Endometriosis and environmental factors: A critical review.

This review provides an overview of current knowledge on the relationship between various environmental factors and endometriosis. We successively searched for a given exposure factor combined with the word "endometriosis." The literature was comprehensively analyzed and summarized by quoting only the most important and recent studies on each exposition factor. The data focused primarily on endocrine disruptors, such as dioxins and polychlorinated biphenyls, that appear to have the strongest effect. Intriguing data suggest a link with night work, sun exposure and red meat consumption. For the other risk factors studied, particularly those related to lifestyle (tobacco consumption, alcohol, coffee, soy, physical exercise), the data are not sufficient to draw conclusions. In summary, the epidemiological evidence does not support a strong, scientific link between exposure to environmental factors and endometriosis. The complexity of this disease requires advanced study designs and standardized methodology. Future studies should be carefully designed to address these issues to advance our understanding of the impact of the environment and its consequences on endometriosis.

Objective assessment of obstetrics residents' surgical skills in caesarean: Development and evaluation of a specific rating scale.

OBJECTIVE: To develop a modified version of Objective Structured Assessment of Technical Skill (OSATS) rating scale for evaluation of surgical skills specific to caesarean and to assess its relevance in documenting the residents' learning curve during their training. Secondarily, to verify the scale's stability to caesarean's level of difficulty and comparing self-assessment to hetero-assessment in order to propose a practical application of this rating scale during residency. STUDY DESIGN: We conducted a multicentre observational prospective study, from May 2018 to November 2018. All residents at that time could participate and fill in the rating scale after caesarean. Senior surgeons had to fill in the same rating scale. We analysed correlation between self-assessments and hetero-assessments and sensitivity to change of the rating scale. Analysis of feature's relevance was performed by principal component analysis, factor analysis and reliability analysis. RESULTS: In total, 234 rating scales were completed evaluating 18 residents. Our study demonstrated that our rating scale could be used to evaluate surgical skills of residents during caesarean and distinguish their year of residency (p < 0.001) with a high correlation between self and hetero-assessment (Intraclass Correlation coefficient for global score: 0.78; 95% CI 0.68-0.86). The principal component analysis revealed two dimensions corresponding to the two parts of the rating scale and the factorial analysis allowed us to confirm distribution of features according to these two dimensions. Cronbach's alpha allowed us to highlight the percentage of representation of the scale's features in relation to all potential theoretical features (0.93, 95% CI 0.82-0.95). CONCLUSION: Our rating scale could be used for self-assessment during residency and as a hetero-assessment tool for validating defined stages of the internship.

Qualitative study of self-reported experiences of infertile women with polycystic ovary syndrome through on-line discussion forums.

OBJECTIVES: To highlight the self-reported experiences and disease perceptions of infertile women with polycystic ovary syndrome (PCOS). METHODS: A qualitative study using an inductive method was conducted on infertile women with PCOS who shared their self-reported experiences on French-speaking on-line forums. RESULTS: 785 comments by 211 women on 7 forums were analyzed. Women complained of late diagnosis and lack of information regarding PCOS. PCOS and infertility showed negative psychological impact on daily life. This impact appeared to be alleviated by the sharing of knowledge and experience enabled by these forums. CONCLUSION: The self-reported experience of infertile women with PCOS is interesting for health practitioners. The psychological impact of PCOS and perceptions of illness appear to be improved by sharing experiences between women with PCOS, suggesting a beneficial support role of online discussion forums.

Laparoscopic Essure® Device Removal by En Bloc Salpingectomy-Cornuectomy with Intraoperative X-Ray Checking: A Retrospective Cohort Study.

