Evaluating antenatal breastmilk expression outcomes: a scoping review.

BACKGROUND: Antenatal breastmilk expression (aBME) is recommended by some healthcare providers to improve lactation, breastfeeding, and newborn outcomes, particularly for women with diabetes as they face unique challenges with breastfeeding. However, there is limited evidence of the potential harms and benefits of this practice. Our objective was to conduct a scoping review to map the literature describing maternal and newborn outcomes of aBME. METHODS: We searched Medline, Embase, CINAHL, Cochrane Database of Systematic Reviews, British Library E-Theses Online Services (EThOS) database, OpenGrey, and Clinical trials.gov from inception to January 2020. Studies in English that reported on the effect of aBME on maternal and newborn outcomes, and the experiences of women who have engaged in the practice were included for screening. Titles, abstracts, and full-text articles were screened by two independent reviewers. A critical appraisal and clinical consultation were conducted. Key findings were extracted and summarized. RESULTS: We screened 659 studies and 20 met the inclusion criteria. The majority of included studies (n = 11, 55.0%) were published after 2015, and seven (35.0%) originated from Australia. Ten (50.0%) studies provided data on high-risk obstetrical populations, including those with diabetes (n = 8), overweight or obesity (n = 1), and preeclampsia (n = 1). Commonly reported outcomes included breastfeeding status at discharge or follow-up, mode of delivery, newborn blood glucose, and time to establishing full lactation. Maternal experiences were related to challenges with aBME, confidence and mastery, perceived impact, security and altruism, learning and resources, and physical symptoms as a result of aBME. The critical appraisal demonstrated limited high-quality evidence surrounding aBME. CONCLUSIONS: Our findings demonstrate increasing interest in the safety, efficacy, and acceptability of aBME. Existing studies are heterogenous with variable research questions, outcomes, study designs, and methodology. The recommendations made in this review can be used to help inform  future studies evaluating aBME.

Maternal and newborn outcomes of antenatal breastmilk expression: a scoping review protocol.

INTRODUCTION: Mothers with diabetes face unique challenges associated with breastfeeding initiation and maintenance. Antenatal breastmilk expression (BME) may be suggested to mothers, including mothers with diabetes, to improve breastfeeding, maternal, and infant outcomes postpartum. However, there have been few evaluations of the potential harms and benefits of this practice. The objective of our scoping review will be to broadly examine the literature describing maternal and infant outcomes of antenatal BME. METHODS AND ANALYSIS: This scoping review will address the research question: 'Among women who engaged in antenatal BME, what maternal and infant outcomes have been evaluated?' A search of published and unpublished studies available in English will be conducted in February 2020 using the following databases: Medline (OVID), Embase (OVID), CINAHL (EBSCOHost), and Cochrane Database of Systematic Reviews (OVID). A search of the British Library E-Theses Online Services (EThOS) database and OpenGrey will be conducted to identify relevant grey literature. This scoping review will use a five-step framework to guide the selection, extraction, and analysis of eligible studies. Clinical consultation will be included as a sixth step to our methodology. Literature reporting on the effect of antenatal BME on maternal and infant outcomes, breastfeeding initiation and duration, and the experiences of women who have engaged in the practice will be considered. The data will be summarised with attention paid to high-risk obstetrical populations such as women with diabetes. Our results will be reported as outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. ETHICS AND DISSEMINATION: Research ethics board approval will not be required due to the nature of the study's methodology. The results of this review will be disseminated through peer-reviewed publication and presentation at relevant conferences. TRAIL REGISTRATION NUMBER: Open Science Framework (osf.io/gfp2q).

Patient Perspectives on Managing Type 1 Diabetes During High-Performance Exercise: What Resources Do They Want?

OBJECTIVE: Athletes with type 1 diabetes face unique challenges that make it difficult for health care providers to offer concise recommendations for diabetes management. Moreover, little is known about patient preferences for diabetes management during high-level and competitive exercise. We undertook a qualitative study to understand patient perspectives on managing type 1 diabetes during exercise. METHODS: A qualitative design using focus groups was selected. Samples of 5-10 participants per group were recruited to participate in one of three 1.5-hour sessions focusing on experiences in managing diabetes, supports, and desired resources. Sessions were audiotaped and transcribed verbatim. Data were analyzed iteratively among team members. RESULTS: The study included 21 participants (10 male and 11 female) with a mean age of 41 years. Most participants used trial and error to manage their blood glucose around exercise. Frequent monitoring of blood glucose was a common strategy and a challenge during exercise. Hypoglycemia after exercise and adrenaline-fueled hyperglycemia during exercise were the most prevalent concerns. Most participants relied on themselves, an endocrinologist, or the Internet for support but said they would prefer to rely more on peers with type 1 diabetes and mobile apps. Peer support or mentorship was strongly supported with recommendations for moving forward. CONCLUSION: This study highlights the individualized nature of balancing glycemic control in athletes and athletes' heavy self-reliance to develop strategies. Expanding the availability of resources such as peer mentoring and mobile apps could potentially support athletes with type 1 diabetes.

