Influence of organizational factors on the offer and success rate of a trial of labor after cesarean section in Belgium: an ecological study.

BACKGROUND: Trial of Labor After Cesarean is an important strategy for reducing the overall rate of cesarean delivery. Offering the option of vaginal delivery to a woman with a history of cesarean section requires the ability to manage a potential uterine rupture quickly and effectively. This requires infrastructure and organization of the maternity unit so that the decision-to-delivery interval is as short as possible when uterine rupture is suspected. We hypothesize that the organizational characteristics of maternity units in Belgium have an impact on their proposal and success rates of trial of labour after cesarean section. METHODS: We collected data on the organizational characteristics of Belgian maternity units using an online questionnaire. Data on the frequency of cesarean section, trial of labor and vaginal birth after cesarean section were obtained from regional perinatal registries. We analyzed the determinants of the proposal and success of trial of labor after cesarean section and report the associations as mean proportions. RESULTS: Of the 101 maternity units contacted, 97 responded to the questionnaire and data from 95 was included in the analysis. Continuous on-site presence of a gynecologist and an anesthetist was associated with a higher proportion of trial of labor after cesarean section, compared to units where staff was on-call from home (51% versus 46%, p = 0.04). There is a non-significant trend towards more trial of labor after cesarean section in units with an operating room in or near the delivery unit and a shorter transfer time, in larger units (> 1500 deliveries/year) and in units with a neonatal intensive care unit. The proposal of trial of labor after cesarean section and its success was negatively correlated to the number of cesarean section in the maternity unit (Spearman' rho = 0.50 and 0.42, p value < 0.001). CONCLUSIONS: Organizational differences in maternity units appear to affect the proposal of trial of labor after cesarean section. Addressing these organizational factors may not be sufficient to change practice, given that general tendency to perform a cesarean section in the maternity unit is the main contributor to the percentage of trial of labor after cesarean.

Water soluble swallow for leak detection after total laryngectomy post radiotherapy.

AIM: Pharyngeal leak (PL) and pharyngocutaneous fistula (PCF) are serious complications following total laryngectomy and their incidence is higher in the salvage setting. The aim of this study is to describe the accuracy of water soluble swallow (WSS) to rule out salivary postoperative leak after salvage total laryngectomy (STL) to expedite start of oral intake. MATERIAL AND METHODS: Retrospective study including patients undergoing STL between 2008 and 2021 at Guy's Hospital. WSS was routinely performed within 15 days post operation. RESULTS: Sixty-six patients underwent STL. Nine developed clinically diagnosed PCF; one died before having WSS. Fifty-six patients underwent WSS post STL. WSS was performed within 15 days after STL when no postoperative complications occurred (76.8%). Among patients undergoing WSS with no clinical suspicion for fistula (56), PL was identified in 15 cases (26.8%). They were managed conservatively; PCF was avoided in 7(46.7%) cases. Three patients (7.3%) developed PCF after having started oral intake with a negative WSS. These three cases were further analysed, 2 cases where recorded at the beginning of the studied period when less experience was available possibly leading to incorrect results. Sensitivity and negative predictive value (NPV) for fistula prediction were 72.7% and 92.7%, respectively. CONCLUSION: Taking into account the high NPV of WSS, it is safe to start oral intake after negative WSS. Further studies to evaluate its accuracy earlier on after SLT are justified taking into account the results and the impact that delayed feeding has on patient's quality of life.

Post-therapeutic surveillance of HPV-driven oropharyngeal cancers: are we ready to change our practices?

PURPOSE: Although HPV-positive and negative oropharyngeal cancers are two distinct diseases, Post-Therapeutic Surveillance (PTS) modalities are similar. Adjusting PTS strategies to HPV status will represent a massive practice change that raises the issue of its acceptability, by both physicians and patients. METHODS: Two distinct surveys were designed and submitted, respectively, to HPV-positive patients and physicians (surgeons, radiation and medical oncologists) involved in head and neck cancer treatment. RESULTS: 133 patients and 90 physicians have participated to the study. Most patients were reluctant to embrace new PTS options (remote consultations, nurse consultations and smart phone applications). However, 84% of patients would be favorable to use HPV Circulating DNA (HPV Ct DNA) measurement to guide surveillance modalities. 57% of physicians acknowledged that our current PTS strategy is improvable and most of them would accept the use of new monitoring options from the third year of follow-up. 87% of physicians would be interested to participate to a trial comparing the current PTS strategy to a new approach, where monitoring modalities (number of visits, imaging prescription) would depend on HPV Ct DNA level. CONCLUSIONS: Patients and physicians are aware that PTS modalities should depend on HPV status. Their adhesion is a prerequisite to any potential changes. Strategies based on HPV Ct DNA measurement should be assessed within a randomized clinical trial.

