Two-dimensional antiferromagnetic nodal-line semimetal and spin Hall effect in MnC4

Nodal-line semimetals, characterized by Dirac-like crossings along one dimensionalk-space lines, represent a unique class of topological materials. In this study, we investigate the intriguing properties of room-temperature antiferromagneticMnC4and its nodal-line features both with and without spin-orbit coupling (SOC). In the absence of SOC, we identify a doubly degenerate Dirac-nodal line, robustly protected by a combination of time-reversal, mirror, and partial-translation symmetries. Remarkably, this nodal line withstands various external perturbations, including isotropic and anisotropic strain, and torsional deformations, due to the ionic-like bonding between Mn atoms and C clusters. With the inclusion of SOC, we observe a distinctive quasi-Dirac-nodal line that emerges due to the interplay between antiferromagnetism and SOC-induced spin-rotation symmetry breaking. Finally, we observed a robust spin Hall conductivity that aligns with the energy range where the quasi-nodal line appears. This study presents a compelling example of a robust symmetry-protected Dirac-nodal line antiferromagnetic monolayer, which has potential for applications in next-generation spintronic devices.

Looking back, moving forward: A practical guide to implementing the updated ACGME geriatric medicine Milestones 2.0

The Accreditation Council for Graduate Medical Education (ACGME) developed the Milestones as a tool to aid trainee assessment based on the framework of the six core competencies of practice. Variability in the interpretation and application of the original Milestones prompted the ACGME to convene work groups within the different specialties and subspecialties to update the Milestones. The Geriatric Medicine work group was convened in 2019 with the goal of clarifying and simplifying the language of the Milestones, revising content to be specific to geriatrics, and developing supplemental resources to aid in implementation and use. We suggest using a practical, four-step process to implement the updated Milestones, called the Milestones 2.0, in fellowship programs by: (1) training faculty in the use of the Milestones 2.0, including an overview of the background and updates, (2) mapping the Milestones 2.0 to existing assessments, (3) educating fellows about the Milestones 2.0 and (4) presenting and discussing the Milestones 2.0 at Clinical Competency Committee meetings. This systematic approach promotes the development of a shared mental model for trainee assessments.

Geriatrics fellowship during COVID-19: expanding impact, using innovation and maintaining balance

The COVID-19 pandemic provided an opportunity for geriatricians, especially geriatrics fellows, to demonstrate leadership in a crisis that has significantly affected the 65 and older demographic. Given their expertise in care delivery to complex, multimorbid patients, as well as their ability to navigate different healthcare settings, geriatrics fellows became a valuable resource during the pandemic, particularly at one large, urban academic health system. Their training in patient-centered, value-based care helped determine the best course of action for patients not only in the hospital, but also in the community. Utilizing innovative strategies such as a newly developed Palliative Care Hotline (PATCH-24 line), telehealth, and community paramedicine, fellows delivered services to complex patients in community settings. In addition to providing direct patient care, geriatrics fellows also taught their skills to frontline physicians of other specialties. Strong support from the fellowship program's leadership, as well as an ongoing focus on clinician wellbeing and resilience, have been central factors in the success of geriatrics fellows during the COVID-19 crisis.

Transforming Virtual Team-Based Learning for Rural Healthcare Staff: What the Pandemic Taught Us

During COVID-19, many training programs pivoted to virtual formats. For the Rural Interdisciplinary Team Training (RITT) Program, funded by the Veterans Health Administration as part of the Geriatric Scholars Program, there were unique challenges. Given a history of successful accredited in-person, team-based workshops for staff at rural and remote clinics, program developers needed to quickly devise a plan for an effective virtual training for team members working separately from each other. Without the ability to provide in-person education and training, rapid pivoting to virtual modalities was essential for ongoing education of those providing care for older adults. Using a web-based platform, team members and expert trainer facilitation, participants engaged in lively discussions and reflection using the chat feature. RITT adapted the curriculum to better meet the needs of busy healthcare providers working during the pandemic, including increased discussion of how COVID affects older Veterans. Three virtual RITT workshops were held between March 2020 and February 2021 with 64 participants from 12 rural clinics and medical centers. Over 90% of participants agreed or strongly agreed that they were satisfied with the virtual workshop, comparable to those participating in the in-person workshop in earlier years. Similar to others, we have found that the ability to flex a curriculum has benefits to both learners and educators and increases the reach of educational opportunities in gerontology and geriatrics. Particularly in rural areas where travel may be challenging, a virtual format may be a desirable long-term solution for the RITT program.

