Effects of sodium intake and cardiorespiratory fitness on body composition and genetic susceptibility to obesity: results from the Quebec Family Study.

The main aim of this study was to evaluate the effects of Na intake and cardiorespiratory fitness (CRF) on body composition. The study was also intended to assess whether Na intake and/or CRF mediate the genetic susceptibility to obesity. Analyses were performed on a sample of 526 adult participants from the Quebec Family Study for whom a complete data set was available for nutrient and energy intake, CRF and body composition variables. The effects of Na, CRF and their interaction were analysed by comparing sex-specific tertiles using general linear mixed models. In both males and females, we observed a significant effect of Na intake and CRF on all body composition variables. However, in females only, we found that the effect of Na intake on body composition variables varies according to CRF level such that high Na intake was associated with increased body fatness, but only in females with low CRF. This interaction effect remained significant after statistical adjustment for total sugar, fat and energy intake. Using mediation analysis, we also found Na intake and CRF to be significant mediators of the relationship between a polygenic risk score of obesity based on > 500 000 genetic variants and BMI or waist circumference. In conclusion, the current study shows that Na intake influences body composition via mechanisms that interact with aerobic fitness, especially in females. Furthermore, both Na intake and CRF seem to be involved in the expression of the genetic susceptibility to obesity.

Dietary Mediators of the Genetic Susceptibility to Obesity-Results from the Quebec Family Study.

BACKGROUND: Recent studies showed that eating behaviors such as disinhibition, emotional and external eating, and snacking mediate genetic susceptibility to obesity. It remains unknown if diet quality and intake of specific food groups also mediate the genetic susceptibility to obesity. OBJECTIVE: This study aimed to assess if diet quality and intakes of specific food groups mediate the association between a polygenic risk score (PRS) for BMI and BMI and waist circumference (WC). We hypothesized that poor diet quality, high intakes of energy-dense food groups, and low intakes of nutrient-dense food groups mediate the genetic susceptibility to obesity. METHODS: This cross-sectional study included 750 participants (56.3% women, aged 41.5 ± 14.9 y, BMI 27.8 ± 7.5 kg/m2) from the Quebec Family Study. A PRSBMI based on >500,000 genetic variants was calculated using LDpred2. Dietary intakes were assessed with a 3-d food record from which a diet quality score (i.e. Nutrient Rich Food Index 6.3) and food groups were derived. Mediation analyses were conducted using a regression-based and bootstrapping approach. RESULTS: The PRSBMI explained 25.7% and 19.8% of the variance in BMI and WC, respectively. The association between PRSBMI and BMI was partly mediated by poor diet quality (ß = 0.33 ± 0.12; 95% CI: 0.13, 0.60), high intakes of fat and high-fat foods (ß = 0.46 ± 0.16; 95% CI: 0.19, 0.79) and sugar-sweetened beverages (ß = 0.25 ± 0.14; 95% CI: 0.05, 0.60), and low intakes of vegetables (ß = 0.15 ± 0.08; 95% CI: 0.03, 0.32), fruits (ß = 0.37 ± 0.12; 95% CI: 0.17, 0.64), and dairy products (ß = 0.17 ± 0.09; 95% CI: 0.02, 0.37). The same trends were observed for WC. CONCLUSIONS: The genetic susceptibility to obesity was partly mediated by poor diet quality and intakes of specific food groups. These results suggest that improvement in diet quality may reduce obesity risk among individuals with high genetic susceptibility and emphasize the need to intervene on diet quality among these individuals.

Statistical hydrology for evaluating peatland water table sensitivity to simple environmental variables and climate changes application to the mid-latitude/altitude Frasne peatland (Jura Mountains, France).

