Characteristics of respiratory viruses' circulation through a six-year period (2016-2022) in a pediatric population in Normandy, France, and the impact of COVID-19 pandemic.

IMPORTANCE: The report highlights an epidemiological change in the circulation of respiratory viruses in pediatric populations due to strategies adopted against COVID-19 pandemic. COVID-19 has resulted in a significant increase in requests for multiplex respiratory research to identify the virus responsible for the symptoms. The diagnostic needs have increased, and the number of samples analyzed in 2021-2022 is equal to the samples analyzed over the four epidemic periods preceding the pandemic. The report suggests the importance of active surveillance of respiratory viruses' circulation and new recommendations for respiratory virus detection in pediatric patients.

Enuresis and encopresis: Association with child abuse and neglect.

OBJECTIVE: Several reports suggest a possible link between child abuse and enuresis or encopresis but concern small series of children and present therefore methodological biases. The objective of the present study was to clarify this issue by examining the relationships between child abuse and enuresis or encopresis in a large sample of children. METHODS: A multicenter cross-sectional study was conducted on a sample of 428 children in social residential centers in France. Four types of child abuse were considered: sexual abuse, physical abuse, psychological abuse and neglect. The accuracy and reliability of the characterization of the type of abuse as well as that of the sphincter disorder was particularly high. In fact, all the cases benefited from both a social and a psychological investigation and from an observation in a residential center. RESULTS: More than 60% of the children were victims of at least one type of abuse. Encopresis was reported in 15 children (3.5% [95% CI: 2.0%-5.7%]), mostly among boys (13 cases). Enuresis affected 54 of the 390 children aged five years or more (13.8% [95% CI: 10.6%-17.7%]). Most of the cases also appeared in boys (38 cases). Rates of encopresis were found to be seven-fold higher in both psychologically abused and neglect children compared to non-abused children (P=0.01). Concerning enuresis, a weaker but still significant association was found with sexual (OR= 3.3, P=0.025) and physical abuse (OR=2.3, P=0.035). CONCLUSION: Our findings support the hypothesis that enuresis and encopresis are associated with specific types of child abuse.

Rothia spp. infective endocarditis: A systematic literature review.

OBJECTIVE: To describe the epidemiological, clinical, microbiological, and therapeutic features and outcomes of Rothia infective endocarditis (RIE) and extracardiac infections (ECRI). METHODS: We performed a systematic literature review of published cases of RIE and ECRI. RESULTS: After inclusion of a personal case report, 51 cases of RIE and 215 cases of ECRI were reported. Compared with ECRI patients, RIE patients were significantly more often males (80% versus 59%), intravenous drug users (IVDU) (20% versus 3%), immunocompetent (76% versus 31%), and infected with R. dentocariosa (55% versus 13%) but lacked significant differences with regard to median age (45 years [6-79]), rate of orodental abnormalities (33%), and six-month mortality (14%). Following microbiological documentation, RIE was most often treated with a beta-lactam antibiotic alone (39%) for a median duration of six weeks and required surgery in 39% of cases. CONCLUSION: RIE is rare and likely secondary to a dental portal of entry or cutaneous inoculation in IVDU. Its prognosis seems to be favorable.

[Early and later intrahepatic cholestasis of pregnancy (ICP): Study of adverse pregnancy outcomes]. / Cholestases intrahepatiques gravidiques (CIG) précoces et tardives : étude des complications materno-fœtales.

OBJECTIVE: To compare the risk for adverse pregnancy and fetal outcomes in early or late-onset intrahepatic cholestasis of pregnancy (ICP). METHODS: In a retrospective and unicentric analysis, data were collected for all women with ICP (serum bile acid level over 8mol/L) between June 1, 2008 and January 1, 2015. Patients were divided in early-onset ICP (pregnancy duration at diagnosis<33 weeks) and late-onset ICP (pregnancy duration at diagnosis≥33 weeks). The frequency of adverse pregnancy and fetal outcomes was assessed. RESULTS: Among 138 eligible women, 40 were in the early-onset group and 98 in the late-onset group. Adverse pregnancy or fetal outcomes affected significantly more patients in early-onset ICP group (45% versus 17.3%, P<0.05). Threatened preterm birth (30% versus 10.0%, P<0.05) was significantly increased in early-onset ICP group. Prematurity was higher in early-onset group (40.0% versus 28.0%, P=0.23). Early-onset and severe ICP were not significantly linked (P=0.16). CONCLUSION: Early-onset ICP diagnosed before 33 Weeks is associated with adverse pregnancy outcomes, particularly threatened preterm birth.

