Impact of 24 h shifts on urinary catecholamine in emergency physicians: a cross-over randomized trial

24-h shift (24 hS) exposed emergency physicians to a higher stress level than 14-h night shift (14 hS), with an impact spreading on several days. Catecholamines are supposed to be chronic stress biomarker. However, no study has used catecholamines to assess short-term residual stress or measured them over multiple shifts. A shift-randomized trial was conducted to study urinary catecholamines levels of 17 emergency physicians during a control day (clerical work on return from leave) and two working day (14 hS and 24 hS). The Wilcoxon matched-pairs test was utilized to compare the mean catecholamine levels. Additionally, a multivariable generalized estimating equations model was employed to further analyze the independent relationships between key factors such as shifts (compared to control day), perceived stress, and age with catecholamine levels. Dopamine levels were lower during 24 hS than 14 hS and the control day. Norepinephrine levels increased two-fold during both night shifts. Epinephrine levels were higher during the day period of both shifts than on the control day. Despite having a rest day, the dopamine levels did not return to their normal values by the end of the third day after the 24 hS. The generalized estimating equations model confirmed relationships of catecholamines with workload and fatigue. To conclude, urinary catecholamine biomarkers are a convenient and non-invasive strong measure of stress during night shifts, both acutely and over time. Dopamine levels are the strongest biomarker with a prolonged alteration of its circadian rhythm. Due to the relation between increased catecholamine levels and both adverse psychological effects and cardiovascular disease, we suggest that emergency physicians restrict their exposure to 24 hS to mitigate these risks.

The worldwide invasion history of a pest ambrosia beetle inferred using population genomics

Xylosandrus crassiusculus, a fungus-farming wood borer native to Southeastern Asia, is the most rapidly spreading invasive ambrosia species worldwide. Previous studies focusing on its genetic structure suggested the existence of cryptic genetic variation in this species. Yet, these studies used different genetic markers, focused on different geographical areas and did not include Europe. Our first goal was to determine the worldwide genetic structure of this species based on both mitochondrial and genomic markers. Our second goal was to study X. crassiusculus' invasion history on a global level and identify the origins of the invasion in Europe. We used a COI and RAD sequencing design to characterize 188 and 206 specimens worldwide, building the most comprehensive genetic data set for any ambrosia beetle to date. The results were largely consistent between markers. Two differentiated genetic clusters were invasive, albeit in different regions of the world. The markers were inconsistent only for a few specimens found exclusively in Japan. Mainland USA could have acted as a source for further expansion to Canada and Argentina through stepping stone expansion and bridgehead events. We showed that Europe was only colonized by Cluster II through a complex invasion history including several arrivals from multiple origins in the native area, and possibly including bridgehead from the United States. Our results also suggested that Spain was colonized directly from Italy through intracontinental dispersion. It is unclear whether the mutually exclusive allopatric distribution of the two clusters is due to neutral effects or due to different ecological requirements.

Tempo and drivers of plant diversification in the European mountain system

There is still limited consensus on the evolutionary history of species-rich temperate alpine floras due to a lack of comparable and high-quality phylogenetic data covering multiple plant lineages. Here we reconstructed when and how European alpine plant lineages diversified, i.e., the tempo and drivers of speciation events. We performed full-plastome phylogenomics and used multi-clade comparative models applied to six representative angiosperm lineages that have diversified in European mountains (212 sampled species, 251 ingroup species total). Diversification rates remained surprisingly steady for most clades, even during the Pleistocene, with speciation events being mostly driven by geographic divergence and bedrock shifts. Interestingly, we inferred asymmetrical historical migration rates from siliceous to calcareous bedrocks, and from higher to lower elevations, likely due to repeated shrinkage and expansion of high elevation habitats during the Pleistocene. This may have buffered climate-related extinctions, but prevented speciation along elevation gradients as often documented for tropical alpine floras.

Here, the authors use full-plastome phylogenomics and multiclade comparative models to reconstruct the tempo and drivers of six European Alpine angiosperm lineages before and during the Pleistocene. They find that geographic divergence and bedrock shifts drive speciation events, while diversification rates remained steady.

Can functional genomic diversity provide novel insights into mechanisms of community assembly? A pilot study from an invaded alpine streambed

An important focus of community ecology, including invasion biology, is to investigate functional trait diversity patterns to disentangle the effects of environmental and biotic interactions. However, a notable limitation is that studies usually rely on a small and easy-to-measure set of functional traits, which might not immediately reflect ongoing ecological responses to changing abiotic or biotic conditions, including those that occur at a molecular or physiological level. We explored the potential of using the diversity of expressed genes-functional genomic diversity (FGD)-to understand ecological dynamics of a recent and ongoing alpine invasion. We quantified FGD based on transcriptomic data measured for 26 plant species occurring along adjacent invaded and pristine streambeds. We used an RNA-seq approach to summarize the overall number of expressed transcripts and their annotations to functional categories, and contrasted this with functional trait diversity (FTD) measured from a suite of characters that have been traditionally considered in plant ecology. We found greater FGD and FTD in the invaded community, independent of differences in species richness. However, the magnitude of functional dispersion was greater from the perspective of FGD than from FTD. Comparing FGD between congeneric alien-native species pairs, we did not find many significant differences in the proportion of genes whose annotations matched functional categories. Still, native species with a greater relative abundance in the invaded community compared with the pristine tended to express a greater fraction of genes at significant levels in the invaded community, suggesting that changes in FGD may relate to shifts in community composition. Comparisons of diversity patterns from the community to the species level offer complementary insights into processes and mechanisms driving invasion dynamics. FGD has the potential to illuminate cryptic changes in ecological diversity, and we foresee promising avenues for future extensions across taxonomic levels and macro-ecosystems.

