How to Assess Executive Functions in a Low-Educated and Multicultural Population Using a Switching Verbal Fluency Test (the TFA-93) in Neurodegenerative Diseases?

Few neuropsychological tests are available to assess executive dysfunction in low-educated and multicultural populations. To address this issue, the TFA-93, a switching verbal fluency test to assess cognitive flexibility, was administered to 70 healthy controls, 57 patients with a clinical diagnosis of Alzheimer's disease, and 21 with a clinical diagnosis of a neurodegenerative disease associated with frontal disorders. Most of the participants were low-educated and nonnative French speakers. The TFA-93 comprises 2 categorical fluency tasks (animals and fruits) and a fluency task in which participants have to switch between animals and fruits. Correct responses and errors were collected, and a flexibility index expressed the switching cost. Results showed that correct responses were lower, and the switching cost was greater in both patient groups. In low-educated and multicultural populations, the TFA-93 seems to be a good alternative to assess flexibility compared to the standard neuropsychological tools based on academic abilities.

The TMA-93: A New Memory Test for Alzheimer's Disease in Illiterate and Less Educated People.

The present study aimed at validating the Memory Associative Test of the district of Seine-Saint-Denis (TMA)-93, a new test of episodic memory. The TMA-93 was proposed to mostly less educated and multicultural elderly population composed of 376 healthy controls (HC) and 94 patients with Alzheimer's disease (AD). The construct validity was checked by studying correlations with a widely used memory test (the Free and Cued Selective Reminding Test [FCSRT]) in the subsample of literate patients. Results showed that (i) all the TMA-93 scores of the patients with AD were lower than those of the HC, (ii) the TMA-93 total score identified patients with AD with a high sensitivity (88%) and very high specificity (97%), and (iii) the TMA-93 total score was strongly correlated with both free recall and total recall scores of the FCSRT. Taken together, results showed that the TMA-93 is a reliable tool to assess episodic memory in a multicultural, less educated, or illiterate population, with good construct validity for AD diagnostic accuracy.

Concomitant screening for liver fibrosis and steatosis in French type 2 diabetic patients using Fibroscan.

BACKGROUND: Type 2 diabetes is a risk factor for steatohepatitis and fibrosis. Non-invasive liver stiffness (LS) and controlled attenuation parameter (CAP) measurements by Fibroscan allow assessing liver fat and fibrosis. AIM: To determine the prevalence of steatosis and significant fibrosis in a community-based diabetic population. METHODS: LS and CAP were measured in 705 patients using the standard "M probe." A second "XL probe" was used, without CAP measurement, in case of failure with the "M probe." RESULTS: LS and CAP measurements were obtained in 437 patients (the M group), LS measurements (LSM) with the XL probe being available in additional 232 patients. After the combined use of both probes, LSM failure and unreliable result were 1.6% and 5.6% respectively. Overall, 12.7% (n=85), 7.3% and 2.1% exhibited significant or advanced fibrosis or cirrhosis (LSM≥8 kPa, ≥9.6 kPa, ≥13 kPa respectively), half of the patients with LSM≥8 kPa displayed normal liver tests. Significant and severe steatosis were measured in 75% and 24% of the M group patients. By multivariate analysis, factors associated with severe fibrosis were age, overweight, high GGT. Forty-seven patients with LSM≥8 kPa underwent liver biopsy; 93% had steatosis and 51% severe fibrosis. A significant correlation was found between LSM values and fibrosis score with an accuracy rate of 83%, 68% and 83% for LSM≥8 kPa, ≥9.6 kPa and ≥13 kPa respectively. CONCLUSIONS: The prevalence of significant steatosis is very high and significant fibrosis affect 12.7% of the patients. Fibroscan is an effective procedure to screen for fibrosis and steatosis in diabetic patients.

TNI-93: A New Memory Test for Dementia Detection in Illiterate and Low-Educated Patients.

