MD Mahé

Candice Ostrowka

Louis Journeau † ‡

Ludovic Plaisance † ‡

Géraldine Poenou † ‡

Salah Eddine Mecherour

Hélène Helfer

Isabelle Mahé
email: isabelle.mahe@aphp.fr

† ‡°

Isabelle Pr

Educational diagnosis of patients under oral anticoagulant therapy: development of a 4-category patient profiling score based on a retrospective study and prospective analysis

Keywords: anticoagulant, therapeutic education, educational diagnosis, profiling score, compliance

whether they are published or not. The documents may come

3

Profiling on standardized educational diagnosis is the first step to enable the patient to acquire the minimum core knowledge, regardless of baseline compliance profile and provide him with more personalized therapeutic education, adapted to the patient's individual profile.

We designed a reproducible score to serve this objective.

The perspective is to adapt therapeutic education programs to each category of patient so that they can acquire the knowledge that is noteworthy for their treatment.

Background

Oral anticoagulants are the reference treatment for the prevention of thromboembolic events in atrial fibrillation (AF), venous thromboembolism (VTE) and mechanical cardiac valve prostheses. Their use doubled between 2000 and 2012 [START_REF] Ansm | ANSM rapport Mai[END_REF]. An American study suggested that the number of patients requiring long-course anticoagulation therapy will increase by 2.5-fold over the period 2000-2050 [START_REF] Go | Prevalence of Diagnosed Atrial Fibrillation in Adults: National Implications for Rhythm Management and Stroke Prevention: the AnTicoagulation and Risk Factors In Atrial Fibrillation (ATRIA) Study[END_REF].

Unfortunately, these treatments have side-effects, the most feared of which is intracerebral hemorrhage [START_REF] Ansm | ANSM rapport Mai[END_REF]. A 2003 study by the French Health Authority found that vitamin-K antagonists (VKA) are the main cause of iatrogenic hemorrhage, leading to 17,000 hospital admissions and 5,000 deaths per year in France, with a mean cost of €315 m between 2012 and 2014 [START_REF] Ansm | ANSM rapport Mai[END_REF]. Direct oral anticoagulants (DOAC), being easy to use and requiring no biological monitoring, may be better accepted by patients [START_REF] Atkinson | Hierarchical construct validity of the treatment satisfaction questionnaire for medication (TSQM version II) among outpatient pharmacy consumers[END_REF] but clinical trial data have to be confirmed in real life [START_REF] Keita | Assessment of quality of life, satisfaction with anticoagulation therapy, and adherence to treatment in patients receiving long-course vitamin K antagonists or direct oral anticoagulants for venous thromboembolism[END_REF].

According to Haynes et al. [START_REF] Haynes | Can simple clinical measurements detect patient noncompliance?[END_REF], treatment efficacy correlates directly with patient's compliance to the prescribed treatment. However, it is estimated that almost 50% of patients with chronic pathology do not adhere sufficiently to their treatment, and therefore fail to reach the expected benefit [6]. Borne et al.'s retrospective study of 2,900 outpatients, beginning DOAC treatment for non-valvular AF between 2010 and 2015, measured compliance in terms of the number of recharges according to the number of days' treatment during the first year [START_REF] Borne | Adherence and outcomes to direct oral anticoagulants among patients with atrial fibrillation: findings from the veterans health administration[END_REF]. A quarter of patients showed suboptimal compliance, and low compliance was correlated with vascular event rate.

The aim of therapeutic education according to the World Health Organization (WHO) is "to help patients acquire or maintain the skills they need to optimally manage living with a chronic disease" [START_REF]Education thérapeutique du patient: définition, finalité et organisation[END_REF]. Worldwide, it has been an integral part of patient healthcare management and the care-pathway. It should enable the patient to acquire knowledge in order to improve compliance and avoid clinical complications by ensuring safe use of medication. Therefore, it is essential to identify patients at risk of non-compliance, and target them for taking part to a Therapeutic Education Program (TEP). The first step of a TEP is educational diagnosis, as not all patients have the same understanding capacity and adherence before treatment initiation. After a personalized program has been drawn up, taking into account learning priorities, TEP sessions are scheduled, followed by knowledge assessment.

However, the objectives and the corresponding benefits on adherence may depend on the included population. In the international prospective controlled, randomized IMPACT AF study including patients receiving DOACs for AF, one group received standard education and the other a TEP with regular follow-up, interaction between the health professionals involved in the treatment [START_REF] Vinereanu | A multifaceted intervention to improve treatment with oral anticoagulants in atrial fibrillation (IMPACT-AF): an international, cluster-randomised trial[END_REF]. The proportion of patients still using DOACS after the first year of treatment was higher in the TEP group than in the standard education group, suggesting that educational intervention should improve DOACs patients' use.

In contrast, the AEGEAN trial, which was an international multicenter prospective controlled randomized study of 1,162 patients beginning apixaban treatment for AF, did not yield similar results. One group received a proactive TEP, the other standard information. TEP and anticoagulation clinic management seemed to show no benefit in terms of adherence to apixaban: the number of consecutive intakes measured by an electronic device was identical in both groups [START_REF] Montalescot | Adherence and Persistance to APIXABAN treatment in patients with non valvular atrial fibrillation is high and similar with standard of care patient education or with additional educationnal program: the randomized AEGEAN study[END_REF]. A recent meta-analysis failed to demonstrate a clear benefit from TEP in term of outcomes, knowledge scores, and time in therapeutic range [START_REF] Paquette | A systematic review and meta-analysis of supplemental education in patients treated with oral anticoagulation[END_REF]. These findings suggest that the patients included in the study might have been selected, with better than usual understanding and compliance capacity due to the design of the study and the need for written informed consent). It suggests that TEPs may show greater benefit in patients with lower compliance capacity. Indeed, Drouin et al. showed that high level of knowledge is not a pre-requisite for optimal compliance a quarter of patients reported not knowing the role of oral anticoagulation therapy, but overall compliance was nevertheless good [START_REF] Drouin | Oral anticoagulants adherence in elderly patients treated for atrial fibrillation in the era of direct oral anticoagulants[END_REF]. Patients do not necessarily all need the same types of knowledge and knowledge does not always correlate with compliance, especially for those who do not wish to or cannot know any more about the treatment and the disease. The TEP, as defined by the "Agences Régionales de Santé" (the regional healthcare regulating agencies in France), seems to promote good compliance, but in practice is poorly adapted and non-standardized in terms of educational diagnosis [START_REF] Wofford | Best strategies for patient education about anticoagulation with warfarin: a systematic review[END_REF]. Therapeutic education should therefore be guided by distinguishing certain patient profiles before referring the patient to different TEPs in order to improve subsequently compliance [START_REF] Montalescot | Adherence and Persistance to APIXABAN treatment in patients with non valvular atrial fibrillation is high and similar with standard of care patient education or with additional educationnal program: the randomized AEGEAN study[END_REF].

Given this diversity of needs, it seems necessary to define a minimal core knowledge base for all patients.

The internal medicine department of Louis Mourier Hospital, a university hospital belonging to the Assistance Publique -Hôpitaux de Paris (AP-HP) and Paris 7 University, France, has been running a TEP for patients taking oral anticoagulants since 2014 that has been authorized by the local Regional healthcare agency. Based on this experience, we were able to determine various patient profiles with specific needs in therapeutic education.

The present study consisted in drawing up and validating a simple questionnaire to identify different patient profiles in therapeutic education for anticoagulation. The score was based on a retrospective analysis of patients receiving anticoagulant therapy involved in a TEP over a 1-year period and was then tested prospectively in another cohort.

Methods

Objective

The main objective of the study was to draw up a simple educational diagnostic tool able to distinguish different profiles of patients taking anticoagulants.

The secondary objectives were to assess the reproducibility of this tool, the feasibility of implementing this educational diagnosis in usual care, and having it performed by physicians non specialists in therapeutic education.

Methods

a) Ethics and Consent to Participate

Patients were included in the TEP after they provided oral and written consent to participate in the education program (Authorized by Regional Health Authorities number 14/20) and data are used for research purpose. The consent form was included in the education program project that was submitted and approved by French Health Regional Authorities (Authorization number ARS ETP/14/20).

b) Retrospective study

The first part of this research consisted in a retrospective observational study of consecutive hospital patients with indications for or ongoing anticoagulation therapy and who had been included in the Louis Mourier Hospital's TEP between October 2014 and December 2015. There were no exclusion criteria.

For standard educational diagnosis, the department's trained and certified TEP leader organized individual 30-minute educational diagnosis sessions assessing the patient's needs and knowledge concerning TEPs. This assessment was identical for all patients and based as usual on four topics: "pathology", "treatment", "risk" and "caregiver". It was. The "pathology" category assessed the patient's knowledge regarding the pathology and the associated risks. The "treatment" category assessed the patient's knowledge regarding the treatment, the possible biological monitoring and difficulties or side effects; as well as the patients 'self-estimated compliance to the treatment and self-medication. The "risks" category assessed knowledge of treatment associated risks, overdose signs, and resources in case of problems. The "caregiver-assistance" category assessed which help was available in terms of treatment knowledge. (See Appendix 2:

Profile identification score after decision tree)

Patients were interviewed on their living conditions, occupational status, place of residence, any difficulties in taking treatment, leisure activities (liable to cause wounds or hematomas), anticoagulation therapy, and associated pathologies. Problems, resources, hindrances, and gray areas were summed up to define personalized TEP objectives.

