Stress and brain functional changes in patients with Crohn's disease: A functional magnetic resonance imaging study

BACKGROUND

In Crohn's disease (CD) patients, stress is believed to influence symptoms generation. Stress may act via central nervous system pathways to affect visceral sensitivity and motility thus exacerbating gastrointestinal symptoms. The neural substrate underpinning these mechanisms needs to be investigated in CD. We conducted an explorative functional magnetic resonance imaging (fMRI) study in order to investigate potential differences in the brain stress response in CD patients compared to controls.

METHODS

17 CD patients and 17 healthy controls underwent a fMRI scan while performing a stressful task consisting in a Stroop color-word interference task designed to induce mental stress in the fMRI environment.

KEY RESULTS

Compared to controls, in CD patients the stress task elicited greater blood oxygen level dependent (BOLD) signals in the midcingulate cortex (MCC).

CONCLUSIONS & INFERENCES

The MCC integrate "high" emotional processes with afferent sensory information ascending from the gut. In light of these integrative functions, the stress-evoked MCC hyperactivity in CD patients might represent a plausible neural substrate for the association between stress and symptomatic disease. The MCC dysfunction might be involved in mechanisms of central disinhibition of nociceptive inputs leading to amplify the visceral sensitivity. Finally, the stress-evoked MCC hyperactivity might affect the regulation of intestinal motility resulting in exacerbation of disease symptoms and the autonomic and neuroendocrine regulation of inflammation resulting in enhanced inflammatory activity.

[Feasability and morbidity of apical and anterior mesh repair, a multicenter cohort study]

OBJECTIVE

To assess safety anatomic results, satisfaction patient and to report short-term results of a new surgical approach for a combined treatment of pelvic organ prolapse (POP) of anterior and medium compartments.

MATERIAL AND METHODS

A longitudinal case series of 83 consecutive patients operated between January 2012 and April 2014 in four tertiary centers by 8 surgeons. Potential complications have been reported. The satisfaction of patients was conducted at 6 weeks post-procedure. The anatomical evaluation was conducted at 6 weeks and 6 months post-procedure. Anatomic success was defined as prolapse stage<1 (POPQ) for both anterior and apical compartment.

RESULTS

Mean age was 69.2±8.6 years. There were two intraoperative complications: a bladder injury and an ureteral injury. Postoperative complications were 14/83 (16.8%) transient urinary retentions. Seventy-three patients out of 83 (87.9%) were available for anatomic evaluation at 6 months. Anatomical success at 6 months for both anterior and apical compartments was 68/73 (93.1%). Patient satisfaction rate at 6 months was 79/83 (95.1%). Four subjects/73 (5.5%) experienced mesh exposure treated conservatively.

CONCLUSION

In the current series, uterovaginal suspension anterior using a mesh Nuvia^® was associated with correct anatomical results and a good satisfaction of patients. This technique seems reproducible and associated with few complications. Prospective, comparative and long-term data are required to confirm these results.

LEVEL OF EVIDENCE

4.

[Parental project of general medicine residents from Aix-Marseille university: Theoretical knowledge in reproduction and behavior towards parenting]

OBJECTIVES

Analyze residents' intentions about parenting and knowledge about fertility, as well as their alleged behavior towards a diagnosis of diminished ovarian reserve.

MATERIALS AND METHODS

Prospective study with distribution of self-administered questionnaire to residents of Aix-Marseille university from June to September 2015. The questionnaire was composed of a first descriptive part including generic and personal informations about the residents and their intentions towards parenting. The second part was a 9 questions survey aimed at testing their knowledge about fertility and ovarian reserve and a final question placing them in a situation of a diminished ovarian reserve diagnosis in order to analyze their reactions.

RESULTS

The overall participation rate was 53.2%, including 220 women with an average age of 27 years (SD: 1.8 years) and 116 men with an average age of 27.3 years (SD: 2.2 years). The 11.8% of female residents (n=26) already had one or more children vs.6.9% of male residents (n=8). Among the residents without children, 99% of females (n=192) and 91.7% of males (n=99) said they wanted to have children in the future, planning an average age to have their first child of 29.6 years (SD: 1.9 years) for females and 30.4 years (SD: 2.2 years) for men. Moreover, 58.3% of female residents (n=112) and 53.5% of male residents (n=53) reported that they were postponing their plan to have children after the completion of their medical studies. In a simulation of couples facing a diagnosis of diminished ovarian reserve, 73.6% of females and 61.2% of males would be ready to change their life choices and conceive a baby sooner than originally planned.