POS0668 REAL WORLD EFFECTIVENESS OF BARICITINIB IN THE SWISS RHEUMATOID ARTHRITIS REGISTER (SCQM-RA)

Background:

When not responding to conventional synthetic DMARDs (csDMARDs), rheumatoid arthritis (RA) patients may receive biological DMARDs (bDMARDs) or targeted synthetic DMARDs (tsDMARDs) including baricitinib (BARI). While BARI has demonstrated efficacy in randomized controlled trials, limited studies have established comparative effectiveness in real world settings, in particular when used in b/tsDMARD-naïve patients.

Objectives:

To analyze the effectiveness of BARI versus alternative bDMARDs, as assessed by drug maintenance over time and by response rates at 12 months.

Methods:

This is a nested study of RA patients, within the prospective Swiss Clinical Quality Management (SCQM) observational cohort.

All treatment courses (TC) with BARI or alternative bDMARDs initiated between 2017-09-01 and 2020-06-01, with at least one follow-up visit, were included. TC with BARI were compared to TC with alternative bDMARDs (non-BARI), including all b/tsDMARDs except rituximab. The non-BARI group was then subdivided into TNF inhibitors (TNFi) and other mode of action bDMARDs (OMA), excluding tsDMARDs. A secondary analysis focusing specifically on b/tsDMARD naïve patients was conducted.

Baseline characteristics were compared using ANOVA or χ2 tests. A Cox-model survival analysis assessed drug maintenance. 12-month response rates were estimated using an attrition-corrected, confounder-adjusted approach (1). CDAI score ≤10 defined low disease activity state (LDA), and CDAI score ≤2.8 defined remission.

Results:

Overall, 1218 eligible TC (from 1028 patients) were initiated during the study period (273 in BARI, 154 other tsDMARD, 473 in TNFi and 318 in OMA). Drug maintenance was significantly shorter for TNFi compared to BARI, even after adjustment for potential confounders (Hazard ratio (HR) for drug discontinuation 1.85 (95% CI [1,40 – 2,43]); p < 0.001). Drug maintenance was also numerically shorter for the OMA group compared to BARI, but the difference was not significant (HR 1.18 (95% CI [0.87 – 1.60]); p = 0.28). These differences were larger when analysing only bDMARD-naïve patients (Figure 1a).

All TC taken together, the rates of LDA and remission did not differ significantly between the 3 groups at 12 months. LDA ranged from 63% to 67% (BARI vs OMA p = 0.87; BARI vs TNFi p = 0.81) and remission from 19% to 23% (BARI vs OMA p = 0.30; BARI vs TNFi p = 0.77; Figure 1b).

Conclusion:

BARI demonstrated a significantly higher overall drug maintenance than TNFi, and a similar drug maintenance to OMA, both in a bDMARD-naïve population and in the overall population. The adjusted 12-month response rates did not differ between BARI, TNFi and OMA groups. These results suggest that prescription of BARI after csDMARD has at least similar outcomes as alternative bDMARDs.

References:

[1]Lauper, K., et al. Sat0588. Annals of the Rheumatic Diseases 78 (2019).

Table 1.

Baseline characteristics of studied population

VariableOverall comparison:BARI vs non-BARISubgroup analysis 1:by bDMARD type (tsDMARD excluded)Subgroup analysis 2:In b/tsDMARD-naïve patientsBARI(TC = 273; 273 patients)Non-BARI(altogether)(TC = 945; 755 patients)p valuesTNFi(TC = 473; 408 patients)OMA(TC = 318; 298 patients)p values(vs BARI)BARI(n = 46)TNFi(n = 225)OMA(n = 65)p valuesMean (SD)Otherwise: n %Mean (SD)Otherwise: n %Mean (SD)Otherwise: n %Concomitant csDMARD41 %46 %0.1754 %41 %<0.0150 %61 %48 %0.1Line of Therapy-1st (= bio-naive)17 %35 %<0.0148 %20 %<0.01100 %100 %100 %-2nd20 %23 %23 %23 %-3rd19 %16 %11 %24 %-4th or later44 %26 %18 %33 %Female78%74 %<0.2174 %73 %0.2870 %71 %74 %0.88Age59 (14)56 (14)0.0152 (15)58 (13)<0.0157 (15)51 (14)57 (16)<0.01Disease duration (years)13 (10)10 (9)<0.018 (9)11 (9)<0.015.5 (6.45)5 (7)6.5 (9)0.243CDAI baseline15 (9)15 (10)0.914 (9)16 (11)0.0513 (7)14 (9)14 (10)0.72Previous tsDMARD (non-BARI)33 %8 %<0.014 %11 %<0.010 %0 %0 %TC duration > 12-months37 %29 %0.0127 %30 %0.0237 %29 %34 %0.52

BARI = baricitinib, TNFi = TNF inhibitors, OMA = other mode of action, Non-BARI = TNFi + OMA + other tsDMARDs, SD = standard deviation.

