Ultra rapid lispro improves postprandial glucose control compared with lispro in patients with type 1 diabetes: Results from the 26-week PRONTO-T1D study.

AIMS: To evaluate the efficacy and safety of ultra rapid lispro (URLi) versus lispro in adults with type 1 diabetes in a 26-week, treat-to-target, phase 3 trial. MATERIALS AND METHODS: After an 8-week lead-in to optimize basal insulin glargine or degludec, patients were randomized to double-blind mealtime URLi (n = 451) or lispro (n = 442), or open-label post-meal URLi (n = 329). The primary endpoint was change from baseline glycated haemoglobin (HbA1c) to 26 weeks (non-inferiority margin 0.4%), with multiplicity-adjusted objectives for postprandial glucose (PPG) excursions after a meal test. RESULTS: Both mealtime and post-meal URLi demonstrated non-inferiority to lispro for HbA1c: estimated treatment difference (ETD) for mealtime URLi -0.08% [95% confidence interval (CI) -0.16, 0.00] and for post-meal URLi +0.13% (95% CI 0.04, 0.22), with a significantly higher endpoint HbA1c for post-meal URLi versus lispro (P = 0.003). Mealtime URLi was superior to lispro in reducing 1- and 2-hour PPG excursions during the meal test: ETD -1.55 mmol/L (95% CI -1.96, -1.14) at 1 hour and - 1.73 mmol/L (95% CI -2.28, -1.18) at 2 hours (both P < 0.001). The rate and incidence of severe, documented and postprandial hypoglycaemia (<3.0 mmol/L) was similar between treatments, but mealtime URLi demonstrated a 37% lower rate in the period >4 hours after meals (P = 0.013). Injection site reactions were reported by 2.9% of patients on mealtime URLi, 2.4% on post-meal URLi, and 0.2% on lispro. Overall, the incidence of treatment-emergent adverse events was similar between treatments. CONCLUSIONS: The results showed that URLi provided good glycaemic control, with non-inferiority to lispro confirmed for both mealtime and post-meal URLi, while superior PPG control was demonstrated with mealtime dosing.

Mindfulness based stress reduction (MBSR(BC)) in breast cancer: evaluating fear of recurrence (FOR) as a mediator of psychological and physical symptoms in a randomized control trial (RCT).

To investigate the mechanism(s) of action of mindfulness based stress reduction (MBSR(BC)) including reductions in fear of recurrence and other potential mediators. Eighty-two post-treatment breast cancer survivors (stages 0-III) were randomly assigned to a 6-week MBSR(BC) program (n = 40) or to usual care group (UC) (n = 42). Psychological and physical variables were assessed as potential mediators at baseline and at 6 weeks. MBSR(BC) compared to UC experienced favorable changes for five potential mediators: (1) change in fear of recurrence problems mediated the effect of MBSR(BC) on 6-week change in perceived stress (z = 2.12, p = 0.03) and state anxiety (z = 2.03, p = 0.04); and (2) change in physical functioning mediated the effect of MBSR(BC) on 6-week change in perceived stress (z = 2.27, p = 0.02) and trait anxiety (z = 1.98, p = 0.05). MBSR(BC) reduces fear of recurrence and improves physical functioning which reduces perceived stress and anxiety. Findings support the beneficial effects of MBSR(BC) and provide insight into the possible cognitive mechanism of action.

Lead contamination in French children's homes and environment.