Evolution of maternal and neonatal outcomes before and after the adoption of the IADPSG/WHO guidelines in Belgium: A descriptive study of 444,228 pregnancies.

Objectives: To appraise adverse pregnancy outcomes after the adoption of IADPSG/WHO guidelines in Belgium. Methods: A retrospective study of the Center for Perinatal Epidemiology registry was conducted. Demographic changes and adverse pregnancy outcomes were compared between a pre- and post-guideline period in women with and without hyperglycemia in pregnancy (HIP). Adjusted odds ratios with a 95% confidence interval (CI) were used to compare maternal and neonatal outcomes controlling for potential confounders (maternal age, body mass index (BMI), hypertension, parity, and multiple births). Results: The prevalence of HIP increased (6.0%-9.2%). In the overall population regardless of glycemic status, gestational weight gain (12.3 ± 5.7 vs 11.9 ± 5.8; p < 0.001), hypertension (0.92; 95% CI, 0.89-0.94; p < 0.001), and neonatal intensive care unit/special care nursery (0.89; 95% CI, 0.87-0.91; p < 0.001) decreased despite increasing maternal age and pre-pregnancy BMI. Emergency cesarean section rates (1.07; 95% CI, 1.05-1.09; p < 0.001) increased, but not in the HIP population (1.02; 95% CI, 0.95-1.10; ns). The overall incidence of preterm birth (1.09; 95% CI, 1.06-1.12; p < 0.001), stillbirth (1.10; 95% CI, 1.01-1.21; p < 0.05), and perinatal mortality (1.10; 95% CI, 1.01-1.19; p < 0.05) increased, except in the HIP population (1.03; 95% CI, 0.95-1.11; ns), (1.04; 95% CI, 0.74-1.47; ns) and (1.09; 95% CI, 0.80-1.49; ns), respectively. The overall incidence of small- for-gestational-age remained unchanged (0.99; 95%CI, 0.97-1.01; ns) regardless of glycemic status. In the HIP population, large-for-gestational age (0.90; 95% CI, 0.84-0.95; p < 0.001) and macrosomia (0.84; 95% CI, 0.78-0.92; p < 0.001) decreased. Conclusion: After the implementation of IADPSG/WHO guidelines, the prevalence of HIP increased by 53.7% and the incidence of major HIP-related pregnancy complications appears to be lower. However, we cannot conclude that the reduction of LGA-macrosomia is due to a better management of diabetes or due to greater recruitment of women with mild HIP associated with a lower risk of obstetrical complications.

Oropharyngeal cancer: First relapse description and prognostic factor of salvage treatment according to p16 status, a GETTEC multicentric study.

INTRODUCTION: Although Human Papilloma Virus (HPV)-driven oropharyngeal cancer (OPC) prognosis is significantly better than that of other head and neck cancers, up to 25% of cases will recur within 5 years. Data on the pattern of disease recurrence and efficiency of salvage treatment are still sparse. MATERIAL AND METHOD: Observational study of all recurrent OPCs diagnosed, following a curative intent treatment, in seven French centers from 2009 to 2014. p16 Immunohistochemistry was used to determine HPV status. Clinical characteristics, distribution of recurrence site, and treatment modalities were compared by HPV tumor status. Overall survival was examined using Kaplan-Meier and multivariate Cox regression modeling. RESULTS: 350 recurrent OPC patients (246 p16-negative and 104 p16-positive patients). The site of recurrence was more frequently locoregional for p16-negative patients (65.4% versus 52.9% in p16-positive patients) and metastatic for p16-positive patients (47.1% versus 34.6% in p16-patients, p = 0.03). Time from diagnosis to recurrence did not differ between p16-positive and p16-negative patients (12 and 9.6 months, respectively, p-value = 0.2), as the main site of distant metastasis (all p-values ≥0.10). Overall and relapse-free survival following the first recurrence did not differ according to p16 status (p-values from log-rank 0.30 and 0.40, respectively). In multivariate analysis, prognosis factors for overall survival in p16-negative patients were distant metastasis (HR 2.11, 95% CI 1.30-3.43) and concurrent local and regional recurrences (HR 2.20, 95% CI 1.24-3.88). CONCLUSION: With the exception of the initial site of recurrence, the pattern of disease relapse and the efficiency of salvage treatment are not different between p16-positive and negative OPCs.

