Framing the wider determinants of health: Reflections and learning from a knowledge mobilisation exercise with an English local authority

Background

Health inequalities remain a persistent problem in the UK. One contributing factor may be how health inequalities are framed in professional and public debate. Dominant understandings of health focus on the individual, personal choice, lifestyle and (un)healthy behaviour. This project sought to reframe health inequalities as a 'systemic' or structural problem using extant guidance. This was intended to support the work of a local authority in England working to address health inequalities.

Project design

An academic-practitioner participatory knowledge mobilisation exercise with a local authority public health team using recent guidance and reflective feedback and the iterative development of actionable tools. There were four discrete stages to the exercise.

Methods

Two on-line and one face-to-face participatory, deliberative workshops designed to co-create reframed public health challenges and solutions based on team portfolios. Iterative feedback provided by the researcher to support the development of actionable tools.

Results

Six topic areas were developed with a systemic framing: 1. Food insecurity, 2. Obesity, 3. Prostate cancer among Black men, 4. Cost of living, 5. Mental health, suicide prevention and Gypsy, Roma, Traveller communities, 6. Healthy streets. Reflections from the process revealed some perceived advantages of engaging in a systemic framing of the wider determinants of health, some limitations and issues to consider in a local setting. Benefits included: Clarity in a complex field; structured thinking about what to communicate and how; eliminated jargon; could be made locally relevant. Challenges included: Sustaining a consistent framing; maintaining the technique; knowing if was making a difference; slipping back into dominant (individualised) framings, especially in free-flowing discussion.

Conclusions

The process of reframing the wider determinants of health using recent guidance in a local authority setting was broadly helpful in developing coherence and consistency across the public health team. There were challenges to adopting the approach and evaluation of its impact locally would be beneficial.

Divergent Synthesis of 6- or 7-Aza-Indazoles via Intramolecular Diels-Alder Cascade of Pyrazines

Pyrazines are reactive 4π partners in intermolecular Diels-Alder cycloaddition with exceptionally activated dienophiles or in an intermolecular version at elevated temperatures. Herein, it is shown that an intramolecular cascade could occur even at room temperature, delivering a collection of 6- or 7-aza-indazoles. An interesting substituent effect of the cycloaddition precursor on the product distribution was uncovered, and in situ NMR studies were conducted to gain insights into this unexpected selectivity.

Characterization of the skin-to-bone mechanical interaction on porcine scalp: A combined experimental and computational approach

Fasciae are soft tissues permitting a large but finite sliding between organs, but also between skin and its underlying elements. The contribution of fasciae has been seldomly reported in the literature, and is usually neglected or overly simplified within simulations. In the present contribution, we propose to use peeling tests in order to quantify the skin-to-bone interaction associated with a simple computational approach based on a geometrical modeling of the skin-to-bone interface. To this aim, a new experimental set up combined with a computational model to characterize the skin-to-bone interaction were proposed. The current work is devoted to the porcine scalp complex since it constitutes a common mechanical surrogate for the human scalp complex. The ad hoc computational approach and peeling set up were firstly evaluated on a validation material, before being used to characterize the skin-to-bone interaction within 6 porcine specimens harvested from the scalp. Our experimental setup allowed to measure the peeling response of porcine scalp, showing a three-regimes response including a plateau force. The computational approach satisfyingly reproduced the peeling response based uniquely on experimental-based parameters and on a discrete modeling of skin-to-bone interface. The presented methodology is a first attempt to propose a computationally efficient geometrically based model able to take into account the skin-to-bone interaction up to failure and corroborated by experimental data, and may be largely extended to the modeling of soft interactions between biological human tissues in the future.

A preliminary quantification of the clinical gesture during vacuum assisted delivery on a training dummy

BACKGROUND

The vacuum assisted delivery represents, in France, the most used operative vaginal delivery technique. The purpose was to provide a preliminar quantification of the operator's hand kinematics while performing a vacuum assisted delivery.

