Are Energy and Protein Intakes Lower Than Requirements in Older Adults? An Urgent Issue in Hospitals and Nursing Homes.

Energy and protein intakes lower than requirements are associated with worsening health outcomes. Here we set out to evaluate gaps between energy and protein intakes and requirements in older adults in hospitals and in nursing homes (NH). A cross-sectional study included 360 inpatients and residents aged 75 years and older in two acute care wards; i.e., a multidisciplinary care unit (MCU) and a geriatric care unit (GCU), a geriatric rehabilitation unit (GRU), and two NH. Intakes were measured for three days. Requirements were based on French National Health Authority recommendations. Energy and protein intakes were under the minimum requirement of 30 kcal/kg/day and 1.2 g/kg/day in 89.5% and 100% of MCU patients, respectively, 75.5% and 64.2% of GCU patients, 92.7% and 90.9% of GRU patients, and 83.8% and 83.8 of NH residents. Intake-to-requirement gaps were not significantly associated with malnutrition, except in the GCU group where non-malnourished patients had higher energy gaps than malnourished patients. Intakes fell dramatically short of requirements in older adults in both hospital and NH settings irrespective of malnutrition status. A new paradigm based on a patient-centered approach should be developed to adapt meals served in hospital and in NH.

Quality Indicators during Delivery and the Immediate Postpartum Period: A Modified Delphi Study.

BACKGROUND: Our research hypothesis was that most French indicators of quality of care have been validated by experts who are not clinicians and might not always be meaningful for clinicians. Our objective was to define a core set of measurable indicators of care quality during delivery and the immediate postpartum period relevant to clinical practice. METHODS: A steering committee comprising nine specialists in obstetrics and/or public health conducted a literature review to develop potential indicators. A panel of obstetrician-gynecologists and midwives working in a delivery unit rated each indicator for appropriateness in a two-round Rand-modified Delphi procedure and a physical meeting. The consensus among the panelists was assessed. RESULTS: In the first round, 145 panelists (110 obstetrician-gynecologists and 35 midwives) assessed 77 indicators and 3 definitions: 6 related to labor onset, 20 to delivery, 3 to pain management, 23 to neonatal morbidity/mortality, and 28 to maternal morbidity. In the second round, 132 panelists (98 obstetrician-gynecologists and 34 midwives) assessed 42 indicators and 1 definition. The final set comprised 50 indicators and 2 definitions. CONCLUSIONS: This Delphi procedure selected 50 indicators that reflect the quality of perinatal care. These indicators should be recorded in each French maternity ward's birth register for each delivery.

Selflife: A Life Skills Development Tool to Prevent Sexual Violence among Healthcare Students.

BACKGROUND: in France, 14.5% of women and 3.9% of men aged 20-69 years have experienced sexual violence. Of these, 40% will go on to develop posttraumatic stress disorder. Sexual violence is therefore a major public health issue. In the present study, we tested a life skills development tool (Selflife) designed to prevent sexual violence in a population of healthcare students. METHODS: a total of 225 French healthcare students were randomly divided into a control group using case studies (n = 114) and a group using Selflife (n = 111) to discuss the topic of sexual violence. After the session, they completed self-report questionnaires collecting sociodemographic data and probing their feelings about their participation, their life skills, and their verdict on the intervention. RESULTS: compared with controls, participants in the Selflife group reported gaining more knowledge about sexual violence, a greater sense of improving their life skills, and greater satisfaction with the intervention. CONCLUSIONS: these results suggest that, in addition to providing information about sexual violence, Selflife helped students develop their life skills, thereby empowering them to act when confronted with sexual violence. Its impact on prevalence and on the psychological and psychiatric consequences remains to be assessed.

Refining the design of a smartphone application for people with chronic low back pain using mixed quantitative and qualitative approaches.

