[And if it happened to children? Adapting medical care during terrorist attacks with multiple pediatric victims]. / Et si c'était des enfants ? Adaptation de la prise en charge médicale en cas d'attentats terroristes avec de nombreux enfants victimes.

In light of the recent terrorist attacks in Europe, we need to reconsider the organization of rescue and medical management and plan for an attack involving multiple pediatric victims. To ensure quick surgical management, but also to minimize risk for on-site teams (direct threats from secondary terrorist attacks targeting deployed emergency services), it is crucial to evacuate patients in a swift but orderly fashion. Children are vulnerable targets in terrorist attacks. Their anatomical and physiological characteristics make it likely that pediatric victims will suffer more brain injuries and require more, often advanced, airway management. Care of multiple pediatric victims would also prove to be a difficult emotional challenge. Civilian medical teams have adapted the military-medicine principles of damage control in their medical practice using the MARCHE algorithm (Massive hemorrhage, Airway, Respiration [breathing], Circulation, Head/Hypothermia, Evacuation). They have also learned to adapt the level of care to the level of safety at the scene. Prehospital damage control principles should now be tailored to the treatment of pediatric patients in extraordinary circumstances. Priorities are given to hemorrhage control and preventing the lethal triad (coagulopathy, hypothermia, and acidosis). Managing hemorrhagic shock involves quickly controlling external bleeding (tourniquets, hemostatic dressing), using small volumes for fluid resuscitation (10-20ml/kg of normal saline), quickly introducing a vasopressor (noradrenaline 0.1µg/kg/min then titrate) after one or two fluid boluses, and using tranexamic acid (15mg/kg over 10min for loading dose, maximum 1g over 10min). Prehospital resources specifically dedicated to children are limited, and it is therefore important that everyone be trained and prepared for a scene with multiple pediatric patients.

Duration of lack of money for basic needs and growth delay in the Quebec Longitudinal Study of Child Development birth cohort.

OBJECTIVE: To examine the relationship between duration of lack of money for basic needs and growth delay in a birth cohort. METHODOLOGY: Mothers of children (n = 1929) from the Quebec Longitudinal Study of Child Development (QLSCD) participating when the children were ages 2(1/2) and 4 years were interviewed at home and data were extracted from birth records. Children's height at 4 years old was transformed into an age- and sex-adjusted z-score. A z-score under the 10th percentile of the Centers for Disease Control and Prevention population growth curve was equated with growth delay. Lack of money for basic needs (paying for rent, electricity and/or heating, clothing, medications or other needs) when the children were ages 2(1/2) and 4 years was reported by the mother. RESULTS: Only 2.5% of children experienced two episodes of lack of money for basic needs. Logistic regression analyses showed that, after adjusting for confounding variables, the probability of growth delay at 4 years among children whose families experienced two episodes of lack of money was higher than for their peers who had not lacked money (OR 3.43; 95% CI 1.54 to 7.66). Experiencing lack of money only at 2(1/2) years showed higher but not significant odds of growth delay at 4 years (OR 1.51; 95% CI 0.84 to 2.72), whereas the likelihood of growth delay was similar for children who experienced lack of money only at 4 years and for their counterparts who never lacked money (OR 0.74; 95% CI 0.26 to 2.11). CONCLUSION: In an industrialised country toddlers whose families experienced persistent lack of money for basic needs are more likely to have growth delay even after controlling for neonatal conditions and their mothers' characteristics.

Validation of a measure of maternal perception of the child's health status.

BACKGROUND: The main objective of this population-based and cross-sectional study was to determine the validity of maternal perception as an indicator of the 17-month-old child's health status. METHODS: Data from this study came from the Quebec Longitudinal Study of Child Development (QLSCD, Round 1999) which was based on a representative sample of babies born in Québec in 1997 and 1998. The analyses were based on the 2045 children aged 17 months who participated in the survey in 1999. Maternal perception of the child's health status was examined as a function of a series of children's health indicators, namely the presence of acute health problems (last 3 months), asthma attacks since birth, presence of chronic problem and hospitalizations during the previous 12 months. Confounding influences of both maternal and child-related characteristics were controlled in the analyses. RESULTS: Sequential logistic regressions indicated that maternal perception was strongly associated with the different health indicators even after controlling for confounding variables. However, a significant interaction between the child's gender and the presence of chronic health problems was observed. The association between maternal perception of the child's health and the presence of chronic health problems was stronger for boys than for girls. CONCLUSIONS: The analyses confirm that the mother's perception of the health status of her 17-month-old child corresponds with the actual health status of the child as reflected by the presence or absence of selected health problems.

