Perinatal morbidity among women with a previous caesarean delivery (PRISMA trial): a cluster-randomised trial.

BACKGROUND: Women with a previous caesarean delivery face a difficult choice in their next pregnancy: planning another caesarean or attempting vaginal delivery, both of which are associated with potential maternal and perinatal complications. This trial aimed to assess whether a multifaceted intervention, which promoted person-centred decision making and best practices, would reduce the risk of major perinatal morbidity among women with one previous caesarean delivery. METHODS: We conducted an open, multicentre, cluster-randomised, controlled trial of a multifaceted 2-year intervention in 40 hospitals in Quebec among women with one previous caesarean delivery, in which hospitals were the units of randomisation and women the units of analysis. Randomisation was stratified according to level of care, using blocked randomisation. Hospitals were randomly assigned (1:1) to the intervention group (implementation of best practices and provision of tools that aimed to support decision making about mode of delivery, including an estimation of the probability of vaginal delivery and an ultrasound estimation of the risk of uterine rupture), or the control group (no intervention). The primary outcome was a composite risk of major perinatal morbidity. This trial was registered with ISRCTN, ISRCTN15346559. FINDINGS: 21 281 eligible women delivered during the study period, from April 1, 2016 to Dec 13, 2019 (10 514 in the intervention group and 10 767 in the control group). None were lost to follow-up. There was a significant reduction in the rate of major perinatal morbidity from the baseline period to the intervention period in the intervention group as compared with the control group (adjusted odds ratio [OR] for incremental change over time, 0·72 [95% CI 0·52-0·99]; p=0·042; adjusted risk difference -1·2% [95% CI -2·0 to -0·1]). Major maternal morbidity was significantly reduced in the intervention group as compared with the control group (adjusted OR 0·54 [95% CI 0·33-0·89]; p=0·016). Minor perinatal and maternal morbidity, caesarean delivery, and uterine rupture rates did not differ significantly between groups. INTERPRETATION: A multifaceted intervention supporting women in their choice of mode of delivery and promoting best practices resulted in a significant reduction in rates of major perinatal and maternal morbidity, without an increase in the rate of caesarean or uterine rupture. FUNDING: Canadian Institutes of Health Research (CIHR, MOP-142448).

Type of infertility and prevalence of congenital malformations.

BACKGROUND: Children conceived with assisted reproductive technologies (ART) or after a long waiting time have a higher prevalence of congenital malformations, but few studies have examined the contribution of type of infertility. OBJECTIVES: To quantify the association between causes of infertility and prevalence of malformations. METHODS: We compared the prevalence at birth of all and severe malformations diagnosed up to age 2 between 6656 children born in 1996-2017 to parents who had previously been assessed for infertility a an academic fertility clinic ("exposed") and 10,382 children born in the same period to parents with no recent medical history of infertility ("reference"). We estimated prevalence ratios (PR) and prevalence differences (PD), by infertility status, type of treatment (non-ART, ART), and infertility diagnosis, in all children and among singletons. RESULTS: Compared with children of parents with no infertility, children of parents with infertility had a higher prevalence of malformations (both definitions), particularly following ART conceptions. After accounting for treatment, ovulatory disorders were associated with a higher prevalence of both all (PR 1.49, 95% confidence interval (CI) 1.15, 1.93; PD 3.8, 95% CI 1.0, 6.6) and severe (PR 1.53, 95% CI 1.02, 2.29; PD 1.8, 95% CI -0.2, 3.7) malformations (the estimates refer to exposed children conceived without treatment). Unexplained and male factor infertility were associated with all and severe malformations, respectively. Estimates among singletons were similar. A diagnosis of ovulatory disorders was associated with all malformations also in analyses restricted to exposed children, regardless of treatment (we did not examine severe malformations, due to limited power). CONCLUSIONS: In this study, ovulatory disorders were consistently associated with a higher prevalence of congenital malformations (including severe malformations) among live births, regardless of mode of conception.

Adherence and efficacy of mandibular advancement splint treatment of sleep-disordered breathing during pregnancy: a pilot study.

