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Background: Renal biopsy (RB) is necessary for the diagnosis, prognosis, and therapy guidance of native kidney diseases. Few studies have compared outcomes of RB procedures. We retrospectively compared the safety and efficiency of five biopsy procedures. Methods: The number of glomeruli on light microscopy (LM) and on immunofluorescence (IF) and serious adverse events following RB performed in five nephrology units (C1–C5) were collected. C1 performed ultrasound (US) assessment before RB and used a 14-gauge core-cutting needle biopsy gun, C2 US guidance and a 14-gauge needle, C3 tomodensitometry guidance and a 14-gauge needle, C4 US guidance and a 16-gauge needle, and C5 tomodensitometry guidance and a 16-gauge needle. Results: RB was performed in 943 adults between January 2006 and July 2010. Serious adverse events occurred in 1.5% of biopsies. The complication rate was not different between nephrology units. The mean number of glomeruli on biopsy was 14.2 ± 8.6 with LM and 4.4 ± 3.3 on IF. It was different according to the nephrology unit for LM (p = 0.01) and for IF (p < 0.001). The number of failed biopsies was influenced by the nephrology unit and radiological guidance technique, favoring real-time US guidance. Failed biopsies using US or tomodensitometry assessment before RB was certainly due to kidney imprecise localization since it was often non-renal tissue sampling. At least 10 glomeruli were found in 69% of biopsies on LM. This rate varied according to the nephrology unit (p = 0.004) and was higher when 14-gauge needles were used in comparison with 16-gauge needles. Conclusion: RB is safe regardless of the technical procedure, but radiological guidance and needle size influence the efficiency of biopsies.

STUDY DESIGN Prospective study. OBJECTIVE The aim of this prospective study is to analyze the influence of Modic type on the clinical results of lumbar total disc arthroplasty. SUMMARY OF BACKGROUND DATA Some patients with lumbar disc degeneration have endplate signal changes on magnetic resonance images, which have been classified by Modic. Modic-1 endplates changes are associated with an inflammatory phase of the disease whereas Modic-2 endplates changes correspond to a quiescent phase with a fatty replacement. The effect of Modic endplate changes on the clinical results of lumbar fusion has been studied by multiple authors, but the influence of Modic type on clinical outcomes of lumbar disc replacement is not known. METHODS A total of 221 patients with a mean age of 42 years were included in this study. Of which, 107 patients were classified Modic 0, 65 Modic 1, and 49 Modic 2. Clinical evaluation (Oswestry Disability Index [ODI], lumbar and radicular pain using the Visual Analog Score [VAS]) was performed preoperatively and at 3, 6, 12, and 24 months minimum postoperatively. RESULTS Mean follow-up was 30 months (24-72 months). Significant clinical improvement (P < 0.05) was observed in pain and ODI between the preoperative evaluation and final follow-up. Multivariate analysis between the 3 groups demonstrated a significant difference in Oswestry Disability Index (size of the effect was measured at -0.3 [-0.55-0.04]) and on the radicular pain (size of the effect was measured at -0.4 [-0.7-0.1]), with lower scores in the group classified Modic 1. CONCLUSION Superior results were achieved in the group of patients with Modic-1 endplate changes on magnetic resonance images. These data may be helpful in patient selection and in preoperative patient counseling.

Aims: To evaluate auxological parameters in children and adults with a 22q11.2 microdeletion syndrome (22q11.2 DS) and to compare prevalence of obesity to that in the French general population. Methods: 102 patients with 22q11.2 DS (49 males, 53 females) were recruited from birth to adulthood through a reference center in southern France. Results: Mean BMI Z score and mean height were normal (0.07 ± 1.49 SD, –0.87 ± 1.36 SDS, respectively). 16.1% of patients were overweight (including obese), 57% out of them being born small for gestational age for length versus 25% of non-overweight patients. During infancy, BMI increased in girls (+0.89 SD Z score). Childhood: 14.7% were overweight, prevalence similar to that of the in French children population. Adulthood: 19.2% were overweight. BMI Z scores were inversely correlated with neonatal length (p = 0.026) and female sex (p = 0.032) but positively associated with neonatal weight (p = 0.036). From analysis of neonatal data, 22q11.2 DS newborns were significantly shorter with regard to their weight (p < 0.01), even though mean neonatal measures were above –2 SDS. Conclusions: Our study did not find a higher prevalence of overweight in 22q11.2 DS to that in the French population. The BMI Z score was inversely correlated with neonatal length and female gender but positively associated with neonatal weight.

Objectifs L’objectif principal est de mesurer l’impact des particules en suspension (PM), estime a proximite du domicile des enfants, sur les admissions pour exacerbation d’asthme aux urgences dans le departement des Bouches-du-Rhone en 2013 chez l’enfant. Materiel et methodes Un cas temoins emboite dans une cohorte est realise chez les enfants de 3 a 18 ans. L’appariement etait aleatoire sur le jour de la consultation aux urgences. L’exposition aux PM 10 et PM 2,5, les donnees meteorologiques, polliniques et virologiques du jour de consultation etaient correlees au code geographique du domicile du patient et analysees par rapport au motif de consultation. Resultats principaux Notre etude concernait 68 897 consultations, dont 1182 asthmatiques. L’exposition a court terme aux PM 10 etait associee a un exces de risque de consultation pour asthme (RR = 1,02, IC 95 % :1,01–1,04 ; p = 0,02). Le sexe masculin, le jeune âge et la temperature etaient egalement des facteurs de risque. Par contre, le vent etait retrouve comme facteur protecteur. Conclusion Les PM 10 et certains facteurs meteorologiques, estimes au plus proche du domicile des enfants, augmentent le risque de consultation aux urgences pour exacerbation d’asthme chez les enfants de 3 a 18 ans dans les Bouches-du- Rhone.

SummaryBackgroundDespite improvement in revascularization strategies, microvascular obstruction (MO) lesions remain associated with poor outcome after ST-segment elevation myocardial infarction (STEMI).AimsTo establish a bedside-available score for predicting MO lesions in STEMI, with cardiac magnetic resonance imaging (CMR) as the reference standard, and to test its prognostic value for clinical outcome.MethodsPatients with STEMI of4 accurately identified microcirculatory injuries (sensitivity 84%; specificity 82%) and independently predicted the presence of MO lesions on CMR. MO score>4 predicted adverse cardiovascular events during the first year after STEMI (relative risk 2.60 [1.10–6.60], p=0.03).ConclusionsMO lesions are frequent in PCI-treated STEMI and are associated with larger MIs. MO score accurately predicted MO lesions and identified patients with poor outcome post-STEMI.

The classical models of epidemics dynamics by Ross and McKendrick have to be revisited in order to incorporate elements coming from the demography (fecundity, mortality and migration) both of host and vector populations and from the diffusion and mutation of infectious agents. The classical approach is indeed dealing with populations supposed to be constant during the epidemic wave, but the presently observed pandemics show duration of their spread during years imposing to take into account the host and vector population changes as well as the transient or permanent migration and diffusion of hosts (susceptible or infected), as well as vectors and infectious agents. Two examples are presented, one concerning the malaria in Mali and the other the plague at the middle-age.

