{"paper_id":"ed3967b9-a56d-452e-9a4d-d3c3f2a6e20a","body_text":"R E S E A R C H A R T I C L E Open Access\nTriage using a self-assessment questionnaire to\ndetect potentially life-threatening emergencies in\ngynecology\nCyrille Huchon 1,2*, Alexandre Dumont 2,3, Anne Chantry 4, Bruno Falissard 5 and Arnaud Fauconnier 1,2\nAbstract\nObjective: Acute pelvic pain is a common reason for emergency room visits that can indicate a potentially\nlife-threatening emergency (PLTE). Our objective here was to develop a triage process for PLTE based on a\nself-assessment questionnaire for gynecologic emergencies (SAQ-GE) in patients experiencing acute pelvic pain.\nMethods: In this multicenter prospective observational study, all gynecological emergency room patients seen for\nacute pelvic pain between September 2006 and April 2008 completed the SAQ-GE after receiving appropriate\nanalgesics. Diagnostic procedures were ordered without knowledge of questionnaire replies. Laparoscopy was the\nreference standard for diagnosing PLTE; other diagnoses were based on algorithms. In two-thirds of the population,\nSAQ-GE items significantly associated with PLTEs ( P < 0.05) by univariate analysis were used to develop a decision\ntree by recursive partitioning; the remaining third served for validation.\nResults: Of 344 derivation-set patients and 172 validation-set patients, 96 and 49 had PLTEs, respectively. Items\nsignificantly associated with PLTEs were vomiting, sudden onset of pain, and pain to palpation. Sensitivity of the\ndecision tree based on these three features was 87.5% (95% confidence interval (95% CI), 81%-94%) in the derivation\nset and 83.7% in the validation set. Derivation of the decision tree provided probabilities of PLTE of 13% (95% CI,\n6%-19%) in the low-risk group, 27% (95% CI, 20%-33%) in the intermediate-risk group and 62% (95% CI, 48%-76%) in\nthe high-risk group, ruling out PLTE with a specificity of 92.3%; (95% CI, 89%-96%). In the validation dataset, PLTE\nprobabilities were 16.3% in the low-risk group, 30.6% in the intermediate-risk group, and 44% in the high-risk group,\nruling out the diagnosis of PLTE with a specificity of 88.6%.\nConclusion: A simple triage model based on a standardized questionnaire may assist in the early identification of\npatients with PLTEs among patients seen in the gynecology emergency room for acute pelvic pain.\nKeywords: Gynecologic emergencies, Triage, Sensitivity, Questionnaire\nIntroduction\nAcute pelvic pain is the leading reason for gynecological\nemergency room visits [1]. However, only a minority of\nthese patients require emergency surgery. Thus, in a study\nof 205 patients seen at the gynecological emergency room\nof a French hospital in 2011, only 24 (12%) required\nhospital admission and 9 (4.5%) surgical treatment [2].\nThe early identification of patients with potentially life-\nthreatening emergencies (PLTEs) requiring prompt sur-\ngical treatment is crucial [3].\nIn general emergency rooms, nurses typically prioritize\npatients to ensure that those with serious conditions are\nseen first by the emergency physicians. Triage scales\nsuch as the Emergency Severity Index [4] are used to de-\ntermine whether medical care is required immediately,\nwithin a few minutes, within the next hour, or can be\ndelayed. However, these scales are not well suited to\ngynecological emergencies [5], in which the main chal-\nlenge consists in identifying patients with PLTEs, whose\ncondition may not be immediately alarming but may\n* Correspondence: cyrillehuchon@yahoo.fr\n1Service de gynécologie & obstétrique, CHI Poissy-St-Germain, 10 rue du\nchamp Gaillard, BP 3082 78303, Poissy CEDEX, France\n2Equipe d’accueil EA 7285 « Risques, cliniques et sécurité en santé des femmes\net en santé périnatale », Université Versailles-Saint-Quentin en Yvelines, 78000\nVersailles, France\nFull list of author information is available at the end of the article\nWORLD JOURNAL OF \nEMERGENCY SURGERY \n© 2014 Huchon et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative\nCommons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and\nreproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain\nDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,\nunless otherwise stated.