Pre-stroke socioeconomic status predicts upper limb motor recovery after inpatient neurorehabilitation

BACKGROUND

Lower socioeconomic status (SES) is associated with higher mortality rates and the likelihood of receiving less evidence-based treatment after stroke. In contrast, little is known about the impact of SES on recovery after discharge from inpatient rehabilitation. The aim of this study was to investigate the influence of SES on long-term recovery after stroke.

PATIENTS AND METHODS

In a prospective, observational, multicentre study, inpatients were recruited towards the end of rehabilitation. The 12-month follow-up focussed on upper limb motor recovery, measured by the Fugl-Meyer score. A clinically relevant improvement of ≥5.25 points was considered recovery. Patient-centric measures such as the Patient-reported Outcomes Measurement Information System-Physical Health (PROMIS-10 PH) provided secondary outcomes. Information on schooling, vocational training, income and occupational status pre-stroke entered a multidimensional SES index. Multivariate logistic regression models calculating odds ratios (ORs) and corresponding confidence intervals (CIs) were applied. SES was added to an initial model including age, sex and baseline neurological deficit. Additional exploratory analyses examined the association between SES and outpatient treatment.

RESULTS

One hundred and seventy-six patients were enrolled of whom 98 had SES and long-term recovery data. Model comparisons showed the SES-model superior to the initial model (Akaike information criterion (AIC): 123 vs. 120, Pseudo R²: 0.09 vs. 0.13). The likelihood of motor recovery (OR = 17.12, 95%CI = 1.31; 224.18) and PROMIS-10 PH improvement (OR = 20.76, 95%CI = 1.28; 337.11) were significantly increased with higher SES, along with more frequent use of outpatient therapy (p = .02).

CONCLUSIONS

Higher pre-stroke SES is associated with better long-term recovery after discharge from rehabilitation. Understanding these factors can improve outpatient long-term stroke care and lead to better recovery.KEY MESSAGEHigher pre-stroke socioeconomic status (SES) is associated with better long-term recovery after discharge from rehabilitation both in terms of motor function and self-reported health status.Higher SES is associated with significantly higher utilization of outpatient therapies.Discharge management of rehabilitation clinics should identify and address socioeconomic factors in order to detect individual needs and to improve outpatient recovery. Article registration: clinicaltrials.gov NCT04119479.

Red blood cell transfusion in surgery: an observational study of the trends in the USA from 2011 to 2016

Guidelines recommend restrictive red blood cell transfusion strategies. We conducted an observational study to examine whether the rate of peri-operative red blood cell transfusion in the USA had declined during the period from 01 January 2011 to 31 December 2016. We included 4,273,168 patients from all surgical subspecialties. We examined parallel trends in rates of the following: pre-operative transfusion; prevalence of bleeding disorders and coagulopathy; and minimally invasive procedures. To account for changes in population and procedure characteristics, we performed multivariable logistic regression to assess whether the risk of receiving a transfusion had declined over the study period. Clinical outcomes included peri-operative myocardial infarction, stroke and all-cause mortality at 30 days. Peri-operative red blood cell transfusion rates declined from 37,040/441,255 (8.4%) in 2011 to 46,845/1,000,195 (4.6%) in 2016 (p < 0.001) across all subspecialties. Compared with 2011, the corresponding adjusted OR (95%CI) for red blood cell transfusion decreased gradually from 0.88 (0.86-0.90) in 2012 to 0.51 (0.50-0.51) in 2016 (p < 0.001). Pre-operative red blood cell transfusion rates and the prevalence of bleeding disorders decreased, whereas haematocrit levels and the proportion of minimally invasive procedures increased. Compared with 2011, the adjusted hazard ratios (95%CI) in 2012 and 2016 were 0.96 (0.90-1.02) and 1.05 (0.99-1.11) for myocardial infarction, 0.91 (0.83-0.99) and 0.99 (0.92-1.07) for stroke and 0.98 (0.94-1.02) and 0.99 (0.96-1.03) for all-cause mortality. Use of peri-operative red blood cell transfusion declined from 2011 to 2016. This was not associated with an increase in adverse clinical outcomes.

Molecular imaging of neuroinflammation in patients after mild traumatic brain injury: a longitudinal 123 I-CLINDE single photon emission computed tomography study

BACKGROUND AND PURPOSE

Neuroinflammation has been proposed as part of the pathogenesis of post-concussion symptoms (PCS), but the inflammatory response of the human brain to mild traumatic brain injury (mTBI) remains unknown. We hypothesized that a neuroinflammatory response is present in mTBI at 1-2 weeks post-injury and persists in patients with PCS.

METHODS

We scanned 14 patients with mTBI without signs of structural damage at 1-2 weeks and 3-4 months post-injury and 22 healthy controls once using the single photon emission computed tomography tracer ¹²³ I-CLINDE, which visualizes translocator protein (TSPO), a protein upregulated in active immune cells. PCS was defined as three or more persisting symptoms from the Rivermead Post Concussion Symptoms Questionnaire at 3 months post-injury.