Lead in homes is a well-known source of childhood lead exposure, which is still of concern due to the health effects of low lead doses. This study aims to describe lead contamination in the homes of children aged 6 months to 6 years in France (without overseas). Between October 2008 and August 2009, 484 housing units were investigated. Lead in tap water and total and leachable lead levels from floor dust, outdoor soils and paint chips were measured. X-ray fluorescence measurements were carried out on non-metallic and metallic substrates. Nationwide results are provided. The indoor floor dust lead (PbD) geometric mean (GM) was 8.8 µg/m² (0.8 µg/ft²) and 6.8 µg/m² (0.6 µg/ft²) for total and leachable lead respectively; 0.21% of homes had an indoor PbD loading above 430.5 µg/m² (40 µg/ft²). The outdoor play area concentration GM was 33.5 mg/kg and 21.7 mg/kg in total and leachable lead respectively; 1.4% of concentrations were higher than or equal to 400 mg/kg. Outdoor floor PbD GM was 44.4 µg/m² (4.1 µg/ft²) that was approximately 3.2 times higher than the GM of indoor PbD. Lead-based paint (LBP) was present in 25% of dwellings, LBP on only non-metallic substrates was present in 19% of homes and on metallic substrates in 10% of dwellings. The GM of lead concentrations in tap water was below 1 µg/L; 58% of concentrations were lower than 1 µg/L and 2.9% were higher than or equal to 10 µg/L. The age cut-off for homes with lead would be 1974 for paint and 1993 for indoor floor dust. This study provides, for the first time, a look at the state of lead contamination to which children are exposed in French housing. Moreover, it provides policy makers an estimate of the number of French dwellings sheltering children where abatement should be conducted.

Intra-articular Fracture at the Base of the Proximal Phalanx in the Index Finger Following a Punching Mechanism in a Patient with an Ipsilateral Ulnar Claw Deformity: A Case Report.

Introduction: Altercations involving punching forces constitute 18.5% of all hand injuries. Intra-articular proximal phalanx base fractures of the index finger only account for 0.5% of all hand fractures. There is a paucity of ulnar claw deformities discussed in the literature, likely because ulnar neuropathies rarely remain untreated long enough to progress to deformity. We present the first reported case of a chronic ulnar claw deformity leading to an uncommon finger fracture pattern through an altered punching mechanism. Case Report: A 62-year-old right-hand dominant male who presented to the emergency department for a behavioral health examination was found to have an intra-articular fracture at the base of the proximal phalanx in the left index finger. This occurred secondary to an altered punching mechanism influenced by an existing ulnar claw deformity. Radiographs of the left hand revealed a simple, non-angulated, and minimally displaced oblique fracture at the base of the proximal phalanx. Diffuse edema and ecchymosis of the index finger and gross hypothenar, intrinsic, and adductor pollicis muscle atrophy were observed. A single source of ulnar clawing could not be elicited on the clinical examination alone. Management involving non-operative treatment with buddy-tape and non-weight bearing for 2 weeks was instituted. The patient did not follow-up with orthopedics for repeat evaluation. Conclusion: This case demonstrates a unique fracture that likely occurred due to altered punching biomechanics from an ulnar claw deformity. The authors recommend that clinicians use their best judgment when comparing clinical findings to seemingly benign imaging studies. Early immobilization is crucial to prevent collapse and surgical intervention of intra-articular phalangeal fractures.

A Review of Pediatric Distal Radius Buckle Fractures and the Current Understanding of Angled Buckle Fractures.

Distal radius buckle fractures (DRBFs) are the most common pediatric fractures and resemble the rounded portion of a Greek pillar or torus. They result from compressive forces applied to a child's highly plastic radius. DRBFs lack cortical and physeal disruption, which makes them relatively stable. In this review, we discuss angled DRBFs, a hypothesized subset of buckle fractures that results from an off-center compressive force. Some authors refute the existence of angled DRBFs, instead proposing new criteria for DRBF classification: measuring more than 1 cm away from the physis with two to three inflection points. Without universal diagnostic criteria, misdiagnosis is common, and the utilization of flexible treatment modalities is infrequent. Rigid immobilization with short-arm casting continues to be the mainstay of treatment in clinical practice. Yet, new protocols implementing removable elastic bandages have had comparable results to casting, including reduced healthcare expenditure, less stiffness, and improved convenience and patient tolerability. Despite the discrepancies in categorizing DRBFs, complication rates remain low, and diagnostic confusion insignificantly affects clinical outcomes. Angled DRBFs have been theorized to have intraphyseal extension, making them unstable Salter-Harris fractures. Radiographic evidence supporting or denying this claim is limited. Further research is essential to determine the stability of the angled DRBF subtype and whether they should continue to be defined and managed as buckle fractures.

