Patterns, predictors, and outcomes of frailty trajectories in community-dwelling older adults: Results from the FREEDOM Cohort Study

OBJECTIVES

To identify subgroups of people with distinct frailty trajectories, identify baseline characteristics associated with these trajectories, and determine their coincident clinical outcomes.

DESIGN

This study examined the longitudinal database from the FREEDOM Cohort Study.

SETTING AND PARTICIPANTS

All 497 participants of the FREEDOM (French Acronym for "FRagilitéEtEvaluation àDOMicile" / In English "Frailty and Evaluation at Home") cohort requested a comprehensive geriatric assessment. Community-dwelling subjects over 75 years, or over 65 years with at least two comorbidities were included.

METHODS

Frailty was assessed using Fried's criteria, depression using the Geriatric Depression Scale (GDS) and cognitive function using the Mini Mental State Examination (MMSE) questionnaire. Frailty trajectories were modelled using k-means algorithms. Predictive factors were determined by multivariate logistic regression. Clinical outcomes included incident cognitive deficit, falls and hospitalization.

RESULTS

The trajectory models allowed determine four frailty trajectories: "robust stable" (Trajectory A, 26.8%), "pre-frail worsening to frailty" (Trajectory B, 35.8%), "frail improving to less frailty" (Trajectory C, 23.3%), and "frail worsening to more frailty" (Trajectory D, 14.1%). Trajectory B was associated with age (OR 1.2 (95CI, 1.05 - 1.17)), potential cognitive deficit/dementia (OR 2.01 (95CI, 1.01- 4.05)) and depressive symptoms (OR 2.36 (95CI, 1.36 - 4.12)). Hypertension was distinguishing factor between" trajectory B vs. C and D. Depressive symptoms were two time more associated with D (OR 10.51) vs. C (OR 4.55). The incidence of clinical outcomes was significantly increased in poor frailty trajectories.

CONCLUSIONS AND IMPLICATIONS

This study allowed to determine frailty trajectories among older subjects requested a comprehensive geriatric assessment. The more significant predictive factors associated with poor frailty trajectory were advanced in age, potential cognitive deficit/dementia, depressive symptoms and hypertension. This emphasizes the need for adequate measures to controlled hypertension, depressive symptoms and to maintain or improve cognition in older adults.

Risk factors of frailty and functional disability in community-dwelling older adults: a cross-sectional analysis of the FREEDOM-LNA cohort study

BACKGROUND

Frailty is a geriatric syndrome associated with disability and negative health outcome. To determine the factors associated with frailty and functional disability in older participants living in community in France. We included 753 community-dwelling old participants with available frailty data at baseline.

RESULTS

Overall, 31.9% were frail, 58.3% were prefrail, and 9.8% were robust. The SMAF (French acronym for Functional Autonomy Measurement System) score was significantly lower (mean ± standard deviation: -25.8 ± 11.2) in frail participants compared to prefrail (-14.3 ± 9.7) or robust participants (-8.1 ± 7.0); 82% of frail older participants had limitation in at least one ADL and 97.5% in at least one IADL compared to 54.2 and 76.8%, respectively of pre-frail and 29.7 and 47.3% of robust participants. Age, depression, impaired cognition and diabetes were significantly associated with higher odds of frailty. These variables were also strongly associated with functional disability. Female gender, polypharmacy, and smoking were additional variables significantly associated with degraded SMAF and/or ADL/IADL.

CONCLUSIONS

This study showed that functional disability increased proportionally to frailty, and depression, cognitive decline and diabetes are modifiable risk factors significantly associated with frailty and functional disability.

Prevalence of tachyphagia at lunch and associated factors in a population of workers

PURPOSE

Obesity is a public health problem worldwide. The eating habits of French workers need to be clarified. In particular, tachyphagia (meal lasting < 15 min) promotes weight gain. The present study aimed to investigate the presence of tachyphagia at lunchtime, the factors associated with tachyphagia, and the relationship between tachyphagia and obesity among workers.

METHODS

This cross-sectional study was conducted between January and May 2016 in five departments of occupational medicine. An anonymous self-administered questionnaire was used to gather general declarative data, such as weight and height (to calculate body mass index [BMI]) and information about lunchtime habits, including the time spent eating.

RESULTS

A total of 415 workers with a mean age of 41.1 ± 12.6 years were included. The mean BMI was 23.8 ± 4.6 kg/m², and the prevalence of obesity was 15.9%. Tachyphagia occurred in 20.3% of the cases and was more frequent in younger workers. Multivariate analysis revealed that skipping meals, eating standing up, and eating fast food were positively associated with tachyphagia (p = 0.015, p = 0.028, and p = 0.027, respectively). Older age and eating with colleagues/friends were negatively associated with tachyphagia (p = 0.003 and p < 0.0001, respectively). No significant association was observed between tachyphagia and obesity.

CONCLUSION

Our study provides important information about the lunchtime habits of workers. Maintaining commensality is crucial, particularly in young workers. Companies should play a role in organising their employees' lunch breaks. Level III Evidence obtained from well-designed cohort or case-control analytic studies.

Frailty and functional dependence in older population: lessons from the FREEDOM Limousin - Nouvelle Aquitaine Cohort Study

Background

Monitoring frailty indicators in elderly people is recommended to identify those who could benefit from disability prevention programs. To contribute to the understanding of the development of frailty in the elderly, we have created the FREEDOM-LNA cohort constituting an observational study of ageing in general population. Here, we described the characteristics of a cohort of elderly subjects who are followed for determination of frailty and loss of independence trajectories.

