[Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]

OBJECTIVE

To provide guidelines for the pelvic clinical exam in gynecology and obstetrics.

MATERIAL AND METHODS

A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature.

CONCLUSIONS

The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.

National institutions should improve the information made available to patients about cervical smears

OBJECTIVE

To assess the quality of the content of leaflets tools and websites of national institutions in United Kingdom and France informing patients about cervical smears.

METHODS

We collected and analyzed the data and information on these two websites and leaflets made for patients. We screened those tools with the UP TO DATE SCIENTIFIC EVIDENCE IPDAS grid.

RESULTS

None of the tools specify the level of evidence of the studies on which cervix cancer screening is based. The risk of complication due to cancer is poor. The effectiveness of screening in absolute value is not available. The risks and side-effects due to cervical smears are specified without the frequency.

CONCLUSION

Information is truncated and pushes readers towards taking part in screening. This is not in accordance with the quality criteria of shared decision making.

PRACTICE IMPLICATIONS

Patients should take part in the creation of decision making tools, so that the information is the most suited to their representations and understanding. This is why the documents made available by institutions should be based on recognized scientific sources. Responsible of health programs should be independent and separated from those responsible of information tool creation.

Correlates of premature pap test screening, under 25 years old: analysis of data from the CONSTANCES cohort study

Background

Many countries currently recommend that screening for cervical cancer begin at the age of 25 years. Premature screening (before that age) could lead to unnecessary follow-up examinations and procedures that turn out to be useless. Our objective is to ascertain if the use of particular contraceptive methods are associated with premature screening.

Methods

This cross-sectional study based on the CONSTANCES cohort enabled us to include 4297 women younger than 25 years. The factors associated with premature screening were modeled by logistic regression. Missing data were handled by multiple imputations. The multivariate analyses were adjusted for sex life, social and demographic characteristics, and health status.

Results

Nearly half (48.5%) the women younger than 25 years had already undergone premature screening. Women not using contraceptives (aOR 0.3, 95% CI 0.3–0.5) and those using nonmedicalized contraceptives (condom, spermicide, etc.) (aOR 0.5, 95% CI 0.4–0.6) had premature screening less often than women using birth control pills. Higher risks of premature screening were observed in 20-year-old women (aOR 2.7, 95% CI 2.2–3.3) and in those with more than 5 lifetime partners (aOR 2.5, 95% CI 2.0–3.1), compared respectively with women who were younger and those with 5 or fewer lifetime partners.

Conclusion

Young women using contraceptives that require a doctor’s prescription are exposed to premature screening more often than those not using contraception and those with nonmedicalized contraceptives.

The Characteristics of Care Provided to Population(s) in Precarious Situations in 2015. A Preliminary Study on the Universal Health Cover in France

Background: The French Universal Health Cover (CMU) aims to compensate for inequalities between precarious and non-precarious populations, enabling the former to access to free healthcare. These measures rely on the principle that precarious populations' health improves if healthcare is free. We designed a study to examine whether CMU fails to compensate for inequalities in reimbursed drugs prescriptions in precarious populations. Material and method: This retrospective pharmaco-epidemiological study compared the Defined Daily Dose relative to different reimbursed drugs prescribed by general practitioners (GPs) to precarious and non-precarious patients in France in 2015. Data were analysed using Mann-Whitney tests. Findings: 6 out of 20 molecules were significantly under-reimbursed in precarious populations. 2 were over-reimbursed. The 12 remaining molecules did not differ between groups. Interpretation: The under-reimbursement of atorvastatin, rosuvastatin, tamsulosine and timolol reflects well-documented epidemiological differences between these populations. In contrast, the equal reimbursement of amoxicillin, pyostacine, ivermectin, salbutamol and tiopropium is likely an effect of lack of compensation for inequalities. Precarious patients are more affected by diseases that these molecules target (e.g., chronic bronchitis, bacterial pneumonia, cutaneous infections). This could also be the case for the equal and under-reimbursement of insulin glargine and metformin (targeting diabetes), respectively, although this has to be considered with caution. In conclusion, the French free healthcare cover does not fail to compensate for all but only for some selective inequalities in access to reimbursed drugs prescriptions. These results are discussed with respect to the interaction of the doctor-patient relationship and the holistic nature of primary care, potentially triggering burnout and empathy decrease and negatively impacting the quality of care in precarious populations.

Correction to: Efficacy of phloroglucinol for the treatment of pain of gynaecologic or obstetrical origin: a systematic review of literature of randomised controlled trials

The correct presentation of the Author names are shown in this paper.