Patients then underwent 2 therapeutic education sessions of about 1 hour each. The first focused on learning and managing treatment, and the second on side-effects and precautions. With the patient's agreement, the TEP leader could run further sessions.

(See Appendix 1: Standard educational diagnosis.). For this retrospective part of the study, data were extracted from the data of the TEP.

c) Questionnaire

We analyzed retrospectively patients' responses to the four topics covered in standard educational diagnosis (Appendix 1).

Twelve key items were defined based on the 4 topics discussed above and the TEP leader's experience in therapeutic education.

We have built a questionnaire (Appendix 4).comprised those 12 items, and taking into account whether the patients were willing to enhance their knowledge or not: (2 focused on pathology), 6 questions on treatment, 3 questions on risks), and 1 question on caregiver. The questionnaire determined what the patient wanted to know, through a final question: "Do you want to know more?" Questions were closed, with 1 point for each positive answer. Patients were scored and their profile was determined.

By questioning the patient about his knowledge of the disease (about the risks inherent to the disease or the reason why they were taking anticoagulant), signs of overdose, and who to contact for help regarding the treatment, the clinician can quickly identify gaps in the patient's knowledge or points that the patient wishes to be clarified. Moreover, the "treatment" section of the questionnaire focused directly on the possibility of forgetting treatment or difficulties in taking it, thus directly identifying factors for noncompliance via the interview, as recommended by Borne et al [START_REF]Education thérapeutique du patient: définition, finalité et organisation[END_REF]. The questionnaire underlying the present score represents the minimum knowledge the patient need to acquire.

Overall, after completing educational diagnosis 4 different profiles were identified. The "initiation" profile was determined on the decision tree ahead of the questionnaire, depending on whether the patients had already received anticoagulation therapy.

Patients with a score superior or equal to 9 were deemed "competent"; those between 9 and 4 were deemed as "needing education", below 4 they were in the "learning underway" category.

The questionnaire was pre-tested in patients by clinicians and the TEP leader. It was simple, for both patient and clinician, and could be easily administered by medical or paramedical staff. Educational assessment by a clinician (usually an intern) using the questionnaire took about 15 minutes; standard educational assessment was then performed by the TEP leader in the TEP premises and took about 35 minutes.

d) Prospective study

The second part of this research consisted in a prospective observational study of consecutive patients admitted to the internal medicine department with indications foror who were on -anticoagulation therapy between January 1 and September 30, 2016, and included in the TEP.

Non-inclusion criteria comprised institutionalized patients or patients with dementia whose treatment was administered by the paramedical staff, and patients refusing to answer the questionnaire.

Scores were assessed in a double-blind procedure by a clinician and the TEP leader. The clinician's score helped identify the patient's profile while the TEP leader performed blindly standard educational diagnosis and identified the patient's profile, considered as the reference. The two assessments were then compared. After 3 months, follow-up by telephone or in consultation determined whether there had been any hemorrhagic or thrombotic events (objective benefit assessment criterion), last INR, whether treatment was ongoing. (See Appendix 3: Follow-up questionnaire) Data were collected orally during interviews, using a prescription software data form, anonymized and registered in a standard table numbered 1 to 100 and 1 to 39, then entered under Microsoft Excel (2011) for analysis.

e) Analysis

Basic statistical assessment was conducted with the Excel software (Microsoft).

Quantitative variables were reported as mean, median, standard deviation and range.

Descriptive variables were reported as numbers and percentages. Data for both studies were entered directly in a Microsoft Excel 2011 spread-sheet as figures and appropriate statistical analyses were performed, as numbers and percentages.

Results

Retrospective study

Thirty-eight patients were included; mean age was 69 years (range 30-91 years), and median age 71 years. Gender distributions were comparable between the various anticoagulants. Mean age of patients taking VKA and DOACS was similar (respectively 73.7 and 71.3 years). Forty percent of patients under VKA were aged ≥ 80 years, compared to 30% for DOACs. Of the 38 patients, anticoagulation therapy was indicated for non-valvular AF in 28.9% (n=11), in 56% (n=21) for pulmonary embolism (PE), in 15.8% (n=6) for deep venous thrombosis (DVT).

Of the 16 patients already under anticoagulants at admission, 41% (n=7) were taking warfarin (Coumadine®), 24% (n=4) fluindione (Préviscan®), 22% (n=3) rivaroxaban (Xarelto®), and 14% (n=2) apixaban (Eliquis®). The remaining 12 patients were naive for anticoagulation

We identified four groups of patients, according to their profile, based on standard educational diagnosis and the questionnaire: 58% (n=22) were categorized as "Initiation", 18% (n=7) were categorized as "Competent": they had maximum scores for the 4 key items: "Pathology", "Treatment", "Risk" "Caregiver". In addition, 21% (n=8) had gaps in their knowledge and were categorized as "learning underway". One patient was categorized as "needing education"

Prospective study

The study flowchart is detailed in Figure 1. The population comprised 76 patients: thirty-eight percent (n= 29) male, mean age 84 years (range, 36-97 years). Finally, 53 patients were able to have the score assessed.

For 26 patients, scores were assessed in a double-blind procedure by a clinician and the TEP leader. Data collected are summarized in Table 2. Mean age was 84 years.

Anticoagulation therapy was indicated for non-valvular AF in 65% (n=17), in 35% (n=9) for PE and/or DVT.

The profiles determined from the questionnaire were concordant with those determined by the TEP leader (Table 1).

Eleven patients were categorized as "Initiation"; 6 had little or no relevant knowledge ("Needing education"); for 3, learning was "Underway"; 6 were "Competent", with sufficient core knowledge for good compliance. Three, classified as "Competent", did not "want to know more"; all the other patients answered this question in the affirmative (Table 2).

Discussion

To our knowledge, this is the first study to standardize educational diagnosis using a tool able to distinguish 4 patient profiles in a study population representative of the general population under anticoagulants in terms of age and profile.

The objective was to propose a simple tool making it possible for any clinician in charge of a patient on anticoagulant to categorize him in terms of educational needs, the therapeutic education being provided afterwards by the specialist.

It should be borne in mind that it is difficult to grasp the determining factors of compliance. In previous studies, we hypothesized that compliance was linked to quality of life and satisfaction in patients with VTE and AF. Overall, the experience of patients under oral anticoagulation therapy for AF managed on an outpatient basis was good, with comparable quality of life under DOACs and VKA, and significantly greater satisfaction under DOACs, but without impact on adherence. Taking account of patient preference in "shared decision-making" for the choice of type of anticoagulant could improve the patients' experience of treatment [START_REF] Keita | Assessment of quality of life, satisfaction with anticoagulation therapy, and adherence to treatment in patients receiving long-course vitamin K antagonists or direct oral anticoagulants for venous thromboembolism[END_REF] [START_REF] Benzimra | Real-life experience of quality of life, treatment satisfaction, and adherence in patients receiving oral anticoagulants for atrial fibrillation[END_REF].

Even when patients understand the risks and benefits of treatment, whether they will prove compliant or not is unpredictable. In theory, individuals are supposed to make rational choices on the basis of the information provided and/or available to them, but it has been shown that the information actually used in making choices is limited and that cultural and cognitive biases come into play. In both the choice of treatment -in which the patient should be involved -and compliance with the treatment, it is very difficult to know if the patient is acting in his or her own best interests or if some irrational factors remain, making prolonged treatment (which implies chronic disease) difficult for the patient to accept [START_REF] Palacio | Patient values and preferences when choosing anticoagulants[END_REF]. The active involvement of health-care professionals associated with personalized therapeutic education based on educational diagnosis helps reveal the individual's intrinsic issues and can positively impact on his or compliance [START_REF] Palacio | Patient values and preferences when choosing anticoagulants[END_REF] [START_REF] Stacey | Decision aids for people facing health treatment or screening decisions?[END_REF].

The "Initiation" profile seems especially important, as the impact of TEP is greater at treatment initiation, as shown in the IMPACT AF study [START_REF] Vinereanu | A multifaceted intervention to improve treatment with oral anticoagulants in atrial fibrillation (IMPACT-AF): an international, cluster-randomised trial[END_REF]. Twenty-two patients in the retrospective study (56%) and 11 patients in the prospective study (42%) were initiating treatment. The profile "Needing education" does not necessarily require more therapeutic education than the other profiles. Especially since the abilities of observance are different for everyone. It is more difficult to assess compliance with DOACs than with VKAs, for which there are intermediate markers of good compliance. Only half of patients receiving DOACs for the first time are able to say which drug they have been prescribed [START_REF] Rey | Compétences des patients vis-à-vis de leur traitement anticoagulant oral par antivitamine K et anticoagulant oraux direct[END_REF]. This may be different for VKAs, where regular INR assay should help patients keep in mind the usefulness of their treatment [START_REF] Mahé | Utilisation et suivi biologique des antivitamines K en pratique médicale courante[END_REF].

Standardizing educational diagnosis allows TEP leader to spend more time with patients who need it most. Profiles were thus determined independently of previous information and experience, but were directly related to individual needs, hemorrhage or thrombosis risk and level of knowledge.

