Hyperinsulinemia in nonobese women reporting a moderate weight gain at the beginning of menopause: a useful early measure of susceptibility to insulin resistance.

OBJECTIVE: At menopause, the frequent weight gain excess could be related to insulin resistance. This study evaluated the prevalence of hyperinsulinemia in nonobese women reporting a moderate increase in weight at the beginning of menopause. METHODS: Women who were postmenopausal for 1 to 5 years and reporting a weight gain of 5 to 15 kg were evaluated for weight, eating habits, physical activity, body circumferences, fasting blood glucose level, insulin level, and lipid profile. An oral glucose tolerance test was performed in subgroups of 21 hyperinsulinemic women and 21 normoinsulinemic women matched for age, weight, height, body mass index, and hysterectomy. RESULTS: Among 279 postmenopausal women reporting a weight gain of 8.7 +/- 4.4 kg, insulin level was increased in 49 (17.6%) women as compared with normoinsulinemic women (108.53 +/- 31.35 vs 58.96 +/- 14.52 pmol/L, respectively; P < 0.001). Differences were also found for glucose (5.24 +/- 0.37 vs 5.05 +/- 0.42 mmol/L, respectively; P = 0.003), insulin resistance as estimated by homeostasis model assessment HOMA-2-IR (2.01 +/- 0.53 vs 1.10 +/- 0.27, respectively; P < 0.001), weight (72.6 +/- 8.0 vs 69.9 +/- 7.1 kg, respectively; P = 0.023), body mass index (28.3 +/- 2.3 vs 27.2 +/- 2.3 kg/m2, respectively; P = 0.003), and waist circumference (89.8 +/- 5.8 vs 86.0 +/- 6.5 cm, respectively; P < 0.001). Triglyceride levels were higher (1.47 +/- 0.66 vs 1.17 +/- 0.61 mmol/L, respectively; P = 0.002) and high-density lipoprotein cholesterol level was lower (1.54 +/- 0.35 vs 1.72 +/- 0.42 mmol/L, respectively; P = 0.007) in the hyperinsulinemic and normoinsulinemic groups. Although insulin levels were higher in 21 hyperinsulinemic women at all times that oral glucose tolerance tests were performed, levels of glucose were also above those of 21 matched normoinsulinemic women at 1 and 2 hours and remained greater than 6.0 mmol/L at 2 hours. CONCLUSIONS: Because insulin resistance is frequently associated with weight gain in nonobese women at menopause, the measurement of fasting insulin, along with glucose, lipids, and waist circumference, may help to identify those who are at higher risk of developing glucose intolerance, metabolic syndrome, diabetes, and cardiovascular diseases and to implement early preventive measures.

Do children undergoing cancer procedures under pharmacological sedation still report pain and anxiety? A preliminary study.

OBJECTIVES: We aimed to quantify children's levels of pain and fear during needle puncture procedures in a context where intravenous sedation-analgesia seems to be effective for pain and anxiety relief. The relevance of a nonpharmacological intervention in the pharmacological regimen was evaluated. DESIGN: Fear and pain were assessed by children, parents and physicians, on a visual analog scale (VAS, 0-10 cm), before and during puncture procedures. Higher scores represented more intense pain/fear. RESULTS: During 4 consecutive months, 18 children were recruited, but four were excluded from analyses because they did not receive the full sedation regimen (midazolam/ketamine) (N = 14, mean age +/- SD: 9.9 +/- 3.4 years). Parents self-reported their own anxiety before the procedure (4.69 +/- 3.17), but no correlation was found with their children's self-reported fear. Before procedures, the children's fear was self-reported on a VAS by children (2.93 +/- 2.93), parents (4.45 +/- 2.87), and physicians (3.67 +/- 2.48). During procedures under sedation, the children's pain (1.71 +/- 2.74) did not correlate with the parents' (4.01 +/- 3.23) and physicians' (1.83 +/- 2.32) ratings. Children anticipating high levels of pain and fear on the VAS experienced higher levels of pain (r = 0.65, P < 0.05) and fear (r = 0.59, P < 0.05) during the procedures. Sixteen parents (16/18) agreed to participate with their children if a study evaluating hypnosis for pain and anxiety was conducted. CONCLUSIONS: Sedation is effective in lowering levels of fear and pain in children during procedures, but they still anticipate fear before the procedures. Parents are anxious for their children. Future hypnotic intervention could be helpful for children as well as parents to cope with anxiety during procedures.

