Usability, accuracy, and cost-effectiveness of a medical software for early pregnancies: a retrospective study.

STUDY QUESTION: Can early pregnancies be accurately and cost-effectively diagnosed and managed using a new medical computerized tool? SUMMARY ANSWER: Compared to the standard clinical approach, retrospective implementation of the new medical software in a gynaecological emergency unit was correlated with more accurate diagnosis and more cost-effective management. WHAT IS KNOWN ALREADY: Early pregnancy complications are responsible for a large percentage of consultations, mostly in emergency units, with guidelines becoming complex and poorly known/misunderstood by practitioners. STUDY DESIGN, SIZE, DURATION: A total of 780 gynaecological emergency consultations (446 patients), recorded between November 2018 and June 2019 in a tertiary university hospital, were retrospectively encoded in a new medical computerized tool. The inclusion criteria were a positive hCG test result, ultrasonographical visualization of gestational sac, and/or embryo corresponding to a gestational age of 14 weeks or less. Diagnosis and management suggested by the new computerized tool are named eDiagnoses, while those provided by a gynaecologist member of the emergency department staff are called medDiagnoses. PARTICIPANTS/MATERIALS, SETTING, METHODS: Usability was the primary endpoint, with accuracy and cost reduction, respectively, as secondary and tertiary endpoints. Identical eDiagnoses/medDiagnoses were considered as accurate. During follow-up visits, if the updated eDiagnoses and medDiagnoses became both identical to a previously discrepant eDiagnosis or medDiagnosis, this previous eDiagnosis or medDiagnosis was also considered as correct. Four double-blinded experts reviewed persistent discrepancies, determining the accurate diagnoses. eDiagnoses/medDiagnoses accuracies were compared using McNemar's Chi square test, sensitivity, specificity, and predictive values. MAIN RESULTS AND THE ROLE OF CHANCE: Only 1 (0.1%) from 780 registered medical records lacked data for full encoding. Out of the 779 remaining consultations, 675 eDiagnoses were identical to the medDiagnoses (86.6%) and 104 were discrepant (13.4%). From these 104, 60 reached an agreement during follow-up consultations, with 59 medDiagnoses ultimately changing into the initial eDiagnoses (98%) and only one discrepant eDiagnosis turning later into the initial medDiagnosis (2%). Finally, 24 remained discrepant at all subsequent checks and 20 were not re-evaluated. Out of these 44, the majority of experts agreed on 38 eDiagnoses (86%) and 5 medDiagnoses (11%, including four twin pregnancies whose twinness was the only discrepancy). No majority was reached for one discrepant eDiagnosis/medDiagnosis (2%). In total, the accuracy of eDiagnoses was 99.1% (675 + 59 + 38 = 772 eDiagnoses out of 779), versus 87.4% (675 + 1 + 5 = 681) for medDiagnoses (P < 0.0001). Calculating all basic costs of extra consultations, extra-medications, extra-surgeries, and extra-hospitalizations induced by incorrect medDiagnoses versus eDiagnoses, the new medical computerized tool would have saved 3623.75 Euros per month. Retrospectively, the medical computerized tool was usable in almost all the recorded cases (99.9%), globally more accurate (99.1% versus 87.4%), and for all diagnoses except twinning reports, and it was more cost-effective than the standard clinical approach. LIMITATIONS, REASONS FOR CAUTION: The retrospective study design is a limitation. Some observed improvements with the medical software could derive from the encoding by a rested and/or more experienced physician who had a better ultrasound interpretation. This software cannot replace clinical and ultrasonographical skills but may improve the compliance to published guidelines. WIDER IMPLICATIONS OF THE FINDINGS: This medical computerized tool is improving. A new version considers diagnosis and management of multiple pregnancies with their specificities (potentially multiple locations, chorioamnionicity). Prospective evaluations will be required. Further developmental steps are planned, including software incorporation into ultrasound devices and integration of previously published predictive/prognostic factors (e.g. serum progesterone, corpus luteum scoring). STUDY FUNDING/COMPETING INTEREST(S): No external funding was obtained for this study. F.B. and D.G. created the new medical software. TRIAL REGISTRATION NUMBER: NCT03993015.