PURPOSE: Sleep-disordered breathing (SDB) is common in pregnancy and is associated with adverse health consequences for both mother and child. Mandibular advancement splints (MAS) have been shown to improve sleep quality, daytime sleepiness and snoring in non-pregnant women. The effectiveness of MAS for treating SDB in pregnancy is unknown. This pilot study aimed to evaluate the efficacy and adherence to MAS in pregnant women with SDB. METHODS: Women with mild-moderate SDB (apnea-hypopnea index (AHI) 10-29/h) on level 2 polysomnography (PSG) performed at 22.0 ± 5.5 weeks' gestation were treated with a MAS during pregnancy to 6 months postpartum. An embedded micro-recorder measured adherence. PSG was repeated while on titrated treatment, and off treatment in the postpartum period. RESULTS: Among 17 women completing the study, MAS was worn ≥ 4 h/night for 57.5 ± 36.7% of nights during the antepartum period. While using MAS, nightly snoring time decreased from 25.9 ± 24.5% at baseline to 6.4 ± 7.8% when treated during pregnancy (p = .003). AHI decreased from 17.6 ± 5.1 to 12.9 ± 6.3 (p = .02) and fell by ≥ 30% and below 15/h in 60% of participants. During the postpartum period, MAS was used for ≥ 4 h/night on 24.8 ± 27.9% of nights. Moreover, the mean AHI off MAS was 17.9 ± 13.1; 88% of women had persistent SDB (AHI ≥ 10). CONCLUSIONS: In this cohort, treatment efficacy and objective adherence were variable. Device use was less frequent in the postpartum period even though a substantial number of women had persistent SDB after delivery. Clinical trial registered with  www. CLINICALTRIALS: gov number: NCT03138291.

Directive clinique no 439 : Diagnostic et prise en charge du vasa prævia.

OBJECTIF: Résumer les données probantes actuelles et énoncer des recommandations pour le diagnostic et la classification du vasa prævia et pour la prise en charge des femmes ayant reçu ce diagnostic. POPULATION CIBLE: Femmes enceintes présentant un vasa prævia ou des vaisseaux ombilicaux péricervicaux. OPTIONS: En cas de diagnostic soupçonné ou confirmé de vasa prævia ou de vaisseaux ombilicaux péricervicaux, prendre en charge la patiente à l'hôpital ou à domicile, puis pratiquer une césarienne avant terme ou à terme ou entreprendre une épreuve de travail. RéSULTATS: Hospitalisation prolongée, accouchement prématuré, césarienne et morbidité et mortalité néonatales. BéNéFICES, RISQUES ET COûTS: Les femmes ayant un vasa prævia ou des vaisseaux ombilicaux péricervicaux présentent un risque accru d'issues défavorables maternelles, fœtales ou postnatales, à savoir un diagnostic potentiellement erroné, un besoin d'hospitalisation, une restriction inutile des activités, un accouchement précoce et une césarienne inutile. L'optimisation des protocoles de diagnostic et de prise en charge peut améliorer les issues maternelles, fœtales et postnatales. DONNéES PROBANTES: Des recherches ont été effectuées dans les bases de données Medline, PubMed, Embase et Cochrane Library, de leur création jusqu'à mars 2022, à partir de termes MeSH et de mots clés liés à la grossesse, au vasa prævia, aux vaisseaux prævia, à l'hémorragie ante partum, au col court, au travail prématuré et à la césarienne. Le présent document est un résumé des données probantes et non pas une revue méthodologique. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Fournisseurs de soins obstétricaux, y compris obstétriciens, médecins de famille, infirmières, sages-femmes, spécialistes en médecine fœto-maternelle et radiologistes. RéSUMé POUR TWITTER: En cas de cordon et de vaisseaux ombilicaux non protégés dans les membranes près du col (vasa prævia y compris), une caractérisation échographique et une prise en charge avisée s'imposent pour réduire les risques pour le bébé et la mère pendant la grossesse et l'accouchement. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Guideline No. 439: Diagnosis and Management of Vasa Previa.