Disclosure of Interests:

Benoit GILBERT: None declared, Delphine Courvoisier: None declared, Denis Mongin: None declared, Kim Lauper Consultant of: Gilead Galapagos, Grant/research support from: AbbVie, Clementine Perrier Shareholder of: Eli Lilly, Employee of: Eli Lilly, Rudiger Muller Consultant of: AbbVie, Novartis, Grant/research support from: GEBRO Pharma, Axel Finckh Speakers bureau: AbbVie, BMS, Pfizer, Eli-Lilly, Consultant of: AbbVie, BMS, Pfizer, Eli-Lilly, Grant/research support from: BMS, Pfizer, Eli-Lilly

[Securing the patient's care path receiving oral anticancer therapy: Experimentation around a pharmaceutical hospital-to-community liaison]

Due to the increasing prescription of oral anticancer therapies, the inpatient care pathway has shifted to an outpatient care pathway. This transformation requires an interdisciplinary coordination to provide a continuum of care and ensure therapeutic monitoring, as well as patient safety. To better support patients on oral anticancer therapies, a task group named "hospital-to-community pharmacist coordination" has been set up to create tools aiming at standardising the information exchanged between ambulatory and hospital pharmacists. A retrospective study examined the utilisation of the tools over a period of one year. The task group identified the expectations of all parties regarding the care pathways of patients undergoing oral chemotherapy, which lead to the creation of computerised exchange tools (integrated into the computerised patient's medical file). Over the course of this study, the cancer centre's pharmaceutical team contacted 425 ambulatory pharmacists regarding the prescription of oral chemotherapy to patients. Forty-two follow-ups from ambulatory pharmacists, gathering information on 34 patients, were submitted to the cancer centre pharmacists (7,7%). These first follow-ups allowed pharmaceutical responses regarding patient compliance, drug interaction and toxicities.

THU0203 REAL WORLD EFFECTIVENESS OF BARICITINIB IN THE SWISS RHEUMATOID ARTHRITIS REGISTER (SCQM-RA)

Background:

Patients with rheumatoid arthritis (RA) intolerant or not responding adequately to conventional synthetic DMARD (csDMARD) usually receive biological DMARDs (bDMARDs) or targeted synthetic DMARDs (tsDMARDs) as 2ndline. Baricitinib (BARI), a once-daily oral selective Janus kinase inhibitor, is efficient in randomised controlled trials but still lacks evidence for effectiveness in real world settings.

Objectives:

To characterise patients initiating treatment with BARI or other alternative bDMARDs, and to perform an analysis of drug maintenance.

Methods:

This is an observational, prospective, cohort study, within the Swiss Clinical Quality Management (SCQM) register.

All treatment courses (TC) initiated between 2017-09-01 and 2019-10-01 were considered, comparing TC with BARI (BARI group) to TC with alternative bDMARDs, either TNF inhibitors (TNFi group) or other mode of action bDMARDs (OMA group), excluding rituximab.

Baseline characteristics were compared using ANOVA or χ2 tests. The crude drug maintenance was assessed by survival analysis (Kaplan-Meier). To correct for potential confounding factors, a Cox proportional hazard model was used. Missing values were imputed using multiple imputation with chained equations.

Results:

During the study period, 979 TC were initiated (240 in BARI group, 461 in TNFi group and 278 in OMA group). BARI was prescribed to significantly older patients, with longer disease durations and more previous treatment failures (Table 1). Unadjusted drug maintenance was significantly shorter in the TNFi compared to the BARI group (log rank p = 0.019). After adjustment for potential confounding factors, the hazard of TNFi discontinuation remained higher than for BARI (Hazard Ratio (HR) 1.48 (95% CI = [1.05 – 2.09]; p = 0.02)). A similar trend was observed when comparing the OMA drugs to BARI, with a HR for discontinuation of 1.42 (95% CI = [0.98 – 2.05]; p = 0.06) (Figure 2). Covariates significantly associated with decreased drug maintenance were concomitant csDMARD and concomitant glucocorticoids (Figure 2).

Table 1.

Baseline characteristics of studied population

VariableCategoriesBaricitinib(TC = 240; 240 patients)Mean (SD)Otherwise: n %TNFi(TC = 461; 397 patients)Mean (SD)Otherwise: n %OMA bDMARDs(TC = 278; 253 patients)Mean (SD)Otherwise: n %P valuesConcomitant csDMARD at baseline45 %54 %46 %0.02Line of Therapy1st20 %46 %22 %<0.012nd22 %25 %26 %3rd14 %14 %26 %4thor later43 %16 %27 %Gender (female)80 %71 %74 %0.05Age59 (13)53 (14)59 (13)<0.01Seropositivity (ACPA and/or RF)75 %71 %79 %0.04HAQ-DI Score0.9 (0.7)0.7 (0.6)0.8 (0.6)0.02Disease duration (years)12 (10)9 (10)11 (9)<0.01CDAI baseline19 (10)15 (12)19 (14)0.09

Legend

TC = Treatment Courses. SD = Standard Deviation. TNFi = TNF inhibitors. OMA bDMARDs = Other Mode of Action biological DMARDs. csDMARD = conventional synthetic DMARD. ACPA = Anti Citrullinated Peptide Antibodies. RF = Rheumatoid Factor. HAQ-DI= Health Assessment Questionnaire Disability Index. CDAI = Clinical Disease Activity Index.

Conclusion:

In this preliminary analysis, baricitinib was prescribed to older patients, with longer disease durations, and more previous treatment failures compared to alternative bDMARDs. Baricitinib demonstrated a significantly higher drug maintenance than TNFi, while similar trend was observed in comparison to OMA drugs.

Conflict of interest:

This analysis has been made possible by financial support of Eli Lilly (Suisse) SA to the Geneva University Hospitals (HUG).

