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International audience; The tapeworm Echinococcus multilocularis is the causative agent of alveolar echinococcosis, the most serious parasitic disease for humans in Europe. In Europe, the E. multilocularis lifecycle is based on a prey–predator relationship between the red fox and small rodents. Over the last three decades, the surveillance of E. multilocularis infection in red foxes has led to the description of a wider distribution pattern across Europe. France constitutes the current European western border, but only the north-eastern half of the country is considered endemic. The red fox is the host mainly targeted in E. multilocularis surveillance programmes, but surveys targeting small rodents may be useful for obtaining molecular data, especially when the time-consuming trapping is already carried out in dedicated pest-control programmes. Here, we screened for parasitic lesions in the livers of 1238 Arvicola terrestris voles originating from the historical, but neglected focal area located in central France (Auvergne region) and from Hautes-Alpes, a recently identified endemic department in south-eastern France. This screening identified six voles infected with E. multilocularis in Hautes-Alpes and none in Puy-de-Dôme (Auvergne region) after molecular confirmation. The absence of infected rodents from Puy-de-Dôme can be mainly explained by the generally low prevalence reported in intermediate hosts. The infected Hautes-Alpes samples come all from the same trapping site situated at around 5 km from one of the three fox faecal samples with E. multilocularis DNA collected 15 years prior, thereby confirming the existence and persistence of the E. multilocularis lifecycle in the area. All the rodent E. multilocularis samples from Hautes-Alpes showed the same EmsB microsatellite marker profile. This profile has previously been described in Europe only in the Jura department (central eastern France), located at least 180 km further north. Successive migrations of infected foxes from the historical focal area, including from Jura, to Hautes-Alpes may explain the detection of the parasite in A. terrestris in Hautes-Alpes. Existing trapping efforts in areas where farmers trap A. terrestris for surveillance and pest control can be an effective complement to sampling foxes or fox faeces to obtain E. multilocularis molecular profiles.

Objective To assess the choice and attitude of pregnant women regarding CMV serological screening and CMV prevention behaviors in pregnancy. Study design In this cross-sectional study, pregnant women were recruited in a single center during routine prenatal screening tests at 11–16 weeks. Participants filled out a questionnaire assessing knowledge about congenital CMV (cCMV) infection, risk perception and willingness to have CMV serological screening as well as their attitude toward CMV prevention behaviors. Results Among 234 pregnant women, 74.4 % (95 % confidence interval: 68.8–80.0 %) wanted CMV serological screening in pregnancy. The factors significantly associated with the desire for screening were perceived risk and perceived severity of cCMV. An informed choice regarding CMV screening (value-consistent, based on good knowledge and deliberated) was performed by 54 % of women who chose the screening and 30 % of women who declined the screening (p = 0.039). The median scores regarding attitudes toward CMV prevention behaviors were 3.7/5 for avoiding sharing behaviors and 4.0/5 for not kissing a child on the lips. Conclusion The majority of pregnant women want to have CMV serological screening once informed about congenital CMV infection. New tools need to be developed to allow for informed choice regarding CMV serological screening in pregnancy.

Using baseline data from a community-collaborative cohort of women living with HIV in Canada, we assessed the prevalence and correlates of help-seeking among 1,057 women who reported experiencing violence in adulthood (≥16 years). After violence, 447 (42%) sought help, while 610 (58%) did not. Frequently accessed supports included health care providers ( n = 313, 70%), family/friends ( n = 244, 55%), and non-HIV community organizations ( n = 235, 53%). All accessed supports were perceived as helpful. Independent correlates of help-seeking included reporting a previous mental health diagnosis, a history of injection drug use, experiencing childhood violence, and experiencing sexism. We discuss considerations for better supporting women who experience violence.

We wished to evaluate the efficacy, safety, and acceptability of cabergoline for lactation inhibition in women who live with HIV. In this multicenter prospective observational study, cabergoline was offered as a single oral dose of 1 mg within the first 48 h postpartum. Women were recruited if they delivered a live infant after 35 weeks of gestational age. Participants filled out a questionnaire regarding symptoms of lactation and cabergoline adverse effects on day 2 and day 14 postpartum. On day 14, they also completed a questionnaire about their satisfaction with cabergoline treatment. Prolactin serum level was measured on both visits. Among 68 participants, all but one received cabergoline. The overall effectiveness defined by partial or complete success at day 14 was 98.3% (confidence intervals: 89.5–99.9). At day 14, 67.4% of women who received cabergoline had prolactin serum levels

Objective There is no consensus on the use of cytomegalovirus (CMV)–specific hyperimmunoglobulins (CSHIGs) for suspected congenital CMV infections during pregnancy, but this therapy is currently used in some countries. The objectives of this study were to describe tolerability and pregnancy outcome following treatment with monthly intravenous CSHIG and compare rates of positive PCR and postnatal symptoms according to whether CSHIGs were given or not. Methods This retrospective cohort study included all pregnant women who were diagnosed with primary CMV infection or congenital CMV infection at the Centre Hospitalier Universitaire Sainte-Justine (Montreal, QC) between 2005 and 2016. CSHIG was discussed with pregnant women who received positive CMV PCR results from amniotic fluid or if ultrasound anomalies suggested congenital infection and there was serologic evidence of maternal primary infection (therapeutic group). CSHIG was also offered as prophylaxis in pregnant women without fetal ultrasound anomalies but with evidence of maternal primary infection, when amniocentesis either had negative results or was not performed (prophylactic group). A matched analysis was performed to control for timing of maternal infection, amniocentesis, and type and timing of ultrasound anomaly. Results Sixteen women received CSHIG, and 55 had no CMV-specific treatment. CSHIG treatment was well-tolerated. In bivariate analyses, the risk of congenital CMV infection and postnatal symptoms did not significantly decrease with CSHIG treatment, in both the therapeutic and the prophylactic groups. After matching, there was still no difference in outcomes between CSHIG-treated and untreated women. Conclusion The effectiveness of CSHIG in preventing congenital CMV infection and its clinical manifestations could not be demonstrated.

Background Women comprise nearly one-quarter of people living with human immunodeficiency virus (HIV) in Canada. Compared with men, women living with HIV experience inequities in HIV care and health outcomes, prompting a need for gendered and tailored approaches to HIV care. Method Peer and academic researchers from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study conducted focus groups to understand women's experience of seeking care, with the purpose of identifying key characteristics that define a women-centered approach to HIV care. Eleven focus groups were conducted with 77 women living with HIV across Quebec, Ontario, and British Columbia, Canada. Results Women envisioned three central characteristics of women-centered HIV care, including i) coordinated and integrated services that address both HIV and women's health care priorities, and protect against exclusion from care due to HIV-related stigma, ii) care that recognizes and responds to structural barriers that limit women's access to care, such as violence, poverty, motherhood, HIV-related stigma, and challenges to safe disclosure, and iii) care that fosters peer support and peer leadership in its design and delivery to honor the diversity of women's experiences, overcome women's isolation, and prioritize women's ownership over the decisions that affect their lives. Conclusion Despite advances in HIV treatment and care, the current care landscape is inadequate to meet women's comprehensive care needs. A women-centered approach to HIV care, as envisioned by women living with HIV, is central to guiding policy and practice to improve care and outcomes for women living with HIV in Canada.