The score makes it possible to move beyond the usual dichotomies of DOAC vs. VKA or young vs. old subjects, and to focus solely on the patient's needs. In addition, educational diagnosis standardized by using the score was quicker (15 min) than the usual procedure (about 35 min), and can be performed by any clinician, given its reproducibility by the questionnaire.

Twenty-three out of 26 patients (87%) wished to know more about their treatment among them 85% still had gaps in their core knowledge ("Needing education" or "Learning underway" profiles), and so the time saved by the use of the score can serve for extra TEP sessions. This is also the case for patients with the greatest needs, such as those with high hemorrhage risk, CHA2DS2VASc score >2 or multiple pathologies [START_REF] Stacey | Decision aids for people facing health treatment or screening decisions?[END_REF] which was the case for 80% of patients who underwent double assessment. TEP can be adapted to the patient's demands, needs, educational level and all factors affecting compliance [START_REF] Izazola-Conde | Face-to-face education to optimize knowledge in patients initiating oral anticoagulant treatment (OAT)[END_REF] [START_REF] Clarkesmith | Educational and behavioural interventions for anticoagulant therapy in patients with atrial fibrillation[END_REF].

In the present study, 58% of patients without anticoagulant treatment were prescribed DOACs, and 6 patients receiving fluindione (Préviscan®) or acenocoumarol (Sintrom®) were transferred to DOACs (mainly apixaban (Eliquis®). This is due to difficulty in stabilizing the INR in most cases, or to relieve the patient from regular and unpleasant biological monitoring. The patient is thus actively involved in the treatment decision, which should influence compliance [START_REF] Raparelli | Adherence to oral anticoagulant therapy in patients with atrial fibrillation. Focus on non-vitamin K antagonist oral anticoagulants[END_REF] [START_REF] Bartoli-Abdou | Exploration of adherence and patient experiences with DOACs one year after switching from vitamin-k antagonists-insights from switching study[END_REF]. It is essential to emphasize the provision of information and to put the patient in a position of responsibility from the outset of treatment. Borne et al. investigated factors for good compliance in a subgroup analysis of elderly subjects frequently presenting geriatric syndromes: malnutrition, low body-weight, sarcopenia, cognitive disorder, risk of falling [START_REF]Education thérapeutique du patient: définition, finalité et organisation[END_REF]. Most authors showed multiple morbidities, and polymedication which complicated the initiation and longterm maintenance of anticoagulation therapy. Those patients would need more in-depth education, but also had more professional medical and paramedical support, with help in taking treatment, which may suggest better basic compliance capacity, as reported in AEGEAN study [START_REF] Montalescot | Adherence and Persistance to APIXABAN treatment in patients with non valvular atrial fibrillation is high and similar with standard of care patient education or with additional educationnal program: the randomized AEGEAN study[END_REF].

Score assessment showed a perfect reproducibility between patient profiles as determined by clinicians, who were clinicians with no specialization in TEPs, and by the TEP leader. The questionnaire represents the minimum core knowledge the patient needs to acquire.

Given the good reproducibility of the questionnaire, this core knowledge could be imparted in community medical practice. Therapeutic education as it is today, and as recommended by guidelines, is time-consuming for both care-givers and patients, when at the same time hospital stays are getting shorter. It seems essential to transfer part of the patient profile assessment to non-specialist. The specialist in therapeutic education can therefore focus its activity on therapeutic education and therefore improve compliance.

Our findings and patient profile identification from educational diagnosis can have implications for the content and the progress of therapeutic education.

For patients who are categorized as « initiation », the ETP program will be the same as usual : educational diagnosis followed by a first education session about the disease and a second session about the risk of bleeding.

For patients who are categorized as « competent », the patient requires only reminders, the education sessions can help increase their knowledge but key points have already been acquired. A single session instead of two are required.

For patients who are categorized as « needing education », two education session have to be planned.

For patients who are categorized as « learning underway », those patients need more time to acquire the minimum knowledge and competence. Additional sessions to the two usual are required to know key points about the disease and the treatment. The participation of caregivers can be useful for those patients.

The present study has certain limitations. The score was tested in a double-blind procedure on 26 of the initial 76 patients. The score is not suited for institutionalized patients, who do not manage treatment by their own, or to patients with cognitive impairment. It could, however, be proposed to care-givers, although this was not the objective here. Moreover, scores could not be established for 23 patients due to problems of understanding or to refusal.

It seems necessary to develop TEPs for care-givers, who are sometimes more directly than patients involved in compliance to treatment. Likewise, inviting spouses or relatives to the TEP could improve compliance. The present population was exclusively hospital-based; but administering the questionnaire towards the end of the hospital stay, to stabilized patients, makes the study population more similar to an outpatient population. Although therapeutic education was mainly designed by hospital teams, the general practitioner has a key role to play. Giving the appointments for the patient to take part in therapeutic education sessions is an integral part of the community-hospital education network [23], for which the general practitioner is indispensable [24]. The score need to be tested in a more general outpatient population.

Conclusion

Profiling on standardized educational diagnosis is the first step to enable the patient to acquire the minimum core knowledge, regardless of baseline compliance profile and provide him with more personalized therapeutic education, adapted to the patient's individual profile. The present score seems to serve this objective. The purpose is to be able to adapt TEPs to each category of patient so that they can acquire the knowledge that is noteworthy for their treatment.

Community assessment of the present profiling score is necessary to enable clinicians to guide their patients effectively and achieve optimal compliance with anticoagulation therapy, whatever the patient's baseline compliance capacity [START_REF] Clarkesmith | Patients' experiences of atrial fibrillation and non-vitamin K antagonist oral anticoagulants (NOACs), and their educational needs: A qualitative study[END_REF].

12-9 points <9-4points <4-0 points Competent

Learning underway Needing education

Table 1 : Double-blind assessment of educational diagnosis

 1

	Patient n°	Profile according to score	Profile according to standard
		(score/12)	educational diagnosis
	17	I	I
	19	E (4)	E
	21	I	I
	24	I	I
	25	I	I
		I	I
	30	I	I
	35	E (2)	E
	36	L (7)	L
	41	L (6)	L
	46	E (3)	E
	53	I	I
	55	C (10)	C
	59	C (9)	C
	62	E (4)	E
	63	L (5)	L
	72	I	I
	73	C (9)	C
	80	I	I
	82	E (4)	E
	83	C (11)	C
	85	E (1)	E
	86	I	I
	96	C (9)	C
	100	C (9)	C
	110	I	I
	Competent: C
	Learning underway: L
	Needing education: E
	Initiation of treatment: I

All authors have read and approved the manuscript -Acknowledgements : none

Disclosure of interest

The authors declare that they have no competing interest.

Declarations

Ethics approval and consent to participate : patients gave written consent to participate in the therapeutic education program as stated in the manuscript. This program including the consent form has been approved by French Health Regional Authorities (ARS ETP/14/20).All patients included in the TEP provided oral and written consent to participate in the education program (Authorized by Regional Health Authorities number 14/20) and data are used for research purpose. As patients gave consent to participate and for the use of their data for research purpose as presented in the project and approved by French Health Regional Authorities (ARS ETP/14/20), no additional submission to an ethic committee was performed -Consent for publication : Authors declare that they consent to the publication if the manuscript is accepted -Availability of data and material : yes -Competing interests : Authors declare that they have no potential conflicts of interest that might be relevant to the contents of this manuscript.

-Funding : No external funding was used in the preparation of this manuscript -Authors' contributions CO : interview of patients, writing the manuscript LJ : reading and improvement of the manuscript LP : reading and improvement of the manuscript GP : reading and improvement of the manuscript SE : reading and improvement of the manuscript HH : therapeutic education leader, interview of patients IM : design of the study, co-writing the manuscript Resources: Obstacles:

Gray areas:

PERSONALIZED OBJECTIVES Appendix 3: decision tree and profile identification score

Profile score for patients under anticoagulation therapy, following decision-tree Decision-tree for patient under anticoagulation therapy

The patient is or has been under anticoagulation therapy

YES NO


Celine Gaullier

Sylvie Dousset
email: sylvie.dousset@univ-lorraine.fr

Nicole Baran

Geraldine Kitzinger

Charlotte Coureau

Céline Gaullier

Géraldine Kitzinger

Influence of hydrodynamics on the water pathway and spatial distribution of pesticide and metabolite concentrations in constructed wetlands