S. Bataille, V. Moal, J. Gaudart, M. Indreies, R. Purgus, B. Dussol, C. Zandotti, Y. Berland, H. Vacher-Coponat. Cytomegalovirus risk factors in renal transplantation with modern immunosuppression Transpl Infect Dis 2010: 12: 480–488. All rights reserved Background. Immunosuppressive regimens have lowered the rate of kidney rejection, but with increasing immunodeficiency-related complications. New cytomegalovirus (CMV) prophylaxis also has become available. The impact of these 2 developments on CMV diseases has not been well evaluated. We conducted a randomized trial comparing a drug regimen common in the 1980s, cyclosporin A (CsA) with azathioprine (Aza), with a drug combination used most today, tacrolimus (Tac) with mycophenolate mofetil (MMF), and we analyzed CMV risk factors in kidney transplant patients. Methods. The 300 patients included in the trial underwent the same universal prophylaxis and preemptive therapy. CMV events and risk factors were prospectively recorded. Results. With preventive and preemptive strategies combined for 3 months, CMV replication was detected in 32.6% and CMV disease in 18.1% of patients. Multivariate analysis on risk factors for CMV disease were CMV donor (D)/recipient (R) matching and first month renal function (risk ratio [95% confidence interval]: 1.02 [1.01; 1.04]; P=0.011), but not the immunosuppressive regimen (P=0.35). The D+/R− combination increased the risk of CMV disease by a factor of 9 (P

Introduction La proximite d’un environnement favorable a la transmission (ex. presence de gites larvaires pour le cas du paludisme) modifie l’exposition aux maladies transmissibles. Lors d’essais cliniques, cette heterogeneite spatiale de l’exposition pourrait influer sur les resultats si elle n’est pas prise en compte dans la randomisation ou dans l’analyse. L’objectif de ce travail etait de quantifier l’impact de l’heterogeneite spatiale et de comparer ses methodes d’analyse. Methode Huit scenarios ont ete simules (50 echantillons, 1000 individus) avec des parametres issus de la litterature : localisation suivant un processus de Poisson inhomogene, risque de base (0,37) ; effet âge (RR = 0,8) ; effet sexe nul. La difference a porte sur l’effet traitement faible ou fort (RR = 0,8 ; 0,25) ; la densite de gites faible ou forte (0,25 ; 0,75) et l’effet gite faible ou fort (RR = 1,2 ; 3). La randomisation entre sujets « traites » et « temoins » a permis la simulation de l’essai. L’impact de l’heterogeneite spatiale de l’exposition a ete quantifie par la mesure du biais et de l’erreur quadratique moyenne (MSE) sur l’estimation de l’effet du traitement lors de l’analyse par un modele de Cox non spatial. L’heterogeneite spatiale a ete modelisee suivant trois methodes : modele additif generalise (GAM) avec des fonctions splines bivariees ; modele d’equations aux derivees partielles stochastiques (SPDE) ; modele de Poisson. Les modeles SPDE et Poisson (fonction de Matern) ont utilise la methode bayesienne (INLA). Resultats Deux grandes categories de scenarios ont ete identifiees lors de l’analyse de l’efficacite du traitement. Faible densite des gites (0,25) avec effet faible (RR = 1,2) : le biais et le MSE du Cox etaient faibles. La modelisation spatiale a apporte peu d’amelioration. Le SPDE tendait a sous-estimer les forts effets du traitement. Forte densite des gites (0,75) avec effet fort (RR = 3) : le biais et le MSE du Cox etaient eleves et similaires a ceux du GAM. La modelisation spatiale avec SPDE et Poisson a permis d’ameliorer le biais et le MSE mais ils etaient plus faibles et moins variant pour le Poisson. Conclusion Sur la base des scenarios simules, ces resultats ont montre, que dans un essai clinique, la randomisation classique n’eliminait pas completement l’impact de l’heterogeneite spatiale. Il donc est necessaire de le prendre en compte dans la modelisation pour les maladies liees a une exposition heterogene.

The study design includes prospective evaluation of percutaneous osteosynthesis associated with cement kyphoplasty on 18 patients. The objective of the study is to assess the efficacy of a percutaneous method of treating burst vertebral fractures in patients without neurological deficits. Even if burst fractures are frequent, no therapeutic agreement is available at the moment. We report in this study the results at 2 years with a percutaneous approach for the treatment of burst fractures. 18 patients were included in this study. All the patients had burst vertebral fractures classified type A3 on the Magerl scale, between levels T9 and L2. The patients' mean age was 53 years (range 22-78 years) and the neurological examination was normal. A percutaneous approach was systematically used and a kyphoplasty was performed via the transpedicular pathway associated with percutaneous short-segment pedicle screw osteosynthesis. The patients' follow-up included CT scan analysis, measurement of vertebral height recovery and local kyphosis, and clinical pain assessments. With this surgical approach, the mean vertebral height was improved by 25% and a mean improvement of 11.28 degrees in the local kyphotic angle was obtained. 3 months after the operation, none of the patients were taking class II analgesics. The mean duration of their hospital stay was 4.5 days (range 3-7 days) and the mean follow-up period was 26 months (range 17-30 months). No significant changes in the results obtained were observed at the end of the follow-up period. Minimally invasive methods of treating burst vertebral fractures can be performed via the percutaneous pathway. This approach gives similar vertebral height recovery and kyphosis correction rates to those obtained with open surgery. It provides a short hospital stay, however, and might therefore constitute a useful alternative to open surgical methods.

Contexte : Depuis 2006/2007, l'enseignement de lecture critique d'articles (LCA) scientifiques en DCEM3 mis en place a la faculte de medecine de Marseille se deroule en mode hybride, avec l'aide, en amont et en aval du cours en presentiel, de la plate-forme numerique eCUME (e-Cursus a l'Universite de la MEditerranee). Buts : Decrire l'utilisation par les etudiants de cette nouvelle plate-forme pedagogique et rechercher une association entre son utilisation et les scores obtenus a l'examen de LCA. Methodes : Cette etude a inclus 275 etudiants inscrits pour la premiere fois en DCEM3 en 2007/2008 et presents a l'examen de LCA. Les traces de connexion concernant 91 ressources didactiques reparties en huit types informationnels ont ete analysees. Resultats : Parmi les 275 etudiants, 195 ont accede a au moins une des ressources etudiees (70,9 %). L'ensemble des etudiants ont consulte une mediane de 15 ressources (entre 0 et 150). Les quartiles d'utilisation de la plate-forme pedagogique etaient significativement lies au score final sur 20 (10,6 ; 10,7 ; 11,8 ; 11,6 pour respectivement 0 ; 1 a 15 ; 16 a 39 et 40 a 150 consultations de ressources didactiques ; p ). Apres ajustement sur le niveau general (scores hors LCA en DCEM3) et specifique (score de LCA en DCEM2) de l'etudiant, ceux ayant accede a plus de 15 ressources conservaient un meilleur score final (p = 0{,}001 ). Conclusion : L'utilisation, meme debutante, par les etudiants d'une nouvelle plate-forme numerique pour la pedagogie et l'investissement pedagogique realise peuvent avoir un impact positif sur l'apprentissage de la lecture critique d'articles scientifiques.

OBJECTIVE: Osteoporotic compression fractures, which can lead to neurological com- plications in some cases, are an increasingly frequent occurrence. These lesions require decompression surgery with or without spinal stabilization procedures. In this article, we present the preliminary results obtained using open kyphoplasty, a new method of treating vertebral compression disorders. METHODS: Sixteen patients were included in this prospective study, and a total of 17 vertebrae were treated. All of the patients had vertebral compression fractures associated with neurological disorders. The surgical treatment consisted of open kyphoplasty after laminectomy and decompression. Short-segment vertebral osteosynthesis was also performed in patients with pronounced local kyphosis. Pain was rated at clinical assessments, and radiological assessments were performed to determine the restored vertebral height and the correction of any local vertebral kyphosis. RESULTS: Analysis of the results obtained using this method showed that vertebral height was significantly improved (P < 0.001) and local kyphosis was significantly reduced (P < 0.001). The mean operating time was 90 minutes. The neurological status of all patients improved; 14 patients recovered completely from their neurological symptoms. The last 2 patients had associated neurological disease but were able to walk. There were 2 superficial postoperative infections. CONCLUSION: This method for treating severe osteoporotic compression fractures associated with neurological disorders gives successful results and can be used to treat neurological compression fractures while consolidating the vertebral body. Therefore, this less invasive approach seems to be particularly useful for treating compression fractures in the thoracolumbar spine junction in elderly patients who often have comorbidities.

