[Simulation training for French obstetrics and gynecology residents: A national survey in 2022]

OBJECTIVES

To evaluate the use of simulation among French Obstetrics and Gynecology residency programs.

METHODS

A survey was conducted with all 28 French residency program directors. The questionnaire covered equipment and human resources, training programs, types of simulation tools and time spent.

RESULTS

Of the cities hosting a residency program, 93% (26/28) responded regarding equipment and human resources, and 75% (21/28) responded regarding training program details. All respondents declared having at least one structure dedicated to simulation. A formal training program was reported by 81% (21/26) of cities. This training program was mandatory in 73% of the cases. There was a median number of seven senior trainers involved, three of whom had received a specific training in medical education. Most of declared simulation activities concerned technical skills in obstetrics and surgery. Simulations to practice breaking bad news were offered by 62% (13/21) of cities. The median number of half-days spent annually on simulation training was 55 (IQR: 38-83).

CONCLUSION

Simulation training is now widely available among French residency programs. There remains heterogeneity between centers regarding equipment, time spent and content of simulation curricula. The French College of Teachers of Gynecology and Obstetrics has proposed a roadmap for the content of simulation-based training based on the results of this survey. An inventory of all existing "train the trainers" simulation programs in France is also provided.

Role of chromosomal imbalances in the pathogenesis of DSD: A retrospective analysis of 115 prenatal samples

Differences of sex development (DSDs) are a group of congenital conditions characterized by a discrepancy between chromosomal, gonadal, and genital sex development of an individual, with significant impact on medical, psychological and reproductive life. The genetic heterogeneity of DSDs complicates the diagnosis and almost half of the patients remains undiagnosed. In this context, chromosomal imbalances in syndromic DSD patients may help to identify new genes implicated in DSDs. In this study, we aimed at describing the burden of chromosomal imbalances including submicroscopic ones (copy number variants or CNVs) in a cohort of prenatal syndromic DSD patients, and review their role in DSDs. Our patients carried at least one pathogenic or likely pathogenic chromosomal imbalance/CNV or low-level mosaicism for aneuploidy. Almost half of the cases resulted from an unbalanced chromosomal rearrangement. Chromosome 9p/q, 4p/q, 3q and 11q anomalies were more frequently observed. Review of the literature confirmed the causative role of CNVs in DSDs, either in disruption of known DSD-causing genes (SOX9, NR0B1, NR5A1, AR, ATRX, …) or as a tool to suspect new genes in DSDs (HOXD cluster, ADCY2, EMX2, CAMK1D, …). Recurrent CNVs of regulatory elements without coding sequence content (i.e. duplications/deletions upstream of SOX3 or SOX9) confirm detection of CNVs as a mean to explore our non-coding genome. Thus, CNV detection remains a powerful tool to explore undiagnosed DSDs, either through routine techniques or through emerging technologies such as long-read whole genome sequencing or optical genome mapping.

[CNGOF-SFT Expert Report and Guidelines for Smoking Management during Pregnancy-Short Text]

OBJECTIVES

To provide up-to-date evidence-based guidelines for the management of smoking cessation during pregnancy.

METHODS

Systematic review of the international literature. We identified papers published between January 2003 and April 2019 in Cochrane PubMed, and Embase databases with predefined keywords. All reports published in French and English relevant to the areas of focus were included and classified according the level of evidence ranging from 1 (highest) to 4 (lowest). The strength of the recommendations was classified according to the Haute Autorité de santé, France (ranging from A, highest to C, lowest).