Socio-economic disparities in preterm birth: causal pathways and mechanisms.

Preterm birth is the leading cause of infant mortality in industrialised societies. Its incidence is greatly increased among the socially disadvantaged, but the reasons for this excess are unclear and have been relatively unexplored. We hypothesise two distinct sets of causal pathways and mechanisms that may explain social disparities in preterm birth. The first set involves chronic and acute psychosocial stressors, psychological distress caused by those stressors, increased secretion of placental corticotropin releasing hormone (CRH), changes in sexual behaviours or enhanced susceptibility to bacterial vaginosis and chorioamnionitis, cigarette smoking or cocaine use, and decidual vasculopathy. The second hypothesised pathway is a gene-environment interaction based on a highly prevalent mutation in the gene for methylenetetrahydrofolate reductase (MTHFR), combined with low folate intake from the diet and from prenatal vitamin supplements, consequent hyperhomocysteinemia, and decidual vasculopathy. We propose to test these hypothesised pathways and mechanisms in a nested case-control study within a prospectively recruited and followed cohort of pregnant women with singleton pregnancies who deliver at one of four Montreal hospitals that serve an ethnically and socio-economically diverse population. Following recruitment during the late first or early second trimester, participating women are seen at 24-26 weeks, when a research nurse obtains a detailed medical and obstetric history; administers several scales to assess chronic and acute stressors and psychological function; obtains blood samples for CRH, red blood cell and plasma folate, homocysteine, and DNA for the MTHFR mutation; and performs a digital and speculum examination to measure cervical length and vaginal pH and to obtain swabs for bacterial vaginosis and fetal fibronectin. After delivery, each case (delivery at < 37 completed weeks following spontaneous onset of labour or prelabour rupture of membranes) and two controls are selected for placental pathological examination, hair analysis of cotinine, cocaine, and benzoylecgonine, and analysis of stored blood and vaginal specimens. Statistical analysis will be based on multiple logistic regression and structural equation modelling, with sequential construction of models of potential aetiological determinants and covariates to test the hypothesised causal pathways and mechanisms. The research we propose should improve understanding of the factors and processes that mediate social disparities in preterm birth. This improved understanding should help not only in developing strategies to reduce the disparities but also in suggesting preventive interventions applicable across the entire socio-economic spectrum.

Socio-economic disparities in pregnancy outcome: why do the poor fare so poorly?

In this paper, we review the evidence bearing on socio-economic disparities in pregnancy outcome, focusing on aetiological factors mediating the disparities in intrauterine growth restriction (IUGR) and preterm birth. We first summarise what is known about the attributable determinants of IUGR and preterm birth, emphasising their quantitative contributions (aetiological fractions) from a public health perspective. We then review studies relating these determinants to socio-economic status and, combined with the evidence about their aetiological fractions, reach some tentative conclusions about their roles as mediators of the socio-economic disparities. Cigarette smoking during pregnancy appears to be the most important mediating factor for IUGR, with low gestational weight gain and short stature also playing substantial roles. For preterm birth, socio-economic gradients in bacterial vaginosis and cigarette smoking appear to explain some of the socio-economic disparities; psychosocial factors may prove even more important, but their aetiological links with preterm birth require further clarification. Research that identifies and quantifies the causal pathways and mechanisms whereby social disadvantage leads to higher risks of IUGR and preterm birth may eventually help to reduce current disparities and improve pregnancy outcome across the entire socio-economic spectrum.

[Recruitment of Montreal women of very low socioeconomic status for a randomized clinical study]. / Le recrutement d'un groupe de femmes montréalaises de status socio-économique très faible dans une étude clinique randomisée.

Studies show that it is difficult to recruit women of low socioeconomic status as clinical research participants. Such an objective was attained though as our results demonstrate in an evaluative study of a program implemented to lower the percentage of low birthweight in four CLSCs of the Island of Montreal between 1994 and 1996. The global recruitment strategy enabled us to reach 56.2% of our goal in 1994 and 77.4% in 1996. Two conclusions can be drawn from this result: the effectiveness of the three methods of recruitment varied according to each participating CLSC, and the global strategy, combined with the mobilization of community resources, was successful in enrolling women of low socioeconomic status.

[The Edinburgh Postnatal Depression Scale: the validity of its Quebec version for a population low socioeconomic status mothers]. / L'échelle de dépression postnatale d'Edimbourg: validité au Québec auprès de femmes de statut socio-économique faible.