Keywords: Pond, ditch, isolated area, main channel, convection, dispersion

ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

Nomenclature

Introduction

To protect or restore the surface water quality as required by the EU Water Framework Directive [START_REF] Joce | Council of 23 October 2000 Establishing a Framework for Community Action in the field of Water Policy[END_REF], constructed wetlands (CWs) have been presented as a potential solution for reducing agricultural inputs such as nitrates and pesticides in surface water [START_REF] Alvord | Atrazine fate and transport in the Des Plaines Wetlands[END_REF][START_REF] Gregoire | Mitigation of agricultural nonpoint-source pesticide pollution in artificial wetland ecosystems[END_REF][START_REF] Vymazal | The use of constructed wetlands for removal of pesticides from agricultural runoff and drainage: A review[END_REF]. These CWs have emerged as a cost-effective practice to reduce contaminant loading from drainage [START_REF] Schultz | Design and placement of a multi-species riparian buffer strip system[END_REF][START_REF] Moore | Transport and fate of atrazine and lambda-cyhalothrin in an agricultural drainage ditch in the Mississippi Delta[END_REF][START_REF] Tournebize | Codesign of constructed wetlands to mitigate pesticide pollution in a drained catch-basin: a solution to improve groundwater quality[END_REF]Vallée et al. 2015) and have been described as good environmental practices [START_REF] Joce | European Parliament and the Council of 12 December 2006 on the Protection of Groundwater against Pollution and Deterioration[END_REF]. A recent review summarizes 32 studies related to the remediation of organophosphorus pesticides in 117 CWs during 2001-2017 worldwide, shown that organophosphorus pesticides were removed with efficiency up to 87 ± 16.6% [START_REF] Liu | A review on removal of organophosphorus pesticides in constructed wetland: Performance, mechanism and influencing factors[END_REF]). Another study reported efficiency removal > 80 % for 8 pesticides in a CW with a HRT varying from 3 to 35 days [START_REF] Maillard | Pesticide Mass Budget in a Stormwater Wetland[END_REF]. On the contrary, another study reported efficiency removal varying from -50% to 14% in mean for 15 pesticides in 2 CWs, with a HRT varying from 5 h to 17 days (Vallée et al. 2015b). These authors have suggested that major processes are pesticide adsorption and degradation. The main processes of dissolved pesticide mitigation from CW water are adsorption on sediments [START_REF] Matamoros | Organic micropollutant removal in a full-scale surface flow constructed wetland fed with secondary effluent[END_REF][START_REF] Stehle | Pesticide Risk Mitigation by Vegetated Treatment Systems: A Meta-Analysis[END_REF], absorption by plants [START_REF] Moore | Aqueous pesticide mitigation efficiency of Typha latifolia (L.), Leersia oryzoides (L.) Sw., and Sparganium americanum Nutt[END_REF]) and degradation in aqueous or sediment phases [START_REF] Elsayed | Bacterial communities in batch and continuous-flow wetlands treating the herbicide S-metolachlor[END_REF]). The main process of particulate pesticide removal is the sedimentation of total suspended solids (TSS) on which pesticides are adsorbed [START_REF] Koskiaho | Flow velocity retardation and sediment retention in two constructed wetland-ponds[END_REF][START_REF] Maillard | Removal of dissolved pesticide mixtures by a stormwater wetland receiving runoff from a vineyard catchment: An inter-annual comparison[END_REF].

Some studies reported the important role of hydraulic parameters on pesticide mitigation. For example, the hydraulic residence time (HRT), which indicates how long the inflow is retained in the wetland, is considered to be one of the main factors influencing the pesticide mitigation effectiveness of CWs [START_REF] Elsaesser | Assessing the influence of vegetation on reduction of pesticide concentration in experimental surface flow constructed wetlands: Application of the toxic units approach[END_REF][START_REF] Stehle | Pesticide Risk Mitigation by Vegetated Treatment Systems: A Meta-Analysis[END_REF]Vallée et al. 2015). Generally, the mean HRT, determined with tracer data, is shorter than the nominal HRT (corresponding to the ratio of wetland volume on the flow rate) due to the presence of short-circuits, inducing a decrease in the hydraulic performance; i.e., the total CW volume is not affected by water [START_REF] Martinez | Hydraulic analysis of Orlando easterly wetland[END_REF]. Short-circuits have been reported as one of the main drawbacks to the effectiveness of CWs because water is transported from the inlet to the outlet by preferential flow, which decreases the mean HRT and the effective volume (i.e., the CW volume used for pesticide mitigation) [START_REF] Thackston | Residence time distributions of shallow basins[END_REF]. Schematically, the volume of the CW can be divided into three hydraulic zones [START_REF] Kadlec | Detention and mixing in free water wetlands[END_REF][START_REF] Werner | Wetland residence time distribution modeling[END_REF][START_REF] Martinez | Hydraulic analysis of Orlando easterly wetland[END_REF]: (1) a main channel with preferential flow;

(2) a temporary storage zone (mixing zone) showing exchanges with the main channel; and (3) a dead zone, which is more isolated from the main channel than the mixing zone. The mixing and dead zones are considered isolated areas [START_REF] Martinez | Hydraulic analysis of Orlando easterly wetland[END_REF] and are differentiated by their exchange rate with the main channel, such as a lower water speed and solute dispersion in the case of dead zones than in mixing zones. The distribution of these three hydraulic zones could be spatially and temporally influenced by (i) CW morphology: the length-to-width ratio, the inlet/outlet configurations and the presence of obstructions [START_REF] Su | Optimal design for hydraulic efficiency performance of free-water-surface constructed wetlands[END_REF], and by (ii) hydraulic parameters such as HRT, flow rate and water depth [START_REF] Liu | Variations of effective volume and removal rate under different water levels of constructed wetland[END_REF][START_REF] Shih | Tracer Experiments and Hydraulic Performance Improvements in a Treatment Pond[END_REF].

Thus, considering that at a local scale inside the CW, the HRT occurring in the isolated areas could be longer than in the main channel, we can hypothesize that pesticide mitigation processes such as adsorption, absorption, and degradation would be enhanced in these areas. In addition, these hydraulic zones might move inside the CW depending of the flow rate changes in the field. To our knowledge, there is no study regarding the role of these hydraulic zones such as the main channel and isolated zones on pesticide and metabolite mitigation.

Thereby, we investigated the influence of the flow rate on the water pathway distribution (main channel, isolated areas) in two CWs (a succession of three ponds and a ditch with lateral enlargement) and subsequently on the mitigation of pesticides and metabolites in dissolved and particulate phases. Bromide-tracing experiments were carried out at 3 flow rates in the pond and at 2 flow rates in the ditch. In addition, the spatial distribution of pesticide and metabolite concentrations in aqueous (dissolved and particulate) and sediment phases was evaluated to determine the contribution of the main channel and isolated areas to pesticide and metabolite mitigation.

Materials and methods

Constructed wetlands

The two CWs are located under temperate climate, with mean precipitation varying from 1.9 to 3.5 mm/day and mean water volume drained varied from 0.3 to 4.5 mm/day. The dominant cultures on crop fields are wheat, barley, maize and rapeseed (Table 1). More details about climatological, hydraulic and agricultural context of these two CWs are given in Table 1.

The two studied CWs were built in autumn 2010 in a regulatory grass strip, and spontaneous vegetation recovered the entire CW in two years. Thus, during our experiments, the vegetation was present throughout the year, and its influence on the hydrodynamic dispersion as reported by [START_REF] Jenkins | The hydraulic efficiency of fringing versus banded vegetation in constructed wetlands[END_REF]

Tracer experiment

The inlet and outlet flow rates were measured continuously using a pollubac (1515 DA, POLLUBAC®) and an ultra-sound flow meter (950-US 50 Hz, SIGMA); a mean flow rate was recorded every 30 min of measurement. Three experiments were conducted in the pond CW (at high flow = HF, mean flow = MF and low flow = LF), and two were conducted in the ditch CW (MF and LF) (Table 2). All tracer tests were conducted in dry weather conditions, so no precipitation must be considered. However, despite no rainfall, flow rates varied between the beginning and the end of the tracer experiments. Of the five tracer experiments, flow rates varied from 3 % (pond-HF) to 30 % (pond-LF) (Table 2). The estimation of the water transport parameters was done considering a constant flow rate, which was chosen as the mean flow rate (Table 2). The CW's water volume was monitored manually thanks to limnimetric scales (one limnimetric scale is localised in each of the 3 pond and in each of the 3 parts of the ditch). Besides, CW's geometries were determined by topographic measurements. For each tracer experiment, the volume of water was calculated with Autocad® and ADTOPO® softwares based on water level observed in the field.

For each experiment, an instantaneous pulse of 5 to 15 L of 200 g.L -1 bromide (in the form of KBr) was injected inside the pollubac at the CW inlet at a flow rate of 4 L.min -1 using the pump of an automatic sampler (SD-900 SIGMA) (Table 2).

Water was collected at the outlet of both wetlands in two steps: (i) manually sampling approximately every 5 min (from 4 to 9 h, which was chosen according to the nominal HRT, Table 2 and Table A1), and (ii) automatic sampling every 2 h during the subsequent 2 to 5 days, until the bromide concentration was believed to be under the limit of quantification (LOQ). These two steps constitute the total sampling period (Table 2). Additionally, spatial water sampling was manually performed by using a telescopic surface water sampler (except for the experiment pond-HF) to determine water pathways (blue numbered circles on Fig. 1), with variable frequencies between 2 min and 30 min (during 4 to 9 h) according to the localization. All samples were collected in a 20 mL clean PE bottle, transported under refrigeration (almost 10°C) to the laboratory and then stored at 4°C prior to analysis.

Samples were filtered through a 0.22 µm cellulose acetate filter, and then 1 mL aliquots were transferred to polypropylene vials for analysis with a Dionex ICS-3000 ion chromatographic instrument (Sunnyvale, CA, USA) using Chromeleon® software (version 6.80). Concentrations of Br -were analysed using an AS20 guard column (4 x 50 mm) with a polymeric AS20 analytical column (4 mm x 250 mm). The LOQ was 50 µg.L -1 . Certified standard solutions from Inorganic Ventures (Washington, USA) were used for calibration.