\nHuchon et al. World Journal of Emergency Surgery 2014, 9:46\nhttp://www.wjes.org/content/9/1/46\n\ndeteriorate rapidly [3]. Examples of these PL TEs, present-\ning with acute pelvic pain as a common signal precursor,\ninclude ectopic pregnancy [3,6], adnexal torsion [7] or\ntuboovarian abscess [8] which can lead to hemodynamic\ninstability, organ failures, severe morbidity and death. Tri-\nage tools specifically designed for gynecological emergen-\ncies may be useful to rapidly identify patients in whom\nendovaginal ultrasonography by a gynecologist or radiolo-\ngist may detect a condition requiring prompt treatment,\nthus protecting the patient from life-threatening or\nfunction-threatening events [6,8,9].\nA self-assessment questionnaire for gynecological\nemergencies (SAQ-GE) recently developed by our group\nfor the assessment of acute pelvic pain in women with\ngynecologic emergencies has been used to build clinical\nprediction rules for tubal rupture complicating ectopic\npregnancy [10] and for adnexal torsion [11]. Our object-\nive here was to develop and validate a clinical prediction\nrules for identifying PLTEs in emergency room patients\nwith acute pelvic pain, based on SAQ-GE items.\nMethods\nEthical aspects\nThe study was approved by the French Department of\nHigher Education and Research (n°06.336) and by the\nFrench National Committee for Information Technology\nand Individual Liberties (n°906253).\nStudy design and setting\nWe conducted a prospective multicenter study in five\ngynecology departments in the Paris metropolitan\narea, France. Four departments were in teaching hospi-\ntals (Poissy-Saint Germain en Laye, Créteil, Port-Royal,\nand Louis Mourier) and one was in a general hospital\n(Versailles).\nSelection of Participants\nFrom September 2006 to April 2008, all patients at least\n18 years of age who presented to study-center gynecological\nemergency rooms with acute pelvic pain were eligible to\ncomplete the SAQ-GE on a voluntary basis. Exclusion\ncriteria were a history of chronic pelvic pain, neuro-\nlogical or psychiatric disease, hemodynamic instability,\nand no knowledge of French. Patients with a verbal 11-\npoint numerical rating scale (NRS) pain score lower\nthan 1 and those with bartholinitis or breast pain were\nexcluded.\nSelf-Assessment Questionnaire for Gynecological\nEmergencies (SAQ-GE)\nThe SAQ-GE was developed using a qualitative method\n[12] and advice from a panel of French experts, as\nreported in detail elsewhere [10,11]. The 89 items\ncover six domains: (i) qualitative description of pain, (ii)\nintensity of pain, (iii) location and (iv) time-course of\npain, (v) vaginal bleeding, and (vi) other signs.\nThe SAQ-GE was completed by the patients after ap-\npropriate initial pain management and before diagnostic\ninvestigations or surgery. The nurses collected the com-\npleted questionnaires, which were not made available to\nthe physicians. Thus, in this non-interventional study, all\ndiagnostic and therapeutic decisions were made without\nknowledge of the questionnaire replies.\nMethods and measurements\nThe final diagnosis was the diagnosis at hospital dis-\ncharge established based on the physical examination,\nabdominal and endovaginal ultrasound, routine biology\n(if needed), computed tomography (CT) of the abdomen\nand pelvis (if needed), and surgical procedures (if\nneeded: laparoscopy, dilatation and curettage, or diag-\nnostic hysteroscopy). The diagnosis of ectopic pregnancy\nwas based on laparoscopy or on an algorithm [13,14],\nwith laparoscopy being performed when a complication\nwas suspected (i.e., abundant hemoperitoneum with\nactive bleeding and/or tubal rupture), as well as in\npatients with contraindications to medical treatment.\nPelvic inflammatory disease was diagnosed based either\non laparoscopy, if deemed necessary, or on noninvasive\ndiagnostic models [15,16]. Other diagnoses based on\nsurgical findings were abundant hemoperitoneum re-\nlated to ovarian cyst rupture, adnexal torsion, appendi-\ncitis, and intestinal obstruction.