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Volume 5, No. 11, December 2007
From Your Colleagues
Burt Attico, Phoenix
Random glucose test would have missed 5 of 6 women with GDM
OBJECTIVE: To compare the accuracy measures of the random glucose test and the 50-g glucose challenge test as screening tests for gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS: In this prospective cohort study, pregnant women without preexisting diabetes in two perinatal centers in the Netherlands underwent a random glucose test and a 50-g glucose challenge test between 24 and 28 weeks of gestation. If one of the screening tests exceeded predefined threshold values, the 75-g oral glucose tolerance test (OGTT) was performed within 1 week. Furthermore, the OGTT was performed in a random sample of women in whom both screening tests were normal. GDM was considered present when the OGTT (reference test) exceeded predefined threshold values. Receiver operating characteristic (ROC) analysis was used to evaluate the performance of the two screening tests. The results were corrected for verification bias.
RESULTS: We included 1,301 women. The OGTT was performed in 322 women. After correction for verification bias, the random glucose test showed an area under the ROC curve of 0.69 (95% CI 0.61-0.78), whereas the glucose challenge test had an area under the curve of 0.88 (0.83-0.93). There was a significant difference in area under the curve of the two tests of 0.19 (0.11-0.27) in favor of the 50-g glucose challenge test.
CONCLUSIONS: In screening for GDM, the 50-g glucose challenge test is more useful than the random glucose test.
The authors recommend that despite easy implementation, low costs, and relative high specificity, random glucose measurement should not be used as a screening test for GDM. Until superior screening alternatives become available, the 50-g glucose challenge test should be the preferred screening test for GDM.
OB/GYN CCC Editorial comment:
Glucose Challenge Better Than Random Glucose to Screen for Gestational Diabetes
Wouldn’t it be easier just to perform a random blood glucose to be able to screen or diagnose gestational diabetes mellitus (GDM) ?
Yes, it would be easier.
Unfortunately, the random glucose test would have missed 5 of 6 women with GDM.
The van Leeeuwen et al study above confirms previous literature on GDM screening
- The random glucose test would have missed 5 of 6 women with GDM.
- 2.8% had an abnormal random glucose test and 13.0% had an abnormal 50-g glucose challenge test.
- 14.1% had at least 1 abnormal test result, and 1.5% had positive screen results on both tests.
- The OGTT was performed in 24.8%, including 79.3% of those with an abnormal initial screening test.
- A total of 3.7% of women were diagnosed with GDM based on the OGTT.
- The 50-g glucose challenge test had 5 times the sensitivity of the random glucose test (70.2% vs 14.6%).
- Specificity of the random glucose test was 97.6% vs 89.1% for the 50-g glucose challenge test.
- Positive predictive value was 18.9% for the random and 19.8% for the 50-g glucose challenge test.
- Negative predictive value was 96.8% for the random glucose and 98.7% for the 50-g glucose challenge test.
- The diagnostic odds ratio was 7.0% for the random glucose and 19.4% for the 50-g glucose challenge test.
- The likelihood ratio for a normal test result was 0.88 for the random glucose and 0.33 for the 50-g glucose challenge test.
- Area under the ROC was 0.69 for the random glucose and 0.88 for the 50-g glucose challenge test.
- The 50-g glucose challenge test was a better predictor for GDM than the random glucose test based on the area under the ROC.
Though well meaning, some providers try apply the use of basal maintanence glucose levels to GDM screening. Instead these providers subject their patients to multiple other inaccurate screens, e. g., random blood glucose, fasting glucose, and 2 hour post prandial levels. In the end their patients are subject more individual venopunctures and less accruate screening.
GDM is diagnosis based on a carbohydrate challenge, not basal levels. On the other hand, management after the diagnosis has been made, is based on daily fasting and post parandial levels. We should take care not to confuse the two different processes.
van Leeuwen M, et al Comparison of accuracy measures of two screening tests for gestational diabetes mellitus. Diabetes Care. 2007 Nov;30(11):2779-84. Epub 2007 Aug 13.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17698616
Gordon Belcourt, Montana Wyoming Tribal Leaders
2007 URBAN INDIAN HEALTH REPORT
Table 2 for your quick look
Copies available from Judith.Thierry@ihs.gov
Terry Cullen, Chief Information Officer , HQE
Call for Presentation Abstracts Announced for U.S. Public Health Symposium
The Scientific Program Committee for the 2008 U.S. Public Health Service Scientific & Training Symposium has announced a Call for Presentation Abstracts for the symposium, which will be held June 9-12 at the Tucson (AZ) Convention Center. The symposium, which is organized by the PHS Commissioned Officers Foundation, attracts more than 1,000 federal, tribal, state and local public health officials each year.
