Jacques Blacher

Université Paris Descartes, Lutetia Parisorum, Île-de-France, France

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Publications (285)860.89 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: During year 2013, several recommendations for the management of hypertension were published: recommendations of the French and European Societies of Hypertension and two recommendations from the USA, those from the ACC/AHA/CDC groups and those from the JNC 8. The recommendations of the JNC 8 are not, strictly speaking, the recommendations of JNC 8, since they are neither endorsed by their sponsor: the National Heart, Lung and Blood Institute (NHLBI), nor by any other supervisor. They only commit their authors. Just before the publication of the JNC 8, "competing" recommendations, jointly produced by the AHA, ACC and CDC, were jointly published in Hypertension and in the Journal of American College of Cardiology, with different preferred treatment choices and significantly different algorithms. The authors of the JNC 8 have only included in their literature review randomized controlled trials of sufficient power. Randomized controlled trials are clearly the gold standard of comparative trials in medicine, but can they summarize all the knowledge? The authors of the JNC 8 propose in subjects over 60, a therapeutic threshold and target blood pressure of 150/90mmHg. This original threshold is poorly supported by the evidence and possibly increases the risk of physicians' inertia. The issue of experts' conflicts of interest has greatly changed the rules of drafting guidelines for clinical practice. Knowing that the vast majority of clinical trials is promoted by drug industry, could guidelines be strictly without any conflict of interest? Finally, recommendations for practice should have as primary, if not unique, objective to improve the practice.
    Presse medicale (Paris, France : 1983). 09/2014;
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    ABSTRACT: Hypertension is the most prevalent chronic disease worldwide. Lifestyle behaviors for its prevention and control are recommended within worldwide guidelines. Nevertheless, their combined relationship with blood pressure (BP) level, particularly in the general population, would need more investigations. Our aim in this study was to evaluate the relative impact of lifestyle and nutritional factors on BP level.
    American journal of hypertension. 09/2014;
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    ABSTRACT: En Francia, casi un tercio de las personas con edades comprendidas entre los 18 y los 74 años padecen hipertensión arterial. En 2006, el tratamiento farmacológico de esta afección supuso para el conjunto de los regímenes de la Seguridad Social un gasto de 2,3 mil millones de euros. Es una enfermedad de etiologías multifactoriales en la que la modificación de la alimentación y del estilo de vida contribuye a mejorar su control. Así, está demostrado que la reducción en el consumo excesivo de sal, la práctica regular de una actividad física, la reducción ponderal, la disminución del consumo excesivo de alcohol, el consumo de frutas y verduras ricas en potasio y las dietas DASH (dietary approaches to stop hypertension) y mediterránea disminuyen el nivel de presión arterial. Sin embargo, la combinación de varias medidas dietéticas parece no tener un efecto aditivo, en el que se sumarían los beneficios de cada una de ellas por separado, sino un efecto «infraaditivo». Esta observación justificaría una adaptación individual de las estrategias dietéticas en función del paciente. A pesar de su probada eficacia, el cumplimiento de estas medidas por parte de los pacientes constituye un verdadero desafío para la salud pública que requiere un seguimiento dietético así como una formación práctica de los profesionales sanitarios no especializados en nutrición.
    EMC - Tratado de Medicina. 09/2014; 18(3):1–7.
  • M E Safar, J Blacher
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    ABSTRACT: In recent years, treatment strategies for hypertension have often focused on combination therapies that include diuretics and renin angiotensin aldosterone system blockers such as angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. However, in clinical practice, a significant number of patients do not respond completely to these combination treatments, and long-term reduction of cardiovascular risk remains insufficient. The particularly high residual cardiovascular risk of hypertensive patients, even when adequately treated with strategies based on renin angiotensin aldosterone system blockers, speaks in favor of new, innovative strategies. Thus, it has become relevant to consider whether it is always necessary to block plasma renin activation and whether other guideline-approved combinations should be considered routinely. Diuretic/calcium channel blocker combinations, which are supported by significant long-term evidence, are put forth as a preferred combination in the main guidelines, but are still underused by physicians who do not yet have easy access to such treatments. Fixed-dose indapamide sustained release/amlodipine is the first such single-pill combination to become available. Complementary mechanisms of action of these two molecules are expected to lead to greater and longer-term reductions in systolic blood pressure and pulse pressure and potentially to the reduction of cardiovascular risk.