\nAmong patients who did not undergo emergency\nlaparoscopy, those who were pregnant were followed\nuntil a definitive diagnostic was made [17]. In nonpreg-\nnant patients, when the findings of all examinations\nwere deemed normal and the pain subsided with appro-\npriate analgesia by the end of the visit or hospitalization,\na diagnosis of idiopathic acute pelvic pain was made.\nAfter discharge, patients were encouraged to return to\nthe gynecological emergency room in the event of pain\nrecurrence.\nOutcomes\nFor the purpose of the study, patients were classified ac-\ncording to whether they had a prospectively recorded\ndiagnosis of PLTE. PLTEs were defined as gynecological\nor nongynecological disorders causing acute pain and as-\nsociated with a high risk of complications likely to cause\nresidual impairments, severe morbidity, or death within\na short period in the absence of appropriate emergency\nsurgical or radiological treatment [3]. This definition\nincluded (i) ectopic pregnancy with tubal rupture or ac-\ntive bleeding or fetal cardiac activity or hemoperitoneum\nexceeding 300 mL [9,18]; (ii) complicated pelvic inflamma-\ntory disease with tuboovarian abscess or pelvic peritonitis\n[8,15,19]; (iii) adnexal torsi on [11]; (iv) hemoperitoneum\nHuchon et al. World Journal of Emergency Surgery 2014, 9:46 Page 2 of 6\nhttp://www.wjes.org/content/9/1/46\n\nexceeding 300 mL due to rupture of hemorrhagic ovar-\nian cysts or other gynecological causes (uterine rupture\nin the first trimester of pregnancy, rupture of a pedun-\nculated uterine fibroid, rupture of an arteriovenous mal-\nformation, or uterine perforation); (v) appendicitis; and\n(vi) intestinal obstruction.\nAnalysis\nWe randomly assessed two-thirds of the patients to the\nderivation dataset and the remaining third to the valid-\nation dataset. All statistical tests were done using Stata\n11.0 (Stata Corp., College Station, TX, USA).\nSAQ-GE replies of patients with a final diagnosis of\nPLTE were compared to those of the other patients by\nunivariate analysis using Pearson ’s chi-square test or\nFisher’s exact test. Variables significantly associated with\nPLTE with P values <0.05 were classified as possible pre-\ndictors. For each of these variables, we computed sensi-\ntivity, specificity, the positive likelihood ratio (Lr+) and\nnegative likelihood ratio (Lr-), and the crude diagnostic\nodds ratio with their 95% confidence interval (95% CI).\nVariables significantly associated with PLTEs by uni-\nvariate analysis were used for multivariable analysis by\nrecursive partitioning to create a decision tree based on\nthe best combination of variables. The decision tree\nidentified groups at high, intermediate, and low risk for\nPLTEs based on the sequential Lr values [20]. When a\ndata was missing for a patient, it was considered absent.\nFor each of the three groups, we computed the probabil-\nity of PLTE with the 95% CI. Sensitivity of the decision\ntree was defined as the number of patients with PLTEs\nin the high- and intermediate-risk groups over the total\nnumber of patients with PLTEs.\nFinally, we assessed the performance of the decision\ntree in the validation dataset.\nResults\nCharacteristics of the study patients\nAt the five study centers, 574 of about 992 eligible patients\ncompleted the SAQ-GE. Among them, 516 met our inclu-\nsion criteria and were entered into the study. A final diag-\nnosis of PL TE was made in 145 (28.1%) patients. T able 1\nlists the main patient characteristics and diagnoses in the\noverall population of 516 patients, of whom 344 were ran-\ndomly allocated to the derivation dataset and 172 to the\nvalidation dataset. PLTEs were diagnosed in 96 (27.9%)\nderivation-dataset patients and 49 (28.5%) validation-\ndataset patients. Patient characteristics were not signifi-\ncantly different in the two datasets (data not shown).\nMain results\nTable 2 reports the results of the univariate analysis.\nNone of the SAQ-GE items had Lr + values greater than\n4 or Lr- values lower than 0.25.