The culture of doubt: Do medical students really experience clinical uncertainty when they should?

Uncertainty is a fundamental aspect of medical practice, necessitating incorporation into undergraduate medical training. The integrative model of uncertainty tolerance (UT) developed by Hillen and Han serves as a comprehensive framework for exploring clinical uncertainty. While studies have extensively examined UT dimensions, including sources, responses, and moderators, the factors influencing the perception of uncertainty stimuli remain underexplored. However, students' ability to perceive uncertainty and their approach to uncertain stimuli play a crucial role in enabling them to develop adaptive responses to uncertainty, necessary for their comfort in these situations. Defining uncertainty as a metacognitive state suggests significant variability in its perception among individuals and within an individual over time. Moreover, several studies have demonstrated the substantial influence of various individual and contextual factors on how individuals perceive and respond to uncertainty. In this paper, the authors present multiple hypotheses to address the question of whether students genuinely perceive uncertainty stimuli when they should. The authors argue that students' personal relationship with their knowledge is essential in their ability to identify clinical uncertainty, particularly concerning the limits of medical knowledge. Therefore, they propose that an academic culture fostering doubt, through exposing students to a variety of perspectives, would enhance their ability to identify uncertainty zones in a clinical situation at an early stage. Drawing on Dewey's situational theory, the authors emphasize the importance of better understanding, in a work setting, the influence of contextual and situational characteristics on individual perceptions of uncertainty. In line with this idea, ethnographic studies would offer valuable insights into identifying the relationship between the students, their work environment, and their perception of clinical uncertainty.

Advanced Insights into Human Uterine Innervation: Implications for Endometriosis and Pelvic Pain

(1) Background: Understanding uterine innervation, an essential aspect of female reproductive biology, has often been overlooked. Nevertheless, the complex architecture of uterine innervation plays a significant role in conditions such as endometriosis. Recently, advances in histological techniques have provided unprecedented details about uterine innervation, highlighting its intricate structure, distribution, and density. The intricate nature of uterine innervation and its influence on pathologies such as endometriosis has garnered increasing attention. (2) Objectives: This review aims to compile, analyze, and summarize the existing research on uterine innervation, and investigate its implications for the pathogenesis of endometriosis and associated pain. (3) Methods: A systematic review was conducted in line with PRISMA guidelines. Using the PubMed database, we searched relevant keywords such as "uterine innervation", "endometriosis", and "pain association". (4) Results: The initial literature search yielded a total of 3300 potential studies. Of these, 45 studies met our inclusion criteria and were included in the final review. The analyzed studies consistently demonstrated that the majority of studies focused on macroscopic dissection of uterine innervation for surgical purposes. Fewer studies focused on micro-innervation for uterine innervation. For endometriosis, few studies focused on neural pain pathways whereas many studies underlined an increase in nerve fiber density within ectopic endometrial tissue. This heightened innervation is suggested as a key contributor to the chronic pain experienced by endometriosis patients. (5) Conclusions: The understanding of uterine innervation, and its alterations in endometriosis, offer promising avenues for research and potential treatment.

A reappraisal of the deep uterine vein: a multimodal exploration with implications for pelvic surgery

PURPOSE

Pelvic gynecological surgeries, whether for malignant or benign conditions, frequently result in functional complications due to injuries to the autonomic nervous system. Recognizing the deep uterine vein (DUV) as an essential anatomical reference can aid in preserving these structures. Despite its significance, the DUV is infrequently studied and lacks comprehensive documentation in Terminologia Anatomica. This research endeavors to elucidate a detailed characterization of the DUV.

METHODS

We undertook a systematic literature review aligning with the "PRISMA" guidelines, sourcing from PUBMED and EMBASE. Our comprehensive anatomical examination encompassed cadaveric dissections and radio-anatomical evaluations utilizing the Anatomage® Table.

RESULTS

The literary exploration revealed a consensus on the DUV's description based on both anatomical and surgical observations. It arises from the merger of cervical, vesical, and vaginal veins, coursing through the paracervix in a descending and rearward direction before culminating in the internal iliac vein. The hands-on anatomical study further delineated the DUV's associations throughout its course, highlighting its role in bifurcating the uterus's lateral aspect into two distinct zones: a superior vascular zone housing the uterine artery and ureter and an inferior nervous segment below the DUV representing the autonomic nerve pathway.

CONCLUSION

A profound understanding of the subperitoneal space anatomy is paramount for pelvic surgeons to mitigate postoperative complications. The DUV's intricate neurovascular interplays underscore its significance as an indispensable surgical guide for safeguarding nerves and the ureter.

[First-line management of infertile couple. Guidelines for clinical practice of the French College of Obstetricians and Gynecologists 2022]

OBJECTIVE

To update the 2010 CNGOF clinical practice guidelines for the first-line management of infertile couples.

MATERIALS AND METHODS

Five major themes (first-line assessment of the infertile woman, first-line assessment of the infertile man, prevention of exposure to environmental factors, initial management using ovulation induction regimens, first-line reproductive surgery) were identified, enabling 28 questions to be formulated using the Patients, Intervention, Comparison, Outcome (PICO) format. Each question was addressed by a working group that had carried out a systematic review of the literature since 2010, and followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) methodology to assess the quality of the scientific data on which the recommendations were based. These recommendations were then validated during a national review by 40 national experts.

RESULTS

The fertility work-up is recommended to be prescribed according to the woman's age: after one year of infertility before the age of 35 and after 6months after the age of 35. A couple's initial infertility work-up includes a single 3D ultrasound scan with antral follicle count, assessment of tubal permeability by hysterography or HyFOSy, anti-Mullerian hormone assay prior to assisted reproduction, and vaginal swabbing for vaginosis. If the 3D ultrasound is normal, hysterosonography and diagnostic hysteroscopy are not recommended as first-line procedures. Chlamydia trachomatis serology does not have the necessary performance to predict tubal patency. Post-coital testing is no longer recommended. In men, spermogram, spermocytogram and spermoculture are recommended as first-line tests. If the spermogram is normal, it is not recommended to check the spermogram. If the spermogram is abnormal, an examination by an andrologist, an ultrasound scan of the testicles and hormonal test are recommended. Based on the data in the literature, we are unable to recommend a BMI threshold for women that would contraindicate medical management of infertility. A well-balanced Mediterranean-style diet, physical activity and the cessation of smoking and cannabis are recommended for infertile couples. For fertility concern, it is recommended to limit alcohol consumption to less than 5 glasses a week. If the infertility work-up reveals no abnormalities, ovulation induction is not recommended for normo-ovulatory women. If intrauterine insemination is indicated based on an abnormal infertility work-up, gonadotropin stimulation and ovulation monitoring are recommended to avoid multiple pregnancies. If the infertility work-up reveals no abnormality, laparoscopy is probably recommended before the age of 30 to increase natural pregnancy rates. In the case of hydrosalpinx, surgical management is recommended prior to ART, with either salpingotomy or salpingectomy depending on the tubal score. It is recommended to operate on polyps>10mm, myomas 0, 1, 2 and synechiae prior to ART. The data in the literature do not allow us to systematically recommend asymptomatic uterine septa and isthmoceles as first-line surgery.

