Search

Double outlet left ventricle (DOLV) is a rare congenital heart defect where the aorta and the pulmonary trunk arise predominantly from the morphologic left ventricle. The clinical manifestations depend upon the location of the ventricular septal defect in relation to the great arteries, degree of pulmonary and aortic outflow tract obstruction, and other associated cardiac defects. We describe a neonate with DOLV, sub-aortic ventricular septal defect, and side-by-side great vessels who continued to require oxygen for desaturation to 60% in the neonatal period. His clinical symptoms were suggestive of persistent pulmonary hypertension, with 5-8% higher saturations in the leg compared to arm. He was started on oral sildenafil and his oxygen requirement decreased from 2 L/min to 0.1 L/min within 24 hours of initiating sildenafil.

RESUME Objectif Offrir, aux fournisseurs de soins de sante, une mise a jour de la directive clinique quant a la prise en charge de la menopause chez les femmes asymptomatiques en sante, ainsi que chez les femmes qui presentent des symptomes vasomoteurs ou urogenitaux; cette mise a jour se penche egalement sur les facteurs associes a la maladie cardiovasculaire, au cancer du sein, a l'urogynecologie et a la sexualite. Issues Les interventions quant au mode de vie, les medicaments d'ordonnance et les traitements de medecine complementaire et parallele sont presentes en fonction de leur efficacite dans la prise en charge des symptomes menopausiques. Des strategies de counseling et therapeutiques en ce qui concerne les preoccupations en matiere de sexualite au cours de la perimenopause et de la postmenopause sont passees en revue. Des approches quant a l'identification et a l’evaluation des femmes exposees a un risque eleve d'osteoporose (ainsi que des options en matiere de prevention et de traitement) sont presentees dans la directive clinique sur l'osteoporose qui accompagne les presentes. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans PubMed et The Cochrane Library, en aout et en septembre 2012, au moyen d'un vocabulaire controle (p. ex. « hormone replacement therapy », « menopause », « cardiovascular diseases » et « sexual function ») et de mots cles (p. ex. « HRT », « perimenopause », « heart disease » et « sexuality »). Les resultats ont ete restreints aux directives cliniques, aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Les resultats ont egalement ete restreints aux documents publies, en anglais ou en francais, a partir de 2009. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'au 5 janvier 2013. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l’evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques, aupres de societes de specialite medicale nationales et internationales, et dans des collections de directives cliniques. Valeurs La qualite des resultats est evaluee au moyen des criteres decrits dans le rapport du Groupe d’etude canadien sur les soins de sante preventifs (Tableau 1).

Forced migration and extended time spent migrating may lead to prolonged marginalization and increased risk of HIV. We conducted a population-based cohort study to examine whether secondary migration status, where secondary migrants resided in a transition country prior to arrival in Ontario, Canada and primary migrants arrived directly from their country of birth, modified the relationship between refugee status and HIV. Unadjusted and adjusted prevalence ratios (APR) and 95% confidence intervals (CI) were estimated using log-binomial regression. In sensitivity analysis, refugees with secondary migration were matched to the other three groups on country of birth, age and year of arrival (+/- 5 years) and analyzed using conditional logistic regression. Unmatched and matched models were adjusted for age and education. HIV prevalence among secondary and primary refugees and non-refugees was 1.47% (24/1629), 0.82% (112/13,640), 0.06% (7/11,571) and 0.04% (49/114,935), respectively. Secondary migration was a significant effect modifier (

BACKGROUND DCM has rarely been reported in children with CD, but is a recognized complication in adults. DCM with uncontrolled heart failure may need heart transplantation, which could be challenging in CD. CASE DESCRIPTION We present a 9-year-old female with CD who was diagnosed with DCM and a measured Ejection fraction ~25.8%. She was initiated on heart failure treatment, but continued to have progressive symptoms and underwent bicaval OHT three months after her initial presentation. Her post-operative course was complicated by perforation of the rectosigmoid junction requiring exploratory laparotomy and primary repair of the perforation. This was believed to be secondary to her underlying CD and possibly reperfusion injury after heart transplant. During the first-year post heart transplant, she had 4 episodes of acute cellular rejection. These episodes were treated with high dose steroids with good results. The patient has been in remission from CD since transplantation. For the last two years she is doing well, with no further rejection episodes on current immunosuppression. CONCLUSION DCM, though rare, can occur in patients with CD, whether active or in remission. The development of DCM could be insidious and keeping a high index of suspicion is important and subtle signs suggestive of cardiac involvement should warrant further investigation. The post-transplant management can be challenging with early morbidity in the first post-transplant year but overall good median survival and quality of life for our patient to date.