RESULTS

Across brain regions, patients had significantly higher ¹²³ I-CLINDE binding to TSPO than healthy controls, both at 1-2 weeks after the injury in all patients (P = 0.011) and at 3-4 months in the seven patients with PCS (P = 0.006) and in the six patients with good recovery (P = 0.018). When the nine brain regions were tested separately and results were corrected for multiple comparisons, no individual region differed significantly, but all estimated parameters indicated increased ¹²³ I-CLINDE binding to TSPO, ranging from 2% to 19% in all patients at 1-2 weeks, 13% to 27% in patients with PCS at 3-4 months and -9% to 17% in patients with good recovery at 3-4 months.

CONCLUSIONS

Neuroinflammation was present in mTBI at 1-2 weeks post-injury and persisted at 3-4 months post-injury with a tendency to be most pronounced in patients with PCS.

Helicopter vs. ground transportation of patients bound for primary percutaneous coronary intervention

BACKGROUND

Implementation of the first Danish helicopter emergency medical service (HEMS) was associated with reduced time from first medical contact to treatment at a specialized centre for patients with suspected ST elevation myocardial infarction (STEMI). We aimed to investigate effects of HEMS on mortality and labour market affiliation in patients admitted for primary percutaneous coronary intervention (PCI).

METHODS

In this prospective observational study, we included patients with suspected STEMI within the region covered by the HEMS from January 1, 2010, to April 30, 2013, transported by either HEMS or ground emergency medical services (GEMS) to the regional PCI centre. The primary outcome was 30-day mortality.

RESULTS

Among the 384 HEMS and 1220 GEMS patients, time from diagnostic ECG to PCI centre arrival was lower with HEMS (median 71 min vs. 78 min with GEMS; P = 0.004). Thirty-day mortality was 5.0% and 6.2%, respectively (adjusted OR = 0.82, 95% CI 0.44-1.51, P = 0.52. Involuntary early retirement rates were 0.62 (HEMS) and 0.94 (GEMS) per 100 PYR (adjusted IRR = 0.68, 0.15-3.23, P = 0.63). The proportion of patients on social transfer payments longer than half of the follow-up time was 22.1% (HEMS) vs. 21.2% (adjusted OR = 1.10, 0.64-1.90, P = 0.73).

CONCLUSION

In an observational study of patients with suspected STEMI in eastern Denmark, no significant beneficial effect of helicopter transport could be detected on mortality, premature labour market exit or work ability. Only a study with random allocation to one system vs. another, along with a large sample size, will allow determination of superiority of helicopter transport.

The Role of Genetics in Defining Reference Values and Health Status

Since its establishment, the Center for Preventive Medicine in Vandoeuvre-les-Nancy, France, performed specific studies on healthy humans, and its approach was very useful for defining reference values. Prevention should extend its interest to chronic diseases. The majority of important adult disorders are partially genetically determined. Genetic markers are also useful as exclusion or as partition criteria in the production of reference values. Results are presented that were obtained for apolipoproteins E, B and AIV, frequencies of these polymorphisms in the Lorraine population, and relationships between these polymorphisms and lipid metabolism-related parameters. Health checkup centers, in particular those involved in family screening, are well suited for reassembling many data concerning environmental factors: tobacco consumption, alimentation habits, or alcohol and drug consumption. Simultaneous determination of genetic markers could allow the determination of an individual’s susceptibility or resistance to developing a disease and to prepare a preventive action.

The effect of CT scanners in the trauma room - an observational study

BACKGROUND

A CT scanner incorporated in the trauma resuscitation bay may benefit trauma patients by fastening work-up times; however, evidence in the area is still sparse. We assessed if time from admission to first CT scan was lower after incorporation of a CT scanner in the resuscitation bay.

METHODS

We included trauma patients admitted in two 1-year periods, before and after a major rebuilding of the trauma room. Beforehand, one CT scanner was located in an adjacent room. After the rebuilding, two mobile CT scanners were placed in the resuscitation bays, where a moving gantry was combined with a trauma resuscitation table. Subgroup analyses were performed on severely injured and patients with traumatic brain injury.

RESULTS

We included 784 patients before and 742 patients after the reconstruction. Case-mix differed between study periods as there was a higher proportion of severe injuries, traumatic brain injury and penetrating trauma in the after period. We found a minor increase in time to CT in the after period (20 vs. 21 min, P = 0.008). In a multivariate regression analysis adjusted for differences in case-mix and with time to CT as outcome, period was an insignificant explanatory variable [β (before vs. after): 0.96 min 95% CI: 0.9-1.02, P = 0.3]. In both subgroups, we found no significant difference in time to CT.

CONCLUSION

We found no reduction in time to CT scan, when comparing a period with mobile CT scanners incorporated in the resuscitation bay to an earlier period with a CT scanner next to the trauma room.

