BACKGROUND Given the extent of the COVID-19 pandemic and uncertainty around the timing of its con... more BACKGROUND Given the extent of the COVID-19 pandemic and uncertainty around the timing of its containment, understanding the experiences and responses of the perinatal population is essential for planning responsive maternity care both during and after the pandemic. The aim of this study was to explore the experiences of pregnant people and their responses to the COVID-19 pandemic, and to identify how health care providers can support this population. METHODS This was a mixed-methods, descriptive study with cross-sectional and qualitative descriptive components. We conducted the study between Mar. 20 and May 31, 2020, in British Columbia, Canada. Any pregnant person at any gestational age living in BC was eligible to participate. We collected quantitative data using online survey tools, including the Edinburgh Postnatal Depression Scale (EPDS) and the 7-item Generalized Anxiety Disorder questionnaire (GAD-7). We collected qualitative data using open-ended questions to explore people...
Background: Anemia is common in neurocritically ill patients. Considering the limited clinical ev... more Background: Anemia is common in neurocritically ill patients. Considering the limited clinical evidence in this population, preclinical data may provide some understanding of the potential impact of anemia and of red blood cell transfusion in these patients. We aim to estimate the association between different transfusion strategies and neurobehavioral outcome in animal models.Methods: We will conduct a systematic review of comparative studies of red blood cell transfusion strategies using animal models of traumatic brain injury, ischemic stroke or cerebral hemorrhage. We will search MEDLINE, EMBASE and Web of Science databases for eligible studies. Two independent reviewers will perform study selection and data extraction. We will report our results in a descriptive synthesis focusing on characteristics of included studies, reported outcomes, risk of bias and construct validity. If appropriate, we will also perform a quantitative synthesis and pool results using random-effect model...
Objective Preeclampsia is associated with placental vascularization disorders. Ultrasonographic s... more Objective Preeclampsia is associated with placental vascularization disorders. Ultrasonographic sphere biopsy (USSB) of the placenta can estimate the vascularization of the placenta and potentially the risk of preeclampsia. We aimed to explore the factors related to placental vascularization measured with USSB in the first trimester. Study Design A prospective cohort was conducted in women recruited at 11 to 14 weeks. Three-dimensional acquisition of the placenta with power Doppler was undertaken along with crown-rump length (CRL). Using USSB of the full placental thickness at its center, vascularization index, flow index, and vascular flow index were measured. Pearson's correlation coefficients and multivariate linear regression were used to correlate the vascularization indices with CRL and maternal characteristics. Results A total of 5,612 women were recruited at a mean gestational age of 12.8 ± 0.6 weeks. We observed that vascularization indices increase with CRL. After adju...
Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC, 2018
Low-dose aspirin started in early pregnancy significantly reduces the risk of preeclampsia (PE) i... more Low-dose aspirin started in early pregnancy significantly reduces the risk of preeclampsia (PE) in high-risk women, especially preterm PE. This study aimed to evaluate the influence of maternal characteristics on the risk of PE in nulliparous women. The Great Obstetrical Syndromes (GOS) study recruited nulliparous women with singleton pregnancies at 11 to 13 weeks. The following maternal characteristics were collected: age, BMI, ethnicity, chronic diseases, smoking, and assisted reproductive technologies. Relative weight analyses were conducted, and predictive multivariate proportional hazard models were constructed. Receiver operating characteristic curve analyses with their area under the curve (AUC) were used to evaluate the value of each factor for the prediction of PE and preterm PE. The study also evaluated the SOGC guidelines for identification of women at high risk of PE. Of 4739 participants, 232 (4.9%) developed PE, including 30 (0.6%) with preterm PE. In univariate analys...
Canadian journal of surgery. Journal canadien de chirurgie, 2016
Hemorrhagic shock is responsible for 45% of injury fatalities in North America, and 50% of these ... more Hemorrhagic shock is responsible for 45% of injury fatalities in North America, and 50% of these occur within 2 h of injury. There is currently a lack of evidence regarding the trajectories of patients in hemorrhagic shock and the potential benefit of level I/II care for these patients. We aimed to compare mortality across trauma centre designation levels for patients in hemorrhagic shock. Secondary objectives were to compare surgical delays, complications and hospital length of stay (LOS). We performed a retrospective cohort study based on a Canadian inclusive trauma system (1999-2012), including adults with systolic blood pressure (SBP) < 90 mm Hg on arrival who required urgent surgical care (< 6 h). Logistic regression was used to examine the influence of trauma centre designation level on risk-adjusted surgical delays, mortality and complications. Linear regression was used to examine LOS. Compared with level I centres, adjusted odds ratios (and 95% confidence intervals [C...
The purpose of this study was to report the intraobserver and interobserver reliability of transv... more The purpose of this study was to report the intraobserver and interobserver reliability of transvaginal 3-dimensional (3D) sonographic measurement of lower uterine segment thickness. Methods-A prospective study of 60 pregnant women with previous low transverse cesarean deliveries was performed between 35 and 39 weeks' gestation. Two observers, blinded to the clinical data, independently measured the full lower uterine segment thickness by 2-dimensional (2D) transvaginal sonography. Three-dimensional volume data sets of the lower uterine segment were captured and analyzed more than 2 months later by both observers independently. Intraobserver, interobserver, and intermethod reliability was evaluated by median absolute differences, nonparametric limits of agreement, intraclass correlation coefficients (ICCs), and κ coefficients.