INTRODUCTION: A mobile application has the potential to involve people with chronic NSLBP in their rehabilitation. To refine the design of a smartphone application for people with chronic NSLBP using mixed quantitative and qualitative approaches. METHODS: We used a user-centred design approach involving people with chronic NSLBP and healthcare professionals (HCPs). We used a three-step methodology: developing consensus on the features, content, and design of the app; developing a user interface; and usability testing of the app and assessing users' experience. Transcripts of interviews of users were analyzed by qualitative content analysis. RESULTS: A total of 18 people (aged 45 [23-53] years old) with chronic NSLBP, and 7 HCPs (aged 29.5 [25-55] years old) involved in NSLBP management were interviewed. The overall experience of using the smartphone eLombactif app was initially assessed. Then, with close-ended questions we evaluated users' judgements on the content, its presentation and navigation. Finally, we asked for suggestions: "application content and functionality" and "content presentation" from participants regarding the use and development of the app analyzed by a qualitative methodology. CONCLUSIONS: This study described how we refined the design of our application for people with chronic NSLBP using a qualitative and quantitative approaches. This methodology allows for deepening the knowledge of the needs and expectations of potential users by measuring their user experience.IMPLICATIONS FOR REHABILITATIONNon-specific low back pain (NSLBP) is a major global public health issue leading to considerable economic cost and is primarily responsible for pain and disability.Mobile application has the potential to involve people with chronic NSLBP in their rehabilitation.This study described how we refined the design of our application for people with chronic NSLBP using a qualitative and quantitative approaches.

Girl-boy differences in perceptions of health determinants and cancer: a more systemic view of girls as young as 6 years.

Introduction: To model and analyze the differences between girls' and boys' conceptions of the determinants of health and cancer, as expressed and perceived by children and adolescents. Method: A multicentric qualitative study was conducted in five schools (ages 6-11 years), four middle schools (ages 11-15 years), and three high schools (ages 15-18 years). A multi-phase protocol (phase 1 uses the e.Photoexpression© and phase 2 uses the Photonarration) enables children and teenagers to express themselves through photography and storytelling. Results: A total of 4,174 qualitative productions were produced by 1,068 children, of which 47% were girls and 53% were boys, all in the ages of 6-18 years. From the results of the productions, it can be noticed that children mentioned and were aware of 30 determinants of health and cancer. The three determinants most mentioned were "Consumption of psychotropic drugs", "Diet", and "Harmful environment". Among these 30 determinants, some were mentioned to a greater or lesser extent by girls and boys. These significant gender differences are present for 20 determinants of health and cancer. These differences evolve with age: (1) In elementary school (ages 6-11), girls gave significantly more importance (p < 0.05) to 11 determinants, while boys attached significantly more importance (p < 0.05) to 2 determinants. (2) In middle school (ages 11-16), girls gave significantly (p < 0.05) more importance to 12 determinants, while boys gave significantly (p < 0.05) more importance to one determinant. (3) In high school (ages 15-18 years), girls gave significantly (p < 0.05) more importance to 13 determinants. There was no significant difference (p < 0.05) in favor of boys for high school students. Girls also have a more systemic view of health determinants than boys. The increase in the number of determinants cited by girls is significant (p = 0.017) between the ages of 6-11 and 15-18 years. This gap widens with age (+1.45 determinants) for girls and (+0.68 determinants) for boys between elementary school and high school. Conclusion: The determinants identified as predominantly female or male, as well as age-related specificities, constitute a resource for effective preventive action, as close as possible to the needs and particularities of a population. This mapping of people's conceptions could provide a decision-making aid in defining the strategic orientations of prevention policies.

Prediction of Iron Deficiency Anemia in Third Trimester of Pregnancy Based on Data in the First Trimester: A Prospective Cohort Study in a High-Income Country.

