High-spatial resolution epidemic surveillance of bacterial meningitis in the African meningitis belt in Burkina Faso.

Despite improved surveillance capacities and WHO recommendations for subdistrict analysis, routine epidemic surveillance of acute bacterial meningitis in the African meningitis belt remains largely limited to the district level. We evaluated the appropriateness and performance of analyses at higher spatial resolution. We used suspected meningitis surveillance data at health centre (HC) resolution from Burkina Faso from 14 health districts spanning years 2004-2014 and analysed them using spatio-temporal statistics and generative models. An operational analysis compared epidemic signals at district and HC-level using weekly incidence thresholds. Eighty-four percent (N = 98/116) of epidemic clusters spanned only one HC-week. Spatial propagation of epidemic clusters was mostly limited to 10-30 km. During the 2004-2009 (with serogroup A meningitis) and 2010-2014 (after serogroup A elimination) period, using weekly HC-level incidence thresholds of 100 and 50 per 100,000 respectively, we found a gain in epidemic detection and timeliness in 9 (41% of total) and 10 (67%), respectively, district years with at least one HC signal. Individual meningitis epidemics expanded little in space, suggesting that a health centre level analysis is most appropriate for epidemic surveillance. Epidemic surveillance could gain in precision and timeliness by higher spatial resolution. The optimal threshold should be defined depending on the current background incidence of bacterial meningitis.

TRANSCOV cohort protocol: an epidemiological study assessing the impact of critically ill COVID-19 patients long distance transfers between intensive care units.

INTRODUCTION: During spring 2020, four regions of France faced a surge of severe COVID-19 patients which threatened to overflow local intensive care units (ICU) capacities. As an emergency response, between 13 March 2020 and 10 April 2020, an estimated 661 patients were transferred from overcrowded ICUs to eight other French regions and four neighbouring countries. The intensity, geographical spread and the diversity of vectors used are unprecedented. The study aims at assessing the impact of these inter-ICU transfers on the short-term and medium-term physical and psychological outcomes in this population of severe COVID-19 patients. METHODS AND ANALYSIS: The TRANSCOV cohort is a multicentre observational retrospective study. All transferred patients between ICUs outside the origin region will be invited to take part. For each transfer, up to four control patients will be selected among those admitted in the same ICU during the same period (±4 days of transfer date). Clinical data will be extracted from medical records and will include haemodynamic and respiratory parameters, as well as clinical severity scores before, during and after transfer. Data linkage with medicoadministrative data will enrich the clinical database and allow follow-up up to 1 year after initial admission. ETHICS AND DISSEMINATION: The study has been approved by the French Ethics and Scientific Committee on the 16 July 2020 (file no. 2046524). The results will be disseminated via publication of scientific articles and communications in national and international conferences. TRIAL REGISTRATION NUMBER: 20 CO 015 CZ.

Repetitive transcranial magnetic stimulation for neuropathic pain: a randomized multicentre sham-controlled trial.