STUDY OBJECTIVE: To evaluate the feasibility, efficacy, and morbidity of Essure® device removal via laparoscopic en bloc salpingectomy-cornuectomy resection (LSC) and the utility of confirmation of complete removal with an intraoperative X-ray of the removed specimen (IX-S). DESIGN: Retrospective observational cohort study. SETTING: Academic hospitals of La Conception, Marseille, and Arnaud-de-Villeneuve, Montpellier, France. PATIENTS: Women who were not seeking future fertility seeking Essure® device removal by salpingectomy, between February 2017 and August 2018. INTERVENTIONS: All women underwent LSC. An IX-S was performed to confirm complete Essure® device removal. In the case of an unsatisfactory IX-S, an intraoperative pelvic X-ray control of the patient (IX-P) was performed. If IX-P diagnosed residual Essure® fragments, an additional resection was performed, and the removed tissue was checked by IX-S. MEASUREMENTS AND MAIN RESULTS: We included 72 women, and a total of 140 Essure® devices were removed. The IX-S confirmed complete Essure® device removal in 131 of 140 cases (93.6%) in 63 of 72 women (87.5%). Out of the 9 women with unsatisfactory IX-S, 6 had no residual Essure® fragments at IX-P, and Essure® device removal was considered complete. Three women had a persistent Essure® fragment at IX-P: an additional resection allowed complete removal in 2 cases and resulted in failure in 1 of 140 case (0.7%). There were 2 of 72 women (2.8%) intraoperative complications and 4 of 72 women (5.6%) postoperative grade 1 complications according to the Clavien-Dindo classification. CONCLUSION: Essure® device removal by LSC appears to be an effective and safe procedure. IX-S is a useful method to evaluate whether the removal of Essure® device is complete during an LSC procedure.

Evaluation of a follow-up customized strategy for women treated with methotrexate for an ectopic pregnancy: An observational study.

OBJECTIVE: To evaluate a follow-up customized strategy used in women treated with methotrexate for tubal ectopic pregnancy. STUDY DESIGN: This observational monocentric study took place from November 2009 to December 2015 in the emergency unit at La Conception University Hospital in Marseille, France. 440 women were treated by methotrexate for tubal ectopic pregnancy. Women were assigned in a classic follow up protocol with a weekly hCG evaluation (conventional protocol) if the drop in hCG between D1 and D4 was inferior to 20% or in an alternative follow up (streamlined protocol) with a hCG evaluation at one month. The main outcome measures were the success rate, the proportion of women requiring several methotrexate injections, and the mean number of consultations per women and duration of the follow-up. RESULTS: During this period, the success rate was 348/440 (79.1%). The rate of women requiring 1, 2, or 3 injections and of women lost to follow-up were comparable between the two protocols. The mean number of consultations per woman was 3.6 ± 1.33 vs. 5.95 ± 2.25 days (p < 0.0001), and the follow-up was 27.5 ± 12 vs. 28.1 ± 15.4 (p = 0.6) respectively in the conventional protocol group and the streamlined. CONCLUSION: Our customized strategy allows for a decrease in the number of consultations per woman without changing the success rate or the need for methotrexate injection. hCG count drop between D1 and D4 allows for the selection of a low-risk group that can benefit from appropriate aftercare.

Effect of laparoscopy by single-port endoscopic access in benign adnexal surgery: study protocol for a randomized controlled trial.

BACKGROUND: Laparoscopic surgery has become the preferred surgical approach due to a reduction in postoperative pain, better recovery, shorter hospitalization, and improved esthetic outcomes. Laparoscopic surgery with single-port laparoscopy (SPL) is a laparoscopic surgery technique that is based on making a single parietal incision using a single trocar specifically designed to allow introduction of several instruments. The level of evidence regarding the advantages of SPL in terms of postoperative pain has remained low despite several randomized studies. Adult patients exhibiting a surgical indication for an a priori benign ovarian pathology or for prophylactic purposes that can be performed by laparoscopy will be randomized to receive conventional laparoscopy (CL) or SPL. The aim of our study is to evaluate whether SPL offers advantages over CL in benign adnexal surgery. METHODS: The patients will be evaluated preoperatively to confirm their eligibility. The perioperative data up to 24 h after the intervention, as well as the postoperative data at day 7 and at one month from the intervention will be collected. The primary outcome for the study will be the postoperative pain at 24 h ± 2 h after the intervention. The pain will be assessed by a numeric rating scale of 0-10. Other outcomes will also be assessed, such as pain at other times, the consumption of analgesics, the operative time, perioperative bleeding, the number of additional trocars in the two groups, the incidence of laparoconversion, the esthetic criteria of the scar at one month, the incidence of complications, and the quality of life at one month. DISCUSSION: If our hypothesis is confirmed, this study will provide evidence that the use of SPL can decrease postoperative pain in adnexal surgery. The standard surgical treatment of this condition would thus be modified. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02739724 . Registered on 12 April 2016.

IVF oocyte retrieval: prospective evaluation of the type of anesthesia on live birth rate, pain, and patient satisfaction.

