[Prevention of prematurity's complications]. / Prévention des complications de la prématurité.

Prematurity remains a leading cause of mortality and morbidity in neonates and children. Prevention of preterm birth and of its complications is a major public health issue. From before conception to long term follow up, many health actors are engaged in this preventive strategy with the same goal : to give the best quality of life for these vulnerable young patients. We will review different preventive aspects during antenatal and perinatal period, during NICU (Neonatal Intensive Care Unit) stay and after discharge. Prevention of prematurity's complications requires a global approach including respiratory, nutritional and infectious aspects among others. Neuroprotective strategies are a key point of this global approach.

La prématurité reste une cause majeure de mortalité et morbidité néonatales et infantiles. La prévention des naissances prématurées et de leurs complications est donc un enjeu majeur de santé publique. De la période pré-conceptionnelle au suivi à long terme de ces enfants, nombreux sont les acteurs impliqués dans un même objectif : offrir la meilleure qualité de vie à ces jeunes patients vulnérables. Nous reverrons ici différents aspects préventifs en période anténatale, périnatale, lors du séjour en néonatologie et lors du suivi après la sortie. La prévention des complications de la prématurité nécessite une prise en charge globale intégrée incluant, notamment, des aspects ventilatoires, nutritionnels, infectieux, néphrologiques et métaboliques. La neuroprotection est au centre des préoccupations et guide l'ensemble de l'approche.

Identifying maternal needs following childbirth: comparison between pregnant women and recent mothers.

BACKGROUND: The postnatal period is associated with new needs for mothers. Four categories of needs were highlighted in a previous study: for information, for psychological support, for the sharing of experiences and for practical and material support. To ensure that these four needs are inherent to the postpartum period, the aims of this study is to examine these needs by comparing recent mothers' needs with the needs of pregnant women. METHODS: The 4 needs previously identified were cross-sectionally investigated by online self-reported questionnaires completed by women in their last trimester of pregnancy and by mothers who had a child between 0 and 6 months of age. RESULTS: The 4 needs were largely present during the postpartum period. The need for information seemed to be more present during pregnancy (92.4 %) than during the postpartum period (84.6 %, p = 0.03), but women used the Internet significantly more often to search for information after childbirth (54.8 %) than during pregnancy (41.2 %, p < 0.0001). The needs for psychological support and to share experiences seemed to be closely linked. Even if the global satisfaction with psychological support was fairly high, it weakened after childbirth (p < 0.05). Feelings of loneliness (p < 0.0001) and depression scores (p = 0.01) were also higher during the postpartum period than during pregnancy. Finally, the need for practical support was also more pronounced during the postpartum period than during pregnancy (p = 0.01). CONCLUSIONS: All mothers seem to meet the 4 identified needs during the postpartum period but at different levels of intensity. Trying to meet these needs could offer an opportunity to improve mothers' quality of life.

Balancing benefits and risks of glucocorticoids in rheumatic diseases and other inflammatory joint disorders: new insights from emerging data. An expert consensus paper from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO).

PURPOSE: This consensus review article considers the question of whether glucocorticoid (GC) therapy is still relevant in the treatment of rheumatic diseases, with a particular focus on rheumatoid arthritis (RA), and whether its side effects can be adequately managed. Recent basic and clinical research on the molecular, cellular and clinical effects of GCs have considerably advanced our knowledge in this field. An overview of the subject seems appropriate. METHODS: This review is the result of a multidisciplinary expert working group, organised by European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis. The recent literature was surveyed and the salient evidence synthetized. RESULTS: The pathophysiological basis of RA (and other inflammatory rheumatic diseases) now strongly implicates the adaptive immune system in addition to innate mechanisms. The molecular effect of GCs and differential GC sensitivity is better understood, although exploiting this knowledge is still in its infancy. The newer treatment strategies of early and aggressive control of RA have gr eatly improved clinical outcomes, but improvements are still possible. Newer targeted anti-inflammatory drugs have made an important impact, yet they too are associated with numerous side effects. DISCUSSION: Short durations of moderate doses of GCs are generally well tolerated and have a positive benefit/risk ratio. Patients should be assessed for fracture risk and bone preserving agents and be prescribed calcium and vitamin D supplementation. CONCLUSIONS: Within a strategy of a disease modifying approach to inflammatory disease, combination therapy including a GC is effective approach.