Results

The cohort was composed of 1085 subjects in advanced age (mean: 83.7 ± 6.0 years) and of women in majority (68.3%). Cardiovascular risk factors were present in 88.4% of subjects. Abnormal musculoskeletal signs were reported in 44.0% and neurologic signs in 31.9%. There were 44.8% of subjects at risk of malnutrition (MNA <24) and 73.3% (668/911) at risk of mobility-related disability (SPPB ≤9); 39% (384/973) of subjects had impaired cognitive function (MMSE< 24, adjusted on education) and 49.0% (397/810) had signs of depression (GDS >9); 31.8% (240/753) were frail and 58.3% were pre-frail. Most subjects had at least one disability in ADL (66.9%) and IADL (85.1%). The SMAF indicated a loss of independence in 59.6%. Overall, 59.9% of subjects could not stay at home without at least some help. Consequently, a medical consultation was proposed in 68.2 and 42.1% social supports.

Conclusions

A large part of this cohort was frail or pre-frail and presented signs of loss of independence, which may be explained by multiple factors including impaired health status, poor physical performance, cognition, isolation, depression, or nutrition. This cohort will help to determine factors that adversely influence the trajectory of physical frailty over time.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02834-w.

Assessment of workplace environmental contamination and occupational exposure to cisplatin and doxorubicin aerosols during electrostatic pressurized intraperitoneal aerosol chemotherapy

BACKGROUND

Electrostatic precipitation pressurized intraperitoneal aerosol chemotherapy (ePIPAC) is a novel approach for intraperitoneal drug delivery. As ePIPAC using cisplatin and doxorubicin is performed in an operating room, the challenge is to safely deliver the chemotherapeutic aerosol intraperitoneally while preventing exposure to healthcare workers. The objective of this study was to describe cisplatin and doxorubicin workplace environmental contamination and healthcare worker exposure during ePIPAC.

METHODS

Antineoplastic drugs concentrations of cisplatin and doxorubicin were measured in wipe samples from the operating room, and urine samples were collected from healthcare workers. The air samples were collected in order to detect Cisplatin contamination. Cisplatin was analysed by inductively coupled plasma-mass spectrometry and doxorubicin by ultra-high-performance liquid chromatography coupled with tandem mass spectrometry.

RESULTS

No trace of cisplatin was found in the air. Cisplatin and doxorubicin were detected on the operating room floor, surfaces, devices and personal protective equipment even after a cleaning protocol. No traces of cisplatin or doxorubicin were found in the urine samples.

CONCLUSION

In this study, no internal contamination was found in the ePIPAC surgical team even after implementing two successive ePIPAC procedures. These results showed the effectiveness of the individual and collective protective measures applied. However, the cleaning procedure during ePIPAC should be respected to limit environmental exposure to chemotherapy to cisplatin and doxorubicin during ePIPAC.

Urine cytology screening of French workers exposed to occupational urinary tract carcinogens: a prospective cohort study over a 20-year period

OBJECTIVES

To demonstrate that urine cytology screening can provide relevant epidemiological data for earlier detection of urothelial cancer caused by occupational exposure.

DESIGN

Prospective cohort study.

SETTING

Industries using urothelial carcinogens in France. Urine samples were collected on site, after a work week and were analysed at the University Hospital of Clermont-Ferrand, France.

PARTICIPANTS

Participants were workers exposed to urothelial carcinogens. Women and current smokers at time of study recruitment were exclusion criteria.

OUTCOMES

Urine cells atypia were ranged into three classes: negative/normal, atypical/suspicious/dysplasia or positive/malignant.

RESULTS

We included 2020 workers over a period of 20 years from 1993 to 2013: 606 worked in rubber manufacturing, 692 from metal processing, 245 in chemical industry and 477 in roadwork and building industry. Workers had a mean exposure of 15.2±10.4 years before their first urine cytology screening. There was a mean of 3.4±4.3 urine cytology screenings per worker between 1993 and 2013. 6478 cytology were normal, 462 suspicious and 13 malignant. Suspicious and malignant cytology occurred in 4.8% of workers exposed for 1-10 years, 6.2% for 11-20 years of exposure, 7.6% for 21-30 years and 8.6% for >30 years (p<0.001). Using exposure for 1-10 years as reference, the adjusted OR of receiving a suspicious or malignant diagnosis increased with duration of exposure: OR=1.50 (95% CI 1.10 to 2.05, p=0.01) for 21-30 years and OR=1.78 (95% CI 1.23 to 2.56, p=0.002) for >30 years of exposure. Using metal processing as reference, the risk of pathological urine cytology results increased for rubber manufacturing (OR=1.32, 95% CI 1.05 to 1.65, p=0.02), with a trend for roadwork and building industry (OR=1.39, 95% CI 0.98 to 1.97, p=0.07) and for chemical industry (OR=1.34, 95% CI 0.94 to 1.93, p=0.11).

CONCLUSIONS

Urine cytology is a useful tool in occupational medicine. We promote new guidelines with an early screening of urothelial cancer by cytology, starting with beginning of exposure.

Biomonitoring of 29 trace elements in whole blood from inhabitants of Cotonou (Benin) by ICP-MS

This study aimed to investigate the blood concentration of 29 trace elements, metals or metalloids, in a healthy population of Cotonou not directly exposed to metals in order to propose reference values. Blood samples from 70 blood donors were collected in K2 EDTA tubes for trace elements during September 2015 and a questionnaire was used to assess lifestyle exposure. Blood metal concentrations were determined by inductively coupled plasma mass spectrometry (ICP-MS) equipped with a quadrupole-based reaction cell. Among the selected blood donors 51.4% were aged from 18 to 36 years and 49.6% from 37 to 65 years. Among the 29 elements analyzed As, Pb, Mn, Pd, Sb, Co, Se, Sr showed blood concentrations higher than the reference values found in the literature for non-exposed healthy European populations and their geometric means were respectively 5.81; 47.39; 19.71; 1.91; 7.50; 0.66; 163.01; 30.53μg/L. This study provides the first reference value (5th-95th percentiles) for each element in Cotonou, which enables us to carry out further investigations on environmental and occupational exposure.

