Bordeaux School of Public Health

Background/Objectives: Very few studies describe the various feelings experienced in the emergency department (ED). Our study describes the pain, stress, and negative and positive emotions experienced by patients admitted to the ED in relation to age, gender, and reason for ED admission. Methods: Patients admitted to the ED of seven French hospitals were surveyed as part of the randomised multicentre study SOFTER IV (n = 2846). They reported the intensity of their pain on a numerical rating scale of 0 to 10, the intensity of their stress on an equivalent scale, and their emotions on a five-point rating scale using an adapted version of the Geneva Emotion Wheel proposed by Scherer, based on eight core emotions: fear, anger, regret, sadness, relief, interest, joy, and satisfaction. Results: Patients reported an average pain rating of 4.5 (SD = 3.0) and an average stress rating of 3.4 (SD = 3.1). Forty-six percent reported at least one strong negative emotion, and the two most frequently reported were fear and sadness. Forty-seven percent of patients described feeling at least one strong positive emotion, and the two most frequently reported were interest and relief. Pain was significantly higher among female patients under 60 admitted for injury. Stress was significantly higher among female patients under 60 admitted for illness. Emotions of negative valency were significantly higher among women admitted for injury. Emotions of positive valency were significantly higher among men over 60 admitted for illness. Conclusions: Experiences of pain, stress, and emotions have a strong presence in the ED. The reporting of these feelings varies depending on age, gender, and reason for ED admission.

Background Clonorchiasis is an important foodborne parasitic disease in China caused by Clonorchis sinensis . Accurate and rapid diagnosis of this disease is vital for treatment and control. Traditional fecal examination methods, such as the Kato-Katz (KK) method, are labor-intensive, time-consuming, and have limited acceptance. The FA280, an advanced automated fecal analyzer, increases efficiency while significantly reducing labor load. This study aims to evaluate its performance, applicability, and scalability in clonorchiasis diagnosis to explore its potential application in the future. Methods A mixed-methods study integrating both quantitative and qualitative approaches was conducted. The quantitative component consisted of a cross-sectional survey in Xinhui District, Guangdong, China, to evaluate the diagnostic performance of the FA280. The positive rate and agreement between the FA280 and the KK method were evaluated using McNemar’s test. Additionally, Pearson’s Chi-square test was used to analyze the consistency of positive results between the two methods across various eggs per gram (EPG) groups under different cut-off values. The qualitative component included semi-structured individual interviews with medical staff and institutional administrators to examine the FA280’s applicability and potential for broader adoption, with thematic analysis of the data. Results In the quantitative study of 1000 participants, both the FA280 and KK methods detected clonorchiasis with a positive rate of 10.0%, achieving 96.8% agreement and showing no significant difference ( P > 0.999). The kappa value was 0.82 (95% confidence interval: 0.76–0.88), indicating a strong agreement between the methods. The agreement rate for positive results between the two methods was significantly higher in the high infection intensity group compared to the low infection intensity group ( P < 0.05). The qualitative study, which involved interviews with three medical staff and two administrators revealed that the FA280 outperformed the KK method in testing procedures, detection results, and user acceptance. The benefits, challenges, and suggestions of FA280 promotion were also emphasized. Conclusions This study demonstrated the FA280’s application value in clonorchiasis diagnosis by assessing its detection performance, applicability, and scalability. These findings contribute to the future prevention and control of the disease. Graphical Abstract

Widespread vaccine acceptance is crucial, particularly with emerging infectious diseases like COVID-19. This study assesses COVID-19 vaccine willingness and its influencing factors among healthcare workers (HCWs) and non-HCWs in Lebanon. In November 2020, a web-based survey was conducted among Lebanese adults using snowball sampling. Participants completed an anonymous Arabic questionnaire covering sociodemographics, health status, vaccine intentions, and the Health Belief Model. Multivariable logistic regression was performed to identify factors associated with COVID-19 vaccine acceptance in HCWs and non-HCWs. Of 2802 participants, 51.5% intended to receive the COVID-19 vaccine. HCWs (65.8%) were more willing than non-HCWs (47%). Factors positively linked to acceptance included older age, marital status, urban residence, recent influenza vaccination, heightened susceptibility and benefit perception, concerns about vaccine access, and health authority recommendations. Conversely, vaccine refusal history, safety concerns, and side effect worries reduced intention. Among non-HCWs, female gender, religiosity, and manufacturer reliability concerns, negatively affected acceptance. Good knowledge, public vaccine intake, and self-motivation were positive factors. HCWs were unaffected by these factors. Addressing the concerns and misconceptions surrounding the COVID-19 vaccine, especially among non-HCWs, while promoting the benefits of vaccination, is essential to enhance COVID-19 vaccine acceptance in Lebanon to achieve broader immunization coverage and pandemic control. in the community.