OBJECTIVE: To summarize the current evidence and to make recommendations for diagnosis and classification of vasa previa and for management of women with this diagnosis. TARGET POPULATION: Pregnant women with vasa previa or low-lying fetal vessels. OPTIONS: To manage vasa previa in hospital or at home, and to perform a cesarean delivery preterm or at term, or to allow a trial of labour when a diagnosis of vasa previa or low-lying fetal vessels is suspected or confirmed. OUTCOMES: Prolonged hospitalization, preterm birth, rate of cesarean delivery, and neonatal morbidity and mortality. BENEFITS, HARMS, AND COSTS: Women with vasa previa or low-lying fetal vessels are at an increased risk of maternal and fetal or postnatal adverse outcomes. These outcomes include a potentially incorrect diagnosis, need for hospitalization, unnecessary restriction of activities, an early delivery, and an unnecessary cesarean delivery. Optimization of diagnostic and management protocols can improve maternal and fetal or postnatal outcomes. EVIDENCE: Medline, Pubmed, Embase, and the Cochrane Library were searched from inception to March 2022, using medical subject headings (MeSH) and keywords related to pregnancy, vasa previa, low-lying fetal vessels, antepartum hemorrhage, short cervix, preterm labour, and cesarean delivery. This document presents an abstraction of the evidence rather than a methodological review. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: Obstetric care providers, including obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, and radiologists. TWEETABLE ABSTRACT: Unprotected fetal vessels in placental membranes and cord that are close to the cervix, including vasa previa, need careful characterization by sonographic examination and evidence-based management to reduce risks to the baby and the mother during pregnancy and delivery. SUMMARY STATEMENTS: RECOMMENDATIONS.

Biological impact of iberdomide in patients with active systemic lupus erythematosus.

OBJECTIVES: Iberdomide is a high-affinity cereblon ligand that promotes proteasomal degradation of transcription factors Ikaros (IKZF1) and Aiolos (IKZF3). Pharmacodynamics and pharmacokinetics of oral iberdomide were evaluated in a phase 2b study of patients with active systemic lupus erythematosus (SLE). METHODS: Adults with autoantibody-positive SLE were randomised to placebo (n=83) or once daily iberdomide 0.15 mg (n=42), 0.3 mg (n=82) or 0.45 mg (n=81). Pharmacodynamic changes in whole blood leucocytes were measured by flow cytometry, regulatory T cells (Tregs) by epigenetic assay, plasma cytokines by ultrasensitive cytokine assay and gene expression by Modular Immune Profiling. RESULTS: Iberdomide exhibited linear pharmacokinetics and dose-dependently modulated leucocytes and cytokines. Compared with placebo at week 24, iberdomide 0.45 mg significantly (p<0.001) reduced B cells, including those expressing CD268 (TNFRSF13C) (-58.3%), and plasmacytoid dendritic cells (-73.9%), and increased Tregs (+104.9%) and interleukin 2 (IL-2) (+144.1%). Clinical efficacy was previously reported in patients with high IKZF3 expression and high type I interferon (IFN) signature at baseline and confirmed here in those with an especially high IFN signature. Iberdomide decreased the type I IFN gene signature only in patients with high expression at baseline (-81.5%; p<0.001) but decreased other gene signatures in all patients. CONCLUSION: Iberdomide significantly reduced activity of type I IFN and B cell pathways, and increased IL-2 and Tregs, suggesting a selective rebalancing of immune abnormalities in SLE. Clinical efficacy corresponded to reduction of the type I IFN gene signature. TRIAL REGISTRATION NUMBER: NCT03161483.

Sleep-disordered breathing in high-risk pregnancies is associated with elevated arterial stiffness and increased risk for preeclampsia.

