"Part of the Ritual": Exploring Patient and Physician Decision Making Regarding Anticoagulation Use in Obstetric Antiphospholipid Syndrome.

BACKGROUND: Antiphospholipid syndrome is associated with recurrent pregnancy loss. Low-molecular-weight heparin (LMWH) and/or aspirin (ASA) prophylaxis during pregnancy to prevent future loss is based on limited trial data with mixed results. OBJECTIVES: Given the clinical equipoise, we sought to understand how patients and physicians navigate the decision-making process for use of LMWH and/or ASA in pregnancy. METHODS: We interviewed 10 patients and 10 thrombosis physicians in Ottawa, Canada from January 2017 to March 2018. Patients who had ≥1 late pregnancy loss or ≥2 early losses and persistently positive antiphospholipid antibodies based on the revised Sapporo/Sydney criteria were identified in the a Thrombosis Clinic. Patients were also identified by the TIPPS Study screening logs of excluded patients. Data collection and analysis occurred iteratively, in keeping with constructivist grounded theory methodology. RESULTS: Our analysis generated three themes, present across both patient and physician interviews, which captured a patient-led decision-making experience: (1) managing high stakes, (2) accepting uncertainty, and (3) focusing on safety. Patients and physicians acknowledged the high emotional burden and what was at stake: avoiding further pregnancy loss. Patients responded to their situation by taking action (i.e., using LMWH injections became a "ritual"), whereas physicians reacted by removing themselves from the final decision by "[leaving] it up to the patient." CONCLUSION: Our findings should be considered when designing future research on studying the role for LMWH/ASA in this population, as it suggests that the perceived benefits of treatment go beyond improving pregnancy rates. Rather, patients described potential benefit from the process of taking action, even in the absence of a guaranteed good outcome.

Management and Outcomes of Maturity-Onset Diabetes of the Young in Pregnancy.

Maturity-onset diabetes of the young (MODY) is a group of monogenic disorders that accounts for 1% to 5% of diabetes. The most common mutations are those in the hepatocyte nuclear factor-1-alpha (HNF-1-alpha) and in the glucokinase (GCK) genes. Although management of MODY is well established, no guidelines currently exist for management during pregnancy. Both maternal glycemic control and fetal mutation status are factors that may influence outcomes during pregnancy. The primary aim of this project was to describe cases of MODY during pregnancy to highlight the clinical implications of management of this disorder during pregnancy. The Ottawa Hospital is the primary referral centre for high-risk obstetrical patients, including those with diabetes in pregnancy, in Ottawa, Canada. Referrals between 2008 and 2018 were reviewed and a case series of three women and five pregnancies is described. Together with the illustrative cases, a literature review of MODY in pregnancy is used to highlight clinical considerations unique to MODY in pregnancy. We describe 5 pregnancies with MODY-2 (GCK mutation) and MODY 3 (HNF-1-alpha mutation). Important issues identified included monitoring of fetal growth and individualization of maternal glycemic control, particularly in cases where fetal mutation status is unknown. Management of MODY in pregnancy is challenging and there is little evidence to guide recommendations. Fetal growth can be used to guide management of maternal glycemic targets when fetal mutation status is unknown.

Contemporary Management of the High-Risk Pulmonary Embolism: The Clot Thickens.

Pulmonary embolism (PE) is a common disease process encountered in the acute care setting. It presents on a spectrum of severity with the most severe presentations carrying a substantial risk of morbidity and mortality. In recent years, a wide range of competing treatment strategies have been proposed for the high-risk PE including new catheter-based and extracorporeal techniques, and management has become more challenging. There is currently no consensus as to the optimal approach to treatment. Contemporary management decisions are informed by the balance between the risk of deterioration and the risk of harm from intervention, within the available resources. This review will summarize the current evidence to better inform clinical decision-making in high-risk PE and highlight future directions in management.

Development and Implementation of a Diabetic Ketoacidosis Protocol for Adults With Type 1 and Type 2 Diabetes at a Tertiary Care Multicampus Hospital.