\nFigure 1 shows the decision tree, in which three items\nare taken into account sequentially: vomiting, sudden\nonset of pain, and pain upon self-palpation. Patients with\nno vomiting or pain upon palpation are at low risk, with\na probability of PLTE of 13% (95% CI, 6%-19%). The\nintermediate risk group is defined based on either no\nvomiting but pain upon self-palpation or vomiting but no\nsudden onset of pain; the probability of a PL TE is 27%\n(95% CI, 20%-33%). In the high-risk group, with both\nvomiting and sudden-onset pain, the probability of a PL TE\nis 62% (95% CI, 48%-76%), ruling out PL TE with a specifi-\ncity of 92.3%; (95% CI, 89%-96%) (Figure 1). Sensitivity of\nthe decision tree was 87.5% (95% CI, 81%-94%).\nIn the validation dataset, the diagnostic performance\ncharacteristics of our decision tree were similar to those in\nthe derivation dataset, with most of the validation-dataset\nvalues being within the 95% CI for the derivation-dataset\nvalues. The PL TE probability was 16.3% in the low-risk\ngroup, 30.6% in the intermediate-risk group, and 44% in\nthe high-risk group, ruling out the diagnosis of PL TE with\na specificity of 88.6%. Sensitivity of the decision tree was\n83.7% in the validation dataset.\nDiscussion\nWe built a decision tree for triaging women presenting\nto the emergency room with acute pelvic pain using a\nstandardized yes/no items from a self-questionnaire. The\ndecision tree relies on three simple items: vomiting, pain\nupon self-palpation, and sudden onset of pain. It sepa-\nrates three groups of patients, at low, intermediate, and\nhigh risk for PLTEs, respectively. Sensitivity of the deci-\nsion tree was 87.5% (95% CI, 81%-94%).\nThe time to management of gynecological emergencies\nis the sum of four periods: time from symptom onset to\narrival; time from arrival to the first medical assessment;\ntime from the first medical assessment to the diagnosis,\nwhich usually required pelvic and endovaginal ultrasonog-\nraphy by a specialist [21]; (iv) and time from the diagnosis\nto the implementation of specific treatment, if any is\nneeded. Our decision tree may diminish the time from ar-\nrival to the first medical assessment by helping the nurses\nto identify patients with suspected PLTEs. In a previous\nstudy, mean time from arrival to ultrasonography was\n84 minutes in a gynecological emergency room, and far\nlonger times were found in general emergency rooms [2].\nThen, this decision tree can speed up the use of ultra-\nsound examination that has proven to be reliable for the\ndiagnosis of surgical emergencies [22].\nMost triage tools use clinical decision rules that separ-\nate patients into five triage categories depending on the\nacceptable time to medical management [4,23]. These\nrules are usually established by consensus among ex-\nperts, both for the triage category and for the acceptable\ntime to medical management [23]. We used a different\nHuchon et al. World Journal of Emergency Surgery 2014, 9:46 Page 3 of 6\nhttp://www.wjes.org/content/9/1/46\n\napproach, using statistical data to separate the patient\ngroups and focusing on the diagnosis rather than on ac-\nceptable time to management. Our classification system\ncould serve as a reference for classifying gynecological\nemergencies. Our next step will be to determine the ac-\nceptable time to medical management in each of the\nthree groups, before validating the decision tree in other\nsettings and evaluating its impact in clinical practice\n[23]. Moreover, our triage tool is not expensive. Then, it\ncould be used, after scaling up, in developing countries\nwhere institutional and human resources are often low,\nin order to decrease women ’s severe morbidity.\nTable 1 Characteristics and main diagnoses in the study patients\nOverall population N = 516 PLTE N = 145 Other N = 371\nAge in years, mean ± SD 31.6 ± 7.7 30.7 ± 7.9 31.9 ± 7.6\nGravidity, median [range] 2 [0 –11] 2 [0 –9] 2 [0 –11]\nParity, median [range] 1 [0 –7] 1 [0 –4] 1 [0 –7]\nContraception, n/N (%) 136/504 (27.0) 40/141 (28.4) 96/363 (26.5)\nNRS pain score at admission, mean ± SD 6.4 ± 2.7 6.8 ± 2.7 6.2 ± 2.7*\nDiagnosis\nEctopic pregnancy, n (%) 148 (28.7) 77 (53.1) 71 (19.1)\nPelvic inflammatory disease, n (%) 73 (14.1) 25 (17.2) 48 (12.9)\nUncomplicated ovarian cyst, n (%) 70 (13.6) NA 70 (18.9)\nAdnexal torsion, n (%) 31 (6.0) 31 (21.4) NA\nAppendicitis, n (%) 6 (1.2) 6 (4.1) NA\nRuptured cyst with hemoperitoneum > 300 mL, n (%) 5 (1.0) 5 (3.5) NA\nMiscarriage, n (%) 79 (15.3) NA 79 (21.3)\nMyoma necrobiosis, n (%) 15 (2.9) NA 15 (4.0)\nUrologic disease, n (%) 10 (1.9) NA 10 (2.7)\nOvarian hyperstimulation, n (%) 7 (1.4) NA 7 (1.9)\nOther diagnosis, n (%) 72 (13.9) 1 (0.7) ‡ 71 (19.1)\nPLTE, potentially life-threatening emergencies; NRS, numerical rating scale for pain severity; NA, not applicable; SD, standard deviation.