Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynaecologists and Obstetricians (CNGOF)

OBJECTIVE

To provide French guidelines for the management of women with abnormal uterine bleeding (AUB).

DESIGN

A consensus committee of 26 experts was formed. A formal conflict-of-interest policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding (i.e. pharmaceutical or medical device companies). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The last guidelines from the Collège National des Gynécologues et Obstétriciens Français on the management of women with AUB were published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescents; idiopathic AUB; endometrial hyperplasia and polyps; type 0-2 fibroids; type 3 or higher fibroids; and adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and evidence profiles were compiled. The GRADE® methodology was applied to the literature review and the formulation of recommendations.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 are strong and 17 weak. No response was found in the literature for 14 questions. We chose to abstain from recommendations rather than providing advice based solely on expert clinical experience.

CONCLUSIONS

The 36 recommendations make it possible to specify the diagnostic and therapeutic strategies for various clinical situations practitioners encounter, from the simplest to the most complex.

Combined Chemical and Ecotoxicological Measurements for River Sediment Management in an On-Land Deposit Scenario

Sediment management along engineered river systems includes dredging operations and sediment deposition in the sea (capping) or on land. Thus, determining the ecotoxicological risk gradient associated with river sediments is critical. In this study, we investigated sediment samples along the Rhône River (France) and conducted environmental risk assessment tests with the idea to evaluate them in the future for deposit on soil. Based on an on-land deposit scenario, the capacity of the sediment samples from four sites (LDB, BER, GEC, and TRS) to support vegetation was evaluated by characterising the physical and chemical parameters (pH, conductivity, total organic carbon, grain size, C/N, potassium, nitrogen, and selected pollutants), including polychlorinated biphenyls (PCBs) and metal trace elements. All tested sediments were contaminated by metallic elements and PCBs as follows: LDB > GEC > TRS > BER, but only LDB had levels higher than the French regulatory threshold S1. Sediment ecotoxicity was then assessed using acute (plant germination and earthworm avoidance) and chronic (ostracod test and earthworm reproduction) bioassays. Two of the tested plant species, Lolium perenne (ray grass) and Cucurbita pepo (zucchini), were highly sensitive to sediment phytotoxicity. Acute tests also showed significant inhibition of germination and root growth, with avoidance by Eisenia fetida at the least contaminated sites (TRS and BER). Chronic bioassays revealed that LDB and TRS sediment were significantly toxic to E. fetida and Heterocypris incongruens (Ostracoda), and GEC sediment was toxic for the latter organism. In this on-land and spatialised deposit scenario, river sediment from the LDB site (Lake Bourget marina) presented the highest potential toxicity and required the greatest attention. However, low contamination levels can also lead to potential toxicity (as demonstrated for GEC and TRS site), underlining the importance of a multiple test approach for this scenario.

[Women with a very high risk of breast cancer: contraceptives, hormonal replacement therapy use and personalized screening]

Women with a high family risk of breast cancer are those with an identified genetic predisposition or those who have a suggestive family history without an identified germinal mutation, particularly for BRCA1 and BRCA2. Among these women with a very high risk of breast cancer, the fear of a potentially increased risk of breast cancer linked to some hormonal contraceptives and to the use of hormone replacement therapy, in connection with the general population data collected in literature, has led to certain reluctance to prescribe them to these women. Moreover, confusion often sets due to poor knowledge of the literature. Furthermore, the monitoring procedures consist of breast screening and strategies of risk reduction, based on recent recommendations. In order to improve the gynaecological monitoring throughout their lives, we offer here a review based on an analysis of recent literature and of the recommendations concerning personalized screening, contraception and hormone replacement therapy among women with a very high risk of breast cancer free from this illness.

Management of postmenopausal women: Collège National des Gynécologues et Obstétriciens Français (CNGOF) and Groupe d'Etude sur la Ménopause et le Vieillissement (GEMVi) Clinical Practice Guidelines

AIM

The aim of these recommendations is to set forth an individualized approach to the management of early postmenopausal women (i.e., within the first 10 years after natural menopause) covering all aspects of lifestyle and therapeutic management, with or without menopause hormone therapy (MHT).

MATERIALS AND METHODS

Literature review and consensus of French expert opinion. Recommendations were graded according to the HAS methodology and levels of evidence derived from the international literature, except when there was no good-quality evidence.