METHODS

A group of 21 participants composed of 12 trainees and 9 obstetricians were recorded performing a vacuum assisted delivery on a training dummy, the matching fetal presentation was a left occiput anterior position.

FINDINGS

The mean movement was composed of a first phase corresponding to a descendant pull, followed by an ascendant finish of the gesture. No significative difference were found between the trainees and the obstetricians' mean gesture.

INTERPRETATION

This is the first quantification of the clinical gesture associated with the vacuum assisted delivery.

Hepaticojejunostomy for bile duct injury: state of the art

BACKGROUND

Hepaticojejunostomy (HJ) is the gold standard procedure for the reconstruction of the bile duct in many benign and malignant situations. One of the major situation is the bile duct injury (BDI) after cholecystectomy, either for early or late repair. This procedure presents some specificities associated to a debated management of BDI.

PURPOSE

This article provides a state-of-the-art of the hepaticojejunostomy procedure focusing on bile duct injury including its indications and outcomes CONCLUSION: Performed at the right moment and respecting the technical rules, HJ provides a restoration of the biliary patency in the long term of 80 to 90%. It is the main surgical technique to repair BDI. Complications and failure of this procedure can be difficult to manage. That is why the primary repair requires an appropriate multidisciplinary approach associated with an expert high quality surgical technique.

Bone involvement in primary cutaneous diffuse large B-cell lymphoma, leg-type

Primary cutaneous diffuse large B-cell lymphoma, leg-type (PCDLBCL-LT) is an aggressive cutaneous lymphoma. Bone involvement is rare and poorly described. We present five cases of PCDLBCL-LT with bone localization. In four cases, the bone involvement was diagnosed during the initial staging with positron emission tomography (PET) or computed tomography (CT) scan, and in the fifth case after tibial fracture during treatment with rituximab (RTX) and polychemotherapy (PCT). PCDLBCL-LT can be asymptomatic and involve bone sites distant from cutaneous lesions. None had other extracutaneous involvement. In our series, all patients received RTX-PCT as first-line chemotherapy and all had early relapses or progression. Second-line treatments had poor efficacy. Our series shows that bone involvement seems to be associated with poor prognosis in PCDLBCL-LT. Bone localization is not diagnosed with initial thoracic-abdominal-pelvic CT when asymptomatic and affecting the limbs only. If there is a suspicion of PCDLBCL-LT, patients should undergo systematic investigation with alternative imaging techniques, including PET, both at baseline and if there is any concern during follow-up.

Regression trees to identify combinations of farming practices that achieve the best overall intrinsic quality of milk

Many studies over the last 30 years have shown the effects of farming practices on milk compounds. Combinations of practices may have antagonistic or synergistic effects on milk compounds, but these combination effects remain underinvestigated. Research needs to focus on overall intrinsic milk quality (including sensory, technological, health, and nutritional dimensions) and identify the combinations that can optimize it. The aim of this study was to identify which combinations of farming practices achieved the best scores for sensory, technological, health, and nutritional dimensions and for overall intrinsic milk quality. Ninety-nine private farms were visited once each to sample their bulk tank milk and survey their farming practices. The surveyed practices concerned herd characteristics, feeding management, housing conditions, and milking and milk storage conditions on the day of test. Analyses of bulk tank milk were designed to evaluate the overall intrinsic quality of the milk for 2 target products: raw milk cheese and semi-skimmed UHT milk. Regression trees were then used to identify the combinations of farming practices that achieved the best scores on each dimension and on overall intrinsic quality of the milk. Breed and diet (type of forage) were the most influential factors for sensory and health dimensions and for technological and nutritional dimension scores, respectively, in the cheese assessment. Overall cheese quality was highly positively correlated with these 4 dimension scores. Therefore, breed and diet emerged as the most influential practices in the regression tree for overall cheese quality. However, the combinations of practices that resulted in the best quality scores differed according to dimension studied and product targeted. This suggests that advice on farming practices to improve intrinsic milk quality needs to be adapted according to the end-purpose of the collected milk. This innovative approach combining on-farm data and regression trees provides farm managers with a valuable and practical tool to prioritize practices in terms of their role in shaping milk quality, and to identify the combinations of practices that promote good milk quality and practice thresholds or modalities needed to achieve it.