OBJECTIVE: To validate the TNI-93 test in illiterate and low-educated subjects by setting cutoff scores to discriminate non-demented and demented subjects in a clinical setting (CESILL) and verifying the adequacy of these cutoff scores in a population-based study (AMI cohort). METHOD: We used two study samples. First, a clinical setting (CESILL) comprising normal elderly participants and demented patients, mostly multicultural, low educated, or illiterate, was used to compute the cutoff scores of TNI-93 for the detection of dementia. Second, the AMI cohort, a population-based cohort of retired farmers living in a rural setting, was used as a replication study, to assess the detection properties of the cutoff scores in a different population composed mostly of low-educated older people. RESULTS: When combining the two scores, that is, free recall <6 or total recall <9, TNI-93 can detect dementia with a high sensitivity (87%) and specificity (96%), in the CESILL setting. These cutoff scores were roughly similar in the AMI cohort with high sensitivity (80% sensitivity) and specificity (81% specificity). In both study samples, the level of education had no effect on performance. CONCLUSIONS: The TNI-93 appears to be a good test to detect dementia. The absence of a significant effect of education level on the performances makes the TNI-93 a tool of choice in the screening of dementia in illiterate/low-educated subjects.

Circulating cell membrane microparticles transfer heme to endothelial cells and trigger vasoocclusions in sickle cell disease.

Intravascular hemolysis describes the relocalization of heme and hemoglobin (Hb) from erythrocytes to plasma. We investigated the concept that erythrocyte membrane microparticles (MPs) concentrate cell-free heme in human hemolytic diseases, and that heme-laden MPs have a physiopathological impact. Up to one-third of cell-free heme in plasma from 47 patients with sickle cell disease (SCD) was sequestered in circulating MPs. Erythrocyte vesiculation in vitro produced MPs loaded with heme. In silico analysis predicted that externalized phosphatidylserine (PS) in MPs may associate with and help retain heme at the cell surface. Immunohistology identified Hb-laden MPs adherent to capillary endothelium in kidney biopsies from hyperalbuminuric SCD patients. In addition, heme-laden erythrocyte MPs adhered and transferred heme to cultured endothelial cells, inducing oxidative stress and apoptosis. In transgenic SAD mice, infusion of heme-laden MPs triggered rapid vasoocclusions in kidneys and compromised microvascular dilation ex vivo. These vascular effects were largely blocked by heme-scavenging hemopexin and by the PS antagonist annexin-a5, in vitro and in vivo. Adversely remodeled MPs carrying heme may thus be a source of oxidant stress for the endothelium, linking hemolysis to vascular injury. This pathway might provide new targets for the therapeutic preservation of vascular function in SCD.

Vitamin D deficiency and insufficiency in HIV-infected children and young adults.

BACKGROUND: Vitamin D insufficiency and HIV infection are both risk factors for chronic disorders, so it is important to consider vitamin D status in HIV-infected patients. METHODS: We prospectively investigated serum 25-hydroxyvitamin D (25(OH)D) concentrations, determined by radioimmunoassay, in 113 HIV-infected children (age≤24 years) and 54 healthy controls matched for age and phototype. We assessed the prevalence of vitamin D deficiency and insufficiency (VDD and VDI) defined as 25(OH)D titers of <10 ng/mL and between 10 and 30 ng/mL, respectively, and their predictive factors. RESULTS: The overall prevalence of VDD and VDI was 38.9% and 58.7%, respectively. Mean serum 25(OH)D concentrations were significantly higher in the HIV group than the control group (14.2±6.9 ng/mL vs. 10.4±5 ng/mL, P<0.001). Variables significantly associated with low serum 25(OH)D concentrations in HIV-infected children were dark phototype (P<0.001) and age (r=-0.19, P=0.03). Patients receiving efavirenz had a trend toward lower serum 25(OH)D concentrations (11.1±4.6 ng/mL vs. 14.6±7 ng/mL, P=0.1). Dark phototype was the only independent risk factor for VDD in HIV-infected children (odds ratio=14.6; 95% confidence interval: 2.4-89.9, P=0.004). CONCLUSIONS: VDD and VDI were common in both HIV-infected and control groups, and serum 25(OH)D concentrations were significantly lower in controls than in HIV-infected children.