Gestational weight gain: Toward best practices in managing gestational weight gain in patients with obesity: Comparison of recommendations.

BACKGROUND AND AIMS: In 2009, the Institute of Medicine (IOM) issued recommendations for gestational weight gain (GWG) based on body mass index (BMI). Several studies have challenged those recommendations for women with obesity, considering them too liberal and advising more limited weight gain - or even weight loss - during pregnancy to improve maternal and neonatal outcomes. Our aim was to study how gestational weight gain in women with obesity impacted maternal and fetal complications in the Belgian population. We did this by comparing the results from two groups of patients with obesity: those who met the 2009 IOM standards and those who satisfied the stricter recommendations suggested by other authors. MATERIALS AND METHODS: This is a retrospective cohort study using data collected at the Centre d'Epidémiologie Périnatale (CEpiP) from obese (BMI ≥ 30 kg/m2) pregnant women with live singleton deliveries between 2010 and 2019 in Wallonia-Brussels Federation (n = 65,314). RESULTS: Compared to obese patients whose GWG satisfied the IOM standards, those with GWG meeting the stricter recommendations had lower rates of gestational hypertension (7.1 % vs. 10.1 %; p = 0.0059), cesarean section (22.1 % vs. 26.3 %; p = 0.0074), and macrosomia (12.0 % vs. 17.7 %; p < 0.0001). There was no significant difference in the rate of preterm delivery (6.9 % vs 5.8 %; p = 0.12) or small-for-gestational-age births (7.2 % vs. 6.2 %; p = 0.16). CONCLUSION: Gestational weight gain below that currently recommended by the IOM appears beneficial to the health of mothers with obesity and their children. These data, from our population, further challenge the standards proposed since 2009.

The 2023 Belgian clinical guidance on anticoagulation management in hospitalized and ambulatory COVID-19 patients.

COVID-19 is associated with an increased risk for thrombotic complications. The trials investigating the optimal thromboprophylactic dose are performed in challenging times and seemingly produce conflicting evidence. The burdensome circumstances, divergent endpoints, and different analytical approaches hamper comparison and extrapolation of available evidence. Most importantly, clinicians should provide thromboprophylaxis in hospitalized COVID-19 patients while (re)assessing bleeding and thrombotic risk frequently. The COVID-19 Thromboprophylaxis Working Group of the BSTH updated its guidance document. It aims to summarize the available evidence critically and to guide clinicians in providing the best possible thromboprophylaxis.

Lesion-based detection of early chemosensitivity using serial static FDG PET/CT in metastatic colorectal cancer.

PURPOSE: Medical oncology needs early identification of patients that are not responding to systemic therapy. (18)F-Fluorodeoxyglucose (FDG) positron emission tomography (PET) performed before and early during treatment has been proposed for this purpose. However, the best way to assess the change in FDG uptake between two scans has not been identified. We studied cutoff thresholds to identify responding tumours as a function of the method used to measure tumour uptake. METHODS: The study included 28 metastatic colorectal cancer (mCRC) patients who underwent 2 FDG PET/CT scans (baseline and at day 14 of the first course of polychemotherapy). For 78 tumour lesions, 4 standardized uptake value (SUV) indices were measured: maximum SUV (SUV(max)) and mean SUV in a region obtained using an isocontour (SUV(40 %)), with each of these SUV normalized either by the patient body weight (BW) or body surface area (BSA). The per cent change and absolute change in tumour uptake between the baseline and the early PET scans were measured based on these four indices. These changes were correlated to the RECIST 1.0-based response using contrast-enhanced CT at baseline and at 6-8 weeks on treatment. RESULTS: The 78 tumours were classified as non-responding (NRL, n = 58) and responding lesions (RL, n = 20). Receiver-operating characteristic (ROC) curves characterizing the performance in NRL/RL classification using early FDG PET uptake had areas under the curve between 0.75 and 0.84, without significant difference between the indices. The cutoff threshold in FDG uptake per cent change to get a 95 % sensitivity of RL detection depended on the way uptake was measured: -14 % (specificity of 53 %) and -22 % (specificity of 64 %) for SUV(max) and SUV(40 %), respectively. Thresholds expressed as absolute SUV decrease instead of per cent change were less sensitive to the SUV definition: an SUV decline by 1.2 yielded a sensitivity of RL detection of 95 % for SUV(max) and SUV(40 %). For a given cutoff threshold, the sensitivity was the same whatever the normalization (by BSA or BW). CONCLUSION: A 14 % drop of tumour FDG SUV(max), 22 % drop of SUV(40 %) or 1.2 drop of SUV(max) or SUV(mean) after one single course of polychemotherapy predicts objective response in mCRC lesions with a high sensitivity, potentially allowing the early identification of non-responding patients.