CONCLUSION

Based on strong agreement between experts, we have been able to formulate updated recommendations in 28 areas concerning the initial management of infertile couples.

Adherence to ESGO guidelines and impact on survival in obese patients with endometrial cancer: a multicentric retrospective study

OBJECTIVES

Obesity is known to be both a major risk factor for endometrial cancer and associated with surgical complexity. Therefore, the management of patients with obesity is a challenge for surgeons and oncologists. The aim of this study is to assess the adherence to European Society of Gynaecological Oncology (ESGO) guidelines in morbidly obese patients (body mass index (BMI) >40 kg/m2). The secondary objectives were the impact on overall survival and recurrence-free survival.

METHODS

All the patients who were treated for an endometrial cancer in the 11 cancer institutes of the FRANCOGYN group were included and classified into three weight groups: morbid (BMI >40 kg/m2), obese (BMI 30-40), and normal or overweight (BMI <30). Adherence to guidelines was evaluated for surgical management, lymph node staging, and adjuvant therapies.

RESULTS

In total, 2375 patients were included: 1330 in the normal or overweight group, 763 in the obese group, and 282 in the morbid group. The surgical management of the morbid group was in accordance with the guidelines in only 30% of cases, compared with 44% for the obese group and 48% for the normal or overweight group (p<0.001); this was largely because of a lack of lymph node staging. Morbid group patients were more likely to receive the recommended adjuvant therapy (61%) than the obese group (52%) or the normal or overweight group (46%) (p<0.001). Weight had no impact on overall survival (p=0.6) and morbid group patients had better recurrence-free survival (p=0.04).

CONCLUSION

Adherence to international guidelines for surgical management is significantly lower in morbid group patients, especially for lymph node staging. However, morbidly obese patients had more often the adequate adjuvant therapies. Morbid group patients had a better recurrence-free survival likely because of better prognosis tumors.

Mayer-Rokitansky-Küster-Hauser syndrome patients' interest, expectations and demands concerning uterus transplantation

OBJECTIVE

To better understand patients' conditions and expectations before starting a uterus transplantation (UTx) program for women suffering from Mayer-Rokitansky-Küster-Hauser syndrome (MRKH syndrome).

METHOD

A web-based survey was conducted among MRKH patients via the French national association network from March to August 2020. The questionnaire comprised twenty-eight questions about their desire for parenthood, their condition's characteristics and previous reconstructive procedures, opinions and knowledge about UTx.

RESULTS

Among the 148 participants, 88 % reported a desire for parenthood, and 61 % opted for UTx as their first choice to reach this aim. The possibility of bearing a child and having the same genetic heritage were the main motivations. Once informed about the usual course of an UTx protocol, only 13 % of the participants changed their mind and 3 out of 4 of them opted for UT.

CONCLUSION

Uterus transplantation seems to be the first option to reach motherhood in patients suffering from MRKH syndrome. The development of UTx programs could meet the demands of this already well-informed population.

Simulation training for pelvic examination: A systematic review

OBJECTIVE

Pelvic examination including vaginal digital examination and speculum inspection are crucial medical skills that are challenging to teach for both professors and students, because of its intimate nature. Consequently, education has shifted from a traditional approach to a simulation-enhanced education. This literature review summarizes the level of evidence for these not-so-new training modalities.

METHODS

For this systematic review, the Pudmed database have been consulted using the following keywords: (Pelvic examination OR Vaginal examination) AND simulation. Eligible studies had to be published in French or English within the past 20 years and investigate simulation training for pelvic examination in the field of gynecology and obstetrics. For each paper, the following outcomes were analyzed: Competence, confidence and communication, and were classified according to the Kirkpatrick hierarchy.

RESULTS

About competence, in initial training, one meta-analysis (9 studies of which 4 randomized studies) about pelvic examination teaching on procedural simulators have shown a significant benefit of simulation. One meta-analysis and one systematic review also demonstrated that Gynecological Teaching Associates (GTAs) teaching, who exist in Northern America and Scandinavian countries, was better that pelvic task trainers in terms of technical competence, and comfort. For the vaginal examination of women in labor, two randomized trials also showed a positive impact of pelvic task trainer on students' accuracy.

CONCLUSION

Simulation-enhanced education of pelvic examination brings a significant benefit in comparison to a classic education without simulation in terms of competence, confidence and communication. GTAs have the best impact on competence and communication, but they do not exist currently in France. Hybrid simulation (a patient actor combined with a pelvic task trainer) could be a solution to teach both technical skills and communication.

Hypothermic machine perfusion for uterus transplantation

OBJECTIVE

To describe the feasibility of hypothermic machine perfusion (HMP) in uterus transplantation (UT) to potentially improve the preservation of the uterus and enhance graft preservation in the donation after brainstem death (DBD) context. Uterus transplantation is a new surgical approach to treating absolute uterine infertility; it can be performed after living donation or after DBD. In the DBD context, the uterus is typically the last organ removed after other vital organs, with the exception of the Baylor team, which removes the uterus first. This key aspect imposes an unavoidable mild temperature ischemia for >1 hour on the uterus during the removal of the vital abdominal and chest organs. In renal transplantation, the perfusion machine reduces the risk of delayed graft function; thus, we hypothesized that machine perfusion could result in a reduction of uterus graft dysfunction. The uterus graft dysfunction could be expressed by a low embryo implantation rate, pregnancy loss, or vascular pregnancy diseases such as preeclampsia or fetal growth restriction." To date, static cold storage of the uterus is the only standard method for preservation before transplantation. HMP is an emerging method that could potentially improve the preservation of the uterus to enhance graft preservation in the DBD context.

DESIGN

This video article shows all the technical details of using the HMP for uterine transplantation.

SETTING

University.

ANIMALS

Porcine model.

INTERVENTION

Porcine uterus was retrieved from a DBD domestic animal model and flushed with KPS MP (Bridge To Life Ltd in UK) at 4 °C. After vascular preparation on the back table, the uterus was perfused using KPS MP through a cannula in the aorta using the VitaSmart device (Bridge To Life Ltd in UK) for 18 hours. Then, the uterus was transplanted to the porcine recipient.

MAIN OUTCOME MEASURES

The macroscopic appearance of the uterus at the end of HMP and the assessment of the uterus vascularization after transplantation in the recipient compared with the native uterus.