Effects of Cervical Spine Exercise Protocol on Neck Pain, Pericervical Muscle Endurance, and Range of Motion in Medical Students: A Prospective Study.

Introduction Neck pain is a common and debilitating ailment that places a significant burden on the healthcare system. No practical protocols have been published utilizing a portable, commercially available, and affordable device that significantly reduces acute and chronic neck pain. Methods Forty-six young adults with or without mild-to-moderate neck pain completed a six-week neck stretching and strengthening protocol with a portable cervical stretching and strengthening device. The primary outcome was changes to pericervical muscle endurance. Secondary outcomes were changes to cervical range of motion (ROM), neck length, circumference, and subjective pain, flexibility, and strength. Measurements were obtained on study days 0, 21, and 42. Results A significant increase in pericervical muscle endurance was demonstrated across all planes of cervical motion, ranging from 84% to 105%. Cervical ROM improved across all planes of motion but was only significant in right-side bending (5.3°), left rotation (6.2°), and right rotation (7.8°). Subjective pain evaluated via the Numeric Rating Scale (NRS) saw statistically significant improvement as well (1.33 to 0.51). Subjective assessment of participant cervical pain, strength, and flexibility improved 61.3%, 95.7%, and 97.8%, respectively. Conclusions A six-week pericervical muscle stretching and strengthening program increased pericervical endurance and ROM in young adults. Decreased cervical pain was seen using the NRS and modified pain scale across most participants.

Identification of sources of lead exposure in French children by lead isotope analysis: a cross-sectional study.

BACKGROUND: The amount of lead in the environment has decreased significantly in recent years, and so did exposure. However, there is no known safe exposure level and, therefore, the exposure of children to lead, although low, remains a major public health issue. With the lower levels of exposure, it is becoming more difficult to identify lead sources and new approaches may be required for preventive action. This study assessed the usefulness of lead isotope ratios for identifying sources of lead using data from a nationwide sample of French children aged from six months to six years with blood lead levels ≥25 µg/L. METHODS: Blood samples were taken from 125 children, representing about 600,000 French children; environmental samples were taken from their homes and personal information was collected. Lead isotope ratios were determined using quadrupole ICP-MS (inductively coupled plasma - mass spectrometry) and the isotopic signatures of potential sources of exposure were matched with those of blood in order to identify the most likely sources. RESULTS: In addition to the interpretation of lead concentrations, lead isotope ratios were potentially of use for 57% of children aged from six months to six years with blood lead level ≥ 25 µg/L (7% of overall children in France, about 332,000 children), with at least one potential source of lead and sufficiently well discriminated lead isotope ratios. Lead isotope ratios revealed a single suspected source of exposure for 32% of the subjects and were able to eliminate at least one unlikely source of exposure for 30% of the children. CONCLUSIONS: In France, lead isotope ratios could provide valuable additional information in about a third of routine environmental investigations.

Non-alcoholic Steatohepatitis: From Pathophysiology to Clinical Practice.

Non-alcoholic steatohepatitis (NASH) is becoming a global disease with significant associated comorbidities. To date, there are no commercialized drugs to treat NASH, outside of India; however, there is an abundance of new molecular entities which are in clinical development, some in phase III trials. Many of these trials have created an especially heavy demand for USA-based subjects. Hepatologists currently play a major role in the diagnosis, treatment and clinical-trial enrolment of patients with NASH. However, NASH has a strong metabolic component, with patients often carrying comorbid diseases, such as type 2 diabetes mellitus, obesity, hyperlipidaemia, hypothyroidism and sex steroid disorders. The primary care physician, internist and endocrinologist stand at a pivotal position in the NASH healthcare delivery system, as many of the diseases they commonly encounter are associated with a higher risk of developing NASH. Specialty society practice guidelines are evolving regarding the identification and care of patients with NASH. This review of the literature, and assessment of IQVIA's proprietary patient claims database of diagnosis codes, patient encounters and treatments, substantiates the importance of the primary care provider and endocrinologist in the clinical care and clinical research of patients with NASH.

Minimally Invasive Robot-Guided Dual Cortical Bone Trajectory for Adjacent Segment Disease.