Water transport parameters

To estimate the hydraulic performance of the CWs, water transport parameters were derived from Residence Time Distribution (RTD -corresponding to the bromide restitution curves):

the normalized retention time (tϴ), the effective volume (ev), the number of cells (N), the hydraulic efficiency (λ), the short-circuiting index (t10/tn) and the mixing index (t90/t10), were determined. The hydraulic performance is considered good when all of these parameters are optimized, such as when the water is transported from the inlet to outlet circulating in the whole of volume system, which limits the short-circuit.

The normalized hydraulic retention time tϴ, i.e., the ratio between the mean HRT (tmean) and the nominal HRT (tn), allows the comparison of RTDs of our 5 tracer experiments.

In addition, it corresponds to the effective volume used by water (ev, characterizing the main channel) (dimensionless) [START_REF] Fan | Application of computational fluid dynamic to model the hydraulic performance of subsurface flow wetlands[END_REF] allowing to assess the percentage of isolated areas as follows: (1 -ev) x 100. The nominal HRT (tn) (h) was calculated as the ratio between the CW volume (m 3 ) and the flow rate through the CW (m 3 .h -1 ); tmean, the mean HRT (h), depicted the average time that the water spent in the system (Eq. ( 1)):

t = (1)
where E(t) is the RTD function and is defined by Eq. (2) in the case of pulse injection:

E t = × × × (2)
where C(t) is the bromide concentration (mg.L -1 ) at time t, Q is the flow rate (L.s -1 ) at time t and dtis the interval between two consecutive measurements.

The plug flow conditions could be evaluated with the number of cells (N) used in a tank-in-series model (Eq. ( 3)). Generally, in CWs, the plug flow never occurs, inducing a deviation of the mean HRT (tmean) compared to the nominal HRT (tn). The higher the N is, the more that the flow is a plug-flow.

N = (3)

where σ 2 is a measure of the spread of the RTD and was defined by Eq. ( 4):

= ² (4)
The hydraulic efficiency (λ) can be classified as follows: good hydraulic efficiency (λ>0.75), satisfactory hydraulic efficiency (0.5<λ<0.75) and poor hydraulic efficiency (λ<0.5) [START_REF] Chang | Flow uniformity and hydraulic efficiency improvement of deep-water constructed wetlands[END_REF].

λ = ! "1 - % & ' (5)
Then, short-circuiting and mixing indexes were calculated. Thus, the short-circuiting flow is the situation in which water passes through the CW in less than nominal residence time due to convection process or velocity heterogeneity [START_REF] Teixeira | Performance assessment of hydraulic efficiency indexes[END_REF]. The t10/tn, defined as the required time to recover 10 % of bromide at the outlet normalized to the nominal HRT tn,is considered as the value of short-circuit, i.e., the lower the value is, the higher the short-circuit [START_REF] Guo | Test study of the optimal design for hydraulic performance and treatment performance of free water surface flow constructed wetland[END_REF]). The mixing is due to turbulent diffusion and can also be due to recirculation zones and dead zones [START_REF] Teixeira | Performance assessment of hydraulic efficiency indexes[END_REF]. The t90/t10 ratio is considered as the value of the mixing index; the larger the value is, the more the mixing flow [START_REF] Guo | Test study of the optimal design for hydraulic performance and treatment performance of free water surface flow constructed wetland[END_REF], i.e. the t90/tn was defined as the required time to recover 90 % of bromide at the outlet, normalized to the nominal HRT tn.

Finally, the Peclet number (Pe) allows distinguishing between the different mixing regimes: convective or dispersive flow; i.e., the lower the Pe value is, the higher the water dispersion (Eq. ( 6)) [START_REF] Nameche | Hydrodynamic studies and modelization for aerated lagoons and waste stabilization ponds[END_REF].

Pe = ×* + ×, ×- (6)
where Q is the flow rate (m 3 .h -1 ), L is the length of CW (m), W is the width of CW (m), Z is the height of water (m) and D is the dispersion coefficient (m 2 .h -1 ) defined by Eq. ( 7).

D = α × Vmean (7)
with α the water dispersivity (m) and Vmean (m.h -1 ) the mean water velocity inside the CW (i.e. CW length divided by tmean).

The water dispersivity α was calculated as the mean of two dispersion parameters (dimensionless) which characterized the asymmetrical tracer curve. Those parameters were determined using model.

TSS measurements and pesticide analysis in water samples

Raw water (water + TSS) was manually sampled during the 2016/2017 hydrological season. For the pond CW, the samples were collected every two weeks from 21/11/16 to 22/05/17 (i.e., 12 samples, 7 under drainage and 5 under no-flow periods). For the ditch CW, samples were collected from 13/02/17 to 13/03/17, due to short drainage season (i.e., 3 samples: 2 under drainage and 1 under a no-flow period).

Water samples were collected at the inlet, at the outlet, in the main channel inside the CW (point MC) and in an isolated area (point IA). Points MC and IA were identified by bromide concentration analysis (MC and IA correspond to points 10 and 9 for the pond CW and 6 and 3 for the ditch CW, respectively) (Fig. 1). Under no-flow, the inlet and outlet sampling was performed in stagnant water close to the inlet and outlet, respectively. All samples were collected in 250 mL PE bottles, which were transported under refrigeration to the laboratory where they were homogenized and centrifuged at 7000xg and then stored at -20°C until analysis. The electrical conductivity was measured in situ for all samples with an electrical probe (HQ40D, HACH-LANGE, France). The analysis of pesticides was performed on an Acquity Ultra-Performance Liquid Chromatography system (UPLC, Waters) interfaced to a triple quadrupole mass spectrometer (Quattro Premier XE, Waters) according to 2 methods: (i) method A was performed to analyse 14 pesticides and 4 metabolites, and (ii) method B was performed to analyse 14 metabolites, as detailed in Table A2. Briefly, for method A, the sample was flushed onto the online SPE cartridge (Oasis HLB 25 µm, 2.1 x 20 mm, Waters) with water (neutral pH). Elution was realized using a gradient of acidified water and acidified acetonitrile (0.05 % formic acid -FA) in the Kinetex 1.7 µm C18 100A (100 x 2.1 mm), Phenomenex. For method B, the sample was flushed onto the online SPE cartouche (Oasis HLB 25 µm, 2.1 x 20 mm, Waters) with acidified water (pH of 3.4). Elution was realized using a gradient of acidified water and acidified acetonitrile (0.007 % FA) in the Kinetex PFP 1.7 µm (100 x 2.1 mm), Phenomenex. The analytical standards were purchased from Cluzeau (Sainte-Foy-La-Grande, France), Restek (Lisses, France), Sigma (Lyon, France), Neochema (Bodenheim, Germany) and Techlab (Metz, France). The limit of quantification ranged from 0.01 to 0.05 µg.L -1 according to the molecules.

The analyzed pesticides were chosen because of their frequent application in the agricultural plots due to dominant cultures (i.e. winter wheat, rapeseed and maize), and because of their frequent detection in drainage water according to a previous study (Vallée et al. 2015b).

Moreover, the diversity of the physico-chemical properties of these molecules (Table A2), allow study the potential contrasted behavior. The metabolites were chosen on the one hand because they are metabolites of widely used pesticides, but rarely studied worldwide; and on the other hand, for their high polarity.

To quantify the TSS, 2 L water samples were also manually collected in a 2 L PE bottle. The sampling was performed exclusively at the inlet and outlet due to difficulties in sampling in the MC and IA zones without resuspending the TSS. Then, 250 to 1000 mL of water (depending on particle laden flow) was filtered through 0.7 µm fiber glass filters to separate the largest TSS from the aqueous phase. Before their use, fiber glass filters were cleaned with distilled water, dried at 70°C for 24 h, weighed, and then stored in a glass container. After filtration, filters with the TSS were dried at 70°C for 24 h and then weighed.

Sediment deposition measurement and pesticide concentrations in sediment

Sediment deposition was spatially estimated in the pond and ditch CWs (coloured squares on At the laboratory, sediments were recovered from the trap and stored in a pre-weighed 250 mL PE bottle. An aliquot of 10 mL was taken after homogenization of the sediment for each sample for particle size estimation. Then, the bottles were stored at -20°C for freezedrying, and the bottles were weighed. The quantification of sediment in each trap corresponded to the weight difference between the empty and full bottles. The sedimentation rate, i.e., the mass of sediment collected per square centimetre of trap opening per unit of time, was then calculated for each trap [START_REF] Gardner | Sediment trap dynamics and calibration: a laboratory evaluation[END_REF] for the duration of the drainage season.

The particle sizes were measured within 48 h following the sampling using a laser diffraction technique (Helos, Sympatec GmbH), which can measure particle sizes from 0.2 to 90 µm or from 2.4 to 875 µm, according to the chosen lens. In this study, a range from 0.2 to 90 µm was selected due to the fine particle size distribution determined previously. Aliquots of suspended particles of sediment were introduced in the bath-type sonicator integrated with the granulometer and sonicated for 1 min before measurement. Two consecutive measurements of 10 seconds, each spaced by 5 seconds, were executed to avoid extreme measurements (i.e.

one plant debris measurement was made in the length, biasing the results). Then, they were analysed using one multi-method based on liquid chromatographyelectrospray ionization-tandem mass spectrometry (LCeESI-MS/MS) with multiple reaction monitoring described in Vallée et al. (2015). This method allowed the analysis of 67 pesticides and 3 metabolites listed in Table A3.