I. Resume Objectif le virus de l'hepatite C (VHC) pose une menace de plus en plus serieuse a la sante publique a l'echelle mondiale. Les travailleurs de la sante qui s'occupent des femmes en âge de procreer sont particulierement bien places pour identifier un nombre important de femmes a risque et fournir les services de depistage et de counseling appropries. Le principal objectif de ces lignes directrices est de fournir une information exacte et a jour a tous ceux et celles qui prodiguent des soins de sante en reproduction aux femmes vivant avec le VHC. Ce document vise aussi a sensibiliser le monde medical et le grand public au probleme de l'hepatite C. Options ces lignes directrices ont ete elaborees en tenant compte des domaines suivants de la pratique clinique : la prevention des maladies, le depistage cible des individus a risque d'infection par le VHC, la prise en charge des patientes identifiees dans le contexte des soins de sante en reproduction et la bonne maniere de les diriger vers les soins specialises appropries. Resultats attendus la mise en pratique de ces lignes directrices devrait permettre de mieux identifier les femmes infectees et contribuer au mieux-etre physique et mental des patientes et de leur famille ainsi qu'a la reduction des taux de transmission. Evidence en utilisant MEDLINE, on a mene une recherche approfondie de la litterature medicale, publiee entre 1966 et 2000, en anglais aussi bien qu'en d'autres langues. En fevrier 2000, a Montreal, eut lieu une rencontre d'un groupe pluridisciplinaire compose d'experts dans les domaines de l'obstetrique et de la gynecologie, des maladies infectieuses, de l'hepatologie et de la sante publique. Ce groupe de travail comprenait aussi une patiente et un representant de la Societe de l'hepatite C du Canada. Le niveau d'evidence accompagnant chaque recommandation est base sur les criteres definis par le Groupe de travail canadien sur l'examen medical periodique. Avantages, desavantages et couts du point de vue de la sante publique, il y a des avantages importants a tirer d'une meilleure identification des individus a risque, du diagnostic, du traitement, de la mise en œuvre de pratiques reduisant le risque et les taux de transmission, a la fois au niveau de l'individu et de la collectivite. Cependant, il faut se rappeler que le diagnostic d'une maladie chronique peut entrainer des consequences tres serieuses pour les patientes et leur famille. Recommandations a)Depistage : le depistage universel du VHC n'est pas recommande. Cependant, un depistage selectif devrait etre offert a toutes les femmes qui appartiennent a une categorie quelconque de risque. Les tests devraient n'etre administres qu'apres un counseling approprie et le consentement eclaire de la patiente (III B). b)Soins precedant la conception et au stade precoce de la grossesse : •Idealement, une evaluation precedant la conception ou au stade precoce de la grossesse devrait comprendre le diagnostic du risque d'infection par l'hepatite C, le counseling et les tests necessaires (III B). •Les patientes qui sont conscientes d'un diagnostic positif de VHC devraient etre evaluees avant de devenir enceintes de maniere a identifier les complications qui pourraient compromettre la sante maternelle durant la grossesse (III B). •A elle seule, l'hepatite C ne constitue pas une contreindication de grossesse (Elle est toutefois contre-indiquee en cas de traitement a la ribavirine.) (III B). c)Soins durant la grossesse : •Le risque de transmission verticale est plus grand si la patiente est aussi infectee du virus de l'immunodeficience humaine (VIH) (II-2). •Les soins prenataux doivent satisfaire aux besoins particuliers selon la condition medicale et obstetricale de la patiente, y compris la surveillance de la fonction hepatique (II-2 A). •Les boissons alcooliques doivent etre evitees (II-2 A). •L'immunisation contre l'hepatite A et B selon le besoin (II-2 A). •La cesarienne systematique n'est pas recommandee comme moyen specifique de reduire le risque de transmission verticale de l'hepatite C au moment de la naissance (II-2 D). •L'allaitement n'est pas contre-indique (II-3 B). d)Soins des nouveau-nes : •Tous les enfants nes de meres porteuses du VHC doivent etre examines pour depister la presence de l'hepatite C (III A). e)Contraception et hormonotherapie substitutive : •Il faut recommander aux femmes qui ont des partenaires sexuels multiples d'utiliser des methodes contraceptives de type barriere (II-3 B). •Avant d'envisager la possibilite d'utiliser un contraceptif hormonal ou de suivre une hormonotherapie substitutive, il faut evaluer soigneusement l'etendue de la maladie du foie (III B). f)Precautions universelles : •De maniere a proteger les travailleurs de la sante aussi bien que les patientes, on recommande le recours a certaines precautions universelles/pratiques systematiques et autres precautions pour toutes les patientes (II-2 A). Validation Les references bibliographiques ont ete recueillies a partir de MEDLINE et on a compare les presentes directives a celles en vigueur afin d'en assurer la coherence. Des examinateurs externes, experts dans leurs domaines respectifs, ont aussi ete consultes.

Building on the one hand on the link between immersion and peripheral vision, and on the other hand on the visually induced perceptual illusion of self-motion (vection), the author examines synesthesia through the relationship between peripheral vision and proprioception. The author maintains that immersion in installations results from multimodal perception grounded in motor-sensory activity, and he considers installations and scenographies in which the viewer’s peripheral vision, balance, motion and posture play an important role.

The parasitic species of the Echinococcus granulosus sensu lato (sl) complex are the causative agents of cystic echinococcosis in humans. The lifecycle of E. granulosus sl is essentially domestic, and is based on the consumption by dogs of hydatid cysts in viscera of livestock species. The aim of this study was to survey E. granulosus sensu lato in livestock in France. A 1-year national survey of E. granulosus sl in livestock at the slaughterhouse was organized in 2012 in France, with systematic molecular confirmation. The prevalence of E. granulosus ss nationally was 0.002% in sheep, mainly focused in the Alpine area, and 0.001% in cattle, with the distribution of cases throughout the country. Echinococcus canadensis G6/7 was observed only in Corsica in pigs, with a prevalence of nearly 1% in the island. A national prevalence of 0.0002% was estimated for E. ortleppi in cattle, due to seven cases distributed in two foci. The results of this survey are of particular interest because of the zoonotic risk associated with the presence of these parasite species, for which systematic control at the slaughterhouse should enable their elimination.

International audience; BackgroundOral vaccination with Mycobacterium bovis Bacille of Calmette and Guerin (BCG) has provided protection against M. bovis to badgers both experimentally and in the field. There is also evidence suggesting that the persistence of live BCG within the host is important for maintaining protection against TB. Here we investigated the capacity of badger inductive mucosal sites to absorb and maintain live BCG. The targeted mucosae were the oropharyngeal cavity (tonsils and sublingual area) and the small intestine (ileum).ResultsWe showed that significant quantities of live BCG persisted within badger in tissues of vaccinated badgers for at least 8 weeks following oral vaccination with only very mild pathological features and induced the circulation of IFNγ-producing mononuclear cells. The uptake of live BCG by tonsils and drainage to retro-pharyngeal lymph nodes was repeatable in the animal group vaccinated by oropharyngeal instillation whereas those vaccinated directly in the ileum displayed a lower frequency of BCG detection in the enteric wall or draining mesenteric lymph nodes. No faecal excretion of live BCG was observed, including when BCG was delivered directly in the ileum.ConclusionsThe apparent local loss of BCG viability suggests an unfavorable gastro-enteric environment for BCG in badgers, which should be taken in consideration when developing an oral vaccine for use in this species.

BackgroundOutcome of congenital cytomegalovirus (cCMV) infection in the absence of routine CMV screening and third-trimester scan in North America is scarcely documented. The aim of this study was to assess the severe outcomes related to cCMV according to the indication for screening.MethodsThis was a retrospective study of 84 mother-child pairs followed for cCMV between 2003 and 2017 at CHU Sainte-Justine in Montreal, Canada. Prenatal ultrasound, neonatal symptoms, neuroimaging and severe outcomes (cerebral palsy, severe cognitive impairment, bilateral hearing loss or neonatal death) were reviewed.ResultsAmong 38 cases with abnormal prenatal ultrasound, 41.9% of live-born infants developed severe outcomes. Sixteen (42.1%) were detected in the third trimester. Among 16 cases diagnosed prenatally because of maternal history, all had normal prenatal ultrasound, and none developed severe outcomes. Among cases diagnosed postnatally because of neonatal symptoms, 25% developed severe outcomes. All infants who developed severe outcomes had moderate/severe neonatal symptoms.ConclusionOutcome of cCMV infection varies according to the reason for screening and timing of diagnosis. Any prenatal ultrasound anomaly might indicate a risk of severe outcome, and warrants a detailed ultrasound scan. However, late detection, or postnatal diagnosis, represented more than half of the cases, and awareness of this will help ensuring optimal management.

Background Early antiretroviral therapy (ART) during pregnancy has dramatically reduced the risk of perinatal HIV transmission. However, studies have shown an association between premature delivery and the use of ART during pregnancy (particularly protease inhibitor (PI)-based therapies), which could be explained by placental dysfunction. The objective of this study was to evaluate the association of ART (class, duration of exposure and time of initiation) with placental function by using angiogenic factors placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) as biomarkers. Methods Clinical and biological data from 159 pregnant women living with HIV were analyzed. Levels of each biomarker were measured in the first and second trimester of pregnancy. After logarithmic transformation, we compared these using generalized estimating equations according to (a) the type of ART; (b) the duration of exposure to ART; and (c) the time of initiation of ART. Results After adjusting for variables such as ethnicity, maternal age, gestational age, body mass index, parity, smoking status, and sex of the fetus, we found no significant association between the class of ART (PI-based or not) and serum concentrations of PlGF or sFlt-1. Furthermore, no significant association was found between biomarker levels and the duration of ART exposure or the timing of ART initiation (pre- or post-conception). Conclusions This study suggests that first and second trimester angiogenic factor levels are not significantly associated with ART, regardless of the duration or type (with or without PI). These observations seem reassuring when considering the use of ART during early pregnancy.

Objective Little is known about pregnancy outcomes among women who have acquired human immunodeficiency virus (HIV) through perinatal infection and survived into adulthood. The objectives of this study were to describe pregnancy outcomes among women with perinatal HIV infection (PHIV) in Canada and to identify potential challenges in the prevention of perinatal HIV transmission in this population. Methods A retrospective review of all pregnancies among women with PHIV who were previously followed as children at two tertiary care centres in Montreal, Quebec, was conducted. Data were extracted from pediatric and obstetrical records. Results There were 21 pregnancies among 11 women, and 18 of these pregnancies were unintentional. Mean age at first pregnancy was 19.5 years (range 15–29 years). At the first prenatal visit, 79% had a detectable viral load, 36% were immunosuppressed (CD4 T cell count Conclusion Unplanned pregnancies, difficulties with adherence to ART, and drug resistance were identified challenges in the management of pregnancies among women with PHIV. This study highlights a gap in the reproductive counselling of adolescents with PHIV and the need for close follow-up and adherence support during pregnancy in this population.

