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Older adults face several challenges when accessing specialist care. Advanced practice nurses (APNs) can perform an important role in primary care for older adults, particularly when bolstered with digital tools. In the current study, we conducted a multiple case study of electronic consultations (eConsults) involving APNs to assess how these practitioners use the service to improve access to care. All eConsults submitted by or to an APN in 2019 on behalf of patients aged ≥65 years were reviewed to identify examples from six settings representative of the range of advanced nursing practices. For each setting, a final case was chosen using an iterative process and stratified by specialty and type of advice. Included cases were assessed using a conceptual framework for health care access. Selected cases illustrate how APNs can be effective users of eConsults in a diversity of health care settings. The framework allowed for an in-depth study of access over the range of interactions that take place among patients, caregivers, providers, and the health care system. [Journal of Gerontological Nursing, 48(4), 33–40.], The global population is aging and, by 2050, the United Nations (UN Department of Economic and Social Affairs, 2019) estimates that the number of persons aged ≥80 years will triple. [...]

Canadians take pride in their universal, publicly funded health care system. However, lengthy wait times to see a specialist are a problem. A recent Ontario-based study found that that the [...]

OBJECTIVE--There is evidence of gut barrier and immune system dysfunction in some patients with type 1 diabetes, possibly linked with exposure to dietary wheat polypeptides (WP). However, questions arise regarding the frequency of abnormal immune responses to wheat and their nature, and it remains unclear whether such responses are diabetes specific. RESEARCH DESIGN AND METHODS--In type 1 diabetic patients and healthy control subjects, the immune response of peripheral CD[3.sup.+] T-cells to WPs, ovalbumin, gliadin, α-gliadin 33-mer peptide, tetanus toxoid, and phytohemagglutinin was measured using a carboxyfluorescein diacetate succinimidyl ester (CFSE) proliferation assay. T-helper cell type 1 (Thl), Th2, and Th17 cytokines were analyzed in WP-stimulated peripheral blood mononuclear cell (PBMNC) supernatants, and HLA was analyzed by PCR. RESULTS--Of 42 patients, 20 displayed increased CD[3.sup.+] T-cell proliferation to WPs and were classified as responders; proliferative responses to other dietary antigens were less pronounced. WP-stimulated PBMNCs from patients showed a mixed proinflammatory cytokine response with large amounts of IFN-γ, IL-17A, and increased TNF. HLA-DQ2, the major celiac disease risk gene, was not significantly different. Nearly all responders carried the diabetes risk gene HLA-DR4. Anti-DR antibodies blocked the WP response and inhibited secretion of Thl and Th17 cytokines. High amounts of WP-stimulated IL-6 were not blocked. CONCLUSIONS--T-cell reactivity to WPs was frequently present in type 1 diabetic patients and associated with HLA-DR4 but not HLA-DQ2. The presence of an HLA-DR-restricted Thl and Thl7 response to WPs in a subset of patients indicates a diabetes-related inflammatory state in the gut immune tissues associated with defective oral tolerance and possibly gut barrier dysfunction. Diabetes 58:1789-1796, 2009, The gastrointestinal tract contains the largest collection of immune ceils in the body. In healthy individuals, the gut immune system does not normally mount an immune response against molecules from [...]

OBJECTIVE -- To determine whether women with previous gestational diabetes mellitus (GDM) were screened postpartum for type 2 diabetes according to the Canadian Diabetes Association (CDA) guidelines. RESEARCH DESIGN AND [...]

Blood levels of an amino acid called homocysteine decrease during pregnancy. Folic acid supplements can cause this, and it is also associated with a drop in blood levels of albumin.

Byline: Mark C. Walker, Graeme N. Smith, Sherry L. Perkins, Erin J. Keely, Peter R. Garner Keywords: Homocysteine; medical complications of pregnancy; thrombophilia; folic acid; albumin; vitamin B.sub.12 Abstract: 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 B.sub.12 , 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. (Am J Obstet Gynecol 1999;180:660-4.) Author Affiliation: Ottawa and Toronto, Ontario, Canada From the Departments of Obstetrics and Gynaecology,.sup.a Pathology and Laboratory Medicine,.sup.b and Medicine,.sup.c University of Ottawa, and the Department of Obstetrics and Gynaecology, University of Toronto..sup.d Article History: Received 14 August 1998; Revised 9 November 1998; Accepted 23 November 1998 Article Note: (footnote) [star] Supported by the Physician Services Incorporated Foundation., [star][star] Reprint requests: Mark C. Walker, MD, Mt Sinai Hospital, 600 University Ave, Suite 775B, Toronto, Ontario, Canada M5G 1X9., a 0002-9378/99 $8.00 + 0 6/1/96050

Preliminary results indicate that intensive treatment for pregnant women with gestational diabetes does not seem to significantly affect birth complications. Three hundred women with gestational diabetes were either given routine obstetric care (control group) or monitored closely by diabetic specialists (study group). Glucose levels before and after meals were lower in the study group during the last trimester compared to the control group. The study group delivered slightly but not significantly smaller infants. Cesarean and vaginal delivery rates were similar for both groups.

