Reproductibilité de la mesure du segment inférieur de l'utérus : échographie 3D et vidéo 2D

Tableau d’honneur de la Faculté des études supérieures et postdoctorales, 2012-2013.Nous avons réalisé une étude rétrospective de 60 femmes enceintes ayant un antécédent de césarienne basse transverse. Entre la 35e et la 39e semaine de grossesse, deux observateurs (A et B), à l’insu des données cliniques, ont mesuré de manière indépendante l’épaisseur du segment inférieur de l’utérus par échographie transvaginale. Un examen direct à l’aide de l’échographie 2D a été réalisé par l’observateur A. Des vidéos échographiques et des images 3D du segment inférieur ont été enregistrées par un observateur et analysées ultérieurement, au moins deux mois plus tard, par chacun des observateurs en ordre aléatoire et de manière indépendante. Au moins deux semaines plus tard, l’observateur B a répété l’ensemble des examens des images 3D et des vidéos. La reproductibilité intra et interobservateurs ainsi que la reproductibilité interméthodes ont été évaluées à l’aide de médianes de différences absolues, de limites d’accord non paramétriques, de coefficients de corrélation intraclasse et de coefficients kappa. Les mesures du segment inférieur de l’utérus à l’aide de l’échographie 3D ou de vidéos échographiques 2D ont présenté une excellente reproductibilité. Les deux techniques offrent aussi une bonne reproductibilité de la mesure réalisée par échographie 2D transvaginale en direct, particulièrement lorsque le segment inférieur est mince (moins de 3 mm).A prospective study of 60 pregnant women with previous, low-transverse cesarean was performed between 35 and 39 weeks of gestation. Two observers (Rater A and Rater B), blinded to the clinical data, independently measured full lower uterine segment (LUS) thickness using transvaginal sonography. A full live examination of the LUS using two-dimensional (2D) ultrasound was conducted by Rater A. Ultrasound videos and 3D volume datasets of the LUS were captured by one rater and analyzed ulteriorly, more than 2 months later, by both observers independently in random order. Rater B repeated all examinations of 3D datasets and videos at least two weeks later. Intra- and interobserver and intermethod reliabilities were evaluated by median absolute differences, non-parametric limits of agreement, intraclass correlation coefficients (ICC) and kappa coefficients. Full LUS thickness measured with 3D transvaginal ultrasound datasets or transvaginal sonographic videos has excellent intra- and interobserver reliability. Both methods have also a good reproducibility with live 2D ultrasound examinations, especially when full lower uterine segment is thin (below 3 mm)