Study on the use practices and knowledges of French practitioners about the use of intra-uterine devices in early post-partum contraception in France

OBJECTIVES

Intra-Uterine Device (IUD) insertion is possible in early postpartum. Although this contraception method is recognized and used in lots of country, it seems infrequent and poorly known in France. Our study aims to assess the barriers to the application of this method in France.

METHODS

A questionnaire was sent to obstetricians-gynaecologist professionals and midwives in France, through the affiliation to CNGOF (French National College of Obstetricians and Gynecologists) and to CNSF (French National College of Midwives). Questions were focused on the practices and knowledge about the insertion of IUD in early postpartum.

RESULTS

four hundred eight practitioners responded. Amongst them, 63% knew about the possibility to use IUDs after a vaginal delivery and 31% knew it could be inserted during cesarean section. Ten percent of them used this method. Most of these practitioners (80% of them) would like to discuss the insertion of an IUD in early postpartum with their patients and 71% would like to perform the insertion themselves after training. Besides, this study shows that contraception is rarely addressed by physicians during the follow-up of pregnancies. Less than 15% of respondents report discussing the topic systematically with the patient during the pregnancy follow during pregnancy follow.

CONCLUSION

insertion of IUDs in early postpartum is uncommon in France. The main limitation seems to be a lack of knowledge, but practitioners seem to be interested in this practice. Training courses could be created in order to rase up the adoption of this practice.

Surgical techniques for the removal of Essure® microinserts: a literature review on current practice

PURPOSE

To evaluate the different techniques for Essure^® microinserts removal and to assess the risk of fracture of the device and the intra- and post-operative complications in relation to surgical technique variants.

METHODS

Electronic search in Medline, Scopus and Embase databases using the following keywords: Essure; Essure removal; Essure surgical technique.

RESULTS

Out of 95 articles in the initial database, 17 studies were eligible for inclusion in our literature review. Several surgical techniques have been described in which the most frequent were laparoscopic salpingectomy (LS), laparoscopic cornuectomy (LC), laparoscopic or vaginal hysterectomy (LH, VH) with en-bloc salpingectomy. There were more fractures of the device with the LS procedure (6.25%) followed by the LC technique (2.77%), while there was no fracture with hysterectomy. However, peri-and post-operative complications were more severe and frequent with hysterectomy in comparison with the LC and LS procedures (respectively 8.1% Clavien Dindo grade 3 for the hysterectomy group, 1.11% for the LC procedure and 0.69% for the LS technique).

CONCLUSION

Due to the lack of standardised surgical treatment guidelines, a system of care networks for symptomatic patients with adverse effects related to Essure^® headed by specialised centres may offer a suitable and high-quality management with the appropriate removal techniques within two objectives: limiting the risk of fracture (with an en-bloc removal of the Essure^® microinserts) and avoiding intra- and post-operative complications.

[Treatment of synechiae related to infertility]

Synechiae are intrauterine adhesions that affect the fertility of women. They are most often of post-traumatic origin. The management of pregnancy abortions in the first trimester and post-delivery retention are the main contributing factors. Synechiae is responsible for cycle disorders and repeated pregnancy loss. Hysteroscopy is the reference method for its diagnosis and treatment. The surgical objective is the restoration of a normal sized cavity and a functional endometrium to allow fertilization and implantation. The use of small diameter (5mm) hysteroscopes and no energy or bipolar energy instruments are recommended. Echo guidance facilitates the treatment of severe synechiae and limits the risk of intraoperative perforation. The main risk of treatment is recurrence, particularly in severe cases where multiple operating times are sometimes necessary. An office hysteroscopy at 6 weeks is recommended to identify and treat these recurrences. Different physical, molecular or cellular methods are studied as primary and secondary prevention of postoperative synechiae. The objective of this review is to provide an update on the treatment of synechiae in the context of infertility.