RESULTS

This video shows the cannulation of the iliac vessels, cooling and removal of the uterus on a porcine model, uterus preservation using HMP during 18 hours, and then UT in a new recipient pig with the reperfusion of the transplanted uterus next to the native, intact uterus of the recipient. The macroscopic appearance of the uterus at the end of HMP appeared viable and was perfectly flushed. The assessment of the uterus vascularization after transplantation in the recipient was similar to that of the native uterus. To our knowledge, we describe here for the first time the UT procedure in DBD context on an animal model and the use of HMP for uterus preservation in UT programs; this could increase the number of uterine grafts available for a greater number of female recipients.

CONCLUSION

Hypothermic machine perfusion could allow the duration of cold ischemia to be prolonged without altering the uterine graft. Nevertheless, this assertion has to be validated in a human context.

Estimation of the prevalence of uterine infertility and its different causes in France according to data from a literature review

INTRODUCTION

Uterine infertility (UI) is defined as the complete absence of a uterus (absolute uterine infertility or AUI) or the presence of a non functional uterus (non-absolute uterine infertility or NAUI). The exact prevalence of uterine infertility is currently unknown. Our aim was to assess the number of French women concerned by Uterine Infertility according to a recent literature review.

MATERIALS AND METHODS

We have previously conducted a systematic review of the literature on UI and its various causes in the world. Based on these study and demographic data of 2022 from INSEE (Institut National de la Statistique et des Études Économiques), we attempted to estimate the number of women under 40 years of age in France affected by potential UI using direct standardization.

RESULTS AND DISCUSSION

Based on the estimation from INSEE data, approximately 2066 women of childbearing age would have MRKH syndrome in France, 380 the Androgen Insensitivity Syndrome and 3700 had an haemostasis hysterectomy in France. We did not find data on the prevalence of hysterectomies before the age of 40 in France. For the following pathologies: uterine malformations, radiation uterus, synechiae, myomas and adenomyosis there was a huge amount of missing data, which does not allow us to estimate the number of potentially infertile patients.

CONCLUSION

Prevalence of UI is poorly known. UI probably concerns several thousand patients in France. The creation of a UI registry would make enable to assess the number of patients potentially eligible for adoption, uterus transplantation or even surrogacy.

Assessment of the self-confidence of obstetrics & gynecology fellows to perform a postpartum hemostasis hysterectomy

INTRODUCTION

Hemostasis Hysterectomy (HH) is a last resort surgical procedure performed in situations of uncontrolled post-partum hemorrhage in maternity wards. The chances of being confronted with this situation are scarce during residency, and the situation is not well suited for teaching. Nevertheless, every obstetrician-gynecologist can be confronted with this stressful situation, and should therefore possess the surgical competence required, regardless of his routine practice. The aim of the present study is to evaluate clinical exposure and self-awareness concerning HH amongst obstetrics and gynecology residents and fellows.

MATERIEL AND METHODS

We performed a survey amongst French obstetrics and gynecology fellows. An anonymous survey was sent by email between December 1, 2020 to July 1, 2021.

RESULTS

Half of the interrogated fellows had practiced (as operator) an HH during residency with a senior and only 22,6% in post-residency. During the last year of residency 70% of them had performed less than 10 scheduled hysterectomies as primary operator. The laparoscopic approach was the most frequently practiced. Very few hysterectomies were performed as primary operator. Fellows with a surgical or mixed activity (both gynecological surgery and obstetrical activity in current practice) felt significantly more capable of performing HH compared to those with exclusive obstetrical or reproductive medicine activity; respectively 60% vs 36%, p = 0.008; Odds Ratio: 2.629 (95% CI 1.2214; 5.8094).

CONCLUSION

The number of scheduled hysterectomies or HH performed as primary operator is very low during residency or fellowship. It remains largely inferior to the number deemed necessary in previous publications about the learning curve for scheduled hysterectomy, which varies from 18 to 80 interventions. Nowadays, the increasing number of residents, added to the decrease of hemostasis hysterectomies through better management of post-partum hemorrhage, pushes towards the development of specific training, such as "damage control simulation".

Endometrial cancer of the very elderly: Management and survival in the Francogyn population

INTRODUCTION

We aimed to describe management and survival of patients with endometrial cancer (EC) ≥80 years to identify poor prognosis criteria.

METHODS

We collected clinical, histologic, surgical and follow-up data for patients with EC ≥ 80 years included in a multicenter French cohort (FRANCOGYN) who underwent primary surgical treatment from 1999 to 2019. The outcomes were overall survival (OS) and disease-free survival (DFS). We performed a descriptive analysis then a survival time analysis and comparison using the Kaplan Meier method and log-rank test.

RESULTS

Of the 1647 patients with EC who received treatment during the study period, 184 (11.17%) were ≥80 years. The mean age was 84 years (±3.34). Thirty-three patients (25.4%) died during the follow-up period and 26 relapsed (18.4%). Forty-nine patients were lost to follow-up (27.37%). The median follow-up time was 15.3 months (4.9-28.8). The median OS and DFS was 16.4 months (6.3-24.9) and 13.6 months (4.5-26.6), respectively. Eighty-three patients received adjuvant therapy (45.11%), out of 95 who had a formal or relative indication. Four patients received adjuvant chemotherapy (2.6%), out of 61 who had a formal or relative indication. Inappropriate or underuse of chemotherapy was significantly associated with a lower median OS of 12.6 months [3.73-24] versus 17.3 months [7.93-41.77] when performed appropriately (HR = 4.14, CI 95% [1.62-10.56]), and a lower median DFS of 10.83 months [3.73-24] versus 17.3 months [7.93-28.5] (HR = 9.04, CI 95% [2.04-40.12]).

CONCLUSION

Our results suggest that very elderly patients with EC should receive adjuvant chemotherapy according to the standard care guidelines.

Uterine Factor Infertility, a Systematic Review

Uterine factor infertility (UFI) is defined as a condition resulting from either a complete lack of a uterus or a non-functioning uterus due to many causes. The exact prevalence of UFI is currently unknown, while treatments to achieve pregnancy are very limited. To evaluate the prevalence of this condition within its different causes, we carried out a worldwide systematic review on UFI. We performed research on the prevalence of UFI and its various causes throughout the world, according to the PRISMA criteria. A total of 188 studies were included in qualitative synthesis. UFI accounted for 2.1 to 16.7% of the causes of female infertility. We tried to evaluate the proportion of the different causes of UFI: uterine agenesia, hysterectomies, uterine malformations, uterine irradiation, adenomyosis, synechiae and Asherman syndrome, uterine myomas and uterine polyps. However, the data available in countries and studies were highly heterogenous. This present systematic review underlines the lack of a consensual definition of UFI. A national register of patients with UFI based on a consensual definition of Absolute Uterine Factor Infertility and Non-Absolute Uterine Factor Infertility would be helpful for women, whose desire for pregnancy has reached a dead end.