Here we present a novel application of cortical bone trajectory (CBT) fixation utilizing robotic guidance in a previously instrumented spine with a traditional pedicle screw (PS), obviating the need for a larger posterior incision, reducing the risk of infection, muscular dissection, and likely decreasing hospital length of stay. A 60-year-old woman with prior left L3-L4 extreme lateral interbody fusion and unilateral percutaneous PS placed at L3 to L5 presented with progressive bilateral lower-extremity pain and diminished sensation in the S1 dermatome secondary to adjacent segment disease (ASD). The patient underwent an L5-S1 anterior lumbar interbody fusion for indirect decompression and restoration of segmental lordosis. After the first stage was completed, she was turned prone for posterior percutaneous instrumentation. Given prior instrumentation at L3-L5 on the left side, a robot planning software was used to plan a cortical bone screw on the left L5 pedicle. A left S1 PS was then planned with the screw head aligning with the left L5 cortical bone screw. Instrumentation was then placed percutaneously using the robot bilaterally without issue. Intraoperative fluoroscopic imaging demonstrated accurate placement of PS, and postoperative computed tomography demonstrated the excellent positioning of all PSs. This report is the first documented case of a robotically placed CBT screw placed in the same pedicle as a prior traditional PS for ASD. This method expands the surgical options for ASD to include robotic percutaneous placement of posterior instrumentation at the same level as previous instrumentation.

Assessment of Rod Material Types in Spine Surgery Outcomes: A Systematic Review.

BACKGROUND: Lumbar spine fusion surgery is traditionally performed with rigid fixation. Because the rigidity is often supraphysiologic, semirigid rods were developed. To the best of our knowledge, a comprehensive evaluation of rod material type on surgical outcomes has yet to be conducted. METHODS: A systematic review based on PRISMA guidelines was conducted across 3 electronic databases. After examination for inclusion and exclusion criteria, data were extracted from the studies. RESULTS: Seventeen studies, including 1399 patients, were included in this review. The mean rigid rod fusion rate is 92.2% and 95.5% for semirigid rods (P = 0.129). The mean improvement in back pain was 60.6% in rigid rods and 71.6% in semirigid rods. The improvement in leg pain was 81.9% and 77.2%, respectively. There were no differences in visual analog scale back pain score (P = 0.098), visual analog scale leg pain score (P = 0.136), or in functional improvement between rigid and semirigid rods (P = 0.143). There was no difference (P = 0.209) in the reoperation rate between rigid rods (13.1%) and semirigid rods (6.5%). There was a comparable incidence of adjacent segment disease (3%), screw fracture (1.7%), and wound infection (1.9%) between rod material types. CONCLUSIONS: There is a moderate level of evidence supporting that surgical intervention results in high fusion rates regardless of rod material type. Surgical intervention improves back pain, leg pain, and function, with neither material type showing clear superiority. There are comparable rates of reoperation, development of adjacent segment disease, development of mechanical complications, and incidence of infection in both rigid and semirigid rods. Further studies regarding rod material type are warranted.

Kinetics study of the solid-state acid hydrolysis of chitosan: evolution of the crystallinity and macromolecular structure.

The heterogeneous hydrolysis of fully deacetylated chitosan solid samples was carried out with concentrated HCl. The hydrolysis kinetics was studied at different temperatures and HCl concentrations. From 5 to 50 degrees C in the hydrolysis time range up to 50 h, a monomodal distribution of molecular weights was observed connected to the only degradation of amorphous domains. Between 70 and 90 degrees C and for the hydrolysis longest times, a multimodal distribution appeared with the additional hydrolysis of the crystalline phase. The crystallinity index increased from 57 to 73% with the elimination and partial recrystallization of amorphous regions. X-ray diffraction patterns revealed the presence of the anhydrous polymorph, absent in the starting materials only containing the hydrated polymorph. The apparent crystallite width (from the Scherrer equation) of both the anhydrous and hydrated allomorphs did not vary significantly with time despite the increase in the fraction of anhydrous allomorph. Therefore, the hydrolysis in the solid state was complex, revealing several regimes. The activation energy parameters were deduced, and the mechanisms were discussed.