Resume Objectif Analyser les donnees probantes et formuler des recommandations quant au depistage et a la prise en charge de la candidose vulvovaginale, de la trichomonase et de la vaginose bacterienne. Issues Parmi les issues evaluees, on trouve l'efficacite de l'antibiotherapie, les taux de guerison en ce qui concerne les infections simples et compliquees, et les implications de ces pathologies pendant la grossesse. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans MEDLINE, EMBASE, CINAHL et The Cochrane Library en juin 2013 au moyen d'un vocabulaire controle (p. ex. « vaginitis », « trichomoniasis », « vaginal candidiasis ») et de mots cles (p. ex. « bacterial vaginosis », « yeast », « candidiasis », « trichomonas vaginalis », « trichomoniasis », « vaginitis », « treatment ») appropries. Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Aucune restriction n'a ete appliquee en matiere de date, mais les resultats ont ete limites aux documents rediges en anglais ou en francais. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en mai 2014. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats est evaluee au moyen des criteres decrits par le Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). Declarations Sommaires 1.La candidose vulvovaginale affecte 75 % des femmes a au moins une reprise. Les azoles antifongiques topiques et oraux comptent une efficacite equivalente. (I) 2.Pour etre qualifiee de recurrente, la candidose vulvovaginale doit donner lieu a quatre episodes ou plus par annee. (II-2) 3.Trichomonas vaginalis est un organisme a l'origine d'une infection transmissible sexuellement non virale courante. Le depistage des antigenes (ecouvillonnages vaginaux analyses au moyen d'un immunoessai ou d'un test d'amplification des acides nucleiques) constitue la meilleure facon d'en detecter la presence. (II-2) 4.La prise en charge de la trichomonase au moyen de metronidazole oral, que ce soit a raison de 2 g en une dose unique ou de 500 mg deux fois par jour pendant 7 jours, permet l'obtention de taux de guerison equivalents pouvant atteindre 88 %. Le traitement du partenaire, meme sans depistage prealable, ameliore les taux de guerison. (I-A) 5.Les donnees probantes dont nous disposons a l'heure actuelle quant a l'efficacite des traitements de medecine parallele contre la vaginose bacterienne (probiotiques, vitamine C) sont limitees. (I) Recommandations 1.A la suite du traitement initial, la reussite de la prise en charge de la candidose vulvovaginale recurrente est favorisee par la mise en œuvre d'un traitement d'entretien hebdomadaire au fluconazole oral pendant une periode pouvant atteindre six mois. (II-2A) 2.La resolution de la candidose vulvovaginale symptomatique prise en charge au moyen d'azoles topiques pourrait necessiter un traitement d'une duree prolongee. (1-A) 3.A la suite de la prise en charge de la trichomonase au moyen de metronidazole oral, la tenue d'un test de guerison n'est pas recommandee. (I-D) 4.Le recours a des doses accrues pourrait etre requis dans les cas de trichomonase qui presentent une resistance au traitement. (I-A) 5.En presence d'une infection a Trichomonas vaginalis symptomatique pendant la grossesse, la prevention de l'accouchement preterme justifie la mise en œuvre d'un traitement au metronidazole oral. (I-A) 6.La vaginose bacterienne devrait etre diagnostiquee au moyen de criteres cliniques (Amsel) ou de laboratoire (coloration de Gram et systeme objectif de notation). (II-2A) 7.La vaginose bacterienne symptomatique devrait etre prise en charge au moyen de metronidazole oral, a raison de 500 mg deux fois par jour pendant sept jours. Parmi les solutions de rechange, on trouve le gel vaginal de metronidazole et la clindamycine (comprimes oraux ou creme vaginale). (I-A) 8.Chez les femmes qui presentent de multiples recurrences documentees, la prolongation du traitement contre la vaginose bacterienne est recommandee. (I-A)

Objective: To evaluate the association of antiretroviral therapy (ART) type and duration of exposure with early placental function using biomarkers of aneuploidy screening. Study design: Three hundred thirty-eight pregnant women living with HIV were enrolled in two Canadian centers. Multiple linear regressions were performed adjusting for confounding factors (race, age, gestational age, body mass index, parity, smoking, and fetal sex). Results: Women receiving ART had significantly increased second trimester alpha-fetoprotein (AFP) levels (β = 0.147, 95% CI = [0.067–0.227] for protease inhibitor-based ART and β = 0.176, 95% CI = [0.080–0.272] for ART without protease inhibitor) compared to women who received no treatment. However, there was no significant association between ART type and the levels of free β-human chorionic gonadotrophin (β-hCG), pregnancy-associated plasma protein-A (first trimester), unconjugated estriol, total hCG, and inhibin A (second trimester). No significant association was shown between biomarker levels and duration of ART exposure. Conclusion: Early placental function does not appear to be significantly affected by ART, except for AFP.

Objective To review the evidence and provide recommendations on antibiotic prophylaxis for gynaecologic procedures. Outcomes Outcomes evaluated include need and effectiveness of antibiotics to prevent infections in gynaecologic procedures. Evidence Medline and The Cochrane Library were searched for articles published between January 1978 and January 2011 on the topic of antibiotic prophylaxis in gynaecologic procedures. Results were restricted to systematic reviews, randomized control trials/ controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to June 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of evidence obtained was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1). Benefits, harms, and costs Guideline implementation should result in a reduction of cost and related harm of administering antibiotics when not required and a reduction of infection and related morbidities when antibiotics have demonstrated a proven benefit. Recommendations 1.All women undergoing an abdominal or vaginal hysterectomy should receive antibiotic prophylaxis. (I-A) 2.All women undergoing laparoscopic hysterectomy or laparoscopically assisted vaginal hysterectomy should receive prophylactic antibiotics. (III-B) 3.The choice of antibiotic for hysterectomy should be a single dose of a first-generation cephalosporin. If patients are allergic to cephalosporin, then clindamycin, erythromycin, or metronidazole should be used. (I-A) 4.Prophylactic antibiotics should be administered 15 to 60 minutes prior to skin incision. No additional doses are recommended. (I-A) 5.If an open abdominal procedure is lengthy (e.g., > 3 hours), or if the estimated blood loss is > 1500 mL, an additional dose of the prophylactic antibiotic may be given 3 to 4 hours after the initial dose. (III-C) 6.Antibiotic prophylaxis is not recommended for laparoscopic procedures that involve no direct access from the abdominal cavity to the uterine cavity or vagina. (l-E) 7.All women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence should receive a single dose of firstgeneration cephalosporin. (III-B) 8.Antibiotic prophylaxis is not recommended for hysteroscopic surgery. (II-2D) 9.All women undergoing an induced (therapeutic) surgical abortion should receive prophylactic antibiotics to reduce the risk of postabortal infection. (I-A) 10.Prophylactic antibiotics are not suggested to reduce infectious morbidity following surgery for a missed or incomplete abortion. (I-E) 11.Antibiotic prophylaxis is not recommended for insertion of an intrauterine device. (I-E) However, health care professionals could consider screening for sexually transmitted infections in high-risk populations. (III-C) 12.There is insufficient evidence to support the use of antibiotic prophylaxis for an endometrial biopsy. (III-L) 13.The best method to prevent infection after hysterosalpingography is unknown. Women with dilated tubes found at the time of hysterosalpingography are at highest risk, and prophylactic antibiotics (e.g., doxycycline) should be given. (II-3B) 14.Antibiotic prophylaxis is not recommended for urodynamic studies in women at low risk, unless the incidence of urinary tract infection post-urodynamics is > 10%. (1-E) 15.In patients with morbid obesity (BMI > 35 kg/m 2 ), doubling the antibiotic dose may be considered. (III-B) 16Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary procedure. (III-E)

The use of antiretroviral therapy (ART) has led to a marked reduction in the incidence of perinatal transmission of HIV. With ART, it is possible for the viral load to be reduced to undetectable levels during pregnancy. However, some patients (eg, those with poor adherence or those who acquired HIV during pregnancy) may still exhibit high viral loads by the third trimester. The purpose of this study was to examine the effect of raltegravir in a combination ART regimen in a series of 11 cases in which women presented with high viral loads in the third trimester of pregnancy., OBJECTIVE: To describe the impact of initiating raltegravir (RAL)-containing combination antiretroviral therapy (cART) regimens on HIV viral load (VL) in pregnant women who have high or suboptimal VL suppression late in pregnancy. METHODS: HIV-infected pregnant women who started RAL-containing cART after 28 weeks’ gestation from 2007 to 2013 were identified in two university hospital centres. RESULTS AND DISCUSSION: Eleven HIV-infected women started RAL at a median gestational age of 35.7 weeks (range 31.1 to 38.0 weeks). Indications for RAL initiation were late presentation in pregnancy (n=4) and suboptimal VL suppression secondary to poor adherence or viral resistance (n=7). Mean VL at the time of RAL initiation was 73,959 copies/mL (range

Background Immunization of pregnant women with tetanus-diphtheria-acellular pertussis vaccine (Tdap) provides protection against pertussis to the newborn infant. Methods In a randomized, controlled, observer-blind, multicenter clinical trial, we measured the safety and immunogenicity of Tdap during pregnancy and the effect on the infant's immune response to primary vaccination at 2, 4, and 6 months and booster vaccination at 12 months of age. A total of 273 women received either Tdap or tetanus-diphtheria (Td) vaccine in the third trimester and provided information for the safety analysis and samples for the immunogenicity analyses; 261 infants provided serum for the immunogenicity analyses. Results Rates of adverse events were similar in both groups. Infants of Tdap recipients had cord blood levels that were 21% higher than maternal levels for pertussis toxoid (PT), 13% higher for filamentous hemagglutinin (FHA), 4% higher for pertactin (PRN), and 7% higher for fimbriae (FIM). These infants had significantly higher PT antibody levels at birth and at 2 months and significantly higher FHA, PRN, and FIM antibodies at birth and 2 and 4 months, but significantly lower PT and FHA antibody levels at 6 and 7 months and significantly lower PRN and FIM antibody levels at 7 months than infants whose mothers received Td. Differences persisted prebooster at 12 months for all antigens and postbooster 1 month later for PT, FHA, and FIM. Conclusions This study demonstrated that Tdap during pregnancy results in higher levels of antibodies early in infancy but lower levels after the primary vaccine series. Clinical trials registration NCT00553228.