A French crop-exposure matrix for use in epidemiological studies on pesticides: PESTIMAT

Pesticide exposure assessment is a key methodological issue for epidemiological studies. The history of pesticide has proven difficult to obtain from individuals' report because of the wide range of active ingredients (AIs). We developed a crop-exposure matrix, which intends to reconstitute parameters of pesticide exposure in France since 1950. PESTIMAT is composed of tables crossing crops and AIs by year and providing the following metrics: (1) probability (proportion of farmers having used the AIs); (2) frequency (number of treatment days); and (3) intensity (application rate of the AIs in kg/ha). Metrics were obtained by the combination of six sources: (i) registration information from the Agriculture Ministry; (ii) information from agricultural bodies on products marketed; (iii) agricultural recommendations by the Plant Health Protection body; (iv) treatment calendars provided by farmers; (v) data from associations of farmers; and (vi) data from the industry. To date, 529 AIs usable between 1950 and 2010 are included in PESTIMAT: 160 fungicides; 160 herbicides; and 209 insecticides. When combined with duration and determinants of intensity, the metrics in PESTIMAT will make it possible to calculate exposure scores and to search for dose-effect relationships, an important criterion for causality judgment in epidemiology.

Impact of epilepsy on children and parents in Gabon

Children with epilepsy and their parents face many social and psychological difficulties that remain insufficiently studied in sub-Saharan Africa. The aim here was to assess the quality of life of children with epilepsy and their parents. A community-based cross-sectional survey was conducted in two urban areas and four rural areas of Gabon. Children were screened through key informants, medical sources, and a door-to-door survey. They were clinically selected based on their medical history and a clinical exam conducted by the investigating physician. Electroencephalography had not been carried out because of a lack of material and financial resources. The quality of life of children and their parents was assessed by a structured interview of parents using a questionnaire. Of 317 suspected cases on screening, 83 children with epilepsy were identified. Their mean age was 11.9±4.4years. Twelve percent of the children had neurosensory abnormalities on clinical exam. Sixty-three percent of them attended school; factors associated with schooling were higher score on the sociability subscale, specialized medical advice, and antiepileptic drug treatment. Sociability difficulties, anxiety, cognitive impairment, and behavioral disorders were suspected in 39.8%, 45.8%, 49.4%, and 42.2% of children, respectively. A total of 48.2% of parents expressed a poor quality of life related to their children's illness. A higher score on the cognition subscale, urban residence, specialized medical advice, and a stable income in the household were predictive of poor parental quality of life. Epilepsy influences many aspects of a child's life and the life of the child's parents. Care should incorporate a cognitive assessment of the child and emphasize information for patients and their relatives.

Epidemiology, causes, and treatment of epilepsy in sub-Saharan Africa

SUMMARY

Epilepsy is a common neurological disease in tropical countries, particularly in sub-Saharan Africa. Previous work on epilepsy in sub-Saharan Africa has shown that many cases are severe, partly a result of some specific causes, that it carries a stigma, and that it is not adequately treated in many cases. Many studies on the epidemiology, aetiology, and management of epilepsy in sub-Saharan Africa have been reported in the past 10 years. The prevalence estimated from door-to-door studies is almost double that in Asia, Europe, and North America. The most commonly implicated risk factors are birth trauma, CNS infections, and traumatic brain injury. About 60% of patients with epilepsy receive no antiepileptic treatment, largely for economic and social reasons. Further epidemiological studies should be a priority to improve understanding of possible risk factors and thereby the prevention of epilepsy in Africa, and action should be taken to improve access to treatment.

Searching for a link between the L-BMAA neurotoxin and amyotrophic lateral sclerosis: a study protocol of the French BMAALS programme

INTRODUCTION

Amyotrophic lateral sclerosis (ALS) is the most common motor neurone disease. It occurs in two forms: (1) familial cases, for which several genes have been identified and (2) sporadic cases, for which various hypotheses have been formulated. Notably, the β-N-methylamino-L-alanine (L-BMAA) toxin has been postulated to be involved in the occurrence of sporadic ALS. The objective of the French BMAALS programme is to study the putative link between L-BMAA and ALS.

METHODS AND ANALYSIS

The programme covers the period from 1 January 2003 to 31 December 2011. Using multiple sources of ascertainment, all the incident ALS cases diagnosed during this period in the area under study (10 counties spread over three French regions) were collected. First, the standardised incidence ratio will be calculated for each municipality under concern. Then, by applying spatial clustering techniques, overincidence and underincidence zones of ALS will be sought. A case-control study, in the subpopulation living in the identified areas, will gather information about patients' occupations, leisure activities and lifestyle habits in order to assess potential risk factors to which they are or have been exposed. Specimens of drinking water, food and biological material (brain tissue) will be examined to assess the presence of L-BMAA in the environment and tissues of ALS cases and controls.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the French ethical committee of the CPP SOOM IV (Comité de Protection des Personnes Sud-Ouest & Outre-Mer IV). The results will be published in peer-reviewed journals and presented at national and international conferences.

Population-based epidemiology of amyotrophic lateral sclerosis (ALS) in an ageing Europe--the French register of ALS in Limousin (FRALim register)

BACKGROUND AND PURPOSE

The main objective of establishing the French register of amyotrophic lateral sclerosis (ALS) in the Limousin region (FRALim), was to assess the incidence of ALS, in this ageing region of Europe, over a 12-year period (2000-2011).

METHODS

Patients were included if they lived in Limousin at the time of diagnosis of ALS according to El Escorial revised criteria and were identified by at least one of the following sources: (i) the French national body coordinating ALS referral centres; (ii) public and private hospitals in the region; (iii) health insurance data related to long-term diseases.

RESULTS

The FRALim register identified 279 incident cases (2000-2011). The crude and European population standardized incidences of ALS were as high as 3.19/100,000 person-years of follow-up (95% CI 2.81-3.56) and 2.58/100,000 person-years of follow-up (95% CI 2.27-2.89) respectively. Median age at onset was 70.8 years (interquartile range 63.1-77.1). The standardized sex incidence ratio (male/female) was 1.3 overall, but 1.1 under the age of 65 years, 1.7 between 65 and 75 years and 1.9 above 75 years. The exhaustiveness of the register has been estimated at 98.4% (95% CI 95.6-99.4) by capture-recapture analysis.