PURPOSE: Does the type of anesthesia (paracervical block (PCB) or general anesthesia (GA)) impact live birth rate, pain, and patient satisfaction? METHODS: A non-randomized prospective cohort study was conducted in women treated for IVF. Two groups of patients were prospectively included: the PCB group (n = 234) and the GA group (n = 247). The type of anesthesia was determined by the patients. The primary endpoint was cumulative live birth rate by OR. Secondary endpoints were self-assessment of the patients' peri-operative abdominal and vaginal pain vs the doctors' evaluations during PCB, post-operative abdominal and vaginal pain level, and patient satisfaction in both groups. Pain levels were assessed with a numerical rating scale (NRS). RESULTS: The live birth rate was similar in both groups (19.8% in the GA group vs 20.9% in the PCB group, P = 0.764). During oocyte retrieval in the PCB group, the physicians significantly under-estimated the vaginal pain experienced by the patients (3.04 ± 0.173 for patients vs 2.59 ± 0.113 for surgeons, P = 0.014). Post-operative vaginal and abdominal pain were significantly greater in the PCB group compared to the GA group (2.26 ± 0.159 vs 1.66 ± 0.123, respectively, P = 0.005, and 3.80 ± 0.165 vs 3.00 ± 0.148, respectively, P < 0.001). Patients were more significantly satisfied with GA than with PBC (P < 0.001). CONCLUSION: Because the LBR was similar in both groups and patient satisfaction was high, the choice of anesthesia should be decided by the patients.

Factors associated with a poor prognosis for the IVF-ICSI live birth rate in women with rAFS stage III and IV endometriosis.

PURPOSE: To assess the factors associated with a poor prognosis for a cumulative IVF live birth rate (LBR) in women with stage III and IV endometriosis according to the revised classification of the American Fertility Society (rAFS). METHODS: A retrospective cohort study was conducted between January 1, 2010, and December 31, 2014, in our Reproductive Medicine Center. We analyzed different factors associated with a poor prognosis for a cumulative IVF LBR in women with rAFS stage III and IV endometriosis. A total of 101 patients were included, representing 232 IVF-ICSI cycles and 212 embryo transfers. The primary endpoint was the cumulative LBR per cycle and per patient. RESULTS: The cumulative LBR per cycle was 14.7% (n = 34) and that per patient was 31.7% (n = 32). The cumulative LBR was significantly decreased by active smoking [adjOR = 3.4, 95% CI (1.12-10.60), p = 0.031], poor ovarian response (POR) according to the Bologna criteria [adjOR = 11.5, 95% CI (1.37-96.83), p = 0.024], and rAFS stage IV [adjOR = 3.2, 95% CI (1.13-8.95), p = 0.024]. The cumulative LBR per women was 59.4% without factors associated with a poor prognosis and 25.6% in the case of one factor, and it decreased to 7.7% in the case of two or three factors (p < 0.001). CONCLUSION: Active smoking, POR according to the Bologna criteria, and rAFS stage IV endometriosis had a negative impact on the IVF-ICSI cumulative LBR for women with rAFS stage III and IV endometriosis. Because smoking dramatically decreases the LBR with endometriosis, stopping smoking before IVF-ICSI should be strongly advised.

Development of an evidence-based training program for laparoscopic hysterectomy on a virtual reality simulator.

BACKGROUND: Substantial evidence in the scientific literature supports the use of simulation for surgical education. However, curricula lack for complex laparoscopic procedures in gynecology. The objective was to evaluate the validity of a program that reproduces key specific components of a laparoscopic hysterectomy (LH) procedure until colpotomy on a virtual reality (VR) simulator and to develop an evidence-based and stepwise training curriculum. METHODS: This prospective cohort study was conducted in a Marseille teaching hospital. Forty participants were enrolled and were divided into experienced (senior surgeons who had performed more than 100 LH; n = 8), intermediate (surgical trainees who had performed 2-10 LH; n = 8) and inexperienced (n = 24) groups. Baselines were assessed on a validated basic task. Participants were tested for the LH procedure on a high-fidelity VR simulator. Validity evidence was proposed as the ability to differentiate between the three levels of experience. Inexperienced subjects performed ten repetitions for learning curve analysis. Proficiency measures were based on experienced surgeons' performances. Outcome measures were simulator-derived metrics and Objective Structured Assessment of Technical Skills (OSATS) scores. RESULTS: Quantitative analysis found significant inter-group differences between experienced intermediate and inexperienced groups for time (1369, 2385 and 3370 s; p < 0.001), number of movements (2033, 3195 and 4056; p = 0.001), path length (3390, 4526 and 5749 cm; p = 0.002), idle time (357, 654 and 747 s; p = 0.001), respect for tissue (24, 40 and 84; p = 0.01) and number of bladder injuries (0.13, 0 and 4.27; p < 0.001). Learning curves plateaued at the 2nd to 6th repetition. Further qualitative analysis found significant inter-group OSATS score differences at first repetition (22, 15 and 8, respectively; p < 0.001) and second repetition (25.5, 19.5 and 14; p < 0.001). CONCLUSIONS: The VR program for LH accrued validity evidence and allowed the development of a training curriculum using a structured scientific methodology.