OBJECTIVES: Diabetic ketoacidosis (DKA) is associated with significant morbidity and mortality. Using standardized protocols for DKA management improves outcomes and is recommended in Diabetes Canada's clinical practice guidelines. Audits of DKA care at our institution revealed inconsistent management. We developed, piloted and evaluated a standardized DKA protocol adapted into preprinted order sets for use in the emergency department and the acute monitoring area. METHODS: The protocol was developed by an expert committee on the basis of Diabetes Canada's clinical practice guidelines, a literature review and an environmental survey. A before-and-after analysis was used. Uptake of the DKA protocol and clinical outcomes were monitored through statistical process control. RESULTS: Patients admitted postprotocol (n=55, mean age 37.9 years [SD 17.5 years], 62% male, 85% type 1 diabetes) were compared to those admitted preprotocol (n=55, mean age 43.3 years [SD 17.5 years], 53% male, 67.2% type 1 diabetes). Postimplementation, 87% of patients were managed according to the protocol. Postprotocol ordering of appropriate laboratory investigations increased, appropriate intravenous (IV) fluid resuscitation improved, continuation of IV insulin until anion gap closure increased, mean time to anion gap closure decreased and mean length of stay was reduced. Of those surveyed, 85% of nurses and 74% of physicians felt that the protocol improved patient care, and 75% of patients rated their DKA management as being satisfactory. CONCLUSIONS: Successful implementation of a standardized preprinted protocol for DKA management significantly improved best practices for DKA management and was valued by treating clinicians.

The use of eConsults to improve access to specialty care in thrombosis medicine.

INTRODUCTION: Electronic consultations (eConsults) are asynchronous, consultative electronic-based communications that are aimed to improve efficient and timely access to specialist advice. Our study aim was to evaluate the use and impact of the Canadian Champlain BASE™ (Building Access to Specialists through eConsultation) eConsult service in the specialty of thrombosis medicine. METHODS: We conducted a cross-sectional study that included descriptive statistics of provider and patient demographic information and consultative-specific data. The impact of eConsults on primary care provider (PCP) referral patterns and satisfaction was assessed using a mandatory close-out survey upon completion of each eConsult. RESULTS: There were 162 thrombosis eConsult cases completed between June 2012 and March 2016. The most common referral topics were for thrombophilia testing, management of superficial vein thrombosis, and the choice and duration of anticoagulation for venous thromboembolism. By completing an eConsult, PCPs reported 47.5% of face-to-face consultations were avoided, and 4.3% prompted a thrombosis referral that was not originally contemplated. Primary care providers' responses to a thrombosis eConsult service were overwhelmingly positive, which included appreciation for timely access for patients, expert guidance and providing additional educational opportunities. CONCLUSION: An eConsult service in thrombosis medicine improved timely access to specialist advice and potentially reduces the number of face-to-face consultations needed. Further research is needed to understand how a thrombosis eConsult service affects thrombosis clinic performance data and patient outcomes.

Guidance for the diagnosis of pulmonary embolism during pregnancy: Consensus and controversies.

Pulmonary embolism (PE) is one of the leading causes of maternal mortality despite a low incidence of PE during pregnancy. Several challenges surround the diagnosis of PE in pregnant women and the existing clinical guidelines provide weak recommendations on selecting the appropriate investigations for suspected PE in pregnancy. The purpose of this narrative review is to compare and contrast the recommendations of current clinical guidelines and review the evidence underpinning the recommendations on the evaluation of suspected PE in pregnancy. Consensus and controversies, knowledge gaps and areas requiring further research will be highlighted.

Appropriateness of Dabigatran and Rivaroxaban Prescribing for Hospital Inpatients.

BACKGROUND: Recent approval of the new oral anticoagulants dabigatran and rivaroxaban has led to rapid changes in anticoagulant prescribing practices. Postmarketing reports have highlighted safety concerns with these agents, and their use outside of evidence-based recommendations was noted at the authors' centre. OBJECTIVES: To determine the incidence of and risk factors associated with inappropriate prescribing of dabigatran and rivaroxaban. METHODS: This retrospective cohort study investigated randomly selected dabigatran or rivaroxaban prescriptions for patients admitted to a tertiary teaching hospital between January 2010 and December 2012. Appropriateness of prescribing was determined from the documented indication, drug dosage, patient's renal function, and presence of drug interactions, if applicable. RESULTS: Among a total of 321 medication orders reviewed, the incidence of inappropriate use was 31.2% (34/109) for dabigatran and 26.9% (57/212) for rivaroxaban. Of the 97 reasons for inappropriate use that were identified, the most common were prescribing for an unapproved indication (49/97 [50.5%]), concomitant prescribing of another anticoagulant (22/97 [22.7%]), and high prescribed dose (9/97 [9.3%]). The prescribing service was found to be an independent risk factor for inappropriate prescribing (p = 0.041). Corrections were made to 23.1% (21/91) of the incorrect regimens before hospital discharge. In a sensitivity analysis using calculated ideal body weight to estimate renal function, the overall incidence of inappropriate prescribing increased to 31.5% (101/321). CONCLUSIONS: The proportion of patients with inappropriate prescribing of dabigatran or rivaroxaban in clinical practice was higher than expected. Educational interventions and pharmacy-led initiatives with a focus on appropriate indications, concomitant anticoagulant prescribing, and review of dosage regimens are recommended to improve patient safety.

