OBJECTIVES -To investigate the frequency of severe hypoglycemia (SH) and hypoglycemic coma during the first trimester of type 1 diabetic pregnancy and in the 4 months before gestation and to identify risk indicators predicting first trimester SH in a nonselected nationwide cohort of pregnant women with type 1 diabetes.RESEARCH DESIGN AND METHODS -We conducted a longitudinal cohort survey in 278 pregnant type 1 diabetic women using questionnaires at inclusion and at 17 weeks of gestation, addressing the frequencies of SH (i.e., external help required) and hypoglycemic coma, general characteristics, hypoglycemia awareness, blood glucose symptom threshold, and the Hypoglycemia Fear Survey.RESULTS -The occurrence of SH (including hypoglycemic coma) rose from 0.9 Ϯ 2.4 episodes per 4 months before gestation to 2.6 Ϯ 6.3 episodes during the first trimester (P Ͻ 0.001), including an increase in episodes of coma from 0.3 Ϯ 1.3 to 0.7 Ϯ 3.7 (P ϭ 0.03). The proportion of women affected by SH rose from 25 to 41% (P Ͻ 0.001). First-trimester SH was independently related to a history of SH before gestation (odds ratio CONCLUSIONS -In type 1 diabetic pregnancy, the risk of SH is increased already before pregnancy and rises further during the first trimester. A history of SH before gestation, longer duration of diabetes, an HbA 1c level Յ6.5%, and a higher total daily insulin dose were risk indicators predictive for SH during the first trimester. Further research should aim to elucidate how the benefits of strict glycemic control balance with the markedly increased risk of SH early in pregnancy.[ Diabetes Care 25:554 -559, 2002

There is strong evidence that the avoidance of hyperglycemia is essential inoptimizing pregnancy outcome in type 1 diabetes. The price to pay is a striking increase in severe hypoglycemia (SH), defined as episodes requiring help from another person. During type 1 diabetic pregnancy, occurrence rates of SH up to 15 times higher as in the intensively treated group of the Diabetes Control and Complications Trial (DCCT) are reported. Blood glucose (BG) treatment targets differ considerably between clinics; some authors advocate lower limits as low as 3.3 mmol/l. Improved glycemic control and/or recurrent hypoglycemia (i.e. BG <3.9 mmol/l) may result in impairment of glucose counterregulatory responses. Also, glucose counterregulation may be altered by pregnancy itself. Short-acting insulin analogs may help reduce hypoglycemia with preservation of good glycemic control, but their use during pregnancy has yet to be proven safe.Several clinical studies did not establish an association between maternal hypoglycemia and diabetic embryopathy. However, animal studies clearly indicate that hypoglycemia is potentially teratogenic during organogenesis. Increased rates of macrosomia continue to be observed despite near normal HbA(1c) levels. This may, at least in part, be the result of rebound hyperglycemia elicited by hypoglycemia. Exposure to hypoglycemia in utero may have long-term effects on offspring including neuropsychological defects. It is yet unclear to what extent the benefits of tight glycemic control balance with the increased risk of (severe) hypoglycemia during type 1 diabetic pregnancy. Efforts must be made to avoid low BG, i.e. <3.9 mmol/l, when tightening glycemic control.

Our early experiences suggest that REVIEW can be a useful tool for addressing the hidden curriculum.

These studies suggest that a combination of classroom training, computer-based training and feedback is most effective to improve meaningful use. In addition, the training should be tailored to the needs of the trainees and they should be able to practice in their own time. However, the evidence is very limited and we recommend that governments, hospitals and other policymakers invest more in the development of evidence based educational interventions to improve meaningful use of EHRs.

This study provides a variety of practical insights into implementing mentoring processes in portfolio programmes.

Less background knowledge and a lower age than is usual for the more traditional (later) clerkships do not appear to hinder successful completion of an early clerkship. Indeed, early clerkships have several advantages, such as early observation of the future profession, increased motivation for further study, contextual learning, and improvement of clinical skills.

OBJECTIVE -The sulfonylurea (SU) glyburide may cause severe and prolonged episodes of hypoglycemia. We aimed at investigating the impact of glyburide on glucose counterregulatory hormones during stepwise hypoglycemic clamp studies.RESEARCH DESIGN AND METHODS -We performed stepwise hypoglycemic clamp studies in 16 healthy volunteers (7 women and 9 men aged 44 Ϯ 10 years). We investigated counterregulatory hormonal and symptom responses at arterialized venous plasma glucose levels (PG) of 3.8, 3.2, and 2.6 mmol/l, comparing 10 mg glyburide orally and placebo in a double-blind, randomized crossover fashion.RESULTS -The increase in plasma glucagon with time from PG ϭ 3.8 onward was smaller for glyburide than for placebo (P ϭ 0.014). Plasma glucagon area under the curve (AUC) 60 -180 was lower after glyburide than after placebo (1,774 Ϯ 715 vs. 2,161 Ϯ 856 pmol ⅐ l -1 ⅐ min, P ϭ 0.014). From PG ϭ 3.8 onward, plasma growth hormone (GH) levels with placebo were nearly two times (1.9 [95% CI 1.2-2.9]) as high as with glyburide (P ϭ 0.011). AUC 60 -180 for GH was lower after glyburide than after placebo (geometric mean [range] 665 [356 -1,275] and 1,058 [392-1,818] mU ⅐ l -1 ⅐ min, respectively; P ϭ 0.04). No significant differences were observed for plasma cortisol, epinephrine and norepinephrine, or incremental symptom scores.CONCLUSIONS -The SU glyburide induces multiple defects in glucose counterregulatory hormonal responses, notably decreases in both glucagon and GH release. Diabetes Care 25:107-112, 2002

Physicians have many information needs that arise at the point of care yet go unmet for a variety of reasons, including uncertainty about which information resources to select. In this study, we aimed to identify the various types of physician information needs and how these needs relate to physicians’ use of the database PubMed and the evidence summary tool UpToDate. We conducted semi-structured interviews with physicians (Stanford University, United States; n = 13; and University Medical Center Utrecht, the Netherlands; n = 9), eliciting participants’ descriptions of their information needs and related use of PubMed and/or UpToDate. Using thematic analysis, we identified six information needs: refreshing, confirming, logistics, teaching, idea generating and personal learning. Participants from both institutions similarly described their information needs and selection of resources. The identification of these six information needs and their relation to PubMed and UpToDate expands upon previously identified physician information needs and may be useful to medical educators designing evidence-based practice training for physicians.