[Trends in the use of midurethral slings after the new legislation: A nationwide survey]

INTRODUCTION

The French Department of Health published on October 23, 2020 a decree governing acts associated with mid-urethral sling (MUS) operations. The aim of this study was to evaluate the changes in practice following this new legislation.

METHODS

A cross-sectional study was carried out among French urologists and gynecologists using an online survey to collect changes in practices since the publication of the decree.

RESULTS

From January to February 2021, 436 surgeons participated in the survey. Among these surgeons, 87% were aware of the new legislation and 56% of them considered the decree as useless. The order resulted in an increase in working time in 81% of cases. Among these surgeons, 66% of the surgeons worked in tertiary referral centers for the management of incontinence, of which 55% had a multidisciplinary meeting in urogynecology. Among the surgeons, 31% considered this meeting to be useful but 80% considered that it did not lead to any change in surgical indications, even though 33% of complications of BSU were discussed there. In conclusion, 61% of surgeons felt more reluctant to schedule a BSU placement with this new legislation.

CONCLUSION

The majority of questioned surgeons considered the decree as useless. It generated few changes in practices which already respected the law on information, consultation, consent, experience and training. Most urologists and gynecologists are more reluctant to offer MUS after this new legislation.

LEVEL OF EVIDENCE

4.

Cost-effectiveness analysis of medical management versus conservative surgery for early tubal pregnancy

STUDY QUESTION

Is conservative surgery (laparoscopic salpingotomy) cost-effective, using fertility as the endpoint compared with medical management (Methotrexate) in women with an early tubal pregnancy?

SUMMARY ANSWER

Conservative surgery appeared slightly, but not statistically significantly, more effective than medical management but also more costly.

WHAT IS KNOWN ALREADY

Women with an early tubal pregnancy treated with medical therapy (Methotrexate) or conservative surgery (laparoscopic salpingotomy) have comparable future intrauterine pregnancy rates by natural conception. Also, cost-minimisation studies have shown that medical therapy was less expensive than conservative surgery, but there is no cost-effectiveness study comparing these two treatments with fertility as the endpoint.

STUDY DESIGN, SIZE, DURATION

A multicentre randomised controlled trial-based (DEMETER study) cost-effectiveness analysis of conservative surgery compared with medical therapy in women with an early tubal pregnancy was performed.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

Included women had an ultrasound that confirmed an early tubal pregnancy. They were randomly allocated to conservative surgery or to medical therapy. The study clinical outcome was the intrauterine pregnancy rate. The payer's perspective was considered. Costs of conservative surgery and medical therapy were compared. The analysis was performed according to the intention-to-treat principle. Missing variables were imputed using the fully conditional method. To characterise uncertainty and to provide a summary of it, a non-parametric bootstrap resampling was executed and cost-effectiveness accessibility curves were constructed.

MAIN RESULTS AND THE ROLE OF CHANCE

At baseline, costs per woman in the conservative surgery group and in the medical therapy group were 2627€ and 2463€, respectively, with a statistically significant difference of +164€. Conservative surgery resulted in a marginally, but non-significant (P = 0.46), higher future intrauterine pregnancy rate compared to medical therapy (0.700 vs. 0.649); leading, after bootstrap, to an incremental cost-effectiveness ratio of 1299€ (95% CI = -29 252; +29 919). Acceptability curves showed that conservative surgery could be considered a cost-effective treatment at a threshold of 3201€ for one additional future intrauterine pregnancy.

LIMITATIONS, REASONS FOR CAUTION

A limitation was that monetary valuation was carried out using 2016 euros while the DEMETER study took place from 2005 to 2009. Anyway, the results would not have been very different given the marginal changes in the health insurance reimbursement tariffs during this period.

WIDER IMPLICATIONS OF THE FINDINGS

Conservative surgery can be considered a cost-effective treatment, if the additional cost of 3201€ per additional future intrauterine pregnancy is an acceptable financial effort for the payer.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

NCT 00137982.