Belgian clinical guidance on anticoagulation management in hospitalised and ambulatory patients with COVID-19.

OBJECTIVES: COVID-19 predisposes patients to thrombotic disease. The aim of this guidance document is to provide Belgian health-care workers with recommendations on anticoagulation management in COVID-19 positive patients. METHODS: These recommendations were based on current knowledge and a limited level of evidence. RESULTS: We formulated recommendations for the prophylaxis and treatment of COVID-related venous thromboembolism in ambulatory and hospitalised patients, as well as recommendations for the use of antithrombotic drugs in patients with prior indication for anticoagulation who develop COVID-19. CONCLUSIONS: These recommendations represent an easy-to-use practical guidance that can be implemented in every Belgian hospital and be used by primary care physicians and gynaecologists. Of note, they are likely to evolve with increased knowledge of the disease and availability of data from ongoing clinical trials.

Patient-reported outcomes in terms of swallowing and quality of life after prophylactic versus reactive percutaneous endoscopic gastrostomy tube placement in advanced oropharyngeal cancer patients treated with definitive chemo-radiotherapy: Swall PEG study.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is often used to provide nutritional support in locally advanced head and neck cancer patients undergoing multimodality treatment. However, there is little published data on the impact of prophylactic versus reactive PEG. PEG placement may affect swallowing-related physiology, function, and quality of life. The Swall PEG study is a randomized controlled phase III trial testing the impact of prophylactic versus reactive PEG on patient-reported outcomes in terms of swallowing and quality of life in oropharyngeal cancer patients. METHODS: Patients with locally advanced oropharyngeal cancer receiving chemo-radiotherapy will be randomized to either the prophylactic or reactive PEG tube group. Randomization will be stratified by human papillomavirus (HPV) status and unilateral versus bilateral positive neck lymph nodes. The primary objective of the study is the patient's reported outcome in terms of swallowing (MD Anderson Dysphagia Inventory (MDADI)) at 6 months. Secondary objectives include health-related quality of life, dosimetric parameters associated with patient-reported outcomes, chemo-radiation toxicities, PEG tube placement complications, the impact of nutritional status on survival and toxicity outcomes, loco-regional control, overall survival, the impact of HPV and tobacco smoking on survival outcomes and toxicities, and the cost-effectiveness of each treatment strategy. DISCUSSION: Findings from this study will enhance clinical evidence regarding nutritional management in oropharyngeal cancer patients treated by concurrent chemo-radiation. TRIAL REGISTRATION: ClinicalTrials.gov NCT04019548, study protocol version 2.0_08/08/2019. Registered on 15 July 2019.

Pregnancy and delivery in a patient with a Fontan circulation and primary ciliary dyskinesia: A case report.