SUMMARY RECOMMENDATIONS

The beginning of menopause is an ideal time for each woman to evaluate her health status by assessing her bone, cardiovascular, and cancer-related risk factors that may be amplified by postmenopausal estrogen deficiency and by reviewing her lifestyle habits. Improving lifestyle, including nutrition and physical activity, and avoiding risk factors (notably smoking), should be recommended to all women. MHT remains the most effective treatment for vasomotor symptoms but it could be also recommended as first-line treatment for the prevention of osteoporosis in early postmenopausal women at low to moderate risk for fracture. The risks of MHT differ depending on its type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. There is reasonable evidence that using transdermal estradiol in association with micronized progesterone or dydrogesterone may limit both the venous thromboembolic risk associated with oral estrogens and the risk of breast cancer associated with synthetic progestins. Treatment should be individualized to each woman, by using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of its benefit-risk balance. For bothersome genitourinary syndrome of menopause (GSM) symptoms, vaginal treatment with lubricants and moisturizers is recommended as first-line treatment together with low-dose vaginal estrogen therapy, depending on the clinical course. No recommendation of an optimal duration of MHT can be made, but it must take into consideration the initial indication for MHT as well as each woman's benefit-risk balance. Management of gynecological side-effects of MHT is also examined. These recommendations are endorsed by the Groupe d'Etude sur la Ménopause et le Vieillissement hormonal (GEMVI) and the Collège National des Gynécologues-Obstétriciens Français (CNGOF).

[Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynecologists and Obstetricians (CNGOF)]

OBJECTIVE

To provide French guidelines for the management of women with abnormal uterine bleeding (AUB).

DESIGN

A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, or medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The last guidelines from the Collège national des gynécologues et obstétriciens français (CNGOF) on the management of women with AUB was published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescent; idiopathic AUB; endometrial hyperplasia and polyps; fibroids type 0 to 2; fibroids type 3 and more; adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 present a strong agreement and 17 a weak agreement. Fourteen questions did not find any response in the literature. We preferred to abstain from recommending instead of providing expert advice.

CONCLUSIONS

The 36 recommendations made it possible to specify the diagnostic and therapeutic strategies of various clinical situations managed by the practitioner, from the simplest to the most complex.

Quality of life of patients with bilateral oophorectomy before the age of 45 for the treatment of endometriosis

INTRODUCTION

The study aimed to evaluate the quality of life and associated factors among women who underwent bilateral oophorectomy (BO) before the age of 45 for the treatment of deep infiltrating endometriosis (DIE).

MATERIALS AND METHODS

This cross-sectional study was carried out in 52 women who were treated from January 2014 to December 2019 in 2 public and private DIE surgical centers in Toulouse. All women answered the Menopausal Quality of Life questionnaire (MenQOL). Mean MenQOL scores were compared according to age at BO, smoking, BMI, level of education, delay between BO and the survey and post-BO hormone replacement therapy (HRT) using Mann-Whitney and Anova tests. Spearman's correlation coefficient was used to analyze the correlations between all the MEnQOL domain scores and clinical variables. The variables associated with the outcomes in univariate analyses with p < 0.2 were jointly evaluated using multiple linear regression.

RESULTS

The mean age at the time of the survey was 43.4 ± 3.4 years while the mean age at BO was 40.5 ± 3.4 years. The mean MenQOL score was 3.96 (± 1.45), with the highest scores in the sexual (4.77) and vasomotor (4.01) domains. BMI and smoking were independently and significantly associated with the mean total MenQOL score, all domain scores being significantly higher in overweight/obese women. A trend towards worse MenQOL scores was found in patients who had BO before the age of 41. We did not find any difference according to whether or not they were taking HRT.

CONCLUSION

This is a first study evaluating quality of life in a specific population of oophorectomized women under the age of 45 using MenQOL for DIE. While BO is effective in relieving pain in women with severe DIE, the induced premature menopause is associated with a poor quality of life, which deserves further attention.