CONTEXTE: La récente approbation de deux nouveaux anticoagulants oraux, le dabigatran et le rivaroxaban, a mené à de rapides changements dans les habitudes de prescription pour l'anticoagulothérapie. Des rapports de pharmacovigilance ont relevé des risques pour la santé relativement à ces agents. De plus, on a noté au centre où travaillent les auteurs que ces médicaments n'étaient pas toujours utilisés selon les recommandations fondées sur des données probantes. OBJECTIFS: Déterminer quelle est l'incidence des prescriptions inadéquates de dabigatran et de rivaroxaban et quels sont les facteurs de risque qui y sont associés. MÉTHODES: La présente étude de cohorte rétrospective a examiné des ordonnances choisies au hasard de dabigatran ou de rivaroxaban, lesquelles étaient destinées à des patients admis dans un hôpital universitaire de soins tertiaires entre janvier 2010 et décembre 2012. La pertinence des prescriptions était établie à l'aide des informations consignées sur l'indication, la posologie, la fonction rénale du patient et la présence d'interactions médicamenteuses, le cas échéant. RÉSULTATS: Parmi l'ensemble des 321 ordonnances analysées, l'incidence d'utilisation inadéquate était de 31,2 % (34/109) pour le dabigatran et de 26,9 % (57/212) pour le rivaroxaban. Des 97 raisons d'utilisation inadéquate qui ont été recensées, les plus fréquentes étaient : la prescription pour une indication non approuvée (49/97 [50,5 %]), la prescription concomitante d'un autre anticoagulant (22/97 [22,7 %]) et la prescription d'une dose élevée (9/97 [9,3 %]). Le service auquel appartenait le prescripteur s'est révélé être un facteur de risque indépendant de prescription inadéquate (p = 0.041). Des corrections ont été apportées à 23,1 % (21/91) des schémas erronés avant que le congé ne soit donné. Dans une analyse de sensibilité qui s'appuyait sur le calcul du poids idéal pour estimer la fonction rénale, le taux global d'incidence de prescription inadéquate augmentait à 31,5 % (101/321). CONCLUSIONS: La proportion de patients pour qui la prescription de dabigatran ou de rivaroxaban était inadéquate dans la pratique clinique était plus élevée que prévu. Afin d'améliorer la sécurité des patients, on recommande l'adoption d'interventions éducatives et d'initiatives dirigées par les services de pharmacie qui porteront sur les indications adéquates, la prescription concomitante d'anticoagulants et la révision des schémas posologiques.

Blood pressure goals and treatment in pregnant patients with chronic kidney disease.

As the age of pregnant women and prevalence of obesity and diabetes are increasing, so is the prevalence of medical disorders during pregnancy, particularly hypertension and the associated CKD. Pregnancy can worsen kidney function in women with severe disease, and hypertension puts them at risk for pre-eclampsia and the associated complications. There are no specific guidelines for hypertension management in this population, and tight control will not prevent pre-eclampsia. Women with end-stage kidney disease should be placed on intense dialysis regimens to improve obstetric outcomes, and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are best avoided. This article will review the rationale for a management plan that includes a multidisciplinary team to discuss risks and develop a plan before conception, antepartum monitoring for maternal and fetal morbidity, individualization of medical management using medications with established records during pregnancy, and balancing the level of blood pressure control proved to protect kidney function against the potential effects that aggressive blood pressure control could have on the fetal-placental unit.

Understanding practice: factors that influence physician hand hygiene compliance.