A prospective epidemiological study was conducted to evaluate the incidence of febrile cough episodes among adult Muslims travelling from Marseille to Saudi Arabia during the Hajj pilgrimage and to assess if use of statin had an influence on this incidence. In total, 580 individuals were presented with a questionnaire. A significant proportion of individuals had chronic medical disorders, e.g. diabetes mellitus (132, 22.8%) and hypertension (147, 25.3%). Pilgrims had a low level of education and a low employment rate. Sixty (10.3%) were treated with statins for hypercholesterolemia. Four hundred and fourty-seven pilgrims were presented a questionnaire on returning home. A total of 74 travellers (16.6%) experienced fever during their stay in Saudi Arabia (67 attended a doctor) and 271 (60.6%) had cough (259 attended a doctor); 70 travellers with cough were febrile (25.9%). Seventy per cent of the travellers who suffered cough episodes developed their first symptoms within 3 days, suggesting a human to human transmission of the responsible pathogen, with short incubation time as evidenced by a bimodal distribution of cough in two peaks at a 24 h interval. None of demographical and socioeconomic characteristics, underlying diseases or vaccination against influenza significantly affected the occurrence of cough. Diabetes correlated with an increased risk of febrile cough (OR = 2.02 (1.05–3.89)) as well as unemployment (OR = 2.22 (0.91–5.53)). Use of statins had no significant influence on the occurrence of cough and/or fever during the pilgrimage. This result suggests that while treatment with a statin has been demonstrated to reduce the mortality from severe sepsis associated with respiratory tract infections, it probably does not play a role in the outcome of regular febrile cough episodes as observed in the cohort studied here.

Relative survival assesses the effects of prognostic factors on disease-specific mortality when the cause of death is uncertain or unavailable. It provides an estimate of patients' survival, allowing for the effects of other independent causes of death. Regression-based relative survival models are commonly used in population-based studies to model the effects of some prognostic factors and to estimate net survival. Most often, studies focus on routinely collected prognostic factors for which the proportion of missing values is usually low (around 5 per cent). However, in some cases, additional factors are collected with a greater proportion of missingness. In the present article, we systematically assess the performance of multiple imputation in regression analysis of relative survival through a series of simulation experiments. According to the assumptions concerning the missingness mechanism (completely at random, at random, and not at random) and the missingness pattern (monotone, non-monotone), several strategies were considered and compared: all cases analysis, complete cases analysis, missing data indicator analysis, and multiple imputation by chained equations (MICE) analysis. We showed that MICE performs well in estimating the hazard ratios and the baseline hazard function when the missing mechanism is missing at random (MAR) conditionally on the vital status. In the situations where the missing mechanism was not MAR conditionally on vital status, complete case behaves consistently. As illustration, we used data of the French Cancer Registries on relative survival of patients with colorectal cancer.

Determination of age at the time of death based on the observation of cranial sutures has led to numerous studies with sometimes contradictory results. The initial hypothesis being that suture closure is part of an age-related physiological process, the conflicting results have been interpreted by various authors as secondary to the choice of sutures, under the co-existing influence of pathological factors or genetic factors, or even independent of age. Despite these differences, macroscopic methods remain much used in anthropology and in forensic medicine. In our work, we evaluated the value of the degree of closure of the frontosphenoidal suture in estimating age at death of mature subjects, with the secondary objective of establishing a linear regression which could be used in routine practice. The study concerned bone specimens from individuals whose age, sex and medical history were known. Macroscopic observation was carried out on the ectocranial and endocranial sides according to four stages of closure previously defined. 290 sutures were taken from a population of whom two-thirds were men. The method can be repeated and reproduced and the regression established shows the confidence range for average error to be +/-1.5 years. While this result is of interest in terms of precision in prediction for a group of people, the prediction range is too great (+/-23 years) to be applicable to a single individual as part of a forensic procedure.

Background Various statistical methods have been developed to describe spatial heterogeneity, in terms of high risk zones. If no source can be determined, this heterogeneity can be globally or locally described. Global methods test a statistic estimated over the whole studied geographical area, whereas local methods estimate a statistic on each spatial unit (or regrouping unit). This paper aimed to present, and to compare results of an epidemiological application, of five methods of spatial cluster detection. Methods The two global detection methods were: 1) Moran's coefficient, a classically used autocorrelation coefficient; 2) Tango's statistic, a spatial generalization of the Chi2 statistic. The three local methods were: 1) the local application of Moran's coefficient, proposed by Anselin; 2) the scan statistic, which searches for grouping of spatial units; 3) the oblique regression tree, which splits the studied zone into sub-zones of different risks. These five methods were applied to the description of the spatial heterogeneity of the malaria risk over a hyperendemic village, in Mali. Results All the methods highlighted a significant spatial heterogeneity. Both global methods (Moran's coefficient and Tango's statistic) showed weak spatial correlations. Local Moran's coefficient (with Bonferronis' adjustment) highlighted five spatial units. The scan statistic identified a single high risk cluster. The regression oblique tree split the study area into six sub-zones; the sub-zone with the higher risk was consistent with the cluster identified by the scan statistic. Conclusion These presented methods do not require any previous knowledge of a source. They allow evaluating spatial risk heterogeneity over the entire geographical area under study. It is noteworthy that shape, size, and spatial heterogeneity characteristics (either global or local) of the study area, as well as the definition of the proximity, significantly influence the spatial risk analysis' outcome. Although their results should be cautiously interpreted, these methods are useful for preliminary field studies or epidemiological surveys.

International audience; We present a simple theoretical model of household preventive behavior in response to malaria prevalence. The novelty is to include a trade-off between prevention and treatment in an otherwise standard epidemiological model of disease transmission, which depends on the relative price of treatment with respect to prevention. A relatively low price of treatment reduces prevention.

International audience; Background The human landing catches is the gold standard method used to study the vectors of malaria and to estimate their aggressiveness. However, this method has raised safety concerns due to a possible increased risk of malaria or other mosquito-borne diseases among the mosquito collectors. The aim of this study was to evaluate the incidence of malaria attacks among mosquito collectors and to compare these results with those of non-collectors in a Senegalese village. Methods From July 1990 to December 2011, a longitudinal malaria study involving mosquito collectors and non-collectors was performed in Dielmo village, Senegal. During the study period, 4 drugs were successively used to treat clinical malaria, and long-lasting insecticide-treated nets were offered to all villagers in July 2008. No malaria chemoprophylaxis was given to mosquito collectors. Incidence of uncomplicated clinical malaria and asymptomatic malaria infection were analyzed among these two groups while controlling for confounding factors associated with malaria risk in random effects negative binomial and logistic regression models, respectively. Results A total of 3,812 person-trimester observations of 199 adults at least 15 years of age were analyzed. Clinical malaria attacks accounted for 6.3% both in collectors and non-collectors, and asymptomatic malaria infections accounted for 21% and 20% in collectors and non-collectors, respectively. A non-significant lower risk of malaria was observed in the collector group in comparison with the non-collector group after adjusting for other risk factors of malaria and endemicity level (Clinical malaria: adjusted incidence rate ratio = 0.89; 95% confidence interval = 0.65-1.22; p= 0.47). Conclusion Being a mosquito collector in Dielmo was not significantly associated with an increased risk of malaria both under holoendemic, mesoendemic and hypoendemic conditions of malaria epidemiology. This result supports the view that HLC, the most accurate method for evaluating malaria transmission, may be used without health concerns in Dielmo.

Introduction Plusieurs methodes statistiques permettent d’evaluer l’impact d’un facteur sur la repartition spatiale d’une maladie donnee. Cependant, leur fiabilite est souvent remise en question et des variations spatiales reelles peuvent etre confondues a celles issues d’un bruit statistique, surtout lorsque les indicateurs sanitaires sont disponibles a une echelle tres fine mais tres variable comme celle des communes. Lorsque les incidences sont cartographiees, les comparaisons d’incidence entre aires geographiques ne sont valides que lorsque certains tiers facteurs, associes a la survenue de la maladie, ne different pas significativement entre les unites spatiales. Dans le domaine du cancer, plusieurs etudes ont demontre qu’il existe un lien entre les variations geographiques de certains cancers et le niveau socioeconomique des individus. L’objectif de notre travail etait d’evaluer l’impact de la prise en compte d’un indicateur du niveau socioeconomique dans la detection de clusters spatiaux de cancers, en comparant, de maniere empirique, differentes methodes. Methodes Les tests du I de Moran et Potthoff-Whittinghill ont ete utilises comme methode de detection globale de cluster. Les methodes de detection locale etaient : (i) la methode de l’arbre de regression oblique (SpODT) ; (ii) la methode de balayage de Kulldorff (SATSCAN) et (iii) la methode de lissage bayesien spatial. Ces methodes ont ete utilisees sans covariable, puis avec introduction de l’indice de deprivation socioeconomique de Townsend. Nous avons utilise les donnees d’incidence du registre du cancer de l’Isere concernant les cancers de la prostate, du poumon, du colon rectum et de la vessie, chez les hommes diagnostiques entre 1999 et 2007. Resultats Nous avons montre que les resultats fournis par les differentes methodes de detection etaient globalement coherents pour les sites consideres. Pour le cancer de la prostate uniquement, nous avons mis en evidence une tres faible autocorrelation (I = 0,01 ; p 1,2) dont l’un au centre et trois autres en bordure de carte. Apres introduction de l’indice de Townsend, aucun cluster significatif de cancer de la prostate n’etait retrouve avec SATSCAN. En revanche, l’ajout de ce cofacteur ne modifiait pas les resultats obtenus avec les autres methodes. Conclusion L’absence de modification du clustering spatial avant et apres l’integration de la deprivation suggere que les inegalites socioeconomiques n’impactent pas (ou peu) la variabilite spatiale de l’incidence du cancer de la prostate et que les methodes de detection de cluster restent robustes. De plus, dans ce contexte ou des clusters ont ete detectes en bordure de la zone etudiee, l’impact des effets de bord reste egalement important a evaluer.