Background: Systematic iron supplementation may be harmful in pregnant women with non-depleted iron. Our objectives were to estimate the prevalence of anemia at the third trimester of pregnancy (T3) and to identify the parameters at the first trimester (T1), which best predict anemia at T3. Methods: This prospective cohort study in France included pregnant women at T1 without non-iron deficiency anemia. Clinical and social characteristics, health-related quality of life, blood count, and a frozen blood sample were collected at T1 and/or T3. Secondly, a matched nested case−control study was built for women with anemia at T3 but not at T1. Multivariate analyses and ROC curves were used to identify the best predictive parameter(s) of anemia at T3. Results: The prevalence of anemia at T3 in the cohort (629 women) was 21.9% (95% CI 18.7−25.2%). In the matched nested case−control study (256 women), hemoglobin (Hb), serum ferritin (SF) and the SF/soluble transferrin receptor ratio at T1 were predictive of anemia at T3 (p < 0.001); however, clinical and social characteristics, as serum hepcidin were not. In multivariate analyses, Hb at T1 was the best predictive biomarker of anemia at T3 with a cut-off value of 120 g/L (specificity 87.5%). Conclusions: The prevalence of anemia at the end of pregnancy remained high in a High-Income Country. Clinical, social, and biochemical parameters did not seem useful to predict anemia at T3 and could not guide iron supplementation. We suggest systematically performing a simple blood count in the first trimester of pregnancy and offering oral iron supplementation for women with Hb < 120 g/L.

Does the Quality of Postpartum Hemorrhage Local Protocols Improve the Identification and Management of Blood Loss after Vaginal Deliveries? A Multicenter Cohort Study.

Substandard care, which can result from a delayed recognition of the severity of blood loss, can increase maternal morbidity. Our objectives were to assess the incidence of postpartum hemorrhage (PPH) and of second-line procedures in maternity units according to the quality of their PPH protocol. We used a mixed design, a prospective cohort (3442 women with PPH after vaginal delivery; February−July 2011), and an audit of the written protocols (177 French maternity units; September 2010−June 2011). A quality score was calculated for the protocol of each unit. Maternity units were classified into three categories according to this score: category 1 (total score: 0−8), category 2 (9−12.5), and category 3 (>12.5). The PPH incidence (>500 mL) was 3.2%, 3.3% and 4.6% among maternity units in categories 1, 2 and 3, respectively (p < 0.0001). The incidence of severe maternal morbidity (surgery and/or artery embolization and/or blood transfusion) was higher among maternity units in category 1 (54.8%; 95% CI: 51.9, 57.7) than in either category 2 (50.1%; 95% CI: 47.8, 52.5) or 3 (38.0%; 95% CI: 33.8, 42.4]) (p < 0.0001). The risks of severe maternal morbidity were lower for category 3 than category 1 and 2 (respectively, adjusted RR 0.68, 95% CI 0.60−0.86 and 0.77, 95% CI 0.68−0.87). Finally, maternity units with higher scores identified PPH better and used fewer curative second-line procedures.

Handgrip strength as a valid practical tool to screen early-onset sarcopenia in acute care wards: a first evaluation.

BACKGROUND/OBJECTIVES: Sarcopenia is an age-related muscle disease associated with higher mortality, morbidity risk and health costs. An easy and convenient sarcopenia screening test would be hugely valuable for clinical critical care. The study aimed to assess handgrip strength (HGS) as a screening tool for sarcopenia in acute care-unit inpatients, using the EWGSOP 1 reference-standard definition. SUBJECTS/METHODS: Inpatients, aged 75 years old or above, of two acute care wards-a multidisciplinary care unit (MCU) and a geriatric care unit (GCU), were included between September 2017 and June 2018 in a cross-sectional study. HGS, sarcopenia, nutritional status, functional status, number of medications and sociodemographic data were collected. The accuracy of HGS as a screening test for sarcopenia was assessed by gender using receiver operating characteristic (ROC) curves and area under the curve (AUC) in a population of older patients (n = 223; age: 85.8 yrs; BMI: 26.7 kg/m²). RESULTS: Screening was positive (patients confirmed with sarcopenia by the HGS test) with cut-off values of 18 kg for women and 25.5 kg for men, with ROC analysis giving a sensitivity of 92.9% in women and 78.6% in men. ROC curve analysis found also that HGS should be strictly higher than 15 kg in women and 18 kg in men to maximise AUC. Prevalence of sarcopenia according to the EWGSOP1 definition was 31.8% (95% CI: 22.1-41.6%) in the MCU and 27.8% (95% CI: 19.6-36.0%) in the GCU. CONCLUSIONS: Acute care wards can use HGS as a valid, easy tool for early screening of sarcopenia.