Journal of Obstetrics and Gynaecology Canada, 2011
Objective: To estimate the association between potential influencing factors and lower uterine se... more Objective: To estimate the association between potential influencing factors and lower uterine segment (LUS) thickness at term in women with previous Caesarean section. Methods: We conducted a cohort study of women with previous low-transverse Caesarean section undergoing ultrasonographic measurement of LUS thickness between 35 and 38 weeks' gestation in a tertiary care centre between 2006 and 2009. Measurements of the full LUS thickness and the myometrial LUS thickness were performed both transabdominally and transvaginally. The thinnest measurements for both full and myometrial LUS thicknesses were considered dependent variables. Non-parametric analyses, multivariate linear regression analyses, and multivariate regression analyses were used to evaluate the relationships between LUS thickness and the potential influencing factors of maternal age, interdelivery interval, prior vaginal delivery, and several characteristics of the previous Caesarean section. Results: In 377 women who underwent measurement of LUS thickness, labour before previous Caesarean section was the only characteristic associated with a greater full LUS thickness (an additional 0 .9 mm; 95% CI 0 .5 to 1 .2 mm) in multivariate linear regression analysis. Labour before previous Caesarean section (0 .5 mm; 95% CI 0 .2 to 0 .7 mm) and the use of synthetic sutures (as opposed to catgut sutures) for the closure of the previous hysterotomy incision (0 .3 mm; 95% CI 0 .02 to 0 .5 mm) were the only two variables significantly associated with a thicker myometrial LUS. In multivariate regression analysis, three factors were predictive of a full LUS thickness of > 2 .3 mm: the presence of labour, a recurrent indication for Caesarean section, and the use of synthetic sutures for hysterotomy closure at previous Caesarean section (P < 0 .05). Conclusion: Labour at the time of previous Caesarean section is associated with a thicker LUS near term in the subsequent pregnancy. The use of synthetic sutures for hysterotomy closure is another factor potentially associated with a thicker LUS. Résumé Objectif : Estimer l'association entre les facteurs d'influence possibles et l'épaisseur du segment utérin inférieur (SUI) à terme chez les femmes ayant déjà subi une césarienne .
Background: Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating disease that leads to impo... more Background: Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating disease that leads to important morbidity and mortality in a young patient population. Anemia following aSAH is common and may be exacerbated by the treatments instituted by clinicians as part of standard care. The role and optimal thresholds for red blood cell (RBC) transfusion in this patient population remains unknown. Methods/design: We will conduct a systematic review of the literature using MEDLINE, EMBASE, and EBM Reviews (including Cochrane Central databases) using a comprehensive search strategy for observational and interventional studies of RBC transfusion in aSAH. Our primary objective is to evaluate the association of RBC transfusion with mortality in aSAH patients. Secondary objectives include a) determining associations between RBC transfusion and poor neurologic outcome, b) defining an optimal RBC transfusion threshold in aSAH patients, and c) describing complications associated with RBC transfusion in aSAH patients. We plan a descriptive reporting of all included citations including study characteristics, methodological quality, and reported outcomes. Clinical and statistical heterogeneity observed between studies will be described. If appropriate, meta-analyses of suitable studies and interpretation of their results will be performed. Effect measures will be converted to obtain relative risks and odds ratios (RR and ORs) with 95% confidence intervals and pooled according to study design (randomized trials and observational studies respectively) using a random effects model. Discussion: This review will summarize the existing observational and trial evidence regarding RBC transfusion in aSAH patients. The analytical plan has made considerations for different study designs, both observational and interventional in nature, and will summarize the best available evidence to inform the end user and policy and guideline producers and to highlight areas in need of further study. Systematic review registration: PROSPERO CRD42014014806
Risk-adjusted mortality is widely used to benchmark trauma center care. Patients presenting with ... more Risk-adjusted mortality is widely used to benchmark trauma center care. Patients presenting with isolated hip fractures (IHFs) are usually excluded from these evaluations. However, there is no standardized definition of an IHF. We aimed to evaluate whether there is consensus on the definition of an IHF used as an exclusion criterion in studies evaluating the performance of trauma centers in terms of mortality. We conducted a systematic review of observational studies. We searched the electronic databases MEDLINE, EMBASE, BIOSIS, The Cochrane Library, CINAHL, TRIP Database, and PROQUEST for cohort studies that presented data on mortality to assess the performance of trauma centers and excluded IHF. A standardized, piloted data abstraction form was used to extract data on study settings, IHF definitions and methodological quality of included studies. Consensus was considered to be reached if more than 50% of studies used the same definition of IHF. We identified 8,506 studies of which...
BACKGROUND: According to Donabedian's framework, outcomes covering the following six domains shou... more BACKGROUND: According to Donabedian's framework, outcomes covering the following six domains should be used to evaluate health care quality: death, adverse events, readmissions to hospital, resource use, quality of life, and ability to function in daily activities. The objective of this study was to identify the nonfatal outcomes that have been used to evaluate the performance of trauma hospitals. Secondary objectives were to describe definitions and methodological quality. METHODS: We performed a scoping literature review of studies using at least one nonfatal outcome to evaluate the performance of acute care hospitals for the treatment of general trauma populations. We searched MEDLINE, EMBASE, Cochrane central, CINAHL, BIOSIS, TRIP and ProQuest databases. Methodological quality was evaluated using elements of the STROBE statement and the Downs and Black tool. RESULTS: Of 14,521 citations, 40 were eligible for inclusion. We identified 14 nonfatal outcomes as follows: (i) adverse events including complications (used in 35 evaluations), missed injuries (n = 4), reintubation (n = 2), unplanned intensive care unit admissions (n = 2), and unplanned surgeries (n = 4); (ii) resource use including hospital (n = 19), intensive care unit (n = 15), and ventilator (n = 4) length of stay, inappropriate hospital stay (n = 1), and potentially unnecessary care (n = 1); (iii) hospital readmissions (n = 4); and (iv) ability to function in daily activities including functional capacity (n = 2), and discharge destination (n = 3). No measures of quality of life were identified. There was high heterogeneity in the definitions used. Only 18% of studies had high methodological quality. CONCLUSION: Among recommended domains of nonfatal outcomes, adverse events and resource use were frequently used to evaluate trauma care, readmissions and function in daily activities were rarely used, and quality of life was never used. In addition, definitions of nonfatal outcomes were variable, and methodological quality was low. There is a need to develop valid and reliable performance indicators based on each domain of Donabedian's framework to evaluate trauma care.