rVSVΔG-ZEBOV-GP and Ad26.ZEBOV, MVA-BN-Filo are WHO-prequalified vaccination regimens against Ebola virus disease (EVD). Challenges associated with measuring long-term clinical protection warrant the evaluation of immune response kinetics after vaccination. Data from a large phase 2 randomized double-blind clinical trial (PREVAC) were used to evaluate waning of anti-Ebola virus (EBOV) glycoprotein (GP1,2) antibody concentrations after rVSVΔG-ZEBOV-GP or Ad26.ZEBOV, MVA-BN-Filo vaccination with linear mixed-effect regression models. After a post-vaccination peak, each vaccination strategy was associated with a decrease of anti-EBOV GP1,2 antibody concentrations with distinct kinetics, highlighting a less-rapid decline in antibody levels after vaccination by rVSVΔG-ZEBOV-GP. One year after administration of the vaccine, antibody concentrations were higher in children compared to adults for both vaccines, although with different effect sizes: 1.74-fold higher concentrations (95% confidence interval [CI] [1.48; 2.02]) for children 12–17 years old to 3.10-fold higher concentrations (95% CI [2.58; 3.69]) for those 1–4 years old compared to adults for Ad26.ZEBOV, MVA-BN-Filo versus 1.36-fold (95% CI [1.12; 1.61]) to 1.41-fold (95% CI [1.21; 1.62]) higher than these values for adults, with relatively small changes from one age category of children to another, for rVSVΔG-ZEBOV-GP. Antibody concentrations also differed according to geographical location, pre-vaccination antibody concentration, and sex. In combination with knowledge on memory response, characterization of the major determinants of immune response durability of both vaccinations may guide future EVD control protocols. Trial registration: ClinicalTrials.gov identifier: NCT02876328.

Due to methodological reasons, the X-chromosome has not been featured in the major genome-wide association studies on Alzheimer’s Disease (AD). To address this and better characterize the genetic landscape of AD, we performed an in-depth X-Chromosome-Wide Association Study (XWAS) in 115,841 AD cases or AD proxy cases, including 52,214 clinically-diagnosed AD cases, and 613,671 controls. We considered three approaches to account for the different X-chromosome inactivation (XCI) states in females, i.e. random XCI, skewed XCI, and escape XCI. We did not detect any genome-wide significant signals (P ≤ 5 × 10⁻⁸) but identified seven X-chromosome-wide significant loci (P ≤ 1.6 × 10⁻⁶). The index variants were common for the Xp22.32, FRMPD4, DMD and Xq25 loci, and rare for the WNK3, PJA1, and DACH2 loci. Overall, this well-powered XWAS found no genetic risk factors for AD on the non-pseudoautosomal region of the X-chromosome, but it identified suggestive signals warranting further investigations.

Objectives To investigate factors associated with dermatomyositis (DM) complete clinical response and overall survival with a focus on the use of immunosuppressive therapies in patients with cancer-associated DM. Methods We performed a multicentre, retrospective cohort study. Multivariable survival analyses used a Cox model with time-dependent covariates and adjustments with inverse probability censoring weighting. Results We included 73 patients with cancer-associated DM. Median follow-up was 3.92 years. Overall, 40 (54.8%) patients achieved cancer remission, with DM complete clinical response in 28/40 (70.0%). DM complete clinical response was associated with cancer remission (hazard ratio [HR] 2.46, 95%CI [1.13–5.32]) and younger age (HR 0.68, 95%CI [0.49–0.95]). Risk of mortality was associated with sustained cancer activity (HR 12.93, 95% CI [2.42–69.25]), male sex (HR 2.82, 95% CI [1.19–6.70]), and older age (HR 1.86, 95% CI [1.26–2.79]) but not sustained DM activity (HR 0.40, 95%CI [0.13–1.26]). Oral corticosteroids use was a protective factor only on univariate analysis (HR 0.18, 95% CI [0.08–0.42]). Conclusion This study provides strong evidence of a significant association between the evolutions of DM and cancer, both in terms of overall survival and DM complete clinical response. Immunosuppressive treatments for DM were not significantly associated with mortality. Trial registration ClinicalTrials.gov, NCT04637672.