Coexistence of Brachial Plexus-Anterior Scalene and Sciatic Nerve-Piriformis Variants.

The trunks of the brachial plexus typically pass through the interscalene triangle, between the anterior and middle scalene muscles and superior to the first rib. Likewise, the two components of the sciatic nerve, tibial and common fibular nerves, usually join and pass together inferior to the piriformis muscle. We present a cadaver with anatomic variations of both the right brachial plexus-interscalene triangle relationship and the sciatic nerve-piriformis relationship. The right brachial plexus C5 and C6 roots formed the superior trunk as they passed through a bifurcated anterior scalene muscle, while the C7, C8, and T1 roots passed posterior to the anterior scalene. After passing through the left greater sciatic foramen, the sciatic nerve branched into the common fibular and tibial nerves, which passed through and inferior to the piriformis muscle, respectively. The presence of these anatomic variations may predispose individuals to symptomatic nerve entrapments such as thoracic outlet syndrome and piriformis syndrome. This finding is relevant to clinicians performing invasive procedures and diagnosing neurological conditions.

Acquired Diverticulosis of the Entire Colon in a Cadaver.

Diverticulosis involving the entire colon is rare in Western society. During a routine dissection of a 74-year-old Caucasian female cadaver, who died from vascular disease complications, diverticula were observed in the ascending, transverse, and descending colon. A total of 413 diverticula were manually counted. The majority of diverticula arose from the right and transverse colon, which is atypical of the disease in Western society. Histological examination of sections from sample diverticula reveals morphology consistent with pseudodiverticula, suggestive of acquired disease. Pancolonic diverticulosis may be associated with systemic diseases such as collagen disorders, vascular complications, and increased risk of recurrent diverticulitis. This case is an example of a rare manifestation of diverticular disease that is important for clinicians to recognize when evaluating and treating patients with gastrointestinal symptoms.

Mechanisms involved during the ultrasonically induced depolymerization of chitosan: characterization and control.

The existence of two mechanisms involved in the ultrasonically induced depolymerization of chitosan is evidenced. The first leads to a rapid scission of polymer chains and a lowering of the polydispersity, and the second is responsible for obtaining short polymer chains and oligomers with a polydispersity increase. A systematic experimental study allowed us to identify and quantify the main parameters influencing the chain scission kinetics. Consequently, using a "master curve" approach, a general law of variation of the molecular weight during the depolymerization is proposed. This law can be used in various experimental conditions to easily control the production of chitosan chains of precise length and low polydispersity or a collection of chito-oligosaccharides (COS). Characterization of the latter by (1)H NMR and MALDI-TOF mass spectrometry shows their high purity and an unchanged primary structure.

Pseudo-dry-spinning of chitosan.

A pseudo-dry-spinning process of chitosan without any use of organic solvent or cross-linking agent was studied. A highly deacetylated chitosan (degree of acetylation=2.7%) from squid-pens, with a high weight-average molecular weight (M(W)=540,000 g/mol) was used. The polymer was dissolved in an acetic acid aqueous solution in order to obtain a polymer concentration of 2.4% w/w with a stoichiometric protonation of the -NH(2) sites. The coagulation method consisted of subjecting the extruded monofilament to gaseous ammonia. The alkaline coagulation bath classically used in a wet-spinning process was therefore not useful. A second innovation dealt with the absence of any aqueous washing bath after coagulation. The gaseous coagulation was then directly followed by a drying step under hot air. When the chitosan monofilament coagulated in the presence of ammonia gas, ammonium acetate produced with the fiber could be hydrolyzed into acetic acid and ammonia, easily eliminated in their gaseous form during drying. The pseudo-dry-spinning process did not give rise to any strong degradation of polymer chains. After 2 months at ambient atmosphere, chitosan fibers could then be stored without any significant decrease in the M(W), which remained at a rather high value of 350,000 g/mol. The obtained chitosan fibers showed a smooth, regular and uniformly striated surface.

Exposure of children to metals via tap water ingestion at home: Contamination and exposure data from a nationwide survey in France.