Association of Preoperative Enzian Score with Postoperative Fertility in Patients with Deep Pelvic Endometriosis

INTRODUCTION

Endometriosis is a chronic inflammatory disease with a negative impact on fertility. The Enzian classification provides a precise description of deep pelvic endometriotic lesions, especially in the retroperitoneal area, from preoperative pelvic MRI scans. However, it is not known if it is correlated with postoperative fertility.

STUDY OBJECTIVE

To determine if there is an association between the preoperative Enzian score and postoperative fertility after deep pelvic endometriosis surgery.

DESIGN

We conducted a descriptive, retrospective study using information from the ENDOREN database.

SETTING

This was a retrospective study at the Department of Obstetrics and Gynecology at Rennes University Hospital (France) from January 2013 to May 2019 PATIENTS AND INTERVENTIONS: We used information from the ENDOREN database that included all women who underwent surgery for deep endometriosis and wish to conceive. This surgery was intended in a view to achieve a complete removal of endometriosis.

MEASUREMENTS

The Enzian score was calculated from preoperative MRI scans, and total, spontaneous, and after In Vitro Fertilization (IVF) live births and pregnancies outcomes were collected from the patients'computerized medical records. Univariate and multivariate analysis was performed.

RESULTS

Sixty-eight patients were included. The live-birth rate was 35% (24/68). According to the Enzian classification, 25 patients (35%) were classified in compartment A, 64 patients (94%) in compartment B, and 27 (40%) in compartment C. In multivariate analysis, positive predictor of live birth was single Enzian B score (OR=4.7[1.21; 18.81], p=0.03), negative predictors were uterine adenomyosis and a history of endometriosis surgery. In multivariate analysis, positive predictor of spontaneous live birth was EFI score ≥7 (OR =22.434; CI [1.138; 442.190]). In multivariate analysis, positive predictor was Enzian A score (OR=15.9[2.2; 114.7], p=0.006), and negative predictors was uterine adenomyosis and Enzian B score (OR=0.01[0; 0.495], p=0.02) for live birth after IVF.

CONCLUSION

The present retrospective study cannot strongly conclude about fertility and correlation with Enzian score because the groups are too small. However, it seems that when solely the compartment B is involved by endometriosis, complete full removal of endometriosis leads to better post-operative live births results. Other studies must be done to determine if Enzian classification based on preoperative pelvic MRI could be clinical value in the decision-making strategy for managing infertile patients with deep pelvic endometriosis.

Anatomic and functional mapping of human uterine innervation

OBJECTIVE

To better understand the physiology of pain in pelvic pain pathological conditions, such as endometriosis, in which alterations of uterine innervation have been highlighted, we performed an anatomic and functional mapping of the macro- and microinnervation of the human uterus. Our aim was to provide a 3-dimensional reconstruction model of uterine innervation.

DESIGN

This was an experimental study. We dissected the pelvises of 4 human female fetuses into serial sections, and treated them with hematoxylin and eosin staining before immunostaining.

SETTING

Academic Research Unit.

PATIENTS

None.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Detection of nerves (S100 +) and characterization of the types of nerves. The slices obtained were aligned to construct a 3-dimensional model.

RESULTS

A 3-dimensional model of uterine innervation was constructed. The nerve fibers appeared to have a centripetal path from the uterine serosa to the endometrium. Within the myometrium, innervation was dense. Endometrial innervation was sparse but present in the functional layer of the endometrium. Overall innervation was richest in the supravaginal cervix and rarer in the body of the uterus. Innervation was rich particularly laterally to the cervix next to the parametrium and paracervix. Four types of nerve fibers were identified: autonomic sympathetic (TH+), parasympathetic (VIP+), and sensitive (NPY+, CGRP1+ and VIP+). They were found in the 3 portions and the 3 layers of the uterus.

CONCLUSIONS

We constructed a 3-dimensional model of the human uterine innervation. This model could provide a solid base for studying uterine innervation in pathologic situations, in order to find new therapeutic approaches.

Relationship between uterine veins, ureter and hypogastric nerves for uterine transplantation: an anatomic study

BACKGROUND

Uterine transplantation is on the rise worldwide. In contrast to its arterial anatomy, venous drainage of the uterus is poorly defined in the literature. Our aim was to provide a standardized description of uterine veins through a multimodal approach to establish anatomical landmarks for the uterine transplantation surgeon.

METHODS

Data were obtained from: (1) an anatomical study of eight fresh female cadavers (16 hemipelves) studied separately by an extrafascial dissection from the iliac bifurcation to the uterine pedicle, with analysis of the urinary tract and nerve structures; and (2) a virtual anatomical study from the Anatomage® Table comprising a high-fidelity virtual reconstruction of two deceased female subjects by imaging and anatomical methods.

RESULTS

An inconstant duality of uterine veins was identified: a deep uterine vein of larger caliber, and a superficial uterine vein observed in 25% of cases. A close relationship of the ureter passing posterior to the superficial uterine vein and anterior to the deep uterine vein was evident in the parametrium. The inferior hypogastric plexus was identified in all cases immediately behind the deep uterine vein. The data obtained from the fresh female cadavers were validated by the Anatomage® Table.

CONCLUSIONS

We describe the close relationship of the uterine veins with the ureter and the inferior hypogastric plexus. This knowledge represents a surgical landmark to support the success of uterine transplantation by respecting both the graft and the safety of the living donor by limiting the risk of injuries during uterus procurement. This article is protected by copyright. All rights reserved.

Procurement of Uterus in a Deceased Donor Multi-Organ Donation National Program in France: A Scarce Resource for Uterus Transplantation?

Uterus transplantation is a new possibility for women suffering from absolute uterine infertility to become pregnant and have children. In the case of a deceased donor, a list of exclusion criteria is defined to ensure the high quality of the uterus graft. This study evaluates the number of potentially available uterus grafts based on the pre-defined exclusion criteria in a national deceased donor multi-organ donation program in France. We analyzed the data reported in the CRISTAL database regarding all women aged 18 to 60 on whom organ procurement was performed between 2014 and 2019. Potential deceased women donors were classified into three categories: very ideal donor, ideal donor, and expanded criteria donor. Between 2014 and 2019, 4544 women underwent organ procurement. Using the very ideal donor, ideal donor, and expanded criteria donor classification, we found that, respectively, only 124, 264, and 936 donors were potentially eligible for UTx. This represents 2.8 per million people (PMP) very ideal donors, 3.8 PMP ideal donors, 8.6 PMP expanded criteria donors (ECDs). The restricted number of grafts requires a complementary strategy of living and deceased donors to meet the demand of all women with AUI.

[Guidelines for Clinical Practice of the French College of Obstetricians and Gynecologists 2021: Prophylactic procedures associated with gynecologic surgery]

OBJECTIVE

To draw up recommendations on the use of prophylactic gynecologic procedures during surgery for other indications.