Disclosure of Interests: :

Benoit GILBERT: None declared, Kim Lauper: None declared, Delphine Courvoisier: None declared, Clementine Perrier Shareholder of: Share of Eli Lilly Company, Employee of: I am currently an employee of Eli Lilly Suisse SA, Rudiger Muller Consultant of: AbbVie, Nordic, Sandoz, Axel Finckh Grant/research support from: Pfizer: Unrestricted research grant, Eli-Lilly: Unrestricted research grant, Consultant of: Sanofi, AB2BIO, Abbvie, Pfizer, MSD, Speakers bureau: Sanofi, Pfizer, Roche, Thermo Fisher Scientific

Measuring the impact of the French version of The Whiplash Book on both treatment approach and fear-avoidance beliefs among emergency physicians. A cluster randomized controlled trial

Background

Whiplash-associated disorders have been the subject of much attention in the scientific literature and remain a major public health problem.

Objective

Measure the impact of a validated information booklet on the fear-avoidance beliefs of emergency physicians and their approach to management regarding the treatment of whiplash-associated disorders.

Methods

A prospective cluster randomized controlled study conducted with a sample of emergency medicine physicians. Fear-avoidance beliefs were measured using The Whiplash Belief Questionnaire (WBQ) and Fear-Avoidance Beliefs Questionnaire (FABQ). We assessed the approach to management based on the prescription of pharmacological and non-pharmacological treatments based on the advice given to patients. The validated information booklet was the French version of The Whiplash Book. A set of questionnaires was sent to participants pre- and post-intervention. The experimental intervention was the provision of The Whiplash Book. The control arm did not receive any training or information.

Results

Mean fears and beliefs scores on inclusion were high: WBQ = 19.09 (± 4.06); physical activity FABQ = 11.45 (± 4.73); work FABQ = 13.85 (± 6.70). Improvement in fear-avoidance beliefs scores being greater in the intervention group was further confirmed by the variation in WBQ (-20 [-32; -6] vs. -6 [-16; 9]; p = 0.06), physical activity FABQ (-70 [-86; -50] vs. -15 [-40; 11]; p < 0.001), and work FABQ (-40 [-71; 0] vs. 0 [-31; 50]; p = 0.02). The emergency physicians' initial approach to management was not consistent with current guidelines. Reading the French version of The Whiplash Book could contribute to changing their approach to management in several areas on intra-group analysis.

Conclusion

The French version of The Whiplash Book positively influenced fear-avoidance beliefs among emergency physicians.

Deuxième niveau de compétence pour l’échographie clinique en médecine d’urgence. Recommandations de la Société française de médecine d’urgence par consensus formalisé

La Société française de médecine d’urgence a élaboré en 2016 des recommandations formalisées d’experts définissant le premier niveau de compétence en échographie clinique en médecine d’urgence. Ce niveau est maintenant complété par un deuxième niveau correspondant à une pratique plus avancée utilisant des techniques non envisagées dans le premier niveau comme l’utilisation du Doppler et nécessitant aussi une pratique et une formation plus poussées. Des champs déjà présents dans le premier référentiel sont complétés, et de nouveaux champs sont envisagés. La méthodologie utilisée est issue de la méthode « Recommandations par consensus formalisé » publiée par la Haute Autorité de santé et de la méthode Delphi pour quantifier l’accord professionnel. Ce choix a été fait devant l’insuffisance de littérature de fort niveau de preuve dans certaines thématiques et de l’existence de controverses. Ce document présente les items jugés appropriés et inappropriés par les cotateurs. Ces recommandations définissent un deuxième niveau de compétence en ECMU.

Predictive factors of intracranial bleeding in head trauma patients receiving antiplatelet therapy admitted to an emergency department

Background

In head trauma cases involving antiplatelet agent treatment, the French Society of Emergency Medicine recommends performing computed tomography (CT) scans to detect brain lesions, 90% of which are normal. The value of CT is still debatable given the scarce number of studies and controversial results.

Methods

We used the RATED registry (Registry of patient with Antithrombotic agents admitted to an Emergency Department, NCT02706080) to assess factors of cerebral bleeding related to antiplatelet agents following head trauma.

Results

From January 2014 to December 2015, 993 patients receiving antiplatelet agents were recruited, 293 (29.5%) of whom underwent CT scans for brain trauma. Intracranial bleeding was found in 26 (8.9%). Multivariate analysis revealed these patients more likely to have a history of severe hemorrhage (odds ratio [OR]: 8.47, 95% confidence interval [CI]: 1.56–45.82), dual antiplatelet therapy (OR: 6.46, 95%CI:1.46–28.44), headache or vomiting (OR: 4.27, 95%CI: 1.44–2.60), and abnormal Glasgow coma scale (OR: 8.60; 95%CI: 2.85–25.99) compared to those without intracranial bleeding. The predictive model derived from these variables achieved 98.9% specificity and a negative predictive value of 92%. The area under the ROC curve (AUROC) was 0.85 (95%CI: 0.77–0.93).

Conclusions

Our study demonstrated that the absence of history of severe hemorrhage, dual antiplatelet therapy, headache or vomiting, and abnormal Glasgow coma scale score appears to predict normal CT scan following traumatic brain injury in patients taking antiplatelets. This finding requires confirmation by prospective studies.

Trial registration

ClinicalTrials.gov number: NCT02706080.

Assessment of urinary dipstick in patients admitted to an ED for blunt abdominal trauma

INTRODUCTION

Clinicians still face significant challenge in predicting intra-abdominal injuries in patients admitted to an emergency department for blunt abdominal trauma. This study was thus designed to investigate the value of dipstick urinalysis in patients with blunt abdominal trauma.