Non-anemic iron deficiency: correlations between symptoms and iron status parameters.

OBJECTIVES: To register all symptoms reported by non-anemic menstruating women, and examine the links between these symptoms and iron status parameters available including serum ferritin (SF) in primary care. SUBJECTS AND METHODS: In this cross-sectional study, we collected clinical and biological data from 780 French menstruating women aged 18-50 years. The data included an anonymous questionnaire (biometric information, physical and cognitive symptoms, reduction in physical performance, current quality of life with SF-36 questionnaire) and seven biological parameters available in primary care. We excluded women with anemia (hemoglobin < 12 g/dl) or chronic disease. Correlations were studied for 554 participants in bivariate analysis (BVA) and multivariate analysis (MVA), with adjusted odds ratio (OR). Receiver operating characteristic (ROC) curves were established for significant correlations in MVA (p < 0.05). RESULTS: Among these 554 non-anemic women included, 304 (54.9%) had SF level below 50 µg/l, 103 (18.6%) had SF level below 20 µg/l, and 60 (10.8%) had SF level below 15 µg/l. Iron deficiency was significantly correlated with recent hair loss for SF ≤ 15 µg/l (OR = 2.19 with p = 0.02 in MVA) and SF ≤ 20 µg/l (OR = 2.26 with p < 0.01 in MVA). SF ≤ 20 µg/l was also correlated with limitations due to emotional problems according to SF-36 questionnaire (p = 0.01 in MVA). SF ≤ 50 µg/l was significantly correlated with restless legs syndrome (OR = 2.82 with p = 0.01 in MVA). Only one ROC curve for restless legs syndrome could suggest an optimal SF cut-off point at 39 µg/l (sensitivity 73%, specificity 61%). CONCLUSION: We identified two symptoms significantly more reported by non-anemic iron-deficient menstruating women: recent hair loss for serum ferritin (SF) ≤ 20 µg/l and restless legs syndrome for SF ≤ 50 µg/l. Non-anemic iron deficiency may also impact their quality of life, but further investigation is needed. If one of these symptoms is reported in primary care, the possibility of a symptomatic iron deficiency cannot be ruled out, and iron supplementation should be considered.

Highlighting the impact of social relationships on the propagation of respiratory viruses using percolation theory.

We develop a site-bond percolation model, called PERCOVID, in order to describe the time evolution of all epidemics propagating through respiratory tract or by skin contacts in human populations. This model is based on a network of social relationships representing interconnected households experiencing governmental non-pharmaceutical interventions. As a very first testing ground, we apply our model to the understanding of the dynamics of the COVID-19 pandemic in France from December 2019 up to December 2021. Our model shows the impact of lockdowns and curfews, as well as the influence of the progressive vaccination campaign in order to keep COVID-19 pandemic under the percolation threshold. We illustrate the role played by social interactions by comparing two typical scenarios with low or high strengths of social relationships as compared to France during the first wave in March 2020. We investigate finally the role played by the α and δ variants in the evolution of the epidemic in France till autumn 2021, paying particular attention to the essential role played by the vaccination. Our model predicts that the rise of the epidemic observed in July and August 2021 would not result in a new major epidemic wave in France.

The Forgotten Health-Care Occupations at Risk of Burnout-A Burnout, Job Demand-Control-Support, and Effort-Reward Imbalance Survey.