Ecotoxicological risk assessment of contaminants of emerging concern identified by "suspect screening" from urban wastewater treatment plant effluents at a territorial scale

Urban wastewater treatment plants (WWTP) are a major vector of highly ecotoxic contaminants of emerging concern (CECs) for urban and sub-urban streams. Ecotoxicological risk assessments (ERAs) provide essential information to public environmental authorities. Nevertheless, ERAs are mainly performed at very local scale (one or few WWTPs) and on pre-selected list of CECs. To cope with these limits, the present study aims to develop a territorial-scale ERA on CECs previously identified by a "suspect screening" analytical approach (LC-QToF-MS) and quantified in the effluents of 10 WWTPs of a highly urbanized territory during three periods of the year. Among CECs, this work focused on pharmaceutical residue and pesticides. ERA was conducted following two complementary methods: (1) a single substance approach, based on the calculation for each CEC of risk quotients (RQs) by the ratio of Predicted Environmental Concentration (PEC) and Predicted No Effect Concentration (PNEC), and (2) mixture risk assessment ("cocktail effect") based on a concentration addition model (CA), summing individual RQs. Chemical results led to an ERA for 41 CEC (37 pharmaceuticals and 4 pesticides) detected in treated effluents. Single substance ERA identified 19 CECs implicated in at least one significant risk for streams, with significant risks for DEET, diclofenac, lidocaine, atenolol, terbutryn, atorvastatin, methocarbamol, and venlafaxine (RQs reaching 39.84, 62.10, 125.58, 179.11, 348.24, 509.27, 1509.71 and 3097.37, respectively). Mixture ERA allowed the identification of a risk (RQmix > 1) for 9 of the 10 WWTPs studied. It was also remarked that CECs leading individually to a negligible risk could imply a significant risk in a mixture. Finally, the territorial ERA showed a diversity of risk situations, with the highest concerns for 3 WWTPs: the 2 biggest of the territory discharging into a large French river, the Rhône, and for the smallest WWTP that releases into a small intermittent stream.

[Menopause, menopause hormone therapy and osteoporosis. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]

Postmenopausal osteoporosis is a frequent clinical condition, which affects nearly 1 in 3 women. Estrogen deficiency leads to rapid bone loss, which is maximal within the first years after the menopause transition and can be prevented by menopause hormone therapy (MHT). Assessment of the individual risk of osteoporosis is primarily based on the measurement of bone mineral density (BMD) at the spine and femur by DXA. Clinical risk factors (CRFs) for fractures taken either alone or in combination in the FRAX score were shown not to reliably predict fractures and/or osteoporosis (as defined by a T-score<-2.5) in early postmenopausal women. If DXA measurement is indicated in all women with CRFs for fractures, it can be proposed on a case-by-case basis, when knowledge of BMD is likely to condition the management of women at the beginning of menopause, particularly the benefit-risk balance of MHT. MHT prevents both bone loss and degradation of the bone microarchitecture in early menopause. It significantly reduces the risk of fracture at all bone sites by 20 to 40% regardless of basal level of risk with an estrogen-dependent dose-effect. Given the inter-individual variability in bone response, individual monitoring of the bone effect of MHT is warranted when prescribed for the prevention of osteoporosis. This monitoring is based on repeated measurement of lumbar and femoral BMD (on the same DXA measurement system) after 2years of MHT, the response criterion being no significant bone loss. Discontinuation of treatment is associated with a resumption of transient bone loss although there is a large variability in the rate of bone loss among women. Basically, there is a return to the level of fracture risk comparable to that of in untreated woman of the same age within 2 to 5years. Therefore, when MHT is prescribed for the prevention of osteoporosis in women with an increased risk at the beginning of menopause, measurement of BMD is recommended when MHT is stopped in order to consider further management of the risk of fracture whenever necessary (with possibly another anti-osteoporotic treatment).

[Menopause hormone treatment in practice. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]

Menopause Hormonal Treatment (MHT) was initially developed to correct the climacteric symptoms induced by postmenopausal estrogen deficiency. In non-hysterectomized women, MHT combines estrogens and a progestogen, the latter opposing the negative impact of estrogen on endometrial proliferation. In France, and contrary to the USA and Northern European countries, MHT mainly combines 17β-estradiol, which is the physiological estrogen produced by the ovary, and progesterone or its derivative, dihydrogesterone. France has been a pioneer in the development of cutaneous administration routes (gel or transdermal patch) for estradiol, allowing better metabolic tolerance and a reduction of the risk of venous thromboembolism compared to the oral route. The choice of the doses as well as the treatment regimen is underpinned by tolerance as well as acceptance and compliance. The risk of breast cancer, which is one of the main risks of MHT, is higher with estro-progestogen combinations than with estrogens alone ; the preferential use of progesterone or dihydrogesterone being likely to limit the excess risk of breast cancer associated with MHT at least for duration of treatment of less than 5 to 7 years. The question of the optimal duration of MHT remains an issue and must take into account the initial indication of treatment as well as the benefit-risk balance, which is specific to each woman. Continuation of MHT is conditioned by the benefit-risk balance, which must be evaluated regularly, but also by the evolution of symptoms when MHT is stopped as well as menopause-related health risks or induced by MHT. After stopping MHT, it is necessary to maintain a medical follow-up to be adapted to the clinical situation of each woman and in particular, her cardiovascular and gynecological risk factors.