    American journal of cardiovascular drugs : drugs, devices, and other interventions. 08/2014;
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    ABSTRACT: Pulse wave analysis is a pivotal tool to estimate central haemodynamic parameters. Available commercial devices use applanation tonometry and have been validated against invasive catheterism. We previously observed differences on a radial second systolic peak (rSPB2) between two commonly used devices: SphygmoCor (AtCor, Australia) and PulsePen (DiaTecne, Italy). The aim of our study was to further quantify differences in radial and carotid signals from the two devices.We measured radial and carotid waveforms in 38 patients with minimal changes between systolic, diastolic blood pressure and heart rate.
    Physiological Measurement 08/2014; 35(9):1837. · 1.50 Impact Factor
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    ABSTRACT: Blood pressure (BP) variability is associated with several cardiovascular (CV) risk factors. Is BP variability measurement of any additive value, in terms of CV risk assessment strategies? To answer this question, we analyzed data from the SU.FOL.OM3 secondary prevention trial that included 2501 patients with background of CV disease history (coronary or cerebrovascular disease). BP was measured every year allowing calculation of variability of BP, expressed as s.d. and coefficient of variability (s.d./mean systolic BP) in 2157 patients. We found that systolic BP variability was associated with several CV risk factors: principally hypertension, age, and diabetes. Furthermore, all antihypertensives were positively associated with variability. Logistic regression analysis revealed that three factors were independent predictors of major CV event: coefficient of variability of systolic BP (OR=1.23 per s.d., 95% CI: 1.04-1.46, P=0.016), current smoking (OR=1.94, 95% CI: 1.03-3.66, P=0.039), and inclusion for cerebrovascular disease (OR=1.92, 95% CI: 1.29-2.87, P=0.001). Finally, when comparing logistic regression models characteristics without, and then with, inclusion of BP variability, there was a modest but statistically significant improvement (P=0.04). In conclusion, age, BP and diabetes were the major determinants of BP variability. Furthermore, BP variability has an independent prognostic value in the prediction of major CV events; but improvement in the prediction model was quite modest. This last finding is more in favor of BP variability acting as an integrator of CV risk than acting as a robust independent CV risk factor in this high-risk population.Journal of Human Hypertension advance online publication, 3 July 2014; doi:10.1038/jhh.2014.44.
    Journal of human hypertension. 07/2014;
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    ABSTRACT: To test the hypothesis that left-ventricular hypertrophy (LVH) is better associated with aortic, than brachial, 24-h average blood pressure (BP) in individuals with hypertension.
    Journal of hypertension. 07/2014;
  • J Blacher
    Journal des Maladies Vasculaires 06/2014; · 0.24 Impact Factor
  • Source
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    ABSTRACT: Aortic stiffness, assessed by carotid-to-femoral pulse wave velocity (PWV), often fails to predict cardiovascular (CV) risk and mortality in the very elderly. This may be due to the non-linear association between PWV and compliance or to blood pressure decrease in the frailest subjects. Total arterial compliance (C T) is the most relevant arterial property regarding CV function, compared to local or regional arterial stiffness. A new method for C T estimation, based on PWV, was recently proposed. We aimed to investigate the value of C T to predict all-cause mortality at the elderly. PWV was estimated in 279 elderly subjects (85.5 ± 7.0 years) who were followed up for a mean period of 12.8 ± 6.3 months. C T was estimated by the formula C T = k × PWV(-2); coefficient k is body-size dependent based on previous in silico simulations. Herein, k was adjusted for body mass index (BMI) with a 10 % change in BMI corresponding to almost 11 % change in k. For a reference BMI = 26.2 kg/m(2), k = 37. Survivors (n = 185) and non-survivors (n = 94) had similar PWV (14.2 ± 3.6 versus 14.9 ± 3.8 m/s, respectively; p = 0.139). In contrast, non-survivors had significantly lower C T than survivors (0.198 ± 0.128 versus 0.221 ± 0.1 mL/mmHg; p = 0.018). C T was a significant predictor of mortality (p = 0.022, odds ratio = 0.326), while PWV was not (p = 0.202), even after adjustment for gender, mean pressure and heart rate. Age was an independent determinant of C T (p = 0.016), but not of PWV. C T, estimated by a novel method, can predict all-cause mortality in the elderly. C T may be more sensitive arterial biomarker than PWV regarding CV risk assessment.