Impacts of production conditions on goat milk vitamin, carotenoid contents and colour indices

The content, composition and variation of vitamin compounds in goat milk have been little studied. An experimental design was based on 28 commercial farms, selected considering the main feeding system (based on main forage and especially pasture access), goat breed (Alpine vs Saanen) and reproductive management (seasonal reproduction), in the main French goat milk production area. Each farm received two visits (spring and autumn) that included a survey on milk production conditions and bulk milk sampling. Milk vitamins (A, E, B₂, B₆, B₉, B₁₂) and carotenoid concentrations plus colour indices were evaluated. A stepwise approach determined the variables of milk production conditions that significantly altered milk indicators. The main forage in the diet was the major factor altering goat milk vitamin and carotenoid concentrations and colour indices. Bulk milk from goats eating fresh grass as forage was richer in α-tocopherol (+64%), pyridoxal (+35%) and total vitamin B₆ (+31%), and b* index (characterising milk yellowness in the CIELAB colour space) was also higher (+12%) than in milk from goats eating conserved forages. In milk from goats eating fresh grass, concentrations of pyridoxamine, lutein and total carotenoids were higher than in milk of goats fed corn silage (+24, +118 and +101%, respectively), and retinol and α-tocopherol concentrations were higher than in milk of goats fed partially dehydrated grass (+45 and +55%). Vitamin B₂ concentration was higher in milk of goats eating fresh grass than in milk of goats fed hay or corn silage as forage (+10%). However, bulk milk when goats had access to fresh grass was significantly poorer in vitamin B₁₂ than when fed corn silage (-46%) and in γ-tocopherol (-31%) than when fed conserved forage. Alpine goats produced milk with higher vitamin B₂ and folate concentrations than Saanen goats (+18 and +14%, respectively). Additionally, the milk colour index that discriminates milks based on their yellow pigment contents was 7% higher in milk from Alpine than Saanen herds, but milk from Saanen goats was richer in lutein (+46%). Goat milks were richer in vitamins B₂ and B₁₂ and folates, but poorer in vitamin B₆ in autumn than in spring (+12, +133, +15 and -13%, respectively). This work highlights that goat milk vitamin and carotenoid concentrations and colour indices vary mainly according to the main forage of the diet and secondly according to the breed and season.

Efficacy and safety of osilodrostat in paraneoplastic Cushing's syndrome: a real-world multicenter study in France

CONTEXT

Prospective studies have demonstrated the efficacy of osilodrostat in Cushing's disease. No study has evaluated osilodrostat in a series of patients with paraneoplastic Cushing's syndrome/ectopic ACTH syndrome (PNCS/EAS).

OBJECTIVE

Evaluate in France the real-world efficacy and safety of osilodrostat in PNCS/EAS.

PATIENTS

33 patients with PNCS/EAS with intense/severe hypercortisolism.

METHODS

Retrospective multicenter real-world study. Patients received osilodrostat between May 2019 and March 2022. Median initial dose (range) 4 mg/day (1-60); maximum dose, 20 mg/day (4-100), first, under patient- then cohort- temporary authorizations and after marketing authorization. Regimens used: titration (n = 6), block and replace (n = 16), or titration followed by block and replace (n = 11).