RESULTS

"Counseling", involving globally all kind of non-pharmacological interventions, has a modest benefit on smoking cessation, birth weight and prematurity. Moderate physical activity did not show a significant effect on smoking cessation. The systematic use of feedback by measuring the expired air carbon monoxide concentration do not influence smoking abstinence but it may be used in establishing a therapeutic alliance. The use of self-help interventions and health education are recommended in helping pregnant smokers quit. The prescription of nicotine replacement therapies (NRT) may be offered to any pregnant woman who has failed stopping smoking without medication This prescription can be initiated by the health care professional taking care of the pregnant woman in early pregnancy. There is no scientific evidence to propose the electronic cigarette for smoking cessation to pregnant smokers; it is recommended to provide the same advice and to use methods that have already been evaluated. The use of waterpipe (shisha/narghile) during pregnancy is associated with decreased fetal growth. It is recommended not to use waterpipe during pregnancy. Breastfeeding is possible in smokers, but less often initiated by them. Although its benefit for the child's development is not demonstrated to date, breastfeeding allows the mother to reduce or stop smoking. The risk of postpartum relapse is high (up to 82% at 1 year). The main factors associated with postpartum abstinence are breastfeeding, not having a smoker at home, and having no symptoms of postpartum depression.

CONCLUSIONS

Smoking during pregnancy concerns more than hundred thousand women and their children per year in France. It is a major public health burden. Health care professionals should be mobilized for reducing or even eradicating it.

[Smoking and Breastfeeding - CNGOF-SFT Expert Report and Guidelines on the management for Smoking Management During Pregnancy]

INTRODUCTION

The consequences of smoking have been studied more during pregnancy than during breastfeeding. There is a passage of nicotine and other substances in breast milk and some modifications of milk composition. The objectives of this chapter are to study the benefits of breastfeeding in women who smoke, and the adaptation of smoking, medication and behavioral habits in case of incomplete withdrawal to better guide women.

METHODS

The Medline database, the Cochrane Library and foreign guidelines from 1999 to 2019 have been consulted.

RESULTS

The conservation of the benefit of breastfeeding in smokers with regard to the prevention of respiratory infections, infantile colic, cognitive deficits, obesity, sudden infant death, is not known to date. It is therefore not recommended to include smoking status in the choice of feeding mode for the newborn (professional agreement). However, since breastfeeding is a factor associated with a reduction in smoking and/or withdrawal (NP2), it is recommended to promote breastfeeding in non-weaned women in order to limit smoking (grade B). The use of nicotine replacement therapy is possible during breastfeeding (professional agreement). In the absence of data, bupropion (Zyban®) and varenicline (Champix®) are not recommended for women who are breastfeeding (professional agreement). A free interval between smoking and breastfeeding reduces the concentration of nicotine in milk (NP4). For non-weaned women who are breastfeeding, it is therefore recommended not to smoke just before breastfeeding (professional agreement).

CONCLUSION

The results indicate that breastfeeding is possible in smokers, although less often initiated by them. If the conservation of its benefits for the child is not demonstrated to date, breastfeeding allows the mother to limit smoking.

[In Utero Exposure to Maternal Smoking: Impact on the Child from Birth to Adulthood - CNGOF-SFT Expert Report and Guidelines for Smoking Management during Pregnancy]

INTRODUCTION

Smoking during pregnancy leads to fetal passive smoking. It is associated with several obstetrical complications and is a major modifiable factor of maternal and fetal morbidity. Long-term consequences also exist but are less well known to health professionals and in the general population.

METHODS

Consultation of the Medline® database.

RESULTS

Maternal smoking during pregnancy is associated in the offspring with sudden infant death syndrome (NP2), impaired lung function (NP2), lower respiratory infections and asthma (NP2), overweight and obesity (NP2), cancers (NP3), risk of tobacco use, nicotine dependence and early smoking initiation (NP2). Unadjusted analyses show associations between in utero tobacco exposure and cognitive deficits (NP3), impaired school performance (NP3) and behavioral disorders in children (NP2), which are in a large part explained by environmental factors. There is a cross-generational effect of smoking during pregnancy. For example, an increased risk of asthma is observed in the grandchildren of smoking women (NP4). The respective roles of ante- and post-natal smoking remain difficult to assess.

CONCLUSION

These results highlight the importance of prevention measures against tobacco use in the general population, as well as screening measures and support for smoking cessation before or at the beginning of the pregnancy.

Smoking and smoking cessation in pregnancy. Synthesis of a systematic review

OBJECTIVES

To provide up-to-date evidence-based guidelines for the management of smoking cessation during pregnancy and the post-partum period.