Background: Anemia is a prevalent condition in critically ill patients and red blood cell transfu... more Background: Anemia is a prevalent condition in critically ill patients and red blood cell transfusions are frequent. Although transfusions at low hemoglobin levels have been shown to be associated with equivalent or better outcomes than higher hemoglobin thresholds, clinical equipoise persists in patients with traumatic brain injury considering their susceptibility to secondary cerebral insults such as those from hypoxemia. Methods: Our objectives are to estimate the frequency of red blood cell transfusion in patients with traumatic brain injury and to evaluate transfusion thresholds, determinants and outcomes associated with transfusion strategies. We will conduct a systematic review of cohort studies and randomized controlled trials of patients with traumatic brain injury. We will search MEDLINE, Embase, BIOSIS and the Cochrane Library for eligible studies. Two independent reviewers will screen all identified references. Studies including adult patients with traumatic brain injury reporting data on red blood cell transfusions will be eligible. We will collect data on baseline demographics, trauma characteristics, hemoglobin thresholds, blood transfusions and clinical outcomes (mortality, length of stay, complications, and so on). Two independent reviewers will extract data using a standardized form. We will pool cumulative incidences using DerSimonian and Lair random-effect models after a Freeman-Tukey transformation to stabilize variances. We will pool risk ratios or mean differences with random-effect models and Mantel-Haenszel or inverse variance methods in order to evaluate the association between red blood cell transfusion and potential determinants or outcomes. Sensitivity and subgroup analysis according to timing of red blood cell transfusion, traumatic brain injury severity, year of conduction of the study, risk of bias, notably, are planned. Discussion: We expect to observe high heterogeneity in the proportion of transfused patients across studies and that the global proportion will be similar to the frequency observed in the general medical critically ill population. Our systematic review will allow us to better describe and understand current transfusion practices in patients with traumatic brain injury, a clinical population in which liberal transfusions are still advocated in the absence of evidence-based data. Systematic review registration: PROSPERO: CRD42014007402.
International Journal of Gynecology & Obstetrics, 2011
Objective: To evaluate the best available evidence regarding the association between single-layer... more Objective: To evaluate the best available evidence regarding the association between single-layer closure and uterine rupture. Methods: The PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched for relevant observational and experimental studies that included women with a previous single, low, transverse cesarean delivery who had attempted a trial of labor (TOL). The risks of uterine rupture and uterine dehiscence were assessed by pooled odds ratios (OR) calculated with a random effects model. Results: Nine studies including 5810 women were reviewed. Overall, the risk of uterine rupture during TOL after a single-layer closure was not significantly different from that after a double-layer closure (OR 1.71; 95% confidence interval [CI] 0.66-4.44). However, a sensitivity analysis indicated that the risk of uterine rupture was increased after a locked single-layer closure (OR 4.96; 95% CI 2.58-9.52, P b 0.001) but not after an unlocked single-layer closure (OR 0.49; 95% CI 0.21-1.16), compared with a double-layer closure. Conclusion: Locked but not unlocked single-layer closures were associated with a higher uterine rupture risk than doublelayer closure in women attempting a TOL.
Is hysterosalpingosonography (sono-HSG) an accurate test for diagnosing tubal occlusion in subfer... more Is hysterosalpingosonography (sono-HSG) an accurate test for diagnosing tubal occlusion in subfertile women and how does it perform compared with hysterosalpingography (HSG)? summary answer: sono-HSG is an accurate test for diagnosing tubal occlusion and performs similarly to HSG. what is known already: sono-HSG and HSG are both short, well-tolerated outpatient procedures. However, sono-HSG has the advantage over HSG of obviating ionizing radiation and the risk of iodine allergy, being associated with a greater sensitivity and specificity in detecting anomalies of the uterine cavity and permitting concomitant visualization of the ovaries and myometrium. study design, size, duration: A systematic review and meta-analysis of studies published in any language before 14 November 2012 were performed. All studies assessing the accuracy of sono-HSG for diagnosing tubal occlusion in a subfertile female population were considered. participants/materials, setting, methods: We searched Medline, Embase, Cochrane Library, Web of Science and Biosis as well as related articles, citations and reference lists. Diagnostic studies were eligible if they compared sono-HSG (+HSG) to laparoscopy with chromotubation in women suffering from subfertility. Two authors independently screened for eligibility, extracted data and assessed the quality of included studies. Risk of bias and applicability concerns were investigated according to the Quality Assessment of Diagnostic Accuracy Study (QUADAS-2). Bivariate random-effects models were used to estimate pooled sensitivity and specificity with their 95% confidence intervals (95% CIs), to generate summary receiver operating characteristic curves and to evaluate sources of heterogeneity. main results and the role of chance: Of the 4221 citations identified, 30 studies were eligible. Of the latter, 28 reported results per individual tube and were included in the meta-analysis, representing a total of 1551 women and 2740 tubes. In nine studies, all participants underwent HSG in addition to sono-HSG and laparoscopy, allowing direct comparison of the accuracy of sono-HSG and HSG. Pooled estimates of sensitivity and specificity of sono-HSG were 0.92 (95% CI: 0.82-0.96) and 0.95 (95% CI: 0.90-0.97), respectively. In nine studies (582 women, 1055 tubes), sono-HSG and HSG were both compared with laparoscopy, giving pooled estimates of sensitivity and specificity of 0.95 (95% CI: 0.78-0.99) and 0.93 (95% CI: 0.89-0.96) for sono-HSG, and 0.94 (95% CI: 0.74-0.99) and 0.92 (95% CI: 0.87-0.95) for HSG, respectively. Doppler sonography was associated with significantly greater sensitivity and specificity of sono-HSG compared with its non-use (0.93 and 0.95 versus 0.86 and 0.89, respectively, P ¼ 0.0497). Sensitivity analysis regarding methodological quality of studies was consistent with these findings. We also found no benefit of the commercially available contrast media over saline solution in regard to the diagnostic accuracy of sono-HSG. limitations, reasons for caution: Methodological quality varied greatly between studies. However, sensitivity analysis, taking methodological quality of studies into account, did not modify the results. This systematic review did not allow the distinction between distal and proximal occlusion. This could be interesting to take into account in further studies, as the performance of the test may differ for each localization. wider implications of the findings: Given our findings and the known benefits of sono-HSG over HSG in the context of subfertility, sono-HSG should replace HSG in the initial workup of subfertile couples.