METHODS

We performed a retrospective, multicenter, cohort study involving patients admitted to the emergency department for abdominal traumas, examined by means of urinary dipstick and abdominal CT scan. The primary endpoint was the correlation between microscopic hematuria detected via dipstick urinalysis (defined by the presence of blood on the dipstick urinalysis but without gross hematuria) and abdominal injury, as evidenced on CT scan.

RESULTS

Of the 100 included patients, 56 experienced microscopic hematuria, 17 gross hematuria, and 44 no hematuria. Patients with abdominal injury were more likely to present with hypovolemic shock (odds ratio [OR]: 8.4; 95% confidence interval [CI]: 2.7-26), abdominal wall hematoma (OR: 3.1; 95% CI: 1.2-7.9), abdominal defense (OR: 5.2; 95% CI: 1.8-14.5), or anemia (OR: 3.6; 95% CI: 1.2-10.3). Moreover, dipstick urinalysis was less likely to predict injury, with just 72.2% sensitivity (95% CI: 54.8-85.8), 53.1% specificity (95% CI: 40.2-65.7), and positive and negative predictive values of 46.4% (95% CI: 33.0-60.3) and 77.3% (95% CI: 62.2-88.5), respectively.

CONCLUSION

Dipstick urinalysis was neither adequately specific nor sensitive for predicting abdominal injury and should thus not be used as a key assessment component in patients suffering from blunt abdominal trauma, with physical exam and vital sign assessment the preferred choice.

Making sense of the relationships between Ne, Nb and Nc towards defining conservation thresholds in Atlantic salmon (Salmo salar)

Effective population size over a generation (Ne) or over a reproductive cycle (Nb) and the adult census size (Nc) are important parameters in both conservation and evolutionary biology. Ne provides information regarding the rate of loss of genetic diversity and can be tracked back in time to infer demographic history of populations, whereas Nb may often be more easily quantified than Nc for short-term abundance monitoring. In this study, we propose (1) an empirical context to Waples et al. (2014) who introduced a correction to bias due to overlapping generations, and (2) a mathematical relationship between Ne and Nb for direct application in Atlantic salmon populations in Québec, Canada. To achieve this, we investigate the relationships between Ne, Nb and Nc in 10 Atlantic salmon populations, Canada, for which we genotyped 100 randomly sampled young-of-the year individuals for 5 consecutive years. The results show a positive correlation between Ne, Nb and Nc, suggesting that Nb is an indicative parameter for tracking effective population size and abundance of Atlantic salmon. However, our model allows predicting Nc from Nb values at 27% that can be partly explained by high variance in Nb/Nc both among populations (37%) and among years (19%). This result illustrates the need for thorough calibration of Nb/Nc before using Nb in monitoring programs, as well as a full understanding of the limits of such an approach. Finally, we discuss the importance of these results for the management of wild populations.

Impaired mental well-being and psychosocial risk: a cross-sectional study in female nursing home direct staff

OBJECTIVES

The present study sought to quantify the impaired mental well-being and psychosocial stress experienced by nursing home staff and to determine the relationship between impaired mental well-being assessed on the 12-item General Health Questionnaire (GHQ-12) and exposure to psychosocial stress assessed on Siegrist's effort/reward and overcommitment model.

METHODS

A transverse study was conducted in France on 2471 female employees in 105 nursing homes for the elderly. Personal and occupational data were collected by questionnaire for 668 housekeepers, 1454 nursing assistants and 349 nurses.

RESULTS

36.8% of participants (n=896) showed impaired mental well-being, 42.7% (n=1039) overcommitment and 9% (n=224) effort/reward imbalance. Overcommitment (prevalence ratio (PR)=1.27; 95% CI (1.21 to 1.34)) and effort-reward imbalance (PR=1.19; 95% CI (1.12 to 1.27)) were significantly associated with presence of impaired mental well-being after adjustment for personal factors (age and private life events). Taking effort and reward levels into account, the frequency of impaired mental well-being was highest in case of exposure to great extrinsic effort and low rewards of any type: esteem, PR=3.53, 95% CI (3.06 to 4.08); earnings, PR=3.48, 95% CI (2.99 to 4.06); or job security, PR=3.30, 95% CI (2.88 to 3.78). Participants in situations of overcommitment and of effort/reward imbalance were at the highest risk of impaired mental well-being: PR=3.86, 95% CI (3.42 to 4.35).

CONCLUSIONS

Several changes in nursing home organisation can be suggested to reduce staff exposure to factors of psychosocial stress. Qualitative studies of the relation between impaired mental well-being and psychosocial stress in nursing home staff could guide prevention of impaired mental well-being at work.

How CAGE, RAPS4-QF, and AUDIT Can Help Practitioners for Patients Admitted with Acute Alcohol Intoxication in Emergency Departments?

AIMS

To help clinicians to identify the severity of alcohol use disorders (AUDs) from optimal thresholds found for recommended scales. Especially, taking account of the high prevalence of alcohol dependence among patients admitted to the emergency department (ED) for acute alcohol intoxication (AAI), we propose to define thresholds of severity of dependence based on the AUDIT score.

METHODS

All patients admitted to the ED with AAI (blood alcohol level >0.8 g/L), in a 2-month period, were assessed using the CAGE, RAPS-QF, and AUDIT, with the alcohol dependence/abuse section of the mini international neuropsychiatric interview (MINI) used as the gold standard. To explore the relation between the AUDIT and the MINI the sum of the positive items on the MINI (dependence) as a quantitative variable and as an ordinal parameter were analyzed. From the threshold score found for each scale we proposed intervals of severity of AUDs.