OBJECTIVE: To identify the behavioral determinants--both barriers and enablers--that may impact physician hand hygiene compliance. DESIGN: A qualitative study involving semistructured key informant interviews with staff physicians and residents. SETTING: An urban, 1,100-bed multisite tertiary care Canadian hospital. PARTICIPANTS: A total of 42 staff physicians and residents in internal medicine and surgery. METHODS: Semistructured interviews were conducted using an interview guide that was based on the theoretical domains framework (TDF), a behavior change framework comprised of 14 theoretical domains that explain health-related behavior change. Interview transcripts were analyzed using thematic content analysis involving a systematic 3-step approach: coding, generation of specific beliefs, and identification of relevant TDF domains. RESULTS: Similar determinants were reported by staff physicians and residents and between medicine and surgery. A total of 53 specific beliefs from 9 theoretical domains were identified as relevant to physician hand hygiene compliance. The 9 relevant domains were knowledge; skills; beliefs about capabilities; beliefs about consequences; goals; memory, attention, and decision processes; environmental context and resources; social professional role and identity; and social influences. CONCLUSIONS: We identified several key determinants that physicians believe influence whether and when they practice hand hygiene at work. These beliefs identify potential individual, team, and organization targets for behavior change interventions to improve physician hand hygiene compliance.

Antepartum dalteparin versus no antepartum dalteparin for the prevention of pregnancy complications in pregnant women with thrombophilia (TIPPS): a multinational open-label randomised trial.

BACKGROUND: Thrombophilias are common disorders that increase the risk of pregnancy-associated venous thromboembolism and pregnancy loss and can also increase the risk of placenta-mediated pregnancy complications (severe pre-eclampsia, small-for-gestational-age infants, and placental abruption). We postulated that antepartum dalteparin would reduce these complications in pregnant women with thrombophilia. METHODS: In this open-label randomised trial undertaken in 36 tertiary care centres in five countries, we enrolled consenting pregnant women with thrombophilia at increased risk of venous thromboembolism or with previous placenta-mediated pregnancy complications. Eligible participants were randomly allocated in a 1:1 ratio to either antepartum prophylactic dose dalteparin (5000 international units once daily up to 20 weeks' gestation, and twice daily thereafter until at least 37 weeks' gestation) or to no antepartum dalteparin (control group). Randomisation was done by a web-based randomisation system, and was stratified by country and gestational age at randomisation day with a permuted block design (block sizes 4 and 8). At randomisation, site pharmacists (or delegates) received a randomisation number and treatment allocation (by fax and/or e-mail) from the central web randomisation system and then dispensed study drug to the local coordinator. Patients and study personnel were not masked to treatment assignment, but the outcome adjudicators were masked. The primary composite outcome was independently adjudicated severe or early-onset pre-eclampsia, small-for-gestational-age infant (birthweight <10th percentile), pregnancy loss, or venous thromboembolism. We did intention-to-treat and on-treatment analyses. This trial is registered with ClinicalTrials.gov, number NCT00967382, and with Current Controlled Trials, number ISRCTN87441504. FINDINGS: Between Feb 28, 2000, and Sept 14, 2012, 292 women consented to participate and were randomly assigned to the two groups. Three women were excluded after randomisation because of ineligibility (two in the antepartum dalteparin group and one in the control group), leaving 146 women assigned to antepartum dalteparin and 143 assigned to no antepartum dalteparin. Some patients crossed over to the other group during treatment, and therefore for on-treatment and safety analysis there were 143 patients in the dalteparin group and 141 in the no dalteparin group. Dalteparin did not reduce the incidence of the primary composite outcome in both intention-to-treat analysis (dalteparin 25/146 [17·1%; 95% CI 11·4-24·2%] vs no dalteparin 27/143 [18·9%; 95% CI 12·8-26·3%]; risk difference -1·8% [95% CI -10·6% to 7·1%)) and on-treatment analysis (dalteparin 28/143 [19·6%] vs no dalteparin 24/141 [17·0%]; risk difference +2·6% [95% CI -6·4 to 11·6%]). In safety analysis, the occurrence of major bleeding did not differ between the two groups. However, minor bleeding was more common in the dalteparin group (28/143 [19·6%]) than in the no dalteparin group (13/141 [9·2%]; risk difference 10·4%, 95% CI 2·3-18·4; p=0·01). INTERPRETATION: Antepartum prophylactic dalteparin does not reduce the occurrence of venous thromboembolism, pregnancy loss, or placenta-mediated pregnancy complications in pregnant women with thrombophilia at high risk of these complications and is associated with an increased risk of minor bleeding. FUNDING: Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, and Pharmacia and UpJohn.