Introduction: Accumulating evidence suggests that, in critically ill patients, a lower hemoglobin... more Introduction: Accumulating evidence suggests that, in critically ill patients, a lower hemoglobin transfusion threshold is safe. However, the optimal hemoglobin level and associated transfusion threshold remain unknown in neurocritically ill patients. Methods: We conducted a systematic review of comparative studies (randomized and nonrandomized) to evaluate the effect of hemoglobin levels on mortality, neurologic function, intensive care unit (ICU) and hospital length of stay, duration of mechanical ventilation, and multiple organ failure in adult and pediatric neurocritically ill patients. We searched MEDLINE, The Cochrane Central Register of Controlled Trials, Embase, Web of Knowledge, and Google Scholar. Studies focusing on any neurocritical care conditions were included. Data are presented by using odds ratios for dichotomous outcomes and mean differences for continuous outcomes. Results: Among 4,310 retrieved records, six studies met inclusion criteria (n = 537). Four studies were conducted in traumatic brain injury (TBI), one in subarachnoid hemorrhage (SAH), and one in a mixed population of neurocritically ill patients. The minimal hemoglobin levels or transfusion thresholds ranged from 7 to 10 g/dl in the lower-Hb groups and from 9.3 to 11.5 g/dl in the higher-Hb groups. Three studies had a low risk of bias, and three had a high risk of bias. No effect was observed on mortality, duration of mechanical ventilation, or multiple organ failure. In studies reporting on length of stay (n = 4), one reported a significant shorter ICU stay (mean,-11.4 days (95% confidence interval,-16.1 to-6.7)), and one, a shorter hospital stay (mean,-5.7 days (-10.3 to-1.1)) in the lower-Hb groups, whereas the other two found no significant association. Conclusions: We found insufficient evidence to confirm or refute a difference in effect between lower-and higher-Hb groups in neurocritically ill patients. Considering the lack of evidence regarding long-term neurologic functional outcomes and the high risk of bias of half the studies, no recommendation can be made regarding which hemoglobin level to target and which associated transfusion strategy (restrictive or liberal) to favor in neurocritically ill patients.
To review the ability of imaging techniques to predict incomplete healing of uterine cesarean sca... more To review the ability of imaging techniques to predict incomplete healing of uterine cesarean scars before the next pregnancy. A systematic literature review searched for studies on women who underwent previous low-transverse cesarean, evaluated by hysterography, sonohysterography (SHG), or transvaginal ultrasound (TVU). The median prevalence of scar defects was computed with 95% confidence intervals (95% CIs). Odds ratio (OR, 95% CI) identified risk factors of incomplete healing. The analysis included 21 studies. The proportions of suspected scar defects detected by hysterography, SGH, and TVU were 58% (33 to 70), 59% (58 to 85), and 37% (20 to 65), respectively. Two studies found that women with a large uterine scar defect had a higher risk of uterine rupture or uterine scar dehiscence than those with no scar defect or small scar defect (OR: 26.05 [2.36 to 287.61], p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). The only reported risk factor for scar defect was the occurrence of more than one previous cesarean (OR: 2.24 [1.13, 4.45], p = 0.02). Hysterography, SGH, and TVU can detect uterine scar defects in ~50% of women with previous cesarean.
There is a controversy regarding the benefits of periodontal treatment during pregnancy. We aimed... more There is a controversy regarding the benefits of periodontal treatment during pregnancy. We aimed to evaluate its effect on the risk of preterm birth and to explore the heterogeneity between studies. A systematic review and meta-analysis of randomized controlled trials were performed. Studies in which women were randomized for periodontal treatment versus no treatment were included. Pooled risk ratios (RRs) with their 95% confidence intervals (CIs) were calculated using random-effect models. A sensitivity analysis was performed. Twelve randomized trials were included in the meta-analysis. Pooled estimates showed no significant reduction of preterm birth with periodontal treatment (RR: 0.89; 95% CI: 0.73 to 1.08). However, the substantial heterogeneity among studies (I2 = 52%) could be explained either by the risk of bias, the level of income, or by the use of chlorhexidine mouthwashes as a cointervention. Daily use of chlorhexidine mouthwash was associated with a reduction of preterm birth (RR: 0.69; 95% CI 0.50 to 0.95), with moderate heterogeneity among the five studies included (I2 = 43%). There is an important heterogeneity between randomized trials that evaluated the effect of periodontal treatment on the risk of preterm birth. Chlorhexidine mouthwash as a preventive agent should be further evaluated.
To report the intra- and interobserver reliability of measurement of the lower uterine segment (L... more To report the intra- and interobserver reliability of measurement of the lower uterine segment (LUS) thickness using transvaginal sonographic videos. A prospective study of 60 women with previous, low-transverse cesarean undergoing LUS examination (36 to 39 weeks) was performed. Two observers independently measured full LUS thickness using transvaginal sonography. A video of the LUS was recorded and analyzed more than 2 months later by both observers. Intra- and interobserver reliability was assessed with median absolute differences and interquartile range (IQR), nonparametric limits of agreement, intraclass correlation coefficients (ICC) with 95% confidence interval (95% CI), and kappa coefficients. Median full LUS thickness was 3.6 mm (range: 0.9 to 8.0 mm). Intraobserver repeatability was excellent (median difference: 0.2 mm, IQR: 0.1 to 0.4; ICC: 0.94, 95% CI: 0.90 to 0.96; kappa: 1.00). Interobserver (median difference: 0.3 mm, IQR: 0.2 to 1.3; ICC: 0.91, 95% CI: 0.86 to 0.95; kappa: 0.76, 95% CI: 0.54 to 0.98) and intermethod reproducibility (median difference: 0.4 mm, IQR: 0.2 to 0.8; ICC: 0.82, 95% CI: 0.72 to 0.89; kappa: 0.69, 95% CI: 0.43 to 0.94) were good. However, both interobserver and intermethod reproducibility were improved when LUS thickness was below 3 mm. Full LUS thickness measured from transvaginal sonographic videos has excellent intra- and interobserver reproducibility and good reproducibility with live transvaginal ultrasound.