Management of endometriosis: CNGOF/HAS clinical practice guidelines - Short version

First-line diagnostic investigations for endometriosis are physical examination and pelvic ultrasound. The second-line investigations are: targeted pelvic examination performed by an expert clinician, transvaginal ultrasound performed by an expert physician sonographer (radiologist or gynaecologist), and pelvic MRI. Management of endometriosis is recommended when the disease has a functional impact. Recommended first-line hormonal therapies for the management of endometriosis-related pain are combined hormonal contraceptives (CHCs) or the 52mg levonorgestrel-releasing intrauterine system (IUS). There is no evidence base on which to recommend systematic preoperative hormonal therapy solely to prevent surgical complications or facilitate surgery. After surgery for endometriosis, a CHC or 52mg levonorgestrel-releasing IUS is recommended as first-line treatment when pregnancy is not desired. In the event of failure of the initial treatment, recurrence, or multiorgan involvement, a multidisciplinary team meeting is recommended, involving physicians, surgeons and other professionals. A laparoscopic approach is recommended for surgical treatment of endometriosis. HRT can be offered to postmenopausal women who have undergone surgical treatment for endometriosis. Antigonadotrophic hormonal therapy is not recommended for patients with endometriosis and infertility to increase the chances of spontaneous pregnancy, including postoperatively. Fertility preservation options must be discussed with patients undergoing surgery for ovarian endometriomas.

[Management of endometriosis: CNGOF-HAS practice guidelines (short version)]

First-line investigations to diagnose endometriosis are clinical examination and pelvic ultrasound. Second-line investigations include pelvic examination performed by a referent clinician, transvaginal ultrasound performed by a referent echographist, and pelvic MRI. It is recommended to treat endometriosis when it is symptomatic. First-line hormonal treatments recommended for the management of painful endometriosis are combined with hormonal contraceptives or levonorgestrel 52mg IUD. There is no evidence to recommend systematic preoperative hormonal therapy for the unique purpose of preventing the risk of surgical complications or facilitating surgery. After endometriosis surgery, combined hormonal contraceptives or levonorgestrel SIU 52mg are recommended as first-line therapy in the absence of desire of pregnancy. In case of initial treatment failure, recurrence, or multiple organ involvement by endometriosis, medico-surgical and multidisciplinary discussion is recommended. The laparoscopic approach is recommended for the surgical treatment of endometriosis. HRT may be offered in postmenopausal women operated for endometriosis. In case of infertility related to endometriosis, it is not recommended to prescribe anti-gonadotropic hormone therapy to increase the rate of spontaneous pregnancy, including postoperatively. The possibilities of fertility preservation should be discussed with the patient in case of surgery for ovarian endometrioma.

[Endometriosis medical treatment: Hormonal treatment for the management of pain and endometriotic lesions recurrence. CNGOF-HAS Endometriosis Guidelines]

The available literature, from 2006 to 2017, on hormonal treatment has been analysed as a contribution to the HAS-CNGOF task force for the treatment of endometriosis. Available data are heterogeneous and the general level of evidence is moderate. Hormonal treatment is usually offered as the primary option to women suffering from endometriosis. It cannot be used in women willing to conceive. In women who have not been operated, the first line of hormonal treatment includes combined oral contraceptives (COC) and the levonorgestrel-releasing intra uterine system (52mg LNG-IUS). As a second line, desogestrel progestin only pills, etonogestrel implants, GnRH analogs (GnRHa) with add back therapy and dienogest can be offered. Add back therapy should include estrogens to prevent bone loss and improve quality of life, it can be introduced before the third month of treatment to prevent side effects. The literature does not support preoperative hormonal treatment for the sole purpose of reducing complications or recurrence, or facilitating surgical procedures. After surgical treatment, hormonal treatment is recommended to prevent pain recurrence and improve quality of life. COCs or LNG IUS are recommended as a first line. To prevent recurrence of endometriomas COC is advised and maintained as long as tolerance is good in the absence of pregnancy plans. In case of dysmenorrhea, postoperative COC should be used in a continuous scheme. GnRHa are not recommended in the sole purpose of reducing endometrioma recurrence risk.

[New medical treatments for painful endometriosis: CNGOF-HAS Endometriosis Guidelines]

OBJECTIVE

The objective of this work is to evaluate the place of new treatments in the management of endometriosis outside the context of infertility.