Evaluation of an electronic consultation service in psychiatry for primary care providers.

BACKGROUND: This study explores the effectiveness of an electronic consultation (eConsult) service between primary care providers and psychiatry, and the types and content of the clinical questions that were asked. METHODS: This is a retrospective eConsult review study. All eConsults directed to Psychiatry from July 2011 to January 2015 by Primary care providers were reviewed. Response time and the amount of time reported by the specialist to answer each eConsult was analyzed. Each eConsult was also categorized by clinical topic and question type in predetermined categories. Mandatory post-eConsult surveys for primary care providers were analyzed to determine the number of traditional consults avoided and to gain insight into the perceived value of eConsults. RESULTS: Of the 5597 eConsults, 169 psychiatry eConsults were completed during the study period. The average response time for a specialist to a primary care provider was 2.3 days. Eighty-seven percent of clinical responses were completed by the psychiatrist in less than 15 min. The primary care providers most commonly asked clinical questions were about depressive and anxiety disorders. 88.7% of PCPs rated the eConsult service a 5 (excellent value) or 4. CONCLUSIONS: This study indicates that an eConsult psychiatry service has tremendous potential to improve access to psychiatric advice and expand the capacity to treat mental illness in primary care. Future research may include follow-up with PCPs regarding the implementation of specialist advice.

Using Clinical Questions Asked by Primary Care Providers Through eConsults to Inform Continuing Professional Development.

INTRODUCTION: Continuing professional development (CPD) offerings should address the educational needs of health care providers. Innovative programs, such as electronic consultations (eConsults), provide unique educational opportunities for practice-based needs assessment. The purpose of this study is to assess whether CPD offerings match the needs of physicians by coding and comparing session content to clinical questions asked through eConsults. METHODS: This study analyzes questions asked by primary care providers between July 2011 and January 2015 using a service that allows specialists to provide consultation over a secure web-based server. The content of these questions was compared with the CPD courses offered in the area in which these primary care providers are practicing over a similar period (2012-2014). The clinical questions were categorized by the content area. The percentage of questions asked about each content area was calculated for each of the 12 specialties consulted. CPD course offerings were categorized using the same list of content areas. Percentage of minutes dedicated to each content area was calculated for each specialty. The percentage of questions asked and the percentage of CPD course minutes for each content area were compared. RESULTS: There were numerous congruencies and discrepancies between the proportion of questions asked about a given content area and the CPD minutes dedicated to it. DISCUSSION: Traditional needs assessment may underestimate the need to address topics that are frequently the subject of eConsults. Planners should recognize eConsult questions as a valuable source of practice-associated challenges that can identify professional development needs of physicians.

Offering eConsult to Family Physicians With Patients on a Pain Clinic Wait List: An Outreach Exercise.

Wait times for many chronic pain programs in Canada range from 6 months to 2 years. This project sought to determine the interest of primary care providers (PCPs) in using an electronic consult system for patient(s) waiting for a pain consultation. This cross-sectional study was conducted at the pain clinic of a Canadian tertiary academic health sciences center. Participants were PCPs who had submitted a referral to this clinic. Referrals received between April 1, 2012, and March 31, 2014, were reviewed to determine their appropriateness for eConsult, and a letter providing information about eConsult and encouraging its use was sent to the referring PCP. Of the 585 referrals that were reviewed, 227 were appropriate for eConsult. Fifty-one (26%) of the 194 PCP responses received were positive. Technologies like eConsult may help address the growing demand for specialist advice. In addition to facilitating response to specific questions, the bidirectional nature of eConsult permits its use for educating PCPs about chronic pain treatment. Given that almost one third of responding PCPs indicated an interest in eConsult, its potential reach is vast. Additional study is needed to understand barriers to PCP acceptance and use of eConsult and the uptake of advice given.

Unique Educational Opportunities for PCPs and Specialists Arising From Electronic Consultation Services.

