Impact of prenatal glucose screening on the diagnosis of gestational diabetes and on pregnancy outcomes.

The authors examined the impact of universal screening on the diagnosis of gestational diabetes and its complications. All mothers and newborns registered by the Canadian Institute for Health Information from 1984 to 1996 (even-numbered fiscal years only) were included in the analysis. Over this time period, the proportion of women with gestational diabetes increased ninefold (from 0.3% to 2.7%) while the proportion with prepregnancy diabetes fell from 0.7% to 0.4%. As rates of gestational diabetes increased, a corresponding reduction in the risks of complications (polyhydramnios, amniotic cavity infection, cesarean delivery, and preeclampsia) occurred for women with gestational diabetes. The incidence of gestational diabetes fell in Metro-Hamilton (where screening was discontinued in 1989) but remained high in the rest of Ontario (where screening continued in most areas). No related temporal trends for fetal macrosomia, cesarean delivery, or other diabetes-related complications were observed, regardless of screening policy. The authors concluded that the substantial increase in gestational diabetes in Canada is an artifact caused by universal screening, with no evidence of beneficial effects on pregnancy outcomes.

Workshop to implement the baby-friendly office initiative. Effect on community physicians' offices.

OBJECTIVE: To assess the effect of a self-appraisal questionnaire and a workshop for office staff in promoting the baby-friendly office (BFO). DESIGN: A two-times-three factorial design with a delayed workshop for one of two groups: an early intervention group who attended a workshop for office staff in October 1997 (n = 23) and a late-intervention group who attended in April 1998 (n = 23). Self-appraisals were completed before the workshops by all participants in October 1997, by 37 offices in April 1998, and by 34 offices in October 1998. SETTING: Offices of family physicians and primary care pediatricians in Hamilton-Wentworth, Ont. PARTICIPANTS: Staff of 46 offices; 74% (34/46) completed all three assessments. MAIN OUTCOME MEASURES: Degree of change in implementing each of the "10 Steps to Baby-Friendly Office" and overall average BFO score received by each office. RESULTS: Of the 34 offices completing all assessments, none followed all 10 steps. Initial mean score was 4.4 steps (standard deviation 1.4, n = 46). The workshop intervention improved overall mean scores from 4.3 to 5.6 (P < .001, n = 37). Although office staff completed the BFO self-appraisal tool, it alone had no effect on scores. Areas of improvement were noted in providing information to patients and displaying posters to promote breastfeeding. Key steps, such as not advertising breast milk substitutes and not distributing free formula, did not change. CONCLUSION: The workshop effected a modest but positive change in breastfeeding promotion. The change was maintained at 6 and 12 months after the intervention.

Intrapartum care by general practitioners and family physicians. Provincial trends from 1984-1985 to 1994-1995.

OBJECTIVE: To determine provincial trends in provision of intrapartum care by general practitioners and family physicians (GP/FPs) for the 11 years from 1984 to 1995. DESIGN: Analyses of provincial Medical Care Fee-for-Service Utilization data for births from 1984-1985 to 1994-1995. SETTING: 10 provinces of Canada. MAIN OUTCOME MEASURES: Proportion of vaginal births billed by GP/FPs (expressed as total number of vaginal births billed by GP/FPs divided by total number of vaginal births). RESULTS: In 1994-1995, the proportion of vaginal births billed by GP/FPs ranged from 77.2% in British Columbia and 70.8% in Nova Scotia to 28.9% in Ontario and 23.6% in Prince Edward Island. These proportions have remained relatively high and stable during the period studied in some provinces, such as British Columbia and Nova Scotia, and have declined steadily and notably in others. CONCLUSIONS: Data show that GP/FPs' involvement in vaginal births in most Canadian provinces is decreasing. This trend demonstrates a shift in GP/FPs' practice patterns and could indicate a coming shortage of obstetrical care providers.

Airway disorders in hemifacial microsomia.

The anatomic components of hemifacial microsomia have been classified previously, but their relevance to functional abnormalities has not been stressed. In a recent review of the literature, we found that the frequency and severity of airway disorders, especially those leading to upper airway obstruction and/or obstructive sleep apnea, had not been reported. Accordingly, a retrospective study of 38 patients (21 male, 17 female), aged 6 months to 22 years (mean, 8 years 3 months) with hemifacial microsomia was undertaken to ascertain the frequency and severity of airway disorders in hemifacial microsomia. Upper airway disorders fell broadly within three categories: group I (n = 22, 58 percent) was asymptomatic for airway disturbances; group II (n = 7, 18 percent) had a medical history suspect for intermittent obstructive sleep apnea or had a perioperative apneic event; and group III (n = 9, 24 percent) had a definite history of obstructive sleep apnea or upper airway obstruction requiring tracheotomy or apnea surgery. Group III versus groups II and I had a higher incidence of bilateral involvement (33 percent versus 14 percent and none), a greater percentage of M2, M2a, M2b, and M3 mandibular deformities (88.9 percent versus 28.6 percent and 18.2 percent), more severe orbital involvement (33 percent O2 and O3 versus none in group II and 9 percent in group I), and more severe soft-tissue involvement (89 percent S2 and S3 versus 29 percent and 23 percent). Patients with more severe mandibular and orbital deformities, but not ear or vertebral abnormalities, appear at a greater risk for obstructive sleep apnea. The relationship of OMENS-Plus (extracraniofacial anomalies) to apnea was variable but was found more commonly in group II (86 percent) and group III (56 percent) than in group I (32 percent) patients. Group III patients had a higher frequency of cardiac anomalies (44 percent versus 29 percent in group II and 23 percent in group I). The incidence of obstructive sleep apnea in our population of patients with hemifacial microsomia approaches 24 percent. Patients with hemifacial microsomia should undergo routine screening for obstructive sleep apnea: a positive history warrants polysomnographic and anatomic workup.