RESULTS

The mean age of the sample (122 males, 42 females) was 46 years. Approximately 12% of the patients were identified with alcohol abuse and 78% with dependence (DSM-IV). Cut points were determined for the AUDIT in order to distinguish mild and moderate dependence from severe dependence. A strategy of intervention based on levels of severity of AUD was proposed.

CONCLUSION

Different thresholds proposed for the CAGE, RAPS4-QF, and AUDIT could be used to guide the choice of intervention for a patient: brief intervention, brief negotiation interviewing, or longer more intensive motivational intervention.

Urinary interleukin-8 is a biomarker of stress in emergency physicians, especially with advancing age--the JOBSTRESS* randomized trial

Background

Emergency physicians are exposed to greater stress during a 24-hour shift (24 hS) than a 14-hour night shift (14 hS), with an impact lasting several days. Interleukin-8 (IL-8) is postulated to be a chronic stress biomarker. However, no studies have tracked IL-8 over several shifts or used it for monitoring short-term residual stress. The IL-8 response to the shifts may also increase with age. Conveniently, IL-8 can be measured non-intrusively from urine.

Methods

We conducted a shifts-randomized trial comparing 17 emergency physicians’ urinary IL-8 levels during a 24 hS, a 14 hS, and a control day (clerical work on return from leave). Mean levels of IL-8 were compared using a Wilcoxon matched-pairs test. Independent associations of key factors including shifts, stress, and age with IL-8 levels were further assessed in a multivariable generalized estimating equations model.

Results

Mean urinary IL-8 levels almost doubled during and after a 24 hS compared with a 14 hS or a control day. Furthermore, IL-8 levels failed to return to control values at the end of the third day after the shift despite a rest day following the 24 hS. In the multivariable model, engaging in a 24 hS, self-reported stress, and age were independently associated with higher IL-8 levels. A 24 hS significantly increased IL-8 levels by 1.9 ng (p = .007). Similarly, for every unit increase in self-reported stress, there was a 0.11 ng increase in IL-8 levels (p = .003); and for every one year advance in age of physicians, IL-8 levels also increased by 0.11 ng (p = .018).

Conclusion

The 24 hS generated a prolonged response of the immune system. Urinary IL-8 was a strong biomarker of stress under intensive and prolonged demands, both acutely and over time. Because elevated IL-8 levels are associated with cardiovascular disease and negative psychological consequences, we suggest that emergency physicians limit their exposure to 24 hS, especially with advancing age.

Effects of temperature and food supply on the growth of whitefish Coregonus lavaretus larvae in an oligotrophic peri-alpine lake

The relative roles of temperature and food availability on the seasonal and daily growth of whitefish Coregonus lavaretus larvae were investigated in the oligotrophic peri-alpine Lake Annecy, France. During the spring from 2004 to 2007, surface water temperature and density of potential zooplankton prey were monitored, and 2688 larvae were caught and measured. In addition, the daily growth of 130 larvae was estimated retrospectively by investigating the microstructure of their otoliths. Temperature played the predominant role in controlling both seasonal and daily growth of early larvae. In contrast, the abundance of Mesocyclops leuckarti and larval density was only slightly correlated to larval growth, suggesting no food limitation nor strong interindividual competition over the study period. Overall, these findings run counter to concerns about potential food limitation, but sound a warning about the potential impact of climate change on fish ecology and fisheries management.

Effects of haptoglobin polymorphisms and deficiency on susceptibility to inflammatory bowel disease and on severity of murine colitis

BACKGROUND

Haptoglobin (Hp) is a haemoglobin-binding protein with immunomodulatory properties. Its gene (16q22) harbours a common polymorphism with two different alleles: Hp1 and Hp2. Genotype Hp22 has been shown to be over-represented in different immune diseases. Results in Crohn's disease (CD) are contradictory.

AIMS

To determine whether Hp plays a role in inflammatory bowel disease, both genetically and functionally.

METHODS

1061 patients with CD, 755 with ulcerative colitis (UC) and 152 with primary sclerosing cholangitis, as well as 452 healthy controls, were genotyped using touch-down PCR. To confirm association results, 464 CD trios and 151 UC trios were genotyped. Serum Hp concentrations were determined in 62 individuals of different genotype. Colitis was induced in mice with dextran sulphate sodium (DSS) and oxazolone (Oxa). Cytokine production was evaluated by mRNA quantification in colonic tissue and ELISA on supernatants of mesenteric lymph node cells.

RESULTS

Prevalence of Hp2 was higher in CD and UC than in controls. In the confirmatory cohorts, Hp2 was over-transmitted to the affected offspring. Serum Hp concentrations were higher in individuals with genotypes Hp11 and Hp21 than in those with Hp22 (1.38 vs 0.89 g/l). DSS- and Oxa-induced colitis were more severe in Hp-deficient mice than in control mice and accompanied by higher concentrations (although not statistically significantly different) of tissue mRNA for cytokines. Interleukin-17 production was significantly higher in the presence of Hp-deficient serum compared with wild-type serum.

CONCLUSIONS

The Hp gene may play a role in susceptibility to inflammatory bowel disease. Its implication in other immune diseases underscores the common pathways between these diseases. Experimental models of colitis showed that Hp has a protective role in inflammatory colitis, most likely by inhibiting the production of Th1 and Th17 cytokines.