A patient had primary ciliary dyskinesia with a complex cardiac malformation. As a child, she had benefited from a Fontan surgery to maintain a proper cardiac function. In such patients, whether it is safe to become pregnant is controversial. This case illustrates the possibility of carrying a pregnancy to term and providing a vaginal birth if a rigorous preconception consultation is performed to ensure care by a multidisciplinary specialized team, and the patient is properly informed of the risks.

The musculus pterygoïdeus proprius: an in-vivo approach with magnetic resonance imaging.

There is a limited understanding of the normal function of the pterygoïdeus proprius muscle and the role that this muscle may have in temporomandibular disorders. Despite a well-described anatomical in-vitro approach to this muscle, there are still difficulties in investigating the fossa pterygopalatina. This study reveals an alternative in-vivo approach by magnetic resonance imaging to visualise the muscle in the fossa pterygopalatina on 78 head halves, describe the connections with the musculus temporalis and pterygoïdeus lateralis as well as report the incidence without dealing with the known inconveniences of the dissection approach. The results show an incidence of 12.82% for the musculus pterygoïdeus proprius equally divided between both genders. Two different types of bridging between the musculus temporalis and musculus pterygoïdeus lateralis were also found: (i) 'O' shape (6.41%) and (ii) 'Y' shape (6.41%). This study suggests the use of magnetic resonance imaging to investigate the different connections between vascular and muscular structures in the fossa pterygopalatina. Further research with this approach to link the appearance of the muscle with neurovascular entrapment syndromes is warranted.

Functional imaging of head and neck cancers.

PURPOSE OF REVIEW: Functional imaging including single photon emission computed tomography, PET and MRI techniques in head and neck squamous cell cancer allows disease characterization beyond structure and morphology. RECENT FINDINGS: In patients without clinical signs of lymph node involvement, sensitivity of fluoro-2-deoxy-D-glucose PET is only 50%. This has led to the use of sentinel lymph node scintigraphy that seems to be a valid alternative to elective stage dissection. Additionally, the use of single-photon emission computed tomography-computed tomography imaging enables a more accurate localization of the sentinel lymph node scintigraphy. The fluoro-2-deoxy-D-glucose uptake intensity of the head and neck squamous cell carcinoma sites is related to locoregional control and overall survival. In case of suspicion for residual or recurrent head and neck squamous cell carcinoma after surgery or (chemo)radiotherapy, fluoro-2-deoxy-D-glucose-PET has a high sensitivity and seems to be cost-effective in selecting patients for direct laryngoscopy. Diffusion-weighted MRI in combination with size and morphological criteria is a strong predictor of presence of malignant lymph nodes. Initial reports indicate the use of diffusion-weighted imaging for response assessment as early as 1 week after beginning of radiochemotherapy. Perfusion MRI is studied for the measurement of drug effects on tumour (micro)vascularity and capillary permeability. SUMMARY: Functional imaging improves the initial staging and the detection of residual or recurrent disease following therapy.

Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes.

INTRODUCTION: The postpartum period represents the time of risk for the emergence of maternal postpartum depression. There are no systematic reviews of the overall maternal outcomes of maternal postpartum depression. The aim of this study was to evaluate both the infant and the maternal consequences of untreated maternal postpartum depression. METHODS: We searched for studies published between 1 January 2005 and 17 August 2016, using the following databases: MEDLINE via Ovid, PsycINFO, and the Cochrane Pregnancy and Childbirth Group trials registry. RESULTS: A total of 122 studies (out of 3712 references retrieved from bibliographic databases) were included in this systematic review. The results of the studies were synthetized into three categories: (a) the maternal consequences of postpartum depression, including physical health, psychological health, relationship, and risky behaviors; (b) the infant consequences of postpartum depression, including anthropometry, physical health, sleep, and motor, cognitive, language, emotional, social, and behavioral development; and (c) mother-child interactions, including bonding, breastfeeding, and the maternal role. DISCUSSION: The results suggest that postpartum depression creates an environment that is not conducive to the personal development of mothers or the optimal development of a child. It therefore seems important to detect and treat depression during the postnatal period as early as possible to avoid harmful consequences.