BACKGROUND: Microvascular decompression (MVD) is the reference technique for pharmacoresistant trigeminal neuralgia (TN). OBJECTIVE: To establish whether the safety and efficacy of Gamma Knife surgery for recurrent TN are influenced by prior MVD. METHODS: Between July 1992 and November 2010, 54 of 737 patients (45 of 497 with >1 year of follow-up) had a history of MVD (approximately half also with previous ablative procedure) and were operated on with Gamma Knife surgery for TN in the Timone University Hospital. A single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.6 mm (range, 3.9-11.9 mm) anterior to the emergence of the nerve. A median maximum dose of 85 Gy (range, 70-90 Gy) was delivered. RESULTS: The median follow-up time was 39.5 months (range, 14.1-144.6 months). Thirty-five patients (77.8%) were initially pain free in a median time of 14 days (range, 0-180 days), much lower compared with our global population of classic TN (P = .01). Their actuarial probabilities of remaining pain-free without medication at 3, 5, 7, and 10 years were 66.5%, 59.1%, 59.1%, and 44.3%. The hypoesthesia actuarial rate at 1 year was 9.1% and remained stable until 12 years (median, 8 months). CONCLUSION: Patients with previous MVD showed a significantly lower probability of initial pain cessation compared with our global population with classic TN (P = .01). The toxicity was low (only 9.1% hypoesthesia); furthermore, no patient reported bothersome hypoesthesia. However, the probability of maintaining pain relief without medication was 44.3% at 10 years, similar to our global series of classic TN (P = .85).

International audience; Aims: The VALEO ® vascular stent is a stainless steel, pre-mounted, open-cell stent. Redilation to large diameters and low profile are advantages in growing children. Clinical experience is scarce. This study aimed to analyse our experience with the use of the VALEO ® vascular stent in children. Methods and results: Between June 2010 and December 2012, 41 VALEO ® stents were inserted during 30 transcatheter (group 1) and three perioperative procedures (group 2). Data were retrospectively analysed. Median age at implantation was 3.8 years (four days-23 years), and median weight was 13.3 kg (2.2-53 kg). Indications were: pulmonary artery (n=23), pulmonary vein (n=1) or subhepatic vein (n=1) stenosis, and ductus arteriosus stenting (n=8). Stent placement was achieved in all but one. Acute complications (n=11) included stent dislodgement in two patients and fracture in three patients, with vessel predilatation as a risk factor. Median " stent " follow-up reached 7.83 months (0.4-34.3 months) and included 26 recatheterisations (23 patients, median interval 6.2 months, range 0.2-33 months). Ten stents were redilated. Surgery in six patients (interval 1.9 to 10 months) showed patent endothelialised stents. No " late " type II or III stent fractures were seen. Conclusions: The VALEO ® stent is useful in children. Low radial force is counterbalanced by high flexibility , allowing implantation in distal and tortuous lesions. Early fractures occur. Longer-term follow-up is needed. KEYWORDS • bare metal stent • congenital heart diseases • ductus arteriosus

International audience; Every year, more than 10 million pilgrims arrive in the Kingdom of Saudi Arabia for the Hajj or Umrah. Crowding conditions lead to high rates of respiratory infections among the pilgrims, representing a significant cause of morbidity and a major cause of hospitalization. Pre- and post-Hajj nasal specimens were prospectively obtained from a paired cohort (692 pilgrims) and from nonpaired cohorts (514 arriving and 470 departing pilgrims) from 13 countries. The countries of residence included Africa (44.2%), Asia (40.2%), the United States (8.4%) and Europe (7.2%). Nasal specimens were tested for 34 respiratory pathogens using RT-PCR. A total of 80 512 PCRs were performed. The prevalence of viruses and bacteria increased, from 7.4% and 15.4% before the Hajj to 45.4% and 31.0% after the Hajj, respectively, due to the acquisition of rhinovirus, coronaviruses (229E, HKU1, OC43), influenza A H1N1, Streptococcus pneumoniae, Haemophilus influenzae and Staphylococcus aureus. We did not identify Middle East respiratory coronavirus carriage. At arrival, the prevalence of several viruses was clearly dependent on the pilgrim's country of origin. After Hajj participation, these viruses were isolated among pilgrims from all countries, with few exceptions. No significant differences were observed between paired and nonpaired cohort results. Our results strongly suggest that, given the particularly crowded conditions during the rituals, an international mass gathering such as the Hajj may contribute to the globalization of respiratory pathogens after the cross-contamination of pilgrims harbouring pathogens that easily spread among participants. Influenza and pneumococcal vaccination, face mask use and hand hygiene should be considered in the context of the Hajj.

Resume Introduction Il existe peu d’etudes concernant les problemes medicaux rencontres chez les enfants places a l’Aide sociale a l’enfance (ASE). L’objectif de notre etude etait de decrire la population des mineurs places a l’ASE et ayant fait l’objet d’une notification a la MDPH (Maison departementale des personnes handicapees) des Bouches-du-Rhone au 1er janvier 2014. Patients et methodes Le registre informatique de l’ASE et celui de la MDPH ont ete croises afin d’en extraire les donnees administratives. Apres une analyse des dossiers medicaux MDPH, les informations sur les enfants places (âge gestationnel, deficiences, pathologies) ont ete codees. Resultats Parmi les 2965 mineurs places (0,7 % des mineurs de notre region), 506 (17 %) avaient une notification a la MDPH, contre 2,5 % en population generale. Parmi eux, 80,2 % avaient ete confies suite a une mesure de placement et 50 % des notifications MDPH concernaient les orientations vers un etablissement scolaire et medico-social. On a note 2,1 deficiences par enfant, dont 35,9 % etaient des deficiences du psychisme, 26,4 % des deficiences du langage et de la parole et 21,6 % des deficiences intellectuelles cognitives. Les pathologies rencontrees etaient pour 71 % des troubles mentaux et du comportement. Les enfants les plus jeunes et places en famille d’accueil presentaient plus de pathologies et de deficiences d’organe et peu d’atteintes du psychisme. Les enfants presentant des troubles du comportement etaient en general plus âges et places en foyer. Discussion Le taux de notification MDPH est 7 fois plus eleve parmi les enfants places qu’en population generale. Ce lien entre enfance en danger et handicap est difficile a expliquer, et la psychopathologie des enfants places complexe. Ces resultats illustrent la necessite d’un suivi adapte aux besoins specifiques de ces enfants.

International audience; Background Novel treatments against for tinea capitis are needed, and the natural aminosterol squal-amine is a potential topical antidermatophyte drug candidate. Objectives This phase II randomized double-blind placebo-controlled clinical trial aimed at testing the efficacy and safety of a three-week squalamine ointment regimen for the treatment of tinea capitis. Patients Males aged 6–15 years presenting with tinea capitis were treated with either topical squal-amine ointment or placebo for 3 weeks. The primary endpoint was complete clinical cure. The secondary endpoints were the occurrence of local and/or sys-temic adverse events, mycological cure, and partial clinical response. Prospective follow-up of clinical adverse events was performed daily. Results Five patients were treated with 1 % squal-amine ointment and 15 with placebo. No complete cure was observed. No clinical or biological adverse event was recorded. A significantly (p = 0.03) better hair-growth score, indicating a partial clinical improvement of the tinea capitis lesion, was observed in the patients treated with squalamine compared to those treated with placebo. Conclusion This three-week squalamine ointment regimen was well tolerated and showed an encouraging partial clinical activity for the treatment of tinea capitis. Further studies are needed to evaluate the efficacy of topical squalamine alone against tinea corporis or in combination with a systemic antider-matophyte drug against tinea capitis.