Repetitive transcranial magnetic stimulation (rTMS) has been proposed to treat neuropathic pain but the quality of evidence remains low. We aimed to assess the efficacy and safety of neuronavigated rTMS to the primary motor cortex (M1) or dorsolateral prefrontal cortex (DLPFC) in neuropathic pain over 25 weeks. We carried out a randomized double-blind, placebo-controlled trial at four outpatient clinics in France. Patients aged 18-75 years with peripheral neuropathic pain were randomly assigned at a 1:1 ratio to M1 or DLPFC-rTMS and rerandomized at a 2:1 ratio to active or sham-rTMS (10 Hz, 3000 pulses/session, 15 sessions over 22 weeks). Patients and investigators were blind to treatment allocation. The primary end point was the comparison between active M1-rTMS, active DLPCF-rTMS and sham-rTMS for the change over the course of 25 weeks (Group × Time interaction) in average pain intensity (from 0 no pain to 10 maximal pain) on the Brief Pain Inventory, using a mixed model repeated measures analysis in patients who received at least one rTMS session (modified intention-to-treat population). Secondary outcomes included other measures of pain intensity and relief, sensory and affective dimensions of pain, quality of pain, self-reported pain intensity and fatigue (patients diary), Patient and Clinician Global Impression of Change (PGIC, CGIC), quality of life, sleep, mood and catastrophizing. This study is registered with ClinicalTrials.gov NCT02010281. A total of 152 patients were randomized and 149 received treatment (49 for M1; 52 for DLPFC; 48 for sham). M1-rTMS reduced pain intensity versus sham-rTMS (estimate for Group × Session interaction: -0.048 ± 0.02; 95% CI: -0.09 to -0.01; P = 0.01). DLPFC-rTMS was not better than sham (estimate: -0.003 ± 0.01; 95% CI: -0.04 to 0.03, P = 0.9). M1-rRMS, but not DLPFC-rTMS, was also superior to sham-rTMS on pain relief, sensory dimension of pain, self-reported pain intensity and fatigue, PGIC and CGIC. There were no effects on quality of pain, mood, sleep and quality of life as all groups improved similarly over time. Headache was the most common side effect and occurred in 17 (34.7%), 23 (44.2%) and 13 (27.1%) patients from M1, DLPFC and sham groups, respectively (P = 0.2). Our results support the clinical relevance of M1-rTMS, but not of DLPFC-rTMS, for peripheral neuropathic pain with an excellent safety profile.

Chronic back pain and its association with quality of life in a large French population survey.

BACKGROUND: Chronic back pain is associated with significant burden, yet few epidemiological studies have provided data on chronic back pain, its predictors and correlates in France. METHODS: Data were drawn from a cross-sectional survey conducted in France (n = 17,249) using computer-assisted telephone interviews. Sample age ranges from 18 to 98 with a mean of 46.39 years (SD = 17.44), and was 56.7% female. Medical conditions were assessed using the CIDI, quality of life was assessed using both the physical and mental component scores of the SF-36. RESULTS: Overall, 38.3% of adults reported chronic back pain. Female gender, older age, lower education, manual labor occupation, and population density were significantly associated with the distribution of chronic back pain. Chronic back pain was associated with lower scores on all SF-36 mean scores and on the Physical Composite Score and Mental Composite Score controlling for comorbid medical conditions including other types of chronic pain. CONCLUSION: The study highlights the burden of chronic back pain in the general population and underscores its correlation with quality of life. Such data contribute to raise awareness among clinicians and health policy makers on the necessity of prevention, early diagnosis, proper management and rehabilitation policies in order to minimize the burden associated with chronic pain.

Factors Associated with Parent-Child Discrepancies in Reports of Mental Health Disorders in Young Children.

The study compares parent and child reports of child mental health to determine the relationship between parent-child disagreement and parental psychological and attitudinal factors, and to determine how parent-child disagreement is associated with the use of specialized services. A cross-sectional study was conducted with 1268 children aged 6-11 years using the Dominic Interactive and the Strengths and Difficulties Questionnaire. Psychological distress and negative parental attitudes were associated with greater reporting of mental health problems, leading to greater parent-child agreement on symptom presence, and to parental over-reporting of symptoms. Parent/child agreement was associated with 43.83% of contact with a mental health provider for externalizing and 33.73% for internalizing problems. The contribution of key parental psychological and attitudinal factors in parent-child disagreement on child mental health status may prove helpful in improving the identification of children in need of specialized services.

The association between car accident fatalities and children's fears: A study in seven EU countries.