\n*P < 0.05, Student ’s t test; ‡Intestinal obstruction.\nTable 2 SAQ-GE items significantly associated ( P < 0.05) with PLTE by univariate analysis in the derivation dataset\nTotal, n/N* (%) PLTE, n/N (%) Other, n/N (%) Se (%) Sp (%) LR+ LR- DOR [95% CI]\nPrior surgery for ovarian cyst 53/338 (15.6) 23/93 (24.7) 30/245 (12.2) 24.7 87.8 2.0 0.86 2.4 [1.3-4.4]\nNo history of pain of similar intensity 175/336 (52.1) 65/95 (58.4) 110/241 (45.6) 58.4 54.4 1.3 0.76 2.6 [1.5-4.3]\nPain on one side 184/337 (54.6) 69/92 (75.0) 115/245 (46.9) 75.0 53.1 1.6 0.47 3.4 [2.0-5.9]\nOvarian pain 210/337 (62.3) 69/92 (75.0) 141/245 (57.6) 75.0 42.4 1.3 0.59 2.2 [1.3-3.8]\nPain radiating to the stomach 59/336 (17.6) 23/93 (24.7) 36/243 (14.8) 24.7 85.2 1.7 0.88 1.9 [1.0-3.4]\nSudden onset of pain 170/333 (51.0) 61/94 (64.9) 109/239 (45.6) 64.9 54.4 1.4 0,64 2.2 [1.3-3.6]\nPain exacerbated by movements 248/337 (73.6) 81/94 (86.2) 167/243 (68.7) 86.2 31.3 1.3 0.44 2.8 [1.5-5.5]\nPain upon self-palpation 222/335 (66.3) 75/91 (82.4) 147/244 (60.3) 82.4 39.7 1.4 0.44 3.1 [1.7-5.7]\nVomiting 88/338 (26.0) 44/94 (46.8) 44/244 (18.0) 46.8 82.0 2.6 0.65 4.0 [2.3-6.9]\nRadiating pain 35/309 (11.3) 19/87 (21.8) 16/222 (16.2) 21.8 83.8 1.3 0.93 3.6 [1.7-7.5]\nPenetrating pain 114/329 (34.6) 44/92 (47.8) 70/237 (29.5) 47.8 70.5 1.6 0.74 2.2 [1.3-3.6]\nTwisting pain 72/329 (21.9) 34/93 (36.6) 38/236 (16.1) 36.6 83.9 2.3 0.76 3.0 [1.7-5.3]\nPain leading to syncope 25/332 (7.5) 12/94 (12.8) 13/238 (5.5) 12.8 94.5 2.3 0.92 2.5 [1.1-5.8]\nPain with sensation of oppression 82/333 (24.6) 34/94 (36.2) 48/239 (20.1) 36.2 79.9 1.8 0.80 2.3 [1.3-3.8]\nTorturous pain 68/333 (20.4 29/94 (30.8) 39/239 (16.3) 30.8 83.7 1.9 0.83 2.3 [1.3-4.0]\n*Because of missing data, the total may be different from 344.\nPLTE, potentially life-threatening emergency; Se, sensitivity; Sp, specificity; LR, likelihood ratio; DOR, diagnostic odds ratio; 95% CI, 95% con fidence interval.\nHuchon et al. World Journal of Emergency Surgery 2014, 9:46 Page 4 of 6\nhttp://www.wjes.org/content/9/1/46\n\nA rigorous statistical approach was used to develop\nour decision tree, in contrast to the methods generally\nused by consensus panels [23]. Decision trees developed\nusing recursive partitioning are simple to use. No com-\nputations are needed to determine the risk group to\nwhich a given patient belongs. In addition, recursive par-\ntitioning has been proven equivalent to logistic regres-\nsion in terms of diagnostic efficiency [24,25]. We also\nfound that recursive partitioning and logistic regression\nperformed similarly in our datasets (data not shown).\nThe high predictive values of our model may seem\nsurprising in the light of pathophysiological consider-\nations. Our definition of PLTE encompassed a variety of\nconditions that differ regarding the pathophysiological\nmechanisms responsible for pain [26,27]. However, when\nwe built the SAQ-GE, our main hypothesis was that\nwords used by women to describe acute pelvic pain and\nconcomitant symptoms reflect an underlying sensory ex-\nperience shared by various pathological and anatomical\nabnormalities [27] and not the symptoms of a specific\ndisease. For instance, vomiting strongly predicted both\ntubal rupture [10] and adnexal torsion [28]. Most\ngynecological emergencies may involve the same general\nprotective mechanisms triggered in response to danger,\nsuch as activation of the autonomic nervous system\n[26,27]. Thus, acute pelvic pain and other symptoms as\ndescribed by women may serve as warning signals that\ncan provide diagnostic orientation.