Meeting the Needs of Mothers During the Postpartum Period: Using Co-Creation Workshops to Find Technological Solutions.

BACKGROUND: The postnatal period is associated with many new needs for mothers. OBJECTIVE: The aim of this study was to find technological solutions that meet the needs of mothers during the year following childbirth. METHODS: Two co-creation workshops were undertaken with parents and professionals. The aim of the first workshop was to create a list of all the criteria the proposed solution would have to address to meet the needs of mothers after childbirth. The aim of the second workshop was to create solutions in response to the criteria selected during the first workshop. RESULTS: Parents and health professionals want solutions that include empathy (ie, to help fight against the feelings of abnormality and loneliness), that help mothers in daily life, that are personalized and adapted to different situations, that are educational, and that assures some continuity in their contact with health professionals. In practice, we found that parents and professionals think the solution should be accessible to everyone and available at all times. To address these criteria, technology experts proposed different solutions, such as a forum dedicated to the postpartum period that is supervised by professionals, a centralized website, a system of videoconferencing, an online exchange group, a "gift voucher" system, a virtual reality app, or a companion robot. CONCLUSIONS: The human component seems to be very important during the postnatal period. Nevertheless, technology could be a great ally in helping mothers during the postpartum period. Technology can help reliably inform parents and may also give them the right tools to find supportive people. However, these technologies should be tested in clinical trials.

Detection and characterization of tumor changes in 18F-FDG PET patient monitoring using parametric imaging.

UNLABELLED: In PET-based patient monitoring, metabolic tumor changes occurring between PET scans are most often assessed visually or by measuring only a few parameters (tumor volume or uptake), neglecting most of the image content. We propose and evaluate a parametric imaging (PI) method to assess tumor changes at the voxel level. METHODS: Seventy-eight pairs of tumor images obtained from baseline and follow-up (18)F-FDG PET/CT for 28 patients with metastatic colorectal cancer were considered. For each pair, after CT-based registration of the PET volumes, the 2 PET datasets were subtracted. A biparametric graph of subtracted voxel values versus voxel values in the first PET scan was obtained. A model-based analysis of this graph was used to identify the tumor voxels in which significant changes occurred between the 2 scans and yielded indices characterizing these changes. The Response Evaluation Criteria in Solid Tumors (RECIST) based on the CT images obtained 5-8 wk after the second PET/CT scan were used to classify tumor masses as responding or progressive. On the basis of this classification, we compared the sensitivity and specificity of PI and an approach based on recommendations from the European Organization for Research and Treatment of Cancer (EORTC). RESULTS: For tumor-based classification, the EORTC-based approach had a sensitivity and specificity of 85% and 52%, respectively, for detecting responding lesions, whereas PI had a sensitivity and specificity of 100% and 53%, respectively. None of responding tumors using RECIST was classified as progressive with the PI or EORTC-based criteria. Among the 14 progressive lesions according to RECIST, 12 were identified as progressive with PI whereas EORTC-based criteria classified only 1 as progressive and 13 as stable tumors. Considering the patient-based classification, none of the responders according to RECIST was classified as having progressive disease with the PI and EORTC-based criteria. PI has the advantage of showing a parametric image of the patient response to therapy, indicating potential heterogeneity in tumor response. CONCLUSION: The PI method has been successfully applied to characterize early metabolic tumor changes in 78 lesions from (18)F-FDG PET/CT scans of patients with metastatic colorectal cancer during chemotherapy. The PI findings correlated well with the standard RECIST-based response assessment.

Prediction of maternal predisposition to preeclampsia.