A 23-month-old Caucasian female who had heart transplantation (HT) at 11 days of age was diagnosed with Pneumocystis pneumonia (PCP) in the setting of secondary hypogammaglobulinemia (HGG). She was diagnosed with HGG at 5 months of age and had been receiving monthly intravenous immunoglobulin infusion. This is the first case report describing the clinical course of PCP in a pediatric patient with HGG. She developed PCP 23 months after HT even when she was off steroids and was receiving timely IVIG. The case posed some clinical questions regarding PCP prophylaxis and HGG management.

Objective Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence. Target Population Perimenopausal and postmenopausal women. Benefits, Harms, and Costs Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment. Evidence Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters. 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 physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population. SUMMARY STATEMENTS 1 The vast majority of women in mid-life experience menopausal symptoms, the hallmark being vasomotor symptoms. A significant portion of these women have severe symptoms that greatly affect their quality of life (high). 2 For the management of vasomotor symptoms, menopausal hormone therapy is the most effective option and can be safely initiated in women without contraindications who are younger than 60 years of age or less than 10 years post-menopause (high). 3 Options for menopausal hormone therapy for vasomotor symptoms in women with a uterus include estrogen-progestogen therapy, a tissue-selective estrogen complex, or tibolone. Estrogen alone can be used in women who have had a hysterectomy (high). 4 The safety and efficacy of compounded bioidentical hormone therapy have not been assessed with the same rigour as those of menopausal hormone therapy products approved by Health Canada (moderate). 5 Non-hormonal prescription therapies, including certain antidepressant agents, gabapentinoids, clonidine, and oxybutynin, may offer some relief from hot flashes but have their own adverse effects (moderate). 6 There is emerging evidence that cognitive behavioural therapy may have positive effects on vasomotor symptoms (high). 7 There is insufficient evidence to support the effectiveness of any one natural health product for the management of moderate to severe hot flashes (low). 8 A healthy diet during menopause can reduce the risk of future chronic conditions, aid in weight management, and improve energy levels (high). RECOMMENDATIONS 1 Health care providers should offer menopausal hormone therapy as the most effective option for managing vasomotor symptoms (strong, high). 2 Menopausal hormone therapy can be safely initiated in women without contraindications who are younger than 60 years of age or less than 10 years post-menopause (strong, high). 3 Menopausal hormone therapy should be individualized after careful consideration of symptoms, medical conditions, health risks, family history, treatment goals, patient preferences, and timing of last menstrual period (strong, high). 4 Duration of menopausal hormone therapy should be individualized to the patient, based on ongoing symptoms, benefits, and personal risks. Periodic re-evaluation of menopausal hormone therapy is recommended (strong, high). 5 Women who have experienced loss of ovarian function or with decreased ovarian function before the age of 45 years should consider replacement hormone therapy until the average age of menopause (strong, high). 6 Estrogen-progestogen regimens can be continuous (i.e., estrogen-progestogen taken every day) or follow a cyclic regimen, with estrogen taken every day and progestogen taken for 12–14 days every month. In women with hysterectomy, estrogen alone can be taken every day (strong, high). 7 Options for perimenopausal women include progestogen alone, low-dose combined hormonal contraceptives, menopausal hormone therapy, or estrogen in combination with a levonorgestrel-releasing intrauterine system. (strong, moderate) 8 Non-hormonal prescription therapies can be considered when hormone therapy is contraindicated or not desired (strong, moderate). 9 For cultural traditional therapies, women should be offered the opportunity to work with a cultural leader; health care providers can discuss this option in partnership with women, in order to ensure cultural humility and cultural safety (strong, moderate).