BACKGROUND: Impaired vascular function is a central feature of pathologic processes preceding the onset of preeclampsia. Arterial stiffness, a composite indicator of vascular health and an important vascular biomarker, has been found to be increased throughout pregnancy in those who develop preeclampsia and at the time of preeclampsia diagnosis. Although sleep-disordered breathing in pregnancy has been associated with increased risk for preeclampsia, it is unknown if sleep-disordered breathing is associated with elevated arterial stiffness in pregnancy. OBJECTIVE: This prospective observational cohort study aimed to evaluate arterial stiffness in pregnant women, with and without sleep-disordered breathing and assess the interaction between arterial stiffness, sleep-disordered breathing, and preeclampsia risk. STUDY DESIGN: Women with high-risk singleton pregnancies were enrolled at 10 to 13 weeks' gestation and completed the Epworth Sleepiness Score, Pittsburgh Sleep Quality Index, and Restless Legs Syndrome questionnaires at each trimester. Sleep-disordered breathing was defined as loud snoring or witnessed apneas (≥3 times per week). Central arterial stiffness (carotid-femoral pulse wave velocity, the gold standard measure of arterial stiffness), peripheral arterial stiffness (carotid-radial pulse wave velocity), wave reflection (augmentation index, time to wave reflection), and hemodynamics (central blood pressures, pulse pressure amplification) were assessed noninvasively using applanation tonometry at recruitment and every 4 weeks from recruitment until delivery. RESULTS: High-risk pregnant women (n=181) were included in the study. Women with sleep-disordered breathing (n=41; 23%) had increased carotid-femoral pulse wave velocity throughout gestation independent of blood pressure and body mass index (P=.042). Differences observed in other vascular measures were not maintained after adjustment for confounders. Excessive daytime sleepiness, defined by Epworth Sleepiness Score >10, was associated with increased carotid-femoral pulse wave velocity only in women with sleep-disordered breathing (Pinteraction=.001). Midgestation (first or second trimester) sleep-disordered breathing was associated with an odds ratio of 3.4 (0.9-12.9) for preeclampsia, which increased to 5.7 (1.1-26.0) in women with sleep-disordered breathing and hypersomnolence, whereas late (third-trimester) sleep-disordered breathing was associated with an odds ratio of 8.2 (1.5-39.5) for preeclampsia. CONCLUSION: High-risk pregnant women with midgestational sleep-disordered breathing had greater arterial stiffness throughout gestation than those without. Sleep-disordered breathing at any time during pregnancy was also associated with increased preeclampsia risk, and this effect was amplified by hypersomnolence.

Are different station formats assessing different dimensions in multiple mini-interviews? Findings from the Canadian integrated French multiple mini-interviews.

BACKGROUND: Multiple mini-interviews (MMI) are used to assess non-academic attributes for selection in medicine and other healthcare professions. It remains unclear if different MMI station formats (discussions, role-plays, collaboration) assess different dimensions. METHODS: Based on station formats of the 2018 and 2019 Integrated French MMI (IFMMI), which comprised five discussions, three role-plays and two collaboration stations, the authors performed confirmatory factor analysis (CFA) using the lavaan 0.6-5 R package and compared a one-factor solution to a three-factor solution for scores of the 2018 (n = 1438) and 2019 (n = 1440) cohorts of the IFMMI across three medical schools in Quebec, Canada. RESULTS: The three-factor solution was retained, with discussions, role-plays and collaboration stations all loading adequately with their scores. Furthermore, all three factors had moderate-to-high covariance (range 0.44 to 0.64). The model fit was also excellent with a Comparative fit index (CFI) of 0.983 (good if > 0.9), a Tucker Lewis index of 0.976 (good if > 0.95), a Standardized Root Mean Square Residual of 0.021 (good if < .08) and a Root Mean Square Error of 0.023 (good if < 0.08) for 2018 and similar results for 2019. In comparison, the single factor solution presented a lower fit (CFI = 0.819, TLI = 0.767, SRMR = 0.049 and RMSEA = 0.070). CONCLUSIONS: The IFMMI assessed three dimensions that were related to stations formats, a finding that was consistent across two cohorts. This suggests that different station formats may be assessing different skills, and has implications for the choice of appropriate reliability metrics and the interpretation of scores. Further studies should try to characterize the underlying constructs associated with each station format and look for differential predictive validity according to these formats.