I. Abstract Objective hepatitis C virus (HCV) is an increasingly important public health problem worldwide. Health care workers providing care to women of childbearing age are uniquely placed in their practices to identify a significant proportion of at-risk patients and to provide appropriate screening and counselling. The primary objective of this guideline is to provide accurate, current information to those offering reproductive care to women living with HCV. This document is also intended to raise awareness of HCV in both the medical and general populations. Options the areas of clinical practice considered in formulating this guideline are disease prevention, targeted screening of individuals at risk of contracting HCV, management of identified patients in the context of reproductive care, and the appropriate referral of patients to those with particular expertise. Outcomes implementation of these guidelines should facilitate identification of infected individuals. It should also result in improved physical and mental well-being for patients and their families and reduction in transmission rates. Evidence the literature between 1966 and 2000, including non- English language publications, was extensively searched utilizing Medline. A multidisciplinary group consisting of experts within the fields of obstetrics and gynaecology, infectious diseases, hepatology, and public health convened in Montreal in February 2000. The working group also included a patient and a representative from the Hepatitis C Society of Canada. The level of evidence for the recommendations has been determined using the criteria described by the Canadian Task Force on Periodic Health Examination. Benefits, harms and costs the public health benefits of increased identification of at-risk individuals, diagnosis, treatment, implementation of risk reduction behaviours, and reduced transmission rates, both on an individual and at the community level, are significant. However, it must be remembered that the diagnosis of a chronic disease may have far reaching effects for the individual patient and her family. Recommendations a)Screening •Universal screening for HCV is not recommended, although targeted screening should be offered to all women falling into any at-risk category. Testing should take place following adequate counselling and informed consent of the patient (III B). b)Preconception and early pregnancy care •Ideally, preconception or early pregnancy evaluation should include determination of risk of infection with hepatitis C, counselling, and testing as appropriate (III B). •Patients aware of their HCV positive diagnosis should be evaluated before embarking on pregnancy for complications that may compromise maternal health during pregnancy (III B). •Pregnancy is not generally contraindicated on grounds of HCV infection alone (Although it is contraindicated in the context of ribavirin therapy.) (III B). c)Care during pregnancy •There is a risk of vertical transmission which is greater if the woman is also infected with human immunodeficiency virus (HIV) (II-2 A). •Antenatal care will need to be tailored individually to meet the specific needs of the woman's medical and obstetrical condition, including the monitoring of liver function (II-2 A). •Alcohol should be avoided (II-2 A). •Immunization against hepatitis A and B should be provided as required (II-2 A). •Routine Caesarean section is not recommended as a specific intrapartum measure to reduce the risk of vertical transmission of hepatitis C (II-2 D). •Breastfeeding is not contraindicated (II-3 B). d)Care of infant •All infants born to HCV positive mothers should be evaluated for evidence of hepatitis C infection (III A). e)Contraception and hormone replacement therapy •Barrier methods should be recommended to those with multiple sexual partners (II-3 B). •The extent of liver disease should be carefully evaluated before considering the use of hormonal contraception or hormone replacement therapy (III B). f)Universal precautions •Universal precautions/routine practices and additional precautions are recommended in dealing with all patients for the protection of both health care worker and patient (II-2 A). Validation references were collected through Medline searches and comparison made to existing current guidelines for assessment of consistency. External reviewers expert in their field were also consulted.

Objective This guideline reviews the evidence relating to the care of pregnant women living with HIV and the prevention of perinatal HIV transmission. Prenatal care of pregnancies complicated by HIV infection should include monitoring by a multidisciplinary team with experts in this area. Outcomes Outcomes evaluated include the impact of HIV on pregnancy outcome and the efficacy and safety of antiretroviral therapy and other measures to decrease the risk of vertical transmission. Evidence Published literature was retrieved through searches of PubMed and The Cochrane Library in 2012 and 2013 using appropriate controlled vocabulary (HIV, anti-retroviral agents, pregnancy, delivery) and key words (HIV, pregnancy, antiretroviral agents, vertical transmission, perinatal transmission). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English or French. There were no date restrictions. Searches were updated on a regular basis and incorporated in the guideline to June 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

Resume Objectif La presente directive clinique passe en revue les donnees probantes traitant des soins a offrir aux femmes enceintes vivant avec le VIH et de la prevention de la transmission perinatale du VIH. Les soins prenataux a offrir dans le cadre de grossesses compliquees par une infection par le VIH devraient comprendre un suivi mene par une equipe multidisciplinaire comptant des specialistes du domaine. Issues Parmi les issues evaluees, on trouve l'effet du VIH sur l'issue de la grossesse, ainsi que l'efficacite et l'innocuite du traitement antiretroviral, et celles d'autres mesures visant a attenuer le risque de transmission verticale. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans PubMed et The Cochrane Library en 2012 et en 2013 au moyen d'un vocabulaire controle (p. ex. « HIV », « anti-retroviral agents », « pregnancy », « delivery ») et de mots cles (p. ex. « HIV », « pregnancy », « antiretroviral agents », « vertical transmission », « perinatal transmission ») appropries. Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles rediges en anglais ou en francais. Aucune restriction n'a ete imposee en matiere de date. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en juin 2013. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales Valeurs La qualite des resultats est evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1)

Cystic echinococcosis (CE) is a parasitic zoonosis widespread in the Mediterranean area. The parasite is commonly maintained in a domestic cycle involving dogs and livestock species. As no new data have been made available for the last 15 years concerning the French Mediterranean island of Corsica, a cross-sectional survey at the slaughterhouse was conducted in 2009–2010 to describe the current presence of Echinococcus granulosus sensu lato in intermediate hosts. Only pig infections with the G6/7 genotype of Echinococcus canadensis were observed. No infection was detected in other breeding species but this should be interpreted with caution because 75% of the cows inspected during the survey were calves, and all sheep and goats were younger than two months old. In parallel four wild boars harvested during the 2010–2011 hunting season were also infected by the same genotype. These data constitute the first report of E. canadensis in France and the first molecular characterization of E. granulosus sensu lato in a wild species in France. The current prevalence observed in pigs (5.9%, n = 2527) highlights the fact that CE is still of economic concern on Corsica, an island where certain regional products are produced using pig's liver (“Figatelli”). This prevalence, and the similar one observed in wild boars (4.0%, n = 101), is a consequence of certain breeding practices and hunting practices which enable circulation of the parasite in the environment in close contact with humans.

Intrauterine devices provide an extremely effective, long-term form of contraception that has the benefit of being reversible. Historically, the use of certain intrauterine devices was associated with increased risk of pelvic inflammatory disease. More recent evidence suggests that newer devices do not carry the same threat; however, certain risk factors can increase the possibility of infection.To review the risk of infection with the insertion of intrauterine devices and recommend strategies to prevent infection.The outcomes considered were the risk of pelvic inflammatory disease, the impact of screening for bacterial vaginosis and sexually transmitted infections including chlamydia and gonorrhea; and the role of prophylactic antibiotics.Published literature was retrieved through searches of PubMed, Embase, and The Cochrane Library on July 21, 2011, using appropriate controlled vocabulary (e.g., intrauterine devices, pelvic inflammatory disease) and key words (e.g., adnexitis, endometritis, IUD). An etiological filter was applied in PubMed. The search was limited to the years 2000 forward. There were no language restrictions. Grey (unpublished) literature was identified through searching the web sites of national and international medical specialty societies.The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table). Recommendations 1. All women requesting an intrauterine device should be counselled about the small increased risk of pelvic inflammatory disease in the first 20 days after insertion. (II-2A) 2. All women requesting an intrauterine device should be screened by both history and physical examination for their risk of sexually transmitted infection. Women at increased risk should be tested prior to or at the time of insertion; however, it is not necessary to delay insertion until results are returned. (II-2B) 3. Not enough current evidence is available to support routine screening for bacterial vaginosis at the time of insertion of an intrauterine device in asymptomatic women. (II-2C) 4. Routine use of prophylactic antibiotics is not recommended prior to intrauterine device insertion, although it may be used in certain high-risk situations. (I-C) 5. Standard practice includes cleansing the cervix and sterilizing any instruments that will be used prior to and during insertion of an intrauterine device. (III-C) 6. In treating mild to moderate pelvic inflammatory disease, it is not necessary to remove the intrauterine device during treatment unless the patient requests removal or there is no clinical improvement after 72 hours of appropriate antibiotic treatment. In cases of severe pelvic inflammatory disease, consideration can be given to removing the intrauterine device after an appropriate antibiotic regimen has been started. (I-B) 7. An intrauterine device is a safe, effective option for contraception in an HIV-positive woman. (I-B) 8. An intrauterine device can be considered a first-line contraceptive agent in adolescents. (I-A).