METHODS

A review of the literature was conducted by consulting Medline data until July 2017.

RESULTS

Dienogest is effective compared to placebo in short term (NP2) and long term (NP4) for the treatment of painful endometriosis. In comparison with GnRH agonists, dienogest is also effective in terms of decreased pain and improved quality of life in non-operated patients (NP2) as well as for recurrence of lesions and symptomatology postoperatively (NP2). Data on GnRH antagonists, selective progesterone receptor modulators as well as selective inhibitors (anti-TNF-α, matrix metalloprotease inhibitors, angiogenesis growth factor inhibitors) are insufficient to provide evidence of interest in clinical practice for the management of painful endometriosis (NP3).

CONCLUSION

Dienogest is recommended as second-line therapy for the management of painful endometriosis (Grade B). Because of lack of evidence, aromatase inhibitors, elagolix, SERM, SPRM and anti-TNF-α are not recommended for the management of painful endometriosis (Grade C).

[Medical treatment for the management of painful endometriosis without infertility: CNGOF-HAS Endometriosis Guidelines]

OBJECTIVE

To provide clinical practice guidelines for the management of painful endometriosis in women without infertility.

METHODS

Systematic review of the literature literature since 2006, level of evidence rating, external proofreading and grading of the recommendation grade by an expert group according to HAS methodology.

RESULTS

Combined hormonal contraceptives (COP) and the levonorgestrel-releasing intra-uterin system (LNG-IUS) are recommended as first-line hormonal therapies for the treatment of painful endometriosis (grade B). Second-line therapy relies on oral desogestrel microprogestative, etonogestrel-releasing implant, GnRH analogs (GnRHa) and dienogest (grade C). It is recommended to use add-back therapy containing estrogen in association with GnRHa (grade B). After endometriosis surgery, hormonal treatment relying on COP or LNG-IUS is recommended to prevent pain recurrence (grade B). COP is recommended to reduce the risk of endometrioma recurrence after surgery (grade B) but the prescription of GnRHa is not recommended (grade C). Continuous COP is recommended in case of dysmenorrhea (grade B). GnRHa is not recommended as first line endometriosis treatment for adolescent girl because of the risk of bone demineralization (grade B). The management of endometriosis-induced chronic pain requires an interdisciplinary evaluation. Physical therapies improving the quality of life such as yoga, relaxation or osteopathy can be proposed (expert agreement). Promising medical alternatives are currently under preclinical and clinical evaluation.

Ectopic pregnancy 6 years after subtotal hysterectomy: A case report

BACKGROUND

Only 57 cases of ectopic pregnancy after hysterectomy have been published.

CASE REPORT

A 34-year-old patient with a history of subtotal hysterectomy for postpartum hemorrhage consulted for acute abdominal pain. The diagnosis of ectopic pregnancy was made using blood pregnancy test and transvaginal ultrasound. Emergency laparoscopy was performed.

CONCLUSION

Urine pregnancy test should be performed in case of unexplained haemoperitoneum in patient of childbearing age with a history of hysterectomy. Fistulous tracts between the patent cervix or the vaginal cuff and the peritoneal cavity may allow fecundation. TEACHING POINTS: (1) Ectopic pregnancy remains a differential diagnosis of abdominal pain and haemoperitoneum in patient of childbearing age even after hysterectomy. (2) Fistulous tract between the residual cervix and the peritoneal cavity or tubes may allow fecundation.

Reproducibility of the interpretation of coronal 3D ultrasound view of the uterus to evaluate the position of Essure® 3 months after hysteroscopic procedure

OBJECTIVE

Three-dimensional sonography is a good alternative method to assess the position of microinserts. Adequate position after three months allows for the interruption of other contraception. Objective is to evaluate inter-observer reproducibility of the interpretation of coronal transvaginal 3D ultrasound view of the uterus to evaluate the position of Essure^®.

STUDY DESIGN

Inter-observer reproducibility study. Fifty women underwent successful bilateral placement of microinserts (Essure^®) by hysteroscopy in the Department of Gynaecology of a teaching hospital and were included in the study. At three month, 3D ultrasound coronal views of the fifty uterus (accounting for one hundred microinserts) were assessed by five different observers and microinsert position was classified according to the classification described by Legendre et al. Inter-observer reproducibility in reading the 3D coronal view of the uterus was evaluated.