Outcome and Follow-up of Patients with Endometrial Carcinoma Diagnosed on Operative Hysteroscopic Resection Specimens.

AIM: To study outcomes of patients diagnosed with endometrial carcinoma (EC) after histological analysis of endometrial resections retrieved during operative hysteroscopy performed for a presumed benign lesion. PATIENTS AND METHODS: A retrospective study was conducted using medical records of patients who underwent operative hysteroscopy for a presumed benign lesion with a final diagnosis of EC between January 1994 and April 2014 in two tertiary academic centers. RESULTS: A total of 29 patients were selected. International federation of gynecology and obstetrics (FIGO) classification was distributed as follows: 16 stages IA, 7 stages IB, 4 stages II and 2 stages III. Peritoneal cytology was positive in one case (stage IIIA). Median follow-up was 4.2 years (range=0.3-20.51). Two deaths were observed and were attributed to endometrial cancer. CONCLUSION: Operative hysteroscopy does not appear to influence stage of EC nor cause retrograde seeding of EC for 27/29 (93%) patients. For 2 patients, the impact of operative hysteroscopy remains uncertain.

Risk of coexisting endometrial carcinoma in case of atypical endometrial hyperplasia diagnosed on total hysteroscopic resection.

OBJECTIVE: To evaluate the rate of coexisting endometrial carcinoma or atypical endometrial hyperplasia (AEH) residue in patients who had a total hysteroscopic resection with diagnosis of AEH and without suspicious lesions detected during hysteroscopy. STUDY DESIGN: This retrospective bicentric study included patients diagnosed with AEH on hysteroscopic resection products, and who subsequently underwent secondary hysterectomy. Cases of hysteroscopic appearance suggesting an endometrial carcinoma were excluded. Histopathological results of hysterectomy specimen determined the persistence or absence of AEH and the possible presence of coexisting endometrial carcinoma. RESULTS: Thirty-two patients were selected. Histopathological analysis of hysterectomy specimens diagnosed an absence of AEH in 24/32 (75%) subjects, an AEH residue in 6/32 (18.8%) subjects and a coexisting endometrial carcinoma in 2/32 (6.2%) subjects. CONCLUSION: The risk of missing an endometrial carcinoma in patients diagnosed with AEH based on total hysterocopic resection is low when there is no suspicious hysteroscopic aspect, but this risk cannot be entirely excluded. Total hysteroscopic resection may be a possible alternative to hysterectomy in patients with AEH who refuse hysterectomy or are a high surgical risk. These patients require a close and long term follow-up due to the risks of residual lesion.

Epidemiological, clinical, virological features of hepatitis B newly diagnosed in 2011 in Marseille University hospitals, southeastern France.

Hepatitis B virus (HBV) infection is a public health problem. In France, 0.68% of adults are chronically infected. We aimed to describe the epidemiological, virological and clinical characteristics of HBV infections newly diagnosed in 2011 in University hospitals of Marseille, the second largest French city. HBV serology was performed for 18,130 sera from 15,744 patients. A total of 167 patients were newly-diagnosed with HBV based upon the detection of hepatitis B surface antigen and anti-hepatitis B core antibodies. Clinico-epidemiological features were analyzed for 78 patients. Patients included a majority of men (59%), women being significantly younger with a mean age of 36 ± 17 versus 43.5 ± 16.2 years (P = 0.009). Country of birth was available for 52 patients and 35% of them originated from sub-Saharan Africa. Levels of the liver biological parameters were significantly lower in women compared to men, in whom mean alanine aminotransferase and gammaglutamyl transferase levels were 24 ± 39 versus 37 ± 36 IU/l (P = 0.0001) and 20 ± 20 versus 51 ± 53 IU/l (P = 0.0001), respectively. Co-infections with hepatitis C and human immunodeficiency viruses were found in 5% and 6% of the patients, respectively. HBV DNA was detectable in 90% of the HBeAg-negative patients. In addition, there was a positive correlation between the HBsAg titer and the HBV DNA level (P = 0.001). Genotype D was the most common HBV genotype and was found in 53% of the patients tested, followed by genotype E (21%). HBV remains a major concern with a slightly greater number of new diagnoses than in 2004. HBV genetic diversity was substantial in the present cohort.