    Age 05/2014; · 6.28 Impact Factor
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    ABSTRACT: Predictive value of arterial stiffness in cardiovascular disease has been recognized for many decades. Carotid-femoral pulse wave velocity (cfPWV), as a noninvasive measurement, has been recommended as a gold standard of arterial stiffness, and we believe that this surrogate of arterial stiffness has been refined to the point that its utility in routine clinical practice need to be recommended. Considering the worldwide aging population and aging itself as a major cause of arterial stiffness, we would focus in this article, from a practical point of view, on cfPWV in the elderly, and review the current knowledge on the effect of arterial aging on cfPWV measurements, as well as the significance of its clinical application in the elderly.
    Journal of Hypertension 04/2014; · 4.22 Impact Factor
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    ABSTRACT: Tropical aortitis is a rare and poorly described aortic disease, sometimes confounded with Takayasu's disease, mainly in people from Africa. In this case report, the panaortic aneurysmal disease in a young woman from Haiti, first diagnosed after a work-up on renovascular hypertension, would appear to approach this particular arterial disease with no clinical, radiological or biological argument for an infectious etiology. The initially suspected diagnosis of Takayasu's disease had to be rethought because of the presence of several saccular aneurysms extending from the aortic arch to the infrarenal aorta, rarely described in Takayasu's aortitis. Expert opinions from vascular surgeons and clinicians tagged this aortic disease as similar to tropical aortitis which remained asymptomatic for more than a decade. Hypertension was managed with successful balloon angioplasty of the left renal artery stenosis and anti-hypertensive combination therapy. Surgical management of the extended aortic aneurysms was not proposed because of the stability and asymptomatic nature of the aneurysmal disease and the high risk of surgical morbidity and mortality. More than ten years after diagnosis, the course was marked with inaugural and sudden-onset chest pain concomitant with contained rupture of the descending thoracic aortic aneurysm. This case report underlines the persistent risk of aneurysmal rupture and the importance of an anatomopathological study for the diagnosis of complex aortic disease.
    Journal des Maladies Vasculaires 03/2014; · 0.24 Impact Factor
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    ABSTRACT: Experimental studies provided evidence about mechanisms by which cholesterol, especially high density lipoprotein cholesterol (HDL-C), could influence carcinogenesis, notably through antioxidant and anti-inflammatory properties. However, prospective studies that investigated the associations between specific lipid metabolism biomarkers and cancer risk provided inconsistent results. The objective was to investigate the prospective associations between total cholesterol (T-C), HDL-C, low density lipoprotein cholesterol, apolipoproteins A1 (apoA1) and B, and triglycerides and overall, breast and prostate cancer risk. Analyses were performed on 7,557 subjects of the Supplémentation en Vitamines et Minéraux Antioxydants Study, a nationwide French cohort study. Biomarkers of lipid metabolism were measured at baseline and analyzed regarding the risk of first primary incident cancer (N = 514 cases diagnosed during follow-up, 1994-2007), using Cox proportional hazards models. T-C was inversely associated with overall (HR1mmol/L increment = 0.91, 95 % CI 0.82-1.00; P = 0.04) and breast (HR1mmol/L increment = 0.83, 95 % CI 0.69-0.99; P = 0.04) cancer risk. HDL-C was also inversely associated with overall (HR1mmol/L increment = 0.61, 95 % CI 0.46-0.82; P = 0.0008) and breast (HR1mmol/L increment = 0.48, 95 % CI 0.28-0.83; P = 0.009) cancer risk. Consistently, apoA1 was inversely associated with overall (HR1g/L increment = 0.56, 95 % CI 0.39-0.82; P = 0.003) and breast (HR1g/L increment = 0.36, 95 % CI 0.18-0.73; P = 0.004) cancer risk. This prospective study suggests that pre-diagnostic serum levels of T-C, HDL-C and ApoA1 are associated with decreased overall and breast cancer risk. The confirmation of a role of cholesterol components in cancer development, by further large prospective and experimental studies, may have important implications in terms of public health, since cholesterol is already crucial in cardiovascular prevention.