Interventions for promoting information and communication technologies adoption in healthcare professionals.

BACKGROUND: Information and communication technologies (ICT) are defined as digital and analogue technologies that facilitate the capturing, processing, storage and exchange of information via electronic communication. ICTs have the potential to improve information management, access to health services, quality of care, continuity of services, and cost containment. Knowledge is lacking on conditions for successful ICT integration into practice. OBJECTIVES: To carry out a systematic review of the effectiveness of interventions to promote the adoption of ICT by healthcare professionals. SEARCH STRATEGY: Specific strategies, defined with the help of an information specialist, were used to search the Cochrane Effective Practice and Organisation of Care Group (EPOC) register and additional relevant databases. We considered studies published from January 1990 until October 2007. SELECTION CRITERIA: Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before/after studies (CBAs), and interrupted time series (ITS) that reported objectively measured outcomes concerning the effect of interventions to promote adoption of ICT in healthcare professionals' practices. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed each potentially relevant study for inclusion. We resolved discrepancies by discussion or a third reviewer. Two teams of two reviewers independently extracted data and assessed the quality of included studies. A meta-analysis of study outcomes was not possible, given the small number of included studies and the heterogeneity of intervention and outcomes measures. We conducted qualitative analyses, and have presented the results in a narrative format. MAIN RESULTS: Ten studies met the inclusion criteria. Nine of them were RCTs. All studies involved physicians as participants (including postgraduate trainees), and one study also included other participants. Only two studies measured patient outcomes. Searching skills and/or frequency of use of electronic databases, mainly MEDLINE, were targeted in eight studies. Use of Internet for audit and feedback, and email for provider-patient communication, were targeted in two studies. Four studies showed small to moderate positive effects of the intervention on ICT adoption. Four studies were unable to demonstrate significant positive effects, and the two others showed mixed effects. No studies looked at the long-term effect or sustainability of the intervention. AUTHORS' CONCLUSIONS: There is very limited evidence on effective interventions promoting the adoption of ICTs by healthcare professionals. Small effects have been reported for interventions targeting the use of electronic databases and digital libraries. The effectiveness of interventions to promote ICT adoption in healthcare settings remains uncertain, and more well designed trials are needed.

Printed educational materials: effects on professional practice and health care outcomes.

BACKGROUND: Printed educational materials (PEMs) are widely used passive dissemination strategies to improve knowledge, awareness, attitudes, skills, professional practice and patient outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines and appear to be the most frequently adopted method for disseminating information. OBJECTIVES: To determine the effectiveness of PEMs in improving process outcomes (including the behaviour of healthcare professionals) and patient outcomes. To explore whether the effect of characteristics of PEMs (e.g., source, content, format, mode of delivery, timing/frequency, complexity of targeted behaviour change) can influence process outcomes (including the behaviour of healthcare professionals and patient outcomes). SEARCH STRATEGY: The following electronic databases were searched up to July 2006: (a) The EPOC Group Specialised Register (including the database of studies awaiting assessment (see 'Specialised Register'under 'Group Details'); (b) The Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effectiveness; (c) MEDLINE, EMBASE, CINAHL and CAB Health. An updated search of MEDLINE was done in March 2007. SELECTION CRITERIA: We included randomised controlled trials (RCTs) , controlled clinical trials (CCT), controlled before and after studies (CBAs) and interrupted time series analyses (ITS) that evaluated the impact of printed educational materials on healthcare professionals' practice and/or patient outcomes. There was no language restriction. Any objective measure of professional performance (sch as number of tests ordered, prescriptions for a particular drug), or patient health outcomes (e.g., blood pressure, number of caesarean sections) were included. DATA COLLECTION AND ANALYSIS: Four reviewers undertook data abstraction independently using a modified version of the EPOC data collection checklist. Any disagreement was resolved by discussion among the reviewers and arbitrators. Statistical analysis was based upon consideration of dichotomous process outcomes, continuous process outcomes, patient outcome dichotomous measures and patient outcome continuous measures. We presented the results for all comparisons using a standard method of presentation where possible. We reported separately for each study the median effect size for each type of outcome, and the median of these effect sizes across studies. MAIN RESULTS: Twenty-three studies were included for this review. Evidence from this review showed that PEMs appear to have small beneficial effects on professional practice. RCTs comparing PEMs to no intervention observed an absolute risk difference median: +4.3% on categorical process outcomes (e.g., x-ray requests, prescribing and smoking cessation activities) (range -8.0% to +9.6%, 6 studies), and a relative risk difference +13.6% on continuous process outcomes (e.g., medication change, x-rays requests per practice) (range -5.0% to +26.6%, 4 studies). These findings are similar to those reported for the ITS studies, although significantly larger effect sizes were observed (relative risk difference range from 0.07% to 31%). In contrast, the median effect size was -4.3% for patient outcome categorical measures (e.g., screening, return to work, quit smoking) (range -0.4% to -4.6%, 3 studies)). Two studies reported deteriorations in continuous patient outcome data (e.g., depression score, smoking cessation attempts) of -10.0% and -20.5%. One study comparing PEMs with educational workshops observed minimal differences. Two studies comparing PEMs and education outreach did not have statistically significant differences between the groups. It was not possible to explore potential effect modifiers across studies. AUTHORS' CONCLUSIONS: The results of this review suggest that when compared to no intervention, PEMs when used alone may have a beneficial effect on process outcomes but not on patient outcomes. Despite this wide of range of effects reported for PEMs, clinical significance of the observed effect sizes is not known. There is insufficient information about how to optimise educational materials. The effectiveness of educational materials compared to other interventions is uncertain.

