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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Relevance of botulinum toxin injection and nerve block of rectus femoris to kinematic and functional parameters of stiff knee gait in hemiplegic adults.

Stiff knee gait (SKG) is common in hemiplegic patients. The main focus of treatment is rectus femoris (RF) spasticity. The aims of this study were to evaluate the effect of botulinum toxin injection (BTI) in the RF muscle on peak knee flexion during swing phase and its quantitative and functional impact on gait. We also wished to evaluate the correlation between the effects of nerve block and BTI on peak knee flexion. 10 adult hemiplegic subjects (>6 months post stroke or traumatic brain injury) with SKG and inappropriate RF EMG activity during mid-swing phase were included. 3D gait analysis, clinical and functional assessments (Timed Up and Go test, 10 m walk test, 6 min walk test and the time taken to ascend and descend a flight of stairs) were performed initially, 30 min after anaesthetic block of the RF nerve and one month post BTI. After BTI, there was a significant increase in knee flexion (8 degrees average) and a tendency towards improvement in gait and functional parameters. The effect of the nerve block on peak knee flexion was significantly correlated with the effect of BTI (11 degrees average increase in peak knee flexion after nerve block). We challenge the relevance of RF nerve blocks in this population when EMG and kinematic data are available. Our results indicate that BTI is an effective treatment for SKG in adult hemiplegic subjects, with a significant increase in peak knee flexion, no reduction in hip flexion and a tendency towards functional improvements.

Evaluation of a stair-climbing power wheelchair in 25 people with tetraplegia.

OBJECTIVE: To compare the performance of a power wheelchair with stair-climbing capability (TopChair) and a conventional power wheelchair (Storm3). DESIGN: A single-center, open-label study. SETTING: A physical medicine and rehabilitation hospital. PARTICIPANTS: Patients (N=25) who required power wheelchairs because of severe impairments affecting the upper and lower limbs. INTERVENTIONS: Indoor and outdoor driving trials with both devices. Curb-clearing and stair-climbing with TopChair. MAIN OUTCOME MEASURES: Trial duration and Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) tool; number of failures during driving trials and ability to climb curbs and stairs. RESULTS: All 25 participants successfully completed the outdoor and indoor trials with both wheelchairs. Although differences in times to trial completion were statistically significant, they were less than 10%. QUEST scores were significantly better with the Storm3 than the TopChair for weight (P=.001), dimension (P=.006), and effectiveness (P=.04). Of the 25 participants, 23 cleared a 20-cm curb without help, and 20 climbed up and down 6 steps. Most participants felt these specific capabilities of the TopChair--for example, curb clearing and stair climbing-were easy to use (22/25 for curb, 21/25 for stairs) and helpful (24/25 and 23/25). A few participants felt insecure (4/25 and 6/25, respectively). CONCLUSIONS: The TopChair is a promising mobility device that enables stair and curb climbing and warrants further study.

Analysis of discrepancies between external body examination and forensic autopsy.

At present in France, most of the medico-legal investigations are restricted to death scene investigation, which means there is only an external body examination without subsequent autopsy. The aim of our study was to show the limits of death scene investigation by establishing the rate of discrepancies between the results of external body examination and forensic autopsy.A retrospective study was carried out on 200 autopsy cases which were all preceded by death scene investigation and performed in 2002. For each case, age, sex, body weight, body state, place, and time of death were reported. The number of recent trauma lesions detectable at external body examination and at autopsy was studied. Conclusions about manner and cause of death between death scene investigation and autopsy were also studied. Discrepancy rate about interpretation of the lesions seen at external body examination and at autopsy was determined. Discrepancy between minor external trauma lesions and severe internal trauma lesions was also studied.The mean age of the studied population was 42.4 years. Sex ratio was 2.2. External body examination was limited by body state in 32% of the cases. The mean number of recent external trauma lesions recorded at autopsy was significantly higher than those recorded during death scene investigation. Manner and causes of death were undetermined after death scene investigation in 54.5% and 49% of the cases, respectively. When the cases were determined by death scene investigation, discrepancy rate, respectively, was 5% and 9% of all cases (n = 200) for manner and causes of death.Death scene investigation even carried out by a well-trained forensic physician is not reliable relative to cause and manner of death. Our study underlines the necessity in the future to perform more forensic autopsies in France, relying on the European harmonization of medico-legal autopsy rules.

Effect of beta-blockade on ascending aortic dilatation in children with the Marfan syndrome.

