Introdução: O jejum prolongado pré-operatório aumenta a resistência periférica à insulina. Foi investigado se a abreviação do jejum pré-operatório com uma bebida contendo carboidrato e glutamina melhora a resposta orgânica ao trauma cirúrgico. Métodos: Quarenta e oito pacientes adultas, do sexo feminino (19-62 anos) candidatas a colecistectomia videolaparoscópica eletiva. As pacientes foram aleatoriamente divididas em quatro grupos: grupo jejum convencional (grupo Jejum), ou em três grupos para receber três tipos diferentes bebidas oito horas (400 mL) e duas horas antes da indução anestésica (200ml): água pura (grupo Placebo), água mais dextrinomaltose (grupo carboidrato; 12,5% de dextrinomaltose) e grupo glutamina (grupo glutamina; 12,5% de dextrinomaltose e respectivamente 40 e 10g de glutamina). As amostras de sangue foram coletadas no período pré e pós-operatório. Resultados: não houve nenhum evento de aspiração ou regurgitação do conteúdo gástrico manifesto por sinais e sintomas clínicos, durante a indução anestésica, ou em qualquer outro momento do estudo. Também não houve nenhum óbito ou complicação pós-operatória. A média e o erro padrão médio da resistência à insulina determinada pelo HOMA-IR realizada no pós-operatório foi maior (p<0,05) no grupo que permaneceu em jejum (4,3±1,3) quando comparado com os outros três grupos de pacientes (Placebo, 1,6±0,3); carboidrato, (2,3±0,4) e glutamina, (1,5±0,1). A medida da glutationa peroxidase sérica, medida nos dois períodos foi maior no grupo glutamina (40±3,0) que nos grupos carboidrato (32±2,0) e jejum (32±2,0) (p<0,01). Ao se comparar o comportamento da IL-6 sérica em cada grupo estudado no período pré e pós-operatório, observou-se que o grupo glutamina foi o único sem diferença, enquanto nos demais a IL-6 aumentou no pós-operatório (p<0,01). No período pós-operatório a razão proteína-C-reativa/albumina foi maior no grupo jejum quando comparado com os grupos carboidrato (p=0,04) e glutamina (p=0,01). O balanço nitrogenado acumulativo foi menos negativo no grupo glutamina (-2,5±0,8 gN) que nos grupos placebo (-9,0±2,0 gN; p=0,001) e jejum (-6,6±0,4 gN; p=0,04). Conclusão: A abreviação do jejum pré-operatório com uma bebida contendo carboidrato e glutamina melhora a resistência periférica a insulina, a resposta anti-oxidativa e diminui a resposta inflamatória de pacientes submetidas à colecistectomia videolaparoscópica eletiva / Introduction: Prolonged preoperative fasting increases insulin resistance. We investigated whether an abbreviated preoperative fast with glutamine plus a carbohydrate based beverage would improve the organic response after surgery. Methods: Forty-eight female patients (19-62 years) candidates for video-cholecystectomy were randomized to either standard fasting (fasting group) or to fasting with one of three different beverages. Beverages were consumed 8 hours (400 mL; placebo group: water; glutamine group: water with 50 g maltodextrine plus 40 g glutamine; and carbohydrate group: water with 50 g maltodextrine) and 2 hours (200 mL; placebo group: water; glutamine group: water with 25 g maltodextrine plus 10 g glutamine; and carbohydrate group: water with 25 g maltodextrine) before anesthesia. Blood samples were collected pre- and postoperatively. Results: There were no cases of regurgitation during anesthesia. The mean [SEM] postoperative HOMA-IR was greater (p<0,05) in fasted patients (4,3±1,3) than in the other groups (placebo, 1,6±0,3); carbohydrate, (2.3±0,4); and glutamine, (1,5±0,1). Glutathione peroxidase (U/g hemoglobin) was significantly higher (40±3,0) in glutamine group than both carbohydrate (32±2,0) and fasting (32±2,0) groups (p< 0,01). Interleukin-6 increased in all groups except the glutamine group. The C-reactive protein/albumin ratio was higher in fasting subjects than carbohydrate (p=0,04) and glutamine (p=0,01) groups. The nitrogen balance was less negative in glutamine (-2,5±0,8 gN) than both placebo (-9,0±2,0 gN; p=0,001) and fasting (-6,6±0,4 gN; p=0,04) groups. Conclusions: Preoperative intake of a glutamine-enriched carbohydrate beverage improves insulin resistance and antioxidant defenses, and decreases the inflammatory response after videolaparoscopic cholecystectomy