CONCLUSION

Almost all the general medicine residents have plannedto have children in the future and more than half of them postpone their parental plan after the end of their residency, although the decline of female fertility in relation to aging is widely known among them.

[Induced abortion: Guidelines for clinical practice - Methods]

This work is based on a current review of the literature (Pubmed, Medline, Cochrane library, Cochrane database of systematic reviews, EMBASE, RCOG, ACOG) including meta-analysis, randomised trials, cohorts, reviews, controlled studies published up to 2016 in French or English.

Outcome and Follow-up of Patients with Endometrial Carcinoma Diagnosed on Operative Hysteroscopic Resection Specimens

AIM

To study outcomes of patients diagnosed with endometrial carcinoma (EC) after histological analysis of endometrial resections retrieved during operative hysteroscopy performed for a presumed benign lesion.

PATIENTS AND METHODS

A retrospective study was conducted using medical records of patients who underwent operative hysteroscopy for a presumed benign lesion with a final diagnosis of EC between January 1994 and April 2014 in two tertiary academic centers.

RESULTS

A total of 29 patients were selected. International federation of gynecology and obstetrics (FIGO) classification was distributed as follows: 16 stages IA, 7 stages IB, 4 stages II and 2 stages III. Peritoneal cytology was positive in one case (stage IIIA). Median follow-up was 4.2 years (range=0.3-20.51). Two deaths were observed and were attributed to endometrial cancer.

CONCLUSION

Operative hysteroscopy does not appear to influence stage of EC nor cause retrograde seeding of EC for 27/29 (93%) patients. For 2 patients, the impact of operative hysteroscopy remains uncertain.

[Bowel injuries after port insertion in laparoscopy. Gynerisq's database analysis]

INTRODUCTION

Port insertion is a high-risk period during laparoscopy. The French Gynecologist and Obstetricians College (CNGOF) published recommendations in 2010 to minimize those risks. The aim of our analysis was to establish the accidents' circumstances and consequences and to determine if those incidents could have been depending on whether recommendations had been respected or not.

MATERIAL AND METHODS

Gynerisq is an approved organism by the Haute Autorité de santé (HAS). Its mission is to evaluate and improve practices by a risk management centered approach. We analysed incidents reported by Gynerisq's adherents in an experience report database.

RESULTS

Above 114 incidents analysed in the Gynerisq's database, we reported 31 bowel injuries. Those injuries occurred for 77.4% (24/31) during planned interventions. For 32.3% of the cases (10/31), interventions were judged complex by the surgeons. A total of 54.8% (17/31) of the patients had a history of laparotomy. Above 27 injuries occurred during Veress needle or open laparoscopy, 17 could have been avoided regarding to the surgeon. The causes reported were in 10 cases that the recommendations had not been respected, in 2 cases another cause and in 5 cases no causes were given to explain the incident.

CONCLUSION

Our analysis shows that bowel injuries after port insertion, in open laparoscopy or Veress needle use, do not seem to occur only in an emergency context or during complicated interventions. However, most of the incidents occurred for patients with risk factors.

Methotrexate treatment for ectopic pregnancy after assisted reproductive technology: A case-control study

OBJECTIVES

Ectopic pregnancy (EP) occurs in 2% to 5.6% of pregnancies achieved by assisted reproductive technology (ART). EP treatment options include medical treatment by uses of methotrexate (MTX) systemic injection. The objective of this study was to compare MTX treatment effectiveness for EP occurring spontaneously or following ART.

METHODS

A case-control study performed in the department of obstetrics and gynecology at a tertiary health care center in France. Twenty EP achieved by ART (ART group) and 60 spontaneous EP (SEP group) received MTX treatment between January 2002 and May 2012. The main outcome measures were MTX treatment failure rates, number of MTX injections administered and recovery time.