This paper investigates the construct validity and reliability of a Quebec version of the Edinburgh Postnatal Depression Scale (EPDS) for a population of low-socioeconomic-status mothers. This scale was constructed for the specific purpose of measuring mothers' symptoms of depression during the postnatal period in an effort to alleviate the validity problems that could arise from depression scales intended for the general population. Two hundred and twenty-four mothers participating in a Quebec prevention program, "Naître égaux, grandir en santé" (Martin & Boyer, 1995) filled out the EPDS between the 22nd and the 35th day postpartum. A confirmatory factor analysis, conducted with LISREL, gives a 2-factor structure for the EPDS, the first representing symptoms of depression and the second symptoms of anxiety. This structure differs from the one presented by Cox, Holden, and Sagovsky (1987), authors of the EPDS. It corresponds, however to the results of other authors who looked at the EPDS with confirmatory factor analysis (Pop, Komproe, & van Son, 1992) and indicates a good construct validity. The reliability of the scale also appears satisfactory, with a Cronbach alpha co-efficient of 0.82.

[Conjugal violence during pregnancy: a literature review.]. / Violence conjugale pendant la grossesse : recension des écrits.

Conjugal violence is a complicated issue which scope and consequences are increasingly documented. Among the many facets of the phenomenon, its occurrence during pregnancy is particularly worrisome. This article reviews the scientific literature pertaining to this issue. After establishing the prevalence of conjugal violence during pregnancy, the authors examine the major studies analyzing factors associated with this violence as well as its consequences for the mother and the infant. The article concludes that the current informations, although partial, are sufficient to justify early detection of conjugal violence in order to help future mothers efficiently.

Socio-environmental factors and postnatal depressive symptomatology: a longitudinal study.

This study analyses the relationships between stressful life conditions and postnatal depressive symptomatology in a group of women of low socioeconomic status (SES) and a group of women of high SES from the third to the ninth week postpartum. Nulliparous pregnant women were recruited from the prenatal care clinics of four hospitals. Multiple linear regression analyses demonstrated that after accounting for SES group membership and depressive symptomatology during pregnancy, early postnatal chronic stressors (frequent conflictual episodes with network members, maternal health problems) and social support were linked to later postnatal depressive symptomatology.

[Factors associated with low birth weight: a multivariate analysis]. / Facteurs associés à la naissance des enfants de faible poids: une analyse multivariée.

The low birth weight of infants is a major public health problem of unknown cause in Benin. We recruited 4,213 pregnant women from a maternity ward in Cotonou for a prospective study. The women were interviewed and further information was obtained from their maternity records. The women were followed until delivery. We found that 6.9% of the births occurred pre-term and there was intrauterine growth retardation in 10.9% of cases. Multiple regression analysis showed that the risks of giving birth to underweight infants were highest for women who were themselves underweight, who had complications due to bleeding or malaria or had social and psychological risk factors. For these particular women, unwanted pregnancy (ORa = 1.60; CI = 1.30-2.00) and lifting heavy loads (ORa = 1.30; CI = 1.10-1.60) were high risk factors. However, adequate prenatal care (ORa = 0.85; CI = 0.69-0.99) and having given birth before were protective factors, reducing the likelihood of a low birth weight. These results have implications for preventive care, in terms of nutrition during pregnancy and psychosociological factors.

Depressive symptoms in the late postpartum among low socioeconomic status women.

BACKGROUND: Postpartum depression has been the focus of much research in the past 15 years, but little is known about factors associated with depression of longer duration or later onset. The purpose of this longitudinal study was to analyze the relationship between stressful life conditions and postnatal depression in a group of women of low socioeconomic status from the third week to the sixth month postpartum. METHODS: Nulliparas who met criteria for low socioeconomic status were recruited from the prenatal care clinics of four Montreal hospitals. Questionnaires were verbally administered in the home at 30 weeks' gestation, at 3 and 9 weeks postpartum, and at 6 months postpartum. Blockwise multiple linear regression analyses were performed by entering predictor variables that included sociodemographic characteristics, chronic stressors, life events, and social support network. RESULTS: Sixty-eight women participated in the study. At 6 months postpartum, 38.2 percent of the mothers had a Beck Depression Inventory score of 10 or more. After accounting for previous depression, analyses indicated that chronic stressors (maternal health problems, infant difficulty, lack of money for basic needs, frequent conflicts with network members) and poor social support (informational and emotional) were associated with postnatal depressive symptoms. CONCLUSIONS: Health practitioners should recognize that high depressive symptomatology frequently occurs among low socioeconomic status first-time mothers at six months postpartum. Chronic stressors and inadequate social support are the most important factors associated with this problem.