Peatlands are habitats for a range of fragile flora and fauna species. Their eco-physicochemical characteristics make them as outstanding global carbon and water storage systems. These ecosystems occupy 3% of the worldwide emerged land surface but represent 30% of the global organic soil carbon and 10% of the global fresh water volumes. In such systems, carbon speciation depends to a large extent on specific redox conditions which are mainly governed by the depth of the water table. Hence, understanding their hydrological variability, that conditions both their ecological and biogeochemical functions, is crucial for their management, especially when anticipating their future evolution under climate change. This study illustrates how long-term monitoring of basic hydro-meteorological parameters combined with statistical modeling can be used as a tool to evaluate i) the horizontal (type of peat), ii) vertical (acrotelm/catotelm continuum) and iii) future hydrological variability. Using cross-correlations between meteorological data (precipitation, potential evapotranspiration) and water table depth (WTD), we primarily highlight the spatial heterogeneity of hydrological reactivity across the Sphagnum-dominated Frasne peatland (French Jura Mountain). Then, a multiple linear regression model allows performing hydrological projections until 2100, according to regionalized IPCC RCP4.5 and 8.5 scenarios. Although WTD remains stable during the first half of 21th century, seasonal trends beyond 2050 show lower WTD in winter and markedly greater WTD in summer. In particular, after 2050, more frequent droughts in summer and autumn should occur, increasing WTD. These projections are completed with risk evaluations for peatland droughts until 2100 that appear to be increasing especially for transition seasons, i.e. May-June and September-October. Comparing these trends with previous evaluations of phenol concentrations in water throughout the vegetative period, considered as a proxy of plant functioning intensity, highlights that these hydrological modifications during transitional seasons could be a great ecological perturbation, especially by affecting Sphagnum metabolism.

Management and outcomes of cardiac arrests at nursing homes: A French nationwide cohort study.

BACKGROUND: The incidence of cardiac arrest (CA) in nursing homes is rising. Our objective was to compare nursing home CAs with at-home CAs in patients aged 65 and over with regard to the CAs' characteristics, the use and characteristics of cardiopulmonary resuscitation (CPR), and the outcome. METHODS: We performed an ancillary analysis of a French nationwide cohort of over-65 patients having experienced an out-of-hospital CA (at home or in a nursing home) treated by a physician-manned mobile intensive care unit (MICU) between July 2011 and September 2015. RESULTS: Out of 21,720 CAs, 1907 (9%) occurred in a nursing home. The presence of a witness was more frequent in the nursing home than at home (77% vs. 62%, respectively; p < 0.001) and bystander-initiated CPR was more frequent (62% vs. 34%, respectively; p < 0.001). CPR by a MICU was less likely in the nursing home than at home - even after adjustment for the patients' and CAs' characteristics (adjusted odds ratio (aOR) [95% confidence interval] = 0.49 [0.42-0.57]). A return of spontaneous circulation was less frequent in the nursing home than at home (14% vs. 16%, respectively; OR = 0.86 [0.75-0.99]; p = 0.03) except when CPR was performed by the MICU (31% vs. 26%, respectively; OR = 1.25 [1.07-1.47]; p = 0.005). There was no intergroup difference in the CA outcome at day 30. CONCLUSIONS: Nursing home residents who experience a CA are less likely to receive CPR from a MICU. If CPR is performed, however, the residents' prognosis is no worse than that of patients treated at home.

[Securing patients pathways treated by oral antitumoral: Guidelines for better organization of departments and management of incoming calls]. / Sécurisation des parcours des patients sous traitement anti-tumoraux oraux : recommandations pour une meilleure organisation des services et gestion des appels entrants.

The emergence of oral cancer treatment in oncology has shifted patient follow-up from the hospital to the home. This trend has resulted in an increase in phone and e-mail interactions initiated by patients, but also by pharmacists, by liberal nurses, by general practitioners, and an increase in calls to the emergency response services (SAMU) both for real or perceived emergencies. This increased volume of patient and pharmacist communication has caused significant disruption in the daily activity of affected oncology departments and in particular of the secretariats. The procedures for formulating and securing appropriate responses within a short time frame are generally not established, and as a result, there is a risk that decisions made could be inappropriate for the patient's situation, especially in the case of complications.. Tracking responses to phone calls is necessary and answers should be noted in the medical file, including side effects, in particular the serious AEs for a good quality of care. This guideline describes best practices for oncologists who manage "incoming" calls from patients or professionals involved in the care pathway.

Do emergency physicians trust their patients?