STUDY DESIGN

A systematic review of the international literature was undertaken between January 2003 and April 2019. MEDLINE, EMBASE databases and the Cochrane library were searched for a range of predefined key words. All relevant reports in English and French were classified according to their level of evidence ranging from 1(highest) to 4(lowest). The strength of each recommendation was classified according to the Haute Autorité de Santé (French National Authority for Health) ranging from A (highest) to C (lowest).

RESULTS

"Counselling", including all types of non-pharmacological interventions, has a moderate benefit on smoking cessation, birth weight and prematurity. The systematic use of measuring expired air CO concentration does not influence smoking abstinence, however, it may be useful in assessing smoked tobacco exposure prior to and after quitting. The use of self-help therapies and health education are recommended in helping pregnant smokers quit and should be advised by healthcare professionals. Nicotine replacement therapies (NRT) may be prescribed to pregnant women who have failed to stop smoking after trying non-pharmacological interventions. Different modes of delivery and dosages can be used in optimizing their efficacy. Smoking in the postpartum period is essential to consider. The same treatment options as during pregnancy can be used.

CONCLUSION

Smoking during pregnancy concerns more than a hundred thousand women each year in France resulting in a major public health burden. Healthcare professionals should be mobilised to employ a range of methods to reduce or even eradicate it.

Perinatal grief following neonatal comfort care for lethal fetal condition

BACKGROUND

The objective of the study was to assess perinatal grief experienced after continuing pregnancy and comfort care in women diagnosed with lethal fetal condition compared with termination of pregnancy for fetal anomaly (TOPFA).

METHODS

This was a retrospective observational study which included women who chose to continue their pregnancy after the diagnosis of lethal fetal condition with comfort care support at birth at the Prenatal Diagnosis Center of Rennes Hospital from January 2007 to January 2017. Women were matched with controls who underwent TOPFA for the same type of fetal anomaly, gestational age at diagnosis and year. Women were evaluated by a questionnaire including the Perinatal Grief Scale.

RESULTS

There were 28 patients in the continuing pregnancy group matched with 56 patients in the TOPFA group. Interval between fetal loss and completion of questionnaire was 6±3 years. Perinatal grief score was similar at 61±22 vs 58±18 (p = 0.729) in the continuing pregnancy and TOPFA groups, respectively. Women in the TOPFA group expressed more guilt. The cesarean-section rate in the continuing pregnancy group was 25%.

CONCLUSION

Perinatal grief experienced by women opting for continuing pregnancy and comfort care after diagnosis of a potentially lethal fetal anomaly is not more severe than for those choosing TOPFA.

Improving the quality of transvaginal ultrasound scan by simulation training for general practice residents

Background

Ultrasonography (US) is an essential tool for the diagnosis of acute gynecological conditions. General practice (GP) residents are involved in the first-line management of gynecologic emergencies. They are not familiar with US equipment. Initial training on simulators was conducted.

The aim of this study was to evaluate the impact of simulation-based training on the quality of the sonographic images achieved by GP residents 2 months after the simulation training versus clinical training alone.

Methods

Young GP residents assigned to emergency gynecology departments were invited to a one-day simulation-based US training session. A prospective controlled trial aiming to assess the impact of such training on TVS (transvaginal ultrasound scan) image quality was conducted. The first group included GP residents who attended the simulation training course. The second group included GP residents who did not attend the course. Written consent to participate was obtained from all participants. Images achieved 2 months after the training were scored using standardized quality criteria and compared in both groups. The stress generated by this examination was also assessed with a simple numeric scale.

Results

A total of 137 residents attended the simulation training, 26 consented to participate in the controlled trial. Sonographic image quality was significantly better in the simulation group for the sagittal view of the uterus (3.6 vs 2.7, p = 0.01), for the longitudinal view of the right ovary (2.8 vs 1.4, p = 0.027), and for the Morrison space (1.7 vs 0.4, p = 0.034), but the difference was not significant for the left ovary (2.9 vs 1.7, p = 0.189). The stress generated by TVS after 2 months was not different between the groups (6.0 vs 4.8, p = 0.4).

Conclusion

Simulation-based training improved the quality of pelvic US images in GP residents assessed after 2 months of experience in gynecology compared to clinical training alone.

