The effectiveness of implementing a reminder system into routine clinical practice: does it increase postpartum screening in women with gestational diabetes?

INTRODUCTION: During regular care, women with previous gestational diabetes mellitus (GDM) rarely receive the recommended screening test for type 2 diabetes, a 2-hour oral glucose tolerance test (OGTT), in the postpartum period. The current study examined whether the implementation of a reminder system improved screening rates. METHODS: Based on our previous randomized control trial, we implemented a postpartum reminder (letter or phone call) protocol into routine care at two of three clinical sites. We verified postpartum testing by searching hospital laboratory databases and by linking to the provincial physician service claims database. The primary outcome was the proportion of patients who underwent an OGTT within 6 months of delivery. RESULTS: Women who received care in a setting using a reminder system were more likely to receive an OGTT within 6 months postpartum (28%) compared with usual care (14%). The OGTT rates for both reminder groups were lower than that found in our randomized control trial (28% vs. 60%). CONCLUSION: Although the screening rates remain low, postpartum reminders doubled screening rates using the recommended test, the OGTT.

Changes in homocysteine levels during normal pregnancy.

OBJECTIVE: The objective of this study was to determine the changes in total plasma homocysteine concentration that occur during normal pregnancy. STUDY DESIGN: In this cross-sectional study homocysteine was measured in 155 normal women in the first, second, and third trimesters and in nonpregnant controls. In addition, albumin, serum B12, serum folate, and red blood cell folate concentrations were measured and correlated to homocysteine values. RESULTS: The mean homocysteine concentration (in micromoles per liter) was 5.6 (95% confidence interval 3.9-7.3) at 8-16 weeks' gestation, 4.3 (95% confidence interval 3.5-5.3) at 20-28 weeks' gestation, 5.5 (95% confidence interval 3.3-7.5) at 36-42 weeks' gestation, and 7.9 (95% confidence interval 6.2-9.6) in the nonpregnant control group. Homocysteine was significantly lower in all 3 trimesters of pregnancy compared with nonpregnant controls (P <.001). Homocysteine levels were directly correlated with albumin levels, which decreased during pregnancy. Homocysteine concentrations were decreased in subjects taking folic acid supplementation. CONCLUSION: Serum concentrations of homocysteine decrease during pregnancy. This occurs in association with the physiologic fall in albumin during pregnancy, as well as with folic acid supplementation.

Changes in activated protein C resistance during normal pregnancy.

OBJECTIVE: The objective of this study was to determine the changes in activated protein C resistance that occur during normal pregnancy. STUDY DESIGN: In this cross-sectional study activated protein C was measured in 128 women with normal pregnancies in the first, second, and third trimesters and in nonpregnant control subjects with 24 to 39 women in each group. In addition, factor V, factor VIII, free protein S, and functional protein C were measured and correlated with activated protein C levels. Polymerase chain reaction for factor V Leiden mutation was performed. RESULTS: There was a significant fall in the activity of activated protein C in the second and third trimesters of pregnancy (p < 0.05). This was related to increased factor VIII and decreased free protein S levels (p = 0.002, R2 = 0.20). The prevalence of the factor V Leiden mutation was 7.3%. CONCLUSION: Resistance to activated protein C is increased in the second and third trimesters of pregnancy. This is related to the alterations in other coagulation proteins, a phenomenon normally occurring during pregnancy.

Bone mineral density, sex hormones, and long-term use of neuroleptic agents in men.

OBJECTIVE: To study the prevalence and severity of bone mineral loss and its relationship to sex hormone levels in men on long-term neuroleptic therapy. METHODS: Sixteen men with schizophrenia who were from 19 to 62 years old and had taken neuroleptic medication for 1 to 30 years had bone mineral density (BMD) of the lumbar spine and proximal femur measured by dual-energy x-ray absorptiometry. Results were compared with those from 16 age-matched control subjects. Serum testosterone, sex hormone-binding globulin, free testosterone index (FTI), prolactin, and pituitary gonadotropins were assayed and compared with age-matched Red Cross blood donor controls (N = 23 to 90 for the various assays). RESULTS: At the lumbar spine and at two of the three sites in the proximal femur (trochanter and Ward's triangle but not femoral neck), the BMD was lower in patients than in controls. A statistically significant increase in prolactin and sex hormone-binding globulin and a significantly decreased luteinizing hormone and FTI were found in the treated versus the control group. In the patient group, a significant inverse relationship existed between age and BMD at all sites. Lumbar spine density was related directly to FTI (r = 0.607; P=0.05) and inversely to duration of treatment (r = -0.767; P<0.001), although both correlations were accounted for mainly by age associations in multiple stepwise linear regression. Prolactin values did not correlate with either BMD or FTI. CONCLUSION: BMD was significantly lower with long-term neuroleptic use. In the lumbar spine, these changes may be related to the associated findings of decreased free testosterone and hyperprolactinemia, although the significance of other factors such as an independent drug effect, the psychiatric disease itself, and lifestyle cannot be excluded.

Measurement of human urinary prolactin as a noninvasive study tool.

We used a time-resolved solid-phase fluoroimmunoassay with a sensitivity of 25 ng/L on 40-fold-concentrated urines to measure urine prolactin (PRL) excretion. The nature of the immunoreactive material was verified to be PRL by: (a) column chromatography showing a monomeric 23-kDa peak; (b) similarity between fluoroimmunoassay and bioassay (Nb2 lymphoma cell) results; and (c) Western blot identification. In 20 normal subjects [serum PRL 6.8 (3.8-14.0) micrograms/L, median (and range)], urine PRL excretion was 0.15 (0.07-0.23) ng/h and 0.24 (0.15-0.54) micrograms/mol of creatinine. Urine values in seven hyperprolactinemic patients were all greater than the upper limit of normal. The correlation between urinary excretion rate and serum values was highly significant (r = 0.979; P < 0.001). These results indicate that a monomeric, immunologically reactive, biologically active form of PRL can be measured in urine at concentrations approximately 0.0005 that in serum. This urine PRL method may provide a practical tool for the repetitive, noninvasive study of PRL dynamics in field studies and in patients with reproductive disorders.

Partial androgen insensitivity--are all tissues equal?

Nonaromatizable androgens, administered in high doses to an adult patient with partial androgen insensitivity, failed to result in a change in phallic size despite a clear decline in SHBG and gonadotropin levels. These findings raise the question of differential tissue sensitivity to androgens. Because ancillary laboratory testing does not predict reliably the genital response, a therapeutic trial should be advocated in such cases.

Congenital adrenal hyperplasia with testicular tumors, aggression, and gonadal failure.

Bilateral testicular tumors (adrenal rests) may occur in untreated or poorly controlled congenital adrenal hyperplasia. This case report describes two unique associated phenomena: (1) psychologic disturbances similar to those seen with exogenous androgen abuse, which resolved with appropriate glucocorticoid suppression of androgen over-production by this abnormal adrenal/adrenal rest tissue; and (2) testicular failure which showed a partial, delayed recovery with corticosteroid therapy. The need for a careful history and biochemical screening for all patients with bilateral testicular tumors is reinforced.