[Delays and pathways for patients with endometriosis in France: A multicenter study]

INTRODUCTION

The diagnosis of endometriosis is often difficult to make, generating a median diagnostic delay ranging from 2 to 10.7years. A study of the care pathway of these patients seems essential in order to evaluate the diagnostic delay of endometriosis in France and the factors related to the diagnostic delay.

METHODS

This is a prospective multicenter study, conducted between 2017 and 2019. A questionnaire concerning their care pathway and their feelings about the diagnosis was distributed to all patients consulting for endometriosis. Statistical analyses were performed using the Kruskal-Wallis, Chi² and Student's t tests.

RESULTS

Fifity-seven of the 84 patients (67.8%) who completed the questionnaire were included in the evaluation of diagnostic delays. The total diagnostic delay was 12years (min 0; max 33) and was comparable between all inclusion cities (P=0.68). Regarding the care pathway according to specialties, the diagnosis of endometriosis was made by gynecologists in 81% of patients versus 19% by general practitioners. The time between the onset of symptoms and the first consultation was significantly shorter in favor of the general practitioner (2years versus 4years, P=0.012). 60% of the patients reported that their symptoms were labelled as "normal" by the physicians and 35% of them considered them normal themselves.

CONCLUSION

Our study showed that the delay in diagnosis in France was still very long and that the mechanisms of the delay in management were multifactorial. Awareness raising and training of health care providers remains one of the major areas to be optimized.

[Ambulatory minimally invasive hysterectomy: Limiting factors related to health professionals]

OBJECTIVES

The feasibility of minimally invasive hysterectomy for ambulatory benign pathology has been demonstrated in many international studies. France has a considerable delay of multifactorial origin in this field. The objective of this study is to identify the limiting factors related to health professionals to the realization of minimally invasive ambulatory hysterectomy and to determine possible strategies to increase its rate.

METHODS

This is a cross-sectional survey conducted over 2 months using a self-administered questionnaire sent by email to 180 gynecological surgeons in 2 French regions (Grand Est and Bourgogne-Franche Comté).

RESULTS

A total of 22% of health professionals responded to the survey. The vast majority of practitioners (60%) said they did not carry out ambulatory care by habit. The apprehension of the reaction of the patients (47.5%), the fear of delayed diagnosis of complications (12.5%), the management of pain in the postoperative period (42.5%) also participated in brake of the promotion of ambulatory care.

DISCUSSION

Improvement of the organisation of city and hospital management allowing a better continuity of care (70%), the economic valuation (37.5%) and the increase in the hourly amplitude of the ambulatory surgery unit (5%) would improve the rate of ambulatory care of minimally invasive hysterectomies, according to the gynecologist surgeons surveyed. In addition, a prospective study evaluating the quality of life of patients after ambulatory care of minimally invasive hysterectomy would allow better adherence of health professionals and patients to the ambulatory care project in 70% of cases.

CONCLUSION

The change of mentality of health professionals remains a priority for the promotion of ambulatory surgery in gynecology. Information and communication are therefore essential to the expansion of the ambulatory.

[Specific clinical signs suggestive of endometriosis (excluding adenomyosis) and questionnaires of symptoms, pain and quality of life: CNGOF-HAS Endometriosis Guidelines]

In case of consultation for chronic pelvic pain or suspicion of endometriosis, it is recommended to evaluate the pain (intensity, resonance) and to search out the evocative and localizing symptoms of endometriosis (Grade B). The main symptoms suggestive of endometriosis are: severe dysmenorrhea (NP2), deep dyspareunia (NP2), painful defecation during menstruation (NP2), urinary tract symptoms during menstruation (NP2) and infertility (NP2). In patients with chronic pelvic pain, it is recommended to search deep infiltrating endometriosis in patients with painful defecation during menstruation or severe deep dyspareunia (Grade B). It is recommended to search symptoms suggestive of sensitization in painful patients with endometriosis (Grade B). When suggestive symptoms of endometriosis are present, a directed gynecological examination is recommended, where possible, including examination of the posterior vaginal cul-de-sac (Grade C). In assessing pain intensity or evaluating analgesic effectiveness of a treatment, it is recommended to use a scale to measure the intensity of pain (Grade A). In the management of symptomatic endometriosis, it is recommended to evaluate the quality of life (Grade C).