International audience; The incidence of malaria has decreased recently in parts of Africa, coinciding with the widespread use of long-lasting insecticide-treated nets (LLINs) and artemisinin-based combination therapy (ACT). This reduction was also observed in Dielmo, our study area, and it was associated with the use of ACT as the first-line treatment against malaria beginning in 2006 and the implementation of LLINs in 2008. However, an unexplained slight increase in malaria incidence was observed in October and November of 2013. The aim of this study was to identify individual and environmental risk factors for malaria using a case-control study approach. Thirty cases and sixty controls were investigated. The use of LLINs was protective against malaria (adjusted odds ratio [AOR] = 0.10; 95% confidence interval [95% CI] = 0.02–0.45; P = 0.003). The risk of malaria transmission was high among villagers who watched television outside the house or the bedroom during the night (AOR = 8.83; 95% CI = 1.39–56.22; P = 0.021). The use of LLINs should be reinforced by the use of individual protection measures to avoid malaria transmission outside of the home. BACKGROUND

International audience; To determine when risk for Buruli ulcer is highest, we examined seasonal patterns in a highly disease-endemic area of Cameroon during 2002-2012. Cases peaked in March, suggesting that risk is highest during the high rainy season. During and after this season, populations should increase protective behaviors, and case detection efforts should be intensified.

Premature birth is a factor of increased blood pressure in adulthood. Little is known about the physiologic characteristics of the arterial bed in neonates. The aim of this study was to characterize in vivo the arterial compliance in neonates and its maturation profile in very low birth weight (VLBW) premature infants. A group of stable, VLBW premature infants was compared with a control group of near term neonates. The abdominal aortic wall distensibility coefficient (DC) and whole-body arterial compliance (WBAC) were determined using specifically designed noninvasive methods, based on ultrasonic measurements in combination with synchronous, beat-to-beat recording of aortic pulse pressure (PP). On the fifth day of life, WBAC and the CD were lower in VLBW premature infants than in controls. Furthermore, WBAC and the DC remained unchanged in VLBW premature infants 7 wk after birth. In conclusion, VLBW premature infants are characterized as early as the fifth day of life by high arterial stiffness, which persists when they reach their theoretical term. It can be speculated that early alteration of arterial elastic properties may pave the way for long-term elevation of arterial pressure in VLBW premature infants.

The purpose of this study was to establish the safety and efficacy of repeat Gamma Knife surgery (GKS) for recurrent trigeminal neuralgia (TN).Using the prospective database of TN patients treated with GKS in Timone University Hospital (Marseille, France), data were analyzed for 737 patients undergoing GKS for TN Type 1 from July 1992 to November 2010. Among the 497 patients with initial pain cessation, 34.4% (157/456 with ≥ 1-year follow-up) experienced at least 1 recurrence. Thirteen patients (1.8%) were considered for a second GKS, proposed only if the patients had good and prolonged initial pain cessation after the first GKS, with no other treatment alternative at the moment of recurrence. As for the first GKS, a single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.6 mm (range 4-14 mm) anterior to the emergence of the nerve (retrogasserian target). A median maximum dose of 90 Gy (range 70-90 Gy) was delivered. Data for 9 patients with at least 1-year followup were analyzed. A systematic review of literature was also performed, and results are compared with those of the Marseille study.The median time to retreatment in the Marseille study was 72 months (range 12-125 months) and in the literature it was 17 months (range 3-146 months). In the Marseille study, the median follow-up period was 33.9 months (range 12-96 months), and 8 of 9 patients (88.9%) had initial pain cessation with a median of 6.5 days (range 1-180 days). The actuarial rate for new hypesthesia was 33.3% at 6 months and 50% at 1 year, which remained stable for 7 years. The actuarial probabilities of maintaining pain relief without medication at 6 months and 1 year were 100% and 75%, respectively, and remained stable for 7 years. The systematic review analyzed 20 peer-reviewed studies reporting outcomes for repeat GKS for recurrent TN, with a total of 626 patients. Both the selection of the cases for retreatment and the way of reporting outcomes vary widely among studies, with a median rate for initial pain cessation of 88% (range 60%-100%) and for new hypesthesia of 33% (range 11%-80%).Results from the Marseille study raise the question of surgical alternatives after failed GKS for TN. The rates of initial pain cessation and recurrence seem comparable to, or even better than, those of the first GKS, according to different studies, but toxicity is much higher, both in the Marseille study and in the published data. Neither the Marseille study data nor literature data answer the 3 cardinal questions regarding repeat radiosurgery in recurrent TN: which patients to retreat, which target is optimal, and which dose to use.

Effective response to infectious disease epidemics requires focused control measures in areas predicted to be at high risk of new outbreaks. We aimed to test whether mobile operator data could predict the early spatial evolution of the 2010 Haiti cholera epidemic. Daily case data were analysed for 78 study areas from October 16 to December 16, 2010. Movements of 2.9 million anonymous mobile phone SIM cards were used to create a national mobility network. Two gravity models of population mobility were implemented for comparison. Both were optimized based on the complete retrospective epidemic data, available only after the end of the epidemic spread. Risk of an area experiencing an outbreak within seven days showed strong dose-response relationship with the mobile phone-based infectious pressure estimates. The mobile phone-based model performed better (AUC 0.79) than the retrospectively optimized gravity models (AUC 0.66 and 0.74, respectively). Infectious pressure at outbreak onset was significantly correlated with reported cholera cases during the first ten days of the epidemic (p < 0.05). Mobile operator data is a highly promising data source for improving preparedness and response efforts during cholera outbreaks. Findings may be particularly important for containment efforts of emerging infectious diseases, including high-mortality influenza strains.

Resume Objectif. – Decrire les pratiques des internes en pediatrie concernant l'implication de l'enfant dans la decision medicale et evaluer les relations entre ces pratiques et les caracteristiques des internes (âge, sexe, experience…). Patients et methodes. – Etude multicentrique transversale anonyme realisee aupres de 45 internes en pediatrie. L'autoevaluation de leur pratique par les internes a ete recueillie par l'intermediaire d'un questionnaire ecrit. Resultats. – Quatre-vingt-deux pour cent des internes en pediatrie informaient l'enfant, mais le partenariat avec l'enfant diminuait lorsqu'il s'agissait de lui demander son avis, de lui presenter d'autres choix ou de respecter son refus. Les obstacles principaux au partenariat avec l'enfant etaient : le manque de competence de l'enfant et la situation medicale presente. Aucune relation statistiquement significative n'a pu etre mise en evidence entre les pratiques des internes et leurs caracteristiques. Conclusion. – Le partenariat avec l'enfant lors de prise de decision medicale en pediatrie varie selon les internes et en fonction du degre d'implication demande. L'education pourrait permettre d'augmenter la participation de l'enfant.

Thyroid follicular adenomas (FA) are encapsulated tumors lacking vascular, capsular or lymphatic invasion and the typical nuclear features of papillary carcinoma (PC). However, some FA demonstrate nuclear atypia reminiscent of either follicular carcinomas (FC) or follicular variant of papillary carcinomas (FVPC), suggesting they may represent precursors of malignant transformation. We hypothesized that an objective evaluation of nuclear chromatin patterns could be used to define atypical follicular tumors (AFT) that are likely to be premalignant. To test this hypothesis, we used a computer-aided image analysis system to define the chromatin pattern of nuclei from thyroid tumors. To validate the system, we analyzed 3000 nuclei from 10 FA, 10 FC, and 10 FVPC samples and accurately distinguished between these classes of tumors. Then, we analyzed nine AFT and, in parallel, we analyzed the tumors for activating mutations of N2-RAS and over-expression of RET. The predominant chromatin pattern of AFT was of FA type in two cases, FC type in two cases, and PC type in three cases. One case contained similar numbers of FC and PC nuclei and one was comprised of a mixture of the three nuclear types. Neither RAS mutation nor RET overexpression were detected in FA. N2-RAS mutations were found in 33% of AFT, 20% of FC and 20% of FVPC without correlation with chromatin pattern. Over-expression of RET was detected in 45% of AFT, 20% of FC and 50% of FVPC and was correlated with PC nuclei. These results show that AFT are a heterogenous group of tumors, containing genuine benign tumors and tumors that share morphological and molecular features with follicular and papillary carcinomas that might be precursors of both types of thyroid carcinomas.