Age related evolution of stable collagen reticulation in human skin

The relaxation time of hydrothermal isometric tensions (HIT) was measured in different tissues during collagen hydrolysis. This hydrolysis was shown to have the same activation energy in all skin samples studied, whatever the species and age. Therefore, variations in the HIT relaxation half-time at the boiling point, exclusively reflected variations in the reticulation degree of the stable infinite network of denatured collagen. Stable collagen reticulation was studied in human skin from birth to 70 yrs of age in 113 biopsies, by measuring the relaxation half-time of hydrothermal isometric tension (HIT) at boiling point. This time was observed to vary in three different ways as a function of age: 1) from birth to eight or 10 yrs and from 14-15 yrs until adulthood, it increased constantly, and at the same rate; 2) during early puberty, the striking observation was the dramatic decrease of relaxation time value which remained low for 4-5 yrs thereafter, and 3) from adulthood to 70 yrs of age, relaxation time values were scattered along several plateaux, apparently separated by similar incremental steps. A parallel study on rat and pig skin showed a similar age-related evolution for collagen stable reticulation i.e., a sudden drop of reticulation at puberty, and low values for several months thereafter, followed by a linear increase, at the same rate as that observed for human skin. The study of collagen reticulation in various pathological situations may help to clarify and increase our understanding of the different mechanisms involved in collagen modifications during in vivo growth and aging.

Tendon adaptation to different long term stresses and collagen reticulation in soleus muscle

Leg immobilization with or without soleus muscle denervation was studied in young rabbits. Muscle and tendon were maintained in extension, i.e., in the most lengthened position. Length measurements performed on sarcomeres, muscle fibers and tendon-plus-muscle complexes suggest the following progression in tendon growth rates: normal less than denervated-extended less than innervated-extended. Collagen reticulation was studied as a function of fiber location along these tendons by measuring hydrothermal isometric tension (HIT). Large variations were observed depending on fiber location, and significant modifications were induced by immobilization in extension. The results are discussed in relation to stress as a possible factor controlling collagen maturation in connective tissues.

Tendon adaptation to bone shortening

The ability of tendon to adapt its length to imposed conditions was tested in rat soleus. Shortening of one tibia left tendon insertions intact, but reduced the distance between them. Tendon lengths were found to decrease after a short period of recovery (1 or 2 months) whether surgery was performed in young or adult animals. Comparison of tibia and tendon length correlation in control rats of different ages and in experimental animals showed that adaptation was more complete in young rats than in adult rats. A long period of recovery seemed to improve adaptation only in young rats. Hydrothermal isometric tension measurements indicated that collagen remodeling occurred during tendon adaptation to bone length, with the process being more marked at the muscle-tendon junction.

Hydrothermal isometric tension curves from different connective tissues. Role of collagen genetic types and noncollagenous components

Variations in hydrothermal isometric tension (HIT) were recorded in tendons, ligaments, skin, blood vessels, nerves, palatal mucosa, lungs, muscles, cartilages, demineralized bones and dentine from donors of different ages and species. The curves obtained during a linear rise in temperature from 37 degrees C to 100 degrees C at a rate of 1.15 degrees C/min were classified into three major families, A, B and C, depending on whether these curves displayed an early maximum, two shoulders or a late maximum. The ratio of heat-labile to heat-stable cross-links in the tissue's collagen network was shown to determine the type of curve obtained, but the genetic types of collagen in the tissue and the amount and quality of its noncollagenous components were not important in this respect. These results are discussed in the light of the accepted view that HIT variations are due to the rubber-elastic properties of gelatin.