BACKGROUND Given the extent of the COVID-19 pandemic and uncertainty around the timing of its con... more BACKGROUND Given the extent of the COVID-19 pandemic and uncertainty around the timing of its containment, understanding the experiences and responses of the perinatal population is essential for planning responsive maternity care both during and after the pandemic. The aim of this study was to explore the experiences of pregnant people and their responses to the COVID-19 pandemic, and to identify how health care providers can support this population. METHODS This was a mixed-methods, descriptive study with cross-sectional and qualitative descriptive components. We conducted the study between Mar. 20 and May 31, 2020, in British Columbia, Canada. Any pregnant person at any gestational age living in BC was eligible to participate. We collected quantitative data using online survey tools, including the Edinburgh Postnatal Depression Scale (EPDS) and the 7-item Generalized Anxiety Disorder questionnaire (GAD-7). We collected qualitative data using open-ended questions to explore people...
Background: Anemia is common in neurocritically ill patients. Considering the limited clinical ev... more Background: Anemia is common in neurocritically ill patients. Considering the limited clinical evidence in this population, preclinical data may provide some understanding of the potential impact of anemia and of red blood cell transfusion in these patients. We aim to estimate the association between different transfusion strategies and neurobehavioral outcome in animal models.Methods: We will conduct a systematic review of comparative studies of red blood cell transfusion strategies using animal models of traumatic brain injury, ischemic stroke or cerebral hemorrhage. We will search MEDLINE, EMBASE and Web of Science databases for eligible studies. Two independent reviewers will perform study selection and data extraction. We will report our results in a descriptive synthesis focusing on characteristics of included studies, reported outcomes, risk of bias and construct validity. If appropriate, we will also perform a quantitative synthesis and pool results using random-effect model...
Objective Preeclampsia is associated with placental vascularization disorders. Ultrasonographic s... more Objective Preeclampsia is associated with placental vascularization disorders. Ultrasonographic sphere biopsy (USSB) of the placenta can estimate the vascularization of the placenta and potentially the risk of preeclampsia. We aimed to explore the factors related to placental vascularization measured with USSB in the first trimester. Study Design A prospective cohort was conducted in women recruited at 11 to 14 weeks. Three-dimensional acquisition of the placenta with power Doppler was undertaken along with crown-rump length (CRL). Using USSB of the full placental thickness at its center, vascularization index, flow index, and vascular flow index were measured. Pearson's correlation coefficients and multivariate linear regression were used to correlate the vascularization indices with CRL and maternal characteristics. Results A total of 5,612 women were recruited at a mean gestational age of 12.8 ± 0.6 weeks. We observed that vascularization indices increase with CRL. After adju...
Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC, 2018
Low-dose aspirin started in early pregnancy significantly reduces the risk of preeclampsia (PE) i... more Low-dose aspirin started in early pregnancy significantly reduces the risk of preeclampsia (PE) in high-risk women, especially preterm PE. This study aimed to evaluate the influence of maternal characteristics on the risk of PE in nulliparous women. The Great Obstetrical Syndromes (GOS) study recruited nulliparous women with singleton pregnancies at 11 to 13 weeks. The following maternal characteristics were collected: age, BMI, ethnicity, chronic diseases, smoking, and assisted reproductive technologies. Relative weight analyses were conducted, and predictive multivariate proportional hazard models were constructed. Receiver operating characteristic curve analyses with their area under the curve (AUC) were used to evaluate the value of each factor for the prediction of PE and preterm PE. The study also evaluated the SOGC guidelines for identification of women at high risk of PE. Of 4739 participants, 232 (4.9%) developed PE, including 30 (0.6%) with preterm PE. In univariate analys...
Canadian journal of surgery. Journal canadien de chirurgie, 2016
Hemorrhagic shock is responsible for 45% of injury fatalities in North America, and 50% of these ... more Hemorrhagic shock is responsible for 45% of injury fatalities in North America, and 50% of these occur within 2 h of injury. There is currently a lack of evidence regarding the trajectories of patients in hemorrhagic shock and the potential benefit of level I/II care for these patients. We aimed to compare mortality across trauma centre designation levels for patients in hemorrhagic shock. Secondary objectives were to compare surgical delays, complications and hospital length of stay (LOS). We performed a retrospective cohort study based on a Canadian inclusive trauma system (1999-2012), including adults with systolic blood pressure (SBP) < 90 mm Hg on arrival who required urgent surgical care (< 6 h). Logistic regression was used to examine the influence of trauma centre designation level on risk-adjusted surgical delays, mortality and complications. Linear regression was used to examine LOS. Compared with level I centres, adjusted odds ratios (and 95% confidence intervals [C...
The purpose of this study was to report the intraobserver and interobserver reliability of transv... more The purpose of this study was to report the intraobserver and interobserver reliability of transvaginal 3-dimensional (3D) sonographic measurement of lower uterine segment thickness. Methods-A prospective study of 60 pregnant women with previous low transverse cesarean deliveries was performed between 35 and 39 weeks' gestation. Two observers, blinded to the clinical data, independently measured the full lower uterine segment thickness by 2-dimensional (2D) transvaginal sonography. Three-dimensional volume data sets of the lower uterine segment were captured and analyzed more than 2 months later by both observers independently. Intraobserver, interobserver, and intermethod reliability was evaluated by median absolute differences, nonparametric limits of agreement, intraclass correlation coefficients (ICCs), and κ coefficients.