Resume Objectif. – « Etudier la frequence et l’intensite de la survenue de douleurs pharyngolaryngees postoperatoires apres application locale lors de l’intubation de methylprednisolone vs lidocaine. » Type d’etude. – Etude prospective randomisee en simple aveugle. Patients et methodes. – Soixante patients ASA 1 ou 2, devant subir une intervention chirurgicale pour avulsion de dents de sagesse. Etude de la frequence et de l’intensite de la survenue de douleurs pharyngolaryngees postoperatoires apres application locale lors de l’intubation de methylprednisolone vs lidocaine. Les autres variables etudiees etaient la douleur globale (EVA), la toux et la gene pharyngolaryngee. Lors de la sequence d’intubation, les patients recevaient sous forme d’une pulverisation au niveau de l’epiglotte, des cordes vocales et de la trachee, en fonction de leur groupe, soit de la lidocaine 5 %, soit une solution de methylprednisolone (80 mg dans 5 ml). Les patients etaient interroges a leur arrivee en salle de surveillance post-interventionnelle (SSPI), a la sortie de SSPI, a la reprise de l’alimentation et des boissons puis 24 h apres l’intervention. Les variables ont ete analysees par le test non parametrique de Mann-Whitney. Resultats. – Les resultats ont montre un effet benefique en faveur du groupe ayant recu la methylprednisolone, sur la douleur pharyngolaryngee a la phase postoperatoire precoce (sortie de SSPI) et au moment de la reprise des boissons. Une difference significative en faveur du groupe methylprednisolone sur la toux etait trouvee a la sortie de salle de reveil. Conclusion. – L’administration locale de methylprednisolone peut etre utile dans la prevention des douleurs pharyngolaryngees post-intubation lorsque la chirurgie est ambulatoire.

Introduction La pollution atmospherique a des effets nefastes sur la sante et l’environnement. Les particules en suspension, le dioxyde d’azote (NO2) et l’ozone (O3) sont reconnus comme etant les 3 polluants les plus significatifs en termes d’incidence sur la sante. L’asthme est multifactoriel avec notamment l’exposition a la pollution atmospherique, les conditions meteorologiques, les allergenes, les infections virales qui sont fortement impliques. Cependant, le lieu de residence des patients est rarement etudie en rapport avec ces facteurs. L’objectif principal de notre etude est de mesurer l’impact de la pollution atmospherique, au plus proche du domicile des patients, sur les consultations pour asthme dans les services d’accueil des urgences (SAU) dans la region Provence-Alpes-Cote-D’azur (PACA) en 2013. Methodes Initialement, les variables ont ete selectionnees par un arbre de classification et de regression concernant les patients asthmatiques et traumatologiques, âges de 3 a 99 ans, ayant consulte dans un SAU en PACA du 01 janvier au 31 decembre 2013. Puis, dans une etude cas-temoins emboitee dans une cohorte, chaque controle traumatologique a ete randomise de maniere aleatoire sur le jour, quel que soit le SAU de consultation. Les facteurs environnementaux et la charge virale ont ete relies au code INSEE de residence des patients. Resultats Un total de 794 884 consultations a ete reporte chez les patients de 3 a 99 ans dont 6250 pour asthme et 278 192 pour traumatisme. L’exposition a court terme au NO2, mesuree au plus proche du domicile des patients, est associee a un exces de risque de consultation aux urgences pour asthme (OR ajuste : 1,35 [5 % CI : 1,17–1,57 ; p =

Purpose Recent studies show that low birth weight infants are at a risk of increased arterial blood pressure (BP) in adulthood. This study aimed to distinguish the influence of low birth weight either as a result of fetal growth restriction or preterm birth on arterial properties in adolescents. Methods The effect of low birth weight on BP and arterial stiffness was examined among 90 adolescents aged 14 years who were either born at term with an appropriate birth weight for gestational age (controls, n=41); born preterm with an appropriate birth weight for gestational age (n = 25); or born at term and small for gestational age (SGA) (n = 24). The pulse wave velocity between the carotid and radial arteries was measured to assess arterial stiffness. Results As compared with control subjects, adolescents born with low birth weight as a result of preterm birth were found to have increased systolic BP and carotid–radial pulse wave velocity (117 ± 11 mm Hg vs. 123 ± 11 mm Hg, p = .04 and 7.0 ± .9 m/s vs. 7.7 ± 1.0 m/s, p = .01, respectively), whereas those who were born at term and SGA exhibited values similar to the controls (114 ± 15 mm Hg and 6.8 ± .9 m/s). Conclusion Preterm birth, rather than being SGA at term, increases BP and arterial stiffness in adolescents.

International audience; Evaluation of serum lipase as predictor of severity of acute pancreatitis in children. [J Pediatr Gastroenterol Nutr. 2014]Serum lipase as an early predictor of severity in pediatric acute pancreatitis.

International audience; BACKGROUND: Just as power, type I error of cluster detection tests (CDTs) should be spatially assessed. Indeed, CDTs' type I error and power have both a spatial component as CDTs both detect and locate clusters. In the case of type I error, the spatial distribution of wrongly detected clusters (WDCs) can be particularly affected by edge effect. This simulation study aims to describe the spatial distribution of WDCs and to confirm and quantify the presence of edge effect. METHODS: A simulation of 40 000 datasets has been performed under the null hypothesis of risk homogeneity. The simulation design used realistic parameters from survey data on birth defects, and in particular, two baseline risks. The simulated datasets were analyzed using the Kulldorff's spatial scan as a commonly used test whose behavior is otherwise well known. To describe the spatial distribution of type I error, we defined the participation rate for each spatial unit of the region. We used this indicator in a new statistical test proposed to confirm, as well as quantify, the edge effect. RESULTS: The predefined type I error of 5% was respected for both baseline risks. Results showed strong edge effect in participation rates, with a descending gradient from center to edge, and WDCs more often centrally situated. CONCLUSIONS: In routine analysis of real data, clusters on the edge of the region should be carefully considered as they rarely occur when there is no cluster. Further work is needed to combine results from power studies with this work in order to optimize CDTs performance.

France is a country with a low incidence of tuberculosis. However, there are important local variations: some parts of the city of Marseilles (southern France) presented a yearly incidence greater than 30/100,000 in 2010. The main goal of this study was to evaluate the BCG vaccine coverage among at-risk children younger than 5 years consulting in one of the city's pediatric emergency departments. Material and methods. This descriptive study took place in February 2013 and used a semi-directive questionnaire distributed to parents. Results. One hundred and thirty-five children were included, 98 (72.6 %) were considered as being at risk of tuberculosis and among them 75 (76.5 %, 95 % CI [68.0–85.1]) were vaccinated with BCG. Parents' knowledge of tuberculosis was relevant in 48 % of the respondents. Only 19 % of the parents reported that BCG protects against tuberculosis, but 73 % were in favor of this vaccination. Two criteria significantly increased vaccine coverage among at-risk children: birth in Marseilles and age more than 6 months on the consultation day. The child living in a poor family and type of medical follow-up did not significantly influence BCG vaccine coverage. Conclusion. BCG coverage was high in at-risk children younger than 5 years born in Marseilles. Cooperation between private physicians , maternity hospitals and mothers, and children's public health services probably facilitates this high level of protection., Malgré une faible incidence de la tuberculose en France, il existe de grandes variations à l'échelle communale : certains quartiers de Marseille présentent ainsi une incidence annuelle supérieure à 30/ 100 000. Le but de notre étude etait d'évaluer la couverture vaccinale par le vaccin de Calmette et Guérin (BCG) des enfants à risque aâgés de moins de 5 ans consultant dans un service d'urgences pédiatriques. Matériel et méthodes : Cette étude descriptive a eété réalisée en février 2013 à l'aide d'un questionnaire semi-directif proposé aux parents. Résultats : Cent-trente-cinq enfants ont été inclus, 98 (72,6 %) étaient considérés àrisque de tuberculose et parmi ces derniers 75 (76,5 %, IC 95 % [68,0–85,1]) eétaient vaccinés par le BCG. Seuls 48 % des parents connaissaient la tuberculose et 19 % savaient que le BCG protégeait contre cette maladie, mais 73 % étaient favorables à ce vaccin. Deux paramètres étaient liés à la vaccination des enfants à risque : une naissance à Marseille et un âge supérieur à 6 mois le jour de la consultation. La précarité des conditions de vie et le type de suivi médical n' influençaient pas significativement la couverture vaccinale des enfants à risque. Conclusion : En 2013, la couverture vaccinale par le BCG des enfants de moins de 5 ans nés à Marseille et à risque de tuberculose était correcte mais perfectible. Une coopération entre médecins de ville, maternités et services de protection maternelle et infantile (PMI) permet probablement d'obtenir cette bonne couverture vaccinale.