Where do family practice patients go in case of emergency?

OBJECTIVE: To determine the annual incidence of patient-defined emergencies and patients' use of emergency services at a family medicine teaching unit. DESIGN: Cross-sectional survey. SETTING: Hospital-based family medicine teaching unit in Montreal. PARTICIPANTS: Registered patients attending a family medicine teaching unit during 11 consecutive weekdays. MAIN OUTCOME MEASURES: Annual incidence of patient-defined medical emergencies and use of emergency services at the unit. RESULTS: Eligible patients made 815 visits during the study period; 584 usable questionnaires were returned for a response rate of 71.7%. In the previous 12 months, 37% of patients reported at least one medical emergency. For their last emergency, 42% reported using at least one of the emergency services offered by the clinic. Only 19% of patients with after-hours emergencies reported using our on-call system. Although socioeconomic and clinical variables did not predict the incidence of patient-defined emergencies, multivariate analysis revealed three significant predictors for use: patients with the practice for 5 or more years were more likely to use our services, while patients 75 and older and those with emergencies after hours were less likely to use our services. CONCLUSIONS: In an urban group family practice, annual incidence of medical emergencies among registered patients was 37%. Those whose most recent emergency occurred after hours used the clinics' emergency on-call services disappointingly little.

Retention of neonatal resuscitation skills and knowledge: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: This study compared the effectiveness of two booster strategies designed to improve retention of skills and knowledge in neonatal resuscitation by family practice residents. METHODS: Residents were randomly allocated to one of three groups: video, hands on, or control. Residents in the two experimental groups received a "booster" 3-5 months after the Neonatal Resuscitation Program (NRP) course. All participants completed the follow-up test 6-8 months after taking the course. The main outcome measures consisted of the NRP written examination and the performance checklists. RESULTS: A total of 44 residents completed the study (video, n = 13; hands-on, n = 14; control, n = 17). Overall, participants had significantly lower scores at follow-up than at baseline, indicating deterioration in both neonatal skills and knowledge. Residents in the hands-on booster group made significantly fewer errors across all five checklists in life-supporting but not in lifesaving scores than those allocated to the control and video groups. CONCLUSIONS: The beneficial effect of mannequin practice or video boosters on skills and knowledge retention was less than what had been anticipated, and no benefit could be demonstrated in comparison to the control group. Deteriorating knowledge and skills remain a major concern, since boostering by hands-on or video at 3-5 months do not seem to have an impact on the retention of knowledge or lifesaving skills.

A national survey of use of obstetric procedures and technologies in Canadian hospitals: routine or based on existing evidence?

BACKGROUND: The objective of this national survey was to describe the routine use of procedures and technologies in Canadian hospitals providing maternity care, and to determine the extent to which current use was consistent with the existing evidence and recommended guidelines for maternal and newborn care. METHODS: Representatives of 572 hospitals providing maternity care across Canada were sent questionnaires in the spring and summer of 1993; 523 (91.4%) responded. The primary outcome measures consisted of the self-reported use of obstetric procedures and technologies (perineal shaves, enemas/suppositories, intravenous infusions, initial and continuous electronic fetal heart monitoring, episiotomy rates). Hospitals were grouped according to location, size (number of live births per year), and university affiliation status. RESULTS: The hospitals in the Prairie provinces, in Quebec, and in the Atlantic provinces were significantly less likely than those in Ontario to restrict their use of perineal shaves and enemas to women on admission in labor. Small hospitals were significantly more likely than large hospitals (> 1000 live births) to restrict their use of intravenous infusions, and initial and continuous electronic fetal monitoring. The university-affiliated and nonteaching hospitals were significantly less likely than the university teaching hospitals to have episiotomy rates of less than 40 percent for primiparous women. Small hospitals were more likely than large hospitals to report episiotomy rates of less than 20 percent for multiparous women. CONCLUSIONS: Considerable variations occur in the routine use of obstetric procedures and technologies in Canadian hospitals providing maternity care, according to hospital location, size, and university affiliation status. Despite the existing evidence suggesting that the routine use of these practices and procedures is both unnecessary and potentially harmful, a significant number of Canadian hospitals continued to use them routinely in 1993.