CONCLUSION

It was possible for the first time in France to monitor accurately the incidence of ALS over a long time period. It appears to be in the upper range of data reported in western countries. Patterns displayed here might anticipate the epidemiology of ALS in ageing western countries.

Epilepsy in Cambodia-treatment aspects and policy implications: a population-based representative survey

INTRODUCTION

We tested two treatment strategies to determine: treatment (a) prognosis (seizure frequency, mortality, suicide, and complications), (b) safety and adherence of treatment, (c) self-reported satisfaction with treatment and self-reported productivity, and policy aspects (a) number of required tablets for universal treatment (NRT), (b) cost of management, (c) manpower-gap and requirements for scaling-up of epilepsy care.

METHODS

We performed a random-cluster survey (N = 16510) and identified 96 cases (≥1 year of age) in 24 villages. They were screened by using a validated instrument and diagnosed by the neurologists. International guidelines were used for defining and classifying epilepsy. All were given phenobarbital or valproate (cost-free) in two manners patient's door-steps (March 2009-March 2010, primary-treatment-period, PTP) and treatment through health-centers (March 2010-June 2011, treatment-continuation-period, TCP). The emphasis was to start on a minimum dosage and regime, without any polytherapy, according to the age of the recipients. No titration was done. Seizure-frequency was monthly and self-reported.

RESULTS

The number of seizures reduced from 12.6 (pre-treatment) to 1.2 (end of PTP), following which there was an increase to 3.4 (end of TCP). Between start of PTP and end of TCP, >60.0% became and remained seizure-free. During TCP, ∼26.0% went to health centers to collect their treatment. Complications reduced from 12.5% to 4.2% between start and end of PTP and increased to 17.2% between start and end of TCP. Adverse events reduced from 46.8% to 16.6% between start and end of PTP. Nearly 33 million phenobarbital 100 mg tablets are needed in Cambodia.

CONCLUSIONS

Epilepsy responded sufficiently well to the conventional treatment, even when taken at a minimal dosage and a simple daily regimen, without any polytherapy. This is yet another confirmation that it is possible to substantially reduce direct burden of epilepsy through means that are currently available to us.

Epidemiology of epilepsy in rural Benin: prevalence, incidence, mortality, and follow-up

PURPOSE

Epilepsy is a major clinical and social issue in Africa. This study was conducted to estimate the prevalence, incidence, mortality, and therapeutic outcome in rural Djidja in Benin.

METHODS

This was a two-phase study with a cross-sectional phase and 18 months of follow-up. In the first phase, information was obtained using door-to-door surveys, reports from key informants, and medical sources. People were interviewed using a validated screening questionnaire for epilepsy in tropical regions. The diagnosis of epilepsy was confirmed by a neurologist. We used a capture-recapture method to estimate the number of people with epilepsy (PWE). PWE were followed every month for 18 months after the cross-sectional survey. We asked the health services, the general population, and village leaders in the study area to identify suspected cases of epilepsy occurring during the follow-up. New cases were updated every month after confirmation. Antiepileptic drugs were prescribed to PWE.

KEY FINDINGS

We surveyed 11,668 subjects (male-to-female ratio 0.9) and identified 123 PWE, yielding a prevalence of 10.5 per 1,000 (95% confidence interval (CI) 8.8-12.6/1,000). Combining the three sources, we found 148 PWE and a prevalence of 12.7 per 1,000 (95% CI 10.7-14.9/1,000). After application of the capture-recapture method, the prevalence was estimated to be as high as 38.4 per 1,000 (95% CI 34.9-41.9/1,000). The cumulative incidence was 104.2 per 100,000 and the mean annual incidence was 69.4 per 100,000. The mean annual mortality was 20.8 per 1,000. After treatment, 45% of PWE had total seizure remission and 35% had a decrease in the number of seizures.

SIGNIFICANCE

This study shows that door-to-door survey findings could be improved by using information from other sources. The follow-up suggests that epilepsy could be controlled. Continuous drug delivery and regular follow-up are key.

Population-based study of epilepsy in Cambodia associated factors, measures of impact, stigma, quality of life, knowledge-attitude-practice, and treatment gap

Purpose

Identify epilepsy-associated factors and calculate measures of impact, stigma, quality of life (QOL), knowledge-attitude-practice (KAP) and treatment gap in Prey Veng, Cambodia.

Methods

This first Cambodian population-based case-control study had 96 epileptologist-confirmed epilepsy cases and 192 randomly selected matched healthy controls. Standard questionnaires, which have been used in similar settings, were used for collecting data on various parameters. Univariate and multivariate regression was done to determine odds ratios. Jacoby stigma, 31-item QOL, KAP etc were determined and so were the factors associated with them using STATA software. Treatment gap was measured using direct method.

Key findings

Multivariate analyses yielded family history of epilepsy, difficult or long delivery, other problems beside seizures (mainly mental retardation, hyperthermia), and eventful pregnancy of the subject's mother as factors associated with epilepsy. There was high frequency of seizure precipitants esp. those related to sleep. Population attributable risk (%) was: family history (15.0), eventful pregnancy of subject's mother (14.5), long/difficult birth (6.5), and other problem beside seizures (20.0). Mean stigma (1.9±1.1, on a scale of 3) was mainly related to treatment efficacy. Mean QOL (5.0±1.4 on a scale of 10) was mainly related to treatment regularity. Cause or risk factor could be determined in 56% of cases. Treatment gap was 65.8%.

Significance

Factors in pre- and perinatal period were found to be most crucial for epilepsy risk in Cambodia which inturn provides major prevention opportunities. A global action plan for treatment, stigma reduction and improvement of QOL should be set-up in this country.

Toxocariasis and epilepsy: systematic review and meta-analysis

Objective

Human toxocariasis is a zoonotic infection caused by the larval stages of Toxocara canis (T. canis) and less frequently Toxocara cati (T. cati). A relationship between toxocariasis and epilepsy has been hypothesized. We conducted a systematic review and a meta-analysis of available data to evaluate the strength of association between epilepsy and Toxocara spp. seropositivity and to propose some guidelines for future surveys.