    European Journal of Epidemiology 02/2014; · 5.12 Impact Factor
  • Culture Medicine and Psychiatry 02/2014; · 1.29 Impact Factor
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    ABSTRACT: Central blood pressure (cBP) and pulse pressure amplification (PPA) are receiving renewed interest with the increase in the availability of noninvasive techniques that enable its measurement. However, to date, there is no standardized protocol to validate their accuracy. Although invasive comparison seems intellectually ideal, it will soon raise technical and ethical issues with the growing number of devices to be validated. We proposed a modified ESH-IP2010 protocol for electronic brachial devices to validate noninvasively systolic cBP and pulse pressure amplification, and used it to compare the newly commercialized Centron cBP301 device with radial tonometry SphygmoCor. Radial tonometric SphygmoCor measurements were performed four times alternated with three Centron cBP301 measurements. Each Centron recording was compared with the most favourable SphygmoCor recordings performed immediately before or after and calibrated with Centron peripheral systolic and diastolic blood pressure measurements. Following protocol requirements, 33 individuals (21 men and 12 women) were recruited in the low, medium and high peripheral BP range. Systolic cBP varied from 88 to 188 and the difference between the devices was -0.33±3.28 mmHg (m±SD). It fell within the ESH-IP2010 pass requirements for the number of measurements within 5, 10 and 15 mmHg. The PPA varied from 1.13 to 2.09 and the difference between devices was -0.03±0.11, which showed good agreement for the PPA. The Centron cBP301 device was compared with the similarly calibrated SphygmoCor with a modified ESH-IP2010 protocol. It provided accurate measurements of systolic cBP and PPratio.
    Blood pressure monitoring 01/2014; · 1.62 Impact Factor
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    ABSTRACT: Hyperuricaemia is commonly found in subjects with cardiovascular disease, but its role as risk factor is very controversial. Although several studies reported serum uric acid as a marker of an underlying pathophysiological process, other studies hypothesis a potential causal link between serum uric acid and cardiovascular diseases. Some studies suggest that uric acid is biologically active and may have an atherogenesis role in development of cardiovascular diseases, although the mechanisms are not fully understood. Other studies have shown that uric acid can independently predict the development of some cardiovascular risk factors such as hypertension and metabolic syndrome, as well as myocardial infarction and stroke. The relations between serum uric acid and established cardiovascular risk factors are complex, and these latter could be considered as confounding factors. In this report, we review the inextricably link of serum uric acid to known cardiovascular risk factors, and we describe the possible mechanisms and potential causative role between serum uric acid and cardiovascular events in the general population, in subjects with cardiovascular risk factors and in those with pre-existing cardiovascular diseases. Limited information however is available concerning the impact of urate-lowering treatments on cardiovascular events, whereas only a positive therapeutic trial could give definite answers to the difficult problem of causality of uric acid in relation to cardiovascular risk. Thus, it is time to propose the design of a therapeutic trial, integrating cardiologists and rheumatologists, in order to further decrease cardiovascular risk.
    Joint, bone, spine: revue du rhumatisme 01/2014; · 2.25 Impact Factor
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    ABSTRACT: Tropical aortitis is a rare and poorly described aortic disease, sometimes confounded with Takayasu's disease, mainly in people from Africa. In this case report, the panaortic aneurysmal disease in a young woman from Haiti, first diagnosed after a work-up on renovascular hypertension, would appear to approach this particular arterial disease with no clinical, radiological or biological argument for an infectious etiology. The initially suspected diagnosis of Takayasu's disease had to be rethought because of the presence of several saccular aneurysms extending from the aortic arch to the infrarenal aorta, rarely described in Takayasu's aortitis. Expert opinions from vascular surgeons and clinicians tagged this aortic disease as similar to tropical aortitis which remained asymptomatic for more than a decade. Hypertension was managed with successful balloon angioplasty of the left renal artery stenosis and anti-hypertensive combination therapy. Surgical management of the extended aortic aneurysms was not proposed because of the stability and asymptomatic nature of the aneurysmal disease and the high risk of surgical morbidity and mortality. More than ten years after diagnosis, the course was marked with inaugural and sudden-onset chest pain concomitant with contained rupture of the descending thoracic aortic aneurysm. This case report underlines the persistent risk of aneurysmal rupture and the importance of an anatomopathological study for the diagnosis of complex aortic disease.