Variation in the psychosocial determinants of the intention to prescribe hormone therapy prior to the release of the Women's Health Initiative trial: a survey of general practitioners and gynaecologists in France and Quebec.

BACKGROUND: Theory-based approaches are advocated to improve our understanding of prescription behaviour. This study is an application of the theory of planned behaviour (TPB) with additional variables. It was designed to assess which variables were associated with the intention to prescribe hormone therapy (HT). In addition, variations in the measures across medical specialities (GPs and gynaecologists) and across countries (France and Quebec) were investigated. METHODS: A survey among 2,000 doctors from France and 1,044 doctors from Quebec was conducted. Data were collected by means of a self-administered questionnaire. A clinical vignette was used to elicit doctors' opinions. The following TPB variables were assessed: attitude, subjective norm, perceived behavioural control, attitudinal beliefs, normative beliefs and power of control beliefs. Additional variables (role belief, moral norm and practice pattern-related factors) were also assessed. A stepwise logistic regression was used to assess which variables were associated with the intention to prescribe HT. GPs and gynaecologists were compared to each other within countries and the two countries were compared within the specialties. RESULTS: Overall, 1,085 doctors from France returned their questionnaire and 516 doctors from Quebec (response rate = 54% and 49%, respectively). In the overall regression model, power of control beliefs, moral norm and role belief were significantly associated with intention (all at p < 0.0001). The models by specialty and country were: for GPs in Quebec, power of control beliefs (p < 0.0001), moral norm (p < 0.01) and cytology and hormonal dosage (both at p < 0.05); for GPs in France, power of control beliefs and role belief (both at p < 0.0001) and perception of behavioural control (p < 0.05) and cessation of menses (p < 0.01); for gynaecologists in Quebec, moral norm and power of control beliefs (both at p = 0.01); and for gynaecologists in France, power of control beliefs (p < 0.0001), and moral norm, role belief and lipid profile (all at p < 0.05). CONCLUSION: In both countries, compared with GPs, intention to prescribe HT was higher for gynaecologists. Psychosocial determinants of doctors' intention to prescribe HT varied according to the specialty and the country thus, suggesting an influence of contextual factors on these determinants.

Delayed vasectomy success in men with a first postvasectomy semen analysis showing motile sperm.