White matter hyperintensities index structural abnormalities in the cerebral white matter, including axonal damage. The latter may promote atrophy of the cerebral cortex, a key feature of dementia. Here, we report a study of 51,065 individuals from 10 cohorts demonstrating that higher white matter hyperintensity volume associates with lower cortical thickness. The meta-GWAS of white matter hyperintensities-associated cortical ‘atrophy’ identifies 20 genome-wide significant loci, and enrichment in genes specific to vascular cell types, astrocytes, and oligodendrocytes. White matter hyperintensities-associated cortical ‘atrophy’ showed positive genetic correlations with vascular-risk traits and plasma biomarkers of neurodegeneration, and negative genetic correlations with cognitive functioning. 15 of the 20 loci regulated the expression of 54 genes in the cerebral cortex that, together with their co-expressed genes, were enriched in biological processes of axonal cytoskeleton and intracellular transport. The white matter hyperintensities-cortical thickness associations were most pronounced in cortical regions with higher expression of genes specific to excitatory neurons with long-range axons traversing through the white matter. The meta-GWAS-based polygenic risk score predicts vascular and all-cause dementia in an independent sample of 500,348 individuals. Thus, the genetics of white matter hyperintensities-related cortical atrophy involves vascular and neuronal processes and increases dementia risk.

Context: Surgical site infection (SSI) is responsible for significant morbidity, prolonged hospital stays, and increased costs. Infectious endocarditis (IE) is a rare but serious complication of bacteremia, particularly that resulting from Staphylococcus aureus SSI. The VIRSTA score predicts the risk of IE and determines the priority of transthoracic echocardiography (TTE) in patients with S. aureus bacteremia. The aim of the study was to (1) assess the performance of the VIRSTA score and (2) determine the usefulness of TTE in S. aureus bacteremia related to spinal SSI. Materials and Methods: We carried out a retrospective study of consecutive patients with spinal SSI and S. aureus bacteremia at two university hospitals in France (Bordeaux and Tours) from January 2009 to January 2023. We collected the patients' clinical and surgical characteristics at baseline, VIRSTA score items, TTE results, and medicosurgical management. The associations of these parameters with IE were assessed using the chi-square test and logistic regression models. Results: Of 82 patients with spinal SSI and S. aureus bacteremia, only 1 (1.21%) developed IE. Thirteen patients did not benefit from TTE during hospitalization and were considered free of IE after clinical follow-up. Diabetes mellitus (p < 0.04) and the presence of severe sepsis or septic shock (p < 0.03) were significantly associated with the presence of IE in this population. Conclusions: Incidence of IE in patients with spinal SSI and S. aureus bacteremia is low. The VIRSTA score has high sensitivity but is not accurate for identifying patients at high risk for IE and systematic performance of TTE is complex and not useful in this setting. Level of Evidence: IV.

