Michelle Russell

Rates of postpartum glucose testing after gestational diabetes mellitus.

OBJECTIVE: To estimate rates of postpartum glucose tolerance testing in women diagnosed with gestational diabetes mellitus (GDM) and to assess factors associated with testing. METHODS: This was a retrospective cohort study of 344 women with GDM who received prenatal care in a maternal diabetes clinic during 2001–2004. Rates of postpartum glucose testing were estimated from hospital, clinic, and laboratory records. Demographic, clinical (obstetric history, antenatal, and delivery), and health care information was obtained from chart review. RESULTS: Less than one half (45%) of women with GDM in our cohort underwent postpartum glucose testing—more than one third (36%) of whom had persistent abnormal glucose tolerance. After adjusting for clinical and health care characteristics, there was no independent relationship between most demographic characteristics and postpartum testing. Nor was there an association between clinical characteristics and the likelihood of being tested. Postpartum testing was strongly associated only with attendance of the postpartum visit: 54% of women who attended the visit were tested compared with 17% of women who did not attend (adjusted relative risk 3.04, 95% confidence interval 1.75–5.34, P<.001). CONCLUSION: Although persistent abnormal glucose tolerance was common in our cohort, less than half of the women were tested for it. Our data suggest that to increase rates of postpartum glucose testing, improved attendance at the postpartum visit with greater attention to testing and better continuity between antenatal and postpartum care are required. LEVEL OF EVIDENCE: II-2

Imatinib mesylate and metabolite concentrations in maternal blood, umbilical cord blood, placenta and breast milk

Treatment of maternal chronic myeloid leukemia with imatinib mesylate is avoided because of potential fetal effects. Two women with progression of disease during pregnancy required imatinib therapy. Concentrations of imatinib in maternal blood, placenta, umbilical cord blood and breast milk were 886, 2452, 0 to 157, and 596 ng/ml, respectively. Concentrations of the active metabolite CGP74588 in maternal blood, placenta, umbilical cord blood and breast milk were 338, 1462, 0 and 1513 ng/ml, respectively. As Imatinib and CGP74588 cross the mature placenta poorly, use of the drug after the first trimester may be reasonable under some circumstances. Imatinib and CGP74588 are found in breast milk, and therefore avoidance of breastfeeding is advisable.

Using Web service technologies to create an information broker: an experience report

This paper reports on our experiences with using the emerging Web service technologies and tools to create a demonstration information broker system as part of our research into information management in a distributed environment. To provide a realistic context, we chose to study the use of information in the healthcare domain, and this context sets some challenging parameters and constraints for our research and for the demonstration system. In this paper, we both report on the extent to which existing Web service technologies have proved to be mature enough to meet these requirements, and also assess their current limitations.

Screening and Diagnosis of Gestational Diabetes Mellitus

Screening, diagnosis, and treatment of gestational diabetes mellitus (GDM) are common practice, despite controversy regarding benefits. A review of the literature from 1950 to 2006 revealed 3 randomized controlled trials evaluated the treatment of GDM but 2 of these studies lacked power to detect a difference in outcomes. The single trial with sufficient power showed a 67% lower rate of serious perinatal complication (a composite of shoulder dystocia, nerve injury, fracture, and death) and a 53% lower rate of macrosomia with treatment of GDM. There are no well-designed studies evaluating screening or diagnostic strategies. Treatment of GDM may improve some neonatal and obstetric outcomes, but there is limited evidence useful for determining the best screening method or diagnostic test, strategy, and criteria. Ongoing studies may provide some evidence to guide future research and clinical practice.

Promoting evidence informed service development: a study of falls services in Cheshire

This study investigated two initiatives for preventing falls in Cheshire: public events to raise population awareness about falls and ways of preventing falls, a programme of falls assessments and falls prevention classes. Aim The study aimed to support service development by generating local learning about: the falls risk status of older people attending the public events and their use of services for preventing falls, the efficiency and effectiveness of the falls programme. Methods A local adaptation of an instrument used in similar research was administered to assess the falls risk status of older people attending the public events. This instrument captures data about the age, sex, gait, sensory deficit, falls history, current medication, medical history, mobility and living situation of respondents. Attendees were also asked about their current use of falls services. To evaluate the falls programme data were collected about the characteristics and referral sources of service users and, for users of the falls prevention classes: their mobility and balance on joining and completing the classes; their fear of falling and confidence linked to falls at the start of the classes and six months later; the number of falls they experienced in the six months before starting and after completing the classes. Findings Of the 453 attendees screened, 64.3% were at medium risk of falling or above and 34.3% had suffered previous falls. None were accessing falls prevention services. During its first year, 324 individuals were referred to the falls programme. Overall, among those individuals who provided data for analysis, there was a statistically significant improvement in the ‘clinical’ outcomes assessed and a statistically significant reduction in the occurrence of falls. The majority of respondents indicated that they achieved an improved confidence linked to falls and a reduced fear of falling. Conclusions Studies of this type can provide a valuable contribution to local learning but the characteristics of the research collaborations developed can affect study designs and the quality of the information generated. Improved contracting arrangements between service commissioners and providers may provide an opportunity to increase the rigour of local developmental studies.

Optimum timing for planned delivery of uncomplicated monochorionic and dichorionic twin pregnancies.

To the Editor: We read with interest the article by Breathnach et al on the optimum timing of planned delivery in uncomplicated twin pregnancies, in which the authors weigh the neonatal risk associated with elective delivery at each gestational age against the prospective risk of unanticipated fetal demise in ongoing pregnancies.1 We believe that the results raise questions that may benefit from additional discussion. The authors report that, among uncomplicated monochorionic twins delivered electively at 34 weeks, 35–36 weeks, and 36–37 weeks compared with those that continued beyond each gestation, the odds ratios for adverse perinatal outcomes were 13.5, 4.9, and 5.4, respectively. When using the raw frequency data presented in Table 3 in the article, we were unable to reproduce these results. According to our calculations, when comparing perinatal outcomes among elective monochorionic twin deliveries occurring at 34–34 6/7 weeks with those observed in pregnancies that were electively delivered after 34 6/7 weeks, the odds ratio for perinatal morbidity was 11.75 (95% confidence interval [CI] 1.29 –98.5, P .001). However, we found that, among monochorionic twins delivered electively between 35–35 6/7 and 36–36 6/7 weeks, there was no significantly greater risk of perinatal morbidity compared with those electively delivered later, with odds ratios of 2.27 (95% CI 0.20 to 14.67, P .33) and 2.57 (95% CI 0.32 to 20.34, P .25), respectively. The difference may be in the definitions of adverse perinatal outcome compared with perinatal morbidity, but the authors did not provide a definition of adverse perinatal outcome. The prospective risk of mortality in uncomplicated monochorionic twins at 35–35 6/7 weeks was 1.7% despite intensive monitoring, and, according to our calculations, the odds of perinatal morbidity were not significantly greater when elective delivery occurred after 35 weeks. This suggests that the optimal timing of elective delivery may be sometime after 35 weeks in uncomplicated monochorionic twin gestations.