OBJECTIVE: To determine the frequency of and factors associated with delayed vasectomy success in men with first postvasectomy semen analysis showing motile sperm. DESIGN: Descriptive study. SETTING: One hospital-based family planning clinic and two private clinics from the Quebec City area, Canada. PATIENT(S): Three hundred nine men vasectomized between 1990 and 2001 and who had a first semen analysis showing motile sperm. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Vasectomy success, based on the last available semen analysis-either in the medical record or as requested for the study-and on sterility as established by a telephone-based questionnaire in 2003. RESULT(S): Among the 309 men, 174 (56.3%, 95% confidence interval 50.7%-61.7%) had delayed vasectomy success. Significant independent factors associated with delayed vasectomy success were lower sperm count in the first postvasectomy semen analysis and shorter interval between vasectomy and first postvasectomy semen analysis. CONCLUSION(S): Delayed vasectomy success occurs in more than half of men with a first postvasectomy semen analysis showing motile sperm. The decision to repeat vasectomy should not rely on a single semen analysis showing motile sperm.

Association between the length of the vas deferens excised during vasectomy and the risk of postvasectomy recanalization.

OBJECTIVE: To evaluate the association between the length of the vas deferens excised during vasectomy and the risk of recanalization. DESIGN: Nested case-control study. SETTING: Hospital-based Family Planning Clinic in Quebec City (Canada). PATIENT(S): Among 870 vasectomized men, all 47 cases of spontaneous recanalization and 188 controls whose first semen analysis showed either azoospermia (controls A) or <1 x 10(6)/mL nonmotile sperm (controls B). MAIN OUTCOME MEASURE(S): Spontaneous recanalization defined as a semen analysis showing any motile sperm 6 weeks or more after vasectomy. RESULT(S): Individual vas segments excised ranged from 5 to 20 mm in 227 (97%) of the 235 participants. The mean +/- SD of the average of both segments for each man was 12 +/- 4 mm, identical in cases and in controls. In cases and controls A, the risk ratio (95% confidence interval [CI]) of recanalization with an average of segments of <10 mm and 10-14 mm was 0.6 (0.1-2.0) and 0.6 (0.2-1.6) when compared to 15 mm or more, respectively. In cases vs. controls B, the risk ratio of recanalization was 1.6 (0.4-7.7) and 0.6 (0.2-1.7), respectively. CONCLUSION(S): In this cohort, there was no association between the length of vas segment excised and the risk of recanalization.

Risk factors for difficult delivery in nulliparas with epidural analgesia in second stage of labor.

OBJECTIVE: To identify risk factors for difficult delivery among nulliparas in the second stage of labor with continuous epidural analgesia, and to develop a multivariable model that is predictive of difficult delivery. METHODS: The database is derived from a multicenter randomized trial of delayed pushing for nulliparous women under continuous infusion epidural. Members of this cohort (n = 1862) were randomly divided into two groups: a "Model Development" and a "Model Validation" group. We used univariate and multivariable techniques to assess associations between anthropometric, sociodemographic, and obstetric variables and difficult delivery. RESULTS: With the referent defined as the category of lesser risk, the developed model showed that the risk of difficult delivery was increased for women with height less than 160 cm (odds ratio [OR] 2.1, 90% confidence interval [CI] 1.2, 3.4), prepregnancy weight greater than 65 kg (OR 1.6, 90% CI 1.0, 2.6), age greater than or equal to 35 years (OR 3.0, 90% CI 1.1, 8.1), and gestational age greater than or equal to 41 weeks (OR 1.8, 90% CI 1.1, 2.8). Induction of epidural analgesia late in labor (greater than or equal to 6 cm) was associated with a higher risk of difficult delivery than induction between 3 and 5 cm (OR 1.9, 90% CI 1.3, 2.8). An interval of greater than or equal to 360 minutes between epidural induction and full dilatation increased the risk of difficult delivery (OR 3.8, 90% CI 1.5, 9.5). Fetal station above +2 at full dilatation and a posterior fetal position were both strongly associated with difficult delivery (OR 2.7, 90% CI 1.4, 5.0, and OR 11.2, 90% CI 4.9, 25.6, respectively). For the multivariable predictive model, when the sensitivity was 57%, the specificity was 75%, and the positive predictive value was 35%. CONCLUSION: Our observations concerning maternal characteristics and obstetric variables are consistent with previous observations with the exception of time of induction of the epidural. The predictive model may be useful in defining high-risk populations for subsequent intervention studies designed to assess approaches to reduce difficult delivery.