Background Assessing the potential increased risk of viral rebound (VR) in migrants requires adequate control for sex and acquisition risk groups. Methods People living with HIV1, enrolled in the ANRS CO4‐French Hospital Database on HIV, who achieved virological suppression with antiretroviral therapy (ART) initiated between 2006 and 2016 were included. We first compared the risk of VR, with loss to follow‐up and death considered as competing events, across origin among the HIV acquisition groups, then across acquisition groups among the different origins, and finally across modality of a variable combining sex, acquisition group, and origin. Models were adjusted for clinical and biological confounding factors. Results We included 21 571 French natives (FRA), 10 148 migrants from sub‐Saharan Africa (SSA), 1137 migrants from the non‐French West Indies (NFWI), and 4205 other migrants (OTHER). The 5‐year probability of VR was 19% (95% confidence interval [CI] 19–20) overall, 15% in FRA, 21% in OTHER, 26% in SSA, and 34% in NFWI (p < 0.0001). It was 14% in men who have sex with men (MSM), 23% in heterosexual men, and 23% in women (p < 0.0001). After adjustment, all acquisition groups had a higher risk of VR than MSM from FRA, with men and women from NFWI having the highest risk (adjusted hazard ratio [aHR] 2.46; 95% CI 2.12–2.86 and aHR 2.59; 95% CI 2.20–3.04, respectively). Within each acquisition group, all groups of origin had a higher risk of VR than FRA. Within each region of origin, except the NFWI, heterosexual men had a higher risk of VR than MSM. Conclusions After accounting for sex and acquisition group, migration, especially from NFWI, remains prognostic of VR.

Because 20-30% of patients with sepsis deteriorate to critical illness, biomarkers that provide accurate early prognosis may identify which patients need more intensive treatment versus safe early discharge. The objective was to test the performance of sVEGFR2, suPAR and PCT, alone or combined with clinical signs and symptoms, for the prediction of clinical deterioration. This prospective observational study enrolled patients with suspected infection who met SIRS criteria without organ dysfunction (delta SOFA <2 from baseline) from 16 emergency departments. The primary endpoint was clinical deterioration (increased SOFA score ≥2 points, new or increased organ support, or death) within 72 hours of enrollment. Diagnosis and classification of infection status were adjudicated. 724 patients were enrolled, (54% men, median age 55 [38-70] y-o). Infection origin was abdominopelvic (21%), skin and soft tissues (17%), urinary (16%) and pulmonary (15%). 176 (24%) patients deteriorated, with a 28-day mortality of 1.4%. They had lower sVEGFR2 level (6.17 [5.00-7.40] vs 6.52 [5.40-7.84], p=0.024), higher circulating suPAR (5.25 [3.86-7.50] vs 4.18 [3.16-5.68], p<0.001) and higher PCT level (0.32 [0.08-1.80] vs 0.18 [0.05-0.98], p=0.004). suPAR demonstrated superior performance (AUC=0.65 [0.60-0.70]), compared to other biomarkers (PCT, AUC=0.57 [0.52-0.62] and sVEGFR2, AUC=0.58 [0.53-0.64]). Maximum accuracy was achieved from the combination of clinical information, sVEGFR2 and suPAR, yielding an AUC of 0.74 [0.69-0.78] and NPV 0.90 [0.88-0.94]. sVEGFR2 and suPAR were insufficiently accurate to rule out clinical deterioration. Panels of biomarkers will likely be needed to capture the heterogeneous mechanistic pathways involved in sepsis-related organ failure.

Purpose This study aimed to document utility values and the Visual Analog Scale (VAS) with the 5-level version of the EQ-5D questionnaire in a large sample of patients with inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC). Methods QALY-MICI was a cross-sectional survey across three sources in France. Data were collected between 2019 and 2022 for patients 18 and over. The EQ-5D-5 L, the EQ-VAS, the Short Inflammatory Bowel Disease Questionnaire (SIBDQ), the Harvey-Bradshaw Index (HBI) for CD, and the Walmsley Index for UC (SCCAI) were collected. Results A total of 2,841 patients aged over 18 were recruited (1785 with CD, 1056 with UC). The mean age was 40.2 (SD 14.3). The time since diagnosis was 6 years and over for 61.9% of patients. The most impacted dimensions were usual activities, anxiety/ depression, and pain/ discomfort. The mean utility value was 0.863 (SD 0.172) versus 0.905 (SD 0.158) in the French population (p = 0.007). The mean VAS value was 68 (SD 19.2) versus 73.4 (SD 22.2) in the general population (p = 0.016). Utility values and VAS were similar for CD and UC and higher for men. There was a strong positive correlation between utility values, the VAS, and the SIBDQ score, and a negative correlation between the HBI and the SCCAI. The SIBDQ score and disease activity were the main predictors of utility and VAS. Conclusion The QALY-MICI is, to our knowledge, the first study documenting utility values and VAS using the EQ-5D-5 L questionnaire on a large sample, with a comparison to the general population.