Une grossesse extra-utérine est une grossesse implantée en dehors de la cavité utérine. Il existe quatre thérapeutiques pour leur prise en charge : l’expectative, le traitement médical par méthotrexate, le traitement chirurgical conservateur (salpingotomie) et le traitement chirurgical radical (salpingectomie). Le choix entre ces 4 traitements repose tout d’abord sur des critères de faisabilité (traitement médical et expectative sont par exemple exclus en cas de rupture tubaire). Ces critères de faisabilité peuvent être résumés par la notion d’activité de la GEU. Cette notion permet de différencier les grossesses extra-utérines peu actives pouvant bénéficier d’un traitement médical des grossesses extra-utérines actives requérant un traitement chirurgical.Chaque traitement présente des avantages et des inconvénients et la principale question toujours en suspens concerne la fertilité après prise en charge d’une GEU. L’essai randomisé DEMETER a donc été conçu pour évaluer l’existence éventuelle d’une différence de fertilité de plus de 20% entre traitement médical et traitement chirurgical conservateur d’une part pour les GEU peu actives et entre traitement chirurgical conservateur et radical d’autre part pour les GEU actives.Il n’y a pas de différence significative de plus de 20% de fertilité deux ans après la prise en charge d’une grossesse extra-utérine que ce soit pour les grossesses peu actives entre traitement médical et traitement chirurgical conservateur ou pour les grossesses actives entre traitement chirurgical conservateur et radical. Par ailleurs, cet essai a aussi permis de conclure à la supériorité, en terme d’échec immédiat, du traitement chirurgical conservateur avec injection postopératoire de méthotrexate par rapport au traitement médical pour la prise en charge des GEU peu actives. La plus grande efficacité du traitement chirurgical conservateur est probablement majorée par l’injection postopératoire de méthotrexate. Le taux de conversion d’un traitement chirurgical conservateur vers un traitement chirurgical radical est important : 10% dans le groupe des GEU peu actives et 21% (significativement plus élevé) dans le groupe des GEU actives. Enfin, Le délai de guérison est plus court après traitement chirurgical conservateur qu’après traitement médical.Ces résultats couplés aux données de la littérature permettent d’élaborer des recommandations sur la prise en charge des grossesses extra-utérines. Notamment, pour les GEU peu actives avec un taux d’hCG inférieur à 5000UI/ml sans signe de rupture tubaire ou de défaillance hémodynamique, un traitement médical par méthotrexate doit être proposé sous réserve d’une bonne compliance de la patiente pour le suivi. Une prise en charge par chirurgie conservatrice reste une option valide. Dans ce cas, une injection postopératoire de méthotrexate sera réalisée systématiquement dans les 24 heures suivant l’intervention. Le traitement des GEU actives est chirurgical et la décision entre conservateur et radical a lieu en peropératoire. Enfin, une information aux patientes pourra être délivrée sur l’absence de différence de fertilité 2 ans après le traitement d’une GEU. / An ectopic pregnancy is a pregnancy implanted outside uterine cavity. There are four different treatments to manage tubal ectopic pregnancy: expectation, medical treatment (methotrexate), conservative surgery (salpingotomy) and radical surgery (salpingectomy). The choice between these different treatments is based on feasibility criteria (medical treatment and expectation are not feasible in case of tubal rupture). These feasibility criteria can be summarized by activity of ectopic pregnancy. This activity allowed differentiating less active ectopic pregnancies that can be supported by medical treatment and active ectopic pregnancies that required surgery.All of these treatments present advantages and disadvantages and the major unresolved issue concerns subsequent fertility after management of ectopic pregnancy. Randomized trial DEMETER has thus been designed to evaluate a difference of 20% between medical management and conservative surgery for less active ectopic pregnancy and between conservative and radical surgery for active ectopic pregnancy. Differences for two years subsequent fertility after management of ectopic pregnancy were not more than 20% between medical management and conservative surgery for less active ectopic pregnancy as between conservative and radical surgery for active ectopic pregnancy. This trial also allowed concluding to the superiority of conservative surgery with a systematic postoperative injection of methotrexate compared to medical treatment for management of less active ectopic pregnancy. This superiority might be enhanced by postoperative methotrexate injection. The conversion rate to radical surgery when a conservative surgery is decided is important: 10% for less active ectopic pregnancy and 21% (significantly higher) for active ectopic pregnancy. Recovery time is shorter after conservative surgery compared to medical management.Results of DEMETER trial and literature review allowed