Treatment failure following excision therapy of CIN: the impact of direct colposcopic vision during procedure.

PURPOSE: To assess whether the use of direct colposcopic vision during excision therapy of cervical intraepithelial neoplasia (CIN) has an impact on the risk of treatment failure. METHODS: Data from 285 patients who had had excision therapy with proven CIN at specimen histological analysis were reviewed. Primary endpoint was the occurrence of post-treatment failure defined by the histological diagnosis of CIN 2-3 during follow-up. Data were analysed according to the use of colposcopy at the time of initial therapy of CIN. RESULTS: The use of direct colposcopic vision (DCV) resulted in a significant reduction in the mean height (p = 0.008) and diameter (p < 0.001) of the excised specimen. Patients' median follow-up was 28.4 (±1.3) months. A total of 43 (15.2 %) patients were diagnosed with treatment failure. Compared to excisions performed without any use of colposcopy, DCV was not found to have any significant impact on the risk of treatment failure (HR: 0.58; 95 % CI 0.16-2.13, p = 0.412), neither when compared to excisions performed immediately after colposcopy (HR: 0.91; 95 % CI 0.47-1.79; p = 0.794). The only factors found to have a significant impact on the risk of treatment failure was the identification of clear margins (HR: 0.36; 95 %CI 0.19-0.69; p = 0.002) and the diameter of the surgical specimen (HR: 0.94; 95 %CI 0.89-0.99; p = 0.040). CONCLUSIONS: Although the use of DCV during excision therapy of CIN was associated with a significant reduction in the dimensions of the excised cervical specimen, it did not result in a significant change in the risk of treatment failure.

Intra- and interobserver agreement among obstetric experts in court regarding the review of abnormal fetal heart rate tracings and obstetrical management.

OBJECTIVE: The objective of the study was to evaluate the intra- and interobserver agreement among obstetric experts in court regarding the retrospective review of abnormal fetal heart rate tracings and obstetrical management of patients with abnormal fetal heart rate during labor. STUDY DESIGN: A total of 22 French obstetric experts in court reviewed 30 cases of term deliveries of singleton pregnancies diagnosed with at least 1 hour of abnormal fetal heart rate, including 10 cases with adverse neonatal outcome. The experts reviewed all cases twice within a 3-month interval, with the first review being blinded to neonatal outcome. For each case reviewed, the experts were provided with the obstetric data and copies of the complete fetal heart rate recording and the partogram. The experts were asked to classify the abnormal fetal heart rate tracing and to express whether they agreed with the obstetrical management performed. When they disagreed, the experts were asked whether they concluded that an error had been made and whether they considered the obstetrical management as the cause of cerebral palsy in children if any. RESULTS: Compared with blinded review, the experts were significantly more likely to agree with the obstetric management performed (P < .001) and with the mode of delivery (P < .001) when informed about the neonatal outcome and were less likely to conclude that an error had been made (P < .001) or to establish a link with potential cerebral palsy (P = .003). The experts' intraobserver agreement for the review of abnormal fetal heart rate tracing and obstetrical management were both mediocre (kappa = 0.46-0.51 and kappa = 0.48-0.53, respectively). The interobserver agreement for the review of abnormal fetal heart rate tracing was low and was not improved by knowledge of the neonatal outcome (kappa = 0.11-0.18). The interobserver agreement for the interpretation of obstetrical management was also low (kappa = 0.08-0.19) but appeared to be improved by knowledge of the neonatal outcome (kappa = 0.15-0.32). CONCLUSION: The intra- and interobserver agreement among obstetric experts in court for the review of abnormal fetal heart rate tracing and the appropriateness of obstetrical care is poor, suggesting a lack of objectivity of obstetrical expertise as currently performed in court.

