Diagnosing and providing initial management for patients with Gestational Diabetes: What is the General Practitioner's experience?

Exploring health professionals' knowledge, practices and attitudes regarding gestational diabetes: A cross-sectional Irish national survey

AIM

Gestational diabetes confers short- and long-term risk of mother and offspring health complications. Healthcare professionals such as endocrinologists, diabetes nurses, dietitians, midwives and general practitioners provide gestational diabetes care. We sought to explore healthcare professionals' perspectives on gestational diabetes care during pregnancy and postpartum.

METHODS

Healthcare professionals in the Republic of Ireland, whose role included gestational diabetes care were invited to complete an online 20-item survey between June and September 2022. Social media, professional organisations and personal networks were used for recruitment. Questions included guideline use, postpartum diabetes screening and advice practices. Analyses were performed using SPSS statistical software and free text was coded using NVivo.

RESULTS

Seventeen healthcare professions across primary and secondary care settings participated (n = 127). No differences were noted between groups (medical, nursing/midwifery, allied health/other); therefore, findings were reported as a single group. Healthcare professionals reported using multiple different guidelines to support gestational diabetes management (n = 14). The most cited were 'Health Service Executive guidelines' (24.5%), 'local guidelines' (13.2%) and National Institute for Clinical Excellence guidelines (11.3%); 12.3% cited uncertainty, and 27.5% reported not to follow any named guidelines. For postpartum follow-up, 39% felt clear guidelines were available to support practice, 37% felt appropriate systems were in place and 29% reported effective communication between primary and secondary care services. Qualitative findings emphasised a desire for improved communication between systems, participants and providers, clear interdisciplinary guidelines, and adequate resourcing for gestational diabetes management and postpartum diabetes prevention, including comprehensive support and follow-up.

CONCLUSION

System-level challenges and ineffective communication across settings are barriers to optimum postpartum care. Nationally agreed guidelines for best practice gestational diabetes management including postpartum diabetes prevention are needed.

A Social-Ecological Model Exploring Gestational Diabetes Mellitus Screening Practices Among Antenatal Health Care Providers

Gestational diabetes mellitus (GDM) is associated with adverse health outcomes for the pregnant individual and their baby. Screening approaches for GDM have undergone several iterations, introducing variability in practice among healthcare providers. As such, our study aimed to explore the views of antenatal providers regarding their practices of, and counseling experiences on the topic of, GDM screening in Ontario. We conducted a qualitative, grounded theory study. The study population included antenatal providers (midwives, family physicians, and obstetricians) practicing in Hamilton, Ottawa, or Sudbury, Ontario. Semi-structured telephone interviews were conducted and transcribed verbatim. Transcripts were analyzed using inductive coding upon which codes, categories, and themes were developed to generate a theory grounded in the data. Twenty-two participants were interviewed. Using the social-ecological theory, we created a model outlining four contextual levels that shaped the experiences of GDM counseling and screening: Intrapersonal factors included beliefs, knowledge, and skills; interpersonal factors characterized the patient-provider interactions; organizational strengths and challenges shaped collaboration and health services infrastructure; and finally, guidelines and policies were identified as systemic barriers to health care access and delivery. A focus on patient-centered care was a guiding principle for all care providers and permeated all four levels of the model. Patient-centered care and close attention to barriers and facilitators across intrapersonal, interpersonal, organizational, and policy domains can minimize the impact of variations in GDM screening guidelines. Among care providers, there is a desire for additional skill development related to GDM counseling, and for national consensus on optimal screening guidelines.

Qualitative systematic review of general practitioners' (GPs') views and experiences of providing postnatal care

OBJECTIVES

Develop an understanding of the views and experiences of general practitioners (GPs) about their role in postnatal care, including barriers and facilitators to good care, and timing and content of planned postnatal checks.

DESIGN

Qualitative systematic review.

DATA SOURCES

Electronic database searches of MEDLINE, EMBASE, CINAHL, PubMed, Web of Science, PsychINFO from January 1990 to September 2021. Grey literature and guideline references from National Institute of Health and Care Excellence, WHO, International Federation of Gynecology and Obstetrics, Royal College of General Practitioners, Royal College of Obstetrics and Gynaecology.

INCLUSION CRITERIA

Papers reporting qualitative data on views and experiences of GPs about postnatal care, including discrete clinical conditions in the postnatal period. Papers were screened independently by two reviewers and disputes resolved by a third reviewer.

QUALITY APPRAISAL

The Critical Appraisal Skills Programme checklist was used to appraise studies.