Quality of life following trauma before and after implementation of a physician-staffed helicopter

Background

Implementation of a physician‐staffed helicopter emergency medical service (PS‐HEMS) in Denmark was associated with lower 30‐day mortality in severely injured trauma patients and less time on social subsidy. However, the reduced 30‐day mortality in severely injured patients might be at the expense of a worse functional outcome and quality of life (QoL) in those who survive. The aim of this study was to investigate the effect of a physician‐staffed helicopter on long‐term QoL in trauma patients.

Methods

Prospective, observational study including trauma patients who survived at least 3 years after injury. A 5‐month period prior to PS‐HEMS implementation was compared with the first 12 months after PS‐HEMS implementation. QoL was assessed 4.5 years after trauma by the SF‐36 questionnaire. Primary endpoint was the Physical Component Summary score.

Results

Of the 1994 patients assessed by a trauma team, 1521 were eligible for inclusion in the study. Of these, 566 (37%) gave consent to participate and received a questionnaire by mail, and 402 (71%) of them returned the questionnaire (n = 114 before PS‐HEMS; n = 288 after PS‐HEMS implementation). Older patients, women and patients with trauma in the after PS‐HEMS period were more likely to return the questionnaire. No significant association between QoL and period (before vs. after PS‐HEMS) was found; the Physical Component Summary scores were 50.0 and 50.9 in the before and after PS‐HEMS periods, respectively (P = 0.47). We also found no difference on multivariable analysis with adjustment for sex, age and injury severity score.

Conclusion

No significant difference in QoL among trauma patients was found after implementation of a PS‐HEMS.

Indication for resuscitative thoracotomy in thoracic injuries-Adherence to the ATLS guidelines. A forensic autopsy based evaluation

BACKGROUND

The appropriate indications for Resuscitative Thoracotomy (RT) are still debated in the literature and various guidelines have been proposed. This study aimed to evaluate whether Advanced Trauma Life Support (ATLS) guidelines for RT were applied correctly and to evaluate the proportion of deceased patients with potentially reversible thoracic lesions (PRTL).

METHODS

The database at the Department of Forensic Medicine at Copenhagen University was queried for autopsy cases with thoracic lesions indicated by the SNOMED autopsy coding system. Patients were included if thoracic lesions were caused by a traumatic event with trauma team activation. Patient cases were blinded for any surgical intervention and evaluated independently by two reviewers for indications or contraindications for RT as determined by the ATLS guidelines. Second, autopsy reports were evaluated for the presence of PRTL.

RESULTS

Sixty-seven patients met the inclusion criteria. Two were excluded due to insufficient data. The overall agreement with guidelines was 86% and 77% for blunt and penetrating trauma, respectively. For patients submitted to RT the overall agreement with guidelines was 63% being 45% and 74% for blunt and penetrating trauma, respectively. For patients who did not undergo RT the agreement with guidelines was 100%. In all cases where RT was performed in agreement between guidelines and the clinical decision the autopsy reports showed PRTL in 16 (84%) patients. In cases of non-agreement PRTL were found in 9 (82%) patients.

CONCLUSIONS

Agreement with ATLS guidelines for RT was 63% for intervention and 100% for non-intervention in deceased patients with thoracic trauma. Agreement was higher for penetrating trauma than for blunt trauma. The adherence to guidelines did not improve the ability to predict autopsy findings of PRTL. Although the study has methodical limitations it represents a novel approach to the evaluation of the clinical use of RT guidelines.

Cytochrome P450 polymorphism and postoperative cognitive dysfunction

BACKGROUND

The etiology of postoperative cognitive dysfunction (POCD) remains unclear but toxicity of anesthetic drugs and their metabolites could be important. We aimed to assess the possible association between POCD after propofol anesthesia and various phenotypes owing to polymorphisms in cytochrome P450 encoding genes.

METHODS

We included patients who underwent non-cardiac surgery under total intravenous anesthesia with propofol. POCD was identified using a neuropsychological test-battery administered preoperatively, one week, and three months after surgery. Genotyping of CYP2C19*2, *3, CYP2D6*3, *4, *5 and *6 was performed using pyrosequencing, and patients were characterized according to their phenotype as ultra, extensive, intermediate, or poor metabolizers.

RESULTS

In total, 337 patients with a median age of 67 years were included. 30 (9.4%) out of the 319 patients who underwent neuropsychological testing at one week had POCD, and 24 out of 307 (7.8%) had POCD at three months. None of the examined CYP2C19, 2D6 alleles, or various phenotypes were significantly associated with POCD.

CONCLUSION

Polymorphisms in CYP2C19, or 2D6 genes do not seem to be related to the occurrence of cognitive dysfunction after non-cardiac surgery in patients anesthetised with propofol.

The elderly and general anesthesia

Due to the aging population, the number of elderly patients taking advantage of healthcare services is increasing. A general physical decline of all organ systems and a high frequency of chronic disease accompanying aging.Comorbidity and polypharmacy are therefore common in the elderly. Hence, the administration of general anesthesia to the elderly can be a very challenging task. This paper aims to highlight some of the important issues presented to the elderly undergoing surgery and to suggest some strategies for management.