[Caesarean section at full dilatation: What are the risks to fear for the mother and child?] / Césarienne à dilatation complète : quels sont les risques à craindre pour la mère et l'enfant ?

OBJECTIVES: Caesarean section is associated with increased maternal morbidity compared to a vaginal delivery, especially if it occurs during labour. Little data on caesarean section performed at full dilatation is available. METHODS: This was a retrospective study done in University Hospital of type 3 over a period of ten years, including future primiparous patients who had a caesarean section performed at full dilatation, compared to a control group of patients whose caesarean section was conducted in first part of the labour. We collected different maternal data per- and postoperative and neonatal. RESULTS: In total, 824 patients were enrolled including 412 in each group. For caesarean section at full dilatation, foetal extraction required more manoeuvres (RR=3.05; 95% CI: 2.1; 4.39; P<0.001); we noted more extension of hysterotomy (RR=1.79; 95% CI: 1.30; 2.46; P<0.001). Postoperative and neonatal maternal morbidity was not different, except more frequent neonatal trauma for caesarean section at full dilatation. CONCLUSION: A caesarean section at full dilatation has an excess intraoperative risk and requires great caution. Nevertheless, no significant increase of postoperative and neonatal complications can be proved.

Autologous Adipose Tissue Graft to Treat Hypertensive Leg Ulcer: A Pilot Study.

BACKGROUND: Adipose tissue is an abundant source of mesenchymal stem cells, called adipose-derived stem cells, which have anti-inflammatory and trophic effects to enhance overall tissue repair. OBJECTIVE: To determine the healing effects of autologous adipose tissue graft on hypertensive leg ulcers. METHODS: Prospective pilot study in 1 French dermatology department. Ten patients with a hypertensive leg ulcer were enrolled from April 2013 to June 2015. The primary end point was the wound closure rate at each follow-up visit. The secondary end points were wound characteristics, pain assessment and adverse events. RESULTS: One patient, the only smoker, was lost to follow-up at month 5 (M5). For the 9 non-smokers, wound surfaces constantly and significantly decreased: the median wound closure rate was 73.2% at M3 and 93.1% at M6, p < 0.001. The median wound closure rate of the 10 patients was 63.2% at M3, p < 0.001. Percentages of fibrin and necrosis decreased, granulation tissue increased significantly. Pain rapidly and significantly decreased. No recurrence or adverse event was observed. CONCLUSION: Our data suggest that autologous adipose tissue grafting induces pain relief and promotes wound healing with a good skin quality. Large prospective controlled randomized studies are required to confirm these results.

[Preterm breech before 35 weeks of gestation: What is the influence of the delivery route on neonatal condition?]. / Sièges prématurés avant 35 semaines d'aménorrhée: quelle influence de la voie d'accouchement sur l'état néonatal ?

OBJECTIVE: The mode of delivery for preterm breech is still controversial, while no randomized study has been completed. The question of a protective effect of cesarean section on neonatal outcome arises. The objective of this study was to compare mortality and neonatal morbidity for children born before 35 weeks of gestation in breech presentation, depending on the route of delivery. METHODS: This was a retrospective study done in University Hospital type 3 over five years, comparing neonatal mortality and different neonatal morbidity criteria for children born between 25 weeks of gestation and 34 weeks+6 days spread into two groups according to their mode of delivery: elective caesarean section before labor and vaginal delivery. Statistical analysis was performed with an adjustment for gestational age and weight of the newborn. RESULTS: No significant difference between the two groups was found with regard to neonatal mortality. Among the various morbidity criteria studied, only the head entrapment rate and serious traumatic injury occurrence were significantly increased in the "intent to vaginal delivery" group. pH at birth and Apgar scores at five minutes were not significantly different between the two groups. CONCLUSIONS: This work shows an increased risk of traumatic complications for vaginal delivery with no increase in other neonatal complications. It seems reasonable in this particular context to allow an attempt at vaginal delivery on condition of strict compliance with safety regulations relating to breech delivery.