AIMS: We conducted a cross-sectional study on healthcare workers from the University Hospital in Clermont-Ferrand. They received a self-report questionnaire consisting of the Maslach Burnout Inventory, Job Demand Control Support, Effort-Reward Imbalance model, and questions about ethical conflict in order to investigate on burnout. RESULTS: We included 1774 workers. Overinvestment was the only factor explaining the increase in emotional exhaustion, depersonalization, and the decrease in personal accomplishment. Taking into account the absence of burnout as a reference, overinvestment multiplied the risk of high burnout by 22.0 (5.10 to 94.7). CONCLUSION: Some "forgotten" occupations among healthcare workers are at risk of burnout. Overinvestment was the main factor explaining the increase in the tree dimensions of burnout. Moreover, the two main models of stress at work were highly predictive of burnout.

[Student health representatives at university: Objectives, modalities, and evaluation]. / Les Étudiants Relais Santé à l'université : objectifs, modalités d'action et d'évaluation.

OBJECTIVES: The development of "Student Health Representatives" (ERS), based on the efficiency of prevention strategies among peers, is encouraged by University Health Services (SSU). And yet, the heterogeneity of the local contexts, as well as the lack of a national referential incites reflections as to the stakes, the key factors, and limits of these schemes. In this way, a national training day was organized to respond to the following objectives: What objective and what framework for student health representatives? Which student health representatives and what actions? What type of evaluation for student health representatives? METHOD: 61 university health service professionals (SSU) (32 nurses, 22 doctors, and 7 prevention specialists), representing 29 university health services met and worked on the question of student health representatives.This work on the ERS followed a process of formalized consensus, based on the Glaser technique (Fink 1984). Two workshops with 30 and 31 people were organized, each divided into three groups (six in total). The distribution of each group was decided beforehand, so that there were no more than two members of the same university health service. Each group worked on the following three points: the role of the ERS, student eligibility and definition of their role, and the evaluation of the ERS.A synthesis was drafted after this work of reflection. RESULTS: An analysis with proposed actions was produced for each of the themes. CONCLUSION: Even though the ERS must be reassessed and harmonized at the national level, the objectives, the framework, the themes, and the preventive action must respond to local health prerogatives, adapted to each university health policy.

The Early Impact of the COVID-19 Lockdown on Stress and Addictive Behaviors in an Alcohol-Consuming Student Population in France.

Background: This study evaluated factors linked with perceived stress related to the COVID-19 pandemic and lockdown and addictive behaviors prior to and during lockdown in a sample of students who indicated engaging in alcohol consumption behaviors before lockdown. Methods: Cross-sectional study. French students from four universities participated in this study, and 2,760 students reported alcohol use. During the first week of lockdown, students reported their perceived levels of stress regarding COVID-19. Substance use and addictive behaviors were reported before and during lockdown, and media exposure, demographical, living conditions, and environmental stressors were reported during lockdown. Results: Women reported greater levels of stress (95% CI: 1.18 to 1.93, p < 0.001). Highly-stressed students also report less social support (95% CI: -1.04 to -0.39, p < 0.001) and were more likely to worry about the lockdown (95% CI: 0.27 to -0.65, p < 0.001). Alcohol-related problemswere more prevalent among the most stressed students (95% CI: 0.02 to 0.09, p = 0.004) as well as eating problems (95% CI: 0.04 to 0.36, p = 0.016) and problematic internet use (95% CI, 0.06 to 0.14, p < 0.001). Students reporting the highest levels of stress also indicated more compulsive eating during the previous seven days (95% CI, 0.21 to 1.19, p = 0.005). Conclusions: The level of stress was strongly related to four categories of variables: (i) intrinsic characteristics, (ii) addictive behaviors before lockdown, (iii) lockdown-specific conditions, and (iv) addictive behaviors during the lockdown. Several variables linked to COVID-19 were not directly linked with perceived stress, while perceived stress was found to correlate with daily life organization-related uncertainty and anticipated consequences of lockdown. Importantly, social support seems to be a protective factor on high level of stress.

Modelling the determinants of health and cancers as perceived by children: using imagery as a mediator of expression and narration.