Clinical predictors for diabetes screening in the first year postpartum after gestational diabetes.

BACKGROUND: Postpartum screening for diabetes in women with gestational diabetes (GDM) improves with use of reminder systems. Our primary objective was to identify predictors of diabetes screening in the first year after delivery. METHODS: A retrospective study was performed of 556 women with GDM who received outpatient prenatal care between 2007 and 2009. A mailed reminder system was utilized at two sites. Rates of postpartum glucose testing at 6 and 12 months postpartum were measured. RESULTS: Site of care and non-smoking status were identified as the only predictors of postpartum diabetes screening (p<0.001 and p = 0.02, respectively). Rates of OGTT completion at one year (38% vs. 19% p<0.001) were higher in women who attended clinics with postpartum reminders. CONCLUSIONS: The site of diabetes care in pregnancy is a major predictor of adherence to diabetes screening postpartum. Health care delivery should be considered in the development of strategies to increase screening rates.

Effectiveness of Unfractionated Heparin in Normal Saline versus Dextrose for Achieving and Maintaining Therapeutic Anti-Factor Xa Levels in Patients with Non-ST-Elevation Acute Coronary Syndrome.

BACKGROUND: Unfractionated heparin (UFH) administered by IV infusion is effective in preventing myocardial infarction and death after non-ST-elevation acute coronary syndrome. At the authors' centre, preparations of UFH in 0.9% sodium chloride (normal saline; UFH-NS) were used during a shortage of commercially available UFH in dextrose 5% in water (UFH-D5W), the usual preparation. Anecdotal observations raised concerns about the effectiveness of the saline-based preparation in achieving minimally therapeutic anticoagulation. OBJECTIVE: To compare the effectiveness of UFH-NS and UFH-D5W for achieving and maintaining therapeutic anti-factor Xa levels in patients with non-ST-elevation acute coronary syndrome. METHODS: A retrospective cohort study was conducted with 2 groups of 100 consecutive patients who received either UFH-NS or UFH-D5W for a minimum of 24 h after non-ST-elevation acute coronary syndrome in accordance with a weight-based dosing nomogram. RESULTS: A minimally therapeutic level of anti-Xa (≥ 0.31 IU/mL) was achieved within 24 h for 92% of the patients receiving UFH-D5W and 67% of those receiving UFH-NS (absolute risk difference 25%, 95% confidence interval [CI] 13.4%-36.6%; p < 0.001). Infusion of UFH-NS was associated with lower probability of achieving minimally therapeutic anticoagulation (hazard ratio [HR] 2.30, 95% CI 1.68-3.15; p < 0.001) and maintaining therapeutic anticoagulation (HR 2.31, 95% CI 1.69-3.17; p < 0.001) relative to UFH-D5W. Significant differences in the numbers of patients with subtherapeutic and therapeutic anticoagulation, favouring UFH-D5W, were observed at each of the first, second, and third anti-Xa measurements (p < 0.05). Patients receiving UFH-NS required a greater median number of adjustments to the infusion rate during the first 48 h (1.0 v. 0.5 adjustment per day, p < 0.001). There was no difference between groups in terms of major reductions in hemoglobin. CONCLUSIONS: Infusion of UFH-NS was inferior to UFH-D5W for achieving and maintaining therapeutic anticoagulation in patients with non-ST-elevation acute coronary syndrome. Until further study, saline-based heparin infusions should be used with caution, and patients should be monitored closely to ensure timely achievement and maintenance of therapeutic anticoagulation.