DATA EXTRACTION AND SYNTHESIS

Thematic synthesis involving line-by-line coding, generation of descriptive then analytical themes was conducted by the review team. The Capability, Opportunity, Motivation-Behaviour (COM-B) model was used to develop analytical themes.

RESULTS

20 reports from 18 studies met inclusion criteria. Studies were published from 2008 to 2021, reporting on 469 GPs. 13 were from UK or Australia. Some also reported views of non-GP participants. The clinical focus of studies varied, for example: perinatal mental health, postnatal contraception. Five themes were generated, four mapped to COM-B: psychological capability, physical opportunity, social opportunity and motivation. One theme was separate from the COM-B model: content and timing of postnatal checks. Strong influences were in physical and social opportunity, with time and organisation of services being heavily represented. These factors sometimes influenced findings in the motivation theme.

CONCLUSIONS

GPs perceived their role in postnatal care as a positive opportunity for relationship building and health promotion. Addressing organisational barriers could impact positively on GPs' motivation to provide the best care.

PROSPERO REGISTRATION NUMBER

268982.

MicroRNA-1592 in the Bone Marrow Mesenchymal Stem Cell-Derived Exosomes Inhibits the Glioma Development In Vivo and In Vitro

This study evaluated the role of miRNA-1592 (miR-1592) carried by exosomes that originated from bone marrow mesenchymal stem cell (BMSC) in glioma. BMSCs were cultured and identified, followed by being co-cultured with glioma cells to measure cell invasion, metastasis, and apoptosis by transwell assay and flow cytometry, cell proliferation by MTT, PI3K/AKT signal protein expression by western blot. BMSC-originated exosomes with different concentrations were used as a treatment strategy for established tumor models. The tumor volume was measured and tumor tissues were harvested for immunohistochemistry and immunoblot analysis. After co-culture with BMSC-originated exosomes, glioma cells showed an up-regulated transcription of miR-1592, along with inhibited phosphorylation and activation of PI3K/AKT signal pathway. Moreover, glioma cells exhibited reduced migration and invasiveness In Vitro, which was accompanied by diminished levels of proteins involved in cellular invasiveness. Simultaneously, co-culture with BMSC-originated exosomes can restrain glioma cell proliferation via facilitating cell apoptosis In Vivo and In Vitro. In conclusion, exosome-encapsulated microRNA-1592 from BMSCs can suppress the In Vivo and In Vitro development of glioma through interfering with PI3K/AKT signaling pathway.

Consequences of a Diagnostic Label: A Systematic Scoping Review and Thematic Framework

Objectives: To develop a thematic framework for the range of consequences arising from a diagnostic label from an individual, family/caregiver, healthcare professional, and community perspective.

Design: Systematic scoping review of qualitative studies.

Search Strategy: We searched PubMed, Embase, PsycINFO, Cochrane, and CINAHL for primary studies and syntheses of primary studies that explore the consequences of labelling non-cancer diagnoses. Reference lists of included studies were screened, and forward citation searches undertaken.

Study Selection: We included peer reviewed publications describing the perceived consequences for individuals labelled with a non-cancer diagnostic label from four perspectives: that of the individual, their family/caregiver, healthcare professional and/or community members. We excluded studies using hypothetical scenarios.

Data Extraction and Synthesis: Data extraction used a three-staged process: one third was used to develop a preliminary framework, the next third for framework validation, and the final third coded if thematic saturation was not achieved. Author themes and supporting quotes were extracted, and analysed from the perspective of individual, family/caregiver, healthcare professional, or community member.

Results: After deduplication, searches identified 7,379 unique articles. Following screening, 146 articles, consisting of 128 primary studies and 18 reviews, were included. The developed framework consisted of five overarching themes relevant to the four perspectives: psychosocial impact (e.g., positive/negative psychological impact, social- and self-identity, stigma), support (e.g., increased, decreased, relationship changes, professional interactions), future planning (e.g., action and uncertainty), behaviour (e.g., beneficial or detrimental modifications), and treatment expectations (e.g., positive/negative experiences). Perspectives of individuals were most frequently reported.

Conclusions: This review developed and validated a framework of five domains of consequences following diagnostic labelling. Further research is required to test the external validity and acceptability of the framework for individuals and their family/caregiver, healthcare professionals, and community.