The 2017 Hormone Therapy Position Statement of The North American Menopause Society (NAMS) updates the 2012 Hormone Therapy Position Statement of The North American Menopause Society and identifies future research needs. An Advisory Panel of clinicians and researchers expert in the field of women's health and menopause was recruited by NAMS to review the 2012 Position Statement, evaluate new literature, assess the evidence, and reach consensus on recommendations, using the level of evidence to identify the strength of recommendations and the quality of the evidence. The Panel's recommendations were reviewed and approved by the NAMS Board of Trustees. Hormone therapy (HT) remains the most effective treatment for vasomotor symptoms (VMS) and the genitourinary syndrome of menopause (GSM) and has been shown to prevent bone loss and fracture. The risks of HT differ depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. Treatment should be individualized to identify the most appropriate HT type, dose, formulation, route of administration, and duration of use, using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of the benefits and risks of continuing or discontinuing HT. For women aged younger than 60 years or who are within 10 years of menopause onset and have no contraindications, the benefit-risk ratio is most favorable for treatment of bothersome VMS and for those at elevated risk for bone loss or fracture. For women who initiate HT more than 10 or 20 years from menopause onset or are aged 60 years or older, the benefit-risk ratio appears less favorable because of the greater absolute risks of coronary heart disease, stroke, venous thromboembolism, and dementia. Longer durations of therapy should be for documented indications such as persistent VMS or bone loss, with shared decision making and periodic reevaluation. For bothersome GSM symptoms not relieved with over-the-counter therapies and without indications for use of systemic HT, low-dose vaginal estrogen therapy or other therapies are recommended. This NAMS position statement has been endorsed by Academy of Women's Health, American Association of Clinical Endocrinologists, American Association of Nurse Practitioners, American Medical Women's Association, American Society for Reproductive Medicine, Asociación Mexicana para el Estudio del Climaterio, Association of Reproductive Health Professionals, Australasian Menopause Society, Chinese Menopause Society, Colegio Mexicano de Especialistas en Ginecologia y Obstetricia, Czech Menopause and Andropause Society, Dominican Menopause Society, European Menopause and Andropause Society, German Menopause Society, Groupe d’études de la ménopause et du vieillissement Hormonal, HealthyWomen, Indian Menopause Society, International Menopause Society, International Osteoporosis Foundation, International Society for the Study of Women's Sexual Health, Israeli Menopause Society, Japan Society of Menopause and Women's Health, Korean Society of Menopause, Menopause Research Society of Singapore, National Association of Nurse Practitioners in Women's Health, SOBRAC and FEBRASGO, SIGMA Canadian Menopause Society, Società Italiana della Menopausa, Society of Obstetricians and Gynaecologists of Canada, South African Menopause Society, Taiwanese Menopause Society, and the Thai Menopause Society. The American College of Obstetricians and Gynecologists supports the value of this clinical document as an educational tool, June 2017. The British Menopause Society supports this Position Statement.

Background: Benefits of screening should outweigh its potential harms. We compared various metrics to assess the balance of benefits and harms of cervical cancer screening. Methods: We used a cervical cancer natural history Markov model calibrated to the Canadian context to simulate 100,000 unvaccinated women over a lifetime of screening with either cytology every 3 years or human papillomavirus (HPV) testing every 5 years. We estimated the balance of benefits and harms attributable to screening using various metrics, including colposcopies/life-year gained, and net lifetime quality-adjusted life-years (QALY) gained, a measure integrating women's health preferences. We present the average (minimum–maximum) model predictions. Results: Cytology-based screening led to 1,319,854 screening tests, 30,395 colposcopies, 13,504 life-years gained over a lifetime, 98 screening tests/life-year gained, 2.3 (1.6–3.3) colposcopies/life-year gained, and a net lifetime gain of 10,735 QALY (5,040–17,797). HPV-based screening with cytology triage in the same population would lead to 698,250 screening tests, 73,296 colposcopies, 15,066 life-years gained over a lifetime, 46 screening tests/life-year gained, 4.9 colposcopies/life-year gained (2.9–11.1), and a net lifetime gain of 11,690 QALY (4,409–18,742). HPV-based screening was predicted to prevent more cancers, but also incur more screening harms than cytology-based screening. Conclusions: Metrics using colposcopies as the main harm outcome favored cytology-based screening, whereas metrics based on screening tests and health preferences tended to favor HPV-based screening strategies. Impact: Whether HPV-based screening will improve the balance between benefits and harms of cervical cancer screening depends on how the balance between benefits and harms is assessed.

In this commentary, we briefly summarize knowledge on stigma associated with human papillomavirus (HPV). In addition, we provide suggestions for health care providers to de-stigmatize HPV and improve the delivery of care.

