Can overt diabetes mellitus be predicted by an early A1C value in gestational diabetics?

OBJECTIVE: To test the hypothesis that a hemoglobin A1C value (A1C) in early pregnancy is predictive of overt diabetes mellitus (DM) postpartum in women with gestational diabetes (GDM). STUDY DESIGN: In this case-control analysis of women with an early pregnancy diagnosis of GDM, we estimated the association between an early pregnancy A1C and subsequent diagnosis of DM. Women with a normal postpartum diabetic screen (controls) were compared against those with confirmed postpartum DM (cases). Ability of A1C levels to predict DM was examined via logistic regression analysis and corresponding receiver operating characteristic values. RESULTS: During the 10-year study period 166 women met the inclusion criteria: 140 (84%) had normal postpartum testing (controls), and 26 (16%) were diagnosed with DM (cases). The mean A1C value was significantly higher among cases than controls (6.7 vs. 5.6, p < 0.0001, SD 1.3-5). Cases had A1Cs ranging from 5.5- 11.7%, while controls had A1Cs ranging from 4.3-7.8%. The best discriminatory cut point for postpartum DM was an A1C > 5.9% (sensitivity 81%, specificity 83%, positive predictive value 47%, negative predictive value CONCLUSION: Our findings suggest that an elevated early pregnancy A1C may be predictive of overt DM. Larger studies are needed to further validate this association.

Association of Montevideo units with uterine rupture in women undergoing a trial of labor.

OBJECTIVE: To determine if an association exists between Montevideo units (MVUs) and uterine rupture in women undergoing trial of labor after cesarean (TOLAC). STUDY DESIGN: A case-control study of women who underwent a TOLAC, comparing uterine rupture (n = 9) to successful vaginal birth after cesarean (VBAC) (n = 48) and failed TOLAC (n = 35). MVUs were calculated in 12 10-minute intervals prior to uterine rupture, cesarean delivery, or complete dilation in the VBAC group. MVUs were compared between groups by Wilcoxon rank sum test. The pattern of change of MVUs over time was examined by linear regression mixed models. RESULTS: The MVUs were similar among all groups (medians ranged from 140-175 [VBAC], 145-190 [TOLAC], and 130-195 [ruptures]). The analysis of pattern of change in MVUs over time demonstrated no difference within the VBAC group (p = 0.22) or the failed TOLAC group (p = 0.87), or between groups (VBAC and rupture [p = 0.56], failed TOLAC and rupture [p = 0.37]). A post-hoc power analysis showed a mean difference of 50 MVUs (SD 45) between VBAC and rupture and 55 MVUs (SD 45) between failed TOLAC and rupture can be detected with a power of 80% at a significance of 0.05. CONCLUSION: There is no association between MVUs and uterine rupture in women undergoing a TOLAC.

Effectiveness of Implementation Strategies to Improve Adherence of Physical Therapist Treatment Choices to Clinical Practice Guidelines for Musculoskeletal Conditions: Systematic Review.

OBJECTIVE: The objective of this study was to evaluate the effectiveness of implementation strategies aimed at improving the adherence of physical therapists' treatment choices to clinical practice guidelines for a range of musculoskeletal conditions. METHODS: For this review, searches were performed in several databases combining terms synonymous with "practice patterns" and "physical therapy" until August 2019. The review included randomized controlled trials that investigated any intervention to improve the adherence of physical therapists' treatment choices to clinical practice guidelines or research evidence. Treatment choices assessed by surveys, audits of clinical notes, and treatment recording forms were the primary measures of adherence. Self-reported guideline adherence was the secondary measure. Three reviewers independently assessed risk of bias. Because of heterogeneity across studies, only a narrative synthesis of the results was performed. RESULTS: Nine studies were included. Four demonstrated a positive effect on at least 1 measure of treatment choices for low back pain and acute whiplash. One involved a comparison with no intervention, and 3 involved a comparison with another active intervention. The interventions that demonstrated a positive effect included dissemination of clinical practice guidelines, with additional elements including interactive educational meetings (3 studies), tailored interventions and monitoring of the performance of health care delivery (1 study), peer assessment (1 study), and local opinion leaders plus educational outreach visits (1 study). CONCLUSIONS: Although this review revealed limited trials evaluating interventions to increase physical therapists' use of evidence-based treatments for musculoskeletal conditions compared with no intervention, it highlighted some interventions that may be effective. IMPACT: Dissemination of clinical practice guidelines, interactive educational meetings, tailored interventions and monitoring the performance of health care delivery, peer assessment, and use of local opinion leaders plus educational outreach visits should be implemented to improve physical therapists' adherence to clinical practice guidelines for a range of musculoskeletal conditions.