The rate of collagen maturation in rat and human skin

Hydrothermal Isometric Tension (HIT) relaxation was observed at the boiling point in rat, cat and human skin samples of different ages, after raising the temperature from 37 degrees to 100 degrees C at a rate of 1.15 degrees C/min. A Maxwellian relaxation to nearly zero was observed at the boiling point. A given velocity constant characterized a given tissue whether experiments were performed under pressure or under tensile stress. However, the velocity constant of the relaxation decreased as a function of age for all three species during the period studied. Moreover, the velocity constant decreased at the same constant rate for skin samples of cats aged 1 to nearly 5 years, of rats aged from 9 to 28 months and of children from birth to 10 years. We propose a model, based on the well known rubber-elastic properties of the denatured collagen network. In this model (1) HIT decreases as an exponential function of time during bond scission along the polymeric chains; (2) the velocity constant of the relaxation process is proportional to the rate of bond rupture and inversely proportional to the number of stable polymeric chains originally present per unit volume; (3) the evolution of the velocity constant as a function of aging finds an explanation. The HIT test should find useful applications in pathology and pharmacology, since it provides rapid, precise information on the stable state of collagen reticulation in small biopsies.

Lipid composition of two types of chondrocytes in primary culture

Chondrocytes from articular and growth plate cartilage were grown in primary culture. The lipid content, distribution into different types, as well as the fatty acid patterns of these lipids were compared when the cells had reached stationary phase and were synthesizing maximal amounts of proteoglycans. Numerous significant differences were observed, depending on the origin of the chondrocytes. In particular, growth plate chondrocytes showed increased dry weight, increased lipid content (phosphatides and triglycerides), and decreased cholesterol to phosphatide ratio when compared to articular chondrocytes; they also incorporated more of C18:1 and less C16:0 into their major lipid types. Whether these differences arise from specific metabolic regulation or are a consequence of chondrocyte organization in primary culture remains unclear.

Normal lipid composition of fibroblasts from a case of type II achondrogenesis

Fibroblasts from a case of achondrogenesis type II and fibroblasts from a normal control donor were subcultivated in vitro in parallel. The lipid study on these cells showed similar total lipid content, free cholesterol level, phospholipid distribution and fatty acid patterns, while neutral glycerides were slightly more elevated in the control fibroblasts. The histological finding of Laxova et al. (1973) could not be confirmed.

Biochemistry and histology of the connective tissue of Dupuytren's disease lesions

When compared to age-matched control aponeurosis, lesions of Dupuytren's disease contain higher contents of water, collagen and chondroitin-sulphate, as well as increased proportions of soluble collagens and of reducible cross-links; these indicate synthesis of new collagen. The lesions show also increased amounts of type III collagen and an increased hydroxylation and glycosylation of the reducible cross-links. All these parameters are characteristic of granulation and scar tissues. Type III collagen was located by means of immunofluorescence on thin argyrophilic fibres and also within the large fibre bundles which appeared to be disrupted into microbundles. The increase of type III collagen and the presence of myofibroblasts in the apparently unaffected aponeurosis show that the disease is widespread and suggest that it is initiated within the aponeurosis and propagated by the cells migrating along the collagen bundles.

Isometric tensions developed during the hydrothermal swelling of rat skin

Isometric tensions developed in connective tissue under the influence of temperature have previously been measured by their effect on a "shrinkage" phenomenon observed along the main axis of the collagen fibers. A new device, built and tested in our laboratory enabled us to obtain isometric tension curves by measuring a "swelling" phenomenon observed in other directions. Curves recorded in the two systems have been compared. Shapes were unchanged and the parameters chosen to define these morphologies showed the same values in both types of experiments. The parameters, which are independent of maximal tension, were also found to be independent of the total collagen content of the sample. Interpretation of the results suggests that these parameters depend not only on the nature but also on the density of the collagen crosslinks. The new device is applicable to minute tissue samples, whatever their fragility and fiber orientation.

[Study of the cortical field potentials produced by weak light stimulation in adult rabbits]

On a chronic preparation of an adult Rabbit, the cortical visual evoked response, produced by a weak luminous stimulation activating only the scotopic system is characterized by the suppression of the early surface-positive phase and by a lengthening of the latencies of the following deflection. The profile of the fields of potential corresponding to the various defletions in relation to the depth, has been investigated.

[Variations in the hydrothermic contraction of the rat skin as a function of the age of the animals]

The tension developed in Rat skin by hydrothermal shrinkage is modified with ageing of the animals: the temperature of maximum tension decreases from birth to 1 month, then very slowly increases with age. At higher temperatures than that of maximum tension a relaxation occurs very rapidly in young Rats and in not yet senescent adult skins. These modifications appeared to be related to those of the nature of the intermolecular collagen cross-links with ageing.