Results and discussion

Hydrodynamic of the CWs

After the intense sampling time (step 1), the bromide recovery was 77 %, 111 % and 23 % for HF, MF and LF, respectively, in the pond CW and 47 % and 30 % for MF and LF, respectively, in the ditch CW (Table 2). The total sampling period (from 2 to 5 days, step 1 + step 2) allowed a tracer recovery of 104 % for pond-LF and 97 % for ditch-MF. Only 72 % was recovered for the ditch-LF, possibly due to the total sampling period being too short (i.e., bromide was measured up to 0.2 µg/L in the last sample, 5 days after the beginning of the tracer experiment). Finally, the tracer recoveries were always higher than 70 % after the total sampling period (Table 2), so tracer test data can be processed [START_REF] Lin | Comparison of rhodamine WT and bromide in the determination of hydraulic characteristics of constructed wetlands[END_REF].

Tracer concentrations as a function of time are shown in Fig. 2, and water transport parameters calculated from RTD data are detailed in Table 3. The nominal HRT (tn) was longer than the mean HRT (tm) regardless of the flow rates for the ditch CW and at LF for the pond CW, which suggests short-circuiting for these conditions [START_REF] Wahl | Quantifying the hydraulic performance of treatment wetlands using the moment index[END_REF]. This is confirmed by the values of short-circuiting (t10/tn) and mixing indexes (t90/t10) (Table 2). For both CWs, at LF, t10/tn is lower than at MF and HF, indicating more short-circuiting, and t90/t10 is higher than at MF and HF, indicating more water mixing due to higher water dispersion promoted by low flow rates [START_REF] Guo | Test study of the optimal design for hydraulic performance and treatment performance of free water surface flow constructed wetland[END_REF]. Naturally, these results were consistent with the analysis of the number of serial mixing tanks (N), which are lower at LF, indicating that a lower volume of wetland is affected at LF and the hydraulic regime is considered a mixing flow. In addition, the hydraulic efficiency value (λ) was satisfactory at HF and MF in the pond CW (Table 3), whereas it was poor at LF in the pond CW as well as in the ditch CW regardless of the flow rate [START_REF] Chang | Flow uniformity and hydraulic efficiency improvement of deep-water constructed wetlands[END_REF]. Furthermore, taking all these hydraulic parameters (ev, N, λ, t10) into account, the hydraulic performance is (i) higher at HF

and MF than at LF in the pond CW and (ii) weaker regardless of the flow rate in the ditch CW. Indeed, the flow velocity at the field scale, which is higher for the ditch CW (vmean values from 0.87 to 1.55 m/min) than for the pond CW (vmean values from 0.03 to 0.53 m/min), could promote the short-circuiting in the ditch CW, thus decreasing its hydraulic performance. This larger short-circuiting value may be explained by a higher length-to-width ratio for the ditch (80) than for the pond ( 7), as previously reported by [START_REF] Su | Optimal design for hydraulic efficiency performance of free-water-surface constructed wetlands[END_REF]. Thus, a linear CW such as our ditch, despite the added enlargement, does not appear to be suitable for retaining water for a long time.

Concerning the bromide concentration time series (Fig. 2), for the pond CW, two outlet peaks are identified at LF and MF, indicating two flow paths, while only one peak is visible at HF. This seems to be due to the circulation in pond 3, since only one outlet peak was identified at the outlet of pond 2 (Fig. 3). Indeed, the greater depth of pond 3 (1.2 m compared to 0.5 m in pond 2) could promote deeper water recirculation, inducing two distinct outlet peaks due to a portion of the water being retained and recirculated in this pond. For the ditch CW, only one outlet peak is visible for both flow rates (LF and MF), suggesting that only one major flow path occurred. For both CWs, the outlet peaks appeared slower at LF than at MF or HF (Fig. 2), and this is in agreement with a higher mean HRT at LF (Table 3).

In addition, the outlet peaks at LF for the ditch CW and pond CW are wider than those at MF, suggesting more dispersion here. The presence of isolated areas might contribute to the postponed bromide arrival at the outlet (Fig. 2). The cumulative normalized concentration curves (Fig. 2) provide complementary indications of the water transport processes: the steep slope at the first part of the curve corresponds to convection transport, and the flat part of the curve corresponds to dispersion transport. For the pond CW, the flat part began more rapidly at LF(tϴ = 0.7) than at HF and MF (tϴ = 1), indicating more water dispersion at LF, which is in agreement with the t90/t10 values (Table 3) and the lower values of the Peclet number (Pe).

The lower the Pe value is, the higher the dispersion of water due to low velocity and internal recirculation [START_REF] Nuel | Seasonal and ageing effects on SFTW hydrodynamics study by full-scale tracer experiments and dynamic time warping algorithms[END_REF]. For the ditch CW, regardless of the flow rate, the flat part begins before tϴ = 0.5, indicating more dispersion here than in the pond regardless of the flow rate. Moreover, for both CWs, the equilibrium was reached faster at LF than at MF and HF.

Thus, for the two CWs, the water transport was dominated by convection at HF and MF and by dispersion at LF [START_REF] Nuel | Seasonal and ageing effects on SFTW hydrodynamics study by full-scale tracer experiments and dynamic time warping algorithms[END_REF][START_REF] Gaullier | Wetland hydrodynamics and mitigation of pesticides and their metabolites at pilotscale[END_REF]). Thus, the bromide analysis showed that flow rate influences the water pathways, with a higher proportion of isolated areas at LF (38 % and 89 % for the pond and the ditch, respectively) than at HF or MF (11 % and 68 % for the pond and the ditch, respectively). This corresponds to a volume of isolated areas at LF of 21 m 3 and 20 m 3 for the pond and the ditch, respectively, and at HF or MF of 7-11 m 3 and 26 m 3 for the pond and the ditch, respectively. Thus, the volume of isolated areas inside the ditch CW is quite similar regardless of the flow rate (± 25 %), whereas it is 2 or 3 times higher at LF than at MF/HF in the pond.

Influence of hydrodynamics on water pathways

To locate the isolated areas, the spatial distribution of the bromide concentration inside both CWs was monitored over time (Fig. 3). To maintain the readability of Fig. 3, only the sampling points in the second pond and the sampling points in the enlargement of the ditch CW were drawn. The supplementary sampling points for the first and the third pond are given in Fig. A1 (Supplementary Material).

Focusing on pond 2, at MF, the peak concentration at the outlet (point 12) is lower and more spread out than that at the inlet (point 5), indicating that bromide has circulated from points 5 to 12 by convection and dispersion, corresponding to the main channel. The lower peak concentrations for points 6, 7, 8, 10 and 11 compared to the outlet (point 12) may be explained by a greater transfer of water and tracer by dispersion than by convection from point 5 (Fig. 3). At LF, the concentration peak of bromide was gradually reduced from the inlet (point 5), passing by points 6, 7, 8 and 10, to the outlet (point 12), by convection and dispersion. In addition, all peaks are wider and smaller at LF than at MF, highlighting a greater dispersion due to a water velocity that is ten times slower at LF (Table 3). Point 9 may be considered an isolated area for both flow rates. More precisely, at MF, it was considered a mixing zone due to (i) a more delayed peak time than at the outlet (240 min against 60 min) and (ii) a larger peak than at the outlet, whereas at LF, it was considered a dead zone due to the absence of bromide detection during the tracer experiment. The existence of different hydraulic zones was confirmed by the electrical conductivity distribution measured under seven flow rates inside the pond CW (Fig. 4), allowing to generalize the conclusions obtained with the 3 tracer experiments i.e. heterogeneity within the CWs varying according to flow rates. Indeed, regardless of the flow rate, the electrical conductivity measured in the isolated area (point 9, IA zone) is different than that measured in the inlet, main channel (point 10, MC zone) and outlet. Similarly, the electrical conductivity measured in the main channel (MC zone) was almost equal to those measured in the inlet and outlet under drainage. Under the no-flow period, the electrical conductivity measured in the isolated area (point 9, IA zone) is different from that of the main channel (point 10, MC zone) during the first month of no-flow (I, J). Then, beyond this month (K, L), the electrical conductivity becomes similar in the MC and IA zones, which is possibly due to a very slow dispersion during the no-flow period.

Concerning the ditch, at MF, peak times of points 2-5-6 and 7 were missed due to the fast flow rate. The main channel path at MF corresponds to the middle of enlargement (points 1-5-2-6-7-4). Bromide later reached the border of enlargement (points 8-9-10), and point 3 located behind a tuft of Juncus (Fig. 3). At LF, the bromide concentration decreased from the inlet to the outlet due to convection and dispersion. The peak times for points 2, 3, 7 and 10 are longer than the peak times at the outlet of enlargement (point 4), indicating that these points are clearly affected only by dispersion. Thus, at LF, the main channel was located in the middle of the enlargement and in a part of its left border (5-8-6-9-4). Point 3 could be considered as an isolated area, but not especially a dead zone, as confirmed by the measured electrical conductivity always different at point 3 (corresponding to IA zone, Fig. 4) than in the main channel, inlet and outlet (Fig. 4). Finally, points 7 and 10 could be isolated because of their position in the upper corner of the enlargement, as previously suggested by [START_REF] Sabokrouhiyeh | A numerical study of the effect of wetland shape and inlet-outlet configuration on wetland performance[END_REF]. For the pond, all peaks are wider at LF than at MF, highlighting the greater dispersion occurring at LF. The slow water velocity at LF (vmean, Table 3) allowed for the dispersion of water and solutes in the enlargement, increasing the proportion of the isolated area affected by dispersion compared to MF. Otherwise, at MF, the fast water velocity limited the isolated areas (point 3 and the border area, points 8-9-10) affected by dispersion, whereas water was transported by convection in the middle of enlargement.