Depth of anaesthesia and post-operative cognitive dysfunction

BACKGROUND

A deep level of anaesthesia measured by the bispectral index has been found to improve processing speed as one aspect of cognitive function after surgery. The purpose of the present study was to assess the possible effect of the level of anaesthesia on post-operative cognitive dysfunction (POCD) 1 week after surgery, as assessed by a neuropsychological test battery.

METHODS

We included 70 patients >60 years of age scheduled for elective non-cardiac surgery with general anaesthesia. The depth of anaesthesia was monitored using the cerebral state monitor, which provided a cerebral state index (CSI) value. Cognitive function was assessed by the ISPOCD neuropsychological test battery before and at 1 week (or hospital discharge) after surgery and POCD was defined as a Z score above 1.96.

RESULTS

Five patients were not assessed after surgery. The mean CSI was 40 and 43 in patients with (N=9) and without POCD (N=56), respectively (P=0.41). The cumulated time of both deep anaesthesia (CSI<40) and light anaesthesia (CSI>60) did not differ significantly, and no significant correlation was found between the mean CSI and the Z score.

CONCLUSION

We were unable to detect a significant association between the depth of anaesthesia and the presence of POCD 1 week after the surgery.

Cognitive dysfunction after cardiovascular surgery

This review describes the incidence, risk factors, and long-term consequences of cognitive dysfunction after cardiovascular surgery. Postoperative cognitive dysfunction (POCD) is increasingly being recognized as an important complication, especially in the elderly. A highly sensitive neuropsychological test battery must be used to detect POCD and a well-matched control group is very useful for the analysis and interpretation of the test

RESULTS

Cardiovascular surgery is associated with a high incidence of POCD. Cardiopulmonary bypass was thought to explain this difference, but randomized studies comparing with off-pump coronary artery bypass surgery show contradictory

RESULTS

POCD seems to have important long-term consequences regarding self-assessed quality of life, survival, and labor market attachment.

Improved survival after an out-of-hospital cardiac arrest using new guidelines

BACKGROUND

An out-of-hospital cardiac arrest (OHCA) is associated with a poor prognosis. We hypothesized that the implementations of 2005 European Resuscitation Council resuscitation guidelines were associated with improved 30-day survival after OHCA.

METHODS

We prospectively recorded data on all patients with OHCA treated by the Mobile Emergency Care Unit of Copenhagen in two periods: 1 June 2004 until 31 August 2005 (before implementation) and 1 January 2006 until 31 March 2007 (after implementation), separated by a 4-month period in which the above-mentioned change took place.

RESULTS

We found that 30-day survival increased after the implementation from 31/372 (8.3%) to 67/419 (16%), P=0.001. ROSC at hospital admission, as well as survival to hospital discharge, were obtained in a significantly higher proportion from 23.4% to 39.1%, P<0.0001, and from 7.9% to 16.3%, P=0.0004, respectively. Treatment after implementation was confirmed as a significant predictor of better 30-day survival in a logistic regression analysis.

CONCLUSION

The implementation of new resuscitation guidelines was associated with improved 30-day survival after OHCA.

Choice reaction time in patients with post-operative cognitive dysfunction

BACKGROUND

Post-operative cognitive dysfunction (POCD) is detected by administration of a neuropsychological test battery. Reaction time testing is at present not included as a standard test. Choice reaction time (CRT) data from the first International Study of Post-operative Cognitive Dysfunction study were collected, but the association between POCD and reaction time has not been presented before. We hypothesized that CRT could be used as a screening tool for POCD.

METHODS

Patients aged 60 years or older scheduled for major surgery with general anaesthesia were recruited from 13 centres in nine countries. CRT was measured 52 times using the four boxes test. Patients performed the test before surgery (n=1083), at 1 week (n=926) and at 3 months (n=852) post-operatively. CRT for the individual patient was determined as the median time of correct responses. The usefulness of the CRT as a screening tool for POCD was determined by the receiver-operator characteristic (ROC) curve.

RESULTS

Patients with POCD 1 week after surgery had a significantly longer reaction time compared with patients without POCD: 857 (221) vs. 762 (201) ms, respectively (P<0.0001). Also at 3 months, patients with POCD had a significantly longer CRT. ROC curves revealed that a reaction time of 813 ms was the most appropriate cut-off at 1 week and 762 ms at 3 months but the positive predictive value for POCD was low: 34.4% and 14.7%, respectively.

CONCLUSIONS

Post-operative cognitive dysfunction is associated with impaired performance in the CRT test but the test is a poor predictor of POCD.

