Guideline No. 395-Female Genital Cutting

OBJECTIVES

To decrease the likelihood that the practice of female genital cutting (FGC) be continued in the future and to improve the care of girls and women who have been subjected to FGC or who are at risk by providing (1) information intended to strengthen knowledge and understanding of the practice, (2) information regarding the legal issues related to the practice, (3) guidance for the management of its obstetrical and gynaecological complications, and (4) guidance on the provision of culturally competent care to girls and women affected by FGC.

OPTIONS

Strategies for the primary, secondary, and tertiary prevention of FGC and its complications.

OUTCOMES

The short- and long-term consequences of FGC.

INTENDED USERS

Health care providers delivering obstetrical and gynaecological care.

TARGET POPULATION

Women from countries where FGC is commonly practised and Canadian girls and women from groups who may practise FGC for cultural or religious reasons.

EVIDENCE

Published literature was retrieved through searches of PubMed, CINAHL, and the Cochrane Library in September 2010 using appropriate controlled vocabulary (e.g., Circumcision, Female) and key words (e.g., female genital mutilation, clitoridectomy, infibulation). Searches were updated and incorporated in the guideline revision December 2018.

VALIDATION METHODS

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

There are no anticipated harms or costs to health care facilities with implementation of this guideline. Benefits may include a greater willingness of women living with FGC to seek timely care.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Directive clinique No 395 - Excision génitale féminine

OBJECTIFS

La présente directive clinique vise à diminuer la probabilité que la pratique de l'excision génitale féminine (EGF) se poursuive et à améliorer les soins prodigués aux filles et aux femmes qui ont subi une EGF ou qui risquent d'en subir une en fournissant (1) des renseignements destinés à améliorer les connaissances et la compréhension de la pratique, (2) des renseignements sur les enjeux juridiques liés à cette pratique, (3) des directives relatives au traitement des complications obstétricales et gynécologiques connexes et (4) des directives sur la compétence culturelle dans la prestation de soins aux filles et femmes touchées par l'EGF.

OPTIONS

Des stratégies de prévention primaire, secondaire et tertiaire de l'EGF et de ses complications. RéSULTATS: Les conséquences à court et à long terme de l'EGF.

UTILISATEURS CIBLES

Les fournisseurs de soins de santé qui fournissent des soins obstétricaux et gynécologiques.

POPULATION CIBLE

Les femmes originaires de pays où l'EGF est couramment pratiquée ainsi que les filles et femmes canadiennes issues de groupes où l'EGF est parfois pratiquée pour des motifs culturels ou religieux. DONNéES PROBANTES: Des recherches ont été effectuées en septembre 2010 dans le moteur PubMed et les bases de données CINAHL et Cochrane Library au moyen d'une terminologie contrôlée appropriée (p. ex. Circumcision, Female) et de mots-clés en anglais (p. ex. female genital mutilation, clitoridectomy, infibulation) afin de rassembler la littérature publiée sur le sujet. Les recherches ont été mises à jour et intégrées à la révision de la directive clinique en décembre 2018. MéTHODES DE VALIDATION: La qualité des données probantes contenues dans le présent document a été évaluée en fonction des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs. AVANTAGES, PRéJUDICES, ET COûTS: Aucun coût ni préjudice n'est anticipé pour la mise en œuvre de cette directive clinique dans les établissements de santé. Au nombre des avantages, la directive pourrait inciter les femmes ayant subi une EGF à solliciter rapidement des soins. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Characteristics affecting survival after locally advanced colorectal cancer in Quebec

BACKGROUND

We estimated the relations of sociodemographic, organizational, disease, and treatment variables with the risk of death from colorectal cancer (crc) in a Quebec population-based sample of patients with locally advanced crc (lacrc) who underwent tumour resection with curative intent.

METHODS

Information from medical records and administrative databases was obtained for a random sample of 633 patients surgically treated for stages ii-iii rectal and stage iii colon cancer and declared to the Quebec cancer registry in 1998 and 2003. We measured personal, disease, and clinical management characteristics, relative survival, and through multivariate modelling, relative excess rate (rer) of death.

RESULTS

The relative 5- and 10-year survivals in this cohort were 67.7% [95% confidence interval (ci): 65.8% to 69.6%] and 61.2% (95% ci: 58.3% to 64.0%) respectively. Stage T4, stage N2, and emergency rather than elective surgery affected 18%, 24% and 10% of patients respectively. Those disease progression characteristics each independently increased the rer of death by factors of 2 to almost 5. Grade, vascular invasion, and tumour location were also significantly associated with the rer for death. Receiving guideline-adherent treatment was associated with a 60% reduction in the rer for death (0.41; 95% ci: 0.28 to 0.61), an effect that was consistent across age groups. Clear margins (proximal-distal, radial) and clinical trial enrolment were each associated with a nonsignificant 50% reduction in the rer. Of patients less than 70 years of age and 70 years of age and older, 81.3% and 42.0% respectively received guideline-adherent treatment.

