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The risk of pregnancy complications from either pre-existing or gestational 

 affects approximately 1 in 10 women, while rates also increase due to obesity and pregnancy at a later age.

Data show the risk is 2 to 6 times greater compared to the population without diabetes, with adverse outcomes including congenital anomalies, still birth, preterm birth, and infant death within the first month of life.

Investigators, led by Göher Ayman, PhD of the National Perinatal Epidemiology Unit at the University of Oxford, established a Priority Setting Partnership (PSP) to prioritize women’s health and pregnancy, particularly for future research in diabetes and pregnancy.

The team used the James Lind Alliance (JLA), an initiative based in the UK, to identify research questions that matter most to this subset of patients and healthcare professionals and align funding towards the prioritized needs.

Ayman and team established a PSP between the University of Oxford, Diabetes UK, Diabetes Research and Wellness Foundation, JDRF charity, and JLA.

Women with experience of pregnancy or planning pregnancy, with any type of diabetes, as well as healthcare professionals were invited by investigators in an open survey from June – November 2019.

The participants were asked to suggest 3 questions about any time before, during, and after pregnancy with diabetes, with an intentionally broad scope to reflect public need.

Investigators categorized responses from underrepresented groups, including direct outreach in diabetes and pregnancy clinics and support groups. They also noted outreach efforts were made to address health inequalities in ethnic minorities.

The data was analyzed and grouped into categories, with some questions mapped into 2 or more categories to retain the integrity of the original submission.

Investigators used databases, including the Cochrane Database of Systemic Review, to find evidence of substantial uncertainty for each question. If the list of indicative question had sufficient evidence already available, the phrasing was amended to show the remaining uncertainty.

A second survey from May to July 2020 asked participants to choose up to 10 questions they felt were most important to answer. Investigators then tailed the points for each question, separating the point totals by women, support networks and healthcare professionals.

A final process included a JLA workshop with 25 participants in 4 groups, leading discussions and ranking to agree on the top 10 most important questions for future research.

The original survey had total of 466 responses, with 64% women and support networks, 32% healthcare professionals and 4% who did not answer.

In the survey, participants suggested 1161 questions, with the long-term effects of diabetes in pregnancy on the child being the most frequently asked (20.1%).

The second survey aggregated a total of 60 questions, with 614 responses (20% healthcare professionals). The top questions included long-term effects of diabetes in pregnancy on the child’s general health in women/support groups, and the use of technology for healthcare professionals.

Out of these, 18 questions were then shortlisted for the workshop, which were narrowed down to 10 questions after the workshop concluded.

Investigators found the top 10 areas that needed the most research included:

diabetes technology at any stage pre- to post-pregnancy

the best test for diabetes during pregnancy

diet and lifestyle Interventions for diabetes management during pregnancy

emotional and wellbeing needs of women with diabetes pre- to post-pregnancy

postnatal care and support needs of women

diagnosis and management late in pregnancy

prevention of other types of diabetes in women with gestational diabetes

women’s labor and birth experiences and choices

Investigators concluded the study can inform future research on evidence gaps of need and impact in the concerns of diabetes and pregnancy.

The team also noted that risks to child’s health was the top concern in the US and Canada exercises, but it did not make the top 10 question list. However, they still consider it a highly important topic for a separate study.

“Further research is needed to provide evidence-based health care for women, with or at risk of diabetes complications, who are planning pregnancy or are pregnant, to ensure the best outcomes for them and their children in the short and long-term,” investigators wrote.

The top ten research priorities in diabetes and pregnancy according to women, support networks and healthcare professionals

Articles

A new study finds the top 10 future research priorities into diabetes and pregnancy. 

News

Diabetes

Diabetes condition center page is a comprehensive resource for clinical news and insights on diabetic and cardiometabolic diseases. This page consists of interviews, articles, podcasts, and videos on the research, treatment and development of therapies for type 1 and type 2 diabetes, as well as related endocrinological conditions and illnesses. 

Endocrinology

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Women's Health

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Study Explores Future Research Priorities in Diabetes and Pregnancy Relationship 

Association for Research in Vision and Ophthalmology (ARVO) 2021 Virtual Sessions

 this week showed baseline diabetes severity metrics were not associated with worse likelihood of 

 clearance among patients treated with anti-VEGF therapy aflibercept.

The outcomes, conducted and presented by experts from the Cleveland Clinic, helped correct preconceptions of what patient risk factors and demographic influence capability of DME clearance with the top-line drug class.

The findings also contributed to the annual meeting’s recurring topic of cardiometabolic disease influence on ophthalmic conditions including DME, a leading cause of blindness in the US.