Data Sources

Electronic databases, the database from the Institute of Neuroepidemiology and Tropical Neurology of the University of Limoges (http://www-ient.unilim.fr/) and the reference lists of all relevant papers and books were screened up to October 2011.

Methods

We performed a systematic review of literature on toxocariasis (the exposure) and epilepsy (the outcome). Two authors independently assessed eligibility and study quality and extracted data. A common odds ratio (OR) was estimated using a random-effects meta-analysis model of aggregated published data.

Results

Seven case-control studies met the inclusion criteria, for a total of 1867 participants (850 cases and 1017 controls). The percentage of seropositivity (presence of anti-Toxocara spp. antibodies) was higher among people with epilepsy (PWE) in all the included studies even if the association between epilepsy and Toxocara spp. seropositivity was statistically significant in only 4 studies, with crude ORs ranging 2.04–2.85. Another study bordered statistical significance, while in 2 of the included studies no significant association was found. A significant (p<0.001) common OR of 1.92 [95% confidence interval (CI) 1.50–2.44] was estimated. Similar results were found when meta-analysis was restricted to the studies considering an exclusively juvenile population and to surveys using Western Blot as confirmatory or diagnostic serological assay.

Conclusion

Our results support the existence of a positive association between Toxocara spp. seropositivity and epilepsy. Further studies, possibly including incident cases, should be performed to better investigate the relationship between toxocariasis and epilepsy.

Human toxocariasis is an infection caused by the larval stage of the worms Toxocara canis and less frequently Toxocara cati, common parasites of domestic and peridomestic dogs and cats. It is a cosmopolitan infection, occurring whenever the man-soil-dog relationship is particularly close, especially in tropical countries, where the humid climate favours the survival of parasite eggs in the soil, and in rural settings, where the poor hygiene increases the probability of human infection. Epilepsy affects nowadays at least 65 million of people worldwide and is particularly common in tropical areas, probably because of the presence of cases caused by infectious diseases largely absent in industrialized countries. For several decades, researchers have investigated the possible association between toxocariasis and epilepsy. In this study we conducted a statistical analysis of all the data available on the relationship between these two conditions. The combined results of the 7 studies included indicate an association between the two diseases. Further studies are necessary to demonstrate a causal relationship (i.e. toxocariasis causes epilepsy). Considering that toxocariasis is a preventable and common disease, a better understanding of the relationship between toxocariasis and epilepsy may contribute to improving prevention of epilepsy worldwide.

[Methodology of neuroepidemiological studies in tropical countries: a challenge?]

The purpose of this paper is to highlight the difficulties of applying neuroepidemiological methods in low income countries or developing countries, which are mostly tropical countries, taking advantage of the experience of the Institute of Neuroepidemiology and Tropical Neurology, which was created in Limoges in 1982. These difficulties could be related to several aspects: methodological, logistical, political or economical, linked to ethical issues, even difficulties to publish the studies. However, concept and neuroepidemiological methods should stay the same worldwide, even if their translation into practice could sometimes raise some problems in developing countries. Study protocol should be more detailed. Some specific epidemiological methods could be useful. Collection of data should be standardized. True cooperation at every level is needed for these researches to be valid.

[Geriatric assessment contribution to treatment decision-making in thoracic oncology]

BACKGROUND

Lung cancer is a frequently occurring disease among elderly people. The objective of this study was to search for a relationship between multimodal geriatric assessment and a decision-making in the treatment of patients with this condition.

METHODS

Forty-nine elderly patients (aged 70 years and over) diagnosed with a primary lung cancer underwent a geriatric assessment before decision for treatment was made in a multidisciplinary meeting. We described the impact of the geriatric assessment on the management decisions made.

RESULTS

Almost half of treatment (44.9%) decisions were modified by the geriatric assessment. For patients with so called "pre-frailty" according to Balducci's criteria, 60% of treatment decisions were modified by the results of geriatric assessment (use of only one chemotherapeutic drug, dose disease or best supportive care). For this group of patients, Folstein MMSE and IADL were predictive of change in decision-making, with the threshold estimated to be 26 points. Only the MMSE was significantly associated with the medical decision in multivariate analysis.

CONCLUSION

Geriatric assessment should be integrated into treatment decision-making for patients with primary lung cancer aged more than 70 years, particularly those where frailty is a concern. Folstein's MMSE was predictive in our study for changes in decision-making.

Investigating epilepsy in Africa: 10 years of data collection using a standardized questionnaire in 2,269 peoples with epilepsy

PURPOSE

The need for comparable epidemiologic data on epilepsy from various locations in tropical areas has led in 1994 to the creation of a questionnaire able to standardize information. The Limoges' questionnaire was created to collect information independently of the objectives of each survey performed, and since it has been employed in various continents under tropics latitude. In Africa between 1994 and 2004, 13 epidemiologic surveys in 12 countries were performed by this means. Authors of these works were solicited to communicate their raw data on people with epilepsy (PWE).

METHODS

Information collected was aggregated in a database upon which operations of data management were processed. Undernutrition status was determined using an anthropologic method, according World Health Organization (WHO) recommendations. Factors associated with undernutrition and absence of treatment by phenobarbitone were searched for by using multivariate logistic regression.

KEY FINDINGS

Information about 2,269 PWE was collected. Mean treatment gap and undernutrition were determined, respectively, to be 30.6% [95% confidence interval (95% CI) 28.7-32.6] and 25.4% (95% CI 22.7-28.2). Factors significantly associated with undernutrition and not being treated with phenobarbitone were determined.

SIGNIFICANCE

Despite the different purposes of each study, we were able to pool information in order to characterize and study particular traits of PWE in Africa. Some items of particular importance should be collected systematically and will be highlighted in a newer version of this questionnaire. Because many surveys were undertaken using this tool in tropical areas, a backward compatibility should be ensured.