29 inorganic compounds (Al, As, B, Ba, Be, Bi, Ca, Cd, Ce, Co, Cr, Cu, Fe, Gd, K, Mg, Mn, Mo, Na, Nd, Ni, Pb, Sb, Se, Sr, Tl, U, V and Zn) were measured in the tap water of 484 representative homes of children aged 6months to 6years in metropolitan France in 2008-2009. Parents were asked whether their children consumed tap water. Sampling design and sampling weights were taken into account to estimate element concentrations in tap water supplied to the 3,581,991 homes of 4,923,058 children aged 6months to 6years. Median and 95th percentiles of concentrations in tap water were in µg/L: Al: <10, 48.3, As: 0.2, 2.1; B: <100, 100; Ba: 30.7, 149.4; Ca: 85,000, 121,700; Cd: <0.5, <0.5; Ce: <0.5, <0.5; Co: <0.5, 0.8; Cr: <5, <5; Cu: 70, 720; K: 2210, 6740; Fe: <20, 46; Mn: <5, <5; Mo: <0.5, 1.5; Na: 14,500, 66,800; Ni: <2, 10.2; Mg: 6500, 21,200; Pb: <1, 5.4; Sb: <0.5, <0.5; Se: <1, 6.7; Sr: 256.9, 1004; Tl: <0.5, <0.5; U: <0.5, 2.4; V: <1, 1; Zn: 53, 208. Of the 2,977,123 young children drinking tap water in France, some were drinking water having concentrations above the 2011 World Health Organization drinking-water quality guidelines: respectively 498 (CI 95%: 0-1484) over 700µg/L of Ba; 121,581 (CI 95%: 7091-236,070) over 50mg/L of Na; 2044 (CI 95%: 0-6132) over 70µg/L of Ni, and 78,466 (17,171-139,761) over 10µg/L of Pb. Since it is representative, this tap water contamination data can be used for integrated exposure assessment, in conjunction with diet and environmental (dust and soil) exposure data.

Environmental and dietary exposure of young children to inorganic trace elements.

Children are exposed to toxic metals and metalloids via their diet and environment. Our objective was to assess the aggregate chronic exposure of children aged 3-6years, living in France, to As, Cd, Cr, Cu, Mn, Pb, Sb, Sr, and V present in diet, tap water, air, soil and floor dust in the years 2007-2009. Dietary data came from the French Total Diet Study, while concentrations in residential tap water, soil and indoor floor dust came from the 'Plomb-Habitat' nationwide representative survey on children's lead exposure at home. Indoor air concentrations were assumed to be equal to outdoor air concentrations, which were retrieved from regulatory measurements networks. Human exposure factors were retrieved from literature. Data were combined with Monte Carlo simulations. Median exposures were 1.7, 0.3, 10.2, 34.1, 60.3, 0.7, 0.1, 44.3, 1.5 and 95th percentiles were 4.4, 0.5, 15.8, 61.3, 98.3, 2.5, 0.1, 111.1, 2.9µg/kgbw/d for As, Cd, Cr, Cu, Mn, Pb, Sb, Sr, and V respectively. Dietary exposures dominate aggregate exposures, with the notable exception of Pb - for which soils and indoor floor dust ingestion contribute most at the 95th percentile. The strengths of this study are that it aggregates exposures that are often estimated separately, and uses a large amount of representative data. This assessment is limited to main diet and residential exposure, and does not take into account the relative bioavailability of compounds. These results could be used to help target prevention strategies.

Preseason Perceived Physical Capability and Previous Injury.