A digital health intervention for cardiovascular disease management in primary care (CONNECT) randomized controlled trial.

Digital health applications (apps) have the potential to improve health behaviors and outcomes. We aimed to examine the effectiveness of a consumer web-based app linked to primary care electronic health records (EHRs). CONNECT was a multicenter randomized controlled trial involving patients with or at risk of cardiovascular disease (CVD) recruited from primary care (Clinical Trial registration ACTRN12613000715774). Intervention participants received an interactive app which was pre-populated and refreshed with EHR risk factor data, diagnoses and, medications. Interactive risk calculators, motivational messages and lifestyle goal tracking were also included. Control group received usual health care. Primary outcome was adherence to guideline-recommended medications (≥80% of days covered for blood pressure (BP) and statin medications). Secondary outcomes included attainment of risk factor targets and eHealth literacy. In total, 934 patients were recruited; mean age 67.6 (±8.1) years. At 12 months, the proportion with >80% days covered with recommended medicines was low overall and there was no difference between the groups (32.8% vs. 29.9%; relative risk [RR] 1.07 [95% CI, 0.88-1.20] p = 0.49). There was borderline improvement in the proportion meeting BP and LDL targets in intervention vs. control (17.1% vs. 12.1% RR 1.40 [95% CI, 0.97-2.03] p = 0.07). The intervention was associated with increased attainment of physical activity targets (87.0% intervention vs. 79.7% control, p = 0.02) and e-health literacy scores (72.6% intervention vs. 64.0% control, p = 0.02). In conclusion, a consumer app integrated with primary health care EHRs was not effective in increasing medication adherence. Borderline improvements in risk factors and modest behavior changes were observed.

The Safer Prescription of Opioids Tool (SPOT): A Novel Clinical Decision Support Digital Health Platform for Opioid Conversion in Palliative and End of Life Care-A Single-Centre Pilot Study.

Opioid errors are a leading cause of patient harm. Active failures in opioid dose conversion can contribute to error. Conversion is complex and is currently performed manually using tables of approximate equivalence. Apps that offer opioid dose double-checking are available but there are concerns about their accuracy and clinical validation. This study evaluated a novel opioid dose conversion app, The Safer Prescription of Opioids Tool (SPOT), a CE-marked Class I medical device, as a clinician decision support (CDS) platform. This single-centre prospective clinical utility pilot study followed a mixed methods design. Prescribers completed an initial survey exploring their current opioid prescribing practice. Thereafter prescribers used SPOT for opioid dosage conversions in parallel to their usual clinical practice, then evaluated SPOT through a survey and focus group. SPOT matched the Gold Standard result in 258 of 268 (96.3%) calculations. The 10 instances (3.7%) when SPOT did not match were due to a rounding error. Users had a statistically significant increase in confidence in prescribing opioids after using SPOT. Focus group feedback highlighted benefits in Quality Improvement and Safety when using SPOT. SPOT is a safe, reliable and validated CDS that has potential to reduce harms from opioid dosing errors.

Kinetics of calmodulin binding to calcineurin.

Calcineurin (CaN) binds Ca(2+)-saturated calmodulin (CaM) with relatively high affinity; however, an accurate steady-state K(d) value has not been determined. In this report, we describe, using steady-state and stopped-flow fluorescence techniques, the rates of association and dissociation of Ca(2+)-saturated CaM from CaN heterodimer (CaNA/CaNB) and CaNA only. The rate of Ca(2+)/CaM association was determined to be 4.6 x 10(7) M(-1)s(-1). The rate of Ca(2+)/CaM dissociation from CaN was slower than previously reported and was approximately 0.0012 s(-1). In preparations of CaNA alone (no regulatory CaNB subunit), the dissociation rate was slowed further to 0.00026 s(-1). From these data we calculate a K(d) for binding of Ca(2+)-saturated CaM to CaN of 28 pM. This K(d) is significantly lower than previously reported estimates of approximately 1 nM and indicates that CaN is one of the highest affinity CaM-binding proteins identified to date.