In the second segment of an interview with 

during ARVO 2021, study author Katherin Talcott, MD, of the Cleveland Clinic’s Cole Eye Institute, discussed how the growing diabetes issue in the US will continue to affect visually-impaired patients—especially in this last year, due to COVID-19.

“I think the pandemic has been really hard for a lot of people in a lot of ways,” Talcott explained. “And a lot of our patients with diabetes who had been coming in have been lost to follow-up in the last year, and they have a lot worse macular edema or their diabetes is worse.”

Talcott advocated for more research including that presented at ARVO 2021 which sought projections of treatment response among diabetic patients, noting it’s a frequent practice by specialists to silo their practice from that of others, even when collaboration is opportune.

“I think that we all tend to, unfortunately, focus on our problem and forget about other parts of the body,” she said. “But when we see patients who have disease that’s out of control, that usually means their diabetes is not well-controlled in other reasons as well.”

She also highlighted her own team’s research into the prevalence of visual impairment in patients with diabetes who have suffered from limb loss, emphasizing the significant merging of patient needs.

“I think there’s a lot of overlap that we just don’t think about, and it’s part of the questions that we don’t think about asking,” Talcott said. “There’s definitely a lot more we could be doing to better communicate and understand how different organs are related in diabetes.”

Videos

The diabetes and ophthalmology overlap is significant and growing in the US. A Cleveland Clinic expert discusses crossover research and care.

Ophthalmology

Diabetic Macular Edema

Treating for Vision Loss in Diabetes

Association for Research in Vision and Ophthalmology (ARVO) Virtual Meeting

 showed no significant differences between dexamethasone intravitreal implant (ZURDEX) and fluocinolone acetonide intravitreal implant (ILUVIEN 0.19 mg) in terms of controlling 

However, the investigators noted other key differences, such as efficiency and costs.

Led by Didar Abdula, of Royal Surrey Hospital, UK, the investigative team primarily sought to evaluate the effects of switching from the former therapeutic option to the latter—especially considering that little data exists comparing the two implants. To do this, they retrospectively collected information from medical records and ocular coherence tomography images on patients who used who used either or both implants.

They evaluated visual acuity, central macular thickness, intraocular pressure (IOP), as well as any complications that occurred 3 months prior to or following treatment.

The primary outcomes of the study were control of inflammation, measured by visual acuity and central macular thickness, and need for rescue treatment.

Overall, a total of 14 eyes were examined from 8 patients. Analysis revealed that both treatments were effective in controlling inflammation—as evidenced by the lack of any significant changes in visual acuity before and after switching from the dexamethasone (post-treatment, visual acuity: 0.3-0.2 logMAR) to the fluocinolone acetonide intravitreal implant (post-treatment, visual acuity: 0.1-0.2).

Patients who received either treatment experienced improvements in central macular thickness. As such, those who received dexamethasone improved from an average of 374 μm pre-treatment to 317 μm at 3 months post-treatment. Those who received fluocinolone acetonide intravitreal implant improved from 348 μm to 332 μm.

However, a rise in IOP was observed in both treatment groups—patients who received dexamethasone saw a rise from 12 mmHg to 17 mg, while those who received fluocinolone acetonide saw a more pronounced rise from 14 mmHg to 24 mmHg. Further, a slower restoration of vison—as reported by patients—was noted for fluocinolone acetonide when compared with previous implants of dexamethasone.

Among patients who those who received fluocinolone acetonide, 3 patients (6 eyes) required selective laser trabeculoplasty, trabeculectomy, and glaucoma drops as treatment.

From a physician perspective, a fluocinolone acetonide injector was considered to be less efficient and more difficult to use—requiring more preparation—than a dexamethasone injector.

“Price comparison between the 2 implants is also a factor that needs considering,” Abdula and colleagues argued. They noted fluocinolone acetonide as more expensive that dexamethasone, with the former costing around £5,500 and the latter costing £870 per implant. Further, a median of 3 dexamethasone implants were required for the 3 years prior to switching, thus amounting to £2,610.

OZURDEX® (dexamethasone intravitreal implant) vs ILUVIEN® (fluocinolone acetonide intravitreal implant) 0.19 mg in non-infectious posterior uveitis (NIPU)

There were no significant differences between dexamethasone and fluocinolone acetonide intravitreal implants in controlling inflammation; however, the latter is considered more difficult to use.

Uveitis

Internal Medicine

Internal Medicine condition center page, resources on the topics of medical news and expert insight into internal medicine can be found. Content includes articles, interviews, videos, podcasts, and breaking news on internal medicine research, treatment, and drug development.