CONCLUSIONS

This study is the first Quebec population-based examination of patients with lacrc and their management, outcomes, and outcome determinants. The results can help in planning crc control strategies at a population level.

No effect of scalp cooling on survival among women with breast cancer

Scalp cooling can prevent chemotherapy-induced alopecia in some cancer patients. It is not used in all countries. No data are available regarding its impact, if any, on survival. The aim of this study was to compare overall survival according to whether or not scalp cooling was used during neoadjuvant or adjuvant chemotherapy for non-metastatic breast cancer. We conducted a retrospective cohort study of 1,370 women with non-metastatic invasive breast carcinoma who received chemotherapy in the neoadjuvant or adjuvant setting. A total of 553 women who used scalp cooling came from a tertiary breast cancer clinic in Quebec City (diagnosed between 1998 and 2002) and 817 were treated in other hospitals in the province of Quebec (between 1998 and 2003) where scalp cooling was not routinely available. Overall survival of women who used scalp cooling and those who did not was compared using Cox proportional hazards models. Median follow-up for the scalp-cooled and the non-scalp-cooled groups was 6.3 years and 8.0 years, respectively. Overall mortality was no different (adjusted hazard ratio 0.89, 95 % confidence interval: 0.68-1.17, p = 0.40) among scalp-cooled women, compared to those not getting scalp cooling. Among women getting neoadjuvant or adjuvant chemotherapy for non-metastatic breast cancer, scalp cooling used to prevent chemotherapy-induced alopecia had no negative effect on survival. To our knowledge, this is the first study to compare survival of women who used scalp cooling to that of women who did not.

United Nations Millennium Development Goals 4 and 5: augmenting the role of health professional associations

The present study aimed to assess changes in the organizational capacity of health professional associations (HPAs) before and after a structured capacity building intervention, which included strategic investment of resources at institutional and technical levels. Self-assessments of organizational capacity were conducted by seven HPAs from low-resource countries involved in the FIGO Leadership in Obstetrics and Gynecology for Impact and Change (LOGIC) Initiative in Maternal and Newborn Health. The self-assessment tool comprised a questionnaire focusing on five core organizational dimensions, completed through a participatory and externally facilitated process. Differences were assessed using the two-sided sign test. All seven HPAs made improvements, with gains in an overall index (P=0.017) and in the specific dimensions of culture (P=0.016), operational capacity (P=0.016), performance (P=0.03), and functions (P=0.016). Increased capacity contributed to the ability of each HPA to enhance their credibility and assume leadership in national efforts to improve maternal and newborn health.

Female genital cutting

OBJECTIVE

To strengthen the national framework for care of adolescents and women affected by female genital cutting (FGC) in Canada by providing health care professionals with: (1) information intended to strengthen their knowledge and understanding of the practice; (2) directions with regard to the legal issues related to the practice; (3) clinical guidelines for the management of obstetric and gynaecological care, including FGC related complications; and (4) guidance on the provision of culturally competent care to adolescents and women with FGC.