Journal of Obstetrics and Gynaecology Canada, 2011
Objective: To estimate the association between potential influencing factors and lower uterine se... more Objective: To estimate the association between potential influencing factors and lower uterine segment (LUS) thickness at term in women with previous Caesarean section. Methods: We conducted a cohort study of women with previous low-transverse Caesarean section undergoing ultrasonographic measurement of LUS thickness between 35 and 38 weeks' gestation in a tertiary care centre between 2006 and 2009. Measurements of the full LUS thickness and the myometrial LUS thickness were performed both transabdominally and transvaginally. The thinnest measurements for both full and myometrial LUS thicknesses were considered dependent variables. Non-parametric analyses, multivariate linear regression analyses, and multivariate regression analyses were used to evaluate the relationships between LUS thickness and the potential influencing factors of maternal age, interdelivery interval, prior vaginal delivery, and several characteristics of the previous Caesarean section. Results: In 377 women who underwent measurement of LUS thickness, labour before previous Caesarean section was the only characteristic associated with a greater full LUS thickness (an additional 0 .9 mm; 95% CI 0 .5 to 1 .2 mm) in multivariate linear regression analysis. Labour before previous Caesarean section (0 .5 mm; 95% CI 0 .2 to 0 .7 mm) and the use of synthetic sutures (as opposed to catgut sutures) for the closure of the previous hysterotomy incision (0 .3 mm; 95% CI 0 .02 to 0 .5 mm) were the only two variables significantly associated with a thicker myometrial LUS. In multivariate regression analysis, three factors were predictive of a full LUS thickness of > 2 .3 mm: the presence of labour, a recurrent indication for Caesarean section, and the use of synthetic sutures for hysterotomy closure at previous Caesarean section (P < 0 .05). Conclusion: Labour at the time of previous Caesarean section is associated with a thicker LUS near term in the subsequent pregnancy. The use of synthetic sutures for hysterotomy closure is another factor potentially associated with a thicker LUS. Résumé Objectif : Estimer l'association entre les facteurs d'influence possibles et l'épaisseur du segment utérin inférieur (SUI) à terme chez les femmes ayant déjà subi une césarienne .
Background: Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating disease that leads to impo... more Background: Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating disease that leads to important morbidity and mortality in a young patient population. Anemia following aSAH is common and may be exacerbated by the treatments instituted by clinicians as part of standard care. The role and optimal thresholds for red blood cell (RBC) transfusion in this patient population remains unknown. Methods/design: We will conduct a systematic review of the literature using MEDLINE, EMBASE, and EBM Reviews (including Cochrane Central databases) using a comprehensive search strategy for observational and interventional studies of RBC transfusion in aSAH. Our primary objective is to evaluate the association of RBC transfusion with mortality in aSAH patients. Secondary objectives include a) determining associations between RBC transfusion and poor neurologic outcome, b) defining an optimal RBC transfusion threshold in aSAH patients, and c) describing complications associated with RBC transfusion in aSAH patients. We plan a descriptive reporting of all included citations including study characteristics, methodological quality, and reported outcomes. Clinical and statistical heterogeneity observed between studies will be described. If appropriate, meta-analyses of suitable studies and interpretation of their results will be performed. Effect measures will be converted to obtain relative risks and odds ratios (RR and ORs) with 95% confidence intervals and pooled according to study design (randomized trials and observational studies respectively) using a random effects model. Discussion: This review will summarize the existing observational and trial evidence regarding RBC transfusion in aSAH patients. The analytical plan has made considerations for different study designs, both observational and interventional in nature, and will summarize the best available evidence to inform the end user and policy and guideline producers and to highlight areas in need of further study. Systematic review registration: PROSPERO CRD42014014806
Risk-adjusted mortality is widely used to benchmark trauma center care. Patients presenting with ... more Risk-adjusted mortality is widely used to benchmark trauma center care. Patients presenting with isolated hip fractures (IHFs) are usually excluded from these evaluations. However, there is no standardized definition of an IHF. We aimed to evaluate whether there is consensus on the definition of an IHF used as an exclusion criterion in studies evaluating the performance of trauma centers in terms of mortality. We conducted a systematic review of observational studies. We searched the electronic databases MEDLINE, EMBASE, BIOSIS, The Cochrane Library, CINAHL, TRIP Database, and PROQUEST for cohort studies that presented data on mortality to assess the performance of trauma centers and excluded IHF. A standardized, piloted data abstraction form was used to extract data on study settings, IHF definitions and methodological quality of included studies. Consensus was considered to be reached if more than 50% of studies used the same definition of IHF. We identified 8,506 studies of which...
BACKGROUND: According to Donabedian's framework, outcomes covering the following six domains shou... more BACKGROUND: According to Donabedian's framework, outcomes covering the following six domains should be used to evaluate health care quality: death, adverse events, readmissions to hospital, resource use, quality of life, and ability to function in daily activities. The objective of this study was to identify the nonfatal outcomes that have been used to evaluate the performance of trauma hospitals. Secondary objectives were to describe definitions and methodological quality. METHODS: We performed a scoping literature review of studies using at least one nonfatal outcome to evaluate the performance of acute care hospitals for the treatment of general trauma populations. We searched MEDLINE, EMBASE, Cochrane central, CINAHL, BIOSIS, TRIP and ProQuest databases. Methodological quality was evaluated using elements of the STROBE statement and the Downs and Black tool. RESULTS: Of 14,521 citations, 40 were eligible for inclusion. We identified 14 nonfatal outcomes as follows: (i) adverse events including complications (used in 35 evaluations), missed injuries (n = 4), reintubation (n = 2), unplanned intensive care unit admissions (n = 2), and unplanned surgeries (n = 4); (ii) resource use including hospital (n = 19), intensive care unit (n = 15), and ventilator (n = 4) length of stay, inappropriate hospital stay (n = 1), and potentially unnecessary care (n = 1); (iii) hospital readmissions (n = 4); and (iv) ability to function in daily activities including functional capacity (n = 2), and discharge destination (n = 3). No measures of quality of life were identified. There was high heterogeneity in the definitions used. Only 18% of studies had high methodological quality. CONCLUSION: Among recommended domains of nonfatal outcomes, adverse events and resource use were frequently used to evaluate trauma care, readmissions and function in daily activities were rarely used, and quality of life was never used. In addition, definitions of nonfatal outcomes were variable, and methodological quality was low. There is a need to develop valid and reliable performance indicators based on each domain of Donabedian's framework to evaluate trauma care.