RESULTS

In 11 patients receiving osilodrostat as first-line monotherapy, median 24h- urinary free cortisol (24h-UFC) decreased dramatically (from 26xULN [2.9-659] to 0.11xULN [0.08-14.9]; p < 0.001). In 9 of them, 24h-UFC normalization was achieved in 2 weeks (median). Thirteen additional patients were previously treated with classic steroidogenesis inhibitors but 10/13 were not controlled. In these patients, osilodrostat monotherapy, used in second line, induced a significantly decreased of 24h-UFC (from 2.6xULN [1.1-144] to 0.22xULN [0.12-0.66]; p < 0.01). Nine additional patients received osilodrostat in combination with another anticortisolic drug decreasing 24h-UFC from 11.8xULN (0.3-247) to 0.43xULN (0.33-2.4) (p < 0.01).In parallel, major clinical symptoms/comorbidities improved dramatically with improvement in blood pressure, hyperglycemia and hypokalemia, allowing the discontinuation or dose reduction of their treatments. Adrenal insufficiency (grade 3-4) was reported in 8/33 patients.

CONCLUSIONS

Osilodrostat is a rapidly efficient therapy for PNCS/EAS with severe/intense hypercortisolism. Osilodrostat was generally well tolerated; Adrenal insufficiency was the main side effect.

Analysis of suction-based gripping strategies in wildlife towards future evolutions of the obstetrical suction cup

The design of obstetrical suction cups used for vacuum assisted delivery has not substantially evolved through history despite of its inherent limitations. The associated challenges concern both the decrease of risk of soft tissue damage and failure of instrumental delivery due to detachment of the cup. The present study firstly details some of the suction-based strategies that have been developed in wildlife in order to create and maintain an adhesive contact with potentially rough and uneven substratum in dry or wet environments. Such strategies have permitted the emergence of bioinspired suction-based devices in the fields of robotics or biomedical patches that are briefly reviewed. The objective is then to extend the observations of such suction-based strategies toward the development of innovative medical suction cups. We firstly conclude that the overall design, shape and materials of the suction cups could be largely improved. We also highlight that the addition of a patterned surface combined with a viscous fluid at the interface between the suction cup and scalp could significantly limit the detachment rate and the differential pressure required to exert a traction force. In the future, the development of a computational model including a detailed description of scalp properties should allow to experiment various designs of bioinspired suction cups.

Prediction of Cognitive Decline for Enrichment of Alzheimer's Disease Clinical Trials

BACKGROUND

A key issue to Alzheimer's disease clinical trial failures is poor participant selection. Participants have heterogeneous cognitive trajectories and many do not decline during trials, which reduces a study's power to detect treatment effects. Trials need enrichment strategies to enroll individuals who are more likely to decline.

OBJECTIVES

To develop machine learning models to predict cognitive trajectories in participants with early Alzheimer's disease and presymptomatic individuals over 24 and 48 months respectively.

DESIGN

Prognostic machine learning models were trained from a combination of demographics, cognitive tests, APOE genotype, and brain imaging data.

SETTING

Data from the Alzheimer's Disease Neuroimaging Initiative (ADNI), National Alzheimer's Coordinating Center (NACC), Open Access Series of Imaging Studies (OASIS-3), PharmaCog, and a Phase 3 clinical trial in early Alzheimer's disease were used for this study.

PARTICIPANTS

A total of 2098 participants who had demographics, cognitive tests, APOE genotype, and brain imaging data, as well as follow-up visits for 24-48 months were included.

MEASUREMENTS

Baseline magnetic resonance imaging, cognitive tests, demographics, and APOE genotype were used to separate decliners, defined as individuals whose CDR-Sum of Boxes scores increased during a predefined time window, from stable individuals. A prognostic model to predict decline at 24 months in early Alzheimer's disease was trained on 1151 individuals who had baseline diagnoses of mild cognitive impairment and Alzheimer's dementia from ADNI and NACC. This model was validated on 115 individuals from a placebo arm of a Phase 3 clinical trial and 76 individuals from the PharmaCog dataset. A second prognostic model to predict decline at 48 months in presymptomatic populations was trained on 628 individuals from ADNI and NACC who were cognitively unimpaired at baseline. This model was validated on 128 individuals from OASIS-3.

RESULTS

The models achieved up to 79% area under the curve (cross-validated and out-of-sample). Power analyses showed that using prognostic models to recruit enriched cohorts of predicted decliners can reduce clinical trial sample sizes by as much as 51% while maintaining the same detection power.