CONTEXTE: La perfusion intraveineuse d'héparine non fractionnée (HNF) est efficace pour prévenir l'infarctus du myocarde et la mortalité après la survenue d'un syndrome coronarien aigu sans élévation du segment ST. Au centre hospitalier des auteurs, des préparations de ce médicament dans du chlorure de sodium à 0,9 % (solution physiologique salée [SP]; HNF-SP) ont été utilisées lors d'une pénurie de solutions commercialisées d'HNF dans du dextrose à 5 % dans l'eau (HNF-D5E) d'usage habituel. Quelques observations ont soulevé des inquiétudes quant à l'efficacité des préparations à base de SP pour obtenir une anticoagulation thérapeutique minimale. OBJECTIF: Comparer l'efficacité de l'HNF dans la SP et le D5E pour obtenir et maintenir des concentrations thérapeutiques d'anti-facteur Xa chez des patients ayant subi un syndrome coronarien aigu sans élévation du segment ST. MÉTHODES: Une étude de cohorte rétrospective a été menée à partir de deux séries consécutives de 100 patients qui ont reçu de l'HNF dans une SP ou du D5E pendant un minimum de 24 heures après la survenue du syndrome coronarien aigu sans élévation du segment ST, selon un nomogramme posologique en fonction du poids. RÉSULTATS: Des concentrations thérapeutiques minimales d'anti-Xa (≥ 0,31 UI/mL) ont été obtenues en 24 heures chez 92 % des patients ayant reçu l'HNF-D5E et chez 67 % de ceux ayant reçu l'HNF-SP (différence de risque absolu de 25 %, intervalle de confiance [IC] à 95 % de 13,4 % à 36,6 %; p < 0,001). La perfusion de la préparation à base de SP a été associée à une probabilité plus faible d'obtenir une anticoagulation thérapeutique minimale (rapport de risque [RR] de 2,30, IC à 95 % de 1,68 à 3,15; p < 0,001) et de maintenir une anticoagulation thérapeutique (RR de 2,31, IC à 95 % de 1,69 à 3,17; p < 0,001) par rapport à la préparation dans du D5E. Des différences significatives dans le nombre de patients ayant obtenu une anticoagulation thérapeutique et subthérapeutique, en faveur de l'HNF-D5E, ont été observées à chacune des premières, deuxièmes et troisièmes mesures des concentrations d'anti-Xa (p < 0,05). Les patients ayant reçu l'HNF-SP ont requis un nombre médian supérieur d'ajustements de la vitesse de perfusion pendant les 48 premières heures (1,0 contre 0,5 ajustement par jour, p < 0,001). Il n'y avait aucune différence entre les groupes en termes de réductions importantes de l'hémoglobine. CONCLUSIONS: La perfusion d'HNF-SP s'est révélée inférieure à celle de l'HNF-D5E pour obtenir et maintenir une anticoagulation thérapeutique chez les patients ayant subi un syndrome coronarien aigu sans élévation du segment ST. Jusqu'à ce que d'autres études soient menées, la perfusion d'héparine dans une solution physiologique salée doit être utilisée avec circonspection et les patients doivent être surveillés étroitement afin d'assurer l'obtention en temps opportun et le maintien d'une anticoagulation thérapeutique. [Traduction par l'éditeur].

Improving physician hand hygiene compliance using behavioural theories: a study protocol.

BACKGROUND: Healthcare-associated infections affect 10% of patients in Canadian acute-care hospitals and are significant and preventable causes of morbidity and mortality among hospitalized patients. Hand hygiene is among the simplest and most effective preventive measures to reduce these infections. However, compliance with hand hygiene among healthcare workers, specifically among physicians, is consistently suboptimal. We aim to first identify the barriers and enablers to physician hand hygiene compliance, and then to develop and pilot a theory-based knowledge translation intervention to increase physicians' compliance with best hand hygiene practice. DESIGN: The study consists of three phases. In Phase 1, we will identify barriers and enablers to hand hygiene compliance by physicians. This will include: key informant interviews with physicians and residents using a structured interview guide, informed by the Theoretical Domains Framework; nonparticipant observation of physician/resident hand hygiene audit sessions; and focus groups with hand hygiene experts. In Phase 2, we will conduct intervention mapping to develop a theory-based knowledge translation intervention to improve physician hand hygiene compliance. Finally, in Phase 3, we will pilot the knowledge translation intervention in four patient care units. DISCUSSION: In this study, we will use a behavioural theory approach to obtain a better understanding of the barriers and enablers to physician hand hygiene compliance. This will provide a comprehensive framework on which to develop knowledge translation interventions that may be more successful in improving hand hygiene practice. Upon completion of this study, we will refine the piloted knowledge translation intervention so it can be tested in a multi-site cluster randomized controlled trial.

Screening for type 2 diabetes following gestational diabetes: family physician and patient perspectives.