The blood of women with uncomplicated pregnancies appears to develop an increasing tendency to clot as measured by resistance to activated protein C. Blood samples of 128 women with uncomplicated pregnancies were tested for activated protein C resistance and other clotting factors during each trimester and compared with blood samples from healthy non-pregnant volunteers. Protein C resistance increased as the pregnancies progressed. This resistance was accompanied by changes in other clotting factors including a lowered free protein S count and increased factor VIII count.

Byline: Peter Garner, Nan Okun, Erin Keely, George Wells, Sherry Perkins, Jacques Sylvain, Judy Belcher Keywords: Gestational diabetes; intensive treatment; neonatal outcome Abstract: OBJECTIVES: The purpose of this study was to determine whether strict maternal glycemic control for the treatment of gestational diabetes lessened the risk of fetal macrosomia, birth trauma, neonatal hypoglycemia, and operative delivery. The aim of the pilot study was to prepare for a multicenter trial by assessing patient acceptance of the study, by determining realistic accrual rates, and by detecting any major adverse outcomes in the control group that received routine obstetric care. STUDY DESIGN: The study was a prospective randomized controlled trial comparing fetal-neonatal and maternal outcomes in 300 women with gestational diabetes. Women randomized to the treatment arm were managed by strict glycemic control and tertiary level obstetric care, and women in the control arm received routine obstetric care. RESULTS: Three hundred women with gestational diabetes mellitus were studied. There was no difference in maternal age, weight, or length of gestation between groups. The treatment mean birth weight was 3437 [+ or -] 575 gm compared with 3544 [+ or -] 601 gm in the control group, a difference of 107 gm (not significant). Macrosomia rates were similar. There was no birth trauma in either group. The frequency of neonatal hypoglycemia and other metabolic complications was the same. The mode of delivery also showed similar patterns. The treatment group had significantly lower preprandial and postprandial glucose levels by 32 weeks' gestation, which continued to term. CONCLUSION: This pilot study suggests that intensive treatment of gestational diabetes mellitus may have little effect on birth weight, birth trauma, operative delivery, or neonatal metabolic disorders. It has demonstrated the safety of proceeding to a multicenter trial of sufficient sample size to confirm these findings.(Am J Obstet Gynecol 1997;177:190-5) Author Affiliation: Ottawa, Ontario, Canada Article History: Received 22 August 1996; Revised 31 January 1997; Accepted 20 February 1997 Article Note: (footnote) [star] From the Departments of Obstetrics and Gynecologya and Medicine,b the Clinical Epidemiology Unit,c and the Division of Biochemistry,d University of Ottawa, Ottawa Civic and Ottawa General Hospitals, and the Department of Obstetrics and Gynecology, University of Alberta.e , [star][star] Reprint requests: Peter Garner, MD, Department of Obstetrics and Gynecology, University of Ottawa, Room 505, Civic Parkdale Clinic, Ottawa Civic Hospital, Carling Ave., Ottawa, Ontario, Canada K1Y 4E9., a 6/1/81385

Byline: Mark C. Walker, Peter R. Garner, Erin J. Keely, Gail A. Rock, Marciano D. Reis Keywords: Activated protein C resistance; medical complications of pregnance; thrombophilia Abstract: 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, R.sup.2 = 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. (Am J Obstet Gynecol 1997;177:162-9.) Author Affiliation: Ottawa, Ontario, Canada Article History: Received 18 November 1997; Revised 25 February 1997; Accepted 10 March 1997 Article Note: (footnote) [star] From the Department of Obstetrics and Gynecologya and the Department of Medicine,b University of Ottawa, and the Department of Pathology, University of Toronto.c , [star][star] Reprint requests: Peter R. Garner, MD, MSc, Department of Obstetrics and Gynecology, Civic Parkdale Cinic, Room 505, 737 Parkdale Ave., Ottawa, Ontario, Canada K1Y 1S8., a 6/1/81733

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/S0002-9378(97)70456-3 Byline: Mark C. Walker, Peter R. Garner, Erin J. Keely, Gail A. Rock, Marciano D. Reis Keywords: Activated protein C resistance; medical complications of pregnance; thrombophilia Abstract: 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, R.sup.2 = 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. (Am J Obstet Gynecol 1997;177:162-9.) Author Affiliation: Ottawa, Ontario, Canada Article History: Received 18 November 1996; Revised 25 February 1997; Accepted 10 March 1997 Article Note: (footnote) [star] From the Department of Obstetrics and Gynecologya and the Department of Medicine,b University of Ottawa, and the Department of Pathology, University of Toronto.c , [star][star] Reprint requests: Peter R. Garner, MD, MSc, Department of Obstetrics and Gynecology, Civic Parkdale Cinic, Room 505, 737 Parkdale Ave., Ottawa, Ontario, Canada K1Y 1S8., a 6/1/81733

