"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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The management of thrombophilia during pregnancy: a Canadian survey.

Objective: To determine current Canadian practice patterns in the management of pregnant women with thrombophilia.

Methods: Physician members of the Society of Obstetricians and Gynaecologists of Canada (SOGC) who provide obstetrical care were invited to complete a closed-ended questionnaire in which they were presented 5 clinical scenarios involving thrombophilic pregnancies and asked to give their management recommendations. The 5 scenarios presented in the survey were of a pregnant woman with (1) asymptomatic factor V Leiden (FVL), (2) asymptomatic FVL and a family history of venous thromboembolism (VTE), (3) FVL and recurrent fetal loss, (4) FVL and a previous VTE, or (5) antiphospholipid antibody syndrome and recurrent fetal loss.

Use of low molecular weight heparin in acute venous thromboembolic events in pregnancy.

Objective: To compare the maternal and neonatal outcomes arising from the use of low molecular weight heparin (LMWH) or unfractionated heparin (UFH) in the treatment of acute venous thromboembolism (VTE) in pregnancy.

Study Design: A retrospective review of the charts of all women treated for acute VTE in pregnancy at the Ottawa Hospital from January 1990 to December 1999.

Results: Twenty-three cases were identified, of which 11 were treated with LMWH and 12 with UFH.