OBJECTIVE: To explore primary care provider (PCP) and patient perspectives on postpartum screening for type 2 diabetes (T2DM), including reasons for not completing oral glucose tolerance tests (OGTTs) specifically, preferred provider for organizing screening, and value of reminder letters for facilitating screening. DESIGN: A follow-up survey, administered by fax or telephone, to PCPs and patients who participated in a randomized controlled trial assessing effectiveness of postpartum postal reminders to enhance screening for T2DM in women with gestational diabetes mellitus (GDM). SETTING: The Ottawa Hospital, a university-affiliated tertiary centre in Ottawa, Ont. PARTICIPANTS: A total of 223 female patients with previously identified GDM and their respective PCPs were surveyed; 173 PCPs and 140 patients participated. MAIN OUTCOME MEASURES: Whether or not the patient was screened for T2DM post partum, the test used for screening, the factors contributing to the patient not being screened, perspectives on the importance of screening post partum, and opinions about which care provider should be responsible for screening in the postpartum period. RESULTS: Response rates were 78% (173 of 223) for PCPs and 63% (140 of 223) for patients. Only 37% of the PCP responders had their patients complete OGTTs, while 85% of patient responders reported that they had completed OGTTs. The most common reason PCPs gave for not screening was no postpartum visit from the patient for any reason. Time pressures were the most common reason provided by patients for not being screened. More than 95% of patients and providers agreed that screening for T2DM was important. Patients and PCPs agreed that PCPs should be responsible for screening. Reminder letters were perceived as helpful by more than 85% of patients and PCPs. CONCLUSION: This follow-up survey demonstrates that PCPs and patients value the importance of screening for diabetes, identify the PCP as pivotal to screening, and appreciate a reminder strategy. There continue to be barriers that affect screening rates, despite the perceived importance of screening by PCPs and patients.

Do postal reminders increase postpartum screening of diabetes mellitus in women with gestational diabetes mellitus? A randomized controlled trial.

OBJECTIVE: Women with previous gestational diabetes mellitus rarely receive the recommended 2-hour oral glucose tolerance test (OGTT) after delivery. We sought to determine whether postal reminders to be sent after delivery to a patient, her physician, or both would increase screening rates. STUDY DESIGN: Patients were assigned randomly to 4 groups: reminders sent to both physician and patient, to physician but not patient, or to patient but not physician or no reminders were sent. The primary outcome was the proportion of patients who underwent an OGTT within 1 year after delivery. The secondary outcome was the performance of other postpartum screening tests. RESULTS: OGTT rates were significantly increased in the physician/patient reminder group (49/81 women; 60.5%), in the patient-only reminder group (42/76 women; 55.3%), and in the physician-only reminder group (16/31 women; 51.6%) compared with the no reminder group (5/35 women; 14.3%; P < .05). CONCLUSION: Postpartum reminders greatly increased screening rates for women with gestational diabetes mellitus.

Transvaginal oocyte retrieval for in vitro fertilization complicated by ovarian abscess during pregnancy.

OBJECTIVE: To describe an ovarian abscess presenting very late after oocyte retrieval for IVF with several unusual clinical features. DESIGN: Case report. SETTING: Academic medical center. PATIENT(S): A 35-year-old nulliparous woman underwent IVF with uncomplicated transvaginal oocyte retrieval (TVOR), resulting in a dizygotic twin pregnancy. At 13 weeks of pregnancy she presented with vaginal discharge, but was otherwise constitutionally well. At 30 weeks she developed a low-grade fever, and the diagnosis of ovarian abscess was made. She received broad-spectrum antibiotics, and the abscess was drained percutaneously after cesarean delivery of twins. INTERVENTION(S): Antimicrobial therapy; cesarean section; postpartum percutaneous drainage. MAIN OUTCOME MEASURE(S): Clinical and radiologic resolution of infection. RESULT(S): Complete resolution of the abscess; delivery of healthy twins. CONCLUSION(S): Infectious complications of TVOR and other surgical procedures usually occur within days of the intervention. Our case illustrates the possibility of infectious complications of TVOR presenting months after the procedure. Our patient did not become acutely ill due to the formation of a spontaneous vaginal fistula, which allowed the abscess to drain. The optimal management of this complication is unclear, but final resolution of any pelvic abscess generally requires drainage.