Pap tests for cervical cancer screening test and contraception: analysis of data from the CONSTANCES cohort study

BACKGROUND

In France, a Pap test for cervical cancer screening is recommended every three years for all sexually active women aged 25 to 65 years. Modes of contraception (any or no contraception, with or without a visit to a physician, and with or without a gynecological examination) may influence adhesion to screening: women who use intrauterine device (IUD) should be more up to date with their cervical cancer screening more often than those using other means of contraception. Our objectives were to analyze the association between modes of contraception and Pap tests for screening.

METHODS

This cross sectional study is based on the CONSTANCES cohort enabled us to include 16,764 women aged 25-50 years. The factors associated with adhesion to cervical cancer screening (defined by a report of a Pap test within the previous 3 years) was modeled by logistic regression. Missing data were imputed by using multiple imputations. The multivariate analyses were adjusted for sex life, social and demographic characteristics, and health status.

RESULTS

Overall, 11.2% (1875) of the women reported that they were overdue for Pap test screening. In the multivariate analysis there was no significant difference between women using an IUD and those pills or implant of pap test overdue ORa:0.9 CI95% [0.8-1.1], ORa 1.3 CI95% [0.7-2.7] respectively. Women not using contraceptives and those using non-medical contraceptives (condoms, spermicides, etc.) were overdue more often ORa: 2.6 CI95% [2.2-3.0] and ORa: 1.8 CI95% [1.6-2.1] respectively than those using an IUD.

CONCLUSION

Women seeing medical professionals for contraception are more likely to have Pap tests.

[Pelvic Inflammatory Diseases: Updated Guidelines for Clinical Practice - Short version]

OBJECTIVES

To provide up-to-date guidelines on management of pelvic inflammatory disease (PID).

METHODS

An initial search of the Cochrane database, PubMed, and Embase was performed using keywords related to PID to identify reports in any language published between January 1990 and January 2012, with an update in 2018. All identified reports published in French and English relevant to the areas of focus were included. A level of evidence based on the quality of the data available was applied for each area of focus and used for the guidelines.

RESULTS

PID must be suspected when spontaneous pelvic pain is associated with induced adnexal or uterine pain (grade B). Pelvic ultrasonography is necessary to exclude tubo-ovarian abscess (TOA) (grade C). Microbiological diagnosis requires endocervical and TOA sampling for molecular and bacteriological analysis (grade B). First-line treatment for uncomplicated PID combines ceftriaxone 1g, once, by intra-muscular (IM) or intra-venous (IV) route, doxycycline 100mg×2/d, and metronidazole 500mg×2/d oral (PO) for 10 days (grade A). First-line treatment for complicated PID combines IV ceftriaxone 1 to 2g/d until clinical improvement, doxycycline 100mg×2/d, IV or PO, and metronidazole 500mg×3/d, IV or PO for 14days (grade B). Drainage of TOA is indicated if the collection measures more than 3cm (grade B). Follow-up is required in women with sexually transmitted infections (STI) (grade C). The use of condoms is recommended (grade B). Vaginal sampling for microbiological diagnosis is recommended 3 to 6months after PID (grade C), before the insertion of an intra-uterine device (grade B), before elective termination of pregnancy or hysterosalpingography. Targeted antibiotics on identified bacteria are better than systematic antibioprophylaxis in those conditions.

CONCLUSIONS

Current management of PID requires easily reproducible investigations and antibiotics adapted to STI and vaginal microbiota.

Identifying teenage sexual abuse victims by questions on their daily lives

Child sexual abuse (CSA) is an international public health problem. While general practitioners are perhaps ideally positioned to detect CSA, a lack of simple tools and their discomfort in bringing up such a sensitive subject reduce the likelihood of its being brought up and flagged in primary care. However, it may be possible to identify victims of CSA by observing its consequences on student well-being, overall well-being and risk behavior. This study investigate the predictive value of daily life events possibly associated with CSA: relationship difficulties with peers and teachers, autolytic attempts, self-mutilation, low self-esteem, addiction, poor body image, physical and psychological violence, low quality of sleep. We carried out a crosssectional survey involving a representative sample of 1719 15 year-old adolescents enrolled in 192 randomly drawn schools from two French regions. In their classrooms, they filled out a version of the Health Behavior in School-Aged Children international (HBSC) self-questionnaire. Compared to their coevals, these youth were more likely to regularly consume cannabis, OR 4.40 [1.85; 10.48] and to express fear of violence, OR 2.05 [1.28; 3,28]. They were less likely to feel satisfied about their weight, OR 2.24 [1.13; 4.40] and more likely to feel unaccepted by others, OR 1.65 [1.03; 2.65]. The C-index (concordance statistic) taking into account gender, regular cannabis consumption, fear of violence, not having the right weight and not being accepted by others, was 0.79. The C-index also including self mutilation and autolytic attempts was 0.83. Indirect thematic could likewise facilitate detection and identification of CSA.