Smoking impact on HPV driven head and neck cancer's oncological outcomes?

INTRODUCTION: HPV-driven oropharyngeal cancer (OPC) patients have a better prognosis than their HPV-negative counterparts but several studies have suggested that among HPV-positive patients those with a smoking history had worse oncological outcomes. The aim of our study is to characterize the interplay between tobacco consumption, patient and disease characteristics, and disease control. MATERIALS AND METHODS: All patients diagnosed with HPV-driven OPC and treated with curative intent between 2007 and 2009 and 2011-2016 at Gustave Roussy cancer center were included (n = 282). Demographic, clinical, morphological and tobacco consumption were correlated with oncologic outcomes. RESULTS: 157 (56%) patients had a positive smoking history, including 23.8% who were smoking at the time of diagnosis and 37.6% who had a tobacco consumption exceeding 20 pack-years. In multivariate analysis, the strongest prognostic factor for survival was smoking status at cancer diagnosis, with a hazard ratio (HR) for non-smokers compared to smokers of 0.25 ([0.12, 0.50], p = 0.0001). Smoking history, either more than 20 pack-years or smoking at diagnosis, was associated with local relapse and distant relapse. There was no difference in terms of comorbidity (p = 0.32) and radiotherapy duration (p = 0.93) according to tobacco consumption. DISCUSSION: Smoking is frequent among patients with HPV-driven OPC and increases the risk of death and oncologic failure.

Effect of maternal origin on the association between maternal height and risk of preterm birth in Belgium: a retrospective observational cohort study.

OBJECTIVES: To investigate the effect of maternal origin on the association between maternal height and the risk of preterm birth (PTB). DESIGN: Retrospective observational cohort study. SETTING: Two of the three Belgian regions, including Brussels-Capital and Walloon regions. PARTICIPANTS: A total of 245 204 women spontaneously delivered live singletons between 2009 and 2013. Maternal nationality at the time of birth included Belgium, Congo, French, Italy, Morocco, Poland, Romania and Turkey. OUTCOMES MEASURES: The outcome variable was spontaneous PTB, defined as childbirth occurring at less than 37 weeks' gestation. RESULTS: Average height, demographic characteristics and the spontaneous PTB rate differed according to maternal origin, defined as maternal nationality at birth. The pattern of association between maternal height and the risk of PTB was not uniform by maternal nationality at birth. The low maternal height category was associated with a statistically significant increased risk of spontaneous PTB for Belgian (adjusted OR (aOR) 1.23, 95% CI 1.16 to 1.32), Italian (aOR 1.48, 95% CI 1.12 to 1.96) and Polish (aOR 1.76, 95% CI 1.11 to 2.78), respectively. However, this association was not observed for the women from Congo, France, Morocco, Romania and Turkey. CONCLUSIONS: The association between height and the risk of PTB was modified by maternal nationality, even for mothers from the same region of the world. For example, there was a significant inverse association for the Belgians and Italians but not for French women. Our data suggest that PTB risk assessment should take into account the specific height of maternal origin.

Enhancing the emergence rate of coherent wavefronts from ocean ambient noise correlations using spatio-temporal filters.

Extracting coherent wavefronts between passive receivers using cross-correlations of ambient noise (CAN) provides a means for monitoring the seismoacoustic environment without using active sources. However, using cross-correlations between single receivers can require a long recording time in order to extract stable coherent arrivals from CAN. This becomes an issue if the propagation medium fluctuates significantly during the recording period. To address this issue, this article presents a general spatio-temporal filtering procedure to enhance the emergence rate for coherent wavefronts extracted from time-averaged ambient noise correlations between two spatially separated arrays. The robustness of this array-based CAN technique is investigated using ambient shipping noise recorded over 24 h in the frequency band [250-850 Hz] on two vertical line arrays deployed 143 m apart in shallow water (depth 20 m). Experimental results confirm that the array-based CAN technique can significantly reduce the recording duration (e.g., from 22 h to 30 min) required for extracting coherent wavefronts of sufficient amplitude (e.g., 20 dB over residual temporal fluctations) when compared to conventional CAN implementations between single pairs of hydrophones. These improvements of the CAN technique could benefit the development of noise-based ocean monitoring applications such as passive acoustic tomography.