Measuring health-related quality of life in women with endometriosis: comparing the clinimetric properties of the Endometriosis Health Profile-5 (EHP-5) and the EuroQol-5D (EQ-5D)

STUDY QUESTION

Which of the Endometriosis Health Profile-5 (EHP-5) and the EuroQol-5D (EQ-5D) is the most efficient to assess quality of life in women suffering from endometriosis?

SUMMARY ANSWER

Although EHP-5 and EQ-5D instruments had an excellent responsiveness, EHP-5 has a better discriminative ability than EQ-5 to measure health-related quality of life (HrQoL).

WHAT IS KNOWN ALREADY

Proper measurement of HrQoL is important in endometriosis. While many quality of life instruments are available, few have been completely validated in endometriosis. The EHP-5 and the EQ-5D are short and practical scales, which may be useful. Literature is lacking to determine which one is the most suitable in clinical practice or in clinical research.

STUDY DESIGN, SIZE, DURATION

This prospective and observational study conducted between 1 January 2012 and 31 December 2013 included a total of 253 consecutive women with proven endometriosis, undergoing medical or surgical treatment, in 2 French tertiary care centers.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

Women over 18 years consulting for painful symptoms of at least 3 months' duration or for infertility, with endometriosis proven histologically or radiologically, were requested to fill in the 2 scales before (T0) and 12 months after treatment (T1). Construct validity consisted in testing presupposed relationships between the scales and the characteristics of the patients or the endometriosis. Responsiveness to change was calculated for all patients and in each treatment group. Effect sizes were used according to Cohen's d method.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 216 women filled in completely all the questionnaires at T0 and 133 (61.6%) at T1. EHP-5 and EQ-5D had good discriminative abilities regarding the patients' symptoms, with significant superiority of EHP-5 concerning three of the nine hypotheses. The largest difference was that calculated for the 'intensity of dysmenorrhea' using the Visual Analogic Scale, with respectively effect size from Cohen's d (ES) = 0.86 95% CI (0.54-1.17) for EHP-5 versus 0.48 95% CI (0.16-0.79) for EQ-5D. There were no differences in EHP-5 or in EQ-5D scores between subgroups according to the characteristics of endometriosis. Overall responsiveness was excellent and equivalent for EHP-5 and for EQ-5D, with, respectively, ES = 0.81 95% CI (0.56-1.56) versus ES = 0.95 95% CI (0.68-1.20). In subgroup analyses, EHP-5 was responsive in case of medical treatment with ES = 0.93 95% CI (0.07-1.70), whereas EQ-5D was not, ES = 0.73 95% CI (-0.06-1.47).

LIMITATIONS, REASONS FOR CAUTION

Our study population included patients with symptomatic and mainly severe forms of endometriosis, which may suggest a spectrum bias. The evaluation of responsiveness in case of medical treatment was based on a small number of patients, which limits the interpretation of the difference found between the two scales in this subgroup.

WIDER IMPLICATIONS OF THE FINDINGS

EHP-5 is a simple, efficient and valid tool for evaluating quality of life in daily practice and also valuable to provide a primary outcome in clinical studies evaluating treatment efficacy.

STUDY FUNDING/COMPETING INTEREST(S)

This work was funded by the Direction à la Recherche Clinique et à l'Innovation of Versailles, France. The authors have no conflicts of interest.

TRIAL REGISTER NUMBER

None.

A programmable platform for sub-second multichemical dynamic stimulation and neuronal functional imaging in C. elegans