RESULTS

MTX treatment failure rates observed in ART and SEP groups were similar (3/20 [15%] versus 10/60 [17%]: OR=0.88 [0.22-3.58]). Mean duration of recovery time in patients with successful MTX treatment did not differ between ART and SEP groups (33±14 days versus 28±13 days, P=0.39). A second MTX injection was required more frequently in ART group than in SEP group (10/20 [50%] versus 10/60 [17%]: OR=5 [1.65-15.15]).

CONCLUSIONS

It is concluded that MTX treatment is equally effective for spontaneous EP and EP achieved by ART, two injections of MTX being more frequently required in case of ART.

Mifepristone and misoprostol for cervical ripening in surgical abortion between 12 and 14 weeks of gestation: a randomized controlled trial

OBJECTIVE

Misoprostol and mifepristone are the two substances recommended for cervical preparation during first-trimester surgical abortions to decrease intraoperative bleeding and complications. The objective of the study was to evaluate whether the combination of mifepristone and misoprostol for cervical preparation in an elective surgical abortion between 12 and 14 weeks of gestation can reduce blood loss in comparison to misoprostol or mifepristone alone.

STUDY DESIGN

A randomized controlled trial was performed in Marseille, France between May 2013 and May 2014. Women requesting a surgical abortion under general anesthesia between 12 and 14 weeks of gestation were 198, randomized into three groups: one received 400μg oral misoprostol 3h before surgery, one 200mg oral mifepristone 36h before surgery, and the other, both treatments. The main outcome was the quantity of intraoperative bleeding. The secondary outcomes were duration of intervention, ease of dilatation, and complications.

RESULTS

The quantity of intraoperative bleeding differed significantly between the groups (p=0.001): 222±64mL in the combination group, 329±129mL in the misoprostol group, and 276±119mL in the mifepristone group. The combination was associated with a shorter operative duration (p=0.001): 5±2min in the combination group, 7±5min in the misoprostol group, and 7±3min in the mifepristone group. A hemorrhage was observed for 5 of 55 women (9%) in the combination group, 13 of 51 (25%) in the misoprostol group, and 9 of 56 (16%) in the mifepristone group (p=0.08). No cervical laceration or uterine perforation was reported.

CONCLUSIONS

The combination of mifepristone and misoprostol in cervical preparation for elective surgical abortions between 12 and 14 weeks of gestation significantly reduced blood loss in comparison to misoprostol or mifepristone alone.

Updated French guidelines for diagnosis and management of pelvic inflammatory disease

BACKGROUND

Pelvic inflammatory disease (PID) is commonly encountered in clinical practice.

OBJECTIVES

To provide up-to-date guidelines on management of PID.

SEARCH STRATEGY

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 May 2015.

SELECTION CRITERIA

All identified reports relevant to the areas of focus were included.

DATA COLLECTION AND ANALYSIS

A level of evidence based on the quality of the data available was applied for each area of focus and used for the guidelines.

MAIN RESULTS

PID must be suspected when spontaneous pelvic pain is associated with induced adnexal or uterine pain (grade C). Pelvic ultrasonography is necessary to exclude tubo-ovarian abscess (grade B). Microbiological diagnosis requires vaginal and endocervical sampling for molecular and bacteriological analysis (grade B). First-line treatment for uncomplicated PID combines ofloxacin and metronidazole for 14days (grade B). Treatment of tubo-ovarian abscess is based on drainage if the collection measures more than 3cm (grade B), with combined ceftriaxone, metronidazole, and doxycycline for 14-21days.

CONCLUSIONS

Current management of PID requires easily reproducible investigations and treatment, and thus can be applied worldwide.

[Impact of the loop electrosurgical excision procedure for cervical dysplasia on sexual function]

OBJECTIVE

To assess the consequences of loop electrosurgical excision procedure (LEEP) on the quality of sexual life.

MATERIAL AND METHODS

A prospective observational study in two university hospital departments in Marseille, France, including women requiring a LEEP. Sexual quality of life was assessed before LEEP and three months after the procedure with a self-administered validated questionnaire: the Brief Index of Sexual Functioning for Women (BISF-W).