Metabolic and anti-atherogenic effects of long-term benfluorex in dyslipidemic insulin-resistant sand rats (Psammomys obesus).

Benfluorex is a clinical lipid-lowering agent with antihyperglycemic properties. The effect of long-term oral treatment (10 mg/kg/day for 7.5 months) on carbohydrate and lipid metabolism and aortic morphology was investigated in 24 insulin-resistant sand rats receiving a standard laboratory diet supplemented with cholesterol (2%). Untreated controls (n=34) developed impaired glucose tolerance, hyperinsulinemia, hypertriglyceridemia, hypercholesterolemia and elevated plasma LDL- and VLDL-cholesterol, positively correlated with the proportion of the thoracic aorta displaying oil red O-positive atherosclerosis; ultrastructural examination showed intimal lipid deposits, foam cells, polymorph infiltrates and fibrosis. Benfluorex-treated animals showed significant decreases in glucose intolerance, hyperinsulinemia, hypertriglyceridemia, hypercholesterolemia, and plasma LDL- and VLDL-cholesterol, with no evidence of aortic atheroma. The metabolic benefits of benfluorex may protect against the long-term development of atherosclerosis in the insulin-resistant dyslipidemic syndrome.

Effects of moderate and intensive training on functional activity of central 5-HT1B receptors in the rat substantia nigra.

The efficacy of the selective 5-HT1B receptor agonist CP 93,129 in inhibiting the forskolin-stimulated adenylyl cyclase activity in the rat substantia nigra was reduced by both moderate and intensive prolonged training compared with sedentary resting rats. The concentration-response curves of the agonist were shifted to the right with a sixfold increase of the half-maximal inhibitory concentration. A difference was observed between the two training exercises in regard to further changes in 5-HT1B receptor sensitivity induced by an acute restraint stress. This manipulation did not affect the functional response of the 5-HT1B receptors further in moderately trained rats, whereas an additional desensitization of the 5-HT1B receptors was observed in intensively trained rats. These results strongly suggest the existence of regulation mechanisms altering the functional efficacy of 5-HT1B receptors and, accordingly, affecting the serotonergic activity, since 5-HT1B receptors modulate the neuronal release of the amine.

The endogenous cerebral tetrapeptide 5-HT-moduline reduces in vivo the functional activity of central 5-HT1B receptors in the rat.

5-HT-moduline (Leu-Ser-Ala-Leu, LSAL) is a novel endogenous peptide isolated from rat brain which interacts in vitro specifically with 5-HT(1B) receptors by a non-competitive mechanism. In the present study, we demonstrate that the efficacy of the selective 5-HT(1B) receptor agonist CP 93 129 in inhibiting the forskolin-stimulated adenylyl cyclase activity in the rat substantia nigra was reduced 15 min after intracerebral injection of LSAL compared to vehicle or ALLS (scrambled peptide) injected rats. Accordingly, the concentration-response curve of the agonist is shifted to the right with a 3.5-fold increase of the half-maximal inhibitory concentration compared to vehicle injected rats. Thus, the in vivo desensitization of serotonergic autoreceptors strongly strengthens the important role of 5-HT-moduline in the rapid adaptative control of the serotonergic system, implicated in numerous pathological events as anxiety and depression.

5-hydroxytryptamine-moduline, a new endogenous cerebral peptide, controls the serotonergic activity via its specific interaction with 5-hydroxytryptamine1B/1D receptors.

The serotonergic system controls the activity of neurotransmissions involved in numerous physiological functions. It is also thought to be crucially implicated in various pathologies, including psychiatric disorders such as depression, anxiety, and aggressiveness. The properties of 5-hydroxytryptamine (5-HT)-moduline, a novel endogenous peptide, have been tested in vitro and in vivo. Binding studies have shown that the peptide specifically interacts with 5-HT1B/1D receptors via a noncompetitive mechanism corresponding to a high apparent affinity (EC50 = 10(10) M). The interaction was shown in rat and guinea pig brain tissues and in cells transfected with either 5-HT1B or 5-HT1D beta receptor gene. [3H]5-HT-moduline binds to a single population of sites in mammalian brain (Kd = 0.4 nM in rat, Kd = 0.8 nM in guinea pig) as well as in transfected cells expressing the 5-HT1B or the 5-HT1D beta receptors (Kd = 0.2 and 0.6 nM, respectively). Furthermore, the binding is clearly specific of the LSAL sequence. Autoradiographic studies showed an heterogeneous brain distribution of this site. The interaction of 5-HT-moduline with the 5-HT1B/1D receptor corresponds to a decrease in the functional activity of the receptor (i.e., a decrease in the inhibitory effect of a 5-HT1B agonist on the evoked release of [3H]5-HT from synaptosomal preparation). It was also shown that 5-HT-moduline possess an in vivo effect in the social interaction test in mouse. Finally, it was demonstrated that 5-HT-moduline was released from brain synaptosomal preparation by a K+/Ca(2+)-dependent mechanism. In conclusion, 5-HT-moduline is a novel endogenous peptide regulating the serotonergic activity via a direct action at presynaptic 5-HT receptor. It may play an important role in the physiological mechanisms involving the serotonergic system, particularly in mechanisms corresponding to the elaboration of an appropriate response of the central nervous system to a given stimulus.