Contribution of geolocalisation to neuroepidemiological studies: incidence of ALS and environmental factors in Limousin, France

This article aimed to detect clusters of amyotrophic lateral sclerosis (ALS) and their relationships with exposure of the population to various environmental factors in the Limousin region of France. Methods used were extensively described. We adopted a geographical approach that revealed variations in the incidence of ALS and permitted us to identify three regional clusters and their spatial spread. We considered environmental factors and the potent locations or source of substances or activities hypothesized to be associated with ALS. Notably, we determined which industrial activities seem to affect the incidence of ALS in Limousin. The results were interpreted at a regional level. Among the 50 factors this article considered, paper paste and water treatment plants were particularly geostatistically significant and deserve special attention in the ongoing investigations into high resolution spatial clusters (geographical and epidemiological studies).

Development and validation of an instrument to detect depression in nursing homes. Nursing homes short depression inventory (NH-SDI)

Depression is often overlooked in elderly nursing home residents because symptoms may be masked or dismissed as an inevitable consequence of ageing. Current tools for the detection of depression in institutionalised older people are not always specific.

AIMS

To construct and verify an instrument with which to detect depression in elderly nursing home residents (NH-SDI).

METHOD

Firstly for the construction, 328 elderly people were selected at random from the residents of 17 nursing homes in France, and examined by a single investigator. The examination included a psychiatric assessment, an evaluation of cognitive function using the MMSE, an evaluation of depressive state using four different instruments (mini-GDS, Goldberg, DMAS, CSDD), and assessment of any changes in behaviour in those suffering from dementia, using the NPI. A second stage was to confirm NH-SDI in 99 institutionalised subjects.

RESULTS

Following the selection of items, we created a scale of 16 dichotomous items (NH-SDI). The internal consistency was satisfactory (α Cronbach = 0.85), as was its reliability with a sensitivity of 85.1% and a specificity of 86.5% for a cut-off score above 5.

CONCLUSIONS

The NH-SDI appears to be a useful instrument for the detection of depression in nursing homes and can easily be applied by healthcare staff as part of routine procedures.

Understanding the differences in prevalence of epilepsy in tropical regions

Epilepsy is a frequent chronic neurologic disorder that affects nearly 70 million people worldwide. The majority of people with epilepsy live in developing countries, where epilepsy remains a major public health problem. Wide prevalence differences exist among various populations across sub-Saharan Africa, Latin America, and Asia. In particular, prevalence is lower in Southeast Asia than in sub-Saharan Africa and Latin America. Methodologic problems alone do not seem to explain these differences shown in recent review papers. The distribution of numerous risk or etiologic factors such as infectious diseases with neurologic sequel, head injuries, or genetic factors could explain these differences. Stigmatization of people with epilepsy could lead to underestimating the prevalence of epilepsy, even in well-conducted studies. It is important to standardize the process of epidemiologic monitoring of epilepsy in order to improve the reliability in data comparison. Understanding the reasons for these differences is a crucial issue for eventually raising new hypotheses or prevention strategies.

Specific psychological and behavioral symptoms of depression in patients with dementia

Behavioral and psychological symptoms in dementia (BPSD) are very common, with 90% of patients experiencing at least one during the course of the disease. One-third of persons with dementia have depressive symptoms, and concomitant BPSD are very likely.

OBJECTIVE

This study aimed to characterize the psychological and behavioral manifestations of depression in patients with dementia.

METHODS

We recruited patients with dementia from several nursing homes in the Limousin region of France. Depression was as diagnosed by the Cornell Scale for Depression in Dementia (CSDD) with a cut-off of 7, and BPSD were assessed using the Neuropsychiatric Inventory (NPI).

RESULTS

Of 319 patients with dementia, 42.9% (n =137) were depressed and 75.9% (n = 242) had BPSD. All BPSD were significantly (p < 0.0001) more prevalent among depressed patients, but no significant differences were observed according to sex and age. The NPI showed that the most common additional symptoms in depressed patients were agitation (43.2%), anxiety (42.3%) and irritability (40.1%). Four NPI-based factors were indentified (63.9% of the common variance): factor 1 (disinhibition, irritability, agitation, anxiety), factor 2 (sleep disturbance, aberrant motor behavior, apathy), factor 3 (elation, hallucination, delirium) and the last with eating disorders. Depression in dementia patients was significantly associated with disinhibition, irritability, agitation, and anxiety.

CONCLUSION

BPSD are common and a major problem. Before addressing them as isolated symptoms, it is important to consider comorbidity with depression in order to optimize the therapeutic approach.

Multiple sclerosis and solar exposure before the age of 15 years: case-control study in Cuba, Martinique and Sicily

Few studies report a protective role of childhood solar exposure to multiple sclerosis. Our objective was to confirm the protective role of childhood solar exposure in multiple sclerosis in Cuba, Martinique and Sicily. This was a matched case- control study, and cases met Poser criteria for clinically, laboratory (definite, probable) multiple sclerosis. Controls were resident population, without neurological disorder, living close to cases (within 100 km), matched for sex, age (+/-5 years), residence before age 15. We recruited 551 subjects during a 1-year period (193 cases, Cuba n = 95, Sicily n = 50, Martinique n = 48; 358 controls). Some (89%) met definite clinical multiple sclerosis criteria (relapsing remitting form (with and without sequel) (74%), secondary progressive (21%), primary progressive (5%)). Odds ratios in a uni-variate analysis were: family history of multiple sclerosis (5.1) and autoimmune disorder (4.0); wearing shirt (3.5), hat (2.7), pants (2.4); sun exposure causing sunburn (1.8); sun exposure duration (1 h more/day; weekends 0.91, weekdays 0.86); bare-chested (0.6); water sports (0.2). Independent factors in the multivariate analysis were family history of multiple sclerosis (4.8 (1.50-15.10)), wearing pants under sunlight (1.9 (1.10-3.20)), sun exposure duration (1 h more/ day, weekdays 0.90 (0.85-0.98), weekends 0.93 (0.87-0.99)), water sports (0.23 (0.13-0.40)). We conclude that outdoor leisure activities in addition to sun exposure reports are associated with a reduced multiple sclerosis risk, with evidence of dose response.