[Is vaginal delivery possible for patients with myomectomy? Results of a monocentric study]. / Après myomectomie, les patientes ont-elles le droit d'accoucher par voie basse ? Résultats d'une étude monocentrique.

OBJECTIVE: To compare delivery outcomes according to the scar: myomectomy versus low-segment transverse cesarean. METHODS: A retrospective cohort study was performed in a university type 3 service between 1st January 2006 and 1st January 2012. We compared 18 women who gave birth after myomectomy (exposed group) to 72 women who gave birth after cesarean section (non-exposed group). Women younger than 43 years who underwent laparotomy or laparoscopic myomectomy were included. The primary endpoint was the rate of vaginal delivery. The route of delivery, the rate of uterine rupture, complications of delivery and neonatal outcome were studied. RESULTS: The acceptance rate of vaginal delivery was 55.6% after myomectomies versus 84.7% after cesarean section (P=0.005). The success of vaginal birth was 88.9% after myomectomy versus 73.9% after cesarean (NS). No uterine rupture has occurred after myomectomy against three sub-peritoneal rupture after cesarean. The occurrence of post-partum hemorrhage was not significantly different between the 2 groups (11.1% among exposed group versus 6.9% in the non-exposed group). The cesarean section rate was even higher than the number of hysterotomy was great (P=0.0047). CONCLUSION: This study seems to show that vaginal birth after myomectomy is possible with a success rate similar to vaginal birth after cesarean section.

[A cross-sectional study of trait-anxiety in a group of 111 intellectually gifted children]. / Étude transversale de l'anxiété trait dans un groupe de 111 enfants intellectuellement surdoués.

INTRODUCTION: Intellectually gifted children are often thought to display a high risk for psychopathology. However, this assertion has received only few direct arguments to date, and there is in fact a lack of knowledge on this subject. The aim of this study was to compare trait-anxiety - which is considered as a sensitive and early indicator of psychoaffective difficulties in children - in intellectually gifted children to the norm. METHODS: One hundred and eleven children aged 8 to 12 and with an intellectual quotient (IQ) higher than 129 participated in the study. They were recruited in a hospital department of child and adolescent psychiatry and through psychologists' private practice, where they attended consultation because of academic underachievement and/or social maladjustment. All the children were examined by trained psychiatrists and psychologists: none had a present or past medical or psychiatric condition and, additionally, none had an elevated score on the French version of the Children's Depressive Rating Scale Revised (Moor & Mack, 1982). Parents filled in a questionnaire for the collection of socio-demographic data and children answered the French version of the Revised-Children's Manifest Anxiety Scale (R-CMAS; Reynolds, 1999), a 37-items self-assessment of trait-anxiety, the psychometric properties of which have been validated in children with high IQ. DATA ANALYSIS: Mean scores and subscores on the R-CMAS in the whole studied group and as a function of gender and age were compared to French normative data (Reynolds, 1999) by calculation of 95% confidence intervals; subgroups were compared using Student's t-tests. Proportions of children who's score and subscores exceeded anxiety cut-off norms were compared to normative data using chi-square tests. Statistical significance was considered at the P<0.05 level. RESULTS: The studied group comprised mainly boys, and members of a sibling. Parents mainly lived as man and wife, had high academic levels, and had a professional activity. The confidence intervals of the R-CMAS scores and subscores all comprised their normative value, which denotes that no difference was statistically significant. Comparisons for age and gender showed no significant difference. Proportions of results exceeding the cut-off scores and subscores did not significantly differ from the norms. DISCUSSION: General and dimensional trait-anxiety levels in the studied group were comparable to normative data. These results are in accordance with previous studies of trait-anxiety in children and adolescents with high IQ, which all showed normal or decreased levels. These findings do not corroborate the hypothesis that intellectual giftedness constitutes a risk factor for psychopathology. LIMITS: The studied group was a clinical one, which could limit the generalisation of the results. However, mental disorders were ruled out, and the psychometric and socio-demographic characteristics of the group were in keeping with those described for the general population of gifted children. Moreover, considering that participant children displayed academic underachievement and/or social maladjustment, it can be supposed that their anxiety levels were not lower than those in the general population of gifted children. Secondly, the potentially confusing effect of socio-demographic variables (underrepresentation of low socio-economic levels and single-parent families) could not be statistically taken into account, due to the absence of a specific control group. CONCLUSION: Intellectually gifted children seem not to display increased trait-anxiety. However, further studies are necessary to investigate psychological functioning in gifted children and their risk for psychopathology.

