Maternal occupational exposure to organic solvents and intrauterine growth in the ELFE cohort.

BACKGROUND: In developed countries, about 15% of women are occupationally exposed to solvents. Associations between this maternal occupational exposure and intrauterine fetal growth are inconsistent, but almost no existing study has investigated this relation by solvent family (oxygenated, petroleum, and chlorinated), although they may affect fetal growth differently. OBJECTIVES: To investigate the relations between maternal occupational solvent exposure, by solvent family, and the risk of neonates born small for gestational age (SGA), or with low birthweight, or with small head circumference (HC). METHODS: Among the 18,040 women enrolled in the Elfe rather than included in the Elfe birth cohort, we included 13,026 women who worked during pregnancy (72% of the cohort). Information about maternal occupations and industrial activities during pregnancy was collected by questionnaire at the maternity ward, and completed at 2-month when necessary. Using Matgéné job-exposure matrices, we assessed maternal occupational exposure to solvents. Logistic and multiple linear regressions were used to assess the association between maternal occupational solvent exposure and SGA status, birth weight, and HC. Analyses were conducted for exposure during pregnancy and also stratified by the trimester that pregnancy leave began. RESULTS: We observed a higher risk of SGA newborns among mothers occupationally exposed during pregnancy to petroleum solvents (ORadjusted = 1.26; 95%CI: 1.01 to 1.57). Among women working until the third trimester of pregnancy, we observed a higher risk of SGA newborns to those occupationally exposed to oxygenated solvents (ORadjusted = 1.75; 95%CI: 1.11 to 2.75), a significantly lower birthweight for infants of mothers exposed to petroleum solvents (ßadjusted = -47.37 g; -89.33 to -5.42), and a lower HC among newborns of those occupationally exposed to oxygenated solvents (ßadjusted = -0.28; -0.49 to -0.07) and to chlorinated solvents (ßadjusted = -0.29; -0.53 to -0.05). DISCUSSION: Our results suggest that maternal occupational solvent exposure may influence fetal growth, especially exposure into the third trimester of pregnancy.

Primary anterior cruciate ligament repair: magnetic resonance imaging characterisation of reparable lesions and correlation with arthroscopy.

OBJECTIVES: A recent treatment algorithm suggests that proximal anterior cruciate ligament (ACL) tears with good-to-excellent tissue quality are amenable to primary repair. Our primary objective was to assess the ability of MRI to determine the exact tear location and tissue quality, using arthroscopy as a reference standard. METHODS: In an initial sample of 71 patients with prior ACL surgery (repair or reconstruction), the diagnostic accuracy of MRI was assessed using arthroscopy as a reference standard. Each native ACL tear was graded according to Sherman's arthroscopic classifications during the surgical procedure. MRI scans were retrospectively reviewed for grading, blinded to arthroscopic findings and in consensus by two musculoskeletal radiologists. Tear location and tissue quality were graded using the MRI Sherman tear location (MSTL), MRI Sherman tissue quality (MSTQ) and simplified MRI Sherman tissue quality (S-MSTQ) classifications. Intra- and inter-observer agreement was assessed on a second sample of 77 patients. MRI classification accuracy was compared by McNemar's tests. Intra- and inter-observer agreement was assessed using Cohen's kappa coefficient. RESULTS: Regarding tear location, diagnostic accuracy was 70% (50/71) based on the MSTL classification. Diagnostic accuracy for tissue quality was 52% (15/29) based on the MSTQ classification and 90% (26/29) for the S-MSTQ classification (p = 0.003). Inter-observer agreement was good for MSTL (κ = 0.78) and moderate-to-good for the MSTQ and S-MSTQ classifications (κ = 0.44 and 0.63 respectively). CONCLUSIONS: MRI seems to be accurate in assessing tear location and tissue quality and may help clinicians to predict the reparability of ACL tears. KEY POINTS: • MRI seems to be accurate in assessing tear location and tissue quality and may help clinicians to predict the reparability of ACL tears. • High intra-observer agreement was demonstrated when grading the tear location into one of five types. • The diagnostic accuracy of the simplified MRI tissue quality classification, involving deletion of the ligament stump signal criterion, was better than that observed with the MRI Sherman tissue quality classification, but was moderate to good in terms of inter- and intra-observer agreement.