CONCLUSIONS

Prognostic tools for predicting cognitive decline and enriching clinical trials with participants at the highest risk of decline can improve trial quality, derisk endpoint failures, and accelerate therapeutic development in Alzheimer's disease.

[Acute macular neuroretinopathy: En face OCT description, case series]

Acute macular neuroretinopathy (AMN) is a rare disease characterized by involvement of the outer retinal layers of the macula. The diagnosis of AMN is based on multimodal imaging, combining infrared reflectance (IR) imaging and optical coherence tomography with B-scan analysis (OCT-B). The en face OCT is a tomographic image processing technique, integrating data from entire A-scans to create a frontal retinal image of the desired area. Structural en face OCT imaging appears to be effective in delineating AMN lesions, using segmentation between the outer plexiform line and the ellipsoid line. In the future, analysis of the various modalities of a single OCT acquisition may be sufficient to diagnose AMN.

The association of Greig syndrome and mastocytosis reveals the involvement of the hedgehog pathway in advanced mastocytosis

Mastocytosis is a heterogeneous disease characterized by an abnormal accumulation of mast cells (MCs) in 1 or several organs. Although a somatic KIT D816V mutation is detected in ∼85% of patients, attempts to demonstrate its oncogenic effect alone have repeatedly failed, suggesting that additional pathways are involved in MC transformation. From 3 children presenting with both Greig cephalopolysyndactyly syndrome (GCPS, Mendelian Inheritance in Man [175700]) and congenital mastocytosis, we demonstrated the involvement of the hedgehog (Hh) pathway in mastocytosis. GCPS is an extremely rare syndrome resulting from haploinsufficiency of GLI3, the major repressor of Hh family members. From these familial cases of mastocytosis, we demonstrate that the Hh pathway is barely active in normal primary MCs and is overactive in neoplastic MCs. GLI3 and KIT mutations had a synergistic, tumorigenic effect on the onset of mastocytosis in a GCPS mouse model. Finally, Hh inhibitors suppressed neoplastic MC proliferation in vitro and extend the survival time of mice with aggressive systemic mastocytosis (ASM). This work revealed, for the first time, the involvement of Hh signaling in the pathophysiology of mastocytosis and demonstrated the cooperative effects of the KIT and Hh oncogenic pathways in mice with ASM, leading to the identification of new promising therapeutic targets.

Les engelures apparues pendant le confinement sont associées à une exposition au SARS-CoV-2

Introduction

De nombreux cas d’engelures ont été rapportés depuis le début de la pandémie de Covid-19. Cependant, la RT-PCR et la sérologie ne mettaient pas en évidence d’infection à SARS-CoV-2 chez la majorité des patients. L’hypothèse d’une réponse interféron-médiée au SARS-CoV-2, permettant une clairance rapide du virus qui ne pourrait alors pas activer l’immunité humorale, a été soulevée et pourrait expliquer la séronégativité. Notre objectif était de rechercher une association entre les engelures survenues pendant le premier confinement en France et l’exposition au SARS-CoV-2 au sein des foyers.

Matériel et méthodes

Dans cette étude cas-témoins multicentrique, les cas étaient les 102 individus adressés entre mars et mai 2020 aux CHU de Rennes, Nantes, Angers, Tours, et Brest pour des engelures. Les témoins étaient recrutés à partir des fichiers de volontaires sains tenus par ces hôpitaux. Tous les membres de ces foyers étaient inclus, constituant ainsi 77 foyers cas (262 individus) et 74 foyers témoins (230 individus). L’exposition des foyers au SARS-CoV-2 lors du premier confinement était catégorisée en 3 niveaux : faible, intermédiaire ou élevé, à partir d’un algorithme prenant en compte les symptômes, les contacts à risque et les activités hors du foyer des individus de chaque foyer. Une sérologie SARS-CoV-2 était proposée à tous les individus.