A Phase I, First-in-Human Study of GSK2849330, an Anti-HER3 Monoclonal Antibody, in HER3-Expressing Solid Tumors.

BACKGROUND: GSK2849330, an anti-HER3 monoclonal antibody that blocks HER3/Neuregulin 1 (NRG1) signaling in cancer cells, is engineered for enhanced antibody-dependent cellular cytotoxicity and complement-dependent cytotoxicity. This phase I, first-in-human, open-label study assessed the safety, pharmacokinetics (PK), pharmacodynamics, and preliminary activity of GSK2849330 in patients with HER3-expressing advanced solid tumors. PATIENTS AND METHODS: Patients with various tumor types were prospectively selected for HER3 expression by immunohistochemistry; a subset was also screened for NRG1 mRNA expression. In the dose-escalation phase, patients received GSK2849330 1.4-30 mg/kg every 2 weeks, or 3 mg/kg or 30 mg/kg weekly, intravenously (IV). In the dose-expansion phase, patients received 30 mg/kg GSK2849330 IV weekly. RESULTS: Twenty-nine patients with HER3-expressing cancers, of whom two expressed NRG1, received GSK2849330 (dose escalation: n = 18, dose expansion: n = 11). GSK2849330 was well tolerated. No dose-limiting toxicities were observed. The highest dose, of 30 mg/kg weekly, expected to provide full target engagement, was selected for dose expansion. Treatment-emergent adverse events (AEs) were mostly grade 1 or 2. The most common AEs were diarrhea (66%), fatigue (62%), and decreased appetite (31%). Dose-proportional plasma exposures were achieved, with evidence of HER3 inhibition in paired tissue biopsies. Of 29 patients, only 1 confirmed partial response, lasting 19 months, was noted in a patient with CD74-NRG1-rearranged non-small cell lung cancer (NSCLC). CONCLUSION: GSK2849330 demonstrated a favorable safety profile, dose-proportional PK, and evidence of target engagement, but limited antitumor activity in HER3-expressing cancers. The exceptional response seen in a patient with CD74-NRG1-rearranged NSCLC suggests further exploration in NRG1-fusion-positive cancers. IMPLICATIONS FOR PRACTICE: This first-in-human study confirms that GSK2849330 is well tolerated. Importantly, across a variety of HER3-expressing advanced tumors, prospective selection by HER3/NRG1 expression alone was insufficient to identify patients who could benefit from treatment with this antibody-dependent cell-mediated cytotoxicity- and complement-dependent cytotoxicity-enhanced anti-HER3 antibody. The only confirmed durable response achieved was in a patient with CD74-NRG1-rearranged lung cancer. This highlights the potential utility of screening for NRG1 fusions prospectively across tumor types to enrich potential responders to anti-HER3 agents in ongoing trials.

Accuracy of rating scale interval values used in multiple mini-interviews: a mixed methods study.

When determining the score given to candidates in multiple mini-interview (MMI) stations, raters have to translate a narrative judgment to an ordinal rating scale. When adding individual scores to calculate final ranking, it is generally presumed that the values of possible scores on the evaluation grid are separated by constant intervals, following a linear function, although this assumption is seldom validated with raters themselves. Inaccurate interval values could lead to systemic bias that could potentially distort candidates' final cumulative scores. The aim of this study was to establish rating scale values based on rater's intent, to validate these with an independent quantitative method, to explore their impact on final score, and to appraise their meaning according to experienced MMI interviewers. A 4-round consensus-group exercise was independently conducted with 42 MMI interviewers who were asked to determine relative values for the 6-point rating scale (from A to F) used in the Canadian integrated French MMI (IFMMI). In parallel, relative values were also calculated for each option of the scale by comparing the average scores concurrently given to the same individual in other stations every time that option was selected during three consecutive IFMMI years. Data from the same three cohorts was used to simulate the impact of using new score values on final rankings. Comments from the consensus group exercise were reviewed independently by two authors to explore raters' rationale for choosing specific values. Relative to the maximum (A = 100%) and minimum (F = 0%), experienced raters concluded to values of 86.7% (95% CI 86.3-87.1), 69.5% (68.9-70.1), 51.2% (50.6-51.8), and 29.3% (28.1-30.5), for scores of B, C, D and E respectively. The concurrent score approach was based on 43,412 IFMMI stations performed by 4345 medical school applicants. It provided quasi-identical values of 87.1% (82.4-91.5), 70.4% (66.1-74.7), 51.2% (47.1-55.3) and 31.8% (27.9-35.7), respectively. Qualitative analysis explained that while high scores are usually based on minor details of relatively low importance, low scores are usually attributed for more serious offenses and were assumed by the raters to carry more weight in the final score. Individual drop or increase in final MMI ranking with the use of new scale values ranged from - 21 to + 5 percentiles, with the average candidate changing by ± 1.4 percentiles. Consulting with experienced interviewers is a simple and effective approach to establish rating scale values that truly reflects raters' intent in MMI, thus improving the accuracy of the instrument and contributing to the general fairness of the process.