Stratégies transfusionnelles chez les victimes de traumatismes craniocérébraux

Les pratiques transfusionnelles optimales demeurent incertaines chez les victimes de traumatismes craniocérébraux modérés ou graves. En l’absence de données probantes et en présence de divergences d’opinions parmi les experts quant aux transfusions de culots globulaires chez cette population, nous avons réalisé une revue systématique et deux études de cohortes sur le sujet. Ces 3 études avaient pour objectif de décrire les fréquences de transfusions, d’évaluer les déterminants potentiels et d’estimer l’association entre les transfusions de culots globulaires et les issues cliniques, telle la mortalité. La revue systématique a permis de synthétiser les connaissances disponibles dans les écrits scientifiques actuels relatifs aux transfusions de culots globulaires. Nous avons observé une fréquence importante des transfusions à travers les études, de l’ordre de 36 % (IC 95 % 28 à 44; 23 études) et des seuils transfusionnels variables (de 60 à 100 g/L). Peu d’études ont évalué les déterminants des transfusions. Aucune différence significative de la mortalité chez les patients transfusés comparativement à ceux non transfusés n’a pu être démontrée, mais des durées de séjour plus longues ont été observées à la suite de transfusions. L’étude de cohorte pancanadienne a permis de souligner la variabilité des pratiques transfusionnelles à travers les centres de traumatologie canadiens, avec des fréquences de transfusions par centre allant de 16 à 35 %, avec une moyenne de 28 % (IC 95 % 27 à 29 %). Nous avons pu identifier les traumatismes extracérébraux sérieux et l’anémie comme étant de potentiels déterminants majeurs des décisions transfusionnelles. Par ailleurs, nous avons pu observer une augmentation significative de l’ensemble des issues défavorables chez les patients transfusés. L’étude de cohorte provinciale, à l’aide de données plus précises quant à la temporalité de l’exposition et de la mortalité, nous a permis de caractériser l’évolution des niveaux d’hémoglobine et des pratiques transfusionnelles en cours de séjours hospitaliers à l’unité de soins intensifs. Nous avons pu observer une concentration d’hémoglobine prétransfusionnelle médiane de 81 g/L (étendue interquartile de 67 à 100). Après ajustement, les issues défavorables étaient significativement plus fréquentes chez les patients transfusés que ceux non transfusés. Une tendance non significative vers des rapports de risque plus défavorables à la suite de transfusions chez les patients présentant des niveaux d’hémoglobine plus élevés a été observée pour la majorité des issues.Optimal red blood cell transfusion practices remain unclear for patients with moderate and severe traumatic brain injuries. Considering evidences are lacking and scientific experts have expressed divergent opinions, we conducted a systematic review and two cohort studies to evaluate red blood cell transfusion practices in this population. These three studies had for objective to describe red blood cell transfusions frequency, to evaluate potential determinants and to estimate the association between red blood cell transfusions and clinical outcomes, such as mortality. The systematic review allowed to synthetize knowledge currently available in published studies regarding red blood cell transfusion. We observed a high frequency of transfusion across studies, with 36% (95%CI 28 to 44; 23 studies) being transfused at some point during hospital stay. Reported hemoglobin thresholds varied between 60 and 100 g/L. Few studies evaluated potential determinants. No significant difference in mortality between patients who received transfusion or not was observed. However, lenght of stay were longer following transfusions. Our canadian multicenter cohort study highlighted the variability in transfusionnal practices across the country, with transfusion frequencies varying from16 to 35% (mean 28%, 95%CI 27 to 29%). We identified serious extracerebral traumas and anemia as major determinants of transfusions. We also observed an increased risk of unfavorable outcomes (mortality, complications, lenght of stay) in patients who were transfused compared to those who were not, in adjusted statistical models. Our provincial cohort study, using hospital laboratory and pathology data, allowed to characterize the evolution of hemoglobin levels over intensive care unit stay, as well as transfusion practices. We observed a median pre-transfusional hemoglobin level of 81 g/L (IQR 67 to 100). After adjustment, unfavorable outcomes were significantly more frequent in transfused patients than non transfused. We observed a non significant trend toward higher risk ratios of unfavorable outcomes after transfusions in strata of patients with higher hemoglobin levels in most models

Integrated immunovirological profiling validates plasma SARS-CoV-2 RNA as an early predictor of COVID-19 mortality.

peer reviewedDespite advances in COVID-19 management, identifying patients evolving toward death remains challenging. To identify early predictors of mortality within 60 days of symptom onset (DSO), we performed immunovirological assessments on plasma from 279 individuals. On samples collected at DSO11 in a discovery cohort, high severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral RNA (vRNA), low receptor binding domain–specific immunoglobulin G and antibody-dependent cellular cytotoxicity, and elevated cytokines and tissue injury markers were strongly associated with mortality, including in patients on mechanical ventilation. A three-variable model of vRNA, with predefined adjustment by age and sex, robustly identified patients with fatal outcome (adjusted hazard ratio for log-transformed vRNA = 3.5). This model remained robust in independent validation and confirmation cohorts. Since plasma vRNA’s predictive accuracy was maintained at earlier time points, its quantitation can help us understand disease heterogeneity and identify patients who may benefit from new therapies

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Diagnose écologique du lac Landry de la réserve faunique Duchénier