Children's fear of a car accident occurring to parents or themselves has been used as a concrete example to illustrate one of the symptoms of anxiety disorders such as separation anxiety and generalized anxiety. However, its usage across countries may be questionable where the prevalence of this specific type of injury differs. This cross-sectional study compares samples from seven diverse European countries (Bulgaria, Germany, Italy, Lithuania, Netherlands, Romania, Turkey) to see if an environmental exposure, car accident death rate per 100,000 people (country-wide from WHO data), is associated with children's self-report of car accident fears. In this study, 6-11 year-old children were surveyed by a diagnostic instrument (Dominic Interactive) about several situations and asked if they believed they were similar to a fictional child depicted in said situations. Mothers were surveyed for additional sociodemographic information. Multivariable logistic regression was used to adjust for covariates including mother's age, mother's education, single parenting, and mother's professional inactivity. We report a monotonic relationship between higher car accident death rates and the prevalence of children reporting fear of parent's or own accident. Relative to a reference of 3.9 deaths per 100,000 people, children's odds of reporting fear of parent's accident ranged from 1.99 (95% CI 1.51-2.61) times to 4.84 (95% CI 3.68-6.37) times as the risk of death by car accident increased across countries. A similar result arose from fear of child's own accident, with significant ORs ranging from 1.91 (95% CI 1.53-2.40) to 2.68 (95% CI 2.07-3.47) alongside increased death rates. Given that reporting of these fears accompanies correspondingly high accident death rates, the pertinence of using fear of car accidents as an illustration for some diagnostic item for mental disorders cross-nationally appears to be an issue.

Unmet Need for Specialty Mental Health Services Among Children Across Europe.

OBJECTIVE: The aim of this study was to examine the determinants of use of mental health services for children across Europe, with a specific focus on differences in the availability of mental health resources. METHODS: Data were drawn from the School Children Mental Health in Europe Project. Parent- and teacher-reported child mental health status was based on the Strengths and Difficulties Questionnaire. Sociodemographic characteristics of parents and children, as well as academic performance and use of mental health services in the previous 12 months, were collected. Countries were categorized as having high versus low mental health resources. The sample comprised 4,894 schoolchildren in seven countries. RESULTS: Across Europe, only 25.6% of children with a mental disorder had received mental health services in the previous 12 months, including 31.5% in high-resources countries and 18.9% in low-resources countries (p=.001) (N=4,867). The presence of any mental disorder, maternal psychological distress, gender, living in a single-parent home, and low academic performance were determinants of service use. The effect of resources group on the likelihood of receiving services remained significant when the analyses controlled for all predictors (odds ratio=1.41, p<.01). Determinants differed between groups-maternal psychological distress was associated with service use in high-resources countries, and gender was associated with service use in low-resources countries. CONCLUSIONS: The findings point to a substantial portion of unmet need across Europe and to major differences in access to care in low- versus high-resources countries. Efforts are needed to address unmet need among children with mental disorders, especially in low-resources countries.

Risk factors for child mental health problems in Lithuania: The role of parental nationality.

BACKGROUND: We compare the mental health status of children who reside in Lithuania with parents who are either Lithuanian nationals or non-Lithuanian nationals. METHOD: Data were drawn from the School Child Mental Health Europe survey (SCMHE), a cross-sectional survey of school children aged 6-11years. A total of 1152 Lithuanian children participated, among them 11.7% from a non-Lithuanian family. Child mental health was assessed using the Dominique Interactive (DI) and the parent- and teacher Strength and Difficulties Questionnaire (SDQ). Parental attitudes were evaluated, and socio-demographics were collected. RESULTS: Overall 26.7% of non-Lithuanian versus 17.2% of Lithuanian children reported having an internalizing disorder (p=0.01) mainly due to separation anxiety (16.4% versus 10.2%, p=0.04). Odds ratio (OR) for child-reported internalizing disorders was 1.86 (95% CI=1.17-2.96) once adjusted for other factors including being a girl, to be younger, parental unemployment and low caring and low autonomy parental attitudes which were associated with greater odds of internalizing disorders. In addition, 31.9% of non-Lithuanian reported suicidal thoughts versus 22.0% of Lithuanian children p=.02); OR=1.60 (95% CI=1.04-2.46) once adjusted for single parent, parental unemployment, parental alcohol problems and overreactivity attitude. CONCLUSIONS: Being a non-national minority in Lithuania is a risk factor for child mental health. These findings suggest that further studies are needed to inform local policy-makers on targeted prevention and intervention programs in these children.

Nutrition surveillance using a small open cohort: experience from Burkina Faso.