Inverse probability weighting to handle attrition in cohort studies: some guidance and a call for caution.

BACKGROUND: Attrition in cohort studies challenges causal inference. Although inverse probability weighting (IPW) has been proposed to handle attrition in association analyses, its relevance has been little studied in this context. We aimed to investigate its ability to correct for selection bias in exposure-outcome estimation by addressing an important methodological issue: the specification of the response model. METHODS: A simulation study compared the IPW method with complete-case analysis (CCA) for nine response-mechanism scenarios (3 missing at random - MAR and 6 missing not at random - MNAR). Eighteen response models differing by the type of variables included were assessed. RESULTS: The IPW method was equivalent to CCA in terms of bias and consistently less efficient in all scenarios, regardless of the response model tested. The most effective response model included only the confounding factors of the association model. CONCLUSION: Our study questions the ability of the IPW method to correct for selection bias in situations of attrition leading to missing outcomes. If the method is to be used, we encourage including only the confounding variables of the association of interest in the response model.

Service sanitaire des étudiants en santé : ancrer l'éducation pour la santé dans le cursus des étudiants.

INTRODUCTION: Established in France since 2018, the Student Health Service aims to train students to become actors in health education. METHODS AND RESULTS: A teaching system lasting the equivalent of six weeks full-time has been set up in the third year of medical school in Rennes. The aim is for students to develop the skills needed to carry out interventions based on a project approach, with a variety of audiences, on priority public health themes.New pedagogical approaches have been developed to integrate learning about health promotion and health education into the medical curriculum. Innovations have been implemented: work on the educational posture, tutoring of third-year students by medical interns, a forum for simulation of concrete actions under the supervision of a dual thematic and population-based expertise. Beyond the acquisition of knowledge, the training aims to encourage a reflective approach and is based on peer education.The 240 students of the faculty prepare their project in trinomials throughout the academic year. Their activities take place over ten half-days in more than a hundred establishments in the faculty subdivision and enable them to work with approximately 10,000 people per year. DISCUSSION: Education and health promotion now occupies a central place in the training of third-year students, an essential condition for the sustainable acquisition of this field of expertise by future health professionals.

Improved detection and characterization of arterial occlusion in acute ischemic stroke using contrast enhanced MRA.

BACKGROUND AND PURPOSE: To compare the accuracy and utility of contrast enhanced magnetic resonance angiography (MRA) (CEMRA) to Time of Flight MRA (TOF MRA) during detection and evaluation of occlusions on patients diagnosed with acute ischemic stroke (AIS). METHODS: This single-center study was approved by our local institutional research ethics board. From August 2014 to July 2016, 131 consecutive adult patients with confirmed AIS were included. Detection of an arterial occlusion and its characterization were evaluated independently with CEMRA or TOF MRA by two blinded neuroradiologists, then by consensus using all available MR sequences. A Cohen's Kappa coefficient (κ) and intra-class correlation coefficients (ICC) were used to compare the two techniques. RESULTS: There was substantial concordance in the detection of arterial occlusion between CEMRA and TOF MRA (κ = 0.75). TOF MRA was more likely to show an arterial occlusion than CEMRA (63 versus 52 patients respectively). There were 13 and 1 false positive arterial occlusion with TOF MRA and CEMRA respectively, and 1 false negative with TOF MRA. There was excellent concordance between the location of arterial occlusions and CEMRA and TOF MRA [κ = 0.89 (0.72-0.97)]. CEMRA was significantly more likely to allow measurement of the thrombus than was TOF MRA [38 (75%) versus 14 (22%)] (P < 0.0001). CONCLUSIONS: Our study showed that CEMRA imaging detected arterial occlusions better than TOF MRA in AIS patients and more precisely such that thrombus length and location could be known, which improves the patient's management and care.