Objectives To compare two strategies—a hydrocortisone replacement strategy and a prednisone tapering strategy—for their success in glucocorticoid discontinuation in patients with rheumatoid arthritis (RA) with low disease activity (LDA). Methods The Strategies for glucocorticoid TApering in Rheumatoid arthritis (STAR) study was a double-blind, double-placebo randomised controlled trial including patients with RA receiving a stable dose of glucocorticoid 5 mg/day for ≥3 months and were in LDA for ≥3 months. Patients were randomly assigned in a 1:1 ratio to either replace prednisone with 20 mg/day of hydrocortisone for 3 months, then reduce to 10 mg/day for 3 months before discontinuation or to taper prednisone by 1 mg/day every month until complete discontinuation, contingent on maintaining LDA. The primary outcome was the percentage of patients achieving glucocorticoid discontinuation at 12 months. Other secondary outcomes were proportion of flares, need for additional glucocorticoid use, disease activity, patient-reported outcomes and the results of adrenocorticotropic hormone (ACTH) stimulation tests. Results Of the 102 patients randomised in the trial (mean age 62.4 years, 70.6% females), 53 had hydrocortisone replacement and 49 tapered prednisone. At 12 months, 29 patients (55%) in the hydrocortisone replacement group and 23 patients (47%) in the prednisone tapering group achieved glucocorticoid discontinuation (p=0.4). No difference was observed between groups in the secondary outcomes. No cases of acute adrenal insufficiency were observed; however, 17 patients still had an abnormal ACTH stimulation test at 12 months, with no differences between arms. Conclusion A hydrocortisone replacement strategy was not superior to a prednisone tapering strategy for achieving glucocorticoid discontinuation success in patients with RA in LDA. Trial registration number NCT02997605 .

Shock is a life-threatening condition. This study evaluated if sublingual microcirculatory perfusion on admission is associated with 30-day mortality in older intensive care unit (ICU) shock patients. This trial prospectively recruited ICU patients (≥ 80 years old) with arterial lactate above 2 mmol/L, requiring vasopressors despite adequate fluid resuscitation, regardless of shock cause. All patients received sequential sublingual measurements on ICU admission (± 4 h) and 24 (± 4) hours later. The primary endpoint was 30-day mortality. From September 4th, 2022, to May 30th, 2023, 271 patients were screened, and 44 included. Patients were categorized based on the median percentage of perfused small vessels (sPPV) into those with impaired and sustained microcirculation. 71% of videos were of good or acceptable quality without safety issues. Patients with impaired microcirculation had significantly shorter ICU and hospital stays (p = 0.015 and p = 0.019) and higher 30-day mortality (90.0% vs. 62.5%, p = 0.036). Cox regression confirmed the independent association of impaired microcirculation with 30-day mortality (adjusted hazard ratio 3.245 (95% CI 1.178 to 8.943, p = 0.023). Measuring sublingual microcirculation in critically ill older patients with shock on ICU admission is safe, feasible, and provides independent prognostic information about outcomes. Trial registration NCT04169204.

This review investigates the effectiveness of utilizing foreign physicians or International Medical Graduates to alleviate medical shortages in rural and underserved areas of developed countries. Conducted in February 2024, this systematic review follows PRISMA 2020 guidelines, analysing 15 English-language studies from the United States, Canada, Australia, and New Zealand. The focus is on comparing physicians with international graduation to national graduates in rural and underserved contexts. Results reveal diverse trends across countries: in the United States, national graduates are generally more represented in rural areas, while foreign physicians are more prevalent in Health Professional Shortage Areas. In Canada, foreign graduates are more common in rural areas, varying by province. Australia and New Zealand show foreign physicians practicing more in rural areas than national counterparts. This study underscores significant reliance on foreign physicians to mitigate rural healthcare disparities. While this strategy partially addresses immediate shortages, long-term effectiveness is uncertain due to retention and integration challenges. Future policies should focus on sustainable solutions for equitable healthcare access and physicians’ retention in underserved areas. This review emphasizes also the need for Europe-specific studies and further evaluation of policy effectiveness.