BACKGROUND: Nutritional surveillance remains generally weak and early warning systems are needed in areas with high burden of acute under-nutrition. In order to enhance insight into nutritional surveillance, a community-based sentinel sites approach, known as the Listening Posts (LP) Project, was piloted in Burkina Faso by Action Contre la Faim (ACF). This paper presents ACF's experience with the LP approach and investigates potential selection and observational biases. METHODS: Six primary sampling units (PSUs) were selected in each livelihood zone using the centric systematic area sampling methodology. In each PSU, 22 children aged between 6 and 24 months were selected by proximity sampling. The prevalence of GAM for each month from January 2011 to December 2013 was estimated using a Bayesian normal-normal conjugate analysis followed by PROBIT estimation. To validate the LP approach in detecting changes over time, the time trends of MUAC from LP and from five cross-sectional surveys were modelled using polynomial regression and compared by using a Wald test. The differences between prevalence estimates from the two data sources were used to assess selection and observational biases. RESULTS: The 95 % credible interval around GAM prevalence estimates using LP approach ranged between +6.5 %/-6.0 % on a prevalence of 36.1 % and +3.5 %/-2.9 % on a prevalence of 10.8 %. LP and cross-sectional surveys time trend models were well correlated (p = 0.6337). Although LP showed a slight but significant trend for GAM to decrease over time at a rate of -0.26 %/visit, the prevalence estimates from the two data sources showed good agreement over a 3-year period. CONCLUSIONS: The LP methodology has proved to be valid in following trends of GAM prevalence for a period of 3 years without selection bias. However, a slight observational bias was observed, requiring a periodical reselection of the sentinel sites. This kind of surveillance project is suited to use in areas with high burden of acute under-nutrition where early warning systems are strongly needed. Advocacy is necessary to develop sustainable nutrition surveillance system and to support the use of surveillance data in guiding nutritional programs.

Differential impact of parental region of birth on negative parenting behavior and its effects on child mental health: Results from a large sample of 6 to 11 year old school children in France.

BACKGROUND: In France, one in 10 residents has immigrated mainly from North Africa, West Africa or the Caribbean including the French West Indies. However little is known about how parents from these regions behave when they migrate to countries that have different cultural norms. It is therefore important to determine how ethno-cultural background affects parental behavior and subsequent child mental health in the context of immigration. The objectives are: 1) to compare negative parenting behaviors of French residents from diverse ethno-cultural backgrounds 2) to examine the relationship between parental region of origin and child mental health, and 3) to investigate the extent to which ethno-cultural context moderates the effect of parenting styles on child mental health. METHODS: A cross-sectional study was conducted in 2005 in 100 schools in South-East France. The Dominic Interactive and the parent-reported Strengths and Difficulties Questionnaire were used to assess child psychopathology. The Parent Behavior and Attitude Questionnaire was used to assess parenting styles. The final sample included data on 1,106 mother and child dyads. RESULTS: Caring and punitive attitudes were significantly different across mothers as a function of region of origin. This association was stronger for punitive attitudes with the highest prevalence in the Caribbean/African group, while mothers from Maghreb were more similar to French natives. Differences in caring behaviors were similar though less pronounced. Among children of Maghrebian descent, punitive parenting was associated with an increased risk of internalizing disorders while this association was weaker among children of African and Afro-Caribbean descent. CONCLUSIONS: Parental region of origin is an important component of both parenting styles and their effect on child mental health. Interventions on parenting should consider both the region of origin and the differential impact of origin on the effect of parenting styles, thus allowing for a finer-grained focus on high-risk groups.

Is time spent playing video games associated with mental health, cognitive and social skills in young children?