[Determination of glucose, proteins, blood and leucocytes in urines: evaluation of automated analyzer Aution Max AX 4280]

The aim of this study was to evaluate the automated urine test strip analyzer Aution Max AX 4280 which uses strips able to measure 12 urinary parameters. For precision study, we considered glucose, protein, blood, leukocytes, nitrite, and pH and the four first were compared with usual methods: chemical measurement or microscopic examination. Reproducibility of the semi quantitative results was determined as the proportion of results falling into the same concentration range. Within-run reproducibility assessed using urine specimens were between 83% and 96%. Between day on quality controlled materials, it was higher (96%), and leukocytes were shared between two classes 250 and 500 cells/microL. For glucose and proteins, linearity was good and comparison with quantitative methods yielded high correlation. The false negative fraction was low and there was no false positive results. For blood, fraction of false positive was 7.5% for 0.3 mg/L of hemoglobin compared with microscopic analysis and false negative fraction was 1.3%. For leukocytes, false positive fraction was 4%, false negative one was 7.8%. These results, values for sensitivity, specificity, predictive positive value, predictive negative value permitted to determine the cut-off values to realize second levels analysis: proteins are measured from 0.30 g/L, glucose from 2.8 mmol/L, microscopic urinalysis was performed from hemoglobin more than 0.3 mg/L and leukocytes more than 25 cells/microL.

[Multicenter evaluation of four homogenous LDL-cholesterol assays]

International guidelines emphasize the importance of LDL cholesterol (LDL-C) assay in the care and follow-up of patients with cardiovascular risk. Most studies and common practice use Friedewald's formula for LDL-C calculation. The accuracy of the result depends closely on the precision of the input parameters (total cholesterol, triglycerides (TG) and HDL cholesterol), and discrepancies between calculated LDL-C and measurement by reference methods appear when TG exceed 4.5 mmol/L, or in the presence of abnormal lipoproteins. These restrictions and uncertainties in calculations have prompted the recent development of direct and homogeneous methods that fit all analyzers. A multicenter evaluation of four direct assays of LDL-C (Daiichi, Denka Seiken, Kyowa, Wako) was carried out on 45 serum samples (TG below 3.1 mmol/L) in eight laboratories using different analyzers. For three methods (Daiichi, Kyowa, Wako), the interlaboratory reproducibility was markedly improved relative to that of calculation. A strong correlation was found for all new methods when compared with a beta-quantification assay. Average bias in Denka Seiken assays was greater than Kyowa's and Daiichi's (although less dispersed for the latter) and for Wako all bias were positive. The relationship between bias variations and the lipid parameters of the samples was studied. Three methods, Daiichi, Kyowa and Wako, revealed a significant positive correlation between bias and serum VLDL-C/TG ratio, clearly indicating that cholesterol enrichment of VLDL was a source of variability in these assays. Specificity of the four methods was tested in situation of dyslipidemia by spiking isolated lipoproteins (chylomicrons, VLDL and HDL). This experiment revealed differences in behavior, most evidently upon addition of VLDL. No method was truly specific, but up to 8 mmol/L of TG the variations were acceptable. In the presence of type III hyperlipoproteinemia, however, only the Denka Seiken method was reliable. Linearity up to 20 mmol/L (Daiichi, Denka Seiken) or 14 mmol/L (Kyowa, Wako) of LDL-C allows these tests to be used in main routine cases. New direct assays are an obvious technological advance in terms of analytical performance and conveniency. Their use for the diagnosis and follow-up of hyperlipidemic patients offers an alternative that overcomes the limitations of the Friedewald calculation.

[Reference limits for urine sediments performed on Sysmex UF-50]

The Sysmex UF-50 is an automated flow cytometer for urine sediments analysis. Interpretation of the results needs establishment of reference limits for the different constituents measured. First of all, we checked precision of measurements and stability of urines during transportation. Then, urine samples from 4 to 95 year old subjects were examined with the UF-50, by visual microscopy and test strips. Distributions of results for erythrocytes, leukocytes, epithelial cells, casts, bacteria and conductivity were described in a sample of 680 subjects (364 men and 316 women), with creatininemia below 140 micromol/L, consuming no drugs and for women without intra uterine device and apart from menstruation period. Then, the results were compared with those obtained in groups selected on microscopic analysis and test strip results. UF-50 sensitivity and specificity were 77.5% and 88% for 15 erythrocytes/microL in reference to microscopic urinalysis, they were 91.3% and 87.3% for 15 leucocytes/microL. The reference sample was defined with negative microscopic results. The upper reference limits (centile 97.5) were 16 red blood cells/microL for men 14.5 for women, 13.5 and 33 leucocytes/microL, 8 and 19 epithelial cells/microL, 1,3 and 0,4 casts/microL, 5 500 et 7 700 bacteria/microL, 36,2 et 34,6 conductivity mS/cm. The Sysmex UF-50 is a suitable analyser for urinary sediments. Reference limits may be different from usual reference limits due to variability in performances of other methods.

Die Zervikale Myelopathie als Komplikation der Rheumatoiden Arthritis

Arthritis of the cervical spine with instability of the atlantodental joint is a typical and frequent complicaiton in rheumatoid arthritis. Subsequent cervical myelopathy is rare but usually a severe complication. There is no stringent correlation between arthritis of cervical spine an occurrence of cervical myelopathy. Cervical myelopathy is often difficult to discern from parallel multilating peripheral joint damage, which makes the diagnosis difficult. The decision between conservative and operative therapeutic intervention has to be based on subtle clinical, neurophysiological and radiological assessment and-in particular-requires exact analysis of the course of the underlying rheumatoid arthritis and myelopathy. In this diagnostic process close collaboration of rheumatologist, surgeon and neurologist is essential.