DESIGN

A consensus panel of 19 experts was convened. A formal conflict of interest policy was established at the onset of the process and applied throughout. The entire study was performed independently without funding from pharmaceutical companies or medical device manufacturers. The panel applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system to evaluate the quality of evidence on which the recommendations were based. The authors were advised against making strong recommendations in the presence of low-quality evidence. Some recommendations were ungraded.

METHODS

The panel studied 22 key questions on seven prophylactic procedures: 1) salpingectomy, 2) fimbriectomy, 3) salpingo-oophorectomy, 4) ablation of peritoneal endometriosis, 5) adhesiolysis, 6) endometrial excision or ablation, and 7) cervical ablation.

RESULTS

The literature search and application of the GRADE system resulted in 34 recommendations. Six were supported by high-quality evidence (GRADE 1+/-) and 28 by low-quality evidence (GRADE 2+/-). Recommendations on two questions were left ungraded due to a lack of evidence in the literature.

CONCLUSIONS

A high level of consensus was achieved among the experts regarding the use of prophylactic gynecologic procedures. The ensuing recommendations should result in improved current practice.

In which cases should endometrial destruction be performed during an operative hysteroscopy? Clinical practice guidelines from the French College of Gynaecologists and Obstetricians (CNGOF)

OBJECTIVE

To provide guidelines from the French College of Obstetricians and Gynaecologists (CNGOF), based on the best evidence available, concerning the impact of endometrial destruction on bleeding and endometrial cancer risk reduction in patients candidates for operative hysteroscopy.

METHODS

Recommendations were made according to AGREE II and the GRADE® (Grading of Recommendations Assessment, Development and Evaluation) systems to determine separately the quality of evidence (QE) and in the level of recommendation.

RESULTS

In a retrospective study comparing the incidence of endometrial cancer in 4776 patients with menorrhagia treated with endometrial destruction vs 229 945 patients with a medical treatment. There was a non-significant reduced risk of developing endometrial cancer (HR, 0.45; 95% CI, 0.15-1.40; p = .17). In premenopausal women, five studies compared the incidence of endometrial cancer in patients treated with endometrial ablation/destruction (EA/D) to the incidence of endometrial cancer in a comparable population of women from national registers, all of which show reduced risk of endometrial cancer after endometrectomy. In case of menopausal metrorrhagia, the prevalence of endometrial cancer is 9%, by analogy with the results found in premenopausal patients, the combination of endometrial ablation during operative hysteroscopy seems justified. In a retrospective cohort of 177 non-menopausal patients treated with myomectomy for metrorrhagia and/or menorrhagia, a significantly better control of bleeding at 12 months was found when myomectomy was combined with endometrectomy using roller-ball (OR: 0.18 [95% Cl 0.05-0.63]; p = 0.003).

CONCLUSION

In premenopausal women with heavy menstrual bleeding, when an operative hysteroscopy is performed, it is recommended to propose an endometrial ablation/destruction in order to prevent the risk of endometrial cancer, (QE3) and to prevent recurrence of bleeding (QE2). In menopausal women, it is probably recommended to also perform an endometrial ablation/destruction in case of operative hysteroscopy in order to prevent the risk of endometrial cancer (QE1).

Maternal, foetal and child consequences of immunosuppressive drugs during pregnancy in women with organ transplant: a review

Although pregnancy remains exceptional in women after heart, liver or lung transplant, obstetricians and nephrologists are regularly confronted with pregnancy in renal transplant recipients. National and international registries have described the epidemiology of maternal, foetal and neonatal complications, and transplantation societies have published recommendations on the monitoring of these high-risk pregnancies. In this review, we summarize the existing data on maternal and foetal complications of pregnancies in women after renal transplant, especially the management of immunosuppression. We also describe the few available data on the middle- and long-term outcomes of their children who were exposed in utero to immunosuppressive drugs.

Vulvar and vaginal melanomas: A retrospective study spanning 19 years from a tertiary center

INTRODUCTION

Mucosal melanomas (MM) of the female genital tract are rare a. We aimed to study the prognostic factors of vulvar and vaginal locations of MM.

MATERIAL AND METHOD

A multicenter, retrospective cohort study conducted between 01/01/2000 and 01/06/2019.

RESULT

Of the 33 patients included 25 (75.8 %) had vulvar (VuM) and eight (24.2 %) vaginal melanomas (VaM). VaMs were deeper: median Breslow index: 17.5mm [3.5-22] versus 4.3mm [0.35-18] (p=0.013). Average follow-up was 24.0±59.8 months. Twenty-six patients (78.8 %) experienced recurrence. Disease-free survival was 52.9 % at 1year (64.7 % for VuM and 14.3 % for VaM) and 8.4 % at 3 years (11 % for VuM and 0% for VaM) (p=0.002). Median time to the first recurrence was 9.01 months [CI95 %: 2.07-56.71]. VaM recurred earlier than VuM (3.12 months [CI95 %: 2.07-12.49] versus 17.72 [CI95 %: 3.58-56.71], p=0.011). VaM had a higher risk of recurrence (HR=5.64 [CI95 %: 2.01-15.82], p=0.001) in multivariate analysis. Overall survival was 88.5 % at 1year (100 % for VuM and 50 % for VaM), and 59.4 % at 3 years (69.3 % for VuM and 25 % for VaM). Women with VaM died earlier: median specific death occurrence of 8.76 months [CI95 %: 6.54-24.72] versus 39.61 [CI95 %: 21.89-209.21], p=0.013 (HR=5.08 [CI95 %: 1.39-18.60], p=0.014). A lesion size ≥3cm was associated with an increased risk of mortality (HR=8.45 [CI95 %: 1.60-44.52], p=0.012). In multivariate analysis, vaginal location remained an independent and predictive variable of a higher risk of specific death (HR=8.56 [CI95 %: 1.95-37.64], p=0.005).

CONCLUSION

A vaginal location of MM is associated with a poorer prognosis than a vulvar location.

Single bilateral ovarian venous return in uterine transplant: Validation in an orthotopic auto-transplant model in the Yucatan minipig

BACKGROUND

Uterine transplant (UT) represents an opportunity to treat absolute uterine infertility. However, the use of uterine veins for venous return, in addition to ovarian veins, significantly increases the risk of ureteral wounds in the living donor and UT time for the recipient. Our aim was to demonstrate that dual ovarian venous return is sufficient for graft viability and survival.

METHODS

Uterine orthotopic auto-transplant was performed under general anaesthesia in six Yucatan minipig sows. The uterus graft was implanted with termino-lateral anastomoses between the ovarian and external iliac veins, and between the uterine and external iliac arteries, respectively.

RESULTS

The macroscopic physical aspect of the graft was adequate in 83 % of the sows (5/6) 30 min after reperfusion with a surgical time of 439±54 min (mean anastomosis time: 153±49 min). Two sows died the day after surgery. In the four remaining sows, two uteri were necrotic and two were adequately vascularized on Day 7.