The primary focus of research on the physician-patient relationship has been on patients' trust in their physicians. In this study, we explored physicians' trust in their patients. We held semi-structured interviews with expert emergency physicians concerning a patient they had just been managing. The physicians had been equipped with a head-mounted micro camera to film the encounter from an "own point of view perspective". The footage was used to stimulate recall during the interviews. Several participants made judgments on the reliability of their patients' accounts from the very beginning of the encounter. If accounts were not deemed reliable, participants implemented a variety of specific strategies in pursuing their history taking, i.e. checking for consistency by asking the same question at several points in the interview, cross-referencing information, questioning third-parties, examining the patient record, and systematically collecting data held to be objective. Our study raises the question of the influence of labeling patients as "reliable" or "unreliable" on their subsequent treatment in the emergency department. Further work is necessary to examine the accuracy of these judgments, the underlying cognitive processes (i.e. analytic versus intuitive) and their influence on decision-making.

From Context Comes Expertise: How Do Expert Emergency Physicians Use Their Know-Who to Make Decisions?

STUDY OBJECTIVE: Decisionmaking is influenced by the environment in which it takes place. The objective of our study was to explore the influence of the specific features of the emergency department (ED) environment on decisionmaking. In this paper, we specifically report on the way emergency physicians use their knowledge of their collaborators to make their decisions. METHODS: We conducted a qualitative study on emergency physicians recruited in 3 French hospitals. Physicians were equipped with a microcamera to record their clinical activity from their "own-point-of-view perspective." Semistructured interviews, based on viewing the video, were held with each physician after an actual clinical encounter with a patient. They were then analyzed thematically, using constant comparison and matrices, to identify the central themes. RESULTS: Fifteen expert emergency physicians were interviewed. Almost all of them reported using their knowledge of other health care professionals to assess the seriousness of the patient's overall condition (sometimes even before his or her arrival in the ED) to optimize the patient's treatment and to anticipate future care. CONCLUSION: Emergency physicians interact with many other health care workers during the different stages of the patient's management. The many ways in which experts use their knowledge of other health care professionals to make decisions puts traditional conceptions of expert knowledge into perspective and opens avenues for future research.

Insights into emergency physicians' minds in the seconds before and into a patient encounter.

Clinical reasoning is a core competency in medical practice. No study has explored clinical reasoning occurring before a clinical encounter, when physicians obtain preliminary information about the patient, and during the first seconds of the observation phase. This paper aims to understand what happens in emergency physicians' minds when they acquire initial information about a patient, and when they first meet a patient. The authors carried out in-depth interviews based on the video recordings of emergency situations filmed in an "own-point-of-view-perspective". 15 expert emergency physicians were interviewed between 2011 and 2012. Researchers analysed data using an interpretive approach based on thematic analysis and constant comparison. Almost all participants used a few critical pieces of information to generate hypotheses even before they actually met the patient. Pre-encounter hypotheses played a key role in the ensuing encounter by directing initial data gathering. Initial data, collected within the first few seconds of the encounter, included the patient's position on the stretcher, the way they had been prepared, their facial expression, their breathing, and their skin colour. Physicians also rapidly appraised the seriousness of the patient's overall condition, which determined their initial goals, i.e. initiating emergency treatment or pursuing the diagnostic investigation. The study brings new insights on what happens at the very beginning of the encounter between emergency physicians and patients. The results obtained from an innovative methodological approach open avenues for the development of clinical reasoning in learners.

How and when do expert emergency physicians generate and evaluate diagnostic hypotheses? A qualitative study using head-mounted video cued-recall interviews.

STUDY OBJECTIVE: The ability to make a diagnosis is a crucial skill in emergency medicine. Little is known about the way emergency physicians reach a diagnosis. This study aims to identify how and when, during the initial patient examination, emergency physicians generate and evaluate diagnostic hypotheses. METHODS: We carried out a qualitative research project based on semistructured interviews with emergency physicians. The interviews concerned management of an emergency situation during routine medical practice. They were associated with viewing the video recording of emergency situations filmed in an "own-point-of-view" perspective. RESULTS: The emergency physicians generated an average of 5 diagnostic hypotheses. Most of these hypotheses were generated before meeting the patient or within the first 5 minutes of the meeting. The hypotheses were then rank ordered within the context of a verification procedure based on identifying key information. These tasks were usually accomplished without conscious effort. No hypothesis was completely confirmed or refuted until the results of investigations were available. CONCLUSION: The generation and rank ordering of diagnostic hypotheses is based on the activation of cognitive processes, enabling expert emergency physicians to process environmental information and link it to past experiences. The physicians seemed to strive to avoid the risk of error by remaining aware of the possibility of alternative hypotheses as long as they did not have the results of investigations. Understanding the diagnostic process used by emergency physicians provides interesting ideas for training residents in a specialty in which the prevalence of reasoning errors leading to incorrect diagnoses is high.