The bedside investigation of pulmonary embolism diagnosis study: a double-blind randomized controlled trial comparing combinations of 3 bedside tests vs ventilation-perfusion scan for the initial investigation of suspected pulmonary embolism.

BACKGROUND: We sought to determine whether using combinations of 3 bedside tests (7-variable clinical model, non-enzyme-linked immunosorbent assay D-dimer test, and alveolar dead-space fraction) to exclude pulmonary embolism (PE) before diagnostic imaging was as safe as a standard strategy of starting with ventilation-perfusion (V/Q) scan. METHODS: In this double-blind, randomized, controlled equivalency trial, patients were randomized to initial bedside tests or to initial V/Q scan without bedside tests. Patients assigned to the bedside test group had a sham V/Q scan performed if at least 2 of 3 bedside test results were negative; otherwise, they underwent an actual V/Q scan. Further diagnostic management was determined by a blinded physician after V/Q scan. The primary outcome measure was recurrent venous thromboembolic events during 3 months among patients who were not taking anticoagulant agents after the initial investigations were completed. RESULTS: Four hundred fifty-eight consecutive adults with suspected PE were eligible for the study; 398 of 399 consenting and randomized patients completed the study. The follow-up venous thromboembolic event rate was 2.4% in the bedside test group vs 3.0% in the V/Q scan group (P = .76). Pulmonary embolism was excluded in 34% (67/199) of the bedside test group patients with at least 2 negative results on 3 bedside tests vs 18% (35/199) excluded using only the 7-variable clinical model and the D-dimer test. CONCLUSION: Excluding PE with at least 2 negative results on 3 bedside tests safely eliminates the need for diagnostic imaging in 34% of patients with suspected PE.

Participation of pregnant women in clinical trials: will they participate and why?

The objective of this study is to investigate the willingness of pregnant women to participate in a randomized placebo-controlled clinical trial, and to explore the determinants of their decision making. Cross-sectional survey with semistructured interview and thematic content analysis of pregnant women in a tiertiary care obstetric outpatient clinic. Among the 50 women surveyed, 37 (74%; 95% confidence interval, 60-85%) indicated that they would be willing to participate in a randomized placebo-controlled trial of an injectable medicine given throughout pregnancy, while 5/50 (10%; 95% confidence interval, 3-22%) would decline to participate. Potential benefit to the health of the fetus was ranked as the most important determinant for willingness to participate (68%), followed by benefit to personal health (27%), and altruism (5%). A majority of pregnant women would be willing to participate in a randomized placebo-controlled clinical trial. Pregnant women appear to be willing to accept risks to themselves, if there is a chance that participation in a clinical trial would help their pregnancy and improve their baby's health.

Did publication of a clinical practice guideline recommendation to screen for type 2 diabetes in women with gestational diabetes change practice?

OBJECTIVE: To determine whether women with previous gestational diabetes mellitus (GDM) were screened postpartum for type 2 diabetes according to the Canadian Diabetes Association (CDA) guidelines. RESEARCH DESIGN AND METHODS: The 1998 CDA guidelines recommend that all women diagnosed with GDM be screened postpartum for type 2 diabetes using a 2-h 75-g oral glucose tolerance test (OGTT). The impact of and compliance with this expert opinion-based recommendation is unknown. All women who delivered at the Ottawa Hospital in 1997 (pre-guideline) and 2000 (post-guideline) with confirmed GDM were identified. Using population-based administrative databases, we determined the proportion of these women who had an OGTT, serum glucose test, or glycated hemoglobin (GHb) test in the first postpartum year. Women who had not undergone any blood work were excluded. RESULTS: There were 131 women in 1997 and 123 women in 2000 with confirmed GDM. Of these, only 69 women in 1997 and 52 women in 2000 had blood work recorded in the database. None of these women had an OGTT performed in either period. We found a significant increase in the measurement of serum glucose (50 women pre-guideline [72.1%], 48 women post-guideline [92.3%], P < 0.05) and GHb (8 women pre-guideline [11.6%], 20 women post-guideline [38.5%], P < 0.01). CONCLUSIONS: In our region, physicians are not following the CDA recommendations to screen women with GDM postpartum with an OGTT. However, we did find a significant increase in the measurement of serum glucose and GHb. Publication of expert opinion-based guidelines did not change the postpartum use of an OGTT in these women but may have increased the use of less reliable screening tests for type 2 diabetes.