Maternal death surveillance in Canada relies on hospitalization data, which lacks information on the underlying cause of death. We developed a method for identifying underlying causes of maternal death, and quantified the frequency of maternal death by cause.We used data from the Discharge Abstract Database for fiscal years 2013 to 2017 to identify women who died in Canadian hospitals (excluding Quebec) while pregnant or within 1 year of the end of pregnancy. A sequential narrative based on hospital admission(s) during and after pregnancy was constituted and reviewed to assign the underlying cause of death (based on the World Health Organization's framework). Maternal deaths (i.e., while pregnant or within 42 days after the end of pregnancy) and late maternal deaths (i.e., more than 42 days to a year after the end of pregnancy) were examined separately.We identified 85 maternal deaths. Direct obstetric causes included 8 deaths (9%) related to complications of spontaneous or induced abortion; 9 (11%), to hypertensive disorders of pregnancy; 15 (18%), to obstetric hemorrhage; 11 (13%), to pregnancy-related infection; 16 (19%), to other obstetric complications; and5 (6%), to complications of management. There were 21 (25%) maternal deaths with indirect obstetric causes, and5 (6%) with undetermined causes. Of 120 late maternal deaths, 16 (13%) had direct obstetric causes, among them, 9 deaths by suicide (56%). One hundred late maternal deaths (83%) had indirect obstetric causes; and5 (4%) had undetermined causes.The majority of maternal deaths in Canada have direct obstetric causes, whereas most late maternal deaths have indirect obstetric causes. Suicide is an important direct cause of late maternal death.

BACKGROUND Evolution of left ventricle (LV) function in the pediatric OHT population has not been well described. Our hypothesis was that, in children following OHT without any rejection, there would be progressive normalization of LV size and function over 2 years. METHODS LV function was evaluated using STE and conventional echo parameters at five time points in pediatric OHT patients without any rejection in the first 2 years following OHT and normal controls. LV global peak systolic longitudinal strain (LVPLS) and strain rate, LV peak systolic radial and circumferential strain (LVRS and LVCS), and strain rate were analyzed. RESULTS We had twenty two patients with median age at OHT of 1.27 years ( IQR 0.19, 5.6 years). The LVPLS (mean ± SD) was abnormal in the post-OHT echocardiograms at 1 week (-12.4 ± 3.7) and 1 month (-13.9 ± 3.7) and significantly improved at 6 months (-15.8 ± 3.2), 1 year (-15.7 ± 3.1), and 2 years (-17.8 ± 2.8). However, LVPLS remained below the normal group even at 2 years following OHT (-21.3 ± 1.76). CONCLUSION In children following OHT, despite the absence of rejection, strain values are significantly impaired in the initial months, improve progressively over the first 2 years but remain abnormal compared with healthy controls.

Objective Identifying human papillomavirus (HPV) vaccination motivators and barriers among adults could lead to new approaches to improve HPV vaccination rates in non-pediatric populations. This Canadian survey aimed to assess current knowledge of, attitudes towards, and barriers to the HPV vaccine among the general public. Methods An online panel was used to survey HPV unvaccinated women (n = 802) and vaccinated women (n = 250) 18 to 45 years old, as well as 18- to 26-year-old men (n = 200), in May and June 2016. A 16-item questionnaire collected data on sociodemographic factors, health-seeking behaviours, knowledge of HPV infection and its consequences, and the HPV vaccine. Data were stratified by sex and by vaccination status among women. Results The majority of individuals somewhat or strongly agreed that vaccination is an important aspect of disease prevention (vaccinated women, 93%; unvaccinated women, 85%; and men, 59%). However, a high proportion of patients were concerned about vaccine safety (vaccinated women, 26%; unvaccinated women, 40%; and men, 36%). Moreover, 58% to 61% of participants were generally cautious about taking any vaccine. The number one reported barrier to vaccination was not having a recommendation from a doctor (38%). Cost was seen as a barrier by only 18% to 20% of participants. Conclusion Canadian participants show a broad diversity in HPV knowledge and regarding barriers to vaccination. The youngest populations (vaccinated women and men) showed higher levels of knowledge regarding HPV.

© 2015 The Authors. Exposure to toxic environmental chemicals during pregnancy and breastfeeding is ubiquitous and is a threat to healthy human reproduction. There are tens of thousands of chemicals in global commerce, and even small exposures to toxic chemicals during pregnancy can trigger adverse health consequences. Exposure to toxic environmental chemicals and related health outcomes are inequitably distributed within and between countries; universally, the consequences of exposure are disproportionately borne by people with low incomes. Discrimination, other social factors, economic factors, and occupation impact risk of exposure and harm. Documented links between prenatal exposure to environmental chemicals and adverse health outcomes span the life course and include impacts on fertility and pregnancy, neurodevelopment, and cancer. The global health and economic burden related to toxic environmental chemicals is in excess of millions of deaths and billions of dollars every year. On the basis of accumulating robust evidence of exposures and adverse health impacts related to toxic environmental chemicals, the International Federation of Gynecology and Obstetrics (FIGO) joins other leading reproductive health professional societies in calling for timely action to prevent harm. FIGO recommends that reproductive and other health professionals advocate for policies to prevent exposure to toxic environmental chemicals, work to ensure a healthy food system for all, make environmental health part of health care, and champion environmental justice.