A basic introduction to statistics for the orthopaedic surgeon.

Orthopaedic surgeons should review the orthopaedic literature in order to keep pace with the latest insights and practices. A good understanding of basic statistical principles is of crucial importance to the ability to read articles critically, to interpret results and to arrive at correct conclusions. This paper explains some of the key concepts in statistics, including hypothesis testing, Type I and Type II errors, testing of normality, sample size and p values.

Efficacy and safety of the EZ-IO™ intraosseous device: Out-of-hospital implementation of a management algorithm for difficult vascular access.

OBJECTIVE: Intraosseous access is a rapid and safe alternative when peripheral vascular access is difficult. Our aim was to assess the safety and efficacy of a semi-automatic intraosseous infusion device (EZ-IO) when using a management algorithm for difficult vascular access in an out-of-hospital setting. METHODS: This was a one-year prospective, observational study by mobile intensive care units. After staff training in the use of the EZ-IO device and provision of a management algorithm for difficult vascular access, all vehicles were equipped with the device. We determined device success rate and ease of use, resuscitation fluid volume and drugs administered by the intraosseous route, and complications at insertion site. RESULTS: A total of 4666 patients required vascular access. The EZ-IO device was used in 30 cardiac arrest patients (25 adults; 5 children) and 9 adults with spontaneous cardiac activity. The success rate for first insertion was 84%. Overall success rate (max. 2 attempts) was 97%. The device was used for fluid resuscitation in 16 patients (mean volume: 680ml), adrenaline administration in 24 patients, and rapid sequence induction in 2 patients. There was only one local complication (transient local inflammation). CONCLUSIONS: On implementation of an algorithm for the management of difficult vascular access, the EZ-IO device proved safe and highly effective in both adult and paediatric patients in an out-of-hospital emergency setting. It is a suitable device for consideration as a first-line option for difficult vascular access in this setting.

Bispectral index monitoring is useless during cardiac arrest patients' resuscitation.

AIM: It has been suggested that out-of-hospital bispectral (BIS) index monitoring during advanced cardiac life support (ACLS) might provide an indication of cerebral resuscitation. The aims of our study were to establish whether BIS values during ACLS might predict return to spontaneous circulation, and whether BIS values on hospital admission might predict survival. MATERIALS AND METHODS: This was a prospective observational study in 92 patients with cardiac arrest who received basic life support from a fire-fighter squad and ACLS on arrival of an emergency medical team on the scene. BIS values, electromyographic activity, and signal quality index were recorded throughout resuscitation and out-of-hospital management. RESULTS: Seven patients had recovered spontaneous cardiac activity by the time the medical team arrived on scene. Of the 92 patients, 62 patients died on scene and 30 patients returned to spontaneous cardiac activity and were admitted to hospital. The correlation between BIS values and end-tidal CO(2) during the first minutes of ACLS was poor (r(2)=0.02, P=0.19). Of the 30 admitted patients, 27 died. Three were discharged with no disabilities. There was no significant difference in BIS values on admission between the group of patients who died and the group who survived (P=0.78). CONCLUSIONS: Although BIS monitoring during resuscitation was not difficult, it did not predict return to spontaneous cardiac activity, nor survival after admission to intensive care. Its use to monitor cerebral function during ACLS is therefore pointless.

[Medical education in France and Canada: is there a best system?]. / Formation médicale en France et au Canada. L'un des deux systèmes est-il meilleur que l'autre?