OBJECTIVES: To model and analyse conceptions of determinants of health and cancer that are expressed and perceived by school children aged 6-11 based on a multiphase qualitative protocol. METHODOLOGY: This is a multicentric, qualitative study of human and social sciences conducted among school children aged 6-11 years old. Two different tools were used, e.Photoexpression and Photonarration, in four French schools. This innovative and exploratory method addresses global health during the first phase (e.Photoexpression) and the theme of cancer during the second phase (Photonarration). The children express themselves through photography and narration. RESULTS: 1498 qualitative productions were made by 381 children aged 6-11 years old. The analysis of these productions of expression and narration through images allowed modelling of determinants of health and cancer as perceived by children through 7 fields and 28 categories. The conceptions of determinants of health and child cancer refer to rationalities that are centred on individual determinants (76%), minimise environmental determinants (20%) and conceal the parameters of access to healthcare and social services (3%). DISCUSSION: These findings provide new data to the international literature on children's perceptions of determinants of health and cancer. These research findings, which can be applied to interventions and current practices, will enable prevention workers to act more effectively, closer to children's perceptions and needs.

Nasopharyngeal swab-induced pain for SARS-CoV-2 screening: A randomised controlled trial of conventional and self-swabbing.

BACKGROUND: Massive screening campaigns for SARS-CoV-2 are currently carried out throughout the world, relying on reverse-transcriptase-polymerase chain reaction (RT-PCR) following nasopharyngeal swabbing performed by a healthcare professional. Yet, due to the apprehension of pain induced by nasopharyngeal probing, poor adhesion to those screening campaigns can be observed. To enhance voluntary participation and to avoid unnecessary exposition to SARS-CoV-2, self-swabbing could be proposed. To date, no data have been published concerning pain induced by conventional- or self-swabbing. Thus, the primary objective of the present study was to evaluate pain induced with the conventional swabbing method and compare it to self-swabbing. Secondary objectives focused on swabbing-induced discomfort and acceptability of the two methods. METHODS: The study was conducted in Clermont-Ferrand medical school (France). Overall, 190 students were randomised into two groups and experienced either self- or conventional-swabbing. Each subject had to rate pain, discomfort and acceptability of such swabbing on a 0-10 numeric rating scale. RESULTS: No significant difference was found between the two methods. The mean pain level was 2.5 ± 1.9, 28% rating pain as ≥4/10. Discomfort was 4.8 ± 2.2, 66% indicating significant (≥4/10) discomfort. Higher pain and discomfort were associated with female sex. Acceptability was ≥8/10 for 89.0% of the subjects and all would have accepted to undergo a new test with the same technique if necessary. CONCLUSION: Both conventional and self-swabbing induce low levels of pain for most young healthy volunteers whereas discomfort is very frequent. Nonetheless, both methods are indifferently well-accepted in medical students. Future studies amongst symptomatic subjects are awaited. SIGNIFICANCE: Using the thinnest available swabs, procedural pain induced by nasopharyngeal swabbing for SARS-CoV-2 screening is very low for most subjects and should not limit voluntary participation in screening campaigns. Self-swabbing does not lead to more pain or discomfort compared to conventional swabbing, is well-accepted, and could be proposed to optimize screening campaigns, at least in healthcare professionals.

Les Étudiants Relais Santé à l'université : objectifs, modalités d'action et d'évaluation.

OBJECTIVES: The development of "Student Health Representatives" (ERS), based on the efficiency of prevention strategies among peers, is encouraged by University Health Services (SSU). And yet, the heterogeneity of the local contexts, as well as the lack of a national referential incites reflections as to the stakes, the key factors, and limits of these schemes. In this way, a national training day was organized to respond to the following objectives: What objective and what framework for student health representatives? Which student health representatives and what actions? What type of evaluation for student health representatives? METHOD: 61 university health service professionals (SSU) (32 nurses, 22 doctors, and 7 prevention specialists), representing 29 university health services met and worked on the question of student health representatives.This work on the ERS followed a process of formalized consensus, based on the Glaser technique (Fink 1984). Two workshops with 30 and 31 people were organized, each divided into three groups (six in total). The distribution of each group was decided beforehand, so that there were no more than two members of the same university health service. Each group worked on the following three points: the role of the ERS, student eligibility and definition of their role, and the evaluation of the ERS.A synthesis was drafted after this work of reflection. RESULTS: An analysis with proposed actions was produced for each of the themes. CONCLUSION: Even though the ERS must be reassessed and harmonized at the national level, the objectives, the framework, the themes, and the preventive action must respond to local health prerogatives, adapted to each university health policy.