Health care reform should be driven by the goals of better patient experience, improved population health, lower per capita costs, and improved provider satisfaction. Electronic consultation (eConsult) services have been adopted by several jurisdictions in the United States, Canada, and Europe to improve access to specialists by primary care providers (PCPs) and are being heralded as a key component for delivery of coordinated care. The primary intent of an eConsult service is to provide PCPs with efficient, timely, direct access to specialist expertise to help guide the management of their patients, reduce the need for unnecessary face-to-face specialty consultations, and improve the quality of the initial face-to-face consultation when needed, through the preconsultative communication.In addition to improving access to care, eConsult services have been praised by PCPs and specialists for their educational value, in particular their ability to enrich practice-based learning. Less recognized, but equally important from the educational perspective, include the abilities of eConsult programs to promote reflection by PCPs and specialists, improve collegiality and professionalism between primary and specialist care, inform continuing professional development activities and maintenance of certification, and enhance training programs' teaching of effective communication and care coordination.As eConsult services become increasingly available, the medical community must leverage the educational opportunities inherent in eConsult programs to further improve the delivery of coordinated specialty care. The educational role of eConsults should be considered as a priority outcome in their evaluation and must be highlighted and optimized in next iterations of eConsult systems design.

eCONSULTS TO ENDOCRINOLOGISTS IMPROVE ACCESS AND CHANGE PRIMARY CARE PROVIDER BEHAVIOR.

OBJECTIVE: To describe the impact of an eConsult service on access to endocrinologists along with its influence on changing primary care provider (PCP) course of action and referral behaviors. METHODS: Established in 2011, the Champlain BASE (Building Access to Specialist Care via eConsult) service allows PCPs to access specialist care in lieu of traditional face-to-face referrals. We conducted a cross-sectional study of eConsult cases submitted to endocrinologists by PCPs between April 15, 2011 and January 31, 2015. Usage data and PCP responses to a mandatory closeout survey were analyzed to determine eConsult response times, PCP practice behavior, referral outcomes, and provider satisfaction. Each eConsult was coded according to clinical topic and question type based on established taxonomies. RESULTS: A total of 180 PCPs submitted 464 eConsults to endocrinology during the study period. Specialist median response time was 7 hours, with 90% of responses occurring within 3 days. PCPs received a new or additional course of action in 62% of submitted cases. An unnecessary face-to-face referral was avoided in 44% of all eConsults and in 67% of cases where the PCP initially contemplated requesting a referral. Over 95% of cases were rated at least 4 out of 5 in value for PCPs and their patients. CONCLUSION: The use of eConsult improves access to endocrinologists by providing timely, highly rated practice-changing clinical advice while reducing the need for patients to attend face-to-face office visits. ABBREVIATIONS: BASE = Building Access to Specialist Advice through eConsult PCP = primary care physician UCSF = University of California San Francisco.

Time-motion studies of internal medicine residents' duty hours: a systematic review and meta-analysis.

BACKGROUND: Since the mid-1980s, medical residents' long duty hours have been under scrutiny as a factor affecting patient safety and the work environment for the residents. After several mandated changes in duty hours, it is important to understand how residents spend their time before proposing and implementing future changes. Time-motion methodology may provide reliable information on what residents do while on duty. PURPOSE: The purpose of this study is to review all available literature pertaining to time-motion studies of internal medicine residents while on a medicine service and to understand how much of their time is apportioned to various categories of tasks, and also to determine the effects of the Accreditation Council for Graduate Medical Education (ACGME)-mandated duty hour changes on resident workflow in North America. METHODS: Electronic bibliographic databases were searched for articles in English between 1941 and April 2013 reporting time-motion studies of internal medicine residents rotating through a general medicine service. RESULTS: Eight articles were included. Residents spent 41.8% of time in patient care activities, 18.1% communicating, 13.8% in educational activities, 19.7% in personal/other, and 6.6% in transit. North American data showed the following changes after the implementation of the ACGME 2003 duty hours standard: patient care activities from 41.8% to 40.8%, communication activities from 19.0% to 22.3%, educational activities from 17.7% to 11.6%, and personal/other activities from 21.5% to 17.1%. CONCLUSION: There was a paucity of time-motion data. There was great variability in the operational definitions of task categories reported in the studies. Implementation of the ACGME duty hour standards did not have a significant effect on the percentage of time spent in particular tasks. There are conflicting reports on how duty hour changes have affected patient safety. A low proportion of time spent in educational activities deserves further study and may point to a review of the educational models used.

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.

An assessment of patient information channels and knowledge of physical activity and nutrition during pregnancy.