RESULTS

The k-value was disparate, from 0.26 to 0.82. Inter-observer reproducibility then ranged from fair to almost perfect, depending on a prior knowledge of the position classification.

CONCLUSIONS

Transvaginal 3D coronal view of the uterus is sufficient to assess the positioning of the microinserts when the practionner or the surgeon is familiar with the classification method.

Quality assessment of pelvic ultrasound for uterine myoma according to the CNGOF guidelines

INTRODUCTION

French guidelines regarding the minimum criteria for gynaecological ultrasound were given in a recent report in 2016, by the French National College of Obstetricians and Gynaecologists (CNGOF). An accurate report is essential for the optimal care of women, especially those presenting myomas. The goal of this study was to evaluate the quality of gynaecological ultrasound reports for women with type 0 to 2 uterine myomas, referring to the items contained in the French guidelines.

MATERIALS AND METHODS

A retrospective descriptive study was conducted from reports of ultrasounds performed in private offices and in the gynaecologic department of a hospital, between June 2014 and June 2016 (before the report of CNGOF). These reports involved women who underwent hysteroscopic resection of myoma(s). A search of validated items was conducted for all of the reports, and the missing items were analysed. The different types of practitioners and between hospital and private medical offices were also compared with Chi-square tests.

RESULTS

A total of 138 reports were analysed; 71 were performed in private offices and 67 were performed in the gynaecologic unit of the hospital. Many items were missing in the reports, with disparities between the type of institution (private offices or hospital) and the speciality of practitioners (radiologists or gynaecologists). Specific items regarding myomas, such as the International Federation of Gynaecologists and Obstetricians (FIGO) classification or measurement of the posterior wall, were more often missing in reports from radiologists (89.7% and 79.5%, respectively) than in reports from gynaecologists (21.2% and 34.3%, respectively) (P<0.05). A significant difference was also observed for these data between private offices' reports and hospitals' reports. Items relative to ultrasound structures, such as the appearance of myomas or associated abdominal effusion, were more frequently missing in gynaecologists' reports (88.9% and 49.5%, respectively) compared to radiologists' reports (56.4% and 12.8%, respectively) (P<0.05).

CONCLUSIONS

Certain items are present in all the reports, while others are insufficiently mentioned. These inequalities can be explained in part by the type of practice; however, methods to overcome these difficulties must be developed. Information campaigns to educate professionals on the minimum reporting and training conducted jointly by radiologists and gynaecologist surgeons might improve reports and improve the care of women.

[Interest of saline contrast sonohysterography for the diagnosis of cesarean scar defects]

OBJECTIVES

To determine the interest of saline contrast sonohysterography in the evaluation of number, size and shape of cesarean scar defects in comparison with 3D-transvaginal ultrasound examination.

METHODS

Patients who had surgical reparation of cesarean scar defect by operative hysteroscopy were included in this retrospective study. Before surgery, they all had 3D-transvaginal ultrasound examination and saline contrast sonohysterography to establish the diagnosis. Then those two exams were compared to determine which one is better for cesarean scar defect evaluation, in terms of diagnosis and severity.

RESULTS

Fourteen patients were enrolled, they underwent transvaginal ultrasound and saline contrast sonohysterography before the surgery. 3D-transvaginal ultrasound examination made the diagnosis in 50% of patients with cesarean scar defect, whereas saline contrast sonohysterography enabled to detect 86% of defects, in comparison with hysteroscopy (100%). In 29% of patients, the size and depth of the cesarean scar defect was more important with saline contrast sonohysterography and hysteroscopy than expected by 3D-transvaginal ultrasound examination. After surgical repair, symptoms improvement was found in 82% of case (pain or abnormal uterine bleeding), and fertility was restored in 67%.

CONCLUSION

Saline contrast sonohysterography is better to characterize cesarean scar defects than 3D-transvaginal ultrasound, with a higher sensibility. Moreover, it evaluates more precisely the size and shape of the defect, thus severity.