International audience; Objectives: Urinary tract infections (UTIs) are one of the leading reasons for antibiotic prescriptions in emergency departments (EDs), with half of these antibiotics being inappropriately prescribed. Our objective was to assess the impact of a computerized decision support system (CDSS) on compliance with guidelines on empirical antibiotic prescriptions (antibiotic and duration) for UTIs in EDs. Methods: A multicentre prospective before-and-after controlled interventional study was conducted from 19 March to 28 October 2012. All adults diagnosed with community-acquired UTIs (cystitis, pyelonephritis or prostatitis) at three French EDs were included. The antibiotic therapy was considered compliant with guidelines if the antibiotic and the duration prescribed were in accordance with the national guidelines. Data were collected using electronic medical records. Paired tests were used when comparing periods within each ED and global analyses used multivariate logistic mixed models. Results: Nine hundred and twelve patients were included during the 30 week study period. The CDSS was used in 59% of cases (182/307). The CDSS intervention improved the compliance of antibiotic prescriptions in only one ED in a bivariate analysis (absolute increase +20%, P ¼ 0.007). The choice of the antibiotic was improved in multivariate analyses but only when the CDSS was used [OR¼ 1.94 (95% CI 1.13 –3.32)]. The CDSS also changed the initial diagnosis in 23% of cases, in all three EDs. Conclusions: The CDSS only partially improved compliance with guidelines on antibiotic prescriptions in UTIs.

Background In sub-Saharan Africa, artemisinin-based combination therapy (ACT) and injectable artesunate are the first-line treatments for uncomplicated and severe Plasmodium falciparum malaria, respectively. However, recent studies suggest that delayed anaemia is associated with these treatments in non-immune travellers. This paper aimed to assess the risk factors associated with delayed anaemia after falciparum malaria treatment with artemisinin-containing drugs in malaria-endemic populations. Methods Pooled, individual malaria patient data were extracted from 13 clinical trials performed from 2002 to 2011 in various settings of Mali. Treatment regimens were artemether-lumefantrine, artesunate plus amodiaquine, artesunate plus sulphadoxine-pyrimethamine, artesunate plus sulphamethoxypyrazine-pyrimethamine, artesunate plus mefloquine, artesunate-pyronaridine, artesunate monotherapy, chloroquine, sulphadoxine-pyrimethamine, amodiaquine and sulphadoxine-pyrimethamine plus amodiaquine. Univariate and multivariate analyses were performed using the generalized linear and latent mixed model procedures to assess risk factors associated with haemoglobin concentration evolution and anaemia during the treatment follow-up. Results A total of 5,990 participants were recruited and followed from day 0 to day 28. The participants’ median age was five years, ranging from three months to 70 years. There was a decrease in haemoglobin level on day 7 in all treatment arms, but the magnitude varied across treatments. There was a significant risk of haemoglobin level decrease on day 7 in the artemisinin-based therapy compared to the non-artemisinin treatments. The risk of haemoglobin concentration drop was associated with age group

Background: Trigeminal neuralgia (TN) secondary to megadolichobasilar artery (MBA) compression is considerably difficult to manage surgically. Objective: This study aims to evaluate the safety/efficacy of Gamma Knife surgery (GKS) in this special group of patients. Methods: Between July 1992 and November 2010, 29 patients with >1 year of follow-up presenting with MBA compression were treated with GKS at Timone University Hospital. Radiosurgery was performed using a Gamma Knife (model B, C or Perfexion). A single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 9.1 mm (range: 6-18.2 mm) from the emergence. Results: The median follow-up period was 46.1 months (range: 12.9-157.9 months). Initially, all patients (100%) were pain free; the average time to complete pain relief was 13.5 days (range: 0-240 days). Their actuarial probability of remaining pain free without medication at 0.5, 1 and 2 years was 93.1, 79.3 and 75.7%, respectively, and remained stable until 13 years after treatment. The actuarial probability of hypoesthesia onset at 6 months was 4.3%; at 1 year it reached 13% and remained stable until 13 years after treatment. Conclusions: GKS proved to be reasonably safe and effective on a long-term basis as a first- and/or second-line surgical treatment for TN due to MBA compression.

Background: Trigeminal neuralgia (TN) related to multiple sclerosis (MS) is more difficult to manage pharmacologically and surgically. Objective: This article aims to evaluate the safety and efficacy of Gamma Knife surgery (GKS) in this special group of patients. Methods: Between July 1992 and November 2010, 43 cases with more than 1 year of follow-up were operated with GKS for TN related to MS and prospectively evaluated in the Timone University Hospital, Marseille, France. Radiosurgery using the Gamma Knife (model B or C or Perfexion) was performed. A single 4-mm isocenter was positioned at a median distance of 8 mm (range 5.7-14.7) anterior to the emergence of the nerve. A median maximum dose of 85 Gy (range 75-90) was delivered. Results: The median follow-up period was 53.8 months (12-157.1). Thirty-nine patients (90.7%) were initially pain free. Their actuarial probability of remaining pain free without medication at 6 months, 1, 3, 5 and 10 years was 87.2, 71.8, 43.1, 38.3 and 20.5%, respectively, and remained stable till 12 years. The hypoesthesia actuarial rate at 6 months, 1 and 2 years was 11.5, 11.5 and 16%, and remained stable till 12 years. Conclusions: GKS proved safe and effective in this special group of patients.

International audience; Background:Recurrent events data analysis is common in biomedicine. Literature review indicates that moststatistical models used for such data are often based on time to the first event or consider events within a subjectas independent. Even when taking into account the non-independence of recurrent events within subjects, dataanalyses are mostly done with continuous risk interval models, which may not be appropriate for treatmentswith sustained effects (e.g., drug treatments of malaria patients). Furthermore, results can be biased in cases of aconfounding factor implying different risk exposure, e.g. in malaria transmission: if subjects are located at zonesshowing different environmental factors implying different risk exposures.Methods:This work aimed to compare four different approaches by analysing recurrent malaria episodes from aclinical trial assessing the effectiveness of three malaria treatments [artesunate + amodiaquine (AS + AQ), artesunate +sulphadoxine-pyrimethamine (AS + SP) or artemether-lumefantrine (AL)], with continuous and discontinuous riskintervals: Andersen-Gill counting process (AG-CP), Prentice-Williams-Peterson counting process (PWP-CP), a sharedgamma frailty model, and Generalized Estimating Equations model (GEE) using Poisson distribution. Simulationswere also made to analyse the impact of the addition of a confounding factor on malaria recurrent episodes.Results:Using the discontinuous interval analysis, AG-CP and Shared gamma frailty models provided similarestimations of treatment effect on malaria recurrent episodes when adjusted on age category. The patientshad significant decreased risk of recurrent malaria episodes when treated with AS + AQ or AS + SP arms comparedto AL arm; Relative Risks were: 0.75 (95% CI (Confidence Interval): 0.62-0.89), 0.74 (95% CI: 0.62-0.88) respectively forAG-CP model and 0.76 (95% CI: 0.64-0.89), 0.74 (95% CI: 0.62-0.87) for the Shared gamma frailty model.With both discontinuous and continuous risk intervals analysis, GEE Poisson distribution models failed to detect theeffect of AS + AQ arm compared to AL arm when adjusted for age category. The discontinuous risk interval analysiswas found to be the more appropriate approach.Conclusion:Repeated event in infectious diseases such as malaria can be analysed with appropriate existing modelsthat account for the correlation between multiple events within subjects with common statistical software packages,after properly setting up the data structures.