Metal pollution trajectories and mixture risk assessed by combining dated cores and subsurface sediments along a major European river (Rhône River, France)

In European rivers, research and monitoring programmes have targeted metal pollution from bed and floodplain sediments since the mid-20^th century by using various sampling and analysis protocols. We propose to characterise metal contamination trajectories since the 1960s based on the joint use of a large amount of data from dated cores and subsurface sediments along the Rhône River (ca. 512 km, Switzerland-France). For the reconstruction of spatio-temporal trends, enrichment factors (EF) and geo-accumulation (Igeo) approaches were compared. The latter index was preferred due to the recurrent lack of grain-size and lithogenic elements in the dataset. Local geochemical backgrounds were established near (1) the Subalps and (2) the Massif Central to consider the geological variability of the watershed. A high contamination (Igeo = 3-5) was found for Cd, Cu and Zn from upstream to downstream over the period 1980-2000. This pattern is consistent with long-term emissions from major cities and the nearby industrial areas of the Upper Rhône (Geneva, Arve Valley), and Middle Rhône (Lyon, Chemical Corridor, Gier Valley). Hotspots due to Cu and Zn leaching from vineyards, mining, and highway runoff were also identified, while Pb was especially driven by industrial sources. The recovery time of pollution in sediment varied according to the metals and was shorter upstream of Lyon (15-20 years) than downstream (30-40 years). More widely, it was faster on the Rhône than along other European rivers (e.g. Seine and Rhine). Finally, the ecotoxicological mixture risk of metal with Persistent Organic Pollutants (POPs) for sediment-dwelling organisms showed a medium "cocktail risk" dominated by metals upstream of Lyon, although it is enhanced due to POPs downstream, and southward to the delta and the Mediterranean Sea. Overall, this study demonstrates the heterogeneity of the contamination trends along large fluvial corridors such as the Rhône River.

[Regional state-of-the-art of the access to oncofertility consultation for young women with breast cancer]

OBJECTIVES

According to the 2004 Bioethics Act, oncofertility counselling must be systematically offered to all women of childbearing age before they are exposed to potentially gonadotoxic treatment. The main objective of this study was to evaluate the proportion of women under 40 years of age treated with chemotherapy for breast cancer in Midi-Pyrénées who have received an oncofertility consultation. A secondary objective was to assess practitioners' knowledge on the subject.

METHODS

A cross-reference was made between the databases of the oncology network in Midi-Pyrénées and the two approved centres for the preservation of fertility in the region. A computerized practitioner questionnaire was sent to all surgeons and oncologists who could manage these patients.

RESULTS

From 2012 and 2017, 667 women aged≤40 years received (neo)adjuvant chemotherapy treatment: only 156 (23.4%) had access to an oncofertility consultation and 58 (8.7%) received preservation. This rate (23.4%) varied according to the age of the patients, ranging from 56.9% for those aged 25-29 to 13.4% for those aged 35-39 and the managing institution. Of the 85 practitioners surveyed, 45 (55%) responded to the questionnaire, and of these 20 (44%) knew that ovarian stimulation treatment could be used even in hormone-dependent breast cancer situations and 13 (29%) of practitioners believed that the time required to preserve fertility was more than 1 month.

CONCLUSION

Our study revealed a significant disparity in access to oncofertility consultation. It is essential to set up information and awareness-raising actions on the subject.