[Assessment of job stress after implementation of prevention measures in a pension fund]. / Evaluation du stress au travail après mesures de prévention dans une caisse de retraite.

AIM: Work stress and its impact on health have been widely studied. However, very few studies have examined the effect of implementing measures designed to reduce work stress, a risk factor for psychological health problems. The purpose of this study was to fill this gap. METHODS: Two surveys were conducted in October 2009 and October 2011. 150 employees participated in the first trial, while 108 took part in the second trial. Among them, 74 employees participated in both surveys and were matched. Participation in the two surveys was anonymous and the participants were asked to complete three questionnaires. RESULTS: The intervention was not effective in reducing perceived poor health, accidents, hospitalizations, sick leaves, medication use, musculoskeletal disorders, psychosocial distress and job stress. However, there wasa significant decrease in iso-strain and an increase in social support. Iso-strain decreased, especially among women (p < 0.002) and employees (p < 0.001). The increased support provided by supervisors and colleagues benefited women and employees, while improved emotional support from supervisors and colleagues mainly benefited employees. These trends were associated with psychological and musculoskeletal disorders. CONCLUSIONS: The significant decrease of iso-strain through improved social support suggests that efforts to prevent work-related stress need to be pursued.

Transient elastography as a screening tool for liver fibrosis and cirrhosis in a community-based population aged over 45 years.

BACKGROUND: Liver stiffness measurement (LSM) has been used to measure fibrosis in patients with various types of chronic liver diseases. However, its usefulness as a screening procedure in apparently healthy people had not been evaluated to date. METHODS: 1358 subjects >45 years old from a general population attending for a medical check-up were consecutively enrolled in the study. All subjects were submitted to medical examination and laboratory tests in addition to LSM, performed on the same day by a single operator. Subjects with LSM values >8 kPa were referred to a liver unit for further investigations. RESULTS: 168 subjects were not considered for analysis due to missing data (n=23), LSM failure (n=51) or unreliable LSM values (n=94). Among the 1190 remaining subjects, 89 (7.5%) had LSM >8 kPa including nine patients with LSM >13 kPa. Despite the fact that normal liver tests were observed in 43% of them (38 out of 89), a specific cause of chronic liver disease was found in all cases. Non-alcoholic fatty liver disease (NAFLD) was the likely cause of chronic liver disease in 52 patients, alcoholic liver disease (ALD) in 20, and both causes were associated in seven additional patients. Hepatitis C virus and hepatitis B virus chronic hepatitis was documented in five and four cases, respectively, and primary biliary cirrhosis in one. Liver biopsy was obtained for 27 patients, including the nine patients with LSM >13 kPa, who were diagnosed with liver cirrhosis due to ALD (n=5), chronic hepatitis C (n=3) or chronic hepatitis B (n=1). The 18 remaining biopsies showed liver fibrosis in all cases except one (isolated steatosis), with ALD and NAFLD being present in six and eight cases, respectively. CONCLUSION: LSM proved to be a useful and specific procedure to screen for cirrhosis in the general population and to detect undiagnosed chronic liver disease in apparently healthy subjects.

Sociodemographic factors and attitudes toward food affordability and health are associated with fruit and vegetable consumption in a low-income French population.

