Vulnerabilities during pregnancy. : Analysis of pregnancy outcomes by a combined approach of multiple exposure and joint models.

Les complications et issues défavorables de la grossesse (CIDG), telles que la prématurité, les petits poids de naissance, la pré-éclampsie/éclampsie ou les hémorragies du 2ème et 3ème trimestre de grossesse sont des évènements fréquents et peuvent avoir des conséquences majeures sur le devenir de la mère et/ou du nouveau-né. La plupart des CIDG sont multifactorielles, et les facteurs de risque individuels et collectifs identifiés sont d'origine multiples : environnementale, médico-obstétricale, comportementale ou encore sociodémographique. Cependant, les approches simultanées de ces facteurs sont restreintes et l’impact de ce cumul d’exposition reste inconnu.Les objectifs de cette thèse sont i/ de décrire le cumul des vulnérabilités associées à des facteurs environnementaux, médico-obstétricaux, comportementaux, et sociodémographiques, ii/ d’analyser son impact sur les CIDG, iii/ d’établir un modèle prédictif de facteurs de vulnérabilité.Dans le cadre d’un programme de recherche sur la périnatalité et les expositions combinées à de multiples facteurs (programme PreCEE), une base de données incluant les données médicales, sociodémographiques et environnementales de plus de 10 000 accouchement de femmes habitant à Besançon et dans l’unité urbaine de Dijon (période 2005-2009) a été constituée.La description et l’analyse de quinze facteurs de vulnérabilité chez sur plus de 4000 femmes enceintes ayant accouché à Besançon montrent que l’accumulation de facteurs de vulnérabilité environnementaux, médico-obstétricaux, comportementaux, et socioéconomiques, est significativement associé à un risque accru de CIDG. Une revue des approches statistiques permettant l’analyse simultanée de plusieurs variables expliquées telles que les CIDG a été conduite et a permis de retenir les modèles conjoints à multiples variables expliquées binaires. Une application sur notre jeu de données a mis en évidence que les modèles GLMM multivariés bayésiens se révélaient particulièrement adaptés. Enfin, la construction d’un score de vulnérabilité au cours de la grossesse a été mise en œuvre à partir de quinze facteurs de vulnérabilité de modèles GLMM multivariés bayésiens.Adverse pregnancy outcomes (APO), such as prematurity, low birth weight, pre-eclampsia / eclampsia or bleeding in the 2nd and 3rd trimester of pregnancy are common events and can have major consequences on the future of the mother and / or the newborn. Most APOs are multifactorial, and the individual and collective risk factors identified are of multiple origin: environmental, medico-obstetric, behavioral or socio-demographic. However, simultaneous approaches to these factors are limited and the impact of this cumulative exposure remains unknown.The objectives of this thesis are i / to describe the accumulation of vulnerabilities associated with environmental, medico-obstetric, behavioral, and socio-demographic factors, ii / to analyze its impact on APO, iii / to establish a predictive model of factors As part of a research program on perinatal birth and exposure combined with multiple factors (PreCEE program), a database including medical, socio-demographic and environmental data on more than 10,000 childbirths of women living in Besançon and in the urban unit of Dijon (period 2005-2009) was established.The description and analysis of fifteen vulnerability markers in more than 4,000 pregnant women who gave birth in Besançon show that the accumulation of environmental, medico-obstetric, behavioral, and socioeconomic vulnerability markers is significantly associated with an increased risk of APO. A review of statistical approaches allowing the simultaneous analysis of several dependent variables such as APOs was conducted and allowed to retain joint models for multiple binary outcomes. An application on our dataset has shown that Bayesian multivariate GLMM models are particularly suitable. Finally, the construction of a vulnerability score during pregnancy was implemented using fifteen vulnerability markers from multivariate Bayesian GLMM models

Influence of advancing age on clinical presentation, treatment efficacy and safety, and long-term outcome of pre-excitation syndromes: a retrospective cohort study of 961 patients included over a 25-year period

International audienc

Determinants of primary healthcare seeking behaviours for children during the first 18 months of life in Benin

International audienceBackground:Primary healthcare is a key element of management of childhood illness in Africa. The objectives were to identify primary care seeking determinants among infants and young children up to 18 mo in a birth cohort from Benin.Methods:From 2007 to 2009 in Benin, a birth cohort was followed until the age of 18 mo in three health centres. Multilevel Poisson regression models were fitted to identify the factors related to the monthly number of consultations. Maternal and newborn characteristics and infant general health parameters were considered.Results:A total of 566 children were followed. On average, 0.46 consultations per month per child were recorded. The number of consultations was significantly lower after the first 6 mo of life (p1000 m was associated with fewer consultations (p=0.01). Primiparity was significantly associated with higher care seeking (relative risk 1.17 [95% CI 1.05 to 1.30], p0.16).Conclusions:Development of health structures and improvement of access remain important goals for strengthening of the primary care health system. Studying factors of care seeking behaviour, like parity, can help to identify women more prone to seek care for their child during the first year of life