Résultats

Après ajustement sur l’âge, l’association entre engelures et exposition au SARS-CoV-2 au sein des foyers de confinement était estimée à 3,3, intervalle de confiance à 95 % (1,4–7,3), pour un niveau d’exposition intermédiaire, et à 6,9 (2,5–19,5) pour un niveau d’exposition élevé au SARS-CoV-2. Parmi les 57 foyers cas ayant eu une sérologie, 6 (11 %) avaient développé des anticorps anti- SARS-CoV-2, alors que tous les foyers témoins testés étaient séronégatifs (n = 50).

Discussion

Cette étude cas-témoin démontre l’association entre engelures et exposition des foyers au SARS-CoV-2 durant le premier confinement. Notre critère de jugement étant déclaratif, un biais de mémorisation était possible. Cependant, même si 20 % des patients étaient classés exposés au SARS-CoV-2 par erreur, la mesure d’association resterait significative.

An advanced method to design graded cylindrical scaffolds with versatile effective cross-sectional mechanical properties

The selection of the most-suited bone scaffold for a given clinical application is challenging, and has motivated numerous studies. They are mostly based on the characterization of cellular structures, generated from the three-dimensional repetition of a unit cell. However, the interest of circular graded bone scaffolds has been emphasized since they facilitate nutrient transport from the periphery to the core of the scaffold. In the present contribution, we present an advanced and versatile method to design graded circular porous 2D structures based on the conformal mapping of unit cells. We propose a method to generate 3D porous scaffolds by a multilayer repetition of the circular cross-section, resulting in tunable anisotropy depending on the clinical application. We then analyze the link between the porosities of the obtained structures and their effective elastic mechanical cross-sectional properties, making use of a novel and computationally efficient method allowing exhaustive parametric studies. The comparison of various conformal transformations and unit cell designs emphasizes the extent of mechanical properties and porosities that may be reached for a given constitutive material, including non-standard mechanical properties that open large perspectives towards the development of self-fitting scaffolds.

[Clinical and paraclinical examination of non-traumatic optic neuropathy in the adult population]

Optic neuropathies (ON) occur in a variety of clinical presentations depending on their pattern of occurrence, their topography and the amount of functional visual impairment. Management of an ON requires a sequence of steps: confirm its existence (positive diagnosis): the diagnosis of ON is usually clinical and must be considered in the case of decreased visual acuity, change in color vision, visual field defect, relative afferent pupillary defect (RAPD), and absence of macular pathology; rule out differential diagnoses: determine the cause; etiologic diagnosis is sometimes complex and takes shape from clinical and paraclinical building blocks. The etiology may be vascular, inflammatory or demyelinating, infectious, toxic, vitamin-deficient, compressive (neoplastic or non-neoplastic), hereditary, congenital, traumatic or even pressure-related (glaucoma or advanced intracranial hypertension). Cerebral and orbital imaging with fine cuts of the optic nerves is often a mandatory examination, which is sometimes useful to repeat; identify therapeutic emergencies.

[Ability of ophthalmic technicians to identify a normal ophthalmological examination]

INTRODUCTION

Ophthalmology care has been growing for several years. Since ophthalmic technicians have the opportunity to perform delegated procedures, it is important to evaluate their training.

OBJECTIVE

To evaluate the ability of 3rd year ophthalmic technician students and graduates to assess the normality of an ophthalmological examination and to determine a proposed time delay for seeing an ophthalmologist.

MATERIALS AND METHODS

One hundred records including ophthalmology examinations were shown to 8 ophthalmic technician students in their third year of study and to 3 graduated technicians. Three ophthalmologists determined the content of the files, the pathological nature or not of the case, as well as the proposed time for seeing an ophthalmologist. We calculated the sensitivity and specificity to recognize the normality of the case, as well as the concordance between the proposed time for seeing an ophthalmologist.