[Are gestational weight gain guidelines for obese women still appropriate?] / Les recommandations de prise de poids gestationnelle pour les femmes obèses sont-elles encore adaptées ?

Guidelines for adequate gestational weight gain were proposed in 2009 by the Institute of Medicine. In case of a BMI>30kg/m2, the recommended gestational weight gain should be between 5 and 9kg. However, these recommendations do not distinguish between different grades of obesity. Recent data suggest that the IOM recommendations are not restrictive enough for obese pregnant women and should be adapted to the grade of obesity.

[The cesarean procedure: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]. / La technique de la césarienne : recommandations pour la pratique clinique du Collège national des gynécologues obstétriciens français.

OBJECTIVE: To identify procedures to reduce maternal morbidity during cesarean. MATERIAL AND METHODS: The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations. RESULTS: Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the cesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood loss>1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned cesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommendation). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds. CONCLUSION: In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity.

Prenatally Symptomatic Suprasellar Arachnoid Cyst: When to treat? A case-base update.

INTRODUCTION: Suprasellar Arachnoid Cysts (SAC) are rare heterogeneous entities. Though prenatally diagnosed, they are rarely treated pre-birth. Symptomatic cases are mainly seen in infants. CASE DESCRIPTION: We describe a case of a prenatally symptomatic suprasellar arachnoid cyst treated postnatally. The cyst was diagnosed on a routine ultrasound at 22 weeks, was rapidly evolving in the ultrasounds and the MRI of the 29th week. It then became symptomatic at 30 weeks with episodes of fetal bradycardia, independent to the uterine contractions. Antenatal treatment was discussed but delivery decided in emergency despite the prematurity via C-section. Though well tolerated postnatally, the cyst continued to grow. Endoscopic ventriculo-cysto-cisternostomy was performed on the 5th day of birth. Despite progressive reduction of the cyst, residual brainstem compression and evolving ventriculomegaly lead to a transient extrathecal internal shunting. DISCUSSION/CONCLUSION: Our case suggests that prenatally diagnosed cysts require a close follow-up. Treatment options and timing should be adapted to anatomy, cyst evolution and symptoms whether it is before or after birth.

Litigations in orthopedics and trauma surgery: reasons, dynamics, and profiles.

BACKGROUND: In recent literature, the increasing number of medical litigations, both in terms of the number of cases being filed and the substantive costs associated with lawsuits, has been described. This study aims to provide an overview of the profile of litigation for orthopedic and trauma surgery to describe the differences and the development of the number of cases over time. PATIENTS AND MATERIALS: A retrospective review of all litigations between 2000 and 2017 was conducted using the institutional legal database. The causes of litigation were documented and classified into seven major categories. In addition to plaintiff characteristics, the litigation outcomes and the differences between emergency and elective surgery were analyzed. RESULTS: A total of 230 cases were evaluated. The mean age of the plaintiffs was 44.6 ± 20.1 years, and 56.8% were female. The main reasons for litigation were claimed inappropriate management (46.1%), misdiagnosis (22.6), and poor nursing care (8.3%). Significantly more litigations were filed against surgeons of the orthopedic subspecialty compared with trauma surgeons (78%; p ≤ 0.0001). There were significantly fewer litigations per 1000 cases filed overall in 2009-2017 (65% less; p = 0.003) than in 2000-2008. CONCLUSION: Our results could not confirm the often-stated trend of having more litigations against orthopedic and trauma surgeons. Although the absolute numbers increased, the number of litigations per 1000 patients treated declined. Patients who underwent elective surgery were more likely to file complaints than emergency patients.

[Reprint of: Severe pre-eclampsia: guidelines for clinical practice from the French Society of anesthesiology and intensive care (SFAR) and the French College of gynaecologists and obstetricians (CNGOF)]. / Republication de : recommandations formalisées d'experts. Prise en charge de la patiente avec une pré-éclampsie sévère­RFE communes Société française d'anesthésie-réanimation (SFAR)­Collège national des gynécologues et obstétriciens français (CGNOF).

