Background Diabetes mellitus, particularly type 2 diabetes, is a major public health burden globally. Diabetes is known to be associated with several comorbidities in high-income countries. However, our understanding of these associations in low- and middle-income countries (LMICs), where the epidemiological transition is leading to a growing dual burden of non-communicable and communicable disease, is less clear. We therefore conducted an umbrella review to systematically identify, appraise and synthesise reviews reporting the association between diabetes and multiple key comorbidities in LMICs. Methods We searched Medline, Embase, Global Health, and Global Index Medicus from inception to 14 November 2020 for systematic reviews, with or without meta-analyses, of cohort, case-control or cross-sectional studies investigating the associations between diabetes and cardiovascular disease (CVD), chronic kidney disease (CKD), depression, dengue, pneumonia, and tuberculosis within LMICs. We sought reviews of studies focused on LMICs, but also included reviews with a mixture of high-income and at least two LMIC studies, extracting data from LMIC studies only. We conducted quality assessment of identified reviews using an adapted AMSTAR 2 checklist. Where appropriate, we re-ran meta-analyses to pool LMIC study estimates and conduct subgroup analyses. Results From 11 001 articles, we identified 14 systematic reviews on the association between diabetes and CVD, CKD, depression, or tuberculosis. We did not identify any eligible systematic reviews on diabetes and pneumonia or dengue. We included 269 studies from 29 LMICs representing over 3 943 083 participants. Diabetes was positively associated with all comorbidities, with tuberculosis having the most robust evidence (16 of 26 cohort studies identified in total) and depression being the most studied (186 of 269 studies). The majority (81%) of studies included were cross-sectional. Heterogeneity was substantial for almost all secondary meta-analyses conducted, and there were too few studies for many subgroup analyses. Conclusions Diabetes has been shown to be associated with several comorbidities in LMICs, but the nature of the associations is uncertain because of the large proportion of cross-sectional study designs. This demonstrates the need to conduct further primary research in LMICs, to improve, and address current gaps in, our understanding of diabetes comorbidities and complications in LMICs.

Background Water immersion during labour and birth is recognised as a means of empowering women and reducing need for analgesia. Although waterbirth is a ‘hands off’ birth, midwives are required to monitor progress and assist controlled delivery of the head. Viewing using a handheld mirror can often be restricted due to maternal position or inadequate lighting, which has implications for infection control and manual handling. There is therefore an unmet clinical need for a mirror with an inbuilt light suitable for use in waterbirths. Objectives To i) undertake a scoping exercise with midwives and expecting mothers to identify the appropriate product specifications; ii) develop and iii) test prototypes based on these specifications suitable for commercial manufacture. Design pathway and results Device specification: The device requirements were specified in consultation with midwives of different seniorities attending to their requests and experiences of waterbirths. A novel weekly electronic ‘Comic Book’ (Figure 1) was to facilitate the design process (e.g. nature of illumination, ergonomics of device) and obtain feedback to ensure ongoing engagement with our midwifery target end-users. Prototype development: Schematics and Computer Aided Drawings of potential devices (Figure 2) were used to inform the rapid prototyping techniques used to generate a Phase 1 prototype Following Phase I prototype testing and design modification, a Phase 2 prototype was developed which we are currently preparing for licensing Abstract PD.04 Figure 1 Example of a ‘Comic Book’ Abstract PD.04 Figure 2 Drawings to inform Phase 1 prototype Conclusion Using an innovative and interactive product design process, our multidisciplinary study team have developed an illuminated, flexible prototype mirror for use in waterbirths.