EVIDENCE

Published literature was retrieved through searches of PubMed, CINAHL, and The Cochrane Library in September 2010 using appropriate controlled vocabulary (e.g., Circumcision, Female) and keywords (e.g., female genital mutilation, clitoridectomy, infibulation). We also searched Social Science Abstracts, Sociological Abstracts, Gender Studies Database, and ProQuest Dissertations and Theses in 2010 and 2011. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Summary Statements 1. Female genital cutting is internationally recognized as a harmful practice and a violation of girls' and women's rights to life, physical integrity, and health. (II-3) 2. The immediate and long-term health risks and complications of female genital cutting can be serious and life threatening. (II-3) 3. Female genital cutting continues to be practised in many countries, particularly in sub-Saharan Africa, Egypt, and Sudan. (II-3) 4. Global migration patterns have brought female genital cutting to Europe, Australia, New Zealand, and North America, including Canada. (II-3) 5. Performing or assisting in female genital cutting is a criminal offense in Canada. (III) 6. Reporting to appropriate child welfare protection services is mandatory when a child has recently been subjected to female genital cutting or is at risk of being subjected to the procedure. (III) 7. There is concern that female genital cutting continues to be perpetuated in receiving countries, mainly through the act of re-infibulation. (III) 8. There is a perception that the care of women with female genital cutting is not optimal in receiving countries. (III) 9. Female genital cutting is not considered an indication for Caesarean section. (III) Recommendations 1. Health care professionals must be careful not to stigmatize women who have undergone female genital cutting. (III-A) 2. Requests for re-infibulation should be declined. (III-B) 3. Health care professionals should strengthen their understanding and knowledge of female genital cutting and develop greater skills for the management of its complications and the provision of culturally competent care to adolescents and women who have undergone genital cutting. (III-A) 4. Health care professionals should use their knowledge and influence to educate and counsel families against having female genital cutting performed on their daughters and other family members. (III-A) 5. Health care professionals should advocate for the availability of and access to appropriate support and counselling services. (III-A) 6. Health care professionals should lend their voices to community-based initiatives seeking to promote the elimination of female genital cutting. (III-A) 7. Health care professionals should use interactions with patients as opportunities to educate women and their families about female genital cutting and other aspects of women's health and reproductive rights. (III-A) 8. Research into female genital cutting should be undertaken to explore women's perceptions and experiences of accessing sexual and reproductive health care in Canada. (III-A) The perspectives, knowledge, and clinical practice of health care professionals with respect to female genital cutting should also be studied. (III-A). 9. Information and guidance on female genital cutting should be integrated into the curricula for nursing students, medical students, residents, midwifery students, and students of other health care professions. (III-A) 10. Key practices in providing optimal care to women with female genital cutting include: a. determining how the woman refers to the practice of female genital cutting and using this terminology throughout care; (III-C) b. determining the female genital cutting status of the woman and clearly documenting this information in her medical file; (III-C) c. ensuring the availability of a well-trained, trusted, and neutral interpreter who can ensure confidentiality and who will not exert undue influence on the patient-physician interaction when providing care to a woman who faces language challenges; (III-C) d. ensuring the proper documentation of the woman's medical history in her file to minimize the need for repeated medical histories and/or examinations and to facilitate the sharing of information; (III-C) e. providing the woman with appropriate and well-timed information, including information about her reproductive system and her sexual and reproductive health; (III-C) f. ensuring the woman's privacy and confidentiality by limiting attendants in the room to those who are part of the health care team; (III-C) g. providing woman-centred care focused on ensuring that the woman's views and wishes are solicited and respected, including a discussion of why some requests cannot be granted for legal or ethical reasons; (III-C) h. helping the woman to understand and navigate the health system, including access to preventative care practices; (III-C) i. using prenatal visits to prepare the woman and her family for delivery; (III-C) j. when referring, ensuring that the services and/or practitioners who will be receiving the referral can provide culturally competent and sensitive care, paying special attention to concerns related to confidentiality and privacy. (III-C).

Strengthening the organizational capacity of health professional associations: the FIGO LOGIC Toolkit

Health professional associations, including national associations of obstetrics and gynecology, can have a leading role in influencing and developing health policy and practice. However, in low- and middle-resource countries, the organizational capacity to facilitate this role is often insufficient. The International Federation of Gynecology and Obstetrics LOGIC (Leadership in Obstetrics and Gynaecology for Impact and Change) Initiative has been developing the capacity of national associations in Africa and Asia. Through this work, an electronic resource of materials (http://figo-toolkit.org/) has been brought together to support organizational capacity development, addressing domains such as culture, strategic planning, human resources, project and financial management, performance, external relations, membership services, and the development and revision of clinical guidelines.

The role of health professional associations in the promotion of global women's health

Health professional associations, especially those from countries with the highest maternal death burden, have vital roles to play in improving maternal and newborn health and in achieving the Millennium Development Goals 4 and 5. Possessing the knowledge, skills, and influence to positively impact practice at the service delivery level, they can also advocate for change at the policy level and lobby for higher priority and greater investment in the maternal and newborn health field at the national level. The ability of professional associations to assume this leadership is nevertheless contingent on their institutional capacities to achieve planned goals and objectives in support of their organizational mission and strategic priorities. Since 1998, the Society of Obstetricians and Gynaecologists of Canada (SOGC) has been supporting the capacity development efforts of peer professional associations in low-resource countries. SOGC's work in this specific area has led it to develop and pilot an Organization Capacity Improvement Framework (OCIF) that guides professional associations, incrementally, in successive cycles of capacity development. Building on capacity developed within previous capacity-building cycles, this article summarizes and reports on the recent outcomes of the Asociación de Gynecoloígia y Obstetricia de Guatemala's (AGOG) organizational development efforts and the impact they have had in positioning the association as an important contributor in national efforts to improve maternal and newborn health outcomes in the country.