giving guidelines for management of ectopic pregnancy. Less active ectopic pregnancy with hCG rate less than 5.000UI/l without tubal rupture or hemodynamic failure can be managed in first intention by medical treatment (methotrexate) if the women is assiduous to a close check. However, conservative surgery for less active ectopic pregnancy is a good option. A systematic postoperative injection of methotrexate in the 24 first hours after surgery should be recommended. Active ectopic pregnancy has to be managed surgically and decision between conservative and radical surgery should be done in the operative room. Finally, women have to be informed about the absence of difference between treatments for subsequent fertility.

<p>Promotion of exclusive breastfeeding (EBF), (giving breast milk only without any solids or liquids), has proved to be very challenging in the South African context, although this infant feeding practice has been found to protect babies against diarrhoea and respiratory tract infections and to carry a lower risk of HIV infection than mixed feeding (breastfeeding combined with formula or solids). Study design: The PROMISE-EBF study is a multi-country cluster randomised trial to examine peer support to promote exclusive breastfeeding in Africa. For the South African site in the PROMISE-EBF study, three sites, Paarl, Rietvlei and Umlazi, were selected because of their different geographic settings and each site operated as a separate stratum for cluster selection and randomisation purposes. The clusters were then randomised into intervention and control arms making a total of 17 clusters in each arm. HIV positive and negative women in the intervention arm received support on their choice of infant feeding from the peer supporters who visited them at their homes while the women in the control group only received the standard infant feeding counselling and support provided by health care&nbsp / workers at health facilities. Data collection: Mothers were interviewed at recruitment during the antepartum period to establish eligibility, obtain informed consent and data on socio-economic status. Home visits were scheduled for data collection by trained data collectors at 3, 6, 12 and 24 weeks after birth. Analysis of results: This mini-thesis was a secondary analysis of the PROMISE-EBF data focusing on the South African data only. The data was adjusted for clustering and analysed using SAS. Comparison of variables between the intervention and control groups within sites was done. Results: A significant difference, regarding counselling and infant feeding practices, was observed among all women who received peer support compared to those who received the standard antenatal counselling, with more women in the intervention group (20.5%) practising EBF than those in the control group (12.8%) by Week 3. When the women‟s HIV status was considered, more than 65% of HIV positive and 40% of HIV negative women practised MF and EFF (giving formula milk only with no breast milk) throughout the study, respectively, regardless of the group they were in. For women who hadintended to practise EBF at recruitment, 33% in the control group and 20% in the intervention group actually practised EBF by Week 3. Regarding disclosure and feeding choice, 77.4% of women who had disclosed their HIV status actually practised MF versus 8.6% who practised EBF by Week 3.Conclusion: Community peer counselling should be strengthened as the results from this study showed that a high percentage of women who practised EBF were those who had received counselling, irrespective of their HIV status. The high percentage of HIV positive women who practised high risk feeding, despite receiving infant counselling, is of concern. Disclosure of the women‟s HIV status did not translate to them practising low risk infant feeding methods, which may suggest that there are other issues that determine the women‟s choice of infant feeding.</p>

<p>Promotion of exclusive breastfeeding (EBF), (giving breast milk only without any solids or liquids), has proved to be very challenging in the South African context, although this infant feeding practice has been found to protect babies against diarrhoea and respiratory tract infections and to carry a lower risk of HIV infection than mixed feeding (breastfeeding combined with formula or solids). Study design: The PROMISE-EBF study is a multi-country cluster randomised trial to examine peer support to promote exclusive breastfeeding in Africa. For the South African site in the PROMISE-EBF study, three sites, Paarl, Rietvlei and Umlazi, were selected because of their different geographic settings and each site