Thus, regardless of the CW, the flow rate influences the water pathways and their geometry. For both CWs, the main channel is globally larger at MF or HF than at LF, and subsequently, the isolated areas are more spread out at LF than at MF or HF.

3.3.Influence of hydrodynamics on dissolved pesticide transport

In the pond CW, among the 32 analysed molecules in the dissolved phase, chlortoluron (CLT), two metabolites of metazachlor (OXA metazachlor, ESA metazachlor) and one metabolite of dimetachlor (CGA 369873) were quantified in the four hydraulic zones (inlet, outlet, MC zone and IA zone) during the 12 sampling campaigns (Table A4, Fig. 5). In the ditch CW, two metabolites of metazachlor (OXA metazachlor, ESA metazachlor) and two metabolites of dimetachlor (OXA dimetachlor, ESA dimetachlor) were quantified in the four hydraulic zones (inlet, outlet, MC zone and IA zone) during the three sampling campaigns (Table A4, Fig. 5).

Under the drainage period, for both CWs, the molecule concentrations are different inside the four zones at a given time, as previously shown with the bromide concentration and electrical conductivity values (Fig. 4). No pattern can be highlighted; indeed, pesticide concentrations are sometimes higher in the MC zone and sometimes higher in the IA zone, except for cases G and H in the pond CW. For these two cases, where LF is preceded by MF, the molecule concentrations measured in the IA zone (point 9) are always lower than those in the MC zone (point 10). These results may be explained by a higher mitigation in IA (adsorption in sediments and degradation) and/or a limited water dispersion inside IA. It should also be kept in mind that water entering the CW has a time-dependent composition. In contrast, the concentrations for all MC points (MC + inlet + outlet) are always quite similar for a given sampling campaign, indicating limited pesticide removal from the inlet to outlet.

The few data collected in the ditch (3 samples) limit the ability to draw conclusions for this CW. In conclusion, pesticide concentrations are heterogeneous in the CW during drainage, regardless of whether there are high or low flow rates.

Under the no-flow period, the concentrations of pesticides in the pond (cases I to L), measured in the MC and IA zones, are close, especially after one month of no-flow (Fig. 5).

This observation is consistent with the electrical conductivity values previously described as homogeneous during this no-flow period (Fig. 4). Dispersion is the dominant transport under the no-flow period and slowly leads to a uniform contaminant distribution inside the CW. The distance travelled by diffusion is only approximately 1 cm per day for a molecule (Gaullier et al. 2018). Thus, considering a distance of 2 m from MC to IA, more than 200 days would be necessary for a whole homogenization of the water volume by diffusion. Nevertheless, the homogenization took place in less than one month, which suggests that other processes than diffusion take place, such as wind mixing, vegetation patterns, and bioturbation, as previously observed by [START_REF] Werner | Wetland residence time distribution modeling[END_REF] and [START_REF] Zounemat-Kermani | Hydrodynamic modelling of free water-surface constructed storm water wetlands using a finite volume technique[END_REF].

In conclusion, the dissolved pesticide concentrations show spatial heterogeneity during the drainage phases (LF or MF) (in agreement with the bromide monitoring and conductivity) and during homogenization of the concentrations in the constructed wetland after one month of no flow. On the other hand, no link could be highlighted between the pesticide concentrations and the flow rate or the water pathways.

Influence of hydrodynamics on the sedimentation rate

In addition to being transported by the dissolved phase, pesticides can be transported by the particulate phase via the suspended solids entering the CW via tile drains. The TSS transported by drainage entering the pond CW was 1500 kg in 2016 (75 kg.ha -1 .y -1 or 7.8 kg.day -1 ) and 400 kg in 2017 (20 kg.ha -1 .y -1 or 4.8 kg.day -1 ). In the ditch CW, the TSS entering was 780 kg in 2016 (78 kg.ha -1 .y -1 or 8.3 kg.day -1 ) and 300 kg in 2017 (30 kg.ha -1 .y -1 or 8.8 kg.day -1 ) (Fig. A2). The lower exportation in 2017 than in 2016 may be due in part to a smaller total drained volume in 2017 (23920 m 3 and 2960 m 3 in the pond and the ditch, respectively) than in 2016 (83530 m 3 and 10475 m 3 in the pond and the ditch, respectively).

To understand the transport and fate of solid-bound pesticides inside the CW, we focused on the spatial repartition of pesticide concentrations in sediments, whereas sedimentation is the main process of mitigation for solid-bound pesticides inside the CW, as previously shown by [START_REF] Koskiaho | Flow velocity retardation and sediment retention in two constructed wetland-ponds[END_REF].

The spatial distribution of the sedimentation rate is shown in Fig. 6. The annual sediment accumulation in the pond varied from 1.4 to 8 kg.m -2 .y -1 (0.2 to 1 cm.yr -1 ) in the main channel (T1 to T4), varied from 0.47 to 2.9 kg.m -2 .y -1 (0.1 to 0.4 cm.yr -1 ) in the border area (T5 to T8), and was 4.2 kg.m -2 .y -1 (0.5 cm.yr -1 ) in the isolated area (T9). For the ditch, the sediment accumulation varied from 2 to 12.7 kg.m -2 .y -1 (0.5 to 1.6 cm.yr -1 ) in the main channel (T1 to T3), from 1 to 2.5 kg.m -2 .y -1 (0.1 to 0.3 cm.yr -1 ) in the border area (T4 to T6), and between 4.6 and 5.4 kg.m -2 .y -1 (0.6 and 0.7 cm.yr -1 ) in the two isolated areas (T7 and T8, respectively) (Fig. 6). These sedimentation rates are in accordance with those of [START_REF] Fennessy | Sediment deposition patterns in restored freshwater wetlands using sediment traps[END_REF] who reported rates from 5.9 to 12.8 kg.m -2 .y -1 . For both CWs, the lower sedimentation rates in the border areas than in the MC may be due to an emergence of border traps during low flow rates (T5 to T8 in the pond CW and T4 to T6 in the ditch CW). In addition, the sedimentation rate in MC and IA is almost equal despite a possible greater water volume passing through the MC than through the IA. This result may be explained by a higher resuspension of sediment in the MC than in the IA due to a faster water velocity. This process of resuspension was highlighted (i) by a relatively uniform spatial distribution of sediment particle size inside the CW (Fig. A3) and (ii) by the greater amount of particles settled in both CW traps than the amount of particles reaching the inlet (Fig. A2).

Dimetachlor (DMT) was the single quantified pesticide reaching the CWs by particulate phase only (data not shown) and was also quantified in sediments (Fig. 7). For both CWs, the DMT concentrations in sediment were similar regardless of the sampling zone (Fig. 7), which corroborates the uniform sedimentation inside the CW and even in the isolated area. Thus, the isolated areas can also mitigate solid-bound pesticides by sedimentation.

Otherwise, the resuspension of sediments from the main channel could induce a release of solid-bound pesticides towards the CW outlet, which could lead to a negative mitigation rate of solid-bound pesticides.

Influence of hydrodynamics on the spatial distribution of the pesticide levels in sediments

Concerning the pesticides reaching the CW by dissolved phase only (data not shown), their quantification onto the sediments indicated their adsorption from the dissolved phase, which is the case for epoxyconazole (EPX) in the pond and cyproconazole (CYP) and metconazole (MCZ) in the ditch (Fig. 7). No metabolites were quantified in the sediments, possibly due to their high polarity properties.

For the pond sediment, the EPX concentration is higher in the IA (point 9) than in the MC (ponds 1, 2 and 3). This higher pesticides storage in sediments in IA than MC could be due to: (i) adsorption process of EPX favoured by the dispersion transport in IA, (ii) or/and due to desorption process which could be favoured in MC due to convection transport as previously shown in Gaullier et al. (2018); (iii) or/and due to degradation process, favoured in MC. In the same manner, [START_REF] Schuetz | Multitracer assessment of wetland succession: Effects on conservative and non-conservative transport processes[END_REF] also showed that adsorption was higher in IA (dead zones in their study) compared to zones where convection was dominant, such as the MC in our study.

In the ditch sediment, the CYP and MCZ concentrations were lower in the IA (point 3) than in the MC (inlet, outlet and enlargement) (Fig. 7). This contradictory observation when compared with the pond could be due to the location of the IA. Indeed, the IA was located in the border area of the ditch and sometimes emerged during low flow rates, whereas in the pond, the IA never emerged.

Finally, favourable hydraulic conditions, as shown in isolated areas (slow water velocity, long HRT), could increase the mitigation of dissolved pesticides inside the CW by adsorption on sediment, as demonstrated in the results.

Conclusion

Bromide tracing and electrical conductivity monitoring allowed us to identify and delineate two water pathways (or hydraulic zones) inside the CWs: the main channel with water transported mainly by convection and the isolated areas with water transported by dispersion.