Submission of abstracts are being sought for 30- and 60-minute presentations to be made during concurrent track sessions that will occur on Wednesday and Thursday. There will also be paper and poster sessions. The theme for the 2008 symposium is Public Health Strategies for the New Millennium. The tracks will focus on four themes:
- Strategies for Improving Access to Health Care in the U.S.
- Strategies for Addressing the Growing International Element of Public Health
- Strategies for Improving Public Health Preparedness and Emergency Response
- Strategies for Addressing the Impact of a Changing Environment on Public Health
The themes for the paper and poster session are wide open.
Submissions from the academic community are encouraged. The deadline for submission of presentation abstracts is December 31, 2007. Abstracts will be selected on or about February 15, 2008. Visit www.phscofevents.org for additional details or to submit.
Tony Dekker, PIMC
IHS Comprehensive Updates in Substance Abuse and Dependence (CUSAD)
Every year the IHS offers two Comprehensive Updates in Substance Abuse and
Dependence (CUSAD). The programs are approved for physicians, nurses, pharmacists
and licensed substance abuse counselors. It is usually 30 hours of CE and
IHS scholarships are available. The 2008 programs will be in Phoenix (March
2008) and probably Seattle/Tacoma (date TBA)
The programs in the past offers the DEA required OBOT waiver course.
For any questions contact Anthony Dekker at anthony.dekker@ihs.gov
Scott Giberson, HQE
HEAR ME Project: HIV/AIDS Story-Writing/Video Competition
The HEAR ME Project is again sponsoring its annual HIV/AIDS story writing competition. We need young American Indian / Alaska Native youth to share their story. Please share this within your workplace, clinics, community circles to raise awareness and open discussion. The deadline is Dec 1, 2007. Young people ages 14 to 22 are encouraged to submit their original stories, either real or made up, about vulnerability to HIV and AIDS. The HEAR ME Project has also launched a new video contest that is taking place at the same time as the annual story-writing contest. Entry forms for both contests are included as attachments to this e-mail.
Additional information on these contests may be obtained from the HEAR ME Project Web site, http://www.hearmeproject.org/
Sheila Mahoney, NIH / NICHD
Round out the VBAC debate: Two additional resources
Sheila Mahoney forwarded the citations on several peer reviewed articles on the risk of cesarean delivery vs vaginal delivery which are included in the VBAC discussion below. Below are two other resources to round out that debate.
Increased Cesareans in Women at No Medical Risk
Newsmaker Interview With Eugene Declercq, PhD
Cesarean deliveries have dramatically increased in women with no reported medical risk, according to the results of a large, cross-sectional analysis reported in the Nov. 19 Online First issue of the British Medical Journal. Undergoing a cesarean delivery when there is no medical indication raises serious questions and mandates more research on whether the risks associated with surgery outweigh the benefits in these circumstances.
This study analyzed U.S. national birth certificate data on approximately four million births each year. The investigators defined a new category of mothers at "no indicated risk," defined as mothers with singleton, full-term (37 weeks or longer), vertex presentation births who were not reported to have any medical risk factors and for whom no complications of labor or delivery were listed on the birth certificate. They then examined the increase of primary cesarean deliveries in these women from 1991 to 2001.
To learn more about the implications of this study for obstetrical practice, Medscape's Laurie Barclay interviewed lead author Eugene Declercq, PhD, a professor of obstetrics and gynecology at the Boston University School of Medicine and assistant dean for doctoral education at the Boston University School of Public Health in Massachusetts. http://www.medscape.com/viewarticle/494349
A new documentary by Ricki Lake which addresses the increasing trend towards medicalizaiton of childbirth which Sheila highly recommends
The Business of Being Born
http://www.thebusinessofbeingborn.com/
Contact Sheila Mahoney at mahoneys@MAIL.NIH.GOV
Caroline Peck, Former IHS OB/GYN
Want to improve maternal morbidity / mortality and maternal mental health?
We have an opening for a physician position (public health medical officer) at the California Department of Public Health in our Maternal Child and Adolescent Health Program. We are looking, preferably, for an OBGYN with a public health background who would work with our MCAH Programs with a particular emphasis on the issue of maternal morbidity and mortality and other related programs such as maternal mental health.
Please spread the word about this position. We are eager to find a public health physician to join our MCAH team in CA! http://jobs.spb.ca.gov/wvpos/vadmin_moreinfo.cfm?recno=336037
Contact Karen C. Ramstrom, DO, MSPH, Phone: (916) 650-0386
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OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