Maternal mortality and severe maternal morbidity are devastating for women, their families and care providers. International efforts have been made to develop and to implement data collection, management and surveillance systems that capture pregnancy-related information that can be assessed and used to improve health and system outcomes. At present, Canada does not have a national enquiry process to review maternal deaths, severe morbidity and near misses, and has not set targets for maternal mortality reduction. Maternal mortality rates are critical measures of maternal health and provide important information for analysis of trends and priorities among and within countries. Information about near misses as well as maternal morbidity is crucial to truly understand and to prevent maternal mortality. Canadian experts must work together with governments, provinces and territories to determine key indicators, measurement and meaningful data analysis strategies. These data and their comparisons will form the foundation of evidence to guide programs, policies, priorities and interventions that will ultimately improve the health of mothers and their children.

Resume Objectif Offrir, aux fournisseurs de soins de sante, une mise a jour de la directive clinique quant a la prise en charge de la menopause chez les femmes asymptomatiques en sante, ainsi que chez les femmes qui presentent des symptomes vasomoteurs ou urogenitaux; cette mise a jour se penche egalement sur les facteurs associes a la maladie cardiovasculaire, au cancer du sein, a l'urogynecologie et a la sexualite. Issues Les interventions quant au mode de vie, les medicaments d'ordonnance et les traitements de medecine complementaire et parallele sont presentes en fonction de leur efficacite dans la prise en charge des symptomes menopausiques. Des strategies de counseling et therapeutiques en ce qui concerne les preoccupations en matiere de sexualite au cours de la perimenopause et de la postmenopause sont passees en revue. Des approches quant a l'identification et a l'evaluation des femmes exposees a un risque eleve d'osteoporose (ainsi que des options en matiere de prevention et de traitement) sont presentees dans la directive clinique sur l'osteoporose qui accompagne les presentes. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans PubMed et The Cochrane Library , en aout et en septembre 2012, au moyen d'un vocabulaire controle (p. ex. « hormone replacement therapy », « menopause », « cardiovascular diseases » et « sexual function ») et de mots cles (p. ex. « HRT », « perimenopause », « heart disease » et « sexuality »). Les resultats ont ete restreints aux directives cliniques, aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Les resultats ont egalement ete restreints aux documents publies, en anglais ou en francais, a partir de 2009. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'au 5 janvier 2013. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques, aupres de societes de specialite medicale nationales et internationales, et dans des collections de directives cliniques. Valeurs La qualite des resultats est evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau).

Objective To provide updated guidelines for health care providers on the management of menopause in asymptomatic healthy women as well as in women presenting with vasomotor or urogenital symptoms and on considerations related to cardiovascular disease, breast cancer, urogynaecology, and sexuality. Outcomes Lifestyle interventions, prescription medications, and complementary and alternative therapies are presented according to their efficacy in the treatment of menopausal symptoms. Counselling and therapeutic strategies for sexuality concerns in the peri- and postmenopausal years are reviewed. Approaches to the identification and evaluation of women at high risk of osteoporosis, along with options for prevention and treatment, are presented in the companion osteoporosis guideline. Evidence Published literature was retrieved through searches of PubMed and The Cochrane Library in August and September 2012 with the use of appropriate controlled vocabulary (e.g., hormone therapy, menopause, cardiovascular diseases, and sexual function) and key words (e.g., hormone therapy, perimenopause, heart disease, and sexuality). Results were restricted to clinical practice guidelines, systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Results were limited to publication dates of 2009 onwards and to material in English or French. Searches were updated on a regular basis and incorporated in the guideline until January 5, 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, national and international medical specialty societies, and clinical practice guideline collections. Values The quality of the evidence in this document was rated using the criteria described by the Report of the Canadian Task Force on Preventive Health Care (Table 1).