Microalgal whole-cell biomarkers as sensitive tools for fast toxicity and pollution monitoring of urban wet weather discharges

Urban wet weather discharge (UWWD) management is an important issue. UWWD often represents a significant source of pollution in all aquatic bodies. The occurrence of this pollution is difficult to predict due to the variability of storm events and the unknown contents of urban watershed leached out by rain. Previous studies have tried to demonstrate the ecotoxic impact of UWWD. However, most of them merely highlight the limitations of classic monospecific bioassays, given the high dilution of micropollutants or the presence of nutrients masking toxic effects. Overcoming this problem is therefore of great interest. In this study, we demonstrated the utility of a battery of biomarkers (e.g. membrane permeability, chlorophyll fluorescence, esterase and alkaline phosphatase activities) on the microalgae Chlorella vulgaris to detect the toxic effects of 7 UWWD samples after short exposures (2 and 24 h). These biomarkers are linked to microalgal life traits. Complementarily, monospecific bioassays were carried on Pseudokirchneriella subcapitata, Chlorella vulgaris, Daphnia magna and Heterocypris incongruens to compare their sensitivity to the UWWD samples. No toxic effect was detected in any of the bioassays. Yet, algal biomarkers indicated a disturbance in microalgae physiology, and particularly a perturbation of chlorophyll fluorescence, which was observed in all of the samples tested. While algal membrane permeability was affected by only one UWWD, these two enzymatic activities were stimulated or inhibited depending on the sample. Finally, this study demonstrates the sensitivity of algal biomarkers and the need to develop new, fruitful approaches to characterizing UWWD toxicity.

Assessment of long term ecotoxicity of urban stormwaters using a multigenerational bioassay on Ceriodaphnia dubia: A preliminary study

Standardized ecotoxicity bioassays show some limits to assess properly long-term residual toxicity of complex mixture of pollutants often present at low concentration, such as stormwaters. Among invertebrate organisms used for ecotoxicity testing, the microcrustacean Ceriodaphnia dubia (C. dubia) is considered as one of the most sensitive, especially regarding reproduction impairment as a toxicity endpoint. Consequently, this work explores the interest to perform a multigenerational assay based on the study of the reproduction of C. dubia to assess long-term ecotoxicity of complex mixture, using stormwater samples. With this in mind, a battery of standardized bioassays (Daphnia magna mobility, Pseudokirchneriella subcapitata population growth, Heterocypris incongruens growth and one generation C. dubia reproduction inhibition assays) was performed in parallel to a three generation C. dubia reproduction inhibition assay on 2 stormwater samples. Results highlighted that while all standardized bioassays failed to reveal residual toxicity in the stormwater samples, the C. dubia multigenerational assay exhibited an higher sensitivity than the previous ones. No adverse effect was observed for the first exposed generation, but an increase in mortality and a reproduction disturbance was obtained in the second and third exposed generation depending of the sample. Further experiments are now needed to optimize the exposure protocol of this multigenerational assay.

A chemically-responsive bis-acridinium receptor

The recognition and the chemical-response properties of a bis-acridinium triphenylene receptor were investigated.

Identification and assessment of ecotoxicological hazards attributable to pollutants in urban wet weather discharges

Urbanization has led to considerable pressure on urban/suburban aquatic ecosystems. Urban Wet Weather Discharges (UWWD) during rainfall events are a major source of pollutants leached onto and into urban surfaces and sewers, which in turn affect aquatic ecosystems. We assessed the ecotoxicity of the different compounds identified in UWWD and identified the hazard represented by each of them. To this end, hazard quotient (HQ) values were calculated for each compound detected in UWWD based on their predicted no effect concentration (PNEC) values and their maximum measured effluent concentrations (MEC_max) found in the dissolved part of UWWD. For the 207 compounds identified in UWWD, sufficient data existed for 165 of them to calculate their PNEC. The ecotoxicity of these compounds varied greatly. Pesticides represented a high proportion of the wide variety of hazardous compounds whose HQ values were calculated (94 HQ values), and they were among the most hazardous pollutants (HQ > 1000) transported by stormwater. The hazard of combined sewer overflows (CSO) was linked mainly to heavy metals and pharmaceutical compounds. Consequently, the monitoring of these pollutants should be a priority in the future. The hazard level of certain pollutants could have been underestimated due to their adsorption onto particles, leading to their low concentration in the dissolved phase of UWWD. Hence, an in-depth study of these pollutants will be required to clarify their effects on aquatic organisms.

