Managing diabetes during pregnancy. Guide for family physicians.

OBJECTIVE: To provide a guide family physicians can use to interpret current evidence on treating women with pregestational and gestational diabetes mellitus (GDM) and to develop a model for managing these patients. QUALITY OF EVIDENCE: A MEDLINE search from January 1980 to December 2002 found randomized controlled trials (RCTs) and descriptive studies that had conflicting results regarding screening recommendations. Studies of intensive insulin therapy were predominantly large RCTs (level I evidence). Glycemic targets and guidelines for monitoring pregnant women are based primarily on consensus statements from large national societies. MAIN MESSAGE: Most pregnant women should be screened for GDM. Good glycemic control during pregnancy reduces congenital anomalies and stillbirths. Women failing to meet glycemic targets should be referred to multidisciplinary teams and considered for insulin therapy. Intensive insulin therapy reduces the risk of macrosomia and might reduce cesarean section rates and other serious outcomes. CONCLUSION: Despite controversy, family physicians can follow a plan for managing diabetic patients during pregnancy that is supported by the best available evidence.

The continuing professional development of the Canadian Society of Clinical Chemists and the Canadian Academy of Clinical Biochemists.

The Canadian Society of Clinical Chemists (CSCC) and the Canadian Academy of Clinical Biochemistry (CACB) have recently implemented a new professional development program for its 400 members. The program's goals are: to evaluate and recognize professional development based on self-determined needs, interests, and learning preferences; and to ensure that qualified professionals directing clinical biochemistry laboratories have adequate basic and current knowledge to function competently in their profession. Involvement in the program is currently voluntary and based on a 3-year cycle during which time participants must earn a minimum of 150 credits from at least 3 of 8 categories' learning activities. Of these activities: four are related to updating knowledge (Formal Group Learning related to Laboratory Medicine, Other Formal Group Learning, Self-Directed Learning, Self-Assessment); three are related to the maintenance and implementation of practice skills (Service Associated Learning, Teaching, Change in Practice); and one is related to the advancement of knowledge (Publications and Presentations). One credit is defined as one hour of continuing professional development activity. At the end of each year, members document their activities by submitting a 4 page Annual Summary of Activities (ASA) form. The cost of coordinating the program is minimal as it is administered by a steering committee and smaller working committees, all of whom are voluntary. A basic assumption of our program is that self-management of professional development (PD) is an important prerequisite and indicator of maintenance of competence. By recognizing learning through a number of activities and outcomes, it is anticipated that our program will promote an overall improvement in the quality of Laboratory Medicine throughout Canada.

Problems identified by tutors in a hybrid problem-based learning curriculum.

Problem-based learning (PBL) tutors (n = 27) were interviewed to identify problems they encountered in facilitating a hybrid PBL-lecture curriculum. Analysis of responses yielded six problems for students: "mini-lecturing," dysfunctional group dynamics, completing cases too quickly, superficial research, frustration with tutors who lack content expertise, and lack of support for PBL. These may arise because students lack problem-solving and interpersonal skills needed to benefit from PBL.

Pituitary apoplexy after anticoagulation for unstable angina.

OBJECTIVE: To describe a patient with an undiagnosed pituitary macroadenoma, in whom pituitary apoplexy developed after heparin anticoagulation for treatment of unstable angina. METHODS: We chronicle the clinical course, treatment, and outcome in a 53-year-old woman with pituitary apoplexy. Potential risk factors are also discussed. RESULTS: In a patient with coronary artery disease and unstable angina, heparin anticoagulation therapy was initiated. Shortly thereafter, severe frontal headaches, nausea and vomiting, high fever, diplopia, and visual field deficits developed. A workup for infectious causes and analysis of cerebrospinal fluid were negative. Contrast-enhanced computed tomography of the head revealed a pituitary macroadenoma with a central area of hemorrhage, and pituitary apoplexy was diagnosed. Hydrocortisone sodium succinate was administered intravenously, and ultimately, transsphenoidal resection was performed. Postoperatively, diabetes insipidus developed and persisted. Neurologically, she had near-total blindness of the right eye and temporal hemianopia of the left eye. CONCLUSION: Although pituitary apoplexy is rare, its occurrence can be associated with certain risk factors, including anticoagulation. Clinicians should be aware of this serious condition so that timely diagnosis and treatment can provide the best chance of recovery.

A survey to identify potential outcome indicators for a hospital blood glucose monitoring program.

OBJECTIVE: A survey of operators of a bedside blood glucose monitoring (BGM) program at a tertiary health care institution was performed to identify potential outcome indicators for our quality assurance program. DESIGN AND METHODS: 170 surveys were randomly distributed to each nursing unit. The survey consisted of 20 questions on 4 pages. At the time of the survey, the BGM program consisted of 514 operators and 33 blood glucose meters on 17 inpatient nursing units servicing a total of 445 hospital beds. RESULTS: Seventy-eight percent of surveys were returned. Seventy-one percent of operators used the glucose meter at least once a week, 17% used it less than once a week, and 12% used it less than once a month. When asked how often they thought operators should perform BGM to ensure reliability, 65% stated "at least monthly," 8% said "bimonthly," and 27% said "3 to 4 times a year." In the previous 3 months, 59% of operators recalled "never having to repeat a BGM measurement with the glucose meter." 56% recalled "never having to confirm a BGM result by sending a venous sample to the central laboratory," 38% recalled "sending a venous sample once or twice;" 4% recalled "three or four times;" and 2% recalled "more than four times." Fifty-two percent recalled having to perform a stat analysis "less than once per month," 37% recalled "once or twice per month," and 11% recalled "once or twice per week." CONCLUSIONS: Through this survey we obtained information from our operators about the current functioning of our BGM program. Based on this information, we were able to develop a list of potential outcome indicators that we encourage health care institutions with BGM programs to consider incorporating in their quality assurance (QA) program.

How to develop an effective decentralized laboratory testing program.

In this article, we offer practical guidelines for developing an effective decentralized laboratory testing (DLT) program. Based on more than 10 years of experience with a DLT program for bedside blood glucose monitoring, we have identified eight essential steps in this process, including: developing an effective multidisciplinary DLT committee that oversees the various DLT programs; performing a needs analysis and a cost analysis as part of the application for approval of a program from the DLT committee; instrument selection and method evaluation; and, finally, implementing a DLT program including initiating a quality assurance program. A collaborative effort by everyone from the beginning is an important key to success.