OBJECTIVE: To provide national guidelines for the management of women with severe preeclampsia. DESIGN: A consensus committee of 26 experts was formed. A formal conflict of interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS: The last SFAR and CNGOF guidelines on the management of women with severe preeclampsia was published in 2009. The literature is now sufficient for an update. The aim of this expert panel guidelines is to evaluate the impact of different aspects of the management of women with severe preeclampsia on maternal and neonatal morbidities separately. The experts studied questions within 7 domains. Each question was formulated according to the PICO (Patients Intervention Comparison Outcome) model and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analyzed according to the GRADE® methodology. RESULTS: The SFAR/CNGOF experts panel provided 25 recommendations: 8 have a high level of evidence (GRADE 1±), 9 have a moderate level of evidence (GRADE 2±), and for 7 recommendations, the GRADE method could not be applied, resulting in expert opinions. No recommendation was provided for 3 questions. After one scoring round, strong agreement was reached between the experts for all the recommendations. CONCLUSIONS: There was strong agreement among experts who made 25 recommendations to improve practices for the management of women with severe preeclampsia.

[Toxoplasmosis in pregnancy: Practical Management]. / Toxoplasmose pendant la grossesse : proposition actuelle de prise en charge pratique.

The burden of congenital toxoplasmosis has become small in France today, in particular as a result of timely therapy for pregnant women, fetuses and newborns. Thus, the French screening and prevention program has been evaluated and recently confirmed despite a decline over time in the incidence of toxoplasmosis. Serological diagnosis of maternal seroconversion is usually simple but can be difficult when the first trimester test shows the presence of IgM, requiring referral to an expert laboratory. Woman with confirmed seroconversion should be referred quickly to an expert center, which will decide with her on treatment and antenatal diagnosis. Although the level of proof is moderate, there is a body of evidence in favor of active prophylactic prenatal treatment started as early as possible (ideally within 3 weeks of seroconversion) to reduce the risk of maternal-fetal transmission, as well as symptoms in children. The recommended therapies to prevent maternal-fetal transmission are: (1) spiramycin in case of maternal infection before 14 gestational weeks; (2) pyrimethamine and sulfadiazine (P-S) with folinic acid in case of maternal infection at 14 WG or more. Amniocentesis is recommended to guide prenatal and neonatal care. If fetal infection is diagnosed by PCR on amniotic fluid, therapy with P-S should be initiated as early as possible or continued in order reduce the risk of damage to the brain or eyes. Further research is required to validate new approaches to preventing congenital toxoplasmosis.

Biosurfactants Produced by Phyllosphere-Colonizing Pseudomonads Impact Diesel Degradation but Not Colonization of Leaves of Gnotobiotic Arabidopsis thaliana.

Biosurfactant production is a common trait in leaf surface-colonizing bacteria that has been associated with increased survival and movement on leaves. At the same time, the ability to degrade aliphatics is common in biosurfactant-producing leaf colonizers. Pseudomonads are common leaf colonizers and have been recognized for their ability to produce biosurfactants and degrade aliphatic compounds. In this study, we investigated the role of biosurfactants in four non-plant-pathogenic Pseudomonas strains by performing a series of experiments to characterize their surfactant properties and their role during leaf colonization and diesel degradation. The biosurfactants produced were identified using mass spectrometry. Two strains produced viscosin-like biosurfactants, and the other two produced massetolide A-like biosurfactants, which aligned with the phylogenetic relatedness between the strains. To further investigate the role of surfactant production, random Tn5 transposon mutagenesis was performed to generate knockout mutants. The knockout mutants were compared to their respective wild types with regard to their ability to colonize gnotobiotic Arabidopsis thaliana and to degrade diesel or dodecane. It was not possible to detect negative effects during plant colonization in direct competition or individual colonization experiments. When grown on diesel, knockout mutants grew significantly slower than their respective wild types. When grown on dodecane, knockout mutants were less impacted than during growth on diesel. By adding isolated wild-type biosurfactants, it was possible to complement the growth of the knockout mutants.IMPORTANCE Many leaf-colonizing bacteria produce surfactants and are able to degrade aliphatic compounds; however, whether surfactant production provides a competitive advantage during leaf colonization is unclear. Furthermore, it is unclear if leaf colonizers take advantage of the aliphatic compounds that constitute the leaf cuticle and cuticular waxes. Here, we tested the effect of surfactant production on leaf colonization, and we demonstrate that the lack of surfactant production decreases the ability to degrade aliphatic compounds. This indicates that leaf surface-dwelling, surfactant-producing bacteria contribute to degradation of environmental hydrocarbons and may be able to utilize leaf surface waxes. This has implications for plant-microbe interactions and future studies.