Background: Anemia is a prevalent condition in critically ill patients and red blood cell transfu... more Background: Anemia is a prevalent condition in critically ill patients and red blood cell transfusions are frequent. Although transfusions at low hemoglobin levels have been shown to be associated with equivalent or better outcomes than higher hemoglobin thresholds, clinical equipoise persists in patients with traumatic brain injury considering their susceptibility to secondary cerebral insults such as those from hypoxemia. Methods: Our objectives are to estimate the frequency of red blood cell transfusion in patients with traumatic brain injury and to evaluate transfusion thresholds, determinants and outcomes associated with transfusion strategies. We will conduct a systematic review of cohort studies and randomized controlled trials of patients with traumatic brain injury. We will search MEDLINE, Embase, BIOSIS and the Cochrane Library for eligible studies. Two independent reviewers will screen all identified references. Studies including adult patients with traumatic brain injury reporting data on red blood cell transfusions will be eligible. We will collect data on baseline demographics, trauma characteristics, hemoglobin thresholds, blood transfusions and clinical outcomes (mortality, length of stay, complications, and so on). Two independent reviewers will extract data using a standardized form. We will pool cumulative incidences using DerSimonian and Lair random-effect models after a Freeman-Tukey transformation to stabilize variances. We will pool risk ratios or mean differences with random-effect models and Mantel-Haenszel or inverse variance methods in order to evaluate the association between red blood cell transfusion and potential determinants or outcomes. Sensitivity and subgroup analysis according to timing of red blood cell transfusion, traumatic brain injury severity, year of conduction of the study, risk of bias, notably, are planned. Discussion: We expect to observe high heterogeneity in the proportion of transfused patients across studies and that the global proportion will be similar to the frequency observed in the general medical critically ill population. Our systematic review will allow us to better describe and understand current transfusion practices in patients with traumatic brain injury, a clinical population in which liberal transfusions are still advocated in the absence of evidence-based data. Systematic review registration: PROSPERO: CRD42014007402.
International Journal of Gynecology & Obstetrics, 2011
Objective: To evaluate the best available evidence regarding the association between single-layer... more Objective: To evaluate the best available evidence regarding the association between single-layer closure and uterine rupture. Methods: The PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched for relevant observational and experimental studies that included women with a previous single, low, transverse cesarean delivery who had attempted a trial of labor (TOL). The risks of uterine rupture and uterine dehiscence were assessed by pooled odds ratios (OR) calculated with a random effects model. Results: Nine studies including 5810 women were reviewed. Overall, the risk of uterine rupture during TOL after a single-layer closure was not significantly different from that after a double-layer closure (OR 1.71; 95% confidence interval [CI] 0.66-4.44). However, a sensitivity analysis indicated that the risk of uterine rupture was increased after a locked single-layer closure (OR 4.96; 95% CI 2.58-9.52, P b 0.001) but not after an unlocked single-layer closure (OR 0.49; 95% CI 0.21-1.16), compared with a double-layer closure. Conclusion: Locked but not unlocked single-layer closures were associated with a higher uterine rupture risk than doublelayer closure in women attempting a TOL.
Is hysterosalpingosonography (sono-HSG) an accurate test for diagnosing tubal occlusion in subfer... more Is hysterosalpingosonography (sono-HSG) an accurate test for diagnosing tubal occlusion in subfertile women and how does it perform compared with hysterosalpingography (HSG)? summary answer: sono-HSG is an accurate test for diagnosing tubal occlusion and performs similarly to HSG. what is known already: sono-HSG and HSG are both short, well-tolerated outpatient procedures. However, sono-HSG has the advantage over HSG of obviating ionizing radiation and the risk of iodine allergy, being associated with a greater sensitivity and specificity in detecting anomalies of the uterine cavity and permitting concomitant visualization of the ovaries and myometrium. study design, size, duration: A systematic review and meta-analysis of studies published in any language before 14 November 2012 were performed. All studies assessing the accuracy of sono-HSG for diagnosing tubal occlusion in a subfertile female population were considered. participants/materials, setting, methods: We searched Medline, Embase, Cochrane Library, Web of Science and Biosis as well as related articles, citations and reference lists. Diagnostic studies were eligible if they compared sono-HSG (+HSG) to laparoscopy with chromotubation in women suffering from subfertility. Two authors independently screened for eligibility, extracted data and assessed the quality of included studies. Risk of bias and applicability concerns were investigated according to the Quality Assessment of Diagnostic Accuracy Study (QUADAS-2). Bivariate random-effects models were used to estimate pooled sensitivity and specificity with their 95% confidence intervals (95% CIs), to generate summary receiver operating characteristic curves and to evaluate sources of heterogeneity. main results and the role of chance: Of the 4221 citations identified, 30 studies were eligible. Of the latter, 28 reported results per individual tube and were included in the meta-analysis, representing a total of 1551 women and 2740 tubes. In nine studies, all participants underwent HSG in addition to sono-HSG and laparoscopy, allowing direct comparison of the accuracy of sono-HSG and HSG. Pooled estimates of sensitivity and specificity of sono-HSG were 0.92 (95% CI: 0.82-0.96) and 0.95 (95% CI: 0.90-0.97), respectively. In nine studies (582 women, 1055 tubes), sono-HSG and HSG were both compared with laparoscopy, giving pooled estimates of sensitivity and specificity of 0.95 (95% CI: 0.78-0.99) and 0.93 (95% CI: 0.89-0.96) for sono-HSG, and 0.94 (95% CI: 0.74-0.99) and 0.92 (95% CI: 0.87-0.95) for HSG, respectively. Doppler sonography was associated with significantly greater sensitivity and specificity of sono-HSG compared with its non-use (0.93 and 0.95 versus 0.86 and 0.89, respectively, P ¼ 0.0497). Sensitivity analysis regarding methodological quality of studies was consistent with these findings. We also found no benefit of the commercially available contrast media over saline solution in regard to the diagnostic accuracy of sono-HSG. limitations, reasons for caution: Methodological quality varied greatly between studies. However, sensitivity analysis, taking methodological quality of studies into account, did not modify the results. This systematic review did not allow the distinction between distal and proximal occlusion. This could be interesting to take into account in further studies, as the performance of the test may differ for each localization. wider implications of the findings: Given our findings and the known benefits of sono-HSG over HSG in the context of subfertility, sono-HSG should replace HSG in the initial workup of subfertile couples.