Impact of a visual indicator on the noise level in an emergency medical dispatch centre - a pilot study

International audienceBackground: Noise levels are monitored in call centres. A maximum of 52 to 55 dB(A) is recommended in order to prevent adverse events. We aimed at assessing the noise level and the impact of a visual noise indicator on the ambient noise level in a French Regional Emergency Medical Dispatch Centre (EMDC). Methods: We conducted an observational study in the EMDC of the SAMU25 (University Hospital of Besancon). We measured the noise level using a SoundEarII® noise indicator (Dräger Medical SAS, France). The measurement took place in two phases on three consecutive days from 00:00 to 11:59 PM. At baseline, phase 1, the device recorded the average ambient noise for each minute without visual indication. Secondly, phase 2 included a sensor mounted with a light that would turn on green if noise was below 65 dB(A), orange if noise ever exceeded 65 and red if it exceeded 75 dB(A). Results: In the presence of the visual noise indicator, the L Aeq was significantly lower than in the absence of visual noise indicator (a mean difference of − 4.19 dB; P < 10-3). It was higher than 55 dB(A) in 84.9 and 43.9% of the time in phases 1 and 2, respectively. Conclusions: The noise levels were frequently higher than the standards, and sometimes close to recommended limits, requiring preventive measures. The noise indicator had a positive effect on the ambient noise level. This work will allow the implementation of effective prevention solutions and, based on future assessments, could improve operators' well-being and better care for patient

PreCEE (Pregnancy and Combined Environmental Exposure), a research program in two middle-sized cities - Part 1, Population and methods

International audienceIn urban areas, the density of pollution sources combined with a high number of residents, constitute the optimal conditions for simultaneous exposure of pregnant women to many environmental pollutants. The occurrence of adverse pregnancy outcomes such as preterm delivery or fetal growth disorders could induce heavy consequences on the health of the mother and/or the newborn. What is the exposure level to noise or air pollution of pregnant women living in middle-sized cities? Is there a link between these exposures and prematurity, intra uterine growth disorders...? To answer these questions, the PreCEE research program has been conducted since 2012 in the region of Bourgogne-Franche-Comt�. Nearly 11,000 deliveries that occurred between 2005 and 2009 at the Besan�on or Dijon University Hospital were included. Delivery data, medical and obstetrical history, socio-economic conditions and living environment were collected from medical records. Road and railway traffics were the main noise and air pollution sources of these medium-sized cities. The mother?s address was used to assess environmental exposure to noise and air pollution. Environmental prediction models were used to assess outdoor pollutant exposures using MITHRA-SIG, COPERT IV and ADMS-Urban software. Air pollution, proximity to green spaces and noise were quantified at the living neighbourhood scale of each building. Furthermore, noise levels were also calculated in front of the entire fa�ade and in front of the most exposed fa�ade of each building. A deprivation index was calculated for the two cities. Logistic regression analyses were performed using classical and multilevel models. Many sensitivity analyses were conducted to explore the potential influence of the retained definition of exposure (pollutant, living area, time exposure window), adverse pregnancy outcomes (birth weight standards?) and missing data treatment. Technical, legal, and ethic parts of the project had also to be cautiously considered in the program

PreCEE (Pregnancy and Combined Environmental Exposure), a research program in two middle-sized cities - Part 2, Results and discussion

International audienceData from nearly 11000 deliveries that occurred between 2005 and 2009 at the Besan�on or Dijon (France) were collected during the PreCEE program, including medical, obstetrical, socio-economic and environmental conditions (noise, air pollution, proximity to green spaces). Several approaches were conducted to investigate the relationships between the occurrence of adverse pregnancy outcomes (APO) and the urban environment of two middle-sized cities, and to estimate the potential modulation of vulnerability on the impact of noise or air pollution during pregnancy. The mean NO&lt;sub&gt;2&lt;/sub&gt; level ranged between 24 and 25 �g/m&lt;sup&gt;3&lt;/sup&gt; and the mean L&lt;sub&gt;night&lt;/sub&gt; ranged between 51 and 52 dB(A). The correlation between noise and NO&lt;sub&gt;2&lt;/sub&gt; indices ranged from 0.41 to 0.59. The accumulation of 15 vulnerability markers regrouped in six dimensions (maternal age, smoking, body mass index, socio-economic, medico-obstetrical and environmental vulnerabilities) was analysed in comparison with four APO. Among the 3686 women included in this approach, 21% were not exposed to any marker and 19% accumulated three or more markers among the six dimensions. The risk of APO increased significantly with the cumulative number of vulnerabilities. Secondly, two case-control studies were conducted on preterm delivery on single pregnancies. First, only pregnancies without any associated comorbidities were considered (N=1511). No significant differences in pollutant exposure levels were found between cases and controls in this study. The second study was focused on pregnancies with associated comorbidities (N=2503). The OR associated with NO&lt;sub&gt;2&lt;/sub&gt;&gt;40&#956;g.m&lt;sup&gt;-3&lt;/sup&gt; was 0.83 (95%CI: 0.61-1.13) and the OR associated with L&lt;sub&gt;night&lt;/sub&gt;&_geq;55dB(A) was 1.23 (95%CI: 0.97-1.56). A strong and monotonic association between the cumulative number of comorbidities during pregnancy and preterm delivery was also identified. Low levels of air pollution do not seem to affect preterm delivery. However, moderate noise exposure could potentially affect pregnancy when associated with vulnerability factors