Residential sources of pesticide exposure during pregnancy and the risks of hypospadias and cryptorchidism: the French ELFE birth cohort.

OBJECTIVES: Prenatal occupational exposure to pesticides has been associated with male reproductive tract abnormalities. Little is known about the possible impact of non-occupational pesticide exposure on fetal and child development in the general population. Using data from a nationwide birth cohort, we aimed to assess the association between residential sources of prenatal pesticide exposure and the risks of hypospadias and cryptorchidism. METHODS: Of the 9281 boys in ELFE (French Longitudinal Study of Children), the national French birth cohort, 53 were diagnosed with hypospadias and 137 with cryptorchidism. We assessed residential exposure sources from self-reported domestic use of eight types of pesticide products and French spatial land use data with acreage within a 1000 m radius around each family's home for 21 crop types. We used logistic regression modelling, adjusted for possible confounders that included estimated dietary pesticide intake. Multiple imputations were used to handle missing data. RESULTS: An increased risk of hypospadias was associated with domestic pesticide use against fleas and ticks (OR=2.28, 95% CI 1.09 to 4.75); no associations were found between cryptorchidism and any domestic pesticide use. Slightly increased risks of cryptorchidism were observed in association with all crop acreages near homes during pregnancy, especially for orchards, and no association was observed for hypospadias. CONCLUSIONS: Our results suggest a possible increased risk of hypospadias associated with prenatal use of some domestic pesticide products, likely to contain insecticides, and of cryptorchidism with nearby orchard acreage (crops repeatedly sprayed with pesticides). This work is limited by its modest number of cases.

Remote brain microhaemorrhages may predict haematoma in glioma patients treated with radiation therapy.

OBJECTIVES: To evaluate the prevalence of cerebral remote microhaemorrhages (RMH) and remote haematomas (RH) using magnetic resonance susceptibility-weighted imaging (SWI) among patients treated for gliomas during follow-up. METHODS: We conducted a retrospective single centre longitudinal study on 58 consecutive patients treated for gliomas from January 2009 through December 2010. Our institutional review board approved this study. We evaluated the presence and number of RMH and RH found outside the brain tumour on follow-up MR imaging. We performed univariate and bivariate analyses to identify predictors for RMH and RH and Kaplan-Meier survival analysis techniques. RESULTS: Twenty-five (43%) and four patients (7%) developed at least one RMH or RH, respectively, during follow-up. The risk was significantly higher for patients who received radiation therapy (49% and 8% versus 0%) (p = 0.02). The risk of developing RH was significantly higher in patients with at least one RMH and a high burden of RMH. The mean age of those presenting with at least one RMH or RH was significantly lower. CONCLUSIONS: RMH were common in adult survivors of gliomas who received radiation therapy and may predict the onset of RH during follow-up, mainly in younger patients. KEY POINTS: • Brain RMH and RH are significantly more likely to occur after RT. • RMH occur in almost half of the patients treated with RT. • RMH and RH are significantly more frequent in younger patients. • RH occur only in patients with RMH.

Magnetic resonance post-contrast vascular hyperintensities at 3 T: a new highly sensitive sign of vascular occlusion in acute ischaemic stroke.