We have compared the conception and organization of medical education systems in France and Canada, taking into consideration key means and processes including the organization of curriculum, the selection of students, certification and licensure. The major objective of this comparison is to illustrate the degree to which the organization of medical education is influenced by the specific history and culture of each country. This is particularly important in an era of increasing internationalization in medical education. In Canada, a federalist orientation means a great deal of freedom for each province to determine its own criteria for medical licensure, and for each faculty of medicine to determine its own selection criteria and curriculum organization. Meanwhile, the evaluation of graduates of medical schools and later of specialties is organized at a national level. France, on the other hand, is much more centrist, and controls the "input" of students to medical schools and the nature of their curriculum. However, France allows each faculty of medicine to deliver a diploma that authorizes physician graduates to practice, without an evaluation of student performance at a national level. We show how the selection and evaluation of students in France are influenced by the French Revolutionary principles of "liberté" and the education of a national "elite", while in Canada the goals of "equity" and the guarantee of a level of "minimum competence" under pin a very different system. In conclusion, we highlight the important of taking into consideration these factors before undertaking reform of educational systems or transferring methods from one country to another.

Diagnostic efficiency, embryonic development and clinical outcome after the biopsy of one or two blastomeres for preimplantation genetic diagnosis.

BACKGROUND: Preimplantation genetic diagnosis or screening (PGD, PGS) involves embryo biopsy on Day 3. Opting for one- or two-cell biopsy is a balance between the lowest risk for misdiagnosis on the one hand and the highest chance for a pregnancy on the other hand. METHODS: A prospective controlled trial was designed and 592 ICSI cycles were randomly assigned to the one-cell (group I) or the two-cell group (group II). Primary outcomes were diagnostic efficiency and embryonic development to delivery with live birth (analysed by cycle). The false-positive rate for the PCR cycles is presented as a secondary outcome (analysed by embryo). RESULTS: A strong significant correlation was observed between embryonic developmental stage on Day 3 and post-biopsy in vitro development on Day 5 (P < 0.0001). The influence of the intervention on Day 3 was less significant (P = 0.007): the biopsy of one cell is less invasive than the biopsy of two cells. PCR diagnostic efficiency was 88.6% in group I and 96.4% in group II (P = 0.008). For the fluorescence in situ hybridization (FISH) PGD cycles no significant difference in efficiency was obtained (98.2 and 97.5% in group I and II, respectively). Similar delivery rates with live birth per started cycle were obtained [58/287 or 20.2% in group I versus 52/303 or 17.2% in group II, P = 0.358; the absolute risk reduction = 3.05%; 95% confidence interval (CI): -3.24, 9.34]. Post-PGD PCR reanalysis showed six false positives in 97 embryos (6.2%) in group II and none in group I (91 embryos reanalysed). No false negatives were found. CONCLUSIONS: While removal of two blastomeres decreases the likelihood of blastocyst formation, compared with removal of one blastomere, Day 3 in vitro developmental stage is a stronger predictor for Day 5 developmental potential than the removal of one or two cells. The biopsy of only one cell significantly lowers the efficiency of a PCR-based diagnosis, whereas the efficiency of the FISH PGD procedure remains similar whether one or two cells are removed. Delivery rates with live birth per started cycle were not significantly different.

Constant flow insufflation of oxygen as the sole mode of ventilation during out-of-hospital cardiac arrest.

BACKGROUND: Constant flow insufflation of oxygen (CFIO) through a Boussignac multichannel endotracheal tube has been reported to be an efficient ventilatory method during chest massage for cardiac arrest. METHODS: Patients resuscitated for out-of-hospital cardiac arrest were randomly assigned to standard endotracheal intubation and mechanical ventilation (MV; n =457) or use of CFIO at a flow rate of 15 l/min (n=487). Continuous chest compressions were similar in the two groups. Pulse oximetry level was recorded every 5[Symbol: see text]min. Outcome of initial resuscitation, hospital admission, complications, and discharge from the intensive care unit (ICU) were analyzed. The randomization scheme was changed during the study, but the in-depth analysis was performed only on the first cohort of 341 patients with CFIO and 355 with MV, because of randomization problems in the second part. RESULTS: No difference in outcome was noted regarding return to spontaneous circulation (CFIO 21%, MV 20%), hospital admission (CFIO 17%, MV 16%), or ICU discharge (CFIO 2.4%, MV 2.3%). The level of detectable pulse saturation and the proportion of patients with saturation above 70% were higher with CFIO. Ten patients with MV but only one with CFIO had rib fractures. CONCLUSIONS: CFIO is a simplified alternative to MV, with favorable effects regarding oxygenation and fewer complications, as observed in this group of patients with desperate prognosis.