BACKGROUND: Video games are one of the favourite leisure activities of children; the influence on child health is usually perceived to be negative. The present study assessed the association between the amount of time spent playing video games and children mental health as well as cognitive and social skills. METHODS: Data were drawn from the School Children Mental Health Europe project conducted in six European Union countries (youth ages 6-11, n = 3195). Child mental health was assessed by parents and teachers using the Strengths and Difficulties Questionnaire and by children themselves with the Dominic Interactive. Child video game usage was reported by the parents. Teachers evaluated academic functioning. Multivariable logistic regressions were used. RESULTS: 20 % of the children played video games more than 5 h per week. Factors associated with time spent playing video games included being a boy, being older, and belonging to a medium size family. Having a less educated, single, inactive, or psychologically distressed mother decreased time spent playing video games. Children living in Western European countries were significantly less likely to have high video game usage (9.66 vs 20.49 %) though this was not homogenous. Once adjusted for child age and gender, number of children, mothers age, marital status, education, employment status, psychological distress, and region, high usage was associated with 1.75 times the odds of high intellectual functioning (95 % CI 1.31-2.33), and 1.88 times the odds of high overall school competence (95 % CI 1.44-2.47). Once controlled for high usage predictors, there were no significant associations with any child self-reported or mother- or teacher-reported mental health problems. High usage was associated with decreases in peer relationship problems [OR 0.41 (0.2-0.86) and in prosocial deficits (0.23 (0.07, 0.81)]. CONCLUSIONS: Playing video games may have positive effects on young children. Understanding the mechanisms through which video game use may stimulate children should be further investigated.

Country-level and individual correlates of overweight and obesity among primary school children: a cross-sectional study in seven European countries.

BACKGROUND: The present study aims to estimate childhood overweight and obesity prevalence and their association with individual and population-level correlates in Eastern and Western European countries. METHODS: Data were obtained from the School Children Mental Health in Europe, a cross-sectional survey conducted in 2010 in Italy, Germany, the Netherlands, Romania, Bulgaria, Lithuania and Turkey. The sample consists of 5,206 school children aged 6 to 11 years old. Information on socio-demographics, children's height and weight, life-style and parental attitude were reported by the mothers. Country-level indicators were obtained through several data banks. Overweight and obesity in children were calculated according to the international age and gender-specific child Body Mass Index cut-off points. Multivariable logistic regression models included socio-demographic, lifestyle, mothers' attitude, and country-level indicators to examine the correlates of overweight. RESULTS: Overall prevalence was 15.6% (95% CI = 19.3-21.7%) for overweight and 4.9% (95% CI = 4.3-5.6%) for obesity. In overweight (including obesity), Romanian children had the highest prevalence (31.4%, 95% CI = 28.1-34.6%) and Italian the lowest (10.4%, 95% CI = 8.1-12.6%). Models in the pooled sample showed that being younger (aOR = 0.93, 95% = CI 0.87-0.97), male (aOR = 1.24, 95% CI = 1.07-1.43), an only child (aOR = 1.40, 95% CI = 1.07-1.84), spending more hours per week watching TV (aOR = 1.01, 95% CI =1.002-1.03), and living in an Eastern Country were associated with greater risk of childhood overweight (including obesity). The same predictors were significantly associated with childhood overweight in the model conducted in the Eastern region, but not in the West. Higher Gross Domestic Product and Real Domestic Product, greater number of motor and passenger vehicles, higher percentage of energy available from fat, and more public sector expenditure on health were also associated with lower risk for childhood overweight after adjusting for covariables in the pooled sample and in the east of Europe, but not in the West. CONCLUSIONS: Prevalence rates of overweight and obesity in school children is still high, especially in Eastern regions, with some socio-demographic factors and life-styles associated with being overweight. It is also in the Eastern region itself where better macro-economic indicators are related with lower rates of childhood overweight. This represents a public health concern that deserves special attention in those countries undertaking economic and political transitions.

Suicidal ideation and mental health disorders in young school children across Europe.