    Journal des Maladies Vasculaires 01/2014; · 0.24 Impact Factor
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    ABSTRACT: Four oscillometric devices, including the Omron M6 Comfort, Omron HEM-7420, Withings BP-800, and Polygreen KP-7670, designed for self-blood pressure measurement (SBPM) were evaluated according to the European Society of Hypertension (ESH) International Protocol Revision 2010 in four separate studies. The four devices measure brachial blood pressure (BP) using the oscillometric method. The Withings BP-800 has to be connected to an Apple® iOS device such as an iPhone®, iPad®, or iPod®. The ESH International Protocol Revision 2010 includes a total number of 33 subjects. The difference between observer and device BP values was calculated for each measure. Ninety-nine pairs of BP differences were classified into three categories (≤5 mmHg, ≤10 mmHg, ≤15 mmHg). The protocol procedures were followed precisely in each of the four studies. All four tested devices passed the validation process. The mean differences between the device and mercury readings were: -1.8±5.1 mmHg and -0.4±2.8 mmHg for systolic and diastolic BP, respectively, using the Omron M6 Comfort device; 2.5±4.6 mmHg and -1.2±4.3 mmHg for the Omron HEM-7420 device; -0.2±5.0 mmHg and 0.4±4.2 mmHg for the Withings BP-800 device; and 3.0±5.3 mmHg and 0.3±5.2 mmHg for the Polygreen KP-7670 device. Omron M6 Comfort, Omron HEM-7420, Withings BP-800, and Polygreen KP-7670 readings differing by less than 5 mmHg, 10 mmHg, and 15 mmHg fulfill the ESH International Protocol Revision 2010 requirements, and therefore are suitable for use by patients for SBPM, if used correctly.
    Vascular Health and Risk Management 01/2014; 10:33-44.
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    ABSTRACT: We aimed to investigate the association between baseline plasma fatty acids profile and the risk of future major cardiovascular events in patients with a history of ischaemic heart disease or ischemic stroke. Baseline plasma fatty acids as well as established cardiovascular risk factors were measured in 2,263 patients enrolled in the SUpplementation with FOLate, vitamins B-6 and B-12 and/or OMega-3 fatty acids randomized controlled trial. Incident major cardiovascular, cardiac and cerebrovascular events were ascertained during the 4.7 years of follow up. Hazard ratios were obtained from Cox proportional hazards models after adjustment for cardiovascular risk factors. During the follow-up, 154, 379 and 84 patients had major cardiovascular, cardiac and cerebrovascular events respectively. Upon adjustment for gender, initial event, baseline age and BMI, the risk of developing a major cardiovascular event decreased significantly in successive quartiles of arachidonic acid (Ptrend<0.002), total omega 3 polyunsaturated fatty acids (Ptrend<0.03), docosapentaenoic acid (Ptrend<0.019), docosahexaenoic acid (Ptrend<0.004), eicosapentaenoic acid + docosahexaenoic acid (Ptrend<0.03) and eicosapentaenoic acid + docosapentaenoic acid + docosahexaenoic acid (Ptrend<0.02). This inverse association was borderline significant with increased quartiles of stearidonic acid (Ptrend<0.06). In the full model, only stearidonic acid remained inversely associated with the risk of developing a major cardiovascular event (Ptrend<0.035), a cardiac event (Ptrend<0.016) or a cerebrovascular event (Ptrend<0.014), while arachidonic acid was inversely associated with the risk a cerebrovascular event (Ptrend<0.033). The inverse association of long chain omega 3 polyunsaturated fatty acids with recurrence of Cardiovascular diseases was mainly driven by well-known cardiovascular risk factors. Controlled-Trials.com ISRCTN41926726.