Ankylosing spondylitis (AS) is a chronic progressive multisystemic disease. Patients with AS present a specific set of anesthesia-related challenges, and the parturient with AS presents particular anesthetic considerations. We report our experience with a parturient with advanced AS and offer a novel explanation for the high incidence of epidural failures in this patient population.We present the case of a 36-yr-old primigravida parturient with a very difficult airway and a history of severe AS. The initial treatment plan was to use a continuous epidural for labour analgesia. Despite two successful placements of lumbar epidural catheters, adequate rostral spread of local anesthesia to control her labour pain was never achieved via the epidural route. Thus, continuous spinal anesthesia was used, which provided effective labour analgesia in this patient.We hypothesize that this patient's advanced calcified posterior longitudinal ligament caused a physical barrier to rostral spread of local anesthesia solution within her epidural space. This hypothesis is supported by a recent study highlighting the importance of this ligament in allowing adequate distribution of solution within the epidural space. In addition, the successful use of continuous spinal analgesia adds to the growing body of literature supporting the safety and efficacy of intrathecal catheters for labour analgesia in specific situations.

The aim of this paper is the association of a new variant of Hyperanalytic Wavelet Transform (HWT) with a maximum a posteriori (MAP) filter, named bishrink for the denoising of images affected by additive white Gaussian noise (AWGN). The best results are obtained with the biorthogonal mother wavelets Daubechies 9/7.

Resume Objectif Analyser les resultats et formuler des recommandations sur le recours a l'antibioprophylaxie dans le cadre d'interventions obstetricales. Issues Parmi les issues evaluees, on trouve la necessite et l'efficacite du recours a des antibiotiques aux fins de la prevention des infections dans le cadre d'interventions obstetricales. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans Medline et The Cochrane Library au moyen de la rubrique « antibioprophylaxie dans le cadre d'interventions obstetricales ». Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Les recherches ont ete mises a jour de facon reguliere et les articles publies entre janvier 1978 et juin 2009 ont ete incorpores a la directive clinique. Les lignes directrices actuellement publiees par le American College of Obstetrics and Gynecology ont egalement ete incorporees a la directive clinique. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs Les resultats obtenus ont ete analyses et evalues par le comite sur les maladies infectieuses de la Societe des obstetriciens et gynecologues du Canada sous la gouverne des auteures principales, et les recommandations ont ete formulees conformement aux lignes directrices elaborees par le Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). Avantages, desavantages et couts La mise en œuvre de la presente directive clinique devrait reduire les couts et les torts attribuables a l'administration d'antibiotiques lorsque celle-ci ne s'avere pas requise, ainsi que les torts attribuables a la non-administration d'antibiotiques lorsque ceux-ci pourraient s'averer benefiques. Declarations sommaires 1.Les donnees disponibles ne soutiennent pas le recours a l'antibioprophylaxie en vue d'attenuer la morbidite infectieuse a la suite d'un accouchement vaginal operatoire. (II-1) 2.Nous ne disposons pas de donnees suffisantes pour soutenir ou deconseiller le recours a l'antibioprophylaxie en vue d'attenuer la morbidite infectieuse dans les cas de retrait manuel du placenta. (III) 3.Nous ne disposons pas de donnees suffisantes pour soutenir ou deconseiller le recours a l'antibioprophylaxie au moment de la dilatation-curetage postpartum visant des produits de conception en retention. (III) 4.Les donnees disponibles ne soutiennent pas le recours a l'antibioprophylaxie en vue d'attenuer la morbidite infectieuse a la suite d'un cerclage planifie ou d'urgence. (II-3) Recommandations 1.Toutes les femmes qui subissent une cesarienne planifiee ou d'urgence devraient se voir administrer une antibioprophylaxie. (I-A) 2.Une dose unique d'une cephalosporine de premiere generation devrait constituer l'antibiotique a privilegier pour ce qui est des cesariennes. Lorsque la patiente presente une allergie a la penicilline, on peut avoir recours a la clindamycine ou a l'erythromycine. (I-A) 3.Dans le cas de la cesarienne, l'antibioprophylaxie devrait etre administree de 15 a 60 minutes avant l'incision de la peau. Aucune dose additionnelle n'est recommandee. (I-A) 4.Lorsqu'une intervention a abdomen ouvert est de longue duree (>3 heures) ou que la perte sanguine estimee est superieure a 1 500 ml, une dose additionnelle d'antibiotique prophylactique peut etre administree de 3 a 4 heures a la suite de la dose initiale. (III-L) 5.L'administration d'une antibioprophylaxie peut etre envisagee pour attenuer la morbidite infectieuse associee a la reparation d'une lesion perineale du troisieme ou du quatrieme degre. (I-B) 6.Chez les patientes massivement obeses (IMC > 35), il est possible d'envisager le doublement de la dose d'antibiotiques. (III-B) 7.L'administration d'antibiotiques aux seules fins de prevenir l'endocardite ne devrait pas etre mise en œuvre chez les patientes qui doivent subir une intervention obstetricale, quelle qu'en soit la nature. (III-E)

Resume Objectifs Analyser les principes du diagnostic prenatal de l'infection congenitale a cytomegalovirus (CMV) et decrire les issues des grossesses affectees. Issues Prise en charge efficace de l'infection fœtale a la suite d'une infection a CMV maternelle primaire et secondaire pendant la grossesse. Parmi les symptomes neonataux, on trouve le retard de croissance intra-uterin (RCIU), la microcephalie, l'hepatosplenomegalie, les petechies, l'ictere, la chorioretinite, la thrombocytopenie et l'anemie; parmi les sequelles a long terme, on trouve la surdite de perception, la deficience mentale, le retard du developpement psychomoteur et la deficience visuelle. La presente directive clinique offre un cadre pour le diagnostic et la prise en charge des infections a CMV soupconnees. Resultats Des recherches ont ete menees dans Medline en vue d'en tirer les articles publies en anglais, entre 1966 et 2009, au moyen d'un vocabulaire controle (infection congenitale a CMV) et de mots cles (retard de croissance intra-uterin, microcephalie) appropries. Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Les recherches ont ete regulierement mises a jour et leurs resultats ont ete incorpores a la directive clinique. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Recommandations La qualite des resultats signales dans le present document a ete evaluee au moyen des criteres d'evaluation des resultats decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). 1.Le diagnostic de l'infection a cytomegalovirus (CMV) maternelle primaire pendant la grossesse devrait etre fonde sur l'apparition de novo d'IgG propre au virus dans le serum d'une femme enceinte qui etait auparavant seronegative ou sur la detection d'anticorps IgM specifiques associes a de l'IgG de faible avidite. (II-2A) 2.En presence d'une infection maternelle primaire, les parents devraient etre avises du risque (de 30 % a 40 %) de transmission intra-uterine et d'infection fœtale, et du risque (de 20 % a 25 %) de voir apparaitre des sequelles postnatales lorsque le fœtus est infecte. (II-2A) 3.Le diagnostic prenatal de l'infection a CMV fœtale devrait etre fonde sur l'amniocentese, laquelle devrait etre menee au moins sept semaines a la suite du moment presume de l'infection maternelle et apres la 21 e semaine de gestation. Cet intervalle est important puisqu'il faut de cinq a sept semaines a la suite de l'infection fœtale et de la replication subsequente du virus dans le rein pour qu'une quantite detectable de virus soit secretee dans le liquide amniotique. (II-2A) 4.Le diagnostic de l'infection secondaire devrait etre fonde sur une hausse considerable du titre des anticorps IgM avec ou sans la presence d'anticorps IgM specifiques et en presence d'IgG de forte avidite. Dans les cas etablis d'infection secondaire, le recours a l'amniocentese peut etre envisage, mais le rapport risque–avantage est different en raison du faible taux de transmission. (III-C) 5.A la suite d'un diagnostic d'infection a CMV fœtale, des examens echographiques en serie devraient etre menes toutes les deux a quatre semaines afin de demeurer a l'affut des anomalies echographiques qui pourraient contribuer a la determination du pronostic fœtal; cependant, il est important d'etre conscient que l'absence de constatations echographiques ne garantit pas l'obtention d'une issue normale. (II-2B) 6.La determination quantitative de l'ADN de CMV dans le liquide amniotique peut contribuer a la prediction de l'issue fœtale. (II-3B) 7.Le depistage serologique systematique du CMV chez les femmes enceintes n'est actuellement pas recommande. (III-B) 8.Le depistage serologique du CMV peut etre envisage chez les femmes qui en viennent a presenter des symptomes grippaux pendant la grossesse ou a la suite de la detection de signes echographiques semblant indiquer une infection a CMV. (III-B) 9.Les femmes seronegatives œuvrant dans le domaine de la sante et des soins aux enfants peuvent se voir offrir un suivi serologique pendant la grossesse. Un suivi peut egalement etre envisage dans le cas des femmes enceintes seronegatives qui comptent un enfant en bas âge frequentant une garderie. (III-B)

Background Listeriosis is one of the most severe foodborne illnesses worldwide. Most infections with Listeria are sporadic, but outbreaks do occur. Pregnant women exposed to this organism are at increased risk of chorioamnionitis, preterm labour, prematurity and intrauterine fetal demise. Severe neonatal infection can also occur. Cases Two recent outbreaks in Canada prompted a reassessment of the prevalence and the perinatal impact of this disease. We describe here three cases of perinatal listeriosis. The aim of our report is to demonstrate the variable clinical presentations and to emphasize the difficulty in diagnosing perinatal listeriosis. Conclusion Perinatal listeriosis is a severe disease with many possible clinical presentations. Clinical diagnosis may be difficult, so clinicians must maintain a high index of suspicion.