BACKGROUND: Excessive weight gain during pregnancy increases the risk for obesity in mother and child. Healthy eating and physical activity may help prevent excessive gestational weight gain and minimize offspring risk of developing obesity, diabetes and cardiovascular disease. Our goal was to determine the information channels used by pregnant women to obtain information on nutrition and exercise. METHODS: We collected information about their knowledge of physical activity and nutrition during pregnancy and assessed their satisfaction with this information to identify factors that may be improved upon when designing a behavioural intervention. An anonymous, voluntary questionnaire was completed by 147 pregnant women to identify the proportion who are currently receiving information about exercise from their care provider. RESULTS: The primarily Caucasian sample (age: 30.9 ± 4.2, weeks gestation: 21.4 ± 9.4) completed the survey. A total of 86% are willing to participate in a lifestyle intervention trial. Personal health and the health of their child were cited as top reasons for participation. Most women were not informed as to the importance of appropriate pregnancy-specific energy intake or made aware of their own personal healthy gestational weight gain targets. A total of 63% report receiving some form of information on physical activity during pregnancy. Of those who do not, almost all (93%) would like to receive this information from a care provider. Overall, 88% of women consider it safe to exercise when pregnant. DISCUSSION: Given their responses, nutrition and exercise information offered through a lifestyle intervention during pregnancy may increase healthy behaviours and warrants clinical investigation.

Pregnancy outcomes in diabetes subtypes: how do they compare? A province-based study of Ontario, 2005-2006.

OBJECTIVE: To ascertain differences in pregnancy outcomes between women with diabetes subtypes (type 1 [DM1], type 2 [DM2], women with gestational [GDM])] and non-diabetic women within a large Canadian population. METHODS: We performed a retrospective multi-cohort analysis of all obstetrical deliveries that occurred in the province of Ontario between April 1, 2005, and March 31, 2006. Data were extracted from the Ontario Niday Perinatal Database. RESULTS: Increased rates of major negative maternal and perinatal outcomes (i.e. preterm delivery, Caesarean section, pregnancy-induced hypertension/preeclampsia) occurred in women with DM1. Both DM1 and GDM subtypes were associated with the greatest risk of macrosomia, shoulder dystocia, and congenital anomalies. DM2 did not demonstrate an association with an increased risk of congenital malformations and stillbirth. CONCLUSION: Diabetes in pregnancy, irrespective of subtype, predisposes women to poorer outcomes than those of the general obstetric population. However, this large population analysis is consistent with previous studies in showing that the adversity remains greatest for women with type 1 diabetes.

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.

Prevalence of metabolic markers of insulin resistance in offspring of gestational diabetes pregnancies.

In utero hyperglycemia has been associated with insulin resistance (IR) in children; however, there are limited data in low-risk populations. The purpose of this study was to describe the prevalence of metabolic markers of IR in a primarily Caucasian cohort of gestational diabetes mellitus (GDM) offspring aged 7-11 yr (mean 9.1) and to correlate offspring with maternal indexes. Sixty-eight children were recruited through a follow-up study of women who participated in a randomized controlled trial of minimal intervention vs. tight glycemic control for GDM. All participants had a fasting plasma glucose (FPG), insulin, total cholesterol, high-density lipoprotein cholesterol (HDL-chol), triglyceride (TG) level, and a 2-h oral glucose tolerance test. We calculated homeostasis model assessment (HOMA) and recorded body mass index and waist circumference (WC). Criteria for metabolic syndrome for children included: FPG > 6.0 mmol/L, HDL-chol < 1.03 mmol/L, TG > 1.24 mmol/L, WC > 90% for age and gender, and 2-h glucose > 7.8 mmol/L. Among these children, 45 (66%), 17 (25%), 5 (7%), and 1 (1.5%) had zero, one, two, or three metabolic markers of IR, respectively. Hypertriglyceridemia (21%) was most prevalent, with no child having an elevated FPG. WC (p = 0.018) and TG (p = 0.005) were strong predictors of IR in the offspring after adjustment for age, gender, birthweight, family history, and maternal IR. Maternal and offspring HDL-chol, TG, WC, and HOMA but not fasting or 2-h glucose levels were significantly correlated. We conclude that metabolic markers of IR in children exposed to GDM may be present in the absence of abnormal fasting or 2-h glucose values. Screening strategies that focus on glucose levels may need to be reconsidered to institute early intervention with lifestyle changes for children at risk.

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. Maternal and fetal outcomes were similar between the two groups. Hospital length of stay was shorter in the LMWH group. There was no difference in delivery management between the two groups. There was minor bleeding in 2 women in the UFH group and none in the LMWH group. There was one recurrent VTE during treatment in each of the groups. CONCLUSION: There is no difference in complication rate between LMWH and UFH in the treatment of acute VTE in pregnancy.