CONCLUSIONS

the learning curve was relatively fast, the sole use of bilateral ovarian venous return is possible and might reduce post-surgery morbidity in human living donors as well as UT time for the recipient.

Management of borderline ovarian tumours during pregnancy: Results of a French multi-centre study

OBJECTIVE

To assess the diagnostic and prognostic characteristics of borderline ovarian tumours (BOTs) detected during pregnancy, and to establish an inventory of French practices.

MATERIALS AND METHODS

A retrospective multi-centre case study of 14 patients treated for BOTs, diagnosed during pregnancy between 2005 and 2017, in five French pelvic cancerology expert centres, including data on clinical characteristics, histological tumour characteristics, surgical procedure, adjuvant treatments, follow-up and fertility.

RESULTS

The mean age of patients was 29.3 [standard deviation (SD) 6.2] years. Most BOTs were diagnosed on ultrasonography in the first trimester (85.7 %), and most of these cases (78.5 %) also underwent magnetic resonance imaging to confirm the diagnosis (true positives 54.5 %). Most patients underwent surgery during pregnancy (57 %), with complete staging surgery in two cases (14.3 %). Laparoscopy was performed more frequently than other procedures (50 %), and unilateral adnexectomy was more common than cystectomy (57.5 %). Tumour size influenced the surgical approach significantly (mean size 7.5 cm for laparoscopy, 11.9 cm for laparoconversion, 14 cm for primary laparotomy; P = 0.08), but the type of resection did not. Most patients were initially diagnosed with International Federation of Gynecology and Obstetrics stage IA (92.8 %) tumours, but many were upstaged after complete restaging surgery (57.1 %). Most BOTs were serous (50 %), two cases had a micropapillary component (28.5 %), and one case had a micro-invasive implant. BOTs were bilateral in two cases (14.2 %). Mean follow-up was 31.4 (SD 14.8) months. Recurrent lesions occurred in two patients (14.2 %) and no deaths have been recorded to date among the study population.

CONCLUSION

BOTs remain rare, but this study - despite its small sample size - supports the hypothesis that BOTs during pregnancy have potentially aggressive characteristics.

Recurrence Pattern of Cervical Cancer Based on the Platinum Sensitivity Concept: A Multi-Institutional Study from the FRANCOGYN Group

The standard of care for patients with advanced cervical cancer (ACC) includes platinum-based chemotherapy. The concept of platinum sensitivity is a major prognostic factor for patients with ovarian cancer. The aim of this study was to validate the applicability of the platinum sensitivity concept to ACC patients, and to estimate its prognostic interest in terms of overall survival (OS) and pattern of recurrence (location, timing). Data of women with histologically proven FIGO 2019 stages IB3-IV ACC, treated between May 2000 and November 2017 with platinum-based regimens, were retrospectively abstracted from 12 institutions from the FRANCOGYN Group. Respective 3-year OSs were 52% (95% CI: 40.8%-66.8%), 21.6% (95% CI: 12.6%-37.2%), and 14.6% (95% CI: 4.2%-50.2%), in case of recurrence <6 months, between 6 and 17 months, and ≥18 months (p < 0.001). Risk of metastatic or multisite recurrence was significantly higher in case of recurrence <6 months, and risk of local or isolated infradiaphragmatic nodal recurrence was significantly higher in case of recurrence >18 months (p < 0.001). In multivariate analysis, platinum sensitivity status was a strong prognostic factor for OS after recurrence, independent of histological grade, lympho-vascular space involvement, final lymph node status, and treatment. Platinum sensitivity status may help to classify patients in three prognostic subgroups for OS after recurrence, and appears to be a strong prognostic factor correlated to the pattern of recurrence.

Ovarian response to stimulation for fertility preservation in women with hematologic cancer

PURPOSE

To compare the ovarian response to controlled ovarian hyperstimulation (COH) in patients with hematologic malignancies treated for fertility preservation (FP) and healthy subjects (oocyte donors (OD)).

PATIENTS AND METHODS

Retrospective cohort study comparing 41 women (18-37 years) who underwent COH for oocyte vitrification prior to gonadotoxic treatment for hematologic cancer (FP group) from January 2014 to February 2019 and with 117 women undergoing COH as part of an OD protocol (OD group) during the same period. The number of frozen mature oocytes, number of oocytes retrieved, total dose of rFSH, maximal estradiol levels, percentage of maturity, number of dominant follicles >14 mm, days of stimulation were evaluated. Results were adjusted for age, body mass index (BMI), anti-Mullerian hormone (AMH) and rFSH starting dose.

RESULTS

Patients in the FP group were younger and had a lower BMI than those in the OD group. rFSH starting dose was higher in the FP group (median 225UI (125;450) vs 150UI (87.5;337.5), p < 0.0001). After adjusting for age, BMI and starting rFSH dose according to ANCOVA, more frozen mature oocytes (median 10 (0;45) vs 8 (0;22] p = 0.0055) and retrieved oocytes (median 12 (0;49) vs 11 (0;29) p = 0.0468) were found in the FP group. Other outcome measures did not differ between the groups.

CONCLUSION

Ovarian response after COH in women with a hematologic cancer is similar to that in the general population. A higher number of mature oocytes were collected in the FP group after strong COH.

[Uterus transplantation, current prospect and future indications. State of art with review of literature]

OBJECTIVES

The aim of this review is to summarize the development of UT on worldwide and to develop the new questions posed by this technique in 2020.

METHODS

According to the PRISMA model, via Pubmed, we searched for publications containing the keywords: uterus transplantation; UT and cryopreservation from 2000 to 2020.

RESULTS

At least 76 UTx have been carried out around the world and 19 healthy babies were born. The main indication remains the uterine agenesis (MRKH Syndrome>85% cases) then the history of hysterectomy (hemorrhage of the delivery or cervical cancer) and the non-functional uterus (Asherman's syndrome, diffuse adenomyosis). The 2 types of donors (living and deceased) are developed representing respectively 75% and 25% of the TU; the success rate in terms of return of rules is better in the living donor group and is 79% vs 68% in the deceased donor group. The choice of donor type must take into account the constraints of both procedures. Surgical complications (grade III) for the donor are estimated to be 14% mainly represented by ureter wounds. Technical simplifications concerning the venous return of the graft but also the carrying out of robot-assisted surgery would reduce the operating time for the donor and facilitate the collection process.

CONCLUSION

TU is a complementary alternative to GPA and adoption allowing patients to be surrogates, legal and biological of the baby. An extension of the indications to patients with non absolute uterine infertility is in the process of democratization.

Recommendations for the surgical management of gynecological cancers during the COVID-19 pandemic - FRANCOGYN group for the CNGOF

INTRODUCTION

In the context of the COVID-19 pandemic, specific recommendations are required for the management of patients with gynecologic cancer.