Gut permeability and food allergies

Intestinal permeability is a critical feature of the gastrointestinal epithelium as it must allow an efficient passage of nutrients and restrict the entry of larger molecules, such as protein antigen, in order to facilitate appropriate immune responses towards food antigens. The proper regulation of the epithelial barrier relies on multiple, intricate physiological and immunologic mechanisms, in terms of which recent progresses regarding the cellular and molecular components have been unravelled. In genetically predisposed individuals, breakdown of oral tolerance can occur, leading to the inadequate production of allergen-specific IgE and the recruitment of mast cells in the gastrointestinal mucosa. Under such conditions, the intestinal permeability towards allergen is altered via different mechanisms, with IgE-CD23-mediated transport across the mucosa playing an important amplification role. Additionally, during the effector phase of the allergic reaction, when mast cells degranulate, a series of inflammatory mediators, such as proteases and cytokines, are released and further affects intestinal permeability. This leads to an increase in the passage of allergens and hence contributes to perpetuate the inflammatory reaction. In this review, we describe the importance of properly balanced intestinal permeability in oral tolerance induction and address the processes involved in damaging the intestinal barrier in the sensitized epithelium and during allergic reactions. We conclude by speculating on the effect of increased intestinal permeability on the onset of sensitization towards dietary antigens.

Allergen-specific antibody and cytokine responses, mast cell reactivity and intestinal permeability upon oral challenge of sensitized and tolerized mice

BACKGROUND

Food allergy has reached an epidemic level in westernized countries and although central mechanisms have been described, the variability associated with genetic diversity underscores the still unresolved complexity of these disorders.

OBJECTIVE

To develop models of food allergy and oral tolerance, both strictly induced by the intestinal route, and to compare antigen-specific responses.

METHODS

BALB/c mice were mucosally sensitized to ovalbumin (OVA) in the presence of the mucosal adjuvant cholera toxin, or tolerized by intra-gastric administrations of OVA alone. Antibody titres and cytokines were determined by ELISA, and allergic status was determined through several physiologic parameters including decline in temperature, diarrhoea, mast cell degranulation and intestinal permeability.

RESULTS

OVA-specific antibodies (IgE, IgGs and IgA in serum and feces) were produced in sensitized mice exclusively. Upon intra-gastric challenge with OVA, sensitized mice developed anaphylactic reactions associated with a decline of temperature, diarrhoea, degranulation of mast cells, which were only moderately recruited in the small intestine, and increased intestinal permeability. Cytokines produced by immune cells from sensitized mice included T-helper type 2 cytokines (IL-5, IL-13), but also IL-10, IFN-gamma and IL-17. In contrast, all markers of allergy were totally absent in tolerized animals, and yet the latter were protected from subsequent sensitization, demonstrating that oral tolerance took place efficiently.

CONCLUSION

This work allows for the first time an appropriate comparison between sensitized and tolerized BALB/c mice towards OVA. It highlights important differences from other models of allergy, and thus questions some of the generally accepted notions of allergic reactions, such as the protective role of IFN-gamma, the importance of antigen-specific secretory IgA and the role of mucosal mast cells in intestinal anaphylaxis. In addition, it suggests that IL-17 might be an effector cytokine in food allergy. Finally, it demonstrates that intestinal permeability towards the allergen is increased during challenge.

Thyme and cinnamon extracts induce anion secretion in piglet small intestine via cholinergic pathways

Thymol and cinnamaldehyde, extracted from thyme and cinnamon respectively, have multiple effects on mammalian cells. Although the intestinal mucosa is one of the first tissues they are in contact with when ingested, their effect on intestinal epithelial cells and especially ion secretion has not been established yet. The aim of this study was to investigate the effect of those two substances on electrolyte secretion and absorption across the porcine jejunal epithelium in Ussing chambers. Jejunal tissues from piglets were mounted in Ussing chambers and the short circuit current measured (I(sc)) after addition of thymol or cinnamaldehyde. Thymol and cinnamaldehyde induced a dose-dependent increase is I(sc). The effect of thymol was inhibited in low Cl-, HCO3(-) free or low Cl-/ HCO3(-) free buffers. It was completely blocked when tissues were previously incubated with tetrodotxin and partially inhibited with hexamethonium. Cinnamaldehyde effect was inhibited when HCO3(-) free or low Cl-/ HCO3(-) free buffers were used. It was not affected by tetrodotoxin but reduced by hexamethonium, suggesting direct activation of receptors on epithelial cells. In conclusion, thymol induces Cl- and HCO3(-) secretion via activation of nervous nicotinic receptors while cinnamaldehyde induces HCO3(-) secretion probably via direct activation of nicotinic receptors on epithelial cells.

[Pertrochanteric fractures in elderly subjects aged over 75]

Pertrochanteric fractures constitute a major public health concern. This retrospective multicentric study evaluated outcome after treatment in patients aged over 75 years hospitalized for pertrochanteric fractures over a one year period (May 2004-May 2005). Five University Hospitals in the cities of Angers, Brest, Rennes, Tours, Nantes participated in this evaluation. The quality of the reduction and the position of the osteosynthesis were the two main criteria for good outcome. The type of material implanted had little effect on outcome. The results emphasized the importance of preventing osteoporosis. Fracture prevention and treatment of osteoporosis are crucial, even after fracture.