Perceptions of Emergency Medicine Residents of Multisource Feedback: Different, Relevant, and Useful Information.

STUDY OBJECTIVE: Multisource feedback is a process through which different members of the care team assess and provide feedback on residents' competencies, usually those that are less often addressed by traditional assessment methods (ie, communication, collaboration, and professionalism). Feasibility and reliability of multisource feedback have been addressed in previous research. The present study explores emergency residents' perceptions of multisource feedback provided by teaching physicians, nurses, and patients they have worked with during a rotation in an emergency department (ED). METHODS: A multisource feedback intervention was proposed to residents during 9 months in the ED of a tertiary care university hospital. Residents distributed feedback questionnaires to physicians, nurses, and patients that focused on competencies (collaboration, communication, and professionalism) from the CanMEDS framework. Responses were compiled and reported to participating residents. To assess residents' perceptions of multisource feedback, semistructured group and individual interviews were held 3 months after the intervention. Transcripts were analyzed qualitatively, following Miles and Huberman's method for intrasite case analysis. RESULTS: According to residents (n=10), each source (physicians, nurses, and patients) provided relevant comments that differed significantly in their content. Physicians focused primarily on medical expertise; nurses addressed competencies related to leadership, collaboration, and communication; and patients commented on the competencies of professionalism and communication. Residents concluded that obtaining feedback from nurses and patients was acceptable and useful. They reported modifying certain behaviors after receiving the multisource feedback. CONCLUSION: Residents perceived the multisource feedback to be acceptable and useful for the assessment of medical competencies such as communication, collaboration, professionalism, and leadership.

Guideline No. 393-Diabetes in Pregnancy.

OBJECTIVES: This guideline reviews the evidence relating to the diagnosis and obstetrical management of diabetes in pregnancy. OUTCOMES: The outcomes evaluated were short and long-term maternal outcomes including pre-eclampsia, Caesarean section, future diabetes and other cardiovascular complications; and fetal outcomes including congenital anomalies, stillbirth, macrosomia, birth trauma, hypoglycemia and long-term effects. EVIDENCE: Published literature was retrieved through searches of PubMed and The Cochrane Library using appropriate controlled vocabulary (MeSH terms "diabetes" and "pregnancy"). Where appropriate, 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. VALUES: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. SUMMARY STATEMENTS: RECOMMENDATIONS.

Directive clinique N° 393 - Le diabète pendant la grossesse.

OBJECTIF: La présente Directive passe en revue les données probantes liées au diagnostic et à la prise en charge obstétricale du diabète durant la grossesse. ISSUES: Les issues évaluées étaient les issues maternelles à court et à long terme, dont la prééclampsie, la césarienne, le diabète éventuel et d'autres complications cardiovasculaires et les issues fœtales, dont les anomalies congénitales, la mortinaissance, la macrosomie, le traumatisme de la naissance, l'hypoglycémie et les effets à long terme. RéSULTATS: La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans PubMed et The Cochrane Library au moyen d'un vocabulaire contrôlé (termes MeSH « diabète ¼ et « grossesse ¼) approprié. Le cas échéant, les résultats ont été restreints aux analyses systématiques, aux essais comparatifs randomisés / essais cliniques comparatifs et aux études observationnelles. Aucune limite n'a été imposée en matière de date, mais les résultats ont été limités aux articles publiés en anglais ou en français. VALEURS: La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

No 373 - Insuffisance cervicale et cerclage cervical.