Determinants of fruit and vegetable consumption, including affordability and attitudes, have been poorly investigated, especially in European deprived populations. Our objective was to analyze various determinants of low consumption of fruits and vegetables in disadvantaged participants. Our participants were randomized into 2 groups, 1 which received nutritional advice alone and 1 that also received vouchers that were exchangeable for fruits and vegetables during a 12-mo period. Socioeconomic characteristics, food insufficiency, affordability, and motivation for eating fruits and vegetables were assessed. A short FFQ was administered. Determinants of consumption of <1 fruit or vegetable/d were analyzed using multivariate logistic regression. A total of 295 participants were included (mean age 44.8 y; 133 men, 162 women). At baseline, mean daily consumption of fruits and vegetables was 2.13 +/- 1.57 times/d. Nearly 30% of the sample did not eat fruits and vegetables every day. Determinants of low fruit and vegetable consumption were: age younger than 55 y, education level lower than tertiary, and absence of financial means for buying fruits and vegetables daily. Other determinants were affordability (whether fruits and vegetables are affordable, lack of money in preventing healthy diet) and attitudes (whether one's own diet is healthy, whether or not fruits and vegetables improve health, whether eating fruits and vegetables is a pleasure). Thus, determinants of inadequate consumption of fruits and vegetables in this deprived French population are numerous. The impact of financial difficulties is crucial, as is the perception of affordability of fruits and vegetables.

[Assessment of episodic memory in illiterate elderly]. / Evaluation des capacités de mémoire épisodique de sujets âgés illettrés.

Assessing cognitive functions in illiterate people is a difficult task because most of the neuropsychological tests exploring episodic memory have been validated in formally educated people, are based on verbal material and, therefore, require a good knowledge of language. Two episodic memory tests (TNI93 and TMA93) designed to be used for cognitive impairment screening in illiterate people have been designed, then validated in a multicultural low-educated population. Four hundred and thirty seven subjects aged 60 and over, living in the Seine-Saint-Denis district, received a medical check up offered by the National Health Service and their episodic memory performance was examined with these screening tests. The performance obtained on these tests depends both on age and educational level, as expected. Normative data for screening purpose in population with low education and/or not fluent with the language of the examiner are presented.

Subendocardial viability index is related to the diastolic/systolic time ratio and left ventricular filling pressure, not to aortic pressure: an invasive study in resting humans.

1. The myocardial perfusion relative to left ventricular (LV) workload may be estimated by the subendocardial viability index (SVI). The SVI is a pressure-time integral ratio: the numerator is the area between aortic and LV pressures during diastolic time (DT) and the denominator is the area under the LV pressure curve during systolic time (ST). New non-invasive tonometric devices allow estimation of SVI but neglect LV end-diastolic pressure (LVEDP) in the calculation. The aim of the present study was to determine the haemodynamic correlates of SVI and to test the effects of neglecting LVEDP on SVI estimation. 2. High-fidelity pressures were recorded at rest at the aortic root and LV level in 38 subjects (33 men/five women; mean (+/-SD) age 47 +/- 14 years; nine controls and 29 patients with various cardiac diseases). The SVI (1.16 +/- 0.28) was positively correlated with the DT/ST ratio (1.71 +/- 0.35; r(2) = 0.81) and was negatively correlated with LVEDP (15 +/- 7 mmHg; multiple r(2) = 0.94). The SVI was not related to aortic pressure (mean, pulse, mean systolic, mean diastolic). In 17 patients with LVEDP > 14 mmHg, the SVI calculated assuming zero LVEDP was 33 +/- 15% higher (range 16-70%) than the actual SVI. 3. The DT/ST ratio was the main determinant of the myocardial perfusion relative to cardiac workload and accounted for 81% of SVI variability, whereas aortic pressure did not contribute. Although LVEDP accounted for only 13% of SVI variability, it should be taken into account in the non-invasive calculation of SVI in patients with known or suspected increases in LV filling pressure.

Subendocardial viability ratio estimated by arterial tonometry: a critical evaluation in elderly hypertensive patients with increased aortic stiffness.