\nLimitations\nOne limitation of our study is related to our definition of\nPL TE. This definition was not established by consensus\namong a panel of experts [29]. Nevertheless, our definition\nof PLTE is consistent with clinical reality in patients with\ngynecological emergencies. For instance, ectopic preg-\nnancy can be life threatening in the event of tubal rupture\nwith hemodynamic shock from massive intraabdominal\nbleeding. In this situation, substandard care is often re-\nlated to misdiagnosis [3,6]. We extended this concept to\nall gynecological emergencies that may not pose an im-\nmediate threat but may worsen rapidly. We used acute\npelvic pain as the warning signal for such situations.\nOur definition of PLTE is similar to that used pragmat-\nically in general emergency rooms with the goal of\nidentifying conditions likely to cause serious subsequent\nmanifestations (http://www.acem.org.au/media/policies_\nand_guidelines/G24_Implementation__ATS.pdf). In pa-\ntients with PL TEs as defined for our study, an earlier and\nmore accurate diagnosis allows the rapid provision of ap-\npropriate care, thereby improving patient outcomes in\nterms of both morbidity and mortality.\nAnother limitation may be overfitting of the decision\ntree to our data. However, the validation study in the\nthird of our population not used to build the decision\ntree showed similar diagnostic performance characteris-\ntics and substantial overfitting was also prevented by\nconstructing the SAQ-GE in a preliminary study involv-\ning different patients and experts.\nConclusion\nIn summary, our decision tree is the first dedicated to\nthe diagnosis of PLTEs with a 87.5% sensitivity. In\naddition, it relies on only three simple items of a self-\nquestionnaire. We plan to study the extent to which our\nFigure 1 Decision tree for classifying the risk of potentially-life-threatening emergency in patients presenting to gynecological\nemergency rooms with acute pelvic pain.\nHuchon et al. World Journal of Emergency Surgery 2014, 9:46 Page 5 of 6\nhttp://www.wjes.org/content/9/1/46\n\ndecision tree decreases time to appropriate management\nand improves outcomes in patients presenting with\nacute pelvic pain to crowded emergency rooms.\nCompeting interest\nThe authors declare that they have no competing interests.\nAuthors' contributions\nCH and AF wrote the manuscript. AF, AD and BF designed the study. AAC, CH\nand AF collected the datas. CH, AD and AF performed the statistical analysis.\nFunding\nAssistance Publique-Hôpitaux de Paris (AP-HP).\nAuthor details\n1Service de gynécologie & obstétrique, CHI Poissy-St-Germain, 10 rue du\nchamp Gaillard, BP 3082 78303, Poissy CEDEX, France. 2Equipe d’accueil EA\n7285 « Risques, cliniques et sécurité en santé des femmes et en santé périnatale\n», Université Versailles-Saint-Quentin en Yvelines, 78000 Versailles, France.3UMR\n216, IRD Paris Descartes, 4 Avenue de l ’Observatoire, Paris - Université, 75 006\nParis Descartes, France. 4INSERM, UMR S953, Epidemiological Research Unit on\nPerinatal Health and Women’s and Children’s Health, Hôpital Cochin, Paris,\nFrance. 5INSERM UMR S669, Université Paris Sud, Paris, France.\nReceived: 19 May 2014 Accepted: 7 August 2014\nPublished: 13 August 2014\nReferences\n1. Kontoravdis A, Chryssikopoulos A, Hassiakos D, Liapis A, Zourlas PA: The\ndiagnostic value of laparoscopy in 2365 patients with acute and chronic\npelvic pain. 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N Engl J Med 1973, 288:1272–1275.\ndoi:10.1186/1749-7922-9-46\nCite this article as: Huchon et al. : Triage using a self-assessment\nquestionnaire to detect potentially life-threatening emergencies in\ngynecology. World Journal of Emergency Surgery 2014 9:46.\nSubmit your next manuscript to BioMed Central\nand take full advantage of: \n• Convenient online submission\n• Thorough peer review\n• No space constraints or color figure charges\n• Immediate publication on acceptance\n• Inclusion in PubMed, CAS, Scopus and Google Scholar\n• Research which is freely available for redistribution\nSubmit your manuscript at \nwww.biomedcentral.com/submit\nHuchon et al. World Journal of Emergency Surgery 2014, 9:46 Page 6 of 6\nhttp://www.wjes.org/content/9/1/46","source_license":"CC0","license_restricted":false}