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/S0002-9378(97)70461-7 Byline: Peter Garner, Nan Okun, Erin Keely, George Wells, Sherry Perkins, Jacques Sylvain, Judy Belcher Keywords: Gestational diabetes; intensive treatment; neonatal outcome Abstract: OBJECTIVES: The purpose of this study was to determine whether strict maternal glycemic control for the treatment of gestational diabetes lessened the risk of fetal macrosomia, birth trauma, neonatal hypoglycemia, and operative delivery. The aim of the pilot study was to prepare for a multicenter trial by assessing patient acceptance of the study, by determining realistic accrual rates, and by detecting any major adverse outcomes in the control group that received routine obstetric care. STUDY DESIGN: The study was a prospective randomized controlled trial comparing fetal-neonatal and maternal outcomes in 300 women with gestational diabetes. Women randomized to the treatment arm were managed by strict glycemic control and tertiary level obstetric care, and women in the control arm received routine obstetric care. RESULTS: Three hundred women with gestational diabetes mellitus were studied. There was no difference in maternal age, weight, or length of gestation between groups. The treatment mean birth weight was 3437 [+ or -] 575 gm compared with 3544 [+ or -] 601 gm in the control group, a difference of 107 gm (not significant). Macrosomia rates were similar. There was no birth trauma in either group. The frequency of neonatal hypoglycemia and other metabolic complications was the same. The mode of delivery also showed similar patterns. The treatment group had significantly lower preprandial and postprandial glucose levels by 32 weeks' gestation, which continued to term. CONCLUSION: This pilot study suggests that intensive treatment of gestational diabetes mellitus may have little effect on birth weight, birth trauma, operative delivery, or neonatal metabolic disorders. It has demonstrated the safety of proceeding to a multicenter trial of sufficient sample size to confirm these findings.(Am J Obstet Gynecol 1997;177:190-5) Author Affiliation: Ottawa, Ontario, Canada Article History: Received 22 August 1996; Revised 31 January 1997; Accepted 20 February 1997 Article Note: (footnote) [star] From the Departments of Obstetrics and Gynecologya and Medicine,b the Clinical Epidemiology Unit,c and the Division of Biochemistry,d University of Ottawa, Ottawa Civic and Ottawa General Hospitals, and the Department of Obstetrics and Gynecology, University of Alberta.e , [star][star] Reprint requests: Peter Garner, MD, Department of Obstetrics and Gynecology, University of Ottawa, Room 505, Civic Parkdale Clinic, Ottawa Civic Hospital, Carling Ave., Ottawa, Ontario, Canada K1Y 4E9., a 6/1/81385

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ajog.2009.01.003 Byline: Heather D. Clark (a)(c), Ian D. Graham (c)(d), Alan Karovitch (a)(b), Erin J. Keely (a)(b)(c) Keywords: gestational diabetes mellitus; glucose tolerance test; postpartum testing; reminder Abstract: 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. Author Affiliation: (a) Department of Medicine, University of Ottawa, Ottawa, ON, Canada (b) Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, ON, Canada (c) Ottawa Hospital, and Ottawa Health Research Institute, University of Ottawa, Ottawa, ON, Canada (d) School of Nursing, University of Ottawa, Ottawa, ON, Canada Article History: Received 4 June 2008; Revised 15 October 2008; Accepted 12 January 2009 Article Note: (footnote) Cite this article as: Clark HD, Graham ID, Karovitch A, Keely EJ. Do postal reminders increase postpartum screening of diabetes mellitus in women with gestational diabetes mellitus? A randomized controlled trial. Am J Obstet Gynecol 2009;200:634.e1-634.e7. , Funding was provided by the Canadian Institute of Health Research, Knowledge Translation and Exchange (CIHR-KTE), Grant 200210KTS (H.D.C.).

Interventions for infertility have greatly increased in number and sophistication. Women with multiple medical problems and women near or beyond menopause are now able to conceive. The internist will be called on to assess the risk that infertility interventions pose and to counsel patients accordingly. Knowledge of the medical illnesses associated with infertility, the types of infertility treatments available, and the medical complications of these interventions are required to properly assess this risk. Medical complications of infertility interventions can be direct effects of related drugs and technologies and indirect consequences of the induced pregnancy, multiple gestation, or associated medical conditions. This article reviews the definitions and scope of infertility, the interventions used for treatment of infertility, the medical complications of these interventions, the potential risks of fertility treatment in women unable to conceive spontaneously, and important issues for preconception counseling.