The Perspectives of Diabetes Educators and Dietitians on Diet and Lifestyle Management for Gestational Diabetes Mellitus: A Qualitative Study

This study explores the knowledge and practice of diabetes educators and dietitians on diet and lifestyle management in women with gestational diabetes mellitus (GDM). Diabetes educators and dietitians were recruited from three maternity hospitals in Adelaide (Australia), through snowball and purposive sampling. Thirteen semistructured interviews were conducted, audio recorded, transcribed verbatim, and analysed for codes and themes. Four themes emerged: guidelines and resources, dietary intervention, management delivery, and communication. Diabetes educators and dietitians demonstrated consistent knowledge of nutritional management for GDM and uniform delivery methods. However, a lack of culturally diverse resources was highlighted, along with a lack of continuity of care across the multidisciplinary team. Barriers towards uptake of dietary intervention were reflected by diabetes educators and dietitians as women showing signs of guilt and stress and disengaging from the service. Further exploration on the knowledge and practice of diabetes educators and dietitians for GDM to best inform implementation strategies for knowledge translation of nutritional management is needed. The indication of language and cultural barriers and resources highlight an ongoing key priority area to support the care of women of ethnic minorities.

A Review of the Current Status of Gestational Diabetes Mellitus in Australia-The Clinical Impact of Changing Population Demographics and Diagnostic Criteria on Prevalence

The current status of gestational diabetes mellitus in Australia reveals an almost quadrupling prevalence over the last decade. A narrative review of the current Australian literature reveals unique challenges faced by Australian maternity clinicians when addressing this substantial disease burden in our diverse population. Rising rates of maternal overweight and obesity, increasing maternal age and the diversity of ethnicity are key epidemiological impactors, overlaid by the 2015 changes in screening and diagnostic parameters. Our vast land mass and the remote location of many at risk women requires innovative and novel ideas for pathways to diagnose and effectively manage women with gestational diabetes mellitus. By modifying and modernizing models of care for women with gestational diabetes mellitus, we have the ability to address accessibility, resource management and our acute response to global events such as the COVID 19 pandemic. With continuing research, education and robust discourse, Australia is well placed to meet current and future challenges in the management of gestational diabetes mellitus.

The Feasibility and Preliminary Efficacy of an eHealth Lifestyle Program in Women with Recent Gestational Diabetes Mellitus: A Pilot Study

Self-administered eHealth interventions provide a potential low-cost solution for reducing diabetes risk. The aim of this pilot randomised controlled trial (RCT) was to evaluate the feasibility, including recruitment, retention, preliminary efficacy (primary outcome) and acceptability (secondary outcome) of the "Body Balance Beyond" eHealth intervention in women with previous gestational diabetes mellitus (GDM). Women with overweight/obesity who had recent GDM (previous 24 months) were randomised into one of three groups: 1) high personalisation (access to "Body Balance Beyond" website, individual telehealth coaching via video call by a dietitian and exercise physiologist, and text message support); 2) low personalisation (website only); or 3) waitlist control. To evaluate preliminary efficacy, weight (kg), glycosylated hemoglobin, type A1C (HbA1c), cholesterol (total, low-density lipoprotein (LDL) and high-density lipoprotein (HDL)), diet quality and moderate-vigorous physical activity were analysed at baseline and at 3 and 6 months using generalised linear mixed models. To investigate acceptability, process evaluation was conducted at 3 and 6 months. Of the 327 potential participants screened, 42 women (mean age 33.5 ± 4.0 years and BMI 32.4 ± 4.3 kg/m²) were randomised, with 30 (71%) completing the study. Retention at 6 months was 80%, 54% and 79% for high personalisation, low personalisation and waitlist control, respectively (reasons: personal/work commitments, n = 4; started weight-loss diet, n = 1; pregnant, n = 1; resources not useful, n = 1; and not contactable, n = 5). No significant group-by-time interactions were observed for preliminary efficacy outcomes, with the exception of HDL cholesterol, where a difference favoured the low personalisation group relative to the control (p = 0.028). The majority (91%) of women accessed the website in the first 3 months and 57% from 4-6 months. The website provided useful information for 95% and 92% of women at 3 and 6 months, respectively, although only a third of women found it motivating (30% and 25% at 3 and 6 months, respectively). Most women agreed that the telehealth coaching increased their confidence for improving diet (85%) and physical activity (92%) behaviours, although fewer women regarded the text messages as positive (22% and 31% for improving diet and physical activity, respectively). The majority of women (82% at 3 months and 87% at 6 months) in the high personalisation group would recommend the program to other women with GDM. Recruiting and retaining women with a recent diagnosis of GDM is challenging. The "Body Balance Beyond" website combined with telehealth coaching via video call is largely acceptable and useful for women with recent GDM. Further analysis of the effect on diabetes risk reduction in a larger study is needed.