Vulnerability during pregnancy in an urban environment : do environmental and individual risk factors cumulate?

International audienceApart from demographic, socio-economic, behavioral, nutritional and medico-obstetrical factors, environmental factors have been suggested to be associated with adverse pregnancy outcomes, such as preterm birth, low birth weight or hypertensive disorders. According to a recent review of the literature, there is some suggestive evidence of adverse associations with environmental noise especially for low birth weight. However, the way these individual and environmental vulnerabilities combine has been scarcely studied. The objective of this study was to describe the accumulation of individual, socio-economics, medical and environmental vulnerability markers and to assess their association with adverse pregnancy outcomes.\n\nMethods\nAll the women living in the city of Besançon who delivered a singleton pregnancy at the University Hospital between 2005 and 2009 were included. Individual data were collected from obstetrical records. Long term environmental exposures to noise and air pollution were assessed using environmental prediction models. Finally, 16 vulnerability markers were retained; the occurrence of preterm birth, low birth weight, preeclampsia, and vaginal bleeding during the second or third trimester were considered for analyses.\n\nResults\nAmong the 3701 study women, 28% showed a socio-economic vulnerability, 30% a medico-obstetrical. Near 40% of the women presented environmental vulnerabilities, and 21% were exposed to a noise level above 55 dB(A) during the night. Although no vulnerability marker was observed among 18% of the women, 27% accumulated three or more of the 16 vulnerability markers. A significant and linear association was observed between the cumulative number of vulnerability markers and the occurrence of adverse pregnancy outcomes.\n\nConclusion\nThis study illustrates the interest of a multi criteria approach in health risk assessment, especially when considering environmental noise exposure and its potential impact on maternal and child health

Pregnancy vulnerability in urban areas: a pragmatic approach combining behavioral, medico-obstetrical, socio-economic and environmental factors

International audienceMultiple risk factors are associated with adverse pregnancy outcomes (APO), but how all these different factors combine and accumulate remains unknown. the objective of this observational retrospective study was to describe the accumulation of multiple vulnerability markers in pregnant women living in an urban area. Women living in Besançon (France) who delivered between 2005 and 2009 were included. individual data were collected from the obstetrical records while environmental exposures were collected using environmental prediction models. The accumulation of 15 vulnerability markers, grouped into six dimensions (maternal age, smoking, body mass index (BMi), socioeconomic , medico-obstetrical and environmental vulnerabilities) was described and analyzed in comparison with four Apo. Among the 3686 included women, 20.8% were aged under 20 or over 34 and 21.9% had an extreme pre-pregnancy BMI. 18.8% declared smoking during pregnancy. Women exposed to socioeconomic , medico-obstetrical or environmental vulnerability were 14.2%, 31.6% and 42.4% respectively. While 20.6% were not exposed to any marker, 18.8% accumulated three or more dimensions. The risk of APO increased significantly with the cumulative number of vulnerabilities. Define and validate a vulnerability score could be useful to identify vulnerable women, adapt their pregnancy monitoring and help policy makers to implement appropriate education or health promotion programs

Hyperendemicity of cysticercosis in Madagascar: Novel insights from school children population-based antigen prevalence study

International audienceObjective Taenia solium (Ts) cysticercosis is a neglected zoonotic disease particularly prevalent in Madagascar. Few data are available for children, current data mainly rely on antibody prevalence. We sought to determine the Ts-antigen seroprevalence–determining active cysticercosis—amongst school children from various cities in Madagascar (excluding the capital) and evaluated associated risk factors.Methods In seven cities in Madagascar, the presence of cysticercosis in school children (n = 1751) was investigated in 2007 using the B158/B60 antigen (Ag)-ELISA.Results The overall prevalence based on Ag detection was 27.7% [95%CI: 10–37%]. Risk factors associated with Ag positivity were age, biotope, altitude and annual average rainfall.Conclusion These results highlight the high prevalence of active cysticercosis in Madagascar among school children in an urban setting. This high prevalence as well as the risk factors unraveled point to the emergency to implement appropriate Public Health measure son a national scale

Temporal and Spatial Dynamics of Monkeypox in Democratic Republic of Congo, 2000–2015

International audienc