[Activities of medical practitioners in nursery schools for children under 6 years-old: the expectations of the facilities' directors]

This work aims to describe the activities of nurseries' medical practitioners and the expectations of the nurseries' supervisors. It is based on the analysis of 139 questionnaires received from nursery schools' managers from the Pays de Loire region in 2005. Ninety percent of the nurseries that accommodate children less than six years-old, do employ a medical practitioner. She or he is often a salaried paediatrician with a full-time job or clinical practice, who consults twice a month for two hours and forty minutes in each nursery which employs him/her. Her/his main activity consists of conducting standard medical examinations when children are admitted into the nursery and on-going follow-up of their adaptation and healthy early childhood development. She or he also ensures that hygienic preventive measures are respected in case of an epidemic or other potentially hazardous health situations. Moreover, two-thirds of the establishments offer prevention follow-up for the children, whereas health promotion programmes and interventions are only carried out in just over half of them. Emergency medical procedures are conducted in a quarter of them only. Most of the nursery directors are satisfied with the medical services provided, despite some criticism. They mainly wish that practitioners were more available and more regularly present on-site in order to supply further preventive care, to develop training programmes for other staff members, and to participate in thematic meetings. Encouraging improved synergy between the professionals working in the nurseries, placing child psychologists to work in the facilities and fostering better relationships with the independent medical practitioners would all help the process of development and the evolution of the operational function of the medical practitioners in these structures.

L’utilisation du tabac à chiquer

INTRODUCTION

In France, unlike in the United States and Scandinavia, the use of "smokeless tobacco" (also called "chewing tobacco") was rare, but this habit is starting to expand, especially in the world of sports. At ski championships, for example, it is used as a doping agent. Adolescents in mountain areas are now imitating their competitive-skiing peers.

CASE

A 16-year-old girl living in a ski resort became addicted to the tobacco paste, "Snuss", and consumed 15-20 doses of Snuss daily, together with a dozen cigarettes.

DISCUSSION

"Smokeless tobacco" is emerging as a habit in France, its use encouraged by its discretion, low cost, and rapid induction of addiction. Its growth in Alpine areas requires the urgent development of impact studies to facilitate the organization of information campaigns to treat and prevent its use.

The Spectroscopic Orbit of the Planetary Companion Transiting HD 209458

We report a spectroscopic orbit with period P=3.52433+/-0.00027 days for the planetary companion that transits the solar-type star HD 209458. For the metallicity, mass, and radius of the star, we derive [Fe/H&sqbr0;=0.00+/-0.02, M*=1.1+/-0.1 M middle dot in circle, and R*=1.2+/-0.1 R middle dot in circle. This is based on a new analysis of the iron lines in our HIRES template spectrum and also on the absolute magnitude, effective temperature, and color of the star, and it uses isochrones from four different sets of stellar evolution models. Using these values for the stellar parameters, we reanalyze the transit data and derive an orbital inclination of i=86&fdg;1+/-1&fdg;6. For the planet, we derive a mass of Mp=0.69+/-0.05 MJup, a radius of Rp=1.40+/-0.17 RJup, and a density of rho=0.31+/-0.07 g cm-3.

Use of human sera containing autoantibodies for an immunochemical study of some ribosomal proteins in rat, trout, mussel and fly maggot

Sera from human subjects affected by autoimmune connective tissue diseases and containing antiribosomal autoantibodies were used to analyze by immunoblotting ribosomal proteins from trout (Oncorhynchus mykiss) liver, mussel (Mytilus edulis) hepatopancreas and whole fly maggots (Calliphora vomitoria). As usual in medical analysis of autoantibodies, the reference antigen preparation was extracted from rat liver. With the used sera, six known ribosomal proteins from rat liver were characterized: P0, P1, P2, p30, p25 and p20. These six proteins were all targeted in trout; moreover an important 40 kDa fraction, undetectable in rat pattern, was seen. p30 and p20 were undetected in mussel and fly maggot; but p25, undetected in mussel, is clearly characterized in fly maggot. The interest of these data to infer phylogenic relationships is discussed.

[Activities of twelve enzymes in the blood plasma of rainbow trout and tench subjected to various forms of thermal disturbance]

The levels of ornithine carbamyl transferase, acid phosphatase, alkaline phosphatase, leucine amino peptidase, creatine kinase, amylase, glutamic oxalacetic transaminase, glutamic pyruvic transaminase, lactate deshydrogenase, hydroxybutyrate deshydrogenase, glutamate deshydrogenase and malate deshydrogenase were determined in the plasma of Rainbow Trout and Tench submitted to water temperature increases. In the Rainbow Trout a thermal shock from 12 to 21 degrees, increases activities of some enzymes while temperature increase up to pre-mortem stage causes very important changes in enzymatic levels. In the Tench a thermal shock from 12 to 28 degrees causes more changes of enzymatic activities than a shock from 12 to 25 degrees. In Tench acclimated to 25 degrees, various enzyme levels are increased in comparison with 12 degrees control animals. A high potassium level in water causes complex changes in enzyme levels. The most sensitive enzymes to thermal disturbance are GOT and GPt transaminases which increase whatever the aggression form, amylase when thermal disturbance is moderate, alkaline phosphatase and malate deshydrogenase in case of strong thermal stress. The study of these enzymes is recommended for watching the state of fishes living in artificially heated waters.

[Obtaining an anti-trout (Salmo gairdneri Rich.) immunoglobulin specific serum from rabbits immunized with the slowest serum fraction isolated in polyacrylamide gel electrophoresis]

Rabbits were immunized with the slowest fraction obtained by polyacrylamide gel electrophoresis of normal Trout serum previously cleared of lipoproteins. The antiserum thus obtained reacts specifically with Trout immunoglobulin. This was verified by inhibiting the neutralization of Infectious Pancreatic Necrosis Virus by Trout antibodies, and by comparing it in immunoelectrophoresis with a rabbit antiserum previously obtained by immunization with Trout antibodies-Dinitrophenol-Haemocyanin immune complexes.