[Effect of early intervention programs on neurobehavioral outcome in premature infants after discharge]. / Efficacité des programmes d'intervention précoce après l'hospitalisation sur le développement neurocomportemental des enfants prématurés.

The authors describe the methods and results of the main early intervention programs after discharge in the families of premature infants. There is great variability between the studies concerning the type, frequency, and length of interventions and the length of follow-up. Inconsistent improvement in cognitive and behavioral outcomes in the first 2years of life and at preschool age were noted. Most recent studies underscore that the intervention should take into account parental psychological status, focus on parent-infant interaction, and last a sufficiently long time.

Myocardial strain assessment in cystic fibrosis.

BACKGROUND: The aim of this work was to evaluate myocardial strain analysis as a tool for the early detection of left ventricular functional changes in patients with cystic fibrosis. METHODS: A total of 42 consecutive patients (mean age, 24 ± 7.5 years; 52% men) diagnosed with cystic fibrosis and referred for echocardiographic cardiac function assessment were prospectively enrolled. A group of healthy age-matched and gender-matched volunteers (n = 42) formed the reference population for echocardiographic comparisons. RESULTS: Left ventricular ejection fraction was conserved in both groups but was significantly lower in the cystic fibrosis group. Cardiac function assessment using Doppler tissue imaging parameters revealed that both systolic and diastolic measurements differed between the two groups: mitral peak systolic and diastolic velocities, as well as septal and lateral wall strain rates, were decreased in patients with cystic fibrosis, as was longitudinal strain of both the septal and lateral walls. CONCLUSIONS: Using strain measurements, subclinical changes in left ventricular function were found in patients with cystic fibrosis. These parameters were correlated with the degree of pulmonary involvement severity. These findings have potentially significant clinical implications for the outcomes and follow-up of patients with cystic fibrosis, meriting further studies.

Epstein-Barr virus involvement in the pathogenesis of hydroa vacciniforme: an assessment of seven adult patients with long-term follow-up.

BACKGROUND: Hydroa vacciniforme (HV) is a chronic papulovesicular photodermatosis of childhood, with some cases persisting through adulthood. In children, the Epstein-Barr virus (EBV) has been detected in typical HV and in HV evolving into natural killer/T-cell lymphoma. No exploration of EBV infection has been performed in adult patients with HV with long-term follow-up. OBJECTIVES: To assess EBV infection systematically in blood and in experimentally photoinduced lesions in adult patients with HV. METHODS: Repeated tests for EBV DNA blood load using real-time polymerase chain reaction (PCR) and serological EBV tests were performed in seven adult patients with long-term follow-up. Skin samples from phototest-induced lesions and surrounding normal skin were studied using PCR, in situ hybridization and electron microscopy. ZEBRA protein was detected using immunostaining. Thirty-five patients with other photosensitive disorders were included as controls. RESULTS: The EBV DNA blood load was strongly positive in the seven patients with HV and negative in 34 of 35 of the patients with other photosensitive disorders (P < 0.001). The levels were higher in photosensitive patients with HV than in patients with HV in clinical remission. Ultrastructurally, viral particles were detected in lymphocytes and also in keratinocytes in three experimentally phototest-induced lesions; they were not found in the surrounding normal skin. ZEBRA protein was also detected in phototest-induced lesions, but not in the surrounding normal skin. CONCLUSION: EBV is involved in HV pathogenesis and persists in adult patients with HV. A positive EBV DNA load, specific to HV in the spectrum of photosensitive disorders, might be a useful biomarker in HV.

[Fetal pulse oximetry: clinical practice]. / Oxymétrie de pouls foetal en pratique clinique.

OBJECTIVE: To assess in current practice the application of our protocol of using fetal pulse oximetry during labor, to evaluate whether fetal scalp blood sampling can be reduced and to determinate reliability of fetal pulse oximetry on the prediction of poor neonatal outcomes. STUDY DESIGN: Prospective observational unicenter cohort including 449 patients during two years. All pregnancies were singleton, greater than or equal to 37 weeks' gestation, cephalic presentation, and had non reassuring fetal heart rate. The poor neonatal outcome was defined by one of the followings: arterial umbilical cord pH

Rupture of the scarred uterus.