OBJECTIF: La présente directive clinique vise à fournir aux cliniciens un cadre à utiliser pour déterminer quelles femmes présentent un risque accru d'insuffisance cervicale et dans quelles situations le cerclage aurait une valeur potentielle. DONNéES PROBANTES: Nous avons examiné des études publiées récupérées au moyen de recherches dans PubMed, Medline, CINAHL et The Cochrane Library en 2018 à l'aide d'une terminologie (p. ex., uterine cervical incompetence) et de mots-clés (p. ex., cervical insufficiency, cerclage, Shirodkar cerclage, McDonald cerclage, abdominal, cervical length, mid-trimester pregnancy loss). Nous avons tenu compte des résultats provenant de revues systématiques, d'essais cliniques randomisés, d'essais cliniques contrôlés et d'études observationnelles. Aucune restriction de date ou de langue n'a été employée. Les recherches ont été refaites régulièrement, et les résultats ont été incorporés à la directive clinique jusqu'en juin 2018. Nous avons également tenu compte de la littérature grise (non publiée) trouvée sur les sites Web d'organismes d'évaluation des technologies de la santé et d'autres organismes liés aux technologies de la santé, dans des collections de directives cliniques et des registres d'essais cliniques, et obtenue auprès d'associations nationales et internationales de médecins spécialistes. VALEURS: La qualité des données probantes a été évaluée en fonction des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs. RECOMMANDATIONS.

No. 373-Cervical Insufficiency and Cervical Cerclage.

OBJECTIVE: The purpose of this guideline is to provide a framework that clinicians can use to determine which women are at greatest risk of having cervical insufficiency and in which set of circumstances a cerclage is of potential value. EVIDENCE: Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in 2018 using appropriate controlled vocabulary (e.g., uterine cervical incompetence) and key words (e.g., cervical insufficiency, cerclage, Shirodkar, cerclage, McDonald, cerclage, abdominal, cervical length, mid-trimester pregnancy loss). 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 incorporated in the guideline to June 2018. 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.

Interactions Between Indigenous Women Awaiting Childbirth Away From Home and Their Southern, Non-Indigenous Health Care Providers.

We examine patient-provider interactions for Indigenous childbirth evacuees. Our analysis draws on in-depth interviews with 25 Inuit and First Nations women with medically high-risk pregnancies who were transferred or medevacked from northern Quebec to receive maternity care at a tertiary hospital in a southern city in the province. We supplemented the patient data with interviews from eight health care providers. Three themes related to patient-provider interactions are discussed: evacuation-related stress, hospital bureaucracy, and stereotypes. Findings show that the quality of the patient-provider interaction is contingent on individual health care providers' ability to connect with Indigenous patients and overcome cultural and institutional barriers to communication and trust-building. The findings point to the need for further training of medical professionals in the delivery of culturally safe care and addressing bureaucratic constraints in the health care system to improve patient-provider communication and overall relationship quality.

No. 231-Guidelines for the Management of Vasa Previa.