[Training simulation during the announcement of fetal malformation discovered on screening ultrasound: Results of a pilot study]. / Formation par simulation à l'annonce d'une malformation fœtale découverte en échographie de dépistage : résultats d'une étude pilote.

OBJECTIVES: Breaking bad news (BBN) to a pregnant woman with fetal abnormalities (FA) on ultrasound (US) examination is a challenge. Announcement technique influences patient reaction. Physicians receive little training in BBN. The simulation and using a BBN protocol as the English SPIKES protocol which guides the announcement consultation according to 6 steps (Setting Up, Perception, Invitation, Knowledge, Emotions and Empathy, Strategy and Summary) can be used for this teaching. The objective was to assess feasibility simulation scenarii of BBN for FA discovered during US and to evaluate the usefulness of SPIKES protocol in this situation. METHODS: Two scenarios have been created combining US simulator (US Mentor, Symbionix®) with simulated patient (SP). Scenarii objectives were to diagnose FA and break it to SP. Checklist derived from SPIKES was fulfilled by two investigators thanks to video recording, the SP and every participant (residents, physicians, fetal medicine specialists [FMS]). Participants filled out survey about the usefulness of this exercise too. RESULTS: Nine physicians (3 residents, 4 physicians, 2 FMS) produced 18 scenarii. Seventy-eight percent of physicians thought simulation was like real situation of BBN during US examination. Majority of participant (88%) found that this simulation training could help them to increase their ability to BBN and that it can be used to teach residents (89%) or physicians (100%). FMS had better SPIKES checklist than physicians (P<0,05). CONCLUSION: Simulation scenario of BBN for FA discovered during US is feasible by combining US simulator and SP. SPIKES protocol can be useful but a validated checklist should be created.

Experimental analysis of the influence of cortical bone layers and bone quantity on implant primary stability.

The systematic analysis of parameters impacting implant primary stability is difficult to achieve with human cadavers or animal models, particularly for complex trans-sinus procedures to determine the effects of cortical layers and bone engagement on implant stability before and after a simulated load in vitro. Solid rigid polyurethane blocks, partially intersected by an 8-mm-thick space, were created to imitate tri-cortical situations, the presence of the sinus cavity, and the posterior maxilla with different degrees of bone atrophy. Implants were inserted through the cavity at an angle of 30˚ (scenarios 1 and 2) to imitate the clinical protocol. Controls simulating uni-cortical anchorage and no sinus cavity were also included (controls 1 and 2). Four parameters were measured: peak insertion torque, insertion work, resistance to lateral bending loads and extraction torque. Scenarios 1 and 2 displayed similar peak insertion torque to control 2, where all three groups anchored equal amounts of bone surrogate. The distribution of surrogate bone in contact with trans-cavity implants influenced both extraction torque and the degree of lateral bending. Sufficient peak insertion torque can be attained with a trans-sinus tricortical implant anchorage providing sufficient apical and coronal bone is engaged.

Reproducibility of the interpretation of coronal 3D ultrasound view of the uterus to evaluate the position of Essure® 3 months after hysteroscopic procedure.