1. Increased aortic stiffness predisposes to myocardial ischaemia by increasing the systolic tension-time index and by decreasing aortic pressure throughout diastole. The tonometric subendocardial viability ratio (SEVR) is a non-invasive estimate of myocardial perfusion relative to cardiac workload. The hypothesis that SEVR is impaired in elderly hypertensives with high aortic pulse pressure (PP) was tested in the present study. 2. The SEVR was calculated by radial applanation tonometry in 203 subjects. In addition, diastolic time (DT), systolic time (ST) and mean diastolic and systolic aortic pressures (Pd and Ps, respectively) were calculated. First, 60 subjects matched for age and gender were analysed (20 controls, 20 hypertensives with pulse pressure (PP) < or = 60 mmHg, 20 hypertensives with PP > 60 mmHg; mean (+/-SD) age 64 +/- 9 years; 24 women, 36 men). The remaining 143 subjects, aged 53 +/- 10 years, were analysed subsequently. 3. The SEVR was similar in the three elderly groups (1.39 +/- 0.34, 1.39 +/- 0.28 and 1.35 +/- 0.25, in controls and hypertensive patients with PP < or = 60 and > 60 mmHg, respectively). The SEVR was positively related to DT/ST (r(2) = 0.89) and to DT (r(2) = 0.73) and was negatively related to heart rate (r(2) = 0.56; P < 0.001 each). However, SEVR was not related to ST, PP, mean Pd or mean Ps. At a given DT/ST, SEVR tended to be lower in hypertensives with PP > 60 mmHg than in hypertensives with normal PP. The positive linear relationship between SEVR and DT/ST was confirmed in the remaining 143 subjects (r(2) = 0.90), with no influence of aortic pressure. 4. The tonometric SEVR was not impaired in elderly hypertensive patients with increased aortic stiffness. In resting elderly and middle-aged individuals, the tonometric SEVR was mainly related to DT/ST ratio, not to aortic pressure.

Liver stiffness values in apparently healthy subjects: influence of gender and metabolic syndrome.

BACKGROUND/AIMS: Liver stiffness measurement by transient elastography is a very promising non-invasive method for the diagnosis of fibrosis in chronic liver diseases. However, studies on normal values of liver stiffness in healthy subjects are still lacking. The aim of the present study was to prospectively assess liver stiffness values in the general population and to determine potential factors, which may influence these values. METHODS: Liver stiffness measurements were performed in 429 consecutive apparently healthy subjects, without overt cause of liver disease and normal liver enzymes, undergoing a free medical check-up. RESULTS: Mean liver stiffness value was 5.49+/-1.59 kPa. Transient elastography failure was observed in 4.6% of the cases. The failure rate increased with BMI, reaching 88% for values above 40 kg/m2. Liver stiffness values were higher in men than in women (5.81+/-1.54 vs 5.23+/-1.59 kPa, p=0.0002) and in subjects with BMI>30 kg/m2 (6.26+/-1.89 vs 5.37+/-1.51 kPa, p=0.0003). Metabolic syndrome was diagnosed in 59 (13.7%) subjects. After adjustment for gender and BMI, liver stiffness values were higher in subjects with metabolic syndrome than in those without (6.51+/-1.64 vs 5.33+/-1.51 kPa, p<0.0001). CONCLUSIONS: Liver stiffness values in the general population are influenced independently by gender, BMI and metabolic syndrome.

Association among individual deprivation, glycemic control, and diabetes complications: the EPICES score.

OBJECTIVE: Previous studies have related poor glycemic control and/or some diabetes complications to low socioeconomic status. Some aspects of socioeconomic status have not been assessed in these studies. In the present study, we used an individual index of deprivation, the Evaluation de la Précarité et des Inégalités de santé dans les Centres d'Examens de Santé (Evaluation of Precarity and Inequalities in Health Examination Centers [EPICES]) score, to determine the relationship among glycemic control, diabetes complications, and individual conditions of deprivation. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional prevalence study in 135 consecutive diabetic patients (age 59.41 +/- 13.2 years [mean +/- SD]) admitted in the hospitalization unit of a French endocrine department. Individual deprivation was assessed by the EPICES score, calculated from 11 socioeconomic questions. Glycemic control, lipid levels, blood pressure, retinopathy, neuropathy, and nephropathy were assessed. RESULTS: HbA(1c) level was significantly correlated with the EPICES score (r = 0.366, P < 0.001). The more deprived patients were more likely than the less deprived patients to have poor glycemic control (beta = 1.984 [SE 0.477], P < 0.001), neuropathy (odds ratio 2.39 [95% CI 1.05-5.43], P = 0.037), retinopathy (3.66 [1.39-9.64], P = 0.009), and being less often admitted for 1-day hospitalization (0.32 [0.14-0.74], P = 0.008). No significant relationship was observed with either nephropathy or cardiovascular risk factors. CONCLUSIONS: Deprivation status is associated with poor metabolic control and more frequent microvascular complications, i.e., retinopathy and neuropathy. The medical and economic burden of deprived patients is high.