OBJECTIVES: To describe the etiology of vasa previa and the risk factors and associated condition, to identify the various clinical presentations of vasa previa, to describe the ultrasound tools used in its diagnosis, and to describe the management of vasa previa. OUTCOMES: Reduction of perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short-term and long-term maternal morbidity and mortality. EVIDENCE: Published literature on randomized trials, prospective cohort studies, and selected retrospective cohort studies was retrieved through searches of PubMed or Medline, CINAHL, and the Cochrane Library, using appropriate controlled vocabulary (e.g., selected epidemiological studies comparing delivery by Caesarean section with vaginal delivery; studies comparing outcomes when vasa previa is diagnosed antenatally vs. intrapartum) and key words (e.g., vasa previa). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated into the guideline to October 1, 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 from national and international medical specialty societies. VALUES: The evidence collected was reviewed by the Diagnostic Imaging Committee and the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS: The benefit expected from this guideline is facilitation of optimal and uniform care for pregnancies complicated by vasa previa. SPONSORS: The Society of Obstetricians and Gynaecologists of Canada. SUMMARY STATEMENT: A comparison of women who were diagnosed antenatally and those who were not shows respective neonatal survival rates of 97% and 44%, and neonatal blood transfusion rates of 3.4% and 58.5%, respectively. Vasa previa can be diagnosed antenatally, using combined abdominal and transvaginal ultrasound and colour flow mapping; however, many cases are not diagnosed, and not making such a diagnosis is still acceptable. Even under the best circumstances the false positive rate is extremely low. (II-2) RECOMMENDATIONS.

Impact of sociodemographic characteristics of applicants in multiple mini-interviews.

BACKGROUND: Multiple mini-interviews (MMI) are commonly used for medical school admission. This study aimed to assess if sociodemographic characteristics are associated with MMI performance, and how they may act as barriers or enablers to communication in MMI. METHODS: This mixed-method study combined data from a sociodemographic questionnaire, MMI scores, semi-structured interviews and focus groups with applicants and assessors. Quantitative and qualitative data were analyzed using multiple linear regression and a thematic framework analysis. RESULTS: 1099 applicants responded to the questionnaire. A regression model (R2 = 0.086) demonstrated that being age 25-29 (ß = 0.11, p = 0.001), female and a French-speaker (ß = 0.22, p = 0.003) were associated with better MMI scores. Having an Asian-born parent was associated with a lower score (ß = -0.12, p < 0.001). Candidates reporting a higher family income had higher MMI scores. In the qualitative data, participants discussed how maturity and financial support improved life experiences, how language could act as a barrier, and how ethnocultural differences could lead to misunderstandings. CONCLUSION: Age, gender, ethnicity, socioeconomic status and language seem to be associated with applicants' MMI scores because of perceived differences in communications skills and life experiences. Monitoring this association may provide guidance to improve fairness of MMI stations.

Maternal sleep-disordered breathing and the risk of delivering small for gestational age infants: a prospective cohort study.

OBJECTIVE: It is unclear whether objectively measured maternal sleep-disordered breathing (SDB) leads to poor fetal outcomes. In this study, we prospectively assessed whether polysomnography-based diagnosis of SDB in the third trimester is associated with the delivery of small for gestational age (SGA) infants. STUDY DESIGN: Participants were recruited from a multicentre pregnancy cohort study. Eligible participants were evaluated for SDB based on symptoms (snoring and/or witnessed apnoeas assessed using the Pittsburgh Sleep Quality Index questionnaire) and in-home complete polysomnography in the third trimester. SGA was defined as <10th centile using customised birthweight centiles adjusted for maternal parity, prepregnancy body mass index (BMI), ethnicity, gestational age and infant sex. RESULTS: Of the 234 pregnant participants who completed a sleep study, 82% were Caucasian, with mean (SD) age of 31 (4.3) years and a prepregnancy BMI of 23 (4) kg/m(2). The delivery of SGA infants occurred in 27 (12%) of the study participants. The symptoms of SDB had poor overall sensitivity and specificity for diagnosing SDB identified by polysomnography. Symptoms of SDB in the third trimester demonstrated a potential association with delivering an SGA infant, however this did not reach statistical significance (OR 2.36 (95% CI 0.85 to 6.54, p=0.10)). However, the odds of delivering an SGA infant were significantly increased with polysomnography-based diagnosis of maternal SDB (using apnoea-hypopnoea index cut-off of 10, OR 2.65 (95% CI 1.15 to 6.10, p=0.02)). CONCLUSIONS: Objectively measured SDB in the third trimester is significantly associated with the delivery of SGA infants.