Objective To review the evidence and provide recommendations on the use of antibiotics in preterm premature rupture of the membranes (PPROM). Outcomes Outcomes evaluated include the effect of antibiotic treatment on maternal infection, chorioamnionitis, and neonatal morbidity and mortality. Evidence Published literature was retrieved through searches of Medline, EMBASE, CINAHL, and The Cochrane Library, using appropriate controlled vocabulary and key words (PPROM, infection, and antibiotics). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and new material incorporated in the guideline to July 2008. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. Benefits, Harms, and Costs Guideline implementation should assist the practitioner in developing an approach to the use of antibiotics in women with PPROM. Patients will benefit from appropriate management of this condition. Validation This guideline has been reviewed and approved by the Infectious Diseases Committee and the Maternal Fetal Medicine Committee of the SOGC, and approved by the Executive and Council of the SOGC. Sponsor The Society of Obstetricians and Gynaecologists of Canada. Recommendations 1.Following PPROM at 32 weeks' gestation, antibiotics should be administered to women who are not in labour in order to prolong pregnancy and to decrease maternal and neonatal morbidity (I-A). 2.The use of antibiotics should be gestational-age dependent. The evidence for benefit is greater at earlier gestational ages ( 3.For women with PPROM at >32 weeks' gestation, administration of antibiotics to prolong pregnancy is recommended if fetal lung maturity cannot be proven and/or delivery is not planned (I-A). 4.Antibiotic regimens may consist of an initial parenteral phase followed by an oral phase, or may consist of only an oral phase (I-A). 5.Antibiotics of choice are penicillins or macrolide antibiotics (erythromycin) in parenteral and/or oral forms. (I-A) In patients allergic to penicillin, macrolide antibiotics should be used alone (III-B). 6.The following two regimens may be used (the two regimens were used in the largest PPROM randomized controlled trials that showed a decrease in both maternal and neonatal morbidity): (1) ampicillin2g IV every 6 hours and erythromycin 250 mg IV every 6 hours for 48 hours followed by amoxicillin 250 mg orally every 8 hours and erythromycin 333 mg orally every 8 hours for 5 days (I-A); (2) erythromycin 250 mg orally every 6 hours for 10 days (I-A). 7.Amoxicillin/clavulanic acid should not be used because of an increased risk of necrotizing enterocolitis in neonates exposed to this antibiotic. Amoxicillin without clavulanic acid is safe (I-A). 8.Women presenting with PPROM should be screened for urinary tract infections, sexually transmitted infections, and group B streptococcus carriage, and treated with appropriate antibiotics if positive (II-2B).

Resume Objectif Analyser les resultats et formuler des recommandations quant a l'utilisation d'antibiotiques en presence d'une rupture prematuree des membranes preterme (RPMP). Issues Parmi les issues evaluees, on trouvait l'effet de l'antibiotherapie sur l'infection maternelle, la chorioamnionite et la morbidite et la mortalite neonatales. Resultats La litterature publiee a ete identifiee par l'intermediaire de recherches menees dans PubMed ou Medline, CINAHL et la Cochrane Library, au moyen d'un vocabulaire controle approprie et de mots cles ( PPROM , infection et antibiotics ). Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Aucune restriction quant a la date ou a la langue n'a ete mise en œuvre. Les recherches ont ete regulierement mises a jour et les donnees publiees jusqu'en juillet 2008 ont ete integrees a la directive clinique. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs Les resultats obtenus ont ete evalues par le comite sur les maladies infectieuses de la Societe des obstetriciens et gynecologues du Canada (SOGC), sous la direction des auteurs principaux; les recommandations ont ete formulees en fonction des lignes directrices elaborees par le Groupe d'etude canadien sur les soins de sante preventifs. Avantages, desavantages et couts La mise en œuvre de la presente directive clinique devrait aider les praticiens a elaborer une approche quant au recours a l'antibiotherapie chez les femmes qui presentent une RPMP. Les patientes tireront avantage d'une prise en charge adequate de cette pathologie. Validation La presente directive clinique a ete analysee et approuvee par le comite sur les maladies infectieuses et le comite de medecine fœto-maternelle, et approuvee par le comite executif et le Conseil de la Societe des obstetriciens et gynecologues du Canada. Commanditaire La Societe des obstetriciens et gynecologues du Canada. Recommendations 1.A la suite d'une RPMP a ≤ 32 semaines de gestation, des antibiotiques devraient etre administres aux femmes qui ne sont pas en travail afin de prolonger la grossesse et d'attenuer la morbidite maternelle et neonatale. (I-A) 2.Le recours aux antibiotiques devrait etre fonction de l'âge gestationnel. Les resultats en soutenant les avantages sont plus concluants en ce qui concerne les âges gestationnels moins avances ( 3.En ce qui concerne les femmes qui connaissent une RPMP a > 32 semaines de gestation, l'administration d'antibiotiques visant la prolongation de la grossesse est recommandee lorsque la maturite pulmonaire fœtale ne peut etre prouvee et/ou lorsque l'accouchement n'est pas planifie. (I-A) 4.Les schemas posologiques d'antibiotiques peuvent comprendre une phase parenterale initiale suivie d'une phase orale ou n'etre constitues que d'une phase orale. (I-A) 5.Les antibiotiques a privilegier sont les penicillines ou les antibiotiques macrolides (erythromycine) sous forme parenterale et/ou orale. (I-A) Chez les patientes allergiques a la penicilline, les antibiotiques macrolides devraient etre utilises seuls. (III-B) 6.Les deux schemas posologiques suivants peuvent etre utilises (ils ont tous deux ete utilises par les plus importants essais comparatifs randomises s'etant penches sur la RPMP qui ont indique une baisse de la morbidite maternelle et neonatale) : (1) ampicilline, a raison de 2 g IV toutes les 6 heures, et erythromycine, a raison de 250 mg IV toutes les 6 heures, pendant 48 heures, le tout etant suivi d'amoxicilline, a raison de 250 mg par voie orale toutes les 8 heures, et d'erythromycine, a raison de 333 mg par voie orale toutes les 8 heures, pendant 5 jours (I-A); (2) erythromycine, a raison de 250 mg par voie orale toutes les 6 heures, pendant 10 jours (I-A) 7.L'amoxicilline/acide clavulanique ne devrait pas etre utilisee en raison du risque accru d'enterocolite necrosante que courent les nouveau-nes exposes a cet antibiotique. L'amoxicilline utilisee sans acide clavulanique est sure. (I-A) 8.Les femmes qui connaissent une RPMP devraient faire l'objet d'un depistage visant les infections des voies urinaires, les infections transmissibles sexuellement et le statut de porteuse de streptocoques du groupe B, et elles devraient etre traitees au moyen d'antibiotiques appropries lorsque ce depistage donne des resultats positifs. (II-2B)

Objective This document summarizes the limited experience of SARS in pregnancy and suggests guidelines for management. Outcomes Cases reported from Asia suggest that maternal and fetal outcomes are worsened by SARS during pregnancy. Evidence Medline was searched for relevant articles published in English from 2000 to 2007. Case reports were reviewed and expert opinion sought. Values Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care.