The area and the location of these hydraulic zones fluctuate according to the flow rate. For the ditch and pond, the proportion of isolated areas is greater at low flow rates (0.5 L/s, representing 50 % of annual flow rates) than at medium or high flow rates (4-7 L/s, representing 10 % of annual flow rates). During drainage, these different water pathways led to a heterogeneous distribution of dissolved pesticide concentrations inside the CW, as illustrated for the aqueous phase and the adsorbed pesticide concentrations on sediment. This heterogeneity between the main channel and the isolated areas is more notable at low flow than at high flow in the short term, since isolated areas are affected later by dispersion at LF than at HF. In the long term, this heterogeneity disappears during the no-flow phase due to the dispersion of pesticides and metabolites inside the CWs. Pesticides entering the CW that are adsorbed on TSS are mitigated by sedimentation. The sedimentation rates are quite similar between the main channel and the isolated areas, whereas the isolated areas are (i) less affected by water than the main channel, (ii) less impacted by resuspension of sediments than the main channel and (iii) sometimes emerged (for the ditch). In addition, analyses of pesticides reaching the CW inlet in the dissolved phase only showed that storage in the sediments seems favoured in the isolated areas compared to the main channel. These isolated areas appear effective for dissolved and particulate pesticide mitigation, especially Coloured squares correspond to the location of sediment traps: white for the main channel, green for the borders and orange for isolated areas. In the pond, point 10 was not sampled at MF (7 L/s), and there is no associated curve on the graph.

7 For the pond, the MC zone was collected in point 10, and the IA zone was collected in point 9.

For the ditch, the MC zone was collected in point 6, and the IA zone was collected in point 3 (Figure 3). For the pond, the MC zone was collected in point 10, and the IA zone was collected in point 9.

For the ditch, the MC zone was collected in point 6 and the IA zone was collected in point 3 (Figure 3). **The drained volume higher than total rainfall might be due to runoff from an adjacent plot.

  time to recover 10 % of the injected tracer t90/tn time to recover 90 % of the injected tracer t90/t10 Morrill index

  could be considered similar under all seasons. The first CW located at Ville-sur-Illon (75 km at the South of Nancy, France) consisted roughly of a succession of three ponds of 47.8 m length and 4 to 6.5 m width, with a surface of 215 m 2 and an island at the beginning of the second pond (Fig.1). It received the drainage water from an 8 ha plot(cambisol, FAO 2006) by a drain collector located at inlet of the CW. The CW was entirely vegetated and dominated by Juncus effusus, Juncus inflexus, and Juncus articulatus on the edge of the CW, with Typha latifolia, Typha angustifolia, Epilobium hirsutum and Veronica becabunga inside the CW. The second CW located at Manoncourt-sur-Seille (30 km in the North of Nancy, France) consisted roughly of a ditch of 80 m length and 0.9 m width, and it expanded over 12 m long by 4 m wide, with a surface of 100 m 2 (Fig.1). It received the drainage water from a 10 ha plot(gleyic cambisol, FAO 2006). The CW was entirely vegetated and dominated by Juncus effusus, Juncus conglomerates and grasses. Substrates of both CWs were clayed, which allowed their imperviousness. Both CWs have been precisely topographically levelled allowing the determination of water volume.

Fig. 1 )

 1 Fig.1) using PVC cylindrical sediment traps (25 cm high x 5 cm width, H/W ratio of 5) for

Finally

  , to evaluate the spatial distribution of pesticide concentrations in sediment, a representative sample of each zone (inlet MC, middle MC and outlet MC, and the isolated area) was obtained by mixing four sub-samples. All sub-samples were manually collected in the first upper centimetre of sediment, and in different locations, inside the CW (not in the sediment traps) at the end of each drainage season: in July 2016 for the 2015/2016 season and in April 2017 for the 2016/2017 season. Taking into account the sedimentation rate and its variability, the first centimetre collected can represent one or two years of sedimentationdepending on its location in the CW and on the CW. In 2017, a total of four composite samples were collected per CW: 3 samples in the MC zone from inlet to outlet and 1 in the IA zone (point 9 for the pond CW and point 3 for the ditch CW, Fig.1), whereas only 3 samples in MC were collected in 2016. Indeed, there was no IA zone identified at the beginning of the study in 2016. After sampling, sediments were freeze-dried and then extracted by a modified QuEChERS (Quick, Easy, Cheap, Effective, Rugged and Safe) method detailed in the SM.

Figure captions Figure 1 .Figure 2 .Figure 3 .Figure 4 .Figure 5 .Figure 6 .Figure 7 .

 captions1234567 Figure captions

Figure captions Figure 1 .Figure 2 .Figure 3 .Figure 4 .Figure 5 .Figure 6 .Figure 7 .

 captions1234567 Figure captions

Figure 1 .

 1 Figure 1. Location of the sampling points in photographs taken by a drone (5 November 2018) of the two-constructed wetlands: a succession of three ponds (A) and a ditch (B)

Figure 2 .Figure 3 .

 23 Figure 2. Tracer breakthrough curves and cumulative normalized tracer concentrations (F(t) = ∑E(t) x dt) under various flow rates (HF: high flow, MF: mean flow, LF : low flow) for both wetlands (pond and ditch)

Figure 4 .

 4 Figure 4. Electrical conductivity (µS/cm) in the inlet, outlet, main channel (MC) and isolated area (IA) zones under distinct flow rates (HF: high flow, LF: low flow, MF: mean flow and no flow) for the pond and ditch

Figure 5 .

 5 Figure 5. Pesticide concentrations (µg/L) in the inlet, outlet, main channel (MC) and isolated area (IA) zones under distinct flow rates (HF: high flow, LF: low flow, MF: mean flow and no flow) for the pond and ditch

Figure 6 .Figure 7 .

 67 Figure 6. Spatial distribution of sedimentation rate within the pond and the ditch (MC: main channel, border, IA: isolated area) for the different sediment traps (numbered T1 to T9)

Table 1 .

 1 Meteorological, hydrological and agricultural datas characterizing the two studied constructed wetlands

Table 2 .

 2 Tracer experiment parameters and hydraulic characteristics of the pond and the ditch under various flow rates for the pond and ditch

Table 3 .

 3 Transport parameters derived from the Residence Time Distribution analysis for the pond and ditch under distinct flow rates

	1

Table 1 .

 1 Meteorological, hydrological and agricultural datas characterizing the two studied constructed wetlands.

Table 2 .

 2 Tracer experiment parameters and hydraulic characteristics of the pond and ditch under various flow rates for the pond and ditch

Table 3 .

 3 Transport parameters derived from the Residence Time Distribution analysis for the pond and ditch under distinct flow rates

Table 1 .

 1 Meteorological, hydrological and agricultural data characterizing the two studied constructed wetlands.

	Crop rotation Rainfall*	30-yr	Inlet	Flow rate	Flow	HRT*	Drainage	Dry
		(mm/d)	average	volume*	variation*	distribution	(h)	period*	period*
			rainfall*	(mm/d)	(L/s)			(d)	(d)
			(mm/d)
					POND
	barley/rape/	1.9 -3.2	2.7	2 -4.5** 0.2 -21.5	<2 L/s : 50%	1 -40	7 -43	2 -37
	winter wheat					2-7 L/s : 25%
						>7 L/s : 25%
					DITCH
	rape/winter	1.9 -3.5	2.3	0.3 -0.7 0.01 -11 <0.2 L/s : 50%	1 -181	4 -54	2 -75
	wheat/maize/					0.2-1 L/s : 25%
	winter wheat					1-4 L/s : 21%
						>4 L/s : 4%

* From the beginning (November) to the end of drainage (March-April) during 3 drainage seasons

(2014)(2015)(2016)(2017)

.

Table 3 .

 3 Transport parameters derived from the Residence Time Distribution analysis for the pond and ditch under distinct flow rates

		tn (h)	tmean (h) tθ= ev	N	λ	t10/tn t90/t10	Pe	vmean (m/min)
	Pond-HF	1.7	1.5	0.87	2.3	0.50 0.48	2.3	62	0.53
	Pond-MF	2.5	2.2	0.89	2.5	0.53 0.46	2.1	1697	0.36
	Pond-LF	37.2	23.0	0.62	1.4	0.18 0.14 10.7	11	0.03
	Ditch-MF	2.5	0.8	0.32	1.3	0.07 0.20	1.7	28	1.55
	Ditch-LF	13.0	1.4	0.11	1.1	0.01 0.07	2.1	16	0.87

Acknowledgements

This research received financial support from the Rhin Meuse Water Agency contract n°14A54005, BRGM (French Geological Survey), the University of Lorraine, the FEDER-FSE Lorraine and Massif des Vosges (Fonds Européens de DEveloppement Regional -Fond Social Européen) and the Moselle Basin LTSER. The authors thank J-S. PY (LHN, Nancy) and E. Coisy (BRGM, Orléans) for their helpful laboratory assistance, the farmers and R. Cherrier and F.X. Schott (Chambre Régionale d'Agriculture du Grand Est) for field access. The authors also thank C. Gauthier and V. Dutreuil for drone shooting and D. Billet, A. de Junet, S. Nachin, L. Staedelin, R. Gley and M. Dincher for their helpful sampling work during the tracer tests experiments, and A. Recouvreur and G. Pecheux for their work on the CW topography measurement.

*** The outlet water was sampled every 2 hours until the bromide concentration was lower than the limit of quantification (50 µg/L) **** Three water depths were measured inside the CWs: in the 1 st /2 nd /3 rd ponds and in the inlet/expansion/outlet of the ditch.