Proposal to optimize ecotoxicological evaluation of wastewater treated by conventional biological and ozonation processes

A mixture of urban and hospital effluents (50% v/v) was evaluated for ecotoxicity with an advanced bioassay battery. Mixed effluents were tested before any treatment, after biological treatment alone, and after biological treatment followed by a tertiary ozonation (15 mg O3/L). Laying a high value on the continuance of organisms' fitness, essential to preserve a healthy receiving ecosystem, the main objective of this study was to combine normalized bioassays with newly developed in vivo and in vitro tests in order to assess alteration of embryo development, growth and reproduction, as well as genotoxic effects in aquatic organisms exposed to complex wastewater effluents. Comparison of the bioassays sensitivity was considered. Contrary to the lack of toxicity observed with normalized ecotoxicity tests, endpoints measured on zebrafish embryos such as developmental abnormalities and genotoxicity demonstrated a residual toxicity in wastewater both after a biological treatment followed or not by a tertiary O3 treatment. However, the ozonation step allowed to alleviate the residual endocrine disrupting potential measure in the biologically treated effluent. This study shows that normalized bioassays are not sensitive enough for the ecotoxicological evaluation of wastewaters and that there is a great need for the development of suitable sensitive bioassays in order to characterize properly the possible residual toxicity of treated effluents.

Methods for evaluating the pollution impact of urban wet weather discharges on biocenosis: A review

Rainwater becomes loaded with a large number of pollutants when in contact with the atmosphere and urban surfaces. These pollutants (such as metals, pesticides, PAHs, PCBs) reduce the quality of water bodies. As it is now acknowledged that physico-chemical analyses alone are insufficient for identifying an ecological impact, these analyses are frequently completed or replaced by impact studies communities living in freshwater ecosystems (requiring biological indices), ecotoxicological studies, etc. Thus, different monitoring strategies have been developed over recent decades aimed at evaluating the impact of the pollution brought by urban wet weather discharges on the biocenosis of receiving aquatic ecosystems. The purpose of this review is to establish a synthetic and critical view of these different methods used, to define their advantages and disadvantages, and to provide recommendations for futures researches. Although studies on aquatic communities are used efficiently, notably on benthic macroinvertebrates, they are difficult to interpret. In addition, despite the fact that certain bioassays lack representativeness, the literature at present appears meagre regarding ecotoxicological studies conducted in situ. However, new tools for studying urban wet weather discharges have emerged, namely biosensors. The advantages of biosensors are that they allow monitoring the impact of discharges in situ and continuously. However, only one study on this subject has been identified so far, making it necessary to perform further research in this direction.

[Cognition disorders and parkinsonian syndrome: diffuse Lewy body disease?]

A 68 year old man developed progressive cognitive impairment with an akinetic-rigid syndrome which was atypically responsive to levodopa. The patient died after 18 months and the postmortem examination showed typical Lewy bodies in the substantia nigra and pale bodies in the cortex which were unlabelled by ubiquitin antibodies. This case is particular by the neuropathological examination (no immunoreactivity to antibodies against ubiquitin) and by the abnormal response to treatment (dystonia). These two aspects are discussed.

Kufs' disease presenting as progressive dementia with late-onset generalized seizures: a clinicopathological and electrophysiological study

A 32-year-old woman presented with increasing motor difficulties and memory disturbances. Neurological examination only showed mild cerebellar and extrapyramidal symptoms, whereas neuropsychological evaluation disclosed severe cognitive changes consistent with dementia. Her motor and mental status progressively deteriorated until death, which occurred 5 years after the first admission. One year before death, while she was almost bedridden, symptoms of myoclonic epilepsy first appeared, with frequent generalized seizures and generalized myoclonus, occurring especially upon sensory stimulation or passive joint movements. Pathological examination showed neuronal inclusions typical of Kufs' disease. This case, with primary progressive dementia and late-onset myoclonic epilepsy, differs from previously reported cases. Three special electrophysiological features were abnormal, "giant", evoked potentials; unusually marked photosensitivity; and seizure induction by any sensory stimulation.

[Tardive spino-cerebellar degeneration with amyotrophia, complicating a severe case of pallido-luysian degeneration and diffuse histological lesions of senility. (Anatomo-clinical study of a case with nosographic discussion)]

Anatomo-clinical findings are reported in a case of central nervous system degeneration which began at age 47 and progressed over a three year period. Information obtained prior to the patient's death suggested probable spinocerebellar degeneration with amyotrophies. Postmortem anatomical examination confirmed this diagnosis but also revealed the existence of unsuspected lesions. These clinically non-manifested lesions involved severe pallido-luysian degeneration as well as numerous and diffuse senile plaques. The nosological implications of this case are discussed.