OBJECTIVE: Three-dimensional sonography is a good alternative method to assess the position of microinserts. Adequate position after three months allows for the interruption of other contraception. Objective is to evaluate inter-observer reproducibility of the interpretation of coronal transvaginal 3D ultrasound view of the uterus to evaluate the position of Essure®. STUDY DESIGN: Inter-observer reproducibility study. Fifty women underwent successful bilateral placement of microinserts (Essure®) by hysteroscopy in the Department of Gynaecology of a teaching hospital and were included in the study. At three month, 3D ultrasound coronal views of the fifty uterus (accounting for one hundred microinserts) were assessed by five different observers and microinsert position was classified according to the classification described by Legendre et al. Inter-observer reproducibility in reading the 3D coronal view of the uterus was evaluated. RESULTS: The k-value was disparate, from 0.26 to 0.82. Inter-observer reproducibility then ranged from fair to almost perfect, depending on a prior knowledge of the position classification. CONCLUSIONS: Transvaginal 3D coronal view of the uterus is sufficient to assess the positioning of the microinserts when the practionner or the surgeon is familiar with the classification method.

Cytomegalovirus non-primary infection during pregnancy. Can serology help with diagnosis?

Diagnosis of cytomegalovirus (CMV) primary infection is reliable, but diagnosis of CMV non-primary infection (NPI) is questionable. Our aim is to highlight the difficulties met in diagnosis of CMV NPI. We illustrate that in proven cases of CMV NPI, very different serologic and molecular patterns may be observed and that routine serologic testing may fail to help with diagnosis. These results point out that many data available in literature concerning the prevalence of NPI, materno-fetal transmission rates and consequences of NPI may be wrong. We need to know how frequently they occur, are transmitted and cause fetal damages. Diagnosis of NPI must be improved, along with our understanding of the mechanisms leading to intrauterine CMV transmission and congenital infection in babies born to women with preexisting immunity.

Validity and reliability of the dietary sodium restriction questionnaire in patients with hypertension.

The study aimed to evaluate the reliability and the validity of the dietary sodium restriction questionnaire (DSRQ) in patients with hypertension receiving outpatient treatment at a tertiary care university hospital in Southern Brazil. This instrument is composed of three subscales: attitude, subjective norm and perceived behavioral control. A total of 104 patients were included. They were 63.3±8.9 years old and 75% were females. Cronbach's alpha coefficient for the subscales of attitude, subjective norm and perceived behavioral control were 0.75, 0.37 and 0.82, respectively. The PCA with the extraction of three factors explained a total of 53.5% of the variance. The data suggest that the 15-item DSRQ is reliable and has internal consistency of its construct to measure the barriers and the attitudes of hypertensive patients related to dietary sodium restriction and may be useful to improve blood pressure control.

Prediction of neonatal outcome of TTTS by fetal heart and Doppler ultrasound parameters before and after laser treatment.

OBJECTIVES: To determine the prognostic value of fetal Doppler and echocardiographic parameters for neonatal survival up to 30 days after laser coagulation in monochorionic pregnancies complicated by twin-twin transfusion syndrome (TTTS). METHODS: Fetal echocardiography and outcome data of consecutive cases of TTTS treated by laser were retrospectively reviewed. Hemodynamic and cardiac function parameters were collected before and after laser. RESULTS: Between February 2006 and January 2015, 106 fetoscopic laser were performed. The final analysis was limited to cases with ultrasound within 2 days before laser (n = 77) and 4 weeks after laser (n = 86). Overall neonatal survival rate was 64.9% (135/208) and 77.9% of pregnancies (81/104) had at least one baby alive. For the recipient twin, the preoperative predictors of neonatal survival were umbilical artery (UA) pulsatility index (PI), cerebro-placental PI ratio, UA end diastolic flow (EDF), ductus venosus a-wave, right ventricular myocardial performance index (RV-MPI) and CHOP score. The postoperative predictors of donor survival were donor RV-MPI and recipient UA EDF, umbilical vein pulsations, tricuspid regurgitation, cardiac hypertrophy and CHOP score. CONCLUSION: The hemodynamic predictors of postnatal survival after laser were preoperative signs of recipient cardiomyopathy and postoperative signs of cardiac overload in both twins. © 2016 John Wiley & Sons, Ltd.

Multiple gestations and preterm birth.