[Psychosocial distress and stressful life antecedents associated with smoking. A survey of subjects consulting a preventive health center]. / Souffrance psychosociale et antécédents biographiques traumatiques chez des fumeurs. Enquête auprès de consultants d'un Centre de prévention sanitaire et sociale.

BACKGROUND: The relationship between smoking and various socio-demographic or socio-economic factors, as well as the interactions between depressive mood and smoking are already known. However, the respective contribution of psychological factors and stressful life antecedents during childhood and adolescence warrants further specification. METHODS: 2315 consecutive subjects, aged 16 to 59, consulting for a free work-up in a preventive health centre, supported by the National French Health insurance system, were invited to fill out a series of questionnaires: the GHQ-28 and the LOT, respectively measuring psychosocial distress and dispositional optimism, as well as a questionnaire on socio-demographic, socio-economic and biographical data. RESULTS: 78.1% complete records could be analysed: the "smokers" group (n = 870, 48.1%) declared a current tobacco consumption of at least one cigarette/day. This group was characterized by a predominance of male subjects, older age, modest educational level, low income level and responded to socio-economic criteria of precariousness more frequently (p < 0.001, except for age: p = 0.006). Smoking was also associated with higher levels of psychosocial distress, as assessed by GHQ-28, especially for the depressive mood and anxiety items of the questionnaire (p < 0.001), and with lower levels of dispositional optimism (p < 0.01). As regards biographical data, smokers were characterized by a way of life marked by financial problems, reduced social contacts, and a higher frequency, before the age of 18, of divorce or separation of the parents (p = 0.002), frequent parental quarrels (p < 0.001) or separation from the parents (p < 0.001). The presence of a depressive mood at GHQ-28 as well as frequent parental quarrels remained independent risk factors for smoking in multiple logistic regression (odds ratio respectively equal to 1.61 and 1.34), after adjustment on gender, educational level and the notion of socio-economic precariousness. CONCLUSION: These results highlight the complementary role of socio-economic, psychological factors and certain stressful life antecedents among the determinants of smoking and should be taken into account for tailoring smoking cessation programs.

[Socioeconomic determinism of obesity in the Seine-Saint-Denis area]. / Déterminisme socio-économique de l'obésité en Seine-Saint-Denis.

OBJECTIVE: Obesity is a complex multi-factorial disease. The role of socioeconomic factors is known but few studies have attempted to analyse separately the impact of the various participating factors: oncome, level of education, cultural and social status. METHOD: These factors were analysed in 26,278 persons aging from 16 to 59 years, living in the district and having benefited from a medical check-up in the Seine-Saint-Denis health and social prevention centre, district particularly concerned by socio-economic insecurity. Among these persons, a representative sample of 1804 filled-in an additional questionnaire including questions on their income, level of education, marital status and the area or country of origin. RESULTS: The prevalence of obesity (body mass index or BMI > or = 30 kg/m2) and overweight (MCI = 25 to 29.9 kg/m2) was respectively of 17.6 and 32.7%. Using univariate analysis, the prevalence of obesity was significantly associated with age, gender (higher in women), settled way of life, socio-professional category, low education, marital status and origin (higher in persons from Africa and North Africa). Using a logistic regression model, the risk of obesity was increased 1.45-fold in persons earning less than 838,47 euros and 1.67-fold in persons with low education. Moreover, it was 2.28-fold greater in the un-working population, 1.62-fold in the redundant and 1.5-fold in the working class, compared with the executive-freelance population. CONCLUSION: The risk of obesity is therefore independently related to cultural, economic and social parameters.