OBJECTIVE: To derive a prediction index based on the most salient patient history, laboratory, and clinical parameters for identifying women at high risk for developing preeclampsia (PE). METHODS: Nonpregnant women with a history of PE (n = 101) were compared with nonpregnant parous women with a history of one or more successful normotensive pregnancies (n = 50) but with comparable age, gestation, and parity profiles. The parameters included a medical examination (demographics, patient history, family history, and clinical and obstetrical findings), laboratory investigations (hemostasis, coagulation, and vitamins), and morphological and functional tests (cardiovascular and renal functions). Stepwise logistic regression analysis was applied to develop a three-step PE prediction index based on the most discriminant parameters. RESULTS: Patients with and without PE differed significantly (p < 0.05) with respect to 1) maternal history of chronic hypertension, body mass index, and blood pressure; 2) APTT, PT, activated factor VIII, homocysteine, free protein S and vitamin B1; and 3) relative plasma volume. Based on these three sets of parameters, a three-step PE prediction index was developed. The likelihood ratio of a positive index score was equal to 3.4, 7.3, and 8.8, respectively. Thus, assuming a PE prevalence (or prior probability) of 5%, a patient's chances of developing PE when presenting with a positive score on the three-step prediction index were 15%, 28%, and 32%, respectively. DISCUSSION: In the absence of well defined pre-pregnancy screening guidelines for PE, the present study attempts to proceed in a stepwise fashion by looking at medical examination data first, requesting, if necessary, specific hemostasis and coagulation tests next, and finally measuring the relative plasma volume for confirmatory purposes. This approach offers a satisfactory positive predictive value and cost efficiency ratio.

[Vascular placental pathology in high-risk groups: definition and synopsis]. / La pathologie vasculaire placentaire des groupes à risque. Synthèse-définition.

The vascular placental pathology (VPP) is associated with many etiologies. Some are the consequence of a maternal genetic or acquired predisposition. Others are associated with a chronic maternal disease (hypertension, lupus, obesity, diabetes, ...). Finally, some others are associated with placental implantation leading to fetal ischemia (multiple pregnancy, chorioangioma, primiparity, feto-placental hydrops) or to environmental (altitude) or nutritional factors (famine and specific alimentary depressions). We classify these factors into three categories according to the risk level (moderate, significant and elevated). While any of these factors can increase the risk of VPP, no one is sufficiently sensitive or specific in predict inevitable onset of VPP. In most cases VPP results from a combination of two (or more) risk factors. The risk factors of VPP classified as moderate include age (> or = 35 years), increased blood pressure during the second trimester of pregnancy, a new paternity, dietetic factors or environmental factors, smoking and controlled diabetes (class B, C), or inactive systemic diseases. Risk is significantly elevated among obese (BMI > or = 25), primiparous women, women with a past familial history (first degree) of preeclampsia or eclampsia, cocaine use or association of tobacco and caffeine use, increased placental mass (associated with twin pregnancy, fetal hydrops or molar pregnancy), uncontrolled diabetes, lupus, active scleroderma. Risk is considered to be high among patients with chronic hypertension, women with a past history of preeclampsia, diabetes (class D, F, R), patients with active systemic disease or with antiphospholipid antibodies or women with lupus or renal lesions and/or proteinuria as well as chronic kidney disease resulting in proteinuria, hypertension and renal insufficiency. Finally, the risk of VPP is considered to be increased in the presence of acquired thrombophilia. It remains moderate in the presence of isolated genetic thrombophilia, except in forms presenting with multiple genetic mutations or associated with an hyperhomocysteinemia. A "high-risk group" is defined among women with past history of deep venous thromboembolic events outside pregnancy, or with a past history of placental vascular pathology (intra-uterine death, placental abruptio, severe and precocious placental, intra-uterine growth retardation, early and repetitive fetal loss) and who, in addition, present with acquired thrombophilia (antiphospholipid antibodies, thrombocytemia), unique homozygous genetic thrombophilia, amultiple genetic thrombophilia or unique heterozygous genetic thrombophilia associated with hyperhomocysteinemia. Prophylactic treatment of acquired thrombophilia and of the multiple genetic forms or associated with hypercysteinemia is a logical rationale, particularly among women with a past history of placental vascular pathology, or with a past history of venous thromboembolic events. On the contrary, prophylaxis using low-molecular-weight heparin in the event of asymptomatic genetic thrombophilic mutations and for women without a past history of deep venous thromboembolism or vascular placental pathology remains controversial.