (30.7 ± 5.0 years pre-COVID-19 vs 31.0 ± 5.0 years COVID-19 Year 1 vs 31.3 ± 5 years COVID-19 Year 2; p < 0.001). There were increases in pre-pregnancy body mass index (BMI) (25.5 ± 5.7 kg/m 2 vs 25.7 ± 5.6 kg/m 2 vs 26.1 ± 5.7 kg/m 2 ; p < 0.001), proportion who were obese (17.5% vs 18.1% vs 20.7%; p < 0.001) and proportion with other traditional risk factors for GDM including South Asian ethnicity and prior history of GDM. Rate of GWG and proportion exceeding recommended GWG increased with pandemic exposure (64.3% vs 66.0% vs 66.6%; p = 0.009). GDM diagnosis increased across exposure periods (21.2% vs 22.9% vs 24.8%; p < 0.001). Both pandemic exposure periods were associated with increased risk of GDM on univariate analysis, only COVID-19 Year 2 remaining significantly associated after adjusting for maternal baseline characteristics and GWG (OR 1.17 [1.06, 1.28], p = 0.01)., Conclusions: Diagnosis of GDM increased with pandemic exposure. Progressive sociodemographic changes and greater GWG may have contributed to increased risk. However, exposure to the second year of COVID-19 remained independently associated with GDM after adjusting for shifts in maternal characteristics and GWG., (© 2023. The Author(s).)