INTRODUCTION: The aim of this study is to measure the prevalence of suicidal ideation and thoughts of death in elementary school children in a European survey and to determine the associated socio-demographic and clinical factors. METHODS: Data refer to children aged 6-12 (N=7062) from Italy, Turkey, Romania, Bulgaria, Lithuania, Germany, and the Netherlands randomly selected in primary schools. Suicidal thoughts and death ideation were measured using a computerized pictorial diagnostic tool from the Dominic Interactive (DI) completed by the children. The Strengths and Difficulties Questionnaire (SDQ) was administrated to teachers and parents along with a socio-demographic questionnaire. RESULTS: Suicidal ideation was present in 16.96% of the sample (from 9.9 in Italy to 26.84 in Germany), death thoughts by 21.93% (from 7.71% in Italy to 32.78 in Germany). SI and DT were more frequent in single-parent families and large families. Externalizing disorders were strongly correlated with SI and DT after controlling for other factors and this was true for internalizing disorders only when reported by the children. CONCLUSION: Recognizing suicidal ideation in young children may be recommended as part of preventive strategies such as screening in the context of the presence of any mental health problems whether externalizing or internalizing.

Parental use of corporal punishment in Europe: intersection between public health and policy.

Studies have linked the use of corporal punishment of children to the development of mental health disorders. Despite the recommendation of international governing bodies for a complete ban of the practice, there is little European data available on the effects of corporal punishment on mental health and the influence of laws banning corporal punishment. Using data from the School Children Mental Health Europe survey, the objective of this cross-sectional study was to examine the prevalence and legal status of corporal punishment across six European countries and to evaluate the association between parental use of corporal punishment and children's mental health. The study found that odds of having parents who reported using occasional to frequent corporal punishment were 1.7 times higher in countries where its use is legal, controlling for socio-demographic factors. Children with parents who reported using corporal punishment had higher rates of both externalized and internalized mental health disorders.

Traffic-related air pollution and the onset of myocardial infarction: disclosing benzene as a trigger? A small-area case-crossover study.

BACKGROUND AND OBJECTIVES: Exposure to traffic is an established risk factor for the triggering of myocardial infarction (MI). Particulate matter, mainly emitted by diesel vehicles, appears to be the most important stressor. However, the possible influence of benzene from gasoline-fueled cars has not been explored so far. METHODS AND RESULTS: We conducted a case-crossover study from 2,134 MI cases recorded by the local Coronary Heart Disease Registry (2000-2007) in the Strasbourg Metropolitan Area (France). Available individual data were age, gender, previous history of ischemic heart disease and address of residence at the time of the event. Nitrogen dioxide, particles of median aerodynamic diameter <10 µm (PM10), ozone, carbon monoxide and benzene air concentrations were modeled on an hourly basis at the census block level over the study period using the deterministic ADMS-Urban air dispersion model. Model input data were emissions inventories, background pollution measurements, and meteorological data. We have found a positive, statistically significant association between concentrations of benzene and the onset of MI: per cent increase in risk for a 1 µg/m3 increase in benzene concentration in the previous 0, 0-1 and 1 day was 10.4 (95% confidence interval 3-18.2), 10.7 (2.7-19.2) and 7.2 (0.3-14.5), respectively. The associations between the other pollutants and outcome were much lower and in accordance with the literature. CONCLUSION: We have observed that benzene in ambient air is strongly associated with the triggering of MI. This novel finding needs confirmation. If so, this would mean that not only diesel vehicles, the main particulate matter emitters, but also gasoline-fueled cars--main benzene emitters-, should be taken into account for public health action.

Use of calcium supplements, vitamin D supplements and specific osteoporosis drugs among French women aged 75-85 years: patterns of use and associated factors.