The FIGO Save the Mothers Initiative: the Uganda-Canada collaboration

In 1998, the ob/gyn associations of Uganda and Canada launched, under the umbrella of the FIGO Save the Mothers Initiative, a district-wide intervention which aimed to increase the availability and utilization of emergency obstetric care (EmOC) services in a rural district of Uganda. The article describes the experience of two professional ob/gyn associations in the development, implementation, monitoring and evaluation of the project. Preliminary results after 24 months of intervention indicate important gains in the capacity of health professionals to deliver EmOC, the availability of emergency transportation services and met need for EmOC.

Complex dysrhythmias in infants and children

Dysrhythmias in infants and children are, in many ways, similar to those in adults, yet several important differences exist in their presentation and management. Complex dysrhythmias most frequently encountered in pediatrics include sinus node dysfunction, chaotic atrial rhythm, atrial flutter, supraventricular tachycardia (including Wolff-Parkinson-White syndrome and junctional ectopic tachycardia), complete atrioventricular block (congenital and acquired), and ventricular dysrhythmias (premature ventricular contractions and ventricular tachycardia). Newer approaches to the diagnosis and management of these dysrhythmias are addressed in this paper.

[Subcutaneous analgesic administration]

In March 1989, Saint Luke's Hospital in Montréal piloted the use of continuous and intermittent subcutaneous injection of analgesics. This practice involved patients whose pain could not be relieved by traditional methods of analgesic administration. The article describes the positive results of the project, and clearly identifies suitable patients. It also outlines the advantages, limiting factors and risks involved with each type of infusion. Procedures for set-up and monitoring are briefly explained. The authors conclude that family members of patients can be easily taught to perform the procedure at home.

The role of body fat in insulin sensitivity of endurance athletes

The purpose of the study was to assess the role of adiposity in the enhanced insulin sensitivity observed in endurance athletes (EA). An oral glucose tolerance test (75 g glucose) was administered to nine EA and to 23 sedentary subjects (SS). Two different strategies were used to investigate the problem. First, body composition indicators and Vo2max were correlated with the delta insulin and delta glucose areas measured for 180 minutes following glucose ingestion. These correlation analyses were performed for the two groups combined (n = 32). No significant correlations were observed between either fat weight or percent body fat versus delta insulin, delta glucose or delta glucose/delta insulin areas. Moreover, no significant correlation was observed between the several subcutaneous fat indicators and delta insulin, delta glucose and delta glucose/delta insulin areas. The second strategy consisted of comparing EA to SS when percent body fat difference was eliminated. This was achieved by two different methods, first by covariance analysis and second by comparing subsamples of trained and non-trained subjects paired with respect to percent body fat. These two comparisons revealed that even when adiposity was equal between the groups, a significantly greater insulin sensitivity was observed in the EA group (p less than 0.01). The present results suggest that adiposity is not the determining factor for the increased insulin sensitivity of trained subjects.

The effect of exercise-training on resting metabolic rate in lean and moderately obese individuals

Two experiments have been performed to establish whether exercise-training has an influence on resting metabolic rate (RMR). In a first study, RMR was measured in a cohort of 59 individuals comprising 20 trained and 39 non-trained subjects. The absolute level of RMR in trained subjects exceeded by 11 percent that observed in the non-trained individuals (P less than 0.01). When comparing regression lines of RMR versus FFM between the two groups, the intercept with the Y axis (RMR values) was also significantly higher in trained subjects (P less than 0.01). The second experiment was conducted to find out whether the trend for an elevated RMR noted in athletes could be reproduced in obese persons engaging in an exercise-training program. Eight moderately obese women were submitted to an 11-week training programme, including 5 hours of aerobic exercise per week performed at a mean intensity of about 50 percent VO2 max. The results showed that exercise-training induced a significant rise in RMR which corresponded to 8 percent of pretraining value in kcal/kg FFM/min (P less than 0.01). Thus, data reported here suggest that aerobic exercise-training is associated with an elevated RMR per unit of fat free mass in both lean and moderately obese individuals.

Successful treatment of Pseudomonas meningitis and septicemia in a leukemic neutropenic adult

Pseudomonas aeruginosa is thought to be one of the main species of bacteria producing infection in leukemic patients, especially in those with neutropenia. Although bacteremia is frequent, hematogenous spread causing secondary meningitis is rarely seen. The mortality rate is extremely high. This is believed to be the first report of a successfully treated secondary meningitis caused by Pseudomonas aeruginosa in an adult leukemic patient with a decreased neutrophil count. The patient was treated with intravenous Carbenicillin and gentamicin, and intrathecal gentamicin. The good clinical response was supported by a prompt return of the CSF to normal and by appropriate CSF antimicrobial concentration and bacteriostatic activity.