MATERIALS AND METHOD

The FRANCOGYN group of the National College of French Gynecologists and Obstetricians (CNGOF) convened to develop recommendations based on the consensus conference model.

RESULTS

If a patient with a gynecologic cancer presents with COVID-19, surgical management should be postponed for at least 15 days. For cervical cancer, radiotherapy and concomitant radiochemotherapy could replace surgery as first-line treatment and the value of lymph node staging should be reviewed on a case-by-case basis. For advanced ovarian cancers, neoadjuvant chemotherapy should be preferred over primary cytoreduction surgery. It is legitimate not to perform hyperthermic intraperitoneal chemotherapy during the COVID-19 pandemic. For patients who are scheduled to undergo interval surgery, chemotherapy can be continued and surgery performed after 6 cycles. For patients with early stage endometrial cancer of low and intermediate preoperative ESMO risk, hysterectomy with bilateral adnexectomy combined with a sentinel lymph node procedure is recommended. Surgery can be postponed for 1-2 months in low-risk endometrial cancers (FIGO Ia stage on MRI and grade 1-2 endometrioid cancer on endometrial biopsy). For patients of high ESMO risk, the MSKCC algorithm (combining PET-CT and sentinel lymph node biopsy) should be applied to avoid pelvic and lumbar-aortic lymphadenectomy.

CONCLUSION

During the COVID-19 pandemic, management of a patient with cancer should be adapted to limit the risks associated with the virus without incurring loss of chance.

Prognostic value of posttreatment FEDG-PET imaging following combined chemoradiation therapy in locally advanced cervical cancer

OBJECTIVES

To evaluate the performances of posttreatment FEDG-PET to predict the prognosis of patients treated with concurrent chemoradiotherapy (CT/RT) for locally advanced cervical cancer.

MATERIALS AND METHODS

The medical records of 131 patients treated in 9 French academic institutions for IB2-IIB cervical cancer and for which a posttherapy FEDG-PET was performed were reviewed. All patients received CT/RT, possibly completed with vaginal brachytherapy (VBT) and completion surgery. Posttreatment FEDG-PET was performed within 3 months after completion of CT/RT or VBT. Incomplete metabolic response (IMR) was defined as the persistence of FEDG uptake.

RESULTS

An IMR was identified in 44 (33.6 %) cases. IMR was associated with higher risk of recurrence (aHR = 2.8; 95 %CI: 1.3-5.7; p = 0.006) and death (aHR = 4.5 ;95 %CI: 1.4-13.8; p = 0.009). Completion surgery was performed in 61 (46.9 %) patients with histologic cervical residual disease identified in 31 (50.8 %). FEDG-PET sensitivity and specificity in predicting cervical residual disease following CT/RT was 48.4 % (95 %CI: 30.8-66) and 80 % (95 %CI: 65.7-94.3), respectively.

CONCLUSIONS

In patients treated with CT/RT for locally advanced cervical cancer, despite limited performances to predict cervical residual disease, posttreatment FEDG-PET is predictive of patients' prognosis and long-term outcome.

Effectiveness of conservative medical treatment for non-tubal ectopic pregnancies: a multicenter study

OBJECTIVE

To assess the effectiveness of conservative treatment for the management of non-tubal ectopic pregnancies (NTEP) METHODS: Retrospective cohort study in three centers (two referral centers) of patients managed for NTEP diagnosed by 2D or 3D ultrasonograhy. Patients underwent one of the following: expectant management, systemic methotrexate (MTX) injection, local MTX injection, combined MTX injection (local and systemic), local injection of hyperosmolar glucose, or misoprostol administration. The primary endpoint was final success defined by resolution of hCG level without need for emergency surgical treatment. Sixty-four patients diagnosed with NTEP were included: 37 (57%) had an interstitial pregnancy, 23 (35.9%) a cesarean scar pregnancy, two (3.1%) a cervical pregnancy and two (3.1%) an ovarian pregnancy.

RESULTS

Six patients (9.4%) underwent expectant management, 24 (37.5%) a systemic MTX injection, 28 (43.8%) a local injection of MTX, three (4.7%) a combined MTX injection, one (1.6%) a local injection of hyperosmolar glucose (1.6%), and two (3.1%) were administered misoprostol. The median age was 32 years (22-45) and mean follow-up was 41 months. The final success rate overall was 92.2%: 100% for expectant management, 87.5% for systemic MTX, 96.4% for local MTX, 100% for combined injection of MTX, 100% for local injection of hyperosmolar glucose, and 50% for misoprostol. No patient required a hysterectomy. Nine (14.1%) patients required surgery, including five (7.8% (5/64)) following a rupture of the NTEP.

CONCLUSIONS

Our results suggest that conservative medical management of NTEP is effective and safe and should be the first-line treatment for pauci-symptomatic patients with an NTEP.

[Guidelines for surgical management of gynaecological cancer during pandemic COVID-19 period - FRANCOGYN group for the CNGOF]

INTRODUCTION

Recommendations for the management of patients with gynecological cancer during the COVID-19 pandemic period.

MATERIAL AND METHOD

Recommendations based on the consensus conference model.

RESULTS

In the case of a COVID-19 positive patient, surgical management should be postponed for at least 15 days. For cervical cancer, the place of surgery must be re-evaluated in relation to radiotherapy and Radio-Chemotherapy-Concomitant and the value of lymph node staging surgeries must be reviewed on a case-by-case basis. For advanced ovarian cancers, neo-adjuvant chemotherapy should be favored even if primary cytoreduction surgery could be envisaged. It is lawful not to offer hyperthermic intraperitoneal chemotherapy during a COVID-19 pandemic. In the case of patients who must undergo interval surgery, it is possible to continue the chemotherapy and to offer surgery after 6 cycles of chemotherapy. For early stage endometrial cancer, in case of low and intermediate preoperative ESMO risk, hysterectomy with bilateral annexectomy associated with a sentinel lymph node procedure should be favored. It is possible to consider postponing surgery for 1 to 2 months in low-risk endometrial cancers (FIGO Ia stage on MRI and grade 1-2 endometrioid cancer on endometrial biopsy). For high ESMO risk, it ispossible to favor the MSKCC algorithm (combining PET-CT and sentinel lymph node biopsy) in order to omit pelvic and lumbar-aortic lymphadenectomies.

CONCLUSION

During COVID-19 pandemic, patients suffering from cancer should not lose life chance, while limiting the risks associated with the virus.

[Borderline Ovarian Tumours: CNGOF Guidelines for Clinical Practice - Value of Tumor Markers]

OBJECTIVES

To evaluate the diagnostic value of serum biomarkers in the management strategy of borderline ovarian tumours (BOT) to make management recommendations.