OBJECTIVE: To assess the risk of uterine rupture of the scarred uterus according to mode of delivery in subsequent births recorded as spontaneous labour, labour induced by oxytocin, labour after ripening with prostaglandin E2, and planned cesarean section. METHODS: Retrospective study of 2,128 births with a low transversal scar after a previous cesarean section. The study population was realised in a level III university hospital from 1995 to 2003. The association between mode of delivery and uterine rupture was studied in a multivariate logistic regression model, and adjusted for specific antenatal confounding factors. RESULTS: Over 9 years, we collected 22 cases (1%), including 11 asymptomatic ruptures in a population of 2,128 scarred uteri out of 28,248 deliveries. Uterine rupture occurred at a rate of 0.3 per 100 among women with repeated cesarean delivery without labour, 1 per 100 among women with spontaneous onset of labour, 1.4 per 100 among women with oxytocin-induced labour, and 2.2 per 100 among women with prostaglandin cervical ripening. Compared to women with a planned cesarean section, women with spontaneous onset of labour were more likely to have uterine rupture (OR: 4.0; 95% CI: 0.8-42.0). A greater relative risk was observed among women with oxytocin-induced labour (OR: 4.3; 95% CI: 0.3-60.0), and particularly those with prostaglandin-induced labour (OR: 8.7; 95% CI: 1.5-97.3, p=0.01). CONCLUSION: In women with a scarred uterus, prostaglandin E2 induction of labour is a risk factor for uterine rupture. The practice of a systematic cesarean section in cases with Bishop score<3, appropriate induction procedure, and rigorous monitoring of the labour, could make for a safer delivery.

[Complications of vacuum extractor deliveries]. / Complications des accouchements assistés par ventouse.

OBJECTIVES: To describe maternal and neonatal complications following deliveries assisted by vacuum extraction and to compare outcomes with those obtained after spontaneous vaginal delivery. We wanted to know if vacuum extractor was a risk factor by itself. MATERIALS AND METHODS: We conducted a retrospective study of two years activity involving 4524 deliveries of which 845 (18.7%) were vacuum extractor assisted. We precisely defined maternal and neonatal complications to compare their rates in spontaneous vaginal delivery and vacuum extractor groups. RESULTS: There were 1333 maternal complications and 114 neonatal complications. The adjusted risks of maternal complications were significantly higher in the vacuum extractor group for simple vaginal tears (OR=3.0; p<0.001), the simple perineal tears (OR=1.8; p<0.001) and third degree perineal tears (OR=2.7; p<0.01). For neonatal complications, the difference was significant for cephalhematomas (OR=10; p<0.001) and scalp abrasions (OR=53; p<0.001). No cases of skull fracture or subgaleal subaponeurotic hemorrhage were recorded. CONCLUSION: Our rates of maternal and neonatal complications after vacuum extractor were similar to those described in the literature. We have been able to show that vacuum extraction is itself a risk factor for third degree perineal tears and cephalhematoma. However, these complications are so infrequent that the advantages of this method of extraction argue in favor of wide use in obstetrics.

Asbestos bodies in the sputum of asbestos workers: correlation with occupational exposure.

A cross-sectional medical survey including collection of three consecutive sputum samples was carried out among 270 retired workers of a textile and friction materials factory, in order to investigate the relationship between asbestos body identification and asbestos exposure. The individual cumulative asbestos exposure, determined by means of a plant-specific job-exposure matrix based on asbestos air measurements in the workshops, proved to be heavy with a mean cumulative exposure of 217 fibres x mL(-1) x yr. Macrophages and asbestos bodies were identified in sputum samples by light microscopy. The lung origin of the sputum, suggested by the presence of macrophages and/or asbestos bodies, was confirmed in 82.6% of subjects, and 53% of these samples were positive for asbestos bodies. The prevalence of asbestos bodies was not related to sex, smoking status or latency. Conversely, multivariate analysis showed a positive relationship with cumulative exposure, duration and intensity of exposure to asbestos, as well as age and time since retirement. These findings suggest that sputum analysis for asbestos bodies may remain a relevant and noninvasive marker of heavy occupational exposure to asbestos, even years after retirement. Owing to the new perspectives in lung cancer screening, it might contribute to the identification of high-risk subjects.