Mental disorders in obese children and adolescents.

OBJECTIVE: To evaluate the type and frequency of psychiatric disorders in obese children and adolescents; to assess the correlation between psychopathology and severity of obesity; to explore the relationship between psychiatric disorders in obese children and obesity and psychopathology in their parents. METHODS: One hundred fifty-five children referred and followed for obesity were evaluated (98 girls and 57 boys; age, 5 to 17 years). Psychiatric disorders were assessed through a standardized diagnostic interview schedule (K-SADS R) and self-report questionnaires completed by the child (STAIC Trait-anxiety and CDI for depression) or his (her) parents (CBCL or GHQ). These obese children were compared with insulin-dependent diabetic (IDDM) outpatient children (N = 171) on questionnaire data. RESULTS: Eighty-eight obese children obtained a DSM-IV diagnosis, most often an anxiety disorder (N = 63). Psychological disorders were particularly pronounced in those obese children whose parents were disturbed. There was no correlation between severity of obesity in the child or his (her) parents and frequency of psychiatric disorders. Compared with diabetic children, they displayed significantly higher internalized and externalized questionnaire scores and poorer social skills. CONCLUSION: These results highlight the importance of including a child psychiatric component in the treatment of obesity, which must engage the whole family.

Methotrexate for the treatment of unruptured tubal pregnancy: a prospective nonrandomized study.

BACKGROUND AND OBJECTIVES: The aim of this study was to compare in a prospective nonrandomized study, the efficacy of 2 methods of administering methotrexate (MTX) in the treatment of ectopic pregnancy (EP): transvaginal injection under sonographic control or intramuscular injection (IM). METHODS: Patients with EP who met specific inclusion criteria for medical treatment were treated with MTX: 63 patients (group 1) were treated by IM and 47 patients (group 2) by transvaginal local injection. In group 1, 50 mg/m2 of MTX was injected intramuscularly; in group 2, transvaginal injection of 1 mg/kg of MTX was injected into the ectopic sac under sonographic control. When an additional dose of MTX was required, it was administrated IM at the dosage of 50 mg/m2 in both groups. RESULTS: The overall success rate, defined by a posttreatment normal hCG level (< 10 mUI/mL) was 71.4% in group 1 versus 91.5% in group 2 (P < 0.01); for patients with hCG levels < 2000 mUI/mL, 83% and 96%, respectively (not significant); for patients with hCG > or = 2000 mUI/mL, 37.5% and 86.4%, respectively (P < 0.01). CONCLUSION: In the medical treatment of EP, the efficacy of MTX is greater when administered by local transvaginal injection than by IM injection. We propose local treatment every time EP can be punctured, especially when hCG levels are > or = 2000 mUI/mL.

Psychopathology and quality of life for adolescents with asthma and their parents.

Asthma is known to have a direct impact on the quality of life of children with asthma and their families as a consequence of the attacks on day-to-day life. Psychopathological factors may be associated with poor quality of life by modulating the handicap and the patient's experience of it. The authors' objective was to evaluate the relationship between emotional and behavioral problems and quality of life, as assessed by the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire. The study group consisted of 100 adolescent outpatients with asthma who were undergoing regular checkups: 70 boys and 30 girls, ages 12 to 19. They were evaluated by means of self-administered questionnaires completed by their parents. Path analysis was used to propose a model of relationships between psychopathology and quality of life. The quality of life of the children with asthma and their parents was clearly associated with the presence or absence of psychological problems in the patients. Emotional problems were associated with the quality of life of both the patients and their parents; behavioral problems had a smaller effect on the quality of life of the parents only. The authors proposed a structural model of the quality of life of adolescents with asthma and their parents in which quality of life is dependent on psychological variables and is responsible for emotional problems. Multivariate analyses indicated that the quality of life of the children with asthma and their parents and the correlation between quality of life and psychopathology depended little on medical variables such as the duration of illness, its pretreatment severity, or hospitalizations in the past year. In contrast, the quality of life of the parents depended on that of the children and vice versa. This study showed that scores on the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire reflected not only the medical status of the patients but also psychological variables, which appeared to be a consequence of the functional handicap associated with asthma. Patients who assess the quality of their lives as poor would benefit from psychological evaluation and support.