Enhanced prevalence of plasmatic soluble MHC class I chain-related molecule in vascular pregnancy diseases.

The major histocompatibility complex class I related chain (MIC) is a stress-inducible protein modulating the function of immune natural killer (NK) cells, a major leukocyte subset involved in proper trophoblast invasion and spiral artery remodeling. Aim of the study was to evaluate whether upregulation of soluble MIC (sMIC) may reflect immune disorders associated to vascular pregnancy diseases (VPD). sMIC was more frequently detected in the plasma of women with a diagnostic of VPD (32%) than in normal term-matched pregnancies (1.6%, P < 0.0001), with highest prevalence in intrauterine fetal death (IUDF, 44%) and vascular intrauterine growth restriction (IUGR, 39%). sMIC levels were higher in preeclampsia (PE) than in IUFD (P < 0.01) and vascular IUGR (P < 0.05). sMIC detection was associated with bilateral early diastolic uterine notches (P = 0.037), thrombocytopenia (P = 0.03), and high proteinuria (P = 0.03) in PE and with the vascular etiology of IUGR (P = 0.0038). Incubation of sMIC-positive PE plasma resulted in downregulation of NKG2D expression and NK cell-mediated IFN-γ production in vitro. Our work thus suggests that detection of sMIC molecule in maternal plasma may constitute a hallmark of altered maternal immune functions that contributes to vascular disorders that complicate pregnancy, notably by impairing NK-cell mediated production of IFN-γ, an essential cytokine favoring vascular modeling.

Medical students as sexual health peer educators: who benefits more?

BACKGROUND: A prospective study was conducted to evaluate the impact of an educational reproductive health program on medical student peer educators and the secondary school pupils whom they taught. METHODS: The Marseille School of Medicine and ten public secondary schools participated in the study. Medical students were recruited and trained as peer educators to promote sexual health in the secondary schools. The medical students and secondary school pupils were evaluated before and after education program. The main outcome measure was the sexual health knowledge score on a 20-item questionnaire (maximum score 20). RESULTS: A total of 3350 students attended the peer-led course conducted by 107 medical students. The medical students' score increased significantly before and after the course (from 15.2 ± 1.8 to 18.3 ± 0.9; p < 0.001). The knowledge score of the pupils increased (from 7.8 ± 4 to 13.5 ± 4.4; p < 0.001). The girls' score was significantly higher than the boys' score after the course, but not before (14.5 ± 3.3 vs 12.5 ± 4.6; p < 0.001). Prior to the course, the score among the female medical students was significantly higher than that of the males. The overall knowledge increase was not significantly different between medical students and secondary school pupils (mean 3.1 ± 1 and 5.7 ± 4 respectively; p > 0.05). CONCLUSIONS: The program was effective in increasing the knowledge of medical students as well as secondary school pupils. Male sexual health knowledge should be reinforced.

Venous thromboembolism prophylaxis in patients undergoing abdominal or pelvic surgery for cancer--a real-world, prospective, observational French study: PRéOBS.

INTRODUCTION: Data on the epidemiology and prevention of venous thromboembolism in patients undergoing abdominal or pelvic cancer surgery in real practice are limited. The primary objective of this observational study was to describe the thromboprophylactic strategy implemented in routine practice. The main secondary objective was to assess the incidence of outcomes. MATERIALS AND METHODS: Patients admitted to public or private hospitals for abdominal or pelvic cancer surgery were included between November 2009 and November 2010; endoscopic route for surgery was the only exclusion criterion. Study outcomes were recorded at hospital discharge and at routine follow-up (generally 9±3weeks). RESULTS: 2380 patients (mean±SD age: 66.4±11.6years, women: 36.8%) admitted to hospital for abdominal (47.8%), urological (41%), or gynaecological (11.2%) cancer surgery were included in the analysis. Of these, 2179 had data available at study end. Perioperative antithrombotic prophylaxis, consisting mainly of low-molecular-weight heparin, was given to 99.5% of patients. At hospital discharge, thromboprophylaxis was continued in 91.7% of patients, 57.4% receiving a 4-6week prophylaxis. This management strategy was associated with an overall venous thromboembolic event rate of 1.9%, 34.7% of events occurring after discharge. Incidences of fatal bleeding, bleeding in a critical organ and bleeding necessitating re-intervention were 0.1%, 0.3% and 1.7%, respectively. Overall mortality was 1.5%. CONCLUSIONS: Thromboprophylaxis is routinely used in French patients undergoing major cancer surgery. For more than a third of patients, however, treatment duration did not comply with best-practice recommendations, which might explain the non-negligible rate of thromboembolic complications still observed in this patient population.