[Use of a job-exposure matrix for the screening of occupational exposure to asbestos]

BACKGROUND

According to a recent French legislation (1995), retired people who have been exposed to an occupational carcinogen can benefit from a specific post-occupational medical follow-up program, supported by the "Caisse Primaire d'Assurance-Maladie" (CPAM), the French health insurance system. However, only very few people presently take access to this social measure. The ESPACES project developed and evaluated a procedure to identify retirees who have been exposed to asbestos during their career, and to inform them about the post-occupational medical follow-up program.

METHODS

This pilot study was performed within the health centers ("Centres d'examens de santé" (CES)) of the health insurance system in a random sample of men who have retired from the six main French administrative divisions between 1994 to 1996. A probability of exposure to asbestos was attributed through a job exposure matrix. Subjects were interviewed in the CES to validate their exposure data. Retired subjects with confirmed exposure to asbestos were referred to their CPAM, to apply for the medical follow-up. The whole process was evaluated through a comparison with control CPAMs, and simulations were performed to assess its sensitivity and specificity, as well as the total number of persons in France who could potentially benefit.

RESULTS

Among the 737 persons classified as exposed by the matrix who came to the CES, the exposure was confirmed for 53.8%, and 143 benefited from the medical follow-up, 17 times more than in a sample of control CPAMs. Based on an annual number of about 250,000 new retirees, simulations showed that a low detection threshold, taking into account the probability and duration of exposure, would yield approximately 25,000 persons coming to the CES, more 6,000 of them benefiting from the follow-up.

CONCLUSION

The proposed detection threshold would allow for a feasible and ethically acceptable generalization, due to the optimization of the false negative and false positive rate.

Evaluation of the quality of coding of job episodes collected by self questionnaires among French retired men for use in a job-exposure matrix

BACKGROUND

and

AIMS

The ESPACES study was intended to identify retirees who may have been, according to their job descriptions, exposed to asbestos during their working lives. As part of this study, we analysed the quality of the occupation and activity sector coding as well as its effect on the subjects' exposure status.

METHODS

The occupation and activity sector for a sample of 450 retired men were coded twice (with the second coder blinded to the first result), according to the international codes for industries (ISIC-1975) and occupations (ISCO-1968). For each series, linking the information about a job episode (dates, ISIC code, ISCO code) with the matrix allowed attribution of a probability of asbestos exposure to each episode and each subject. The asbestos exposure in the two series was compared by the kappa reproducibility coefficient.

RESULTS

The analysis concerned 425 questionnaires. There was at least one difference in the code for either activity sector (ISIC) or occupation (ISCO) in half the episodes (50.2%). The exposure status estimated by the job-exposure matrix did not change between the series for 84.7% of the subjects. The kappa coefficient was 0.64 for all questionnaires, 0.70 when the questionnaire was coded twice by the same coder, and 0.62 when coded by two different coders.

CONCLUSIONS

Despite intra- and inter-differences between coders, the coding of job episodes for the ESPACES study appears satisfactory and hence indicates that the assessment of the subjects' asbestos exposure was assessed without major distortions. This study underlines the usefulness of employing coders specifically trained for this technique.

[Three-year follow-up of infraclinical hypothyroidism: course in a cohort of 97 women aged 45 to 70 years attending healthcare screening centers]

Infraclinical hypothyroidism is a recognized entity defined in terms of laboratory results which occurs more readily in women. The appropriateness of thyroid hormone multicentric prospective study initiated in 1997 has established that infraclinical hypothyroidism occurred in about 3% of women over 45 years of age undergoing routine check-ups at eleven health screening centers. Associated clinical signs and laboratory findings were reported. The purpose of the present study was to describe findings in a 3-year follow-up of these women with infraclinical hypothyroidism in order to assess natural history and appropriate care. Ninety-seven women of the 151 women with a TSH level between 4 and 12 mU/l in the 1997 survey were reviewed during the last three months of 2000. Forty-three of them had taken thyroid hormone replacement drugs since 1997. About 44% of the women examined still had infraclinical hypothyroidism or developing hypothyroidism. There was not significant difference between treated (33%) and non-treated (55%) patients. Clinical and biological signs associated with infraclinical hypothyroidism at the initial examination (elevated serum cholesterol, abnormal ECG, eyelid edema, recent weight gain) were unchanged at the second examination, both in treated and not treated women. A logistic model including all these factors demonstrated that the probability of prescription of thyroid hormone replacement therapy increased 5.4-fold when the starting TSH level was above 6 mU/l and 3.2-fold if ECG abnormalities were present. Using a statistical model with anti TPO antibodies, a level above 64 U/l increased the probability of treatment 7-fold, with ECG findings being related to probability of treatment. Age, cholesterol level, use to lipid lowering drugs, presence of eyelid edema or weight gain were not associated with replacement therapy in this model. No consistent conclusion concerning the appropriateness of screening for infraclinical hypothyroidism can be drawn from these three-year follow-up findings. Another examination scheduled for 2003 should provide further precision concerning the natural history of infraclinical hypothyroidism as well as long-term medical practices and therapeutic impact.