[Age and management decisions in patients with primary lung cancer]

INTRODUCTION

Therapeutic decisions are difficult in elderly patients because of the heterogeneity of this population. Our objective was to evaluate the role of age in the management of patients suffering from primary lung cancer seen in the department of respiratory diseases of the Limoges regional teaching hospital between 2002 and 2004.

METHODS

A cross sectional study analysed the management of 363 patients suffering from primary lung cancer. The patients were divided into two groups according to their age (less than seventy or seventy and over). A comparison was made between the management of the two groups.

RESULTS

The comparisons according to age produced evidence of reduced activity, greater dependence, an increased Charlson score, less frequently administered radiotherapy and chemotherapy, and more frequent symptomatic treatment in the elderly group (p<0.001).

CONCLUSIONS

The geriatric assessment of patients suffering from primary lung cancer should make allowance for the physiological age of the patient and adapt the management to ensure the best quality of life.

Incidence and prevalence of amyotrophic lateral sclerosis in Uruguay: a population-based study

OBJECTIVE

To determine the incidence and prevalence of amyotrophic lateral sclerosis (ALS) in the Republic of Uruguay.

METHODS

The study was performed in Uruguay (3,241,003 inhabitants) during a 2-year period (2002-2003). To ensure complete case ascertainment, multiple sources of information were used, including all the neurologists, other medical specialties, general physicians, neurophysiology laboratories, hospital medical records and death certificates. ALS diagnosis was based on El Escorial criteria. Although all patients with motor neuron disease were enrolled in the follow-up, only probable and definite cases are included in the study.

RESULTS

Between January 1st, 2002, and December 31st, 2003, 89 new patients were diagnosed with probable or definite ALS. The mean annual incidence rate was 1.37 per 100,000 persons. The incidence was higher for men (1.95) than for women (0.84) with a male to female ratio of 2:1. For both, the incidence increased throughout the years showing a peak in the 65-74 age group among men and the 55-64 age group among women. Mean age at onset of ALS disease was 58.7 years. The estimated mean annual incidence for ALS calculated by the capture recapture method was 1.42 (95% CI, 1.13-1.72). On December 31st, 2002, the crude prevalence was 1.9 per 100,000 inhabitants.

CONCLUSIONS

ALS incidence is within a narrow range across countries despite the genetic, environmental and socioeconomic differences when similar prospective design, diagnosis criteria and data analyses are applied.

Disease progression and survival in ALS: first multi-state model approach

Although several prognostic factors have been identified in ALS, there remains some discordance concerning the prognostic significance of the age and clinical form at onset. In order to clarify these findings, we have analysed already known prognostic factors using a multi-state model. Two hundred and twenty-two sporadic ALS patients were followed. A simple unidirectional three-states model was used to summarize clinical course of ALS. States 1 and 2 reflected the progression of neurological impairment and state 3 represented the end of follow-up (tracheotomy or death). Gender, diagnostic delay, body mass index (BMI) and slow vital capacity (SVC) were also recorded. A time-inhomogeneous Markov model with piecewise constant transition intensities was used to estimate the effect of the covariates in each transition. The bulbar form at onset was only correlated with a more rapid clinical progression between state 1 and state 2. In contrast, an advanced age at diagnosis affected only survival from state 2. This methodological approach suggests that these two factors have a different prognostic significance: age at onset is related to patient's survival and the clinical form at onset predicts the progression of motoneuronal impairment in different regions.

[Persistent neurological sequelae due to cerebral malaria in a cohort of children from Mali]

INTRODUCTION

Several neurological complications are associated with cerebral malaria (CM). However, few long-term data from childhood survivors have been published.

METHODS

A cross-sectional study was carried out in Mali among children followed from 1999 to 2002 after serious and complicated malaria. Our aim was to evaluate the persistent neurological sequelae associated with CM.

RESULTS

This study concerned 101 subjects who had had CM. Mean age was 5.6+/-3.6 years. Twenty-eight children presented persistent neurological sequelae (27.7p.cent). Among them eight (7.9p.cent) children had developed these sequelae just after CM and 20 (19.8p.cent) a few months later: headaches, mental retardation, speech delay, bucco-facial dyspraxia, diplegia and frontal syndrome (one case each), dystonia (two cases), epilepsy (five cases) and behavior and attention disorders (15 cases).

CONCLUSIONS

In this study, we show that neurological signs due to CM can persist in the long run. Long-term follow-up and proper management after CM are essential.

Combined use of an antigen and antibody detection enzyme-linked immunosorbent assay for cysticercosis as tools in an epidemiological study of epilepsy in Burundi

OBJECTIVE

To evaluate the benefits of the detection of both circulating antibodies (Ab) and antigens (Ag) for the diagnosis of cysticercosis in people with epilepsy. Neurocysticercosis is a cause of neurological diseases world-wide, especially epilepsy. The clinical symptoms of neurocysticercosis are non-specific and diagnosis is often difficult.

METHODS

Serum samples were collected from subjects in a matched case-control study for epilepsy in the Kiremba area, Burundi, between March and April 2001 (epileptic cases=303; controls without epilepsy=606). The enzyme-linked immunosorbent assay (ELISA) was used for the detection of antibodies (Ab-ELISA) and circulating Ag (Ag-ELISA).

RESULTS

The Ab-ELISA revealed 58.7% positivity in epilepsy cases and 31.4% in healthy controls; and Ag-ELISA revealed 38.3% positivity in epilepsy cases and 20.0% in controls. The matched odds ratios were 3.6 (95% CI: 2.5-4.9) for Ab-ELISA, and 2.9 (95% CI: 2.1-4.3) for Ag-ELISA.