RESULTS

For recognition of a normal case, the sensitivity was 80%, and the specificity was 83% in the group of technician students, and 81% versus 80% respectively in the group of graduated technicians. For the proposed time of consultation for seeing an ophthalmologist, the kappa agreement coefficient was 0.30 in the group of students and 0.41 in the group of graduates (low and moderate agreement respectively).

CONCLUSION

The study showed a good ability of technicians to recognize the normality or not of clinical cases, but their ability to judge the appropriate timing of treatment by an ophthalmologist remains insufficient.

Co-construction of a method for evaluating the intrinsic quality of bovine milk in relation to its fate

There are time-tested assessments for the environmental and economic aspects of sustainability. Its societal aspect has mainly been approached through the assessment of animal welfare. However, the intrinsic quality of milk is seldom taken into account. We developed a participatory construction method for the overall assessment of intrinsic milk quality in its different dimensions (sensory, technological, nutritional and health), according to the fate of the raw milk. Two assessment models were developed, for semi-skimmed standardized ultra-high temperature (UHT) milk and for pressed uncooked non-standardized raw milk cheese. They were constructed by a participatory approach involving experts in the dairy sector with the aim to obtain a diagnostic tool that could be used in the field to help farmers to manage the quality of their milk (by prioritizing improvements on major problems). They were shaped from prerequisite specifications (limited costs and time of application, desire to obtain a transparent tool with all the steps kept visible) and current technical and scientific knowledge. They were based on indicators obtained from raw bulk tank milk analyses (30 for UHT milk and 50 for cheese assessments), which were then aggregated into criteria, principles, dimensions and overall intrinsic quality at farm level. The assessment models had parts in common, for example, same four dimensions, common indicators for health and nutritional dimensions. They also had process-specific features: units chosen, criteria, indicators and weightings in relation to the final product specifications. For instance, sensory and technological dimensions are more complex and preponderant in the cheese assessment (three principles for cheese vs one for UHT milk in both dimensions). Another example is the lack of microbial pathogens (as potential health risk for consumer) in the UHT milk assessment because of pasteurization. The assessment models then underwent a sensitivity analysis and an application in 30 farms in indoor and grazing periods to finally obtain overall UHT milk and cheese quality scores at a 1-year level. The tool was found to be applicable at farm level. However, we observed low overall quality scores with a narrow dispersion, characteristic of a severe evaluation. Even so, the assessment models showed up seasonal differences of the UHT milk and cheese quality at both overall and dimensional levels. In the light of new scientific knowledge and future quality objectives, these are adaptable to other dairy products allowing for their specific features.

Impact of early biochemical diagnosis of anastomotic leakage after rectal cancer surgery: long-term results from GRECCAR 5 trial

Elevated C-reactive protein, should be used to prompt early detection of AL prior to the development of clinical symptoms. Early biochemical diagnosis and intervention of AL mitigates the negative impact of AL on oncological outcomes in patients with rectal cancer.

Impact de la crise de la COVID-19 sur les internes de dermatologie français

Introduction

Lors de la crise de la COVID-19, les internes de dermatologie, comme les autres professionnels de santé, ont été en première ligne. Nous avons souhaité évaluer l’impact de cette pandémie sur leurs pratiques professionnelles, leurs conditions de travail, leur formation universitaire et leur santé mentale.

Matériel et méthodes

Un questionnaire en ligne disponible du 17 au 26 avril a été envoyé à tous les internes français en dermatologie par la mailing list de l’association Futurs dermato-venerologues de France. Le questionnaire comprenait 104 questions dont le questionnaire de burn-out de Maslach.

Des régressions logistiques multivariées ont été effectuées pour examiner les facteurs associés au maintien d’une activité de dermatologie, une moins bonne supervision, une dégradation de la formation et les causes rapportées, et l’impact psychologique via un score de burn-out.