Soluble transferrin receptor (sTfR): biological variations and reference limits

The aim of this study was to establish soluble serum transferrin receptor (sTfR) reference limits. sTfR was measured in 885 healthy subjects from 3 to 91 years old (433 men, 409 women), without hematological abnormalities, using an immunonephelometric assay. The sTfR median concentrations in our population decreased gradually from the group aged 3-10 years to the group aged 21-40 years, then there were no changes in the older groups except for the females >60 years of age. The interindividual variability ranged from 12.6% to 30.3% among different age groups, and the analytical variability was 5%. Biological factors and other factors associated with sTfR concentration variation were examined and accounted for 35% of the sTfR variability in men aged 20 years or less, and 18% in those older than 20 years. Also, they accounted for 45% of the variability in women aged 20 years or less and 14% in those older than 20 years. The main factors statistically associated with sTfR concentration in males were ferritin, orosomucoid, hemoglobin, and tobacco in all age groups and only mean corpuscular volume (MCV) in males less than 20 years old. In the females the main factors were age, orosomucoid, and hemoglobin in all age groups, MCV and tobacco in females less than 20 years old, and ferritin and physical activity in females more than 20 years old. These factors were used to define the exclusion and partition criteria for obtaining the reference samples. Medians for reference values were: 1.60 mg/l in the 3-10-year old group (males and females); 1.42 mg/l in males between 11 and 20 years of age, and 1.33 mg/l in females of the same age. In the other age groups, the median of the reference values was 1.16 mg/l, except in females over 60 years old, for whom it was 1.26 mg/l.

[Screening for colorectal cancer. Study of a population attending a public health clinic]

OBJECTIVES

Screening for colorectal cancer with fecal occult-blood test has been performed in health centers for several years. The aim of this study was to describe participation rate and results in a population attending the Center for preventive medicine at Vandoeuvre-lès-Nancy, France in 1996 and 1997.

PATIENTS AND METHODS

Among 19,325 people aged 50-75 years, the screening test was proposed to 17,917 and performed in 15,527.

RESULTS

Participation rate was 86.7%. Overall positivity was 3.6% higher in men than in women (4.1% versus 3.0%). In the 440 colonoscopies performed, 22 cancers and 84 adenoma polyps were identified (PPV = 24%).

DISCUSSION

These results show good participation rates in a screening program for colorectal cancer during periodic health check-ups. Follow-up for positive subjects was satisfactory but requires good cooperation between specialists and general practitioners to obtain complete information to evaluate the program.

Anhydrous lead(II) heptanoate

The title compound, catena-poly[[(heptanoato-O,O')lead(II)]-micro-heptanoato-O,O':O:O'], [Pb(C(7)H(13)O(2))(2)], is a metallic soap which can be used as a corrosion inhibitor since it forms a passive film at the Pb surface. Its structure is characterized by two-dimensional layers parallel to the bc plane. The layers are packed through van der Waals interactions along the a direction and form blocks parallel to (001). The 6s(2) lone pair of electrons on Pb(II) is stereochemically active in this compound, which leads to a hemidirected octahedral geometry for the O-environment around the Pb atoms.

Factors of variation and reference values for TSH in 45-70 year old women

Thyroid stimulating hormone (TSH) was measured in a sample of 4,403 women, aged 45-70 years in 11 Centers for health screening, to define the interest of this biological indicator for screening subclinical hypothyroidism. The aim of this work was to describe clinical signs, symptoms and medical history linked to TSH variations, to estimate the distribution of this hormone in a general population and reference limits in a selected subgroup. All the participating laboratories used the same third-generation immunoassay on fresh samples. In the general sample population (age mean: 55.2 6.9 yrs), 1.1% presented hyperthyroidism (TSH<0.3 mU/l) and 0.4% had hypothyroidism (TSH>12 mU/l). In the sub-sample of 151 women (3.4%) with TSH between 4-12 mU/l, 131 had subclinical hypothyroidism (FT4>8 ng/l). The TSH mean was significantly lower (- 10 to - 23%) in women presenting a nodular goiter. Inversely, TSH was higher in women with muscle cramps, asthenia, recent weight gain, morning eyelid edema and abnormal electrocardiogram. The reference limits for percentiles 2.5 and 97.5 were 0.43 and 3.71 mU/l on 1 348 subjects after excluding women having one of these symptoms or taking any drug treatment.