Pro- and antinociceptive actions of serotonin (5-HT)1A agonists and antagonists in rodents: relationship to algesiometric paradigm.

In mice injected with formalin into the hindpaw, the 5-HT1A receptor agonists, 8-OH-DPAT and flesinoxan, equipotently inhibited the early phase (EP) and late phase (LP) of licking. At higher doses, they provoked ataxia and inhibited the writhing elicited by intra-abdominal acetic acid. The antagonists, (-)-alprenolol, (-)-tertatolol, WAY-100,135 and S 15931 were more potent against the LP than the EP. They also inhibited writhing, and only at very high doses did they elicit ataxia. In rats, 8-OH-DPAT and flesinoxan increased the current required to elicit vocalisation upon electrical stimulation of the tail. The action of 8-OH-DPAT was blocked by WAY-100,135, which, like other antagonists, was inactive alone. Interestingly, a low dose of 8-OH-DPAT partially inhibited the antinociceptive action of the mu-opioid agonist, morphine, the action of which was dose-dependently facilitated by (-)-alprenolol and S 15931. Administered s.c., 8-OH-DPAT elicited spontaneous tail-flicks (STFs) in rats: these were abolished by WAY-100,135, (-)-tertatolol, (-)-alprenolol and S 15931. STFs were also eliminated by s.c. or i.t. administration of the alpha 2-adrenergic receptor agonist, clonidine, the GABAA agonist, muscimol or the GABAB agonist, baclofen. The mu-opioid, morphine, blocked STFs only at high doses and the kappa-opioid agonists, U 50,488 and U 69,593, even at supra-ataxic doses, were inactive. Antagonists at neurokinin (NK)1 (RP 67580), NK2 (SR 48,968) and bradykinin (BK)2 (Hoe 140) receptors, as well as aspirin, did not block STFs, though indomethacin was effective. Antagonists at the glycine B site coupled to the NMDA receptor, L 687,414, L 701,324 and (+)-HA966, blocked STFs. Furthermore, (+)-HA 966 and the competitive NMDA receptor antagonist, CPP, were active upon i.t. administration. STFs were also blocked by s.c. or i.t. administration of the AMPA antagonists, YM 900 and NBQX. In conclusion, the influence of 5-HT1A ligands upon nociception is dependent upon the algesiometric paradigm. Intriguingly, modulation of 5-HT1A receptor-mediated STFs reveals parallels to neuropathic pain.

[Birth intervals and birth of low weight infants in Benin]. / Intervalles inter-grossesses et naissance des enfants de faible poids au Bénin.

Low birthweight is a public health problem in Benin but its etiology remains unclear. Studies in industrial countries suggest several risk factors including the interval between pregnancies or child spacing. The purpose of this cohort study was to assess the relationship between pregnancy interval and low birthweight in Benin. Data were collected from a total of 2,862 multiparous pregnant women randomly recruited in 1991 at the time of their first prenatal care visit to maternity units in Cotonou, Benin. Sociodemographic information and obstetrical history were obtained by interviewing the mother and reviewing delivery records. About 15% of the women recruited delivered low birthweight children. The relative risks of preterm birthweight and intrauterine growth retardation was calculated in function of three pregnancy intervals: less than 12 months, 12 to 23 months, and 24 to 34 months. It was 1.31 (1.00-1.75), 1.00 (0.70-1.02)) and 0.77 (0.60-0.87) respectively for preterm birthweight and 1.27 (1.03-1.64), 1.17 (0.79-1.39) and 0.79 5 (0.57-0.87) respectively for intrauterine growth retardation. Logistic regression analysis taking into account sociodemographic factors and previous obstetrical history did not show a significant correlation between pregnancy interval and preterm low birthweight or between pregnancy interval and intrauterine growth retardation. Maternal nutritional status, maternal age, number of previous births, and education level were correlated with low birthweight.