Preterm birth is a major concern in modern obstetrics, and an important source of morbidity and mortality in newborns. Among twin pregnancies, especially, preterm birth is highly prevalent, and it accounts for almost 50% of the complications observed in this obstetrical population. In this article, we review the existing literature regarding the prediction and prevention of preterm birth in both symptomatic and asymptomatic twin pregnancies. In asymptomatic twin pregnancies, the best two predictive tests were cervical length (CL) measurement and cervicovaginal fetal fibronectin (fFN) testing. A single measurement of transvaginal CL at 20-24 weeks of gestation <20 mm or <25 mm is a good predictor of spontaneous preterm birth at <28, <32, and <34 weeks of gestation. A CL beyond 25 mm is associated with a 2% risk for birth before 28 weeks and with a 65% chance for a term pregnancy. Cervicovaginal fFN may be slightly less accurate than CL; however, it has a high negative predictive value in women presenting with threatened preterm labor, as <2% of these women will deliver within one week if the fFN is negative. In symptomatic twin pregnancies, no tests have proven accurate in predicting the risk of preterm birth. For the prevention of preterm birth in asymptomatic twins, regardless of CL, no treatment including bed rest, limitation of home activities, prophylactic tocolysis, progesterone, or cerclage has been shown to reduce the rate of preterm birth. Cervical pessaries might be of interest in cases where there is a short cervix (<25 mm and <38 mm, respectively) but these results need to confirmed in future trials.

Impact of at-home self-rehabilitation of the perineum on pelvic floor function in patients with stress urinary incontinence: Results from a prospective study using three-dimensional ultrasound.

OBJECTIVE: Pelvic floor muscle training (PFMT) is the first step of treatment for stress urinary incontinence (SUI). Patients must perform self-retraining exercises of the perineal muscles at home in order to maintain the benefit of the physiotherapy. The aim of this study is to assess the benefit of a perineal electro-stimulator, using three-dimensional ultrasound, during this home-care phase. MATERIALS AND METHODS: A longitudinal prospective study was conducted between May 2012 and May 2013. All patients with de novo SUI benefited from PFMT followed by a self-maintenance of perineal rehabilitation at home with the Keat(®) Pro system. The primary endpoint was the biometric of the levator ani and it was assessed by three-dimensional perineal ultrasound at inclusion, after conventional rehabilitation and at the end of the study after self-rehabilitation. RESULTS: Ten patients were included. All patients (100%) showed a clinical improvement of SUI. The quality of life was significantly improved after PFMT vs. inclusion (P=0.014) and after self-rehabilitation vs. after PFMT (P=0.033). Levator ani muscles were significantly thicker after conventional rehabilitation than at baseline (P=0.004) and significantly thicker after self-rehabilitation than after PFMT (P=0.009). CONCLUSIONS: Conducting self-rehabilitation in addition to conventional PFMT objectively improves the perineal muscle building achieved after conventional rehabilitation.

Blood pressure variability in controlled and uncontrolled blood pressure and its association with left ventricular hypertrophy and diastolic function.

High systolic blood pressure (SBP) variability has been associated with higher risk for target-organ damage. In a cross-sectional study done in a tertiary outpatient hypertension clinic, we compared short-term SBP variability among controlled and uncontrolled hypertensive patients and evaluated the association between higher levels of SBP variability and diastolic function and left ventricular hypertrophy (LVH). Patients were evaluated by 24-h ambulatory blood pressure monitoring and transthoracic Doppler echocardiogram. Blood pressure (BP) variability was evaluated by the time-rate index and high variability corresponded to index values in the top quartile of distribution. Echocardiographic parameters were compared in patients with and without higher BP variability within controlled and uncontrolled office BP (⩽140/90 mm Hg). The analyses included 447 patients with 58±12 years of age, 67% were women, 68% white, 43% current or previous smokers and 32% with diabetes mellitus. Among the whole sample, 137 patients had controlled and 310 uncontrolled BP. The 75th percentile cutoff points for the time-rate index were 0.502 mm Hg min(-1) and 0.576 mm Hg min(-1) for participants with controlled and uncontrolled BP, respectively. After adjustment for confounders, the time-rate index did not differ between controlled and uncontrolled patients. BP variability was not associated with LVH or diastolic function in controlled and uncontrolled BP after adjustment for 24-h SBP and age. Patients with controlled and uncontrolled BP had similar SBP variability assessed by time-rate index, which was not associated with LVH or diastolic function. These findings should be confirmed in studies with larger sample size.