Collagen and myofibroblasts of granulation tissue. A chemical, ultrastructural and immunologic study

In granulation tissue produced in the rat by subcutaneous injection of turpentine oil or polyvynile sponge implantation, the great majority of fibroblasts (myofibroblasts) possess a contractile apparatus which makes them similar to smooth-muscle cells. Chemical analysis shows that these granulation tissues contain a high proportion of Type III collagen, a genetically distinct collagen normally associated with embryonic dermal tissue. Type III collagen may persist up to 9 months after sponge implantation and myofibroblasts are seen in granulation tissue by means of electron microscopy and immunofluorescence. When granulation tissue is resorbed 50 days after turpentine oil injection, myofibroblasts disappear and the dermis contains Type I collagen. The concurrent presence of myofibroblasts and Type III collagen suggests that myofibroblasts, in addition to their contractile activity, synthetize, at least in part, type III collagen.

Urinary excretion of hydroxylysyl glycosides during acute inflammation in the rat

1. Subcutaneous inflammatory granuloma were induced in young rats and the urinary excretion of hydroxyproline and hydroxylysyl glycosides was observed during the period of acute inflammation. 2. All collagen metabolites were increased in the urine and excretion of glucosyl-galactosyl-hydroxylysine was much greater than excretion of galactosyl-hydroxylysine in the first days. 3. It is argued that urinary glucosyl-galactosyl-hydroxylysine is probably derived from hydroxylysyl residues of soluble collagen. 4. This study affords new arguments in favour of the dermal origin of urinary glucosyl-galactosyl-hydroxylysine, at least in skin inflammation.

Collagen in granulation tissues

Collagen is abundantly synthesized in granulation tissues and reaches a concentration higher than in normal neighbouring tissues. Such newly formed collagen is characterized by an abnormally low solubility and an easy degradation by collagenases and collagenolytic cathepsins. The activities of these two types of enzymes are high (especially collagenases) in tissues of acute inflammations when the granuloma is resorbing. These activities are lower in sub-acute inflammation and the collagen content of the persistent granuloma remains high. The collagen synthesized in granulation tissues is cross linked by hydroxylysino-5-keto-norleucine, the stable cross-link of collagen in embryonic skin. It is progressively replaced by the two aldimine cross links of normal adult skin when the granuloma is resorbed (acute inflammations induced in rats; human normal scars). The cross link of embryonic skin, on the contrary, is permanently present in collagen of tissues of subacute, chronic inflammations (sponge implants in rats, human hypertrophic scars and keloids. Studies of the structure of alpha-chains revealed that type III collagen (embryonic collagen) is present in granulation tissues.

Collagen polymorphism in human scars

Collagen similar to the collagen found in embryonic skin (same intermolecular cross-links and same structure of the polypeptide chains) is synthesized in young human scars. Later on, in normal scars, this collagen is replaced by the collagen of adult skin progressively. In contrast, in hypertrophic scars, a high proportion of collagen of "embryonic" type is present permanently. In granulation tissues of chronic inflammation, experimentally developed in rats, similar "embryonic" collagen has been found ; these granuloma are proposed as a model in laboratory animals of human hypertrophic scars.

Characterization of the collagen of human hypertrophic and normal scars

The collagen produced in response to an injury of human skin is initially stabilized by a cross-link derived from hydroxyallysine, and characteristic of embryonic skin. In normal healing there is a change over with time to the cross-link derived from allysine, which is typical of young skin collagen. In contrast, hypertrophic scars fail to follow the time-related changes of normal skin, but retain the characteristics of embryonic collagen, indicating a continued rapid turnover of the collagen. This is further supported by the high proportion of the embryonic Type III collagen present in hypertrophic scars.

[Activity of specific collagenases in developing granulomatous tissues]

Specific collagenases are activated rapidly in inflamed tissues. This activity reaches a higher level in acute inflammation than in chronic inflammation. It appears to be related to an increased metabolic activity of the local fibroblasts.