METHODS

English and French review of literature from 1990 to 2019 based on publications from Pubmed, Medline, Cochrane, with keywords: borderline ovarian tumors, tumour markers, CA125, CA19 9, ACE, CA72 4, TAG72, HE4, ROMA, mucinous, serous, mucinous, endometrioid ovarian tumours, peritoneal implants, recurrence, overall survival, follow-up. Among 1000 references, 400 were selected and only 30 were screened for this work.

RESULTS

Literature review: there is low evidence in literature concerning the discriminating value of serum tumour biomarkers (CA125, CA19-9, CEA, CA72-4, HE4) and specific score between presumed benign ovarian tumour/BOT/ovarian cancer (LE4). Serum CA125 antigen is higher in case of serous borderline ovarian tumour (LE4), increase with the tumor height, the FIGO stage, notably in case of serous borderline ovarian tumor. However, a normal value rate of serum CA125 antigen does not rule out a BOT (LE4). The preoperative positivity rate of CA19 9 in case of TFO is relatively lower than that of CA125 and is higher in mucinous TFO. The preoperative rate of serum CA19 9 antigen increases with the tumour height and the FIGO stage (LE4) and are higher in case of mucinous BOT (LE4). Preoperative rates of serum HE4 are not different between histologic type of BOT. A high level of serum biomarkers (CA125) is a predictive factor of peritoneal implants (LE4) and an independent predictive factor of recurrence (CA125) (LE4).

RECOMMENDATIONS

no recommendation can be made about the use of serum tumour biomarkers (CA125, CA19-9, CEA, CA72-4, HE4) or specific score in order to distinguish benign ovarian tumor/borderline ovarian tumor/ovarian cancer in case of indeterminate mass. In case of suspicion of mucinous ovarian tumour on imaging, the systematic dosage of serum CA19-9 antigen can be proposed (grade C). In case of an ovarian indeterminate mass on imaging; dosage of serum HE4 and C125 is recommended. If preoperative dosage of serum tumor biomarkers is normal, their systematic dosage is not recommended in the follow-up of BOT (grade C). If preoperative dosage of CA125 is high, the systematic dosage of CA125 is recommended in the follow-up of BOT with no precisions about the rhythm and the duration of the follow-up (grade B).

[Pap smear before 25 years old]

OBJECTIVES

Current French recommendations advocate cervical-vaginal screening for cervical cancer from age 25 whereas earlier screening is mostly found in current clinical practice although its consequences are not well understood.

METHODS

A literature review using the MedLine database on the natural history of HPV infections, cytological screening, management of cytological and histological anomalies in adolescents and young women.

RESULTS

The adolescent and young woman have some characteristics that distinguish them from adult women: a high prevalence of HPV infections (making the use of the HPV test unprofitable), accompanied by a higher clearance; frequency of minor cytological abnormalities (for which a cytological surveillance without colposcopy is sufficient) and low-grade histological lesions of low grade the usual prognosis of which is complete recovery; and rarity of CIN3 lesions and absence of invasive lesions, allowing no treatment in patients with CIN2 lesions and compliant to cytological and colposcopic surveillance.

CONCLUSION

Cervical screening in the adolescent and young woman is not a logical attitude and the discovery of cytological or histological lesions requires specific behavior in this particular population.

Atypical epithelial hyperplasia of the breast: state of the art

INTRODUCTION

Atypical epithelial hyperplasia (AEH) of the breast is considered benign histological lesions with breast cancer risk. This review focuses on clinical signification and management of AEH that remains controversial.

AREAS COVERED

A review of published studies was performed using medline database. In this review, we fully describe the current evidence available. In particular, we describe 1) data from immunohistochemistry and molecular studies that suggest AEH is a precursor of breast cancer; 2) epidemiological studies demonstrate low rate of breast cancer in women with AEH; 3) surgical excision is necessary after diagnosis of AEH, such as lobular carcinoma in situ or atypical ductal hyperplasia, on core needle biopsy; 4) although current recommendations are evolving to fewer (if not no) excisions for flat epithelial with atypia and classic lobular neoplasia found on percutaneous biopsy (without radiologic indications for excision). Expert commentary: HEA management steel need prospective evidences, but recent retrospective data give some clue for less invasive management for some of HEA.

HIV Lipodystrophy Case Definition using Artificial Neural Network Modelling

Objective

A case definition of HIV lipodystrophy has recently been developed from a combination of clinical, metabolic and imaging/body composition variables using logistic regression methods. We aimed to evaluate whether artificial neural networks could improve the diagnostic accuracy.

Methods

The database of the case-control Lipodystrophy Case Definition Study was split into 504 subjects (265 with and 239 without lipodystrophy) used for training and 284 independent subjects (152 with and 132 without lipodystrophy) used for validation. Back-propagation neural networks with one or two middle layers were trained and validated. Results were compared against logistic regression models using the same information.

Results

Neural networks using clinical variables only (41 items) achieved consistently superior performance than logistic regression in terms of specificity, overall accuracy and area under the ROC curve. Their average sensitivity and specificity were 72.4 and 71.2%, as compared with 73.0 and 62.9% for logistic regression, respectively (area under the ROC curve, 0.784 vs 0.748). The discriminating performance of the neural networks was largely unaffected when built excluding 13 parameters that patients may not have readily available. The average sensitivity and specificity of the neural networks remained the same when metabolic variables were also considered (total 60 items) without a clear advantage against logistic regression (overall accuracy 71.8%). The performance of networks considering also body composition variables was similar to that of logistic regression (overall accuracy 78.5% for both).

Conclusions

Neural networks may offer a means to improve the discriminating performance for HIV lipodystrophy, when only clinical data are available and a rapid approximate diagnostic decision is needed. In this context, information on metabolic parameters is apparently not helpful in improving the diagnosis of HIV lipodystrophy, unless imaging and body composition studies are also obtained.

Acute ascites with blunt cardiac rupture

A unique case of acute ascites following blunt cardiac rupture is reported. A 32-year-old woman was admitted to another hospital and transferred to the authors' institution in cardiopulmonary shock with a very distended abdomen 2.5 h after a motor vehicle accident. Laparotomy was immediately performed and revealed 4 to 5 L of crystal clear fluid and a severe liver congestion. Cardiac tamponade was suspected and confirmed through a transdiaphragmatic pericardial window. Sternotomy was performed and a single right atrial appendage laceration identified, which was successfully repaired. The literature regarding blunt traumatic cardiac rupture is briefly reviewed, and the possible pathophysiology of ascites in a blunt traumatic cardiac rupture is discussed.

[Joint manifestations in chronic T-cell lymphocytosis and neutropenia]

The authors report the case of a patient suffering from chronic T-cell lymphocytosis and neutropenia (CTLN), detected from seropositive rheumatoid arthritis with attacks of fever. The distinctive features of CTLN, isolated from other forms of chronic T-cell lymphoid leukemias, are recalled. The frequency and nature of joint signs found during this new hematologic entity are described.