[Post-partum: Guidelines for clinical practice--Short text]. / Post-partum: recommandations pour la pratique Clinique--Texte court.

OBJECTIVE: To determine the post-partum management of women and their newborn whatever the mode of delivery. MATERIAL AND METHODS: The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. RESULTS: Because breastfeeding is associated with a decrease in neonatal morbidity (lower frequency of cardiovascular diseases, infectious, atopic or infantile obesity) (EL2) and an improvement in the cognitive development of children (EL2), exclusive and extended breastfeeding is recommended (grade B) between 4 to 6 months (Professional consensus). In order to increase the rate of breastfeeding initiation and its duration, it is recommended that health professionals work closely with mothers in their project (grade A) and to promote breastfeeding on demand (grade B). There is no scientific evidence to recommend non-pharmacological measures of inhibition of lactation (Professional consensus). Pharmacological treatments for inhibition of lactation should not be given routinely to women who do not wish to breastfeed (Professional consensus). Because of potentially serious adverse effects, bromocriptin is contraindicated in inhibiting lactation (Professional consensus). For women aware of the risks of pharmacological treatment of inhibition of lactation, lisuride and cabergolin are the preferred drugs (Professional consensus). Whatever the mode of delivery, numeration blood count is not systematically recommended in a general population (Professional consensus). Anemia must be sought only in women with bleeding or symptoms of anemia (Professional consensus). The only treatment of post-dural puncture headache is the blood patch (EL2), it must not be carried out before 48 h (Professional consensus). Women vaccination status and their family is to be assessed in the early post-partum (Professional consensus). Immediate postoperative monitoring after caesarean delivery should be performed in the recovery room, but in exceptional circumstances, it may be performed in the delivery unit provided safety rules are maintained and regulatory authorities are informed (Professional consensus). An analgesic multimodal protocol developed by the medical team should be available and oral way should be favored (Professional consensus) (grade B). For every cesarean delivery, thromboprophylaxis with elastic stockings applied on the morning of the surgery and kept for at least 7 postoperative days is recommended (Professional consensus) with or without the addition of LMWH according to the presence or not of additional risk factors, and depending on the risk factor (major, minor). Early postoperative rehabilitation is encouraged (Professional consensus). Postpartum visit should be planned 6 to 8 weeks after delivery and can be performed by an obstetrician, a gynecologist, a general practitioner or a midwife, after normal pregnancy and delivery (Professional consensus). Starting effective contraception later 21 days after delivery in women who do not want closely spaced pregnancy is recommended (grade B), and to prescribe it at the maternity (Professional consensus). According to the postpartum risk of venous thromboembolism, the combined hormonal contraceptive use before six postpartum weeks is not recommended (grade B). Rehabilitation in asymptomatic women in order to prevent urinary or anal incontinence in medium or long-term is not recommended (Expert consensus). Pelvic-floor rehabilitation using pelvic-floor muscle contraction exercises is recommended to treat persistent urinary incontinence at 3 months postpartum (grade A), regardless of the type of incontinence. Postpartum pelvic-floor rehabilitation is recommended to treat anal incontinence (grade C). Postpartum pelvic-floor rehabilitation is not recommended to treat or prevent prolapse (grade C) or dyspareunia (grade C). The optimal time for maternity discharge for low risk newborn depends more on the organisation of the post-discharge follow up (Professional consensus). The months following the birth are a transitional period, and psychological alterations concern all parents (EL2). It is more difficult in case of psychosocial risk factors (EL2). In situations of proven psychological difficulties, the impact on the psycho-emotional development of children can be important (EL3). Among these difficulties, postpartum depression is the most common situation. However, the risk is generally higher in the perinatal period for all mental disorders (EL3). CONCLUSION: Postpartum is, for clinicians, a unique and privileged opportunity to address the physical, psychological, social and somatic health of their patients.