Conference

Researchers Compare Intravitreal Implants for Non-Infectious Posterior Uveitis

Prevalence of Treatment-Resistant Depression 

Current Guidelines for Managing Treatment-Resistant Depression 

A panel discussion focused on advances in the management of treatment-resistant depression and the fundamentals of certified treatment centers for the dispensing and administration of esketamine.

Peer Exchange

Evolving Management Strategies for Treatment-Resistant Depression

 With all those considerations and variables, the approach to treating depression is clearly quite complex. There are a lot of opportunities for treatment resistance. Patricia, would you like to speak to the impact on patients? How does this affect the quality of life of so many who are deemed treatment resistant?

Yes, we see it all the time. Our patients suffer when they’re not able to respond to the treatments they receive. Their quality of life is definitely affected, and it decreases. Productivity at work, family life, and social life are all aspects of their lives that are affected. More than that, we have an increased morbidity and mortality in patients with depression who are not treated. In the medical aspect, they’re experiencing much more pain. In the psychiatric realm, there’s an increase in suicidal ideation. Patients who are not treated adequately suffer. We see it every day in our practice.

 Those are great points. It’s very sad to see this human toll of treatment-resistant depression. As far as standardization to approaching this very complex set of issues, the APA [American Psychiatric Association] published guidelines for the treatment of treatment-resistant depression in 2010. Lisa, could you speak to those guidelines?

Yes. I first want to say that 2010 was a long time ago, and a lot has happened in the world of psychiatry since then. Just recently, in February 2020, the Journal of Affective Disorders published a new international consensus statement to try to replace the term treatment-resistant depression with difficult-to-treat depression for all the semantic and conceptual advantages in the way we express things in medicine and express ourselves to patients. That consensus statement in 2010 was looked at again in 2015. In 2015, they agreed on it again. In commenting on it in general, as a scope on the section where they spoke about the scope of practice, where these modalities can be chosen, with esketamine gaining ground and getting FDA approval in 2019, and now with the MDFI indication, this paper can be revisited in those 2 aspects to give psychiatrists better guidelines to practice within.

Great point. If I’m hearing you correctly, we can benefit from not only a better definition of the people we’re working with, which may better describe why they’re not benefiting from current treatments, but also updated guidelines to reflect that.

Absolutely. That’s where it lies. We are moving toward integrative care. To do that, we really need to do integrative care. Our guidelines should reflect that. We have a pretty good task force. A couple of new papers have been published that are definitely moving us toward that.

Thank you for watching this HCPLive® Peer Exchange. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your in-box.

An overview of what is currently recommended by the APA guidelines for the management of treatment-resistant depression, with insight regarding topics that need to be revisited and addressed further to help standardize care for patients. 

Dr Angelos Halaris provides clarity to the definition of treatment-resistant depression and suggests what may contribute to high prevalence rates. 

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Coronavirus

Infectious Disease

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Inflammation

COVID-19 Rates in Immune-Mediated Inflammatory Disease Patients Resemble General Population

A discussion with an investigator on how the SGLT-2 inhibitor may help affected patients.

Cardiology

Cardiology condition center page is a comprehensive resource for clinical news and insights on cardiovascular and cardiometabolic diseases. This page consists of interviews, articles, podcasts, and videos on the research, treatment and development of therapies for heart disease and cardiovascular events, as well as associated diabetes, renal failure, and more.

Could Dapagliflozin Treat Diabetic Retinopathy?

From cross-specialty collaboration to machine learning and public messaging, an expert details strategies for better eye exam and follow-up.

Improving Vision Impairment Risk Monitoring and Messaging

Up to 77% of patients maintained or improved best-corrected visual acuity at 12 month post-injection.

Data Supports Fluocinolone Acetonide Micro Implant Efficacy for Chronic DME

Hispanic and Black patients with chronic eye diseases had higher odds of missing out on appointments.

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Investigators report a low incidence rate of unscheduled or urgent visits within 7 days of injection.


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Females and older patients had higher rates of hospitalizations with CDI than males and younger patients. 

C Difficile Infection

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, IBS and IBD, Crohn's disease, and more.

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Researchers Identify Clear Trends for C Diff Hospitalizations

New data show dasiglucagon a reliable and rapid treatment in restoring plasma glucose levels. 

Clinical

Dasiglucagon Effective in Treating Hypoglycemia in Children and Adolescents with Type 1 Diabetes 

Wally Smith, MD, gives insight on using voxelotor in patients during the COVID-19 pandemic.  

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Latest Clinical News

Study Explores Future Research Priorities in Diabetes and Pregnancy Relationship

Treating for Vision Loss in Diabetes

Researchers Compare Intravitreal Implants for Non-Infectious Posterior Uveitis

Evolving Management Strategies for Treatment-Resistant Depression

Current Guidelines for Managing Treatment-Resistant Depression