Corrélation entre présence d’anticorps anti-antigène de type 2 de la pemphigoïde et démence chez les sujets âgés sans manifestation clinique de pemphigoïde

BACKGROUND

Pemphigoid is a form of auto-immune bullous dermatosis characterised by the production of antibodies directed against components of hemidesmosomes in the basal membrane. The physiopathological process responsible for unmasking of these antigens is unknown. Pemphigoid is more common in elderly subjects and is most often seen in debilitated subjects. The prevalence of pemphigoid anti-pemphigoid antibodies (anti-PB) is not known in the elderly population presenting no dermatological signs evocative of the disease. We studied the prevalence of anti-PBAg2 antibodies in elderly subjects with no signs of pemphigoid as well as in the correlation between the presence of these antibodies and diagnosis of dementia.

PATIENTS AND METHODS

Elderly subjects (aged over 69 years) with no signs of pemphigoid were recruited consecutively in dermatology and geriatrics departments (138 subjects). Details of concomitant medication were recorded for all subjects and clinical examination was performed with calculation of MMS (Mini Mental Score). The subjects were then divided into two groups based on MMS score. The first group comprised subjects without dementia (MMS > 24) while the second comprised subjects with dementia. Serum anti-PBAg2 antibodies were determined by ELISA and indirect immunofluorescence with confirmation by Western blot. Antinuclear antibodies, used as a control for non-specific immune response, were assayed in all serum samples. The prevalence of these antibodies was compared between the two groups.

RESULTS

The two groups were comparable in terms of age, sex and presence of dermatological diseases (ulcers, bedsores, erysipelas). Each group comprised 69 subjects. The overall presence of anti-PBAg2 antibodies in subjects with no signs are suggestive of pemphigoid was 3.6%. Presence of anti-PBAg2 antibodies was associated with diagnosis of dementia (p=0.04; 0% and 7% in groups 1 and 2, respectively). No correlation was seen between the presence of anti-PBAg2 antibodies and concomitant medication or dermatological disease. The overall prevalence of antinuclear antibodies was 14.5% and the figure was similar between the two groups.

DISCUSSION

The presence of anti-PBAg2 could be associated with the diagnosis of dementia in elderly subjects.

Prevalence of anti-cyclic citrullinated peptide and anti-keratin antibodies in patients with primary Sjögren's syndrome

OBJECTIVE

To investigate the prevalence of anti-cyclic citrullinated peptide (anti-CCP) and anti-keratin antibodies (AKA) in patients with primary Sjögren's syndrome.

METHODS

149 patients with a diagnosis of primary Sjögren's syndrome according to the European/American consensus criteria were recruited from three French medical centres. The presence of anti-CCP was determined by enzyme linked immunosorbent assay and of AKA antibodies by indirect immunofluorescence. Radiographs of hands and feet were evaluated at the time of anti-CCP analysis.

RESULTS

Six patients with radiological erosions and nine patients with non-erosive arthritis fulfilling ACR criteria for rheumatoid arthritis were thought to have rheumatoid arthritis and secondary Sjögren's syndrome, while 134 were considered to have primary Sjögren's syndrome (mean (SD) disease duration, 11.1 (6.6) years). Of these, 80 tested positive for IgM rheumatoid factor (RF) (59%), 10 (7.5%) for anti-CCP, 7 (5.2%) for AKA, and 5 (3.7%) for both anti-CCP and AKA. There was no difference in clinical and biological features, including prevalence of RF, between anti-CCP positive and negative patients. The nine Sjögren patients with non-erosive arthritis, fulfilling ACR criteria for rheumatoid arthritis, were all CCP positive. Their response to disease modifying antirheumatic drugs could be different from classical rheumatoid patients.

CONCLUSIONS

Most patients with primary Sjögren's syndrome are negative for AKA and anti-CCP, but positive test results should not rule out this diagnosis. Anti-CCP positive patients, who may be prone to developing rheumatoid arthritis, require cautious clinical and radiographic follow up.