Direct colposcopic vision used with the LLETZ procedure for optimal treatment of CIN: results of joint cohort studies.

PURPOSE: To assess the value of direct colposcopic vision (DCV) for optimizing large loop excision of the transformation zone (LLETZ) for the treatment of cervical intraepithelial neoplasia (CIN). METHODS: Data from 648 patients who underwent excisional procedures for CIN and were included in two previously published cohort studies were retrospectively reviewed. Women who had a LLETZ were included for analysis (n = 436). Margin status, surgical specimen dimensions and volume were analysed according to the use of colposcopy during procedure. RESULTS: Compared to LLETZ guided by previous colposcopy report only, and to LLETZ performed immediately after colposcopy, DCV allowed for a significantly higher rate of clear margins: 33 (52.4 %), 104 (68.0 %) and 142 (84.5 %), respectively (p < 0.001). It also allowed for a significantly higher probability of achieving both negative margins and depth of specimen <10 mm: 10 (15.9 %) cases, 47 (30.7 %) cases and 125 (74.4 %) cases, respectively (p < 0.001). In multivariate analysis, when compared with the use of previous colposcopy report or with colposcopy immediately before the LLETZ, DCV allowed for a significantly higher probability of negative margins (AOR: 4.61; 95 % CI: 2.37-8.99 and AOR: 2.55; 95 % CI: 1.47-4.41), combined negative margins and depth <75th percentile (AOR: 3.67; 95 % CI: 1.97-6.86 and AOR: 3.05; 95 % CI: 1.91-4.87) and combined negative margins and volume <75th percentile (AOR: 12.96; 95 % CI: 5.99-28.05 and AOR: 6.16; 95 % CI: 3.75-10.14), respectively. CONCLUSIONS: When used with the LLETZ procedure, DCV allows for optimal outcomes in terms of negative resection margins, and minimized depth and volume of the excised specimen; and should therefore be recommended.

Prediction of fluid responsiveness in severe preeclamptic patients with oliguria.

PURPOSE: Because severe preeclampsia (SP) may be associated with acute pulmonary oedema, fluid responsiveness needs to be accurately predicted. Passive leg raising (PLR) predicts fluid responsiveness. PLR has never been reported during pregnancy. Our first aim was to determine the percentage of SP patients with oliguria increasing their stroke volume after fluid challenge. Our second aim was to assess the accuracy of PLR to predict fluid responsiveness in those patients. METHODS: Patients with SP were prospectively included in the study. In the subgroup developing oliguria, transthoracic echocardiography was performed at baseline, during PLR and after a 500 ml fluid infusion over 15 min. Fluid responders were defined by a 15 % increase of stroke volume index. Five consecutive measurements were averaged for all parameters. RESULTS: Twenty-three (56 %) out of 41 patients with SP developed oliguria, 12 (52 %) out of these 23 responded to fluid challenge. During PLR, an increase of the velocity time integral of subaortic blood flow (ΔVTI) above 12 % predicted the response with a sensitivity and specificity of 75 [95 % confident interval (CI): 0.42-0.95] and 100 % (95 % CI: 0.72-1.00), respectively. An algorithm combining ΔVTI and the baseline value of VTI predicted fluid responsiveness with a sensitivity and specificity of 100 % (95 % CI: 0.74-1.00) and (95 % CI: 0.75-1.00). Urine output and respiratory variations of inferior vena cava diameter did not predict fluid responsiveness. CONCLUSIONS: Only 52 % of oliguric patients were responders. PLR accurately predicts fluid responsiveness in the specific setting of SP. This noninvasive test should be tested in future algorithms for the management of SP.

Failed early medical abortion: beware of the uterine scar!--Case report.

OBJECTIVES: To increase awareness of the possible existence of a morbidly adherent placenta in case of failed early medical abortion. CASE: We report a case of placenta increta which caused a massive haemorrhage during surgical aspiration following a failed medical abortion. CONCLUSION: Women with a history of caesarean section, who do not respond to a medical regimen for early termination of pregnancy should undergo an ultrasound examination to establish whether this may be due to a placenta accreta, increta or percreta.