RESULTS

Among the 100 women included, 69 filled both questionnaires. Among the 69 women whose outcomes were available, composite BISF-W score was significantly lower before LEEP than three months after LEEP (28.3±13 vs 30.1±13.2; P=0.01). The items scores concerning desire (D1) and orgasm (D5) were significantly improved after LEEP (4.3±2.3 vs 5±2.2 [P<0.001] and 4.3±2.5 vs 4.7±2.6 [P<0.001]).

CONCLUSIONS

This study found an improved quality of sexual life after LEEP. These findings suggest that the psychological impact of HPV infection on sexual function is greater than the anatomical and functional impact of LEEP.

[Hysterectomy for benign pathology: Guidelines for clinical practice]

OBJECTIVE

The objective of the study was to provide guidelines for clinical practice from the French college of obstetrics and gynecology (CNGOF), based on the best evidence available, concerning hysterectomy for benign pathology.

METHODS

Each recommendation for practice was allocated a grade which depends on the level of evidence (guidelines for clinical practice method).

RESULTS

Hysterectomy should be performed by a high volume surgeon (>10 procedures of hysterectomy per year) (grade C). Rectal enema stimulant laxatives are not recommended prior to hysterectomy (grade C). It is recommended to carry out vaginal disinfection using povidone iodine solution prior to an hysterectomy (grade B). Antibioprophylaxis is recommended during a hysterectomy, regardless of the surgical route (grade B). The vaginal or the laparoscopic routes are recommended for hysterectomy for benign pathology (grade B), even if the uterus is large and/or the patient is obese (grade C). The choice between these two surgical approaches depends on others parameters, such as the surgeon's experience, the mode of anesthesia and organizational constraints (operative duration and medico economic factors). Hysterectomy by vaginal route is not contraindicated in nulliparous women (grade C) or in women with previous c-section (grade C). No specific technique to achieve hemostasis is recommended with a view to avoid urinary tract injuries (grade C). In the absence of ovarian pathology and personal or family history of breast/ovarian carcinoma, it is recommended to conserve ovaries in pre-menopausal women (grade B). Subtotal hysterectomy is not recommended in order to diminish the risk of per- or postoperative complications (grade B).

CONCLUSION

The application of these recommendations should minimize risks associated with hysterectomy.

Operative hysteroscopy versus vacuum aspiration for incomplete spontaneous abortion (HY-PER): study protocol for a randomized controlled trial

Background

Incomplete spontaneous abortions are defined by the intrauterine retention of the products of conception after their incomplete or partial expulsion. This condition may be managed by expectant care, medical treatment or surgery. Vacuum aspiration is currently the standard surgical treatment in most centers. However, operative hysteroscopy has the advantage over vacuum aspiration of allowing the direct visualization of the retained conception product, facilitating its elective removal while limiting surgical complications. Inadequately powered retrospective studies reported subsequent fertility to be higher in patients treated by operative hysteroscopy than in those treated by vacuum aspiration. These data require confirmation in a randomized controlled trial comparing fertility rates between women undergoing hysteroscopy and those undergoing vacuum aspiration for incomplete spontaneous abortion.

Methods

After providing written informed consent, 572 women with incomplete spontaneous abortion recruited from 15 centers across France will undergo randomization by a centralized computer system for treatment by either vacuum aspiration or operative hysteroscopy. Patients will not be informed of the type of treatment that they receive and will be cared for during their hospital stay in accordance with standard practices at each center. The patients will be monitored for pregnancy or adverse effects by a telephone conversation or questionnaire sent by e-mail or post over a period of two years. In cases of complications, failure of the intervention or diagnosis of uterine cavity disease, patient care will be left to the discretion of the medical center team.

Discussion

If our hypothesis is confirmed, this study will provide evidence that the use of operative hysteroscopy can increase the number of pregnancies continuing beyond 22 weeks of gestation in the two-year period following incomplete spontaneous abortion without increasing the incidence of morbidity and peri- and postoperative complications. The standard surgical treatment of this condition would thus be modified. This study would therefore have a large effect on the surgical management of incomplete spontaneous abortion.

Trial registration

ClinicalTrials.gov Identifier: NCT02201732; registered on 17 July 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0900-1) contains supplementary material, which is available to authorized users.