International audience; BACKGROUND: Conventional power studies possess limited ability to assess the performance of cluster detection tests. In particular, they cannot evaluate the accuracy of the cluster location, which is essential in such assessments. Furthermore, they usually estimate power for one or a few particular alternative hypotheses and thus cannot assess performance over an entire region. Takahashi and Tango developed the concept of extended power that indicates both the rate of null hypothesis rejection and the accuracy of the cluster location. We propose a systematic assessment method, using here extended power, to produce a map showing the performance of cluster detection tests over an entire region. METHODS: To explore the behavior of a cluster detection test on identical cluster types at any possible location, we successively applied four different spatial and epidemiological parameters. These parameters determined four cluster collections, each covering the entire study region. We simulated 1,000 datasets for each cluster and analyzed them with Kulldorff's spatial scan statistic. From the area under the extended power curve, we constructed a map for each parameter set showing the performance of the test across the entire region. RESULTS: Consistent with previous studies, the performance of the spatial scan statistic increased with the baseline incidence of disease, the size of the at-risk population and the strength of the cluster (i.e., the relative risk). Performance was heterogeneous, however, even for very similar clusters (i.e., similar with respect to the aforementioned factors), suggesting the influence of other factors. CONCLUSIONS: The area under the extended power curve is a single measure of performance and, although needing further exploration, it is suitable to conduct a systematic spatial evaluation of performance. The performance map we propose enables epidemiologists to assess cluster detection tests across an entire study region.

International audience; Background: Studies suggest that road traffic noise increases risks of sleep disturbances, anxiety and depressive symptoms, but few have focused on psychotropic drug use. We examined whether exposure to night-time road traffic noise in Marseilles (France) is associated with an increased risk of purchasing anxiolytic or hypnotic medications. Methods: Cohort of 190 617 inhabitants of Marseilles (aged 18–64 years) covered by the National Health Insurance Fund. We used the CadnaA noise propagation prediction model to calculate a potential road noise exposure indicator at dwellings for the night-period: Ln. Association between the number of purchases of anxio-lytics–hypnotics in 2008–9 and the Ln was analysed with a zero-inflated negative binomial (ZINB) model adjusted for characteristics of individuals (sociodemographic, consultations with general practitioners, presence of chronic psychiatric disorder), prescribers (demographic, specialty, workload) and neighbourhoods (medical density, complaints filed for environmental noise). Analyses were stratified by the deprivation level of the census block of residence to control for the confounding effects of neighbourhood socioeconomic status. Results: The ZINB model showed a small but significant increase in the risk of purchasing higher numbers of anxiolytics–hypnotics for Ln greater than 55 dB(A) only in the low deprivation stratum. Conclusion: We found some evidence that potential exposure to night-time road traffic noise might affect individual use of anxiolytics–hypnotics. Further research based on strictly individual approaches is warranted to assess exposure to road traffic noise more precisely and reliably than allowed by noise propagation prediction models.

BACKGROUND: Since the beginning of the cholera epidemic in Haiti, attack rates have varied drastically with alternating peak and lull phases, which were partly associated with the fluctuating dry, rainy and cyclonic seasons. According to a study conducted in 2012, the toxigenic V. cholerae O1 strain responsible for the outbreak did not settle at a significant level in the Haitian aquatic environment. Therefore, we hypothesize that some areas of lingering cholera transmission during the dry season could play an important role in the re-emergence of outbreaks during the rainy season. Our objective was therefore to describe the dynamics of cholera and assess the fight against the disease during the dry season. METHODS: A field study was conducted from February 19 to March 29, 2013. After identifying the affected communes by analyzing the national cholera database, we visited corresponding health facilities to identify patient origins. We then conducted a field assessment of these foci to confirm the presence of cholera, assess factors associated with transmission and examine the activities implemented to control the epidemic since the beginning of the current dry season. RESULTS: We found that the great majority of Haitian communes (109/140) presented no sign of cholera transmission in February and March 2013. Suspected cases were concentrated in a small number of urban and rural areas, almost all of which were located in the northern half of the country and often in inland locales. In these areas, community health activities appeared insufficient and were often inappropriately targeted. Out of 49 analyzed foci, only 10 had benefited from at least one intervention involving the distribution of water treatment products together with an awareness campaign since December 2012. CONCLUSION: Cholera continues to affect Haiti as observed in early 2013; however, activities implemented to interrupt cholera transmission appear insufficient and poorly suited. This deficiency in the fight against cholera, especially at a period when transmission is weak, may explain the persistence of cholera even in the absence of significant aquatic reservoirs in Haiti.

Background In spite of massive efforts to generalize efficient prevention, such as insecticide-treated mosquito nets (ITN) or long-lasting insecticidal nets (LLINs), malaria remains prevalent in many countries and ITN/LLINs are still only used to a limited extent. Methods This study proposes a new model for malaria economic analysis by combining economic epidemiology tools with the literature on poverty traps. A theoretical model of rational protective behaviour in response to malaria is designed, which includes endogenous externalities and disease characteristics. Survey data available for Uganda provide empirical support to the theory of prevalence-elastic protection behaviours, once endogeneity issues related to epidemiology and poverty are solved. Results Two important conclusions emerge from the model. First, agents increase their protective behaviour when malaria is more prevalent in a society. This is consistent with the literature on "prevalence-elastic behaviour". Second, a ‘malaria trap’ defined as the result of malaria reinforcing poverty while poverty reduces the ability to deal with malaria can theoretically exist and the conditions of existence of the malaria trap are identified. Conclusions These results suggest the possible existence of malaria traps, which provides policy implications. Notably, providing ITN/LLINs at subsidized prices is not sufficient. To be efficient an ITN/LLINs dissemination campaigns should include incentive of the very poor for using ITN/LLINs.

The growth hormone (GH)–insulin-like growth factor-1 (IGF-1) axis is dramatically altered in patients with anorexia nervosa (AN). The aim of the present study was to investigate whether GH and IGF-1 could be predictors of outcome in patients with a restrictive form of AN. Blood levels of GH, IGF-1, adipocytokines, ghrelin, insulin, glucose, and sex and thyroid hormones were measured in eleven women inpatients with AN and in ten healthy women controls. Three stages were compared during refeeding: admission (T0), when BMI reached 16 kg/m2 (T1) and at discharge when BMI reached 17·5 kg/m2 (T2). Clinical status was assessed 6 months after discharge from hospital (T3), and remission was defined by the maintenance of a BMI ≥ 17·5 kg/m2. AN patients in remission (AN-R; n 6) had significantly higher GH levels at admission than those who relapsed (AN-NR; n 5) (PPPr2 0·88, P

Objectives: Oxidative stress is associated with the condition of cystic fibrosis (CF), but no guidelines exist for its assessment or treatment. Our aim was to evaluate a test that measures the blood antioxidant capability in CF children. Methods: This antioxidant capability was assessed by the Kit Radicaux Libres (KRL) test in 44 CF children (24 boys). We recorded also anthropometric measures, pulmonary function, CF severity scores, and plasma nutritional and inflammatory parameters (proteins, vitamins, erythrocyte fatty acids, and micronutrients). We performed univariate and multivariate analyses with linear regression models. Results: The mean age at the first KRL assessment was 12.2 ± 3.8 years. Factors that correlated with decreased antioxidant capacity were mostly related to the severity of pulmonary disease [ forced expiratory volume at 1 second (FEV1), acute exacerbation, and congestion. In multivariate analysis, the correlation between Brasfield score and erythrocyte antioxidant potential remained significant (β = - 0.611, p < 0.001). Among nutritional factors, the ω6/ω3 ratio was significantly correlated to erythrocyte antioxidant potential (β = - 1.213, p = 0.01). Conclusion: The blood antioxidant capability, measured by the KRL test, appears to be an interesting biomarker to evaluate oxidative stress in CF. This study suggests that the ω6/ω3 ratio should be regarded as a nutritional marker in antioxidant management in CF children.