BACKGROUND: Magnetic resonance imaging (MRI) is the diagnostic cornerstone for precisely identifying acute ischaemic strokes and locating vascular occlusions, especially since mechanical thrombectomy has become a reference treatment. We observed that a post-contrast three-dimensional turbo-spin-echo T1-weighted sequence showed striking post-contrast vascular hyperintensities (PCVH) in ischaemic territories. We aimed to evaluate the prevalence and the meaning of this finding. METHODS: This retrospective single centre study included 130 consecutive patients admitted for acute ischaemic stroke with a 3-T MRI performed in the first 12 h of symptom onset from September 2014 through September 2016. Two neuroradiologists blinded to clinical data analysed the first MRI assessments. The association between PCVH and clinical, radiological and follow-up findings was assessed, as well as inter- and intra-observer agreements. RESULTS: Of 130 patients, 105 (81%) had PCVH in the ischaemic territory. PCVH were associated with the presence of thrombus on susceptibility weighted imaging (p < 0.0001) and vascular occlusions on MR angiography (p < 0.0001). All patients with a visible thrombus had PCVH closely surrounding the clot. PCVH were associated with higher initial (p < 0.01) and follow-up (p < 0.01) National Institutes of Health Stroke Scale score, and higher mRS score (p < 0.05). Thrombectomy was the reference treatment for all patients with arterial occlusions. Inter- and intra-observer agreements for the detection of PCVH were excellent (κ = 0.95 and κ = 0.91, respectively). CONCLUSIONS: PCVH during acute strokes are a striking sensitive and reproducible tool for diagnosing and locating vascular occlusions. It may help triage patients who can benefit from thrombectomy. KEY POINTS: • Post-contrast vascular hyperintensities (PCVH) are a sensitive MR finding in acute stroke • PCVH are strongly associated with the presence and location of arterial occlusions • Inter- and intra-observer agreements for the detection of PCVH are excellent • PCVH are visible even in the case of significant motion artefacts • PCVH may help triage patients who can benefit from mechanical thrombectomy.

[Assessment of patient satisfaction following nipple-areolar complex tattooing after breast reconstruction.] / Évaluation de la satisfaction des patientes ayant bénéficié d'un tatouage de la plaque aréolomamelonnaire après reconstruction mammaire.

INTRODUCTION: Nipple-areolar complex tattooing often completes the breast mound reconstruction process after cancer surgery. However, there have been few studies evaluating patient satisfaction with this technique. OBJECTIVE: To assess patients' esthetic satisfaction with the results of tattooing performed by nurses. METHOD: Ninety-eight women participated in the study. Overall satisfaction with reconstruction and satisfaction with the tattoo's color, dimension, position, and form were determined using questionnaires completed by patients and a professional jury. RESULTS: 97% of patients reported overall satisfaction with the results of nipple-areolar reconstruction. The satisfaction rate with the tattoo's color was 67%, with dimension 96%, with form 95%, and with position 94%. The satisfaction rates of the jury were as follows: nipple-areolar reconstruction 79%; color 52%; dimension 77%; form 75%; and position 69%. DISCUSSION: On the whole, the patients were satisfied with the results one year after tattooing and their satisfaction rate was higher than that of the jury's. Only 6.1% of women required a second tattoo because of discoloration. CONCLUSION: Nipple-areolar complex tattooing has a high rate of patient esthetic satisfaction and can be performed by a trained nurse without the need for hospital admission.

Prognosis of patients with severe hyponatraemia is related not only to hyponatraemia but also to comorbidities and to medical management: results of an observational retrospective study.

BACKGROUND: The true cause of death in severe hyponatraemic patients remains controversial. The present study aimed to analyse the relationship between comorbidity, medical management and prognosis in severe hyponatraemic patients. METHODS: Medical records of all patients hospitalised in our institution in 2012 with a plasma sodium ≤120 mmol/l were retrospectively analysed. RESULTS: One hundred forty-seven of 64 723 adult patients (0.2 %) were identified with severe hyponatraemia. In-hospital mortality rate was 24.5 and 50.3 % after a median follow-up of 431 days. Patients with plasma sodium <110 mmol/l had less comorbidity (Charlson Comorbidity Index 2.2 ± 1.9 vs. 4.0 ± 3.1 (plasma sodium 110-115 mmol/l) and 4.2 ± 3.1 (plasma sodium 116-120 mmol/l); P = .02)) and a small trend for less mortality, respectively 40.0, 51.2 and 52.3 % (P = .64). At discharge, nonsurvivors and survivors had similar plasma sodium with 58.3 % of nonsurvivors being normonatraemic. Urine analysis was performed in 74.2 % of cases and associated with lower in-hospital mortality (20.2 % vs. 36.8 %, P = .05). In multivariate Cox analysis, mortality was significantly associated with plasma sodium normalisation (HR 0.35, P < 0.001), urine analysis (HR 0.48, P = .01), Charlson Comorbidity Index (HR 1.23, P < .001) and serum albumin (HR 0.88, P < .001). CONCLUSION: Mortality in severe hyponatraemia appears mainly due to comorbidities although the latter are potentiated by hyponatraemia itself and its management thereby exacerbating the risk of death.