Resume Objectif Analyser les resultats et offrir des recommandations quant a l'immunisation pendant la grossesse. Issues Parmi les issues evaluees, on trouve l'efficacite de l'immunisation, les risques et les avantages pour la mere et le fœtus. Resultats Des recherches ont ete menees dans les bases de donnees Medline et Cochrane en vue d'en tirer les articles, publies avant juillet 2007, portant sur l'immunisation pendant la grossesse. Valeurs Les donnees obtenues ont ete analysees et evaluees par le comite sur les maladies infectieuses de la Societe des obstetriciens et gynecologues du Canada (SOGC), sous la supervision des auteurs principaux, et des recommandations ont ete formulees conformement aux lignes directrices etablies par le Groupe d'etude canadien sur les soins de sante preventifs. Avantages, desavantages et couts La mise en œuvre des recommandations de la presente directive clinique devrait mener a une meilleure immunisation des femmes enceintes et des femmes qui allaitent, a une attenuation du risque d'immunisation contre-indiquee et a une meilleure prevention de la maladie. Recommandations 1.Avant de proceder a l'immunisation de toute femme en âge de procreer, le fournisseur de soins devrait chercher a ecarter la presence possible d'une grossesse chez celle-ci. (III-A) 2.Les fournisseurs de soins devraient obtenir les antecedents quant a l'immunisation de toutes les femmes qui les consultent afin d'obtenir des soins prenatals. (III-A) 3.En general, les vaccins a virus vivant et/ou a virus vivant-attenue sont contre-indiques pendant la grossesse, et ce, en raison de la presence d'un risque (essentiellement theorique) pour le fœtus. (II-3B) 4.Les femmes qui ont recu, par inadvertance, une immunisation au moyen de vaccins vivants ou vivants-attenues pendant la grossesse ne devraient pas etre avisees de proceder a une interruption de grossesse motivee par la presence d'un risque de teratogenicite. (II-2A) 5.Les femmes n'etant pas enceintes qui ont ete immunisees au moyen d'un vaccin vivant ou vivant-attenue devraient etre avisees de reporter la grossesse pendant au moins quatre semaines. (III-B) 6.L'administration de vaccins viraux inactives, de vaccins bacteriens et de toxoides pendant la grossesse est consideree comme etant sure. (II-1A) 7.Les femmes qui allaitent peuvent tout de meme etre immunisees (immunisation passive-active, vaccins vivants ou morts). (II-1A) 8.Les femmes enceintes devraient se voir offrir le vaccin antigrippal lorsque leur grossesse coincide avec la saison de la grippe. (II-1A)

Objective To review the evidence and provide recommendations on immunization in pregnancy. Outcomes Outcomes evaluated include effectiveness of immunization, and risks and benefits for mother and fetus. Evidence The Medline and Cochrane databases were searched for articles published up to June 2007 on the topic of immunization in pregnancy. Values The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. Benefits, Harms, and Costs Implementation of the recommendations in this guideline should result in more appropriate immunization of pregnant and breastfeeding women, decreased risk of contraindicated immunization, and better disease prevention. Recommendations 1.All women of childbearing age should be evaluated for the possibility of pregnancy before immunization. (III-A) 2.Health care providers should obtain an immunization history from all women accessing prenatal care. (III-A) 3.In general, live and/or live-attenuated virus vaccines are contraindicated during pregnancy, as there is a, largely theoretical, risk to the fetus. (II-3B) 4.Women who have inadvertently received immunization with live or live-attenuated vaccines during pregnancy should not be counselled to terminate the pregnancy because of a teratogenic risk. (II-2A) 5.Non-pregnant women immunized with a live or live-attenuated vaccine should be counselled to delay pregnancy for at least four weeks. (III-B) 6.Inactivated viral vaccines, bacterial vaccines, and toxoids are considered safe in pregnancy. (II-1A) 7.Women who are breastfeeding can still be immunized (passive-active immunization, live or killed vaccines). (II-1A) 8.Pregnant women should be offered the influenza vaccine when pregnant during the influenza season. (II-1A)

To provide recommendations for the management of genital herpes infection in women who want to get pregnant or are pregnant and for the management of genital herpes in pregnancy and strategies to prevent transmission to the infant.More effective management of complications of genital herpes in pregnancy and prevention of transmission of genital herpes from mother to infant.Medline was searched for articles published in French or English related to genital herpes and pregnancy. Additional articles were identified through the references of these articles. All study types and recommendation reports were reviewed.Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care.

Resume Objectif La presente directive clinique a pour but de fournir des recommandations aux fournisseurs de soins gynecologiques quant a la prise en charge optimale de l'herpes genital. Issues Prevention plus efficace des complications et de la transmission de l'herpes genital. Resultats Des recherches ont ete menees dans Medline en vue d'en tirer les articles, publies en francais et en anglais, traitant de l'herpes genital et de la gynecologie. Les references que contenaient ces articles ont permis l'identification d'articles supplementaires. Tous les types d'etude et toutes les recommandations ont ete analyses. Recommandations 1.Jusqu'a 70 % de toutes les infections genitales au VHS-2 sont transmises pendant l'elimination asymptomatique; ainsi, le recours aux condoms est recommande afin d'attenuer la probabilite de transmission de la maladie. (II-A) 2.L'obtention d'un diagnostic d'herpes genital fonde sur des resultats de laboratoire est essentielle pour assurer la mise en oeuvre d'une prise en charge efficace. (II-A) 3.Le traitement suppressif est suggere pour les patientes qui presentent •au moins six recurrences par annee •des complications importantes en presence de moins de six recurrences par annee •des problemes importants en ce qui concerne la qualite de vie liee a la sante •un dysfonctionnement social et sexuel •ou qui doivent reduire le risque de transmission a un partenaire sexuel ou au foetus / nouveau-ne. (II-B) 4.L'utilisation de valacyclovir (antiviral), conjointement avec le port de condoms et l'offre de conseils quant aux pratiques sexuelles sures, est recommandee pour les personnes chez lesquelles la presence d'herpes genital a ete prouvee. (I-B) 5.Le depistage systematique ou cible du VHS n'est pas indique. (III-B)

The purpose of this guideline is to provide recommendations to gynaecology health care providers on optimal management of genital herpes.More effective prevention of complications and transmission of genital herpes.Medline was searched for articles published in French and English related to genital herpes and gynaecology. Additional articles were identified through the references of these articles. All study types and recommendation reports were reviewed.1. Up to 70% of all genital HSV-2 infections are transmitted during asymptomatic shedding; therefore, the use of condoms is recommended to lessen the likelihood of disease transmission. (II-A) 2. A laboratory-based diagnosis of genital herpes is essential for its effective management. (II-A) 3. Suppressive treatment is suggested for patients who have * at least 6 recurrences per year * significant complications, but fewer than 6 recurrences per year * their quality of life significantly affected * social and sexual dysfunction * to lower the risk of transmission to a sexual partner or fetus/neonate. (II-B) 4. The use of the anti-viral valacyclovir, coupled with condoms and safer sex counselling, is recommended for individuals with proven genital herpes. (I-B) 5. Routine or targeted HSV screening is not indicated.

Resume Objectif Fournir une mise a jour sur la teratologie en ce qui a trait aux effets des infections et des medicaments d'ordonnance et en vente libre sur la grossesse. Options Le present consensus se limite aux principes de teratologie et aux expositions possibles courantes pendant la grossesse. Resultats Des recherches ont ete menees dans Medline et dans des manuels afin d'en tirer les donnees, publiees avant juin 2006, portant sur les risques teratologiques associes a l'exposition. Le present document constitue un resume de ces donnees. Avantages, desavantages et couts Le present consensus offre aux praticiens un resume des renseignements portant sur les risques teratologiques associes a l'exposition a des medicaments, a des produits chimiques et a des agents infectieux pendant la grossesse.

Background Advances in diagnostic and therapeutic modalities for congenital cytomegalovirus (CMV) infection have generated a mounting interest in identifying mothers susceptible to CMV. The objectives of this study were to evaluate the prevalence and socio-demographic determinants of CMV susceptibility and CMV awareness, among pregnant women, in Montreal, Quebec. Methods Between April and December 2012, women delivering at Centre Hospitalier Universitaire Sainte Justine were recruited for the study. Stored serum from the first trimester of pregnancy was tested for CMV IgG. Knowledge about CMV and socio-demographic characteristics were collected via standardized questionnaire. Results Four hundred and ninety one women were enrolled in the study. Overall, 225 mothers (46 %) were seronegative for CMV, and 85 % (n = 415) were unaware of CMV or the associated risks in pregnancy. Significant risk factors for CMV seronegative status included Canadian vs. foreign born (aOR 6.88, 95 % CI 4.33–10.94), and high vs. low family income (aOR 4.68, 95 % CI 2.09–10.48). Maternal employment status was the only significant predictor of CMV unawareness, with unemployed mothers at the highest risk (aOR 85.6, 95 % CI 17.3–421.3). Conclusions Nearly half of pregnant women studied were at risk of primary infection, and yet, the majority was unaware of potential risks associated with CMV. Canadian born mothers and those with a high socioeconomic status were more likely to be CMV seronegative. Increased education about CMV infection, through public health interventions and obstetrician/pediatric counseling, is needed for all pregnant women. Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-0844-9) contains supplementary material, which is available to authorized users.