operated as a separate stratum for cluster selection and randomisation purposes. The clusters were then randomised into intervention and control arms making a total of 17 clusters in each arm. HIV positive and negative women in the intervention arm received support on their choice of infant feeding from the peer supporters who visited them at their homes while the women in the control group only received the standard infant feeding counselling and support provided by health care&nbsp / workers at health facilities. Data collection: Mothers were interviewed at recruitment during the antepartum period to establish eligibility, obtain informed consent and data on socio-economic status. Home visits were scheduled for data collection by trained data collectors at 3, 6, 12 and 24 weeks after birth. Analysis of results: This mini-thesis was a secondary analysis of the PROMISE-EBF data focusing on the South African data only. The data was adjusted for clustering and analysed using SAS. Comparison of variables between the intervention and control groups within sites was done. Results: A significant difference, regarding counselling and infant feeding practices, was observed among all women who received peer support compared to those who received the standard antenatal counselling, with more women in the intervention group (20.5%) practising EBF than those in the control group (12.8%) by Week 3. When the women‟s HIV status was considered, more than 65% of HIV positive and 40% of HIV negative women practised MF and EFF (giving formula milk only with no breast milk) throughout the study, respectively, regardless of the group they were in. For women who hadintended to practise EBF at recruitment, 33% in the control group and 20% in the intervention group actually practised EBF by Week 3. Regarding disclosure and feeding choice, 77.4% of women who had disclosed their HIV status actually practised MF versus 8.6% who practised EBF by Week 3.Conclusion: Community peer counselling should be strengthened as the results from this study showed that a high percentage of women who practised EBF were those who had received counselling, irrespective of their HIV status. The high percentage of HIV positive women who practised high risk feeding, despite receiving infant counselling, is of concern. Disclosure of the women‟s HIV status did not translate to them practising low risk infant feeding methods, which may suggest that there are other issues that determine the women‟s choice of infant feeding.</p>

Thèse numérisée par la Division de la gestion de documents et des archives de l'Université de Montréal

Introdução: O jejum prolongado pré-operatório aumenta a resistência periférica à insulina. Foi investigado se a abreviação do jejum pré-operatório com uma bebida contendo carboidrato e glutamina melhora a resposta orgânica ao trauma cirúrgico. Métodos: Quarenta e oito pacientes adultas, do sexo feminino (19-62 anos) candidatas a colecistectomia videolaparoscópica eletiva. As pacientes foram aleatoriamente divididas em quatro grupos: grupo jejum convencional (grupo Jejum), ou em três grupos para receber três tipos diferentes bebidas oito horas (400 mL) e duas horas antes da indução anestésica (200ml): água pura (grupo Placebo), água mais dextrinomaltose (grupo carboidrato; 12,5% de dextrinomaltose) e grupo glutamina (grupo glutamina; 12,5% de dextrinomaltose e respectivamente 40 e 10g de glutamina). As amostras de sangue foram coletadas no período pré e pós-operatório. Resultados: não houve nenhum evento de aspiração ou regurgitação do conteúdo gástrico manifesto por sinais e sintomas clínicos, durante a indução anestésica, ou em qualquer outro momento do estudo. Também não houve nenhum óbito ou complicação pós-operatória. A média e o erro padrão médio da resistência à insulina determinada pelo HOMA-IR realizada no pós-operatório foi maior (p<0,05) no grupo que permaneceu em jejum (4,3±1,3) quando comparado com os outros três grupos de pacientes (Placebo, 1,6±0,3); carboidrato, (2,3±0,4) e glutamina, (1,5±0,1). A medida da glutationa peroxidase sérica, medida nos dois períodos foi maior no grupo glutamina (40±3,0) que nos grupos carboidrato (32±2,0) e jejum (32±2,0) (p<0,01). Ao se comparar o comportamento da IL-6 sérica em cada grupo estudado no período pré e pós-operatório, observou-se que o grupo glutamina foi o único sem diferença, enquanto nos demais a IL-6 aumentou no pós-operatório (p<0,01). No período pós-operatório a razão proteína-C-reativa/albumina foi maior no grupo jejum quando comparado com os grupos carboidrato (p=0,04) e glutamina (p=0,01). O balanço nitrogenado acumulativo foi menos negativo no grupo glutamina (-2,5±0,8 gN) que nos grupos placebo (-9,0±2,0 gN; p=0,001) e jejum (-6,6±0,4 gN; p=0,04). Conclusão: A abreviação do jejum pré-operatório com uma bebida contendo carboidrato e glutamina melhora a resistência periférica a insulina, a resposta anti-oxidativa e diminui a resposta inflamatória de pacientes submetidas à colecistectomia videolaparoscópica eletiva / Introduction: Prolonged preoperative fasting increases insulin resistance. We investigated whether an abbreviated preoperative fast with glutamine plus a carbohydrate based beverage would improve the organic response after surgery. Methods: Forty-eight female patients (19-62 years) candidates for video-cholecystectomy were randomized to either standard fasting (fasting group) or to fasting with one of three different beverages. Beverages were consumed 8 hours (400 mL; placebo group: water; glutamine group: water with 50 g maltodextrine plus 40 g glutamine; and carbohydrate group: water with 50 g maltodextrine) and 2 hours (200 mL; placebo group: water; glutamine group: water with 25 g maltodextrine plus 10 g glutamine; and carbohydrate group: water with 25 g maltodextrine) before anesthesia. Blood samples were collected pre- and postoperatively. Results: There were no cases of regurgitation during anesthesia. The mean [SEM] postoperative HOMA-IR was greater (p<0,05) in fasted patients (4,3±1,3) than in the other groups (placebo, 1,6±0,3); carbohydrate, (2.3±0,4); and glutamine, (1,5±0,1). Glutathione peroxidase (U/g hemoglobin) was significantly higher (40±3,0) in glutamine group than both carbohydrate (32±2,0) and fasting (32±2,0) groups (p< 0,01). Interleukin-6 increased in all groups except the glutamine group. The C-reactive protein/albumin ratio was higher in fasting subjects than carbohydrate (p=0,04) and glutamine (p=0,01) groups. The nitrogen balance was less negative in glutamine (-2,5±0,8 gN) than both placebo (-9,0±2,0 gN; p=0,001) and fasting (-6,6±0,4 gN; p=0,04) groups. Conclusions: Preoperative intake of a glutamine-enriched carbohydrate beverage improves insulin resistance and antioxidant defenses, and decreases the inflammatory response after videolaparoscopic cholecystectomy

Magister Public Health - MPH / Promotion of exclusive breastfeeding (EBF), (giving breast milk only without any solids or liquids), has proved to be very challenging in the South African context, although this infant feeding practice has been found to protect babies against diarrhoea and respiratory tract infections and to carry a lower risk of HIV infection than mixed feeding (breastfeeding combined with formula or solids). Study design: The PROMISE-EBF study is a multi-country cluster randomised trial to examine peer support to promote exclusive breastfeeding in Africa. For the South African site in the PROMISE-EBF study, three sites, Paarl, Rietvlei and Umlazi, were selected because of their different geographic settings and each site operated as a separate stratum for cluster selection and randomisation purposes. The clusters were then randomised into intervention and control arms making a total of 17 clusters in each arm. HIV positive and negative women in the intervention arm received support on their choice of infant feeding from the peer supporters who visited them at their homes while the women in the control group only received the standard infant feeding counselling and support provided by health care workers at health facilities. Data collection: Mothers were interviewed at recruitment during the antepartum period to establish eligibility, obtain informed consent and data on socio-economic status. Home visits were scheduled for data collection by trained data collectors at 3, 6, 12 and 24 weeks after birth. Analysis of results: This mini-thesis was a secondary analysis of the PROMISE-EBF data focusing on the South African data only. The data was adjusted for clustering and analysed using SAS. Comparison of variables between the intervention and control groups within sites was done. Results: A significant difference, regarding counselling and infant feeding practices, was observed among all women who received peer support compared to those who received the standard antenatal counselling, with more women in the intervention group (20.5%) practising EBF than those in the control group (12.8%) by Week 3. When the women's HIV status was considered, more than 65% of HIV positive and 40% of HIV negative women practised MF and EFF (giving formula milk only with no breast milk) throughout the study, respectively, regardless of the group they were in. For women who hadintended to practise EBF at recruitment, 33% in the control group and 20% in the intervention