Study of choroidal thickness variations after ingestion of a taurine and caffeine-containing energy drink.

BACKGROUND & AIMS: Choroidal thickness can undergo considerable variations in response to different substances. The aim of this study was to assess the change in choroidal thickness after the ingestion of taurine and caffeine contained in the Red Bull energy drink. METHODS: Enhanced Depth Imaging - Spectral Domain Optical Coherence Tomography was used to measure subfoveal choroidal thickness (SFCT) variations in healthy volunteers at several time points after drinking a Red Bull can (25 cl). RESULTS: Forty eyes of 20 volunteers were enrolled. A significant reduction in SFCT (-14 µm, p < 0.0001) occurred at 1 h after the Red Bull intake, and was even more important (-20.14 µm, p < 0.0001) in eyes with particularly thick choroids (≥ 395 µm). SFCT measurements at 4 h were comparable to baseline. CONCLUSIONS: A concomitant ingestion of caffeine and taurine can induce a transient choroidal thinning that is more marked in eyes with thick choroids. REGISTRATION NUMBER OF CLINICAL TRIAL: NCT02856256.

Use of the COPD Assessment Test (CAT) to screen for COPD in dairy farmers: AIRBAg study.

OBJECTIVES: People at risk of chronic obstructive pulmonary disease (COPD) can benefit from appropriate medical management before severe symptoms appear. This study assesses the value of the COPD Assessment Test (CAT) questionnaire for screening dairy farmers, who tend to be slow or reluctant to seek health care. METHODS: During the time period 2012-2017, 2089 randomly selected dairy farmers in Brittany (France) were invited to complete self-administered questionnaires (including the CAT) and to undergo an occupational health check-up using an electronic mini-spirometer and conventional spirometry. Those showing symptoms suggestive of COPD and/or a ratio FEV1 /FEV6 < 80% were sent to a pulmonologist for a further check-up, including spirometry with a reversibility test. Multivariate logistic models based on CAT scores and socio-demographic or work-related factors were developed to predict COPD. RESULTS: The 1231 farmers who underwent the occupational health check-up included 1203 who met the inclusion/exclusion criteria. Pulmonologist identified 16 (1.3%) cases of COPD. A multivariate logistic regression model (covariates: CAT sum score, on-farm time, BMI, smoking status, free-stall mulching) provided an area under the receiver-operating characteristic curve (AUC) of 0.87 (95% CI: 0.75-0.98). Using a cut-off of 0.007 gave a sensitivity of 93.8% and a specificity of 62.4%. Another model that included CAT breathlessness and the same covariates performed marginally better (AUC = 0.88, 95% CI: 0.77-0.98). CONCLUSION: Our predictive models can both benefit dairy farmers by providing early diagnosis and management of their COPD and avoid unnecessary, costly spirometry during the screening process.

Analysis of postoperative and hematogenous prosthetic joint-infection microbiological patterns in a large cohort.

OBJECTIVES: This study was undertaken to analyze prosthetic joint infection (PJI)-causing microorganisms and compare their distribution patterns according to PJI classification. METHODS: Cohort study from a single referral center for bone-and-joint infections from January 2004 to December 2015. RESULTS: Nine hundred and twenty-six patients, who developed 997 PJIs, involving the hip (62%), knee (35%) and/or shoulder (1%), were included. PJIs were classified as early postoperative (19%), late chronic (30%), hematogenous (35%) and undetermined (16%). Pathogens most frequently isolated from early-postoperative PJIs were staphylococci (57%), with 25% each Staphylococcus aureus or Staphylococcus epidermidis; 21% were polymicrobial and 10% Gram-negative rods. For late-chronic PJIs, the most frequent microbes were staphylococci (61%), predominantly S. epidermidis (35%); anaerobic bacteria were isolated from 15%; 11% were polymicrobial. Hematogenous PJIs were 99% monomicrobial. Although S. aureus was the most frequently isolated species (28%), streptococci were isolated slightly more often than staphylococci (39% vs. 36%). Among streptococci, group B streptococci were the most frequent (15%). The portal of entry was identified for 52% of hematogenous PJIs: 15% cutaneous, 11% dental, 9% gastrointestinal, 6% urinary, and 11% miscellaneous. CONCLUSION: Although a wide variety of microorganisms was isolated from PJIs, specific microbiological patterns were observed according to infection classification.