Objectives In 2012, only 60 doctors provided medical abortion in Canada. Mifepristone-based medical abortion is a gold standard that has now been available in Canada since 2016. While no longer mandatory, the Health Canada/SOGC/CFPC/CPhA Medical Abortion Training Program is the only comprehensive training program in the country, and this program meets the Health Canada definition of "appropriate training". We will provide the current data on training across Canada. Methods This is a descriptive study of the participants in the SOGC Medical Abortion Training Program. Data is classified by province/territory of practice, as well as membership/practice type. Updated information to May 31, 2019 will be provided at the time of presentation. Results As of September 2018, there were 1324 prescribers (physicians and nurse practitioners) as well as 2273 pharmacists trained to prescribe and dispense mifepristone. There were prescribers in every province and territory, including PEI, where there were, until recently, no surgical abortion services. Only Nunavut does not have a pharmacist trained in medical abortion. In comparison to the number of OB/GYNs in Canada, approximately 11.7% of Obstetrician/Gynaecologists were trained in Canada within the first 18 months of availability of mifepristone. Conclusions There has been an over 2200% increase in the number of possible medical abortion providers in Canada since the approval of combination mifepristone-misoprostol. This is reflective of a successful launch of the Medical Abortion Training Program, as well as a coordinated integrated Knowledge Translation (iKT) program and community of practice.

Objective Physicians are the sole prescribers of the human papillomavirus (HPV) vaccine for adults in Canada. This survey of Canadian physicians aimed to explore knowledge, barriers, and preventive practices regarding HPV vaccination. Method A survey of general practitioners (GPs) (n = 337) and obstetrician/gynaecologists (OB/GYNs) (n = 81) was conducted in May and June 2016 using an online panel. Demographic data and information pertaining to HPV knowledge, attitudes, and vaccination practices were collected by using a 22-item questionnaire. Results A total of 83% of GPs recommended or administered HPV vaccine to adults. Among physicians, 99% to 100% strongly agreed that vaccination is an important aspect of disease prevention. Physicians were rarely concerned about vaccine safety (5%–11%). Cost was seen as the number one barrier by 92% to 95% of physicians. Physicians rated consumers’ understanding of HPV to be low (11%–14%, very good; and 49%–56%, somewhat good knowledge). Among physicians, 60% to 66% of said they routinely discussed HPV vaccination with patients. Female physicians demonstrated greater knowledge of HPV than their male counterparts. Conclusion GPs and obstetrician/gynaecologists routinely recommend and administer the HPV vaccine to patients. The majority of physicians showed high levels of knowledge regarding HPV vaccine and associated cancers; however, perceived barriers of cost may limit recommendations for vaccination, particularly among older women or men.

I read with interest Dr. Popadiuk’s commentary[1][1] on cervical cancer screening starting at 25 years of age. I am familiar with the powerful OncoSim tool, but I continue to have nagging concerns that, by doing right for the majority, we may inadvertently leave behind the most disadvantaged.

A 12-day-old infant with pulmonary atresia, intact ventricular septum, and pulmonary blood flow through a ductus arteriosus developed complete shunt obstruction within 12 hr of creation of a modified Blalock-Taussig shunt. Low dose recombinant tissue plasminogen activator was administered locally as two 0.03 mg/kg bolus injections and was followed by balloon angioplasty. This resulted in complete recanalization of the shunt without any hemorrhagic complications.

Since being introduced in the 1940s, cervical cytology - despite its limitations - has had unequivocal success in reducing cervical cancer burden in many countries. However, we now know that infection with human papillomavirus (HPV) is a necessary cause of cervical cancer and there is overwhelming evidence from large-scale clinical trials, feasibility studies and real-world experience that supports the introduction of molecular testing for HPV as the primary technology in cervical cancer screening (i.e., "HPV primary screening"). While questions remain about the most appropriate age groups for screening, screening interval and triage approach, these should not be considered barriers to implementation. Many countries are in various stages of adopting HPV primary screening, whereas others have not taken any major steps towards introduction of this approach. As a group of clinical experts and researchers in cervical cancer prevention from across Canada, we have jointly authored this comprehensive examination of the evidence to implement HPV primary screening. Our intention is to create a common understanding among policy makers, agencies, clinicians, researchers and other stakeholders about the evidence concerning HPV primary screening to catalyze the adoption of this improved approach to cervical cancer prevention. With the first cohort of vaccinated girls now turning 21, the age when routine screening typically begins, there is increased urgency to introduce HPV primary screening, whose performance may be less adversely affected compared with cervical cytology as a consequence of reduced lesion prevalence post-vaccination.