    PLoS ONE 01/2014; 9(4):e92548. · 3.53 Impact Factor
  • J. Blacher
    Journal des Maladies Vasculaires 01/2014; · 0.24 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: During year 2013, several recommendations for the management of hypertension were published: recommendations of the French and European Societies of Hypertension and two recommendations from the USA, those from the ACC/AHA/CDC groups and those from the JNC 8. The recommendations of the JNC 8 are not, strictly speaking, the recommendations of JNC 8, since they are neither endorsed by their sponsor: the National Heart, Lung and Blood Institute (NHLBI), nor by any other supervisor. They only commit their authors. Just before the publication of the JNC 8, “competing” recommendations, jointly produced by the AHA, ACC and CDC, were jointly published in Hypertension and in the Journal of American College of Cardiology, with different preferred treatment choices and significantly different algorithms. The authors of the JNC 8 have only included in their literature review randomized controlled trials of sufficient power. Randomized controlled trials are clearly the gold standard of comparative trials in medicine, but can they summarize all the knowledge? The authors of the JNC 8 propose in subjects over 60, a therapeutic threshold and target blood pressure of 150/90 mmHg. This original threshold is poorly supported by the evidence and possibly increases the risk of physicians’ inertia. The issue of experts’ conflicts of interest has greatly changed the rules of drafting guidelines for clinical practice. Knowing that the vast majority of clinical trials is promoted by drug industry, could guidelines be strictly without any conflict of interest? Finally, recommendations for practice should have as primary, if not unique, objective to improve the practice.
    La Presse Médicale. 01/2014;

Publication Stats

7k Citations
860.89 Total Impact Points

Institutions

  • 2007–2014
    • Université Paris Descartes
      • Faculté de Médecine
      Lutetia Parisorum, Île-de-France, France
    • Alexandra Regional General Hospital
      Athínai, Attica, Greece
  • 2006–2014
    • Université René Descartes - Paris 5
      • • Faculty of medicine
      • • Faculté de Médecine
      Lutetia Parisorum, Île-de-France, France
    • Unilever
      Londinium, England, United Kingdom
  • 2013
    • University of Bologna
      Bolonia, Emilia-Romagna, Italy
  • 2012–2013
    • Tongji Medical University
      • Department of Cardiology
      Shanghai, Shanghai Shi, China
  • 2009–2013
    • Université Paris 13 Nord
      • Unité de recherche en épidémiologie nutritonnelle - UREN (UMR 557) Inserm - INRA - CNAM
      Île-de-France, France
    • National and Kapodistrian University of Athens
      • • Faculty of Medicine
      • • Department of Medicine
      Athínai, Attica, Greece
    • Νοσοκομείο Σωτηρία
      Athínai, Attica, Greece
    • Maastricht University
      • Farmacologie
      Maastricht, Provincie Limburg, Netherlands
  • 2007–2012
    • Assistance Publique – Hôpitaux de Paris
      Lutetia Parisorum, Île-de-France, France
  • 2005–2012
    • Hôtel-Dieu de Paris – Hôpitaux universitaires Paris Centre
      Lutetia Parisorum, Île-de-France, France
    • French Institute of Health and Medical Research
      • Unit of Nutritional Epidemiology
      Paris, Ile-de-France, France
    • Hôpital Paris Saint Joseph
      Lutetia Parisorum, Île-de-France, France
  • 2011
    • Hôpital d'Instruction des Armées Sainte-Anne
      Toulon-sur-Mer, Provence-Alpes-Côte d'Azur, France
  • 2010
    • Hotel Dieu Hospital
      Kingston, Ontario, Canada
    • Hôpital "René-Muret - Bigottini" – Hôpitaux Universitaires Paris-Seine-Saint-Denis
      Île-de-France, France
  • 1999–2009
    • Unité Inserm U1077
      Caen, Lower Normandy, France
  • 2008
    • Pierre and Marie Curie University - Paris 6
      Lutetia Parisorum, Île-de-France, France
  • 2004–2006
    • Institut Pasteur de Lille
      Lille, Nord-Pas-de-Calais, France
    • University Medical Center – Rizk Hospital
      Beyrouth, Beyrouth, Lebanon
    • Centre Hospitalier Universitaire de Montpellier
      Montpelhièr, Languedoc-Roussillon, France
    • Conservatoire National des Arts et Métiers
      • Institut National des Sciences et Techniques de la Documentation
      Lutetia Parisorum, Île-de-France, France
  • 2003
    • Centre Hospitalier Sainte Anne
      Lutetia Parisorum, Île-de-France, France
  • 2002
    • Institute Mutualiste Montsouris
      Lutetia Parisorum, Île-de-France, France
    • Centre D'Investigations Préventives Et Cliniques
      Lutetia Parisorum, Île-de-France, France
  • 1998
    • University of Leuven
      Louvain, Flanders, Belgium