Caenorhabditis elegans (C. elegans) is a prominent model organism in neuroscience, as its small stereotyped nervous system offers unique advantages for studying neuronal circuits at the cellular level. Characterizing temporal dynamics of neuronal circuits is essential to fully understand neuronal processing. Characterization of the temporal dynamics of chemosensory circuits requires a precise and fast method to deliver multiple stimuli and monitor the animal's neuronal activity. Microfluidic platforms have been developed that offer an improved control of chemical delivery compared to manual methods. However, stimulating an animal with multiple chemicals at high speed is still difficult. In this work, we have developed a platform that can deliver any sequence of multiple chemical reagents, at sub-second resolution and without cross-contamination. We designed a network of chemical selectors wherein the chemical selected for stimulation is determined by the set of pressures applied to the chemical reservoirs. Modulation of inlet pressures has been automated to create robust, programmable sequences of subsecond chemical pulses. We showed that stimulation with sequences of different chemicals at the second to sub-second range can generate different neuronal activity patterns in chemosensory neurons; we observed previously unseen neuronal responses to a controlled chemical stimulation. Because of the speed and versatility of stimulus generated, this platform opens new possibilities to investigate neuronal circuits.

Droplet array for screening acute behaviour response to chemicals in Caenorhabditis elegans

Caenorhabditis elegans is an excellent model organism for studying chemosensation as a significant part of its nervous system and genome are devoted to the detection of chemical cues. Studies of decision-making, learning, mating behaviour, and intraspecies communication require measuring the acute behavioural response to chemical stimulation. Such assays require precise and repeatable chemical delivery and are often arduous when performed manually. Microfluidic platforms have been developed for chemosensation studies in C. elegans. However, these platforms lack temporal resolution in chemical delivery necessary for screening acute behaviour and cannot selectively recover animals, a necessary feature for genetic screens. Here we present a droplet array for screening acute behavioural responses of C. elegans to chemical stimulation. Using droplets enables isolating the worms and controlling the chemical environment. The chamber design of the static array allows continuous monitoring of animal behaviour. By combining a gradient of confinement and flow restriction features, we demonstrate selective and sequential trapping of multiple droplets as well as their release on demand. These functions enable repeated capture of animals, monitoring of their behaviour upon chemical stimulation and subsequent release. To demonstrate the ability to screen multiple conditions, we measured worm thrashing activity in response to different concentrations of tetramisole. To illustrate the ability to capture acute behavioural responses, we monitored the behavioural response of male to pheromone stimulation. Due to the versatility of the chamber operation and its ultra-low volume uses of reagents, we envision this platform to be highly suited to combinatorial screening and drug discovery.

Aeration effect on the efficiency of swine manure treatment in a trickling filter packed with organic materials

Effect of aeration rate on the removal of organic matter and nitrogen and on the formation of NH3, N2O and N2 was studied for an extensive biofiltration system packed with an organic media, which was used to treat pig manure. The results show high removal of BOD5 and TSS (99 and > or = 98%), independently of the four aeration rate tested (3.4-34 m3/m2 x h). Aeration rate > or = 4.4 m/h resulted in high ammonia stripping during start-up (> or = 1.0 kg NH3-N/m3 of swine manure treated), while using 3.4 m/h only 0.3 kg NH3-N/m3 were stripped. Complete nitrification was achieved after day 100 of operation, except in the biofilter with the lowest aeration rate. Simultaneous denitrification established in all the biofilters. Applying an aeration rate of 9.4 m/h up to 1.2 kg nitrogen was removed in the form of N2 for each m3 of swine manure treated. Contrary to the expectations, N2 formation and release increased with the aeration rate. This particular behaviour seems to be related to the punctual accumulation of water layers inside the biofilters, caused by the air force flowing in the opposite direction to the water flux. N2O production was quite similar in all biofilters (between 0.25-0.36 kg N2O-N/m3 of swine manure treated).

Nitrogen elimination mechanisms in an organic media aerated biofilter treating pig manure

Biofilters using organic media are known to procure efficient treatment for different types of wastewater, but the nitrogen removal pathways implied are still not well understood. In this study, a lab-scale aerated biofilter using peat and treating pig manure was operated for 180 days, in order to quantify the nitrogen transformations occurring in it. It was shown that stripping was important during the start-up, until nitrification took place. Simultaneous nitrification and denitrification, proved by N2 production, became the principal mechanism after some time. The production of N2O did not seem to come only from heterotrophic denitrification, but also from chemodenitrification and autotrophic denitrification. It has also been found that part of the influent nitrogen was retained in the system during the first 150 days, due to filtration, sorption and assimilation. During the last periods of operation, the nitrogen previously retained has been used by microorganisms, leading to an excessive N2 discharge.