Une diagnose écologique a été réalisée au lac Landry dans la réserve faunique Duchénier le 7 et 8 septembre 2002. L’objectif de cette étude était de caractériser la situation du lac Landry afin de parfaire les connaissances de ce plan d'eau et d’évaluer son potentiel pour l’omble de fontaine (Salvelinus fontinalis). À la lumière des informations recueillies et des résultats obtenus, quelques recommandations ont été émises afin de maintenir et d’améliorer le rendement de ce plan d’eau. Des paramètres ont été évalués pour qualifier le milieu physique soit, la bathymétrie, la physico-chimie et l’inventaire des sites de fraie de l’omble de fontaine. L’inventaire ichtyologique, les descripteurs biologiques et les données de l’exploitation par la pêche sportive ont quant à eux fourni des informations permettant de définir le statut de la communauté ichtyenne. Pour ce qui est de la bathymétrie et de la physico-chimie, le lac Landry rassemble les principales conditions nécessaires à l’omble de fontaine : eaux peu profondes (zones 0-6 m de 84,7%), pH relativement près de la neutralité (7,5 à 8,2), eaux claires et bien oxygénées en surface ainsi qu’une zone plus profonde (8-10 m) servant de refuge en période de réchauffement de l’eau. Le lac Landry semble présenter, en général, un bon potentiel de sites de fraie pour l’omble (présence de gravier et galet). Au total, six espèces ont été recensées par les pêches expérimentales, regroupant un salmonidé et cinq cyprinidés. L’abondance relative de l’omble représente 59,1 %, (CPUE 28,5 individus/nuit-filet et BPUE 5,46 kg/nuit-filet). La communauté ichtyenne du lac Landry est donc principalement composée d’ombles de fontaine. Les autres espèces vivant en sympatrie avec celui-ci peuvent exercer une compétition au niveau des ressources alimentaires. Pour ce qui est des statistiques de pêche, suite à des années où la récolte dépasse 600 individus, on observe une baisse importante de la récolte dans les années qui suivent. Les impacts de cette récolte sont compensés rapidement et la population peut se rétablir d’elle-même étant donné le bon potentiel du milieu. Afin d’offrir une qualité de pêche plus constante sans affecter le capital de la population, il est recommandé de limiter la récolte à 500 ombles par année soit un effort de pêche de 45 jours-pêche. De plus, l’augmentation des efforts pour diminuer le braconnage et une amélioration possible des sites de fraie sous certaines conditions sont également des interventions bénéfiques qui pourraient être envisagés pour améliorer le potentiel salmonicole du lac Landry

Complications following surgeries for endometriosis: A systematic review protocol.

BackgroundEndometriosis is a common gynecological condition with a wide range of symptoms, including infertility, dyspareunia, intestinal disorders, and pelvic pain. Laparoscopy and laparotomy are used widely for diagnosing and managing endometriosis. We will conduct a systematic review and meta-analysis with the aims of reporting complications rates following each type of surgeries for endometriosis and determinants of complications.MethodWe will search Medline (via PubMed), Embase, the Cochrane Library, Web of Science, and Google Scholar for both retrospective and prospective cohorts or trials of at least 30 participants reporting perioperative and postoperative complications for endometriosis surgeries. We will restrict the studies to those conducted after 2011, to be representative of current practices, and will exclude studies of surgeries for gynecological cancer, or other concomitant benign gynecologic surgeries such as myomectomy. Two reviewers will independently screen references and select eligible studies. A standardized form will be used to collect data related to the baseline characteristics, potential determinants of complications, types of interventions, and outcomes. Cumulative incidences of complications will be pooled using DerSimonian and Laird random-effects method. The relation between potential determinants and complications will be reported with risk ratios and their 95% of confidence intervals. Subgroup analysis of surgical approach, surgical procedure, superficial and deep infiltrating endometriosis, and the indication of surgery will be conducted. Sensitivity analyses restricted to studies with low risk of bias will be performed.DiscussionThis systematic review will provide information on the rates of complications for different surgical approaches and procedures for the treatment of endometriosis. It will contribute to inform patients when making decisions regarding their care. Identifying potential determinants of complications will also help to improve care by identifying women being at higher risk of complications.Trial registrationSystematic review registration: CRD42021293865

Aspirin at 75 to 81 mg Daily for the Prevention of Preterm Pre-Eclampsia: Systematic Review and Meta-Analysis

Background: Aspirin at 150 mg daily, initiated in the 1st trimester of pregnancy, prevents preterm pre-eclampsia. We aimed to estimate whether a dose of 75 to 81 mg daily can help to prevent preterm pre-eclampsia as well. Methods: A systematic search was conducted using multiple databases and meta-analyses of randomized controlled trials (RCTs) that compared aspirin initiated in the first trimester of pregnancy to placebo or no treatment, following the PRISMA guidelines and the Cochrane risk of bias tool. Results: We retrieved 11 RCTs involving 13,981 participants. Five RCTs had a low risk of bias, one at unclear risk, and fiver had a high risk of bias. A pooled analysis demonstrated that doses of 75 to 81 mg of aspirin, compared to a placebo or no treatment, was not associated with a significant reduction in preterm pre-eclampsia (8 studies; 12,391 participants; relative risk, 0.66; 95% confidence interval: 0.27 to 1.62; p = 0.36), but there was a significant heterogeneity across the studies (I2 = 61%, p = 0.02). Conclusion: It cannot be concluded that taking 75 to 81 mg of aspirin daily reduces the risk of preterm pre-eclampsia. However, given the significant heterogeneity between the studies, the true effect that such a dose of aspirin would have on pregnancy outcomes could not be properly estimated