group actually practised EBF by Week 3. Regarding disclosure and feeding choice, 77.4% of women who had disclosed their HIV status actually practised MF versus 8.6% who practised EBF by Week 3.Conclusion: Community peer counselling should be strengthened as the results from this study showed that a high percentage of women who practised EBF were those who had received counselling, irrespective of their HIV status. The high percentage of HIV positive women who practised high risk feeding, despite receiving infant counselling, is of concern. Disclosure of the women's HIV status did not translate to them practising low risk infant feeding methods, which may suggest that there are other issues that determine the women's choice of infant feeding. / South Africa

This study compared 3 approaches for handling a fourth level of nesting structure when analyzing data from a cluster-randomized trial (CRT). CRTs can include 3 levels of nesting: repeated measures, individual, and cluster levels. However, above the cluster level, there may sometimes be an additional potentially important fourth level of nesting (e.g., schools, districts, etc., depending on the design) that is typically ignored in CRT data analysis. The current study examined the impact of ignoring this fourth level, accounting for it using a model-based approach, and accounting it using a design-based approach on parameter and standard error (SE) estimates. Several fixed effect and random effect variance parameters and SEs were biased across all 3 models. In the 4-level model, most SE biases decreased as the number of level 3 clusters increased and as the number of level 4 clusters decreased. Also, random effect variance biases decreased as the number of level 3 clusters increased. In the 3-level and complex models, SEs became more biased as the weight level 4 carried increased (i.e., larger intraclass correlation, more clusters at that level). The current results suggest that if a meaningful fourth level of nesting exists, future researchers should account for it using design-based approach; the model-based approach is not recommended. If the fourth level is not practically important, researchers may ignore it altogether.

The strong emphasis placed on improving equality and well-being for all in the Sustainable Development Goals underscores the importance of tackling persistent within-country disparities in maternal mortality and poor health outcomes. Addressing maternal healthcare access barriers is, thus, crucial, particularly in low-resource settings. Numerous studies investigating determinants of maternal healthcare service use in Ethiopia exist but are limited by their focus on individual and household factors, and by methodological weaknesses. A nuanced understanding of the role of socioeconomic and geographic context in influencing access to care is needed to respond effectively. Maternity waiting homes (MWHs) are a potential strategy to address geographical barriers that delay women’s access to obstetric care. However, in addition to concerns about service quality, there is limited evidence on their effectiveness and on what models meet women’s needs. My research goals were, therefore, to contribute to the understanding of what contextual factors influence maternal healthcare service use in general; and to determine whether or not upgraded MWHs operating in an enabling environment could improve delivery care use in rural Ethiopia. My primary data sources were household surveys conducted as part of a cluster-randomized controlled trial evaluating MWHs and local leader training in Jimma Zone, Ethiopia. Random effects multivariable logistic regression analysis of survey data brought to light the social and financial resources that facilitate MWH use, highlighting the need for complementary interventions to make access more equitable. Spatial analyses identified subnational variation in service use at a finer scale than routinely reported and unmasked local variation in the relevance and magnitude of associations between individual-, interpersonal-, and health system factors and maternal healthcare use. These findings have implications for relying upon homogenous national responses to improve equality in access to care and health outcomes. Finally, analysis of trial data found a non-significant effect of interventions on delivery care use likely due to implementation issues and extraneous factors. The need to generate strong evidence of effectiveness of MWHs in improving maternal healthcare service use using sustainable and equitable MWH models using methods appropriate for complex intervention evaluation remains.

No description available.