Substantial evidence exists to support the introduction of molecular testing for human papillomavirus (HPV) as the primary technology in cervical cancer screening. While HPV testing is much more sensitive than cytology for detection of high-grade precancerous lesions, it is less specific. To improve efficiency, it is therefore recommended that a specific test (like cytology) be used in triaging HPV positive women to colposcopy. A number of studies have been conducted that support the use of cytology alone or in conjunction with HPV genotyping for triage. The decision to incorporate genotyping also depends on the commercial HPV test that is selected since not all tests provide results for certain individual high-risk types. Regardless of whether policy officials decide to adopt a triage approach that incorporates genotyping, the use of liquid based cytology (LBC) may also improve screening performance by reducing diagnostic delays. With LBC, the same cell suspension from a single collection may be used for HPV testing and a smear can be immediately prepared if HPV status is positive. This was a critical lesson from a community based demonstration project in Montreal (VASCAR study), where conventional cytology exists and specimen co-collection was not permitted for ethical reasons, requiring HPV positive women to return for an additional screening visit prior to colposcopy.

Objectives To provide health care professionals in Canada with the basic knowledge and tools to provide nutrition guidance to women through their lifecycle. Outcomes Optimal nutrition through the female lifecycle was evaluated, with specific focus on adolescence, pre-conception, pregnancy, postpartum, menopause, and beyond. The guideline begins with an overview of guidance for all women, followed by chapters that examine the evidence and provide recommendations for the promotion of healthy nutrition and body weight at each life stage. Nutrients of special concern and other considerations unique to each life stage are discussed in each chapter. Evidence Published literature, governmental and health agency reports, clinical practice guidelines, grey literature, and textbook sources were used in supporting the recommendations made in this document. Values The quality of evidence was rated using the criteria described in the report of the Canadian Task Force on Preventive Health Care. CHAPTER 2: GENERAL FEMALE NUTRITION: Summary Statements Recommendations CHAPTER 3: ADOLESCENCE NUTRITION: Summary Statements Recommendations CHAPTER 4: PRE-CONCEPTUAL NUTRITION: Summary Statement Recommendations CHAPTER 5: NUTRITION IN PREGNANCY: Summary Statements Recommendations CHAPTER 6: POSTPARTUM NUTRITION AND LACTATION: Summary Statements Recommendations CHAPTER 7: NUTRITION DURING MENOPAUSE AND BEYOND: Summary Statement Recommendations.

OBJECTIFS Doter les professionnels de la sante du Canada de connaissances et d'outils de base, afin qu'ils puissent prodiguer des conseils nutritionnels aux femmes tout au long de leur cycle de vie. ReSULTATS: L'alimentation optimale a fait l'objet d'une evaluation tout au long du cycle de vie de la femme. Elle a porte en particulier sur l'adolescence, la preconception, la grossesse, la periode post-partum, la menopause et au-dela. Le present guide fournit d'abord des directives abregees a l'intention de toutes les femmes. Elles sont suivies de chapitres proposant un examen des donnees probantes, ainsi que des recommandations sur la promotion d'une alimentation saine et d'un poids sante a chaque etape de la vie. Par ailleurs, tous les chapitres presentent une analyse de nutriments d'interet particulier, ainsi que d'autres aspects uniques a chaque etape de la vie. DONNeES PROBANTES: Des documents publies, des rapports d'organismes gouvernementaux et de sante, des lignes directrices de pratique clinique, de la documentation parallele et des extraits de manuels ont servi a etayer les recommandations formulees dans le present document. VALEURS L'evaluation de la qualite des donnees probantes repose sur les criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs. CHAPITRE 2 : CONSEILS GeNeRAUX SUR L'ALIMENTATION FeMININE: Declarations Sommaires Recommandations CHAPITRE 3 : ALIMENTATION DE L'ADOLESCENTE: Declarations Sommaires Recommandations CHAPITRE 4 : ALIMENTATION PReCONCEPTIONNELLE: Declarations Sommaires Recommandations CHAPITRE 5 : ALIMENTATION PENDANT LA GROSSESSE: Declarations Sommaires Recommandations CHAPITRE 6 : ALIMENTATION ET LACTATION POST-PARTUM: Declarations Sommaires Recommandations CHAPITRE 7 : ALIMENTATION PENDANT LA MeNOPAUSE ET AU-DELa: Declarations Sommaires Recommandations.