Multiple pesticide analysis in hair samples of pregnant French women: Results from the ELFE national birth cohort.

BACKGROUND: A growing body of evidence suggests that prenatal exposure to pesticides might impair fetal development. Nonetheless, knowledge about pesticide exposure of pregnant women, especially in Europe, is largely restricted to a limited panel of molecules. AIM: To characterize the concentration of 140 pesticides and metabolites in hair strands from women in the ELFE French nationwide birth cohort. METHODS: Among cohort members who gave birth in northeastern and southwestern France in 2011, we selected those with a sufficient available mass of hair (n = 311). Bundles of hair 9 cm long were collected at delivery. We screened 111 pesticides and 29 metabolites, including 112 selected a priori based on their reported usage or detection in the French environment. The bundles of hair from 47 women were split into three segments to explore the intraindividual variability of the exposure. Intraclass correlation coefficients (ICCs) were computed for the chemicals with a detection frequency >70%. RESULTS: We detected a median of 43 chemicals per woman (IQR 38-47). Overall, 122 chemicals (>20 chemical families) were detected at least once, including 28 chemicals detected in 70-100% of hair samples. The highest median concentrations were observed for permethrin (median: 37.9 pg/mg of hair), p-nitrophenol (13.2 pg/mg), and pentachlorophenol (10.0 pg/mg). The ICCs for the 28 chemicals studied ranged from 0.59 to 0.94. CONCLUSION: Pregnant women are exposed to multiple pesticides simultaneously from various chemical families, including chemicals suspected to be reproductive toxicants or endocrine disruptors. The ICCs suggest that the intraindividual variability of pesticide concentrations in hair is lower than its interindividual variability.

Refractory spasms of focal onset-A potentially curable disease that should lead to rapid surgical evaluation.

PURPOSE: Infantile spasms (IS) can occur as the only seizure type in children with surgically amenable epilepsies. Although early surgery has shown positive effects, little is known regarding outcomes. METHODS: We retrospectively reviewed all children with IS referred to our tertiary center between 2002 and 2014 and try to define factors of outcome. RESULTS: Sixty-eight children with focal onset seizures were referred: twenty children with a hemispheric implication and 48 with one or more lobes involved. The age of onset was significantly earlier in the hemispheric population (8.0 versus 16.7 months in the focal population). There was no difference in the age of onset between anterior and posterior onset zones, as we could expect regarding the maturation gradient. The epilepsy began earlier in life in tuberous sclerosis than in DNET. Only three children of the 48 non-hemispheric patients had a normal MRI at the time of the surgery. Temporal lobe was involved only in a third of the population. More than 86% of the patients were operated on. Patients with hemispheric lesions were operated on younger (2.6 years+/- 2.1 years) compared to 4.6+/- 3.5 years in the whole population. The most frequent etiologies were in descending order: dysplasia, ganglioglioma or dysembryoplastic tumours and tuberous sclerosis. The global seizure outcome was favorable (Engel 1a) in 74.6% of the patients, and 87.9% if the delay between the first seizure and the surgery was less than 36 months. It fell to 64.7% if the delay exceeded 50 months. CONCLUSION: Spasms of focal onset have a similar postsurgical outcome as other seizure types so surgery may be an excellent option for treating selected patients with focal infantile spasms. Volume and type but not topography of the lesion influence the age of onset. MRI is very helpful to locate the pathology in the pediatric population, since only a small portion had a normal MRI.