Aortic root dilatation is the principal life-threatening complication in Marfan syndrome, leading to aortic regurgitation, dissection, and rupture. Beta blockade slows aortic dilatation in adults, but there has been no definitive evidence in children. Therefore, the evolution of aortic diameter at the level of the sinuses of Valsalva in 155 children (82 males, 73 females) aged <12 years who had been diagnosed with Marfan syndrome according to international criteria was retrospectively studied. Affected children treated by beta blockade >or=1 time during their lives (n = 77, mean age at diagnosis 6.1 +/- 3.2 years) were compared with affected children who had never received beta blockers (n = 78; 42 males, mean age 7.4 +/- 5.2 years). A mean delay of 1.3 years was observed between diagnosis and the initiation of beta blockade in the treated group (mean age at initiation 7.5 years). At the time of diagnosis, aortic diameters were similar in the 2 groups, but after 1.3 years, aortic diameters were greater in the group of children in whom beta blockers had been initiated. On univariate analysis, aortic diameter was related to age and height, but not gender or familial history of aortic dissection. On multivariate analysis, treatment and age remained significant determinants of aortic diameter. Beta blockade significantly decreased the rate of aortic dilatation at the level of the sinuses of Valsalva by a mean of 0.16 mm/year (p <0.05), an effect that increased with treatment duration. A trend toward lower cardiac mortality, decreased need for preventive aortic surgery, and less dissection was observed. In conclusion, beta blockade appears to limit aortic dilatation during childhood in patients affected by Marfan syndrome. Therefore, this treatment should be recommended as soon as the diagnosis is made.

The comparability of bispectral index and state entropy index during maintenance of sufentanil-sevoflurane-nitrous oxide anesthesia.

BACKGROUND: Manufacturers recommend maintaining Bispectral (BIS) or Spectral Entropy (State Entropy, SE) indexes between 40 and 60 during the maintenance of anesthesia. We compared these indexes during this period. METHODS: Data were obtained from 58 patients receiving sufentanil-sevoflurane-nitrous oxide anesthesia. The anesthesiologist was blinded to BIS and SE. Artifact-free concurrent BIS and SE values (7792 pairs), automatically recorded at 1-min intervals, were compared using Bland-Altman analysis, Kappa coefficient for agreement and crude proportion of agreement. The occurrence of errors of judgment (Type 1 defined as one parameter <40 and the other >60, or Type 2 defined as BIS and SE values on different sides of a threshold [40 or 60]) was also counted. RESULTS: Bias was -2 with limits of agreement of -18 and 9. Kappa BIS/SE obtained from all patients was 0.537 +/- 0.147; crude agreement >0.80 was observed in 45% of patients. Type 1 number of errors of judgment corresponded to two instances. Median and interquartile values of Type 2 number of errors of judgment were 4.5 [3.0-6.0] when considering a difference between BIS and SE more than 5. CONCLUSION: Although limits of agreement between BIS and SE were large, Kappa value moderate, and crude agreement <0.80 in more than half of the patients, making completely contradictory decisions (e.g., deepening the anesthetic based on one parameter and lightening it based upon the other) would have been exceptional. More common would have been a risk of error between no change versus increasing or decreasing anesthetic depth.

Cetuximab efficacy in patients treated routinely in university hospitals.

INTRODUCTION: The aim of this study was to evaluate the efficacy and tolerance of cetuximab (Cx) in patients with irinotecan-refractory metastatic colorectal cancer (IRMCRC) treated routinely at five university hospitals. PATIENTS AND METHODS: Data from all patients treated with Cx (N=105) during the study period (between January 2004 and September 2005) were included in the analysis. RESULTS: Median number of Cx infusions was 12 (range: 1 to 62). Objective response rate was 24.8%; stable disease in 23.8%; progression in 34.3%; 17.1% of the patients were not evaluable. Digestive and hematological adverse events were grade III in 20% and 12%, respectively, and grade IV in 12% and 11%, respectively. Response rates were higher in patients with acne-like rashes than in patients without (P=0.005). Median time to tumor progression (TTP; intention-to-treat) was 3.9 months (95% CI: 2.6-4.8). Median overall survival after Cx initiation was 8.3 months (95% CI: 6.310.7). Four prognostic factors were significantly associated with a shorter TTP: center (Center 4: HR=2.25, 95% CI: 1.16-4.35, P=0.017); absence of hepatic metastases (HR=2.5, 95% CI: 1.434.37, P=0.001); WHO performance status (HR=1.47, 95% CI: 1.10-1.96, P=0.008); and number of metastatic sites (HR=1.30, 95% CI: 1.05-1.60, P=0.014). CONCLUSION: This analysis of a random population of IRMCRC patients supports Cx efficacy and feasibility, and is in agreement with the results of the BOND study.

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

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

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

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

Cough determinants in patients with neuromuscular disease.

Neuromuscular disease leads to cough impairment. Cough augmentation can be achieved by mechanical insufflation (MI) or manually assisted coughing (MAC). Many studies have compared these two methods, but few have evaluated them in combination. In 155 neuromuscular patients, we assessed determinants of peak cough flow (PCF) using stepwise correlation. Maximal inspiratory capacity contributed 44% of the variance (p<0.001), expiratory reserve volume 13%, and maximal expiratory pressure 2%. Thus, augmenting inspiration seems crucial. However, parameters dependent on expiratory muscles independently influence PCF. We measured vital capacity and PCF in 10 neuromuscular patients during cough augmentation by MI, MAC, or both. MI or MAC significantly improved VC and PCF (p<0.01) as compared to the basal condition and VC and PCF were higher during MI plus MAC than during MAC or MI alone (p<0.01). In conclusion, combining MAC and MI is useful for improving cough in neuromuscular patients.