CONCLUSION

Both Ag- and Ab-ELISA detected a significantly higher number of seropositives among people with epilepsy than among controls. The risk of epilepsy was high in cases with a positive Ag-ELISA, although less important than in cases with positivity for Ab-ELISA. Dead or degenerating cysticerci appear to be more frequently associated with epilepsy than living cysts. The high number of people with circulating Ag of Taenia solium suggests that the study area is a focus of active transmission of the parasite.

Epilepsy in Laos: knowledge, attitudes, and practices in the community

OBJECTIVE

We evaluated beliefs about, attitudes toward, and stigma associated with epilepsy in four districts of central Laos.

METHOD

For this study, 83 people with epilepsy, 83 family members, and 166 matched villagers in Vientiane Province were interviewed.

RESULTS

From patients to families to villagers, there existed a significantly increasing gradient of misbeliefs. Dubbed locally as "mad pig disease," epilepsy was viewed as having a supernatural origin by 25-42% of respondents, a life-threatening disease by 60%, a disease transmissible by consumption of pork meat by 10-21%, and a disease transmissible by contact with patients' saliva by 14.5% of patients and 44% of villagers (P<0.01). Stigma was high. People thought that they should avoid contact or sharing meals with patients (15% of patients, 62% of family members, P<0.001), and that persons with epilepsy should not get a job, get married (29 and 42%, P<0.016), or raise children (33-42%).

CONCLUSION

Wrong beliefs may lead to stigma and hamper access to or compliance with modern epilepsy treatment. In traditional countries, education is the cornerstone of epilepsy management.

Risk factors for epilepsy in rural Lao PDR: a case-control study

The objective of this study was to assess the major etiologic categories of epilepsy in a rural district of the Lao PDR. Thirty-one newly identified patients with confirmed active epilepsy were compared with 124 controls, matched for gender, age and village residence. Risk factors for epilepsy were investigated with particular focus on cysticercosis serology. A history of head trauma (OR=4.7, p=0.05), family history of epilepsy (OR=12.8, p=0.03), and the use of human feces to fertilize domestic vegetable gardens (OR=4.9, p=0.04) were significantly associated with epilepsy. The study did not confirm any direct relation between epilepsy and cysticercosis serology. The cysticercosis seroprevalence was nil in the epilepsy group. This is the first study in the Lao PDR on epilepsy risk factors representing important data for the subregion. Parasitic, environmental, and behavioral factors of this traditional population deserve further studies to explain the missing link between epilepsy and cysticercosis.

Cerebral malaria and sequelar epilepsy: first matched case-control study in Gabon

PURPOSE

Cerebral malaria (CM) is suspected to be a potential cause of epilepsy in tropical areas. The purpose of this article was to evaluate the relationship between CM and epilepsy in Gabon.

METHODS

A matched case-control study was carried out on a sample of subjects aged six months to 25 years and hospitalized between 1990 and 2004 in three hospitals in Libreville, Gabon. Cases were defined as patients suffering from epilepsy and confirmed by a neurologist. Controls were defined as patients without epilepsy. The exposure of interest was CM according to WHO criteria.

RESULTS

In total, 296 cases and 296 controls were included. Of these, 36 (26 cases and 10 controls) had a CM history. The adjusted odds ratio (aOR) to develop epilepsy after CM was 3.9 [95% CI: 1.7-8.9], p<0.001. Additional risk factors were identified: family history of epilepsy: aOR=6.0 [95% CI: 2.6-14.1], p<0.0001, and febrile convulsions: aOR=9.2 [95% CI 4.0-21.1], p<0.0001.

CONCLUSIONS

This first case-control study on that issue suggests that epilepsy-related CM is an underrecognized problem. It emphasizes the need for further studies to better evaluate the role of convulsions during CM.

[Epidemiology of epilepsy in sub-Saharan Africa: a review]

Epilepsy is, above all tropical, moreover, very african in its frequency and gravity. Data on the prevalence of epilepsy shows it to be two or three times more prevalent in tropical zones than in industrialized countries in non tropical areas, however it is rare to find data on the incidence and prognosis of epilepsy in sub-Saharan Africa. It is difficult to determine the relative contribution of each of the causes of epilepsy. Only a few case-control studies have been carried out in sub-Saharan Africa. Infectious diseases, in particular parasitic diseases such as neurocysticercosis or cerebral malaria, seem to be the cause of the majority of the cases of epilepsy. However it is necessary to do additional epidemiological studies to determine the etiologies of epilepsy more precisely in sub-Saharan Africa.

Prevalence of Epilepsy in a Rural District of Central Lao PDR

PURPOSE

To assess the prevalence of epilepsy in a rural district of Lao PDR and to describe the clinical and epidemiological profile of the disease.

METHODS

Door-to-door screening was performed on the entire population of 8 randomly selected villages in the Hinheub district, using an internationally validated and standardized questionnaire. Additional passive case detection was performed through village key informants. Suspected epilepsy patients identified by the questionnaire were revisited and examined by an experienced neurologist on two follow-up visits. The confirmation of epilepsy was based only on an in-depth clinical examination. Electroencephalograms were performed at the district health care center.

RESULTS

In the 8 villages, 277 suspected cases of epilepsy were identified among 4,310 interviewed subjects; 194 of whom (70%) underwent a clinical examination by a neurologist during the first visit while 65 of 83 remaining suspected cases were seen on the second confirmation visit. Twenty-seven persons with epilepsy were identified. Six additional patients were diagnosed in 219 self-referred subjects. An overall prevalence of 7.7 cases of epilepsy per thousand inhabitants was calculated (95% CI 5.3-10.7). Generalized epilepsy (21 cases, 63.6%) was commoner than partial epilepsy (9 cases, 27.3%). The remaining 3 cases (9.1%) were not-classifiable as either generalized or partial. EEG abnormal findings were found in 12 of the 24 patients (50.0%) who had an EEG registration.

CONCLUSIONS

This is the first study in Lao PDR to estimate the prevalence of epilepsy. Compared to Western countries it shows a pattern towards a higher prevalence.