Burnout Among Hospital Non-Healthcare Staff: Influence of Job Demand-Control-Support, and Effort-Reward Imbalance.

OBJECTIVES: To study the prevalence of burnout among non-health care workers (NHCW), the risk and protective factors and to quantify the risk of burnout. METHOD: We conducted a cross-sectional study on the 3142 NHCW of the University Hospital of Clermont-Ferrand. They received a self-assessment questionnaire. RESULTS: Four hundred thirty seven (13.9%) NHCW completed the questionnaires. More than three quarter (75.4%) of NHCW was in burnout, with one in five (18.7%) having a severe burnout. Job demand was the main factor explaining the increase in exhaustion and overinvestment was the main factor explaining the increase in cynicism. Effort-reward imbalance (ERI) multiplied the risk of severe burnout by 11.2, job strain by 3.32 and isostrain by 3.74. CONCLUSION: NHCW from hospital staff are at high risk of burnout. The two major models of stress at work, the job demand-control-support and the ERI, were highly predictive of burnout, with strong dose-response relationships.

Hospital and Population-Based Evidence for COVID-19 Early Circulation in the East of France.

BACKGROUND: Understanding SARS-CoV-2 dynamics and transmission is a serious issue. Its propagation needs to be modeled and controlled. The Alsace region in the East of France has been among the first French COVID-19 clusters in 2020. METHODS: We confront evidence from three independent and retrospective sources: a population-based survey through internet, an analysis of the medical records from hospital emergency care services, and a review of medical biology laboratory data. We also check the role played in virus propagation by a large religious meeting that gathered over 2000 participants from all over France mid-February in Mulhouse. RESULTS: Our results suggest that SARS-CoV-2 was circulating several weeks before the first officially recognized case in Alsace on 26 February 2020 and the sanitary alert on 3 March 2020. The religious gathering seems to have played a role for secondary dissemination of the epidemic in France, but not in creating the local outbreak. CONCLUSIONS: Our results illustrate how the integration of data coming from multiple sources could help trigger an early alarm in the context of an emerging disease. Good information data systems, able to produce earlier alerts, could have avoided a general lockdown in France.

Analysis of the cost effectiveness of different strategies for the antenatal diagnosis of chromosomal aberrations in cases of ultrasound-identified fetal abnormalities.

OBJECTIVE: Principal objective of this work was to analyse the cost effectiveness of different sequences of cytogenetic techniques from the hospital's point of view, after prenatal ultrasound has identified fetal malformations. METHODS: Cytogenetic tests were performed for each case in 3 strategies, and their results are reported and compared to one reference strategy. Two new simulated strategies were considered: chromosomal microarrays alone and a direct test + CMA. MAIN OUTCOMES MEASURES: cost-effectiveness ratio. RESULTS: A single test result was positive in 234 of the 835 pregnancies studied (28%). CMA alone would have identified 239 abnormalities. In the simulated direct test + CMA sequence, the direct test alone would have been positive for 66.1% of the abnormalities identified. When testing was indicated for NT, reference strategy (Direct + karyotyping) costs 1 084.8 euros by positive test results. Strategies Direct + CMA and CMA alone cost respectively 992.7 and 550.0 euros by positive test results. For OUM indications, reference strategy costs 2 937.8 euros by positive test results. Strategies Direct + CMA and CMA alone cost respectively, 2 118.4 and 1 304.7 euros by positive test results. CONCLUSIONS: CMA appears to be the most effective test for prenatal cytogenetic diagnosis of fetal abnormalities identified by ultrasound.