High sensitivity C-reactive protein: biological variations and reference limits

Serum C-reactive protein (CRP) concentration was determined for 3605 subjects using an immunonephelometric assay improved to provide greater sensitivity. Subjects were from 5 to 75 years old and belonging to 1003 nuclear families recruited from the Stanislas Cohort Study between January 1994 and August 1995. Sample values for CRP ranged from 0.17 mg/l to 100 mg/l. Geometric means (mean - SD; mean +/- SD) were in the 5-14 years old group 0.37 (0.17-1.07) mg/l, in the 15-28 years old group 0.47 (0.17-1.38) mg/l and in the 29-75 years old group 0.98 (0.34-2.85) mg/l. For women, the geometric means were 0.38 (0.17-1.10) mg/l, 0.62 (0.20-1.90) mg/l and 0.98 mg/l (0.31-3.13) mg/l respectively. The interindividual variability ranged from 138% to 759% among different age classes. Biological factors associated with CRP concentration variations were examined and accounted for 25% of the CRP variability in men and 40% in women. The main biological factors statistically associated with CRP concentration variations in men were: drugs, leukocyte count, body mass index, tobacco consumption, age, and in women: drugs, leukocyte count, age, body mass index and hemoglobin concentration. These factors were used to define the exclusion and partition criteria when obtaining the reference samples. Medians for reference values ranged from 0.20 to 0.68 mg/l in males and from 0.20 to 0.78 mg/l in women.

[Iron deficiency in patients over 60 years. Descriptive study in the consultant population of health screening centers]

AIM

The aim of the study was to evaluate the frequency of iron deficiency with serum ferritin in elderly population, and to appreciate the opportunity of early screening according to digestive diseases.

SUBJECTS AND METHODS

Data were collected from 3524 men and 3120 women aged 60 to 75 years during a health screening examination. Evaluation of diagnosis and treatment were obtained through questionnaire completed by treating physician.

RESULTS

The frequency of hypoferritinemia was about 2.3% in our population (hypoferritinemia was defined by serum ferritin<20 microg/L or between 20-40 microg/L if C reactive protein was > 12 mg/L). Anemia was found in 3.3% of patients. Logistic regression model adjusting for multiple variables was used to examine factors associated with hypoferritinemia. The probability was greater among non-anemic patients with chronic digestive bleeding (odds-ratio: 2.3), or with positive occult blood testing (odds-ratio: 2.3). Information about the medical follow-up was obtained in 81% of patients with hypoferritinemia. A digestive exploration was made in 38 cases. Digestive disease was found among 24.3% patients with hypoferritinemia, and three colorectal cancers were observed.

CONCLUSION

The screening of hypoferritinemia in elderly population examined in health screening centres could not be recommended as its frequency was low in this population, despite a strong correlation between hypoferritinemia and digestive diseases.

[Strategy for serum ferritin measurement in 16 to 45 year old women in health screening centers]

Even in industrialized countries, the iron-deficiency anemia is frequent in menstruating women. However, the systematic measurement of serum ferritin is not justified. In this study, a strategy for ferritin measurement has been determined from data of centers for health screening, obtained in 6,098 menstruating women. This strategy is based on biological results (hemoglobin, MCV, RDW, GGT, ALAT) and on responses to the questions about blood donation, birth country and contraceptive habits. The measurement of serum ferritin is realized in 64% menstruating women and 23% have an hypoferritinemia (< 20 mg/l).

[Multicenter evaluation on different analyzers of three methods for direct HDL-cholesterol assay]

Most frequently, in routine laboratories, C-HDL is measured in the supernatant after precipitation of apolipoprotein B-containing lipoproteins by the sodium phosphotungstate/magnesium chloride reagent (PTA). This method involves precipitation, centrifugation and decantation steps which prevent full automation of the measurement and decrease the accuracy of the results. Recently, three direct assays for C-HDL including alpha-cyclodextrin sulphate (alpha-CD), polyanions/detergents (PA-D) or antibodies anti-beta-lipoproteins (AC) have been commercialized, in which all steps are fully managed by automated analyzers. These new methods have been compared to the conventional procedure (PTA), in multicenter studies among six laboratories using different analyzers. The C-HDL values measured by the alpha-CD and PA-D assays correlated well with those of the PTA method (r > 0.98), on most of the analyzers. With the AC assay, only the results obtained with the Hitachi 717 analyzer were correlated with C-HDL values of the PTA method. The linearity and specificity studies were evaluated in the laboratory A on a Kone Specific analyzer. The alpha-CD and PA-D assays were linear for C-HDL values from 0 to 5.56 mmol/l, as observed by increasing amounts of HDL2 + HDL3 or serum without lipoprotein isolated by ultracentrifugation. The specificity of these two methods was evaluated simultaneously, by adding various amounts of lipoproteins isolated by sequential ultracentrifugation. No interference was observed when adding chylomicrons up to 13.4 mmol/l of triglycerides for both methods. Inversely, increased C-HDL values were observed with added VLDL from 6 mmol/l of triglycerides for the PA-D assay and from 8 mmol/l for the alpha-CD assay. No interference was observed with added LDL up to 11.5 mmol/l of C-LDL for the alpha-CD assay and up to 6.7 mmol/l for the PA-D assay. In conclusion, the present multicenter evaluation demonstrates that the new procedures for the direct automation of C-HDL are easy and accurate and most of them correlated well with the classical precipitation method. In addition the study provides arguments for a choice between the different direct C-HDL methods.