Noninvasive biomarkers of acute allograft rejection (AAR) following orthotopic heart transplantation (OHT) are needed. The aim of this study was to investigate the accuracy of echocardiographic (ECHO) right ventricular (RV) global functional and resistance indices in the detection of AAR. This retrospective chart review included children with biopsy-proven AAR (grade ≥ 2R cellular or CD4 + antibody-mediated rejection) following OHT and an ECHO within 12 h of the biopsy. ECHO measures: (a) ratio of systolic to diastolic duration (S/D), (b) RV myocardial performance index (MPI) and (c) tricuspid regurgitant gradient to RV outflow tract velocity time integral ratio (TRG/VTI), were derived at baseline, during AAR and at two follow-ups. Sixteen patients [56% male, mean (SD) age at OHT 3.5 (4.3) years] had 16 AAR episodes. S/D (1.15 vs. 1.60, p

The impact of a gynecological cancer diagnosis and the subsequent treatment on women is profound, both physically and psychologically, in particular with respect to sexual function and sexuality. We describe our experience creating a specialized clinic to address concerns about sexual health and rehabilitation. We used a case study approach to describe the clinic's inception and first 2 years of operation. Fifty-six survivors of gynecological cancer were seen at the clinic in the first 2 years. These patients had a significant symptom burden, many related to menopause, as well as those aftereffects of radiation therapy, chemotherapy, and surgical operation as well as psychological and emotional responses to cancer. The most common interventions were education and counseling. Patients reported high levels of satisfaction with their experience at the clinic. We hope our experience may be of assistance to others considering a similar endeavor.

Objectives Immigrants are thought to be healthier than their native-born counterparts, but less is known about the health of refugees or forced migrants. Previous studies often equate refugee status with immigration status or country of birth (COB) and none have compared refugee to non-refugee immigrants from the same COB. Herein, we examined whether: (1) a refugee mother experiences greater odds of adverse maternal and perinatal health outcomes compared with a similar non-refugee mother from the same COB and (2) refugee and non-refugee immigrants differ from Canadian-born mothers for maternal and perinatal outcomes. Design This is a retrospective population-based database study. We implemented two cohort designs: (1) 1:1 matching of refugees to non-refugee immigrants on COB, year and age at arrival (±5 years) and (2) an unmatched design using all data. Setting and participants Refugee immigrant mothers (n=34 233), non-refugee immigrant mothers (n=243 439) and Canadian-born mothers (n=615 394) eligible for universal healthcare insurance who had a hospital birth in Ontario, Canada, between 2002 and 2014. Primary outcomes Numerous adverse maternal and perinatal health outcomes. Results Refugees differed from non-refugee immigrants most notably for HIV, with respective rates of 0.39% and 0.20% and an adjusted OR (AOR) of 1.82 (95% CI 1.19 to 2.79). Other elevated outcomes included caesarean section (AOR 1.04, 95% CI 1.00 to 1.08) and moderate preterm birth (AOR 1.08, 95% CI 0.99 to 1.17). For the majority of outcomes, refugee and non-refugee immigrants experienced similar AORs when compared with Canadian-born mothers. Conclusions Refugee status was associated with a few adverse maternal and perinatal health outcomes, but the associations were not strong except for HIV. The definition of refugee status used herein may not sensitively identify refugees at highest risk. Future research would benefit from further refining refugee status based on migration experiences.

A 15-year-old previously healthy girl presented to the general paediatrics clinic for follow-up for inguinal lymphadenitis diagnosed the week before at a local emergency room. Approximately two weeks before the clinic visit, she developed continuous discomfort in her left inguinal area. A few days later, the discomfort progressed to significant pain, and she noticed swelling in the left inguinal area. The pain was so intense that she walked with a limp, favouring her left leg, and had difficulty climbing stairs. She denied any trauma to her pelvic or inguinal area. When seen in the emergency room, an inguinal ultrasound was completed, which revealed an enlarged lymph node, thought to be inflamed, without any evidence of a hernia. The patient was discharged home on a seven-day course of oral cephalexin and a preparation of hydrocodone and acetaminophen, as needed, for pain. Despite completing the course of antibiotics and taking analgesia, the patient did not have any relief of her pain or swelling. The patient denied fevers or other associated symptoms. On physical examination, the patient was found to have a 3 cm 7 cm ill-defined mass in the left inguinal region, without overlying erythema. The mass was tender to palpation, was not pulsatile and was easily reduced by external pressure. On musculoskeletal examination, she had pain with external rotation of the left hip, yet all other hip movements were full and without associated pain. When asked to walk, the patient had an antalgic gait. A further diagnostic test uncovered the source of the problem.