To review the evidence and provide recommendations on screening for and management of vulvovaginal candidiasis, trichomoniasis, and bacterial vaginosis.OUTCOMES evaluated include the efficacy of antibiotic treatment, cure rates for simple and complicated infections, and the implications of these conditions in pregnancy.Published literature was retrieved through searches of MEDLINE, EMBASE, CINAHL, and The Cochrane Library in June 2013 using appropriate controlled vocabulary (e.g., vaginitis, trichomoniasis, vaginal candidiasis) and key words (bacterial vaginosis, yeast, candidiasis, trichomonas vaginalis, trichomoniasis, vaginitis, treatment). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to May 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, and national and international medical specialty societies.The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Summary Statements 1. Vulvovaginal candidiasis affects 75% of women at least once. Topical and oral antifungal azole medications are equally effective. (I) 2. Recurrent vulvovaginal candidiasis is defined as 4 or more episodes per year. (II-2) 3. Trichomonas vaginalis is a common non-viral sexually transmitted infection that is best detected by antigen testing using vaginal swabs collected and evaluated by immunoassay or nucleic acid amplification test. (II-2) 4. Cure rates are equal at up to 88% for trichomoniasis treated with oral metronidazole 2 g once or 500 mg twice daily for 7 days. Partner treatment, even without screening, enhances cure rates. (I-A) 5. Current evidence of the efficacy of alternative therapies for bacterial vaginosis (probiotics, vitamin C) is limited. (I) Recommendations 1. Following initial therapy, treatment success of recurrent vulvovaginal candidiasis is enhanced by maintenance of weekly oral fluconazole for up to 6 months. (II-2A) 2. Symptomatic vulvovaginal candidiasis treated with topical azoles may require longer courses of therapy to be resolved. (1-A) 3. Test of cure following treatment of trichomoniasis with oral metronidazole is not recommended. (I-D) 4. Higher-dose therapy may be needed for treatment-resistant cases of trichomoniasis. (I-A) 5. In pregnancy, treatment of symptomatic Trichomonas vaginalis with oral metronidazole is warranted for the prevention of preterm birth. (I-A) 6. Bacterial vaginosis should be diagnosed using either clinical (Amsel's) or laboratory (Gram stain with objective scoring system) criteria. (II-2A) 7. Symptomatic bacterial vaginosis should be treated with oral metronidazole 500 mg twice daily for 7 days. Alternatives include vaginal metronidazole gel and oral or vaginal clindamycin cream. (I-A) 8. Longer courses of therapy for bacterial vaginosis are recommended for women with documented multiple recurrences. (I-A).

Resume Objectif La presente directive clinique a pour objectif de fournir des recommandations aux fournisseurs de soins de sante du domaine de l'obstetrique et de minimiser les variations de pratique en ce qui concerne le depistage du VIH, tout en tenant compte des recommandations provinciales et territoriales a ce sujet. Issues Le risque de transmission du VIH de la mere au fœtus est considerable si la mere ne beneficie pas d'un traitement. Une baisse marquee du taux de transmission verticale du VIH de la mere au fœtus constitue l'issue primaire du depistage et de la prise en charge du VIH au cours de la grossesse. Parmi les issues secondaires, on trouve la confirmation de la presence d'une infection au VIH chez la patiente, ce qui permet l'optimisation de sa sante et de sa prise en charge a long terme. Resultats Des recherches ont ete menees dans la Cochrane Library et Medline afin d'y trouver les articles publies de langue anglaise portant sur le depistage du VIH et la grossesse. Des articles additionnels ont ete identifies grâce aux references que contenaient les articles issus de ces recherches. Tous les types d'etude ont ete soumis a l'analyse. Recommandations 1.Toutes les femmes enceintes devraient se soumettre a un depistage du VIH accompagne d'un counseling approprie. Ce depistage se doit d'etre effectuere de facon volontaire. Le depistage devrait etre considere comme une norme de diligence; toutefois, les femmes doivent etre avisees de la politique, de ses risques et de ses avantages, et de leur droit de refus. Les femmes ne doivent pas etre soumises a un depistage a leur insu. (II-2 B) 2.L'offre de counseling predepistage et la decision de la patiente en ce qui a trait au depistage devraient etre documentees dans le dossier de la patiente. (III-B) 3.Les femmes qui refusent de se soumettre au depistage devraient continuer de beneficier de soins prenatals optimaux et leurs preoccupations devraient tout de meme faire l'objet d'une discussion. (III-C) 4.Les femmes devraient se voir offrir un depistage du VIH au cours de leur premiere consultation prenatale. (I-A) 5.Les femmes qui obtiennent des resultats negatifs a la suite du depistage du VIH et qui continuent d'adopter des comportements entrainant des risques eleves devraient faire l'objet d'un nouveau depistage a chacun des trimestres de la grossesse. (II-3 B) 6.Les femmes n'ayant pas beneficie de soins prenatals et dont l'etat serologique relativement au VIH est inconnu devraient se voir offrir un depistage, au moment de leur hospitalisation aux fins du travail et de l'accouchement. Les femmes qui courent des risques eleves de contracter le VIH et dont l'etat serologique est inconnu devraient se voir offrir une prophylaxie au cours du travail, et une prophylaxie anti-VIH devrait etre administree a leurs nouveau-nes au cours de la periode post-partum. (III-B) 7.Les femmes qui obtiennent des resultats positifs a la suite du depistage du VIH devraient faire l'objet d'un suivi gere par des praticiens disposant des connaissances necessaires pour assurer le traitement des femmes seropositives pour le VIH. (III-C)

Since its deployment on Devon Island, Canadian High Arctic, in 2002, the Haughton Mars Project’s Arthur Clarke Mars Greenhouse (ACMG) has supported extreme environment related scientific and operation research that is relevant to Mars analogue studies – each at a specific level of fidelity and complexity. The Greenhouse serves as an initial experimental test-bed supporting field research, from which lessons may be learned to support the design and implementation of future field facilities, and enabling higher fidelity demonstrations. This paper provides an overall description of the ACMG, describes the different subsystems, explains its operational modes, details some results over the three years of operation and discusses future development plans.

A new electrocardiogram (ECG) delineation method is proposed, which uses a hidden Markov tree model. The aim of this approach is, on the one hand, to use wavelet coefficients to characterize the different ECG waves, and, on the other hand, to link these coefficients by a tree structure enabling wave change to be detected. By associating this method with a fusion method between scales based on the concept of context, good results are obtained on a special database created for the risk analysis of atrial fibrillation, particularly in P-wave delineation.

Objective The purpose of this study was to evaluate the efficacy of sublingual nitroglycerin as a tocolytic agent for external cephalic version in parous women. Study design A double-blinded randomized controlled trial was performed. Patients with parity of ≥1 at 36 to 40 weeks of gestation who were eligible for external cephalic version were included. Patients were randomized to receive either two sublingual sprays of 400 μg of nitroglycerin or two sprays of placebo 3 minutes before the trial of external cephalic version. Rates of successful external cephalic version and side effects were compared between groups. Results Of 99 patients in the study, 50 patients received sublingual nitroglycerin, and 49 patients received placebo. There were no differences in maternal age, gestational age, estimated fetal weight, amniotic fluid index, and placental location between the two groups. The success rate of external cephalic version was 48% in the nitroglycerin group compared with 63% in the placebo group ( P =.13). There was a higher incidence of headaches in the nitroglycerin group (42% vs 4%, P Conclusion Sublingual nitroglycerin was associated with a higher rate of headache and did not improve the rate of successful external cephalic version.

Radar images can show great variability from pixel to pixel, which is an obstacle to effective processing. This variability, due to speckle created by the radar wave coherence, necessitates the use of more adapted filters. Previous studies have shown that multiresolution wavelet analysis yields better results but produces artefacts due to multiscale decomposition. This paper proposes a method that reduces these effects by introducing the fractal dimension. The resultant filter combines wavelet decomposition and variance change model based on the level of variance estimated by studying the fractal dimension of the image.

Background: Decreased heart rate recovery (HRR) is a predictor of mortality in patients with coronary artery disease and preserved left ventricular function. We investigated the changes in HRR and assessed the impact of β-blockade therapy on these parameters in patients with symptomatic congestive heart failure (CHF). Methods and Results: HRR, defined as the difference from peak exercise heart rate (HR) to HR measured at 1, 2, and 3 minutes after maximal exercise test, was studied in 23 stable CHF patients and 12 healthy subjects. Patients with CHF performed a maximal exercise test using a Ramp protocol before and after 6 months of therapy with either metoprolol or carvedilol. Patients with CHF exhibited a significantly attenuated HRR compared with healthy subjects at 1 minute (17.8 ± 5.8 versus 26.8 ± 16.2 beats), 2 minutes (34.0 ± 10.6 versus 48.0 ± 11.2 bpm) and 3 minutes (41.0 ± 12.4 versus 60.0 ±12.4 bpm) after exercise (P

Objective: The purpose of this study was to compare the efficacy of sublingual nitroglycerin with that of intravenous ritodrine as a tocolytic agent for external cephalic version in nulliparous women. Study Design: We performed a double-blinded, randomized trial. Nulliparous patients, between 36 and 40 weeks of gestation, were assigned randomly to receive either (1) an intravenous infusion of ritodrine (111 μg/min) for 20 minutes, followed by two puffs of sublingual placebo or (2) an intravenous infusion of sodium chloride 0.9% (placebo) for 20 minutes, followed by two puffs of sublingual 0.4 mg of nitroglycerin. Three minutes after the administration of the sublingual spray, an external cephalic version was attempted. The rate of successful external cephalic version and side effects was compared between groups. Results: Of 74 randomly assigned patients, 38 patients received intravenous ritodrine, and 36 patients received sublingual nitroglycerin. Although not statistically significant, the rate of the successful external cephalic version was higher in the ritodrine group compared with the nitroglycerin group (45% vs 25%, P =.075). The rate of headaches was higher in patients who received nitroglycerin (28% vs 8%, P =.02). Mean blood pressure and maternal heart rate were lower in the nitroglycerin group 10 minutes after the administration of the medication. However, there was no significant difference in the rate of palpitations, hypotension, or fetal bradycardia between the two groups. Conclusion: When compared with intravenous ritodrine, sublingual nitroglycerin was associated with a higher rate of headache, lower blood pressure, and a trend toward a lower rate of successful external cephalic version. (Am J Obstet Gynecol 2003;188:1454-9.)