Résultats

Les internes déclarant une moins bonne supervision étaient les internes les plus avancés dans le cursus (OR 3,24 IC [1,65 ; 6,65], p < 0,001) ou en stage en CH périphériques (OR 2,21 IC [1,14 ; 4,46], p = 0,022). Pour 181 (76 %) internes, la pandémie a eu un effet négatif sur leur formation. La cause principale rapportée par 175 (74 %) d’entre eux était l’annulation des cours et des congrès. Il n’y avait de différence significative, entre les internes des zones fortement touchées ou non concernant la dégradation de leur formation ou des causes possibles liées à cette dégradation. Aucun interne n’était exempt de symptômes de burn-out, cinq (2 %) présentaient des symptômes intermédiaires, 43 (18 %) étaient fortement touchés dans 1 dimension, 76 (32 %) dans 2 et 112 (47 %) dans 3, sans différence significative entre les zones fortement et moins touchées.

Discussion

La crise de la COVID-19 a mis en tension notre système de santé mais également notre capacité à maintenir des activités essentielles pour les internes comme l’enseignement. Ces difficultés n’ont pas été exclusivement du fait du changement d’activité ou de la submersion des services par des patients atteints de la COVID-19, puisque la dégradation de la formation n’était pas corrélée à la situation géographique. La mise en place d’outils dématérialisés pour maintenir un lien et une formation adéquate n’a pas pu être mis en œuvre rapidement et efficacement durant la crise. Des stratégies pour accroître l’utilisation des outils numériques de formation et la télé-dermatologie semblent être des armes essentielles pour lutter en temps de crise épidémique avec le moins de répercussions sur leur travail et leur formation. Ces outils sont également adaptés aux nouvelles générations et aux nouveaux modes d’organisation du travail dans la société, dépassant même le cadre de la médecine et de la dermatologie.

[Haemophilic ankle arthropathy : case reports and review of the literature]

Haemophilic arthropathy affects about half of the patients who suffer from haemophilia. Despite the fact that it's one of the main morbidity factors of haemophilia and that the pathophysiology of its mechanism is slowly better understood, its management is still under discussion. The cases of two men (53 and 54 years old) who suffer from ankle haemophilic arthropathy since several years are reported. For both cases, different aspects of the management are investigated, including a medicated and a physiotherapy approach, and an adequate orthotic. Other treatments are available and sometimes used, such as radio- or arthroscopic synovectomy, corticosteroids or platelet-rich plasma in?ltration or visco-supplementation.

Clinical spectrum of primary adrenal lymphoma: results of a multicenter cohort study

Purpose

We sought to refine the clinical picture of primary adrenal lymphoma (PAL), a rare lymphoid malignancy with predominant adrenal manifestation and risk of adrenal insufficiency.

Methods

Ninety-seven patients from 14 centers in Europe, Canada and the United States were included in this retrospective analysis between 1994 and 2017.

Results

Of the 81 patients with imaging data, 19 (23%) had isolated adrenal involvement (iPAL), while 62 (77%) had additional extra-adrenal involvement (PAL+). Among patients who had both CT and PET scans, 18FDG-PET revealed extra-adrenal involvement not detected by CT scan in 9/18 cases (50%). The most common clinical manifestations were B symptoms (55%), fatigue (45%), and abdominal pain (35%). Endocrinological assessment was often inadequate. With a median follow-up of 41.6 months, 3-year progression-free (PFS) and overall (OS) survival rates in the entire cohort were 35.5% and 39.4%, respectively. The hazard ratios of iPAL for PFS and OS were 40.1 (95% CI: 2.63-613.7, P = 0.008) and 2.69 (95% CI: 0.61-11.89, P = 0.191), respectively. PFS was much shorter in iPAL vs PAL+ (median 4 months vs not reached, P = 0.006), and OS also appeared to be shorter (median 16 months vs not reached), but the difference did not reach statistical significance (P = 0.16). Isolated PAL was more frequent in females (OR = 3.81; P = 0.01) and less frequently associated with B symptoms (OR = 0.159; P = 0.004).

Conclusion

We found unexpected heterogeneity in the clinical spectrum of PAL. Further studies are needed to clarify whether clinical distinction between iPAL and PAL+ is corroborated by differences in molecular biology.