Introduction: Accumulating evidence suggests that, in critically ill patients, a lower hemoglobin... more Introduction: Accumulating evidence suggests that, in critically ill patients, a lower hemoglobin transfusion threshold is safe. However, the optimal hemoglobin level and associated transfusion threshold remain unknown in neurocritically ill patients. Methods: We conducted a systematic review of comparative studies (randomized and nonrandomized) to evaluate the effect of hemoglobin levels on mortality, neurologic function, intensive care unit (ICU) and hospital length of stay, duration of mechanical ventilation, and multiple organ failure in adult and pediatric neurocritically ill patients. We searched MEDLINE, The Cochrane Central Register of Controlled Trials, Embase, Web of Knowledge, and Google Scholar. Studies focusing on any neurocritical care conditions were included. Data are presented by using odds ratios for dichotomous outcomes and mean differences for continuous outcomes. Results: Among 4,310 retrieved records, six studies met inclusion criteria (n = 537). Four studies were conducted in traumatic brain injury (TBI), one in subarachnoid hemorrhage (SAH), and one in a mixed population of neurocritically ill patients. The minimal hemoglobin levels or transfusion thresholds ranged from 7 to 10 g/dl in the lower-Hb groups and from 9.3 to 11.5 g/dl in the higher-Hb groups. Three studies had a low risk of bias, and three had a high risk of bias. No effect was observed on mortality, duration of mechanical ventilation, or multiple organ failure. In studies reporting on length of stay (n = 4), one reported a significant shorter ICU stay (mean,-11.4 days (95% confidence interval,-16.1 to-6.7)), and one, a shorter hospital stay (mean,-5.7 days (-10.3 to-1.1)) in the lower-Hb groups, whereas the other two found no significant association. Conclusions: We found insufficient evidence to confirm or refute a difference in effect between lower-and higher-Hb groups in neurocritically ill patients. Considering the lack of evidence regarding long-term neurologic functional outcomes and the high risk of bias of half the studies, no recommendation can be made regarding which hemoglobin level to target and which associated transfusion strategy (restrictive or liberal) to favor in neurocritically ill patients.
To review the ability of imaging techniques to predict incomplete healing of uterine cesarean sca... more To review the ability of imaging techniques to predict incomplete healing of uterine cesarean scars before the next pregnancy. A systematic literature review searched for studies on women who underwent previous low-transverse cesarean, evaluated by hysterography, sonohysterography (SHG), or transvaginal ultrasound (TVU). The median prevalence of scar defects was computed with 95% confidence intervals (95% CIs). Odds ratio (OR, 95% CI) identified risk factors of incomplete healing. The analysis included 21 studies. The proportions of suspected scar defects detected by hysterography, SGH, and TVU were 58% (33 to 70), 59% (58 to 85), and 37% (20 to 65), respectively. Two studies found that women with a large uterine scar defect had a higher risk of uterine rupture or uterine scar dehiscence than those with no scar defect or small scar defect (OR: 26.05 [2.36 to 287.61], p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). The only reported risk factor for scar defect was the occurrence of more than one previous cesarean (OR: 2.24 [1.13, 4.45], p = 0.02). Hysterography, SGH, and TVU can detect uterine scar defects in ~50% of women with previous cesarean.
There is a controversy regarding the benefits of periodontal treatment during pregnancy. We aimed... more There is a controversy regarding the benefits of periodontal treatment during pregnancy. We aimed to evaluate its effect on the risk of preterm birth and to explore the heterogeneity between studies. A systematic review and meta-analysis of randomized controlled trials were performed. Studies in which women were randomized for periodontal treatment versus no treatment were included. Pooled risk ratios (RRs) with their 95% confidence intervals (CIs) were calculated using random-effect models. A sensitivity analysis was performed. Twelve randomized trials were included in the meta-analysis. Pooled estimates showed no significant reduction of preterm birth with periodontal treatment (RR: 0.89; 95% CI: 0.73 to 1.08). However, the substantial heterogeneity among studies (I2 = 52%) could be explained either by the risk of bias, the level of income, or by the use of chlorhexidine mouthwashes as a cointervention. Daily use of chlorhexidine mouthwash was associated with a reduction of preterm birth (RR: 0.69; 95% CI 0.50 to 0.95), with moderate heterogeneity among the five studies included (I2 = 43%). There is an important heterogeneity between randomized trials that evaluated the effect of periodontal treatment on the risk of preterm birth. Chlorhexidine mouthwash as a preventive agent should be further evaluated.
To report the intra- and interobserver reliability of measurement of the lower uterine segment (L... more To report the intra- and interobserver reliability of measurement of the lower uterine segment (LUS) thickness using transvaginal sonographic videos. A prospective study of 60 women with previous, low-transverse cesarean undergoing LUS examination (36 to 39 weeks) was performed. Two observers independently measured full LUS thickness using transvaginal sonography. A video of the LUS was recorded and analyzed more than 2 months later by both observers. Intra- and interobserver reliability was assessed with median absolute differences and interquartile range (IQR), nonparametric limits of agreement, intraclass correlation coefficients (ICC) with 95% confidence interval (95% CI), and kappa coefficients. Median full LUS thickness was 3.6 mm (range: 0.9 to 8.0 mm). Intraobserver repeatability was excellent (median difference: 0.2 mm, IQR: 0.1 to 0.4; ICC: 0.94, 95% CI: 0.90 to 0.96; kappa: 1.00). Interobserver (median difference: 0.3 mm, IQR: 0.2 to 1.3; ICC: 0.91, 95% CI: 0.86 to 0.95; kappa: 0.76, 95% CI: 0.54 to 0.98) and intermethod reproducibility (median difference: 0.4 mm, IQR: 0.2 to 0.8; ICC: 0.82, 95% CI: 0.72 to 0.89; kappa: 0.69, 95% CI: 0.43 to 0.94) were good. However, both interobserver and intermethod reproducibility were improved when LUS thickness was below 3 mm. Full LUS thickness measured from transvaginal sonographic videos has excellent intra- and interobserver reproducibility and good reproducibility with live transvaginal ultrasound.
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