Screening for small for gestational age using third-trimester ultrasound markers: protocol for a systematic review and meta-analysis of screening test accuracy

Background: Fetal growth restriction (FGR) is a complication of pregnancy associated with major neonatal morbidity and commonly diagnosed at birth based on birth weight below the 5th or the 10th centile. There is no consensus on the use of routine third-trimester ultrasound for the detection of FGR in a general population. This systematic review aims to estimate the performance of third-trimester ultrasound markers in the screening for babies who are small for gestational age in low-risk or general population. Methods: A systematic review of screening test accuracy will be conducted. The databases MEDLINE, Embase, Cochrane Library, and Web of Science will be searched from their inception until December 2017, as well as reference lists of included studies and previous related review articles. Studies screening for FGR in a low-risk or general population using third-trimester ultrasound markers and reporting low birth weight for gestational age (small for gestational age at birth) as a reference will be eligible. Two reviewers will independently screen references for inclusion, assess the risk of bias, and extract data. The Quality Assessment of Diagnostic Accuracy Study 2 (QUADAS-2) tool will be used to assess the methodological quality and validity of individual studies. The hierarchal summary receiver operating characteristic and random effects hierarchal bivariate models (Bivariate) will be used to estimate the pooled sensitivity and specificity of each ultrasound marker and to compare the discriminative ability of the different ultrasound markers. Subgroup and sensitivity analyses will be performed to explore the heterogeneity between studies and to assess the effect of screening tests’ characteristics (e.g., timing) on their discriminative ability. Discussion: This systematic review will determine the relevance of routine third-trimester ultrasound markers in the screening for FGR in low-risk or general population and their usefulness in standard pregnancy care. Additionally, this knowledge synthesis represents a step in the optimization of the discriminative ability of third-trimester ultrasound and predictive tools, allowing for targeted interventions aiming at the reduction of FGR complications and ultimately improving infants’ health. Systematic review registration: This protocol has been registered at PROSPERO: international prospective register of systematic reviews. The register number is CRD42018085564 .Medicine, Faculty ofNon UBCObstetrics and Gynaecology, Department ofReviewedFacult

Aspirin Responsiveness at a Dose of 80 mg and Its Impact on Birth Weight when Used in Twin Pregnancies: The GAP Pilot Randomized Trial

International audienceObjective Daily aspirin, started in the first trimester of pregnancy, is commonly used for the prevention of preeclampsia and fetal growth restriction in multiple gestation. However, the optimal dose remains controversial and the evidence for the use of aspirin in multiple pregnancies is scarce. We aimed to estimate the impact of 80 mg of aspirin in twin pregnancies. Study Design We performed a pilot double-blind randomized trial of women with twin pregnancies recruited between 8 and 14 weeks of gestation. Fifty participants (25 in each group) were randomized to 80 mg of aspirin daily at bedtime or a placebo from randomization until 36 weeks of gestation. Primary and secondary outcomes included the birth weight of live infants, preeclampsia, and aspirin responsiveness evaluated by a platelet aggregation test (platelet function assay [PFA]-100). Results All participants were followed until birth, including 48 and 47 live newborns in the aspirin and the placebo groups, respectively. The mean birth weight difference between the aspirin (2,385 ± 529 g) and placebo (2,224 ± 706 g) groups was of 179 g (95% confidence interval [CI]: −172–531 g, p = 0.32). We observed two (8%) cases of preeclampsia in the aspirin group and no case with placebo (p = 0.49). Most importantly,16 of 24 participants who received aspirin (67%; 95% CI: 45–84%) had a normal PFA-100 test at 22 to 23 weeks, including the two cases of preeclampsia, suggesting that the majority of the participants were nonresponsive to 80 mg of aspirin. Conclusion Our results suggest that the majority of women with twin pregnancies showed a lack of response to a daily dose of 80 mg of aspirin according to the PFA-100 test, compared with the expected 29% of nonresponsiveness in singleton pregnancies. A daily dose of 80 mg of aspirin is likely to be insufficient for the prevention of preeclampsia and other placenta-mediated complications in twin pregnancies