Role of anxiety and depression in the onset of spontaneous preterm labor.

The aim of this cohort study conducted in France in 1997-1998 was to investigate the effects of antenatal anxiety and depression on spontaneous preterm labor. A consecutive series of 634 pregnant women with singleton pregnancies was included. Anxiety and depression were assessed using self-administered questionnaires: Spielberger's State-Trait Anxiety Inventory and the Edinburgh depression scale. Depression scores were dichotomized with a cutoff value suggestive of major depression. The 75th percentile was used for anxiety scores. A logistic regression analysis, controlling for sociodemographic and biomedical factors and including interaction terms, revealed that depression was positively associated with the outcome among underweight women, defined as women with a prepregnancy body mass index below 19 (adjusted odds ratio (OR) = 6.9, 95% confidence interval (CI): 1.8, 26.2). A similar result was observed for trait anxiety in women with a history of preterm labor (adjusted OR = 4.8, 95% CI: 1.1, 20.4). The association was close to significance for state anxiety in women with vaginal bleeding (adjusted OR = 3.6, 95% CI: 0.9, 14.7). These findings show that anxiety and depression, when combined with specific biomedical factors, are associated with spontaneous preterm labor. A synergic action of psychological and biomedical factors on the secretion of placental corticotropin-releasing factor is hypothesized.

[Predictive value of non-automated spermatic parameters and automated kinetic parameters on cleavage rate in fertilization in vitro]. / Valeur prédictive des paramètres spermatiques non automatisés et des paramètres cinétiques automatisés sur les taux de clivage en fécondation in vitro.

The aim of this work was to determine retrospectively in 114 couples the predictive value of semen analysis for the in vitro fertilization (IVF) outcome when sperm evaluation before IVF was assessed by either conventional parameters or a Hamilton-Thorne automated motility analyser. A backward logistic regression analysis was used to study the relative contribution of each conventional or computerized parameter. Computerized sperm values were the worst index for predicting oocyte fertilization. However a tight relationship between morphology and cleavage ratio was observed. Using ROC analysis, under a 18% threshold, cleavage failure was noted in 71% of couples undergoing an IVF program. This study indicates that morphology is the best parameter for predicting cleavage failure.

Nonspecific back pain in children. A search for associated factors in 14-year-old schoolchildren.

BACKGROUND: Nonspecific back pain in children is nearly as common as in adults but is associated with a number of age-specific risk factors including female gender, a family history of low back pain, a high level of physical activity, and prolonged sitting. OBJECTIVE: To investigate potential school-related risk factors for back pain in children, most notably schoolbag weight expressed as a percentage of body weight (relative schoolbag weight), whether the schoolbag is carried by hand or by a shoulder harness, how the child travels to and from school, and sitting positions. PATIENTS AND METHODS: 123 eighth-graders, 58 girls and 65 boys, with a mean age of 14 +/- 0.6 years, completed an anonymous self-questionnaire during a school day involving six hours of classes. Their schoolbag was weighed on the same day. RESULTS: Most respondents traveled to and from school in a vehicle (70%), made one trip in each direction each day (75%), and carried their schoolbag by the shoulder harness (92%). The prevalence of back pain on the study day was 27.6%, whereas the cumulative prevalence for the last 12 months was 82.9% with 16.3% of respondents reporting a single episode of pain, 57.7% recurrent pain, and 8.9% chronic pain. A need for a physician visit for back pain was reported in 18.7% of cases, and 14.6% of respondents had missed school and/or sporting activities because of back pain. Female gender was associated with current back pain (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.2-6.1). A relative schoolbag weight of 20% or more was associated with a history of back pain (OR, 3.1; 95% CI, 1.0-9.2), and this effect was larger in children who traveled to and from school on foot and in those who carried their schoolbag in their hand. Sitting on the edge of the chair while completing the questionnaire was significantly associated with a history of a physician visit for back pain (OR, 3.1; 95% CI, 1.0-9.5). Neither handedness nor the position of the questionnaire on the table were significantly associated with back pain in our study population. CONCLUSIONS: The findings from this cross-sectional study indicate a need for a longitudinal prospective study designed to identify etiologic and prognostic factors of back pain in adolescents, with the goal of devising preventive strategies likely to reduce the risk of low back pain in adulthood.