BACKGROUND: Despite the availability of effective preventive and curative medications for osteoporosis, and guidelines for its diagnosis and management, few individuals are treated for osteoporosis, even among those who have already had a fracture. OBJECTIVES: Our objective was to describe the patterns of use of medication for osteoporosis, i.e., calcium supplements, vitamin D supplements, and specific anti-osteoporotic drugs, such as bisphosphonates, in a large sample of French older women living at home, and to identify individual factors associated with use of these medications overall and in two specific clinical situations. METHODS: Cross-sectional analysis of data from 4,221 women aged 75-85 years who participated in a balance and mobility examination as part of the screening procedure for the Ossébo study, a randomized controlled trial testing the effectiveness of exercise for the prevention of fall-related injuries. Electoral rolls were used to invite women in 16 towns to participate (participation rate 10.3 %). Information collected through questionnaires included current medication use and, in particular, use of osteoporosis medications (specific osteoporosis drugs, calcium and vitamin D supplementation) in the past 6 months, and history of fracture since the age of 50, including fracture locations. Fractures were categorized in three groups: no fracture, major osteoporotic fracture (hip, humerus, wrist, pelvis, and vertebra), and other fracture. RESULTS: Nearly 48 % of the participants reported they did not take calcium or vitamin D supplements or any specific osteoporosis drugs. Of the 2,133 women who reported using osteoporosis medication, 85 % used vitamin D supplements (25 % as the sole medication against this disease), 59 % calcium supplements, and 42 % a specific anti-osteoporotic drug (75 % of them combining it with vitamin D supplementation). The use of any osteoporosis medication was significantly associated (p < 0.001) with a history of a major osteoporotic fracture, lower weight, dual-energy X-ray absorptiometry (DXA) bone-density measurement in the past 5 years, a cancer-screening examination in the past 5 years, and a positive attitude toward medication use in general. Living alone was associated with a lower likelihood of using a specific anti-osteoporotic drug, and a higher education level was associated with a higher likelihood of vitamin D supplementation. Of the 1,553 women who had already had a major osteoporotic fracture, one-third (34.8 %) were not taking any osteoporosis medication. In this subgroup, use of this medication was associated with the same factors as in the overall study population. In particular, neither older age nor a history of falls in the previous 12 months was associated with a higher likelihood of using osteoporosis medication. Among the 909 women who reported using a specific osteoporosis drug, vitamin D use was associated with a higher educational level and a more frequent preventive attitude. CONCLUSION: In France, as in other western countries, women aged 75 years and over are not managed according to guidelines. Further studies should address the barriers encountered in improving quality of care in osteoporosis management.

Referral to rehabilitation after severe traumatic brain injury: results from the PariS-TBI Study.

BACKGROUND: After a severe traumatic brain injury (TBI), some patients are discharged home without rehabilitation, although rehabilitation is assumed to improve outcome. OBJECTIVE: To assess factors that predict referral to rehabilitation following acute care. This study is part of a larger inception cohort study assessing the care network in the Parisian area (France). METHODS: Between July 2005 and April 2007, 504 adults with severe TBI (Glasgow Coma Scale score ≤ 8) were prospectively recruited by mobile emergency services. This study included 254 acute care survivors (80% male, median age 32 years). Data regarding demographics, injury severity, and acute care pathway were collected. The first analysis compared patients referred to a rehabilitation facility with patients discharged to a living place. The second analysis compared patients referred to a specialized neurorehabilitation (NR) facility with patients referred to nonspecialized rehabilitation. Univariate and multivariate statistics were computed. RESULTS: . In all, 162 patients (64%) were referred to rehabilitation, 115 (45%) of which were referred to NR and 47 (19%) to nonspecialized rehabilitation. The following factors were significantly predictive of nonreferral to rehabilitation: living alone, a lower income professional category, pretraumatic alcohol abuse, lower TBI severity, and transfer through a nonspecialized medical ward before discharge. Patients referred to specialized NR were significantly younger and from a higher income professional category. CONCLUSIONS: These results raise concern regarding care pathways because many patients were discharged to living places, probably without adequate assessment and management of rehabilitation needs. Injury severity and social characteristics influenced discharge destination.

A case-control study of cutaneous signs in adult patients with Marfan disease: diagnostic value of striae.