CONTEXT: Patient opinion about the ability to perform athletic maneuvers is important after injury; however, prospective assessment of self-perceived physical capability for athletes before the beginning of a season is lacking. OBJECTIVE: To perform a descriptive analysis of knee, shoulder, and elbow self-perceived measures of physical capability specific to athletics and to compare the measures between athletes with and without a history of injury. DESIGN: Cross-sectional study. SETTING: Preparticipation physical examinations. PATIENTS OR OTHER PARTICIPANTS: A total of 738 collegiate athletes (486 men, 251 women; age = 19 ± 1 years) were administered questionnaires after receiving medical clearance to participate in their sports. Of those athletes, 350 reported a history of injury. MAIN OUTCOME MEASURE(S): Athletes self-reported a history of knee, shoulder, or elbow injury. Perceived physical capability of the 3 joints was evaluated using the Knee Injury and Osteoarthritis Outcome Score Sport and Recreation Function and Knee-Related Quality of Life subscales and the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score. We conducted nonparametric analysis to determine if scores differed between athletes with and without a history of injury. RESULTS: Median values for the Knee Injury and Osteoarthritis Outcome Score Sports and Recreation Function and Knee-Related Quality of Life subscales and the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score for all athletes were 100. Median values for perceived physical capability of athletes with a history of injury were 3 to 12 points lower for each questionnaire before the start of the season (P < .001). CONCLUSIONS: Our study provided descriptive values for individual perceived knee, shoulder, and elbow physical capability of collegiate athletes participating in 19 sports. Athletes who did not report previous injuries perceived their physical capabilities to be nearly perfect, which could set the goal for these athletes to return to participation after injury. Athletes reporting previous injuries perceived less physical capability before the competitive season. Self-assessment of joint-specific capability may supplement preseason physical examinations, identifying particular athletes needing further monitoring or care during a season.

Environmental determinants of different blood lead levels in children: a quantile analysis from a nationwide survey.

Blood lead levels (BLLs) have substantially decreased in recent decades in children in France. However, further reducing exposure is a public health goal because there is no clear toxicological threshold. The identification of the environmental determinants of BLLs as well as risk factors associated with high BLLs is important to update prevention strategies. We aimed to estimate the contribution of environmental sources of lead to different BLLs in children in France. We enrolled 484 children aged from 6months to 6years, in a nationwide cross-sectional survey in 2008-2009. We measured lead concentrations in blood and environmental samples (water, soils, household settled dusts, paints, cosmetics and traditional cookware). We performed two models: a multivariate generalized additive model on the geometric mean (GM), and a quantile regression model on the 10th, 25th, 50th, 75th and 90th quantile of BLLs. The GM of BLLs was 13.8µg/L (=1.38µg/dL) (95% confidence intervals (CI): 12.7-14.9) and the 90th quantile was 25.7µg/L (CI: 24.2-29.5). Household and common area dust, tap water, interior paint, ceramic cookware, traditional cosmetics, playground soil and dust, and environmental tobacco smoke were associated with the GM of BLLs. Household dust and tap water made the largest contributions to both the GM and the 90th quantile of BLLs. The concentration of lead in dust was positively correlated with all quantiles of BLLs even at low concentrations. Lead concentrations in tap water above 5µg/L were also positively correlated with the GM, 75th and 90th quantiles of BLLs in children drinking tap water. Preventative actions must target household settled dust and tap water to reduce the BLLs of children in France. The use of traditional cosmetics should be avoided whereas ceramic cookware should be limited to decorative purposes.

Source contributions of lead in residential floor dust and within-home variability of dust lead loading.

Evidence of the impact of exposure to low levels of lead on children's health is increasing. Residential floor dust is the assumed origin of lead exposure by young children. In this study, we estimate the contribution of different lead sources to household interior floor dust contamination. We also estimate the within-home variability of interior floor dust lead loadings. A multilevel model was developed based on data collected in a French survey in 2008-2009 (484 housing units, 1834 rooms). Missing data were handled by multiple imputation using chained equations. The intra-home correlation between interior floor Log dust lead loadings was approximately 0.6. Dust lead from the landing of an apartment, mostly originating outside the building, was the major contributor to interior floor dust lead. Secondary contributors included the lead-based paint on exterior railings, track-in of the exterior soil of the children's play area into the dwelling, smoking inside the home, demolition of nearby old buildings and sites of pollution in the vicinity. Interior lead-based paint contaminated interior floor dust only in old and non-renovated dwellings. To reduce interior floor dust lead levels in the general population of dwellings, common areas should be maintained, and track-in from the outside should be limited as much as possible.