BACKGROUND: Marfan syndrome (MS) (OMIM 154700) has been associated with various skin manifestations. OBJECTIVE: We sought to clarify the value of skin signs in patients with MS. METHODS: This was a case-control study. A total of 61 consecutive patients (median age: 34 years) seen in the French Reference Centre for MS and Related Disorders and with a confirmed diagnosis of MS were paired with 61 age-, sex-, and height-paired control subjects. All had a structured interview and standardized dermatologic examination. The gold standard for MS diagnosis was the Ghent criteria. RESULTS: Striae of any type were significantly (P = .0001) more frequent in patients with MS (92%) than in control subjects (61%), but specificity was low (39%, 95% confidence interval [CI] 27-52). Striae on unusual locations (other than buttock, hip, or thigh) were more frequent in patients with MS (66%) than in control subjects (16%) (P < .0001). This finding had a high specificity (84%, 95% CI 74-93), without notably decreasing sensitivity (66%, 95% CI 54-77). Hypertrophic, large, or atrophic surgical or posttraumatic, frequently hypopigmented or hyperpigmented, scars were present in 46% of patients with MS and 21% of control subjects (P = .007). Sensitivity was 46% (95% CI 34-58) and specificity 79% (95% CI 67-87). Atypical striae in some control subjects could be attributed to intensive practice of sports. LIMITATION: A few control subjects were selected from patients consulting the MS center but without a diagnosis of MS. CONCLUSION: Striae are a good diagnostic criterion for MS, particularly when arising in unusual sites. Other reported skin signs of MS are infrequent.

Nomograms for aortic root diameters in children using two-dimensional echocardiography.

The evaluation of aortic root dilation is of major importance for the diagnosis and follow-up of patients with diverse diseases, including the Marfan syndrome. However, we noted that the available nomograms suggested a lower aortic root dilation rate in adults (75%) than in children (90%), when the opposite would have been expected. To establish new nomograms, we selected a population of 353 normal children. We took transthoracic echocardiographic measurements of the aortic root diameters at the level of the aortic annulus, sinuses of Valsalva, sinotubular junction, and ascending aorta according to the American Society of Echocardiography recommendations. All diameters correlated well with the height, weight, body surface area, and age (r = 0.75 to 0.84, p <0.0001). Covariance analysis adjusting for body surface area showed slightly larger diameters at the level of the sinuses of Valsalva in male children than in female children (+1 mm, p = 0.0002). Equations and derived nomograms were developed, giving the upper limit of normal (allowing simple recognition of aortic dilation) and the Z score (allowing fine quantification of dilation and differentiation of normal growth from pathologic dilation) for all 4 aortic root diameters (ie, aortic annulus, sinuses of Valsalva, sinotubular junction, and proximal ascending aorta) according to body surface area and gender. We applied the nomograms to 282 children with confirmed Marfan syndrome, of whom 65.2% presented with dilation of the sinuses of Valsalva. In conclusion, we propose equations to calculate the upper limit of normal and Z-score for aortic root diameters measured by 2-dimensional echocardiography, which should be useful tools for the diagnosis and follow-up of aortic root aneurysms in children.

Homicidal and suicidal sharp force fatalities: autopsy parameters in relation to the manner of death.

A retrospective, comparative study was carried out on 118 sharp force fatalities, including 70 homicides and 48 suicides, and covering a 22-year period from 1986 to 2008. The objective was to identify relevant parameters that may be used to distinguish between these two manners of death. The following parameters were analysed: age, gender, number of wounds, type of wounds, anatomical sites of the wounds, presence of wounds affecting bones or cartilage, the longitudinal axis of stab wounds located at the anterior part of the trunk, Injury Severity Score (ISS) and associated traumatic injuries. Our statistical analyses revealed several relevant parameters that may help differentiate the two manners of death. Homicide victims were younger than those who had committed suicide. Homicide cases showed associated stab and cut wounds, whereas suicide cases predominantly showed isolated cut wounds. Wounds located at the head, limbs, hands, nape of the neck, or back were predictive of a homicide, whereas wounds located solely at the anterior parts of the trunk, neck, or forearms were predictive of a suicide. The presence of bone or cartilage wounds was predictive of a homicide and their absence was predictive of a suicide. A vertical longitudinal axis of stab wounds located at the anterior part of the trunk was predictive of a homicide whereas a horizontal axis was predictive of a suicide. ISS was found to be significantly higher in homicide cases than in suicide cases. The presence of defensive or violence-associated traumatic wounds was predictive of a homicide whereas the presence of hesitation-associated wounds or the absence of associated traumatic wounds was predictive of a suicide.