B Khoshnood

New index of social deprivation during pregnancy: results from a national study in France.

Objectives To identify precariousness markers in pregnant women that differ from the usual socioeconomic variables. Methods Data were obtained from the National Perinatal Survey, a representative sample of women giving birth in France in 2010. From six indicators of social vulnerability, four were selected by multiple correspondence analysis. The first axis of this analysis was used, characterised by the following contributory variables: receiving RSA (Revenu de Solidarité Active) allowance; benefitting from the CMU (Couverture Maladie Universelle) system (French social security) or not being insured; not living in own accommodation; and not living with a partner. These four variables were summed to create a deprivation index. Results This index was strongly associated with social maternal characteristics and correctly identified women who were socially vulnerable. Furthermore, it was highly related to the psychosocial context, access to care, behaviours during pregnancy, and pregnancy outcomes. These associations remained significant after adjustment for social variables: compared with no deprivation (no factors), a high level of deprivation (≥3 factors) was associated with late prenatal care (OR 5.8, 95% CI 4.6 to 7.2) and small for gestational age (OR 1.5, 95% CI 1.1 to 1.9). Conclusions This index of social deprivation was associated with health issues and behaviours during pregnancy, even after adjustment for social variables, revealing a dimension not measured by the usual variables. Moreover, it is simple to use and easily reproducible.

Cochran's Q test was useful to assess heterogeneity in likelihood ratios in studies of diagnostic accuracy

OBJECTIVESnEmpirical evaluations have demonstrated that diagnostic accuracy frequently shows significant heterogeneity between subgroups of patients within a study. We propose to use Cochrans Q test to assess heterogeneity in diagnostic likelihood ratios (LRs).nnnSTUDY DESIGN AND SETTINGnWe reanalyzed published data of six articles that showed within-study heterogeneity in diagnostic accuracy. We used the Q test to assess heterogeneity in LRs and compared the results of the Q test with those obtained using another method for stratified analysis of LRs, based on subgroup confidence intervals. We also studied the behavior of the Q test using hypothetical data.nnnRESULTSnThe Q test detected significant heterogeneity in LRs in all six example data sets. The Q test detected significant heterogeneity in LRs more frequently than the confidence interval approach (38% vs. 20%). When applied to hypothetical data, the Q test would be able to detect relatively small variations in LRs, of about a twofold increase, in a study including 300 participants.nnnCONCLUSIONnReanalysis of published data using the Q test can be easily performed to assess heterogeneity in diagnostic LRs between subgroups of patients, potentially providing important information to clinicians who base their decisions on published LRs.

Assessing sociodemographic differences (or lack thereof) in prenatal diagnosis of congenital heart defects: a population-based study

Objectives Our main objective was to assess sociodemographic differences in the probability of prenatal diagnosis of congenital heart defects (CHD); we also looked at differences in termination of pregnancy for fetal anomaly (TOPFA). Design Prospective cohort observational study. Setting Population-based cohort of CHD (live births, TOPFA, fetal deaths) born to women residing in the Greater Paris area (Paris and its surrounding suburbs, N=317u2005538 total births). Participants 2867 cases of CHD, including 2348 (82%) live births, 466 (16%) TOPFA and 53 (2%) fetal deaths. Primary and secondary outcome measures Differences in the probability of prenatal diagnosis by maternal occupation, geographic origin and place of residence; differences in the probability of TOPFA. Results 29.1% (95% CI 27.5% to 30.8%) of all CHD were prenatally diagnosed. Probability of prenatal diagnosis was similar by maternal occupation, geographic origin and place of residence. In contrast, there were substantial differences in the probability of TOPFA by maternal geographic origin; differences by maternal occupation and place of residence were generally smaller and not statistically significant. Conclusions Our findings suggest that an appropriate health system organisation aimed at providing universal, reimbursed specialised services to all women can provide comparable access to prenatal diagnosis for all sociodemographic groups. In contrast, we found substantial differences in TOPFA for women of different geographic origins, which may reflect womens preferences that should be respected, but that can nonetheless lead to the situation where families with fewer resources will be disproportionately responsible for care of newborns with more severe forms of CHD.

Symptomatic Management of Fever in Children: A National Survey of Healthcare Professionals’ Practices in France

Despite the production and dissemination of recommendations related to managing fever in children, this symptom saturates the practices of primary healthcare professionals (HPs). Data on parent practices related to fever are available, but data on HPs’ practices are limited. We studied HPs’ practices, determinants of practices and concordance with recommendations in France. We conducted a national cross-sectional observational study between 2007 and 2008 among French general practitioners, primary care pediatricians and pharmacists. HPs were asked to include 5 consecutive patients aged 1 month to 12 years with acute fever. HPs completed a questionnaire about their practices for the current fever episode. We used a multilevel logistic regression model to assess the joint effects of patient- and HP-level variables associated with this behavior. In all, 1,534 HPs (participation rate 13%) included 6,596 children (mean age 3.7 ± 2.7 years). Physicians measured the temperature of 40% of children. Primary HPs recommended drug treatment for 84% of children (including monotherapy for 92%) and physical treatment for 62% (including all recommended physical treatments for 7%). HPs gave written advice or a pamphlet for 13% of children. Significant practice variations were associated with characteristics of the child (age, fever level and diagnosis) and HP (profession and experience). In France, despite the production and dissemination of national recommendations for managing fever in children, primary HPs’ observed practices differed greatly from current recommendations, which suggests potential targets for continuing medical education.

Prévalence et diagnostic prénatal des malformations en population parisienne

OBJECTIVESnTo assess overall and malformation-specific trends in the prevalence, prenatal diagnosis and pregnancy termination of congenital malformations in the Parisian population.nnnMETHODSnWe used data from the Paris Registry of Congenital Malformations, which includes all births and pregnancy terminations with structural birth defects or chromosomal anomalies. Data on total and live birth prevalence were available for the period 1981-2000 and for prenatal diagnosis and pregnancy terminations for 1983-2000. Twenty malformations were selected for malformation-specific analyses due to their higher frequency and consistent definitions in different classification systems.nnnRESULTSnFor the period 1981-2000, the overall total prevalence of malformations was 3.2%. Prenatal diagnosis rates consistently increased from 16.2% (95% CI, 13.8-18.6) of cases with malformation in 1983 to 69.1% (95% CI, 66.7-71.5) in 2000. Pregnancy terminations increased from 8.8% (95% CI, 7.0-10.8) of cases with malformation in 1983 to 30.1% (95% CI, 27.7-32.6) in 2000.nnnCONCLUSIONnRegistries of congenital malformations provide population-based data on the prevalence of malformations and their associations with other anomalies. Registry-based data can also be used to evaluate the impact of prenatal testing policies for congenital malformations.Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 34 - N° 1-C1 - p. 8-16

Preterm Birth (PTB) and Congenital Heart Defects (CHD): A Population-Based Study

Background and aims: PTB and CHD are the two main causes of mortality, morbidity and disability of perinatal origin. There are little population-based data on the relation between CHD and PTB. The objective of this study was to estimate the prevalence of prematurity in newborns with CHD and to study specific associations between subcategories of CHD and PTB.Methods: We used data from the EPICARD study, a population-based cohort study of CHD in France, including 2349 livebirths with CHD. We used an anatomic and clinical classification of CHD based on the International Paediatric and Congenital Cardiac Code to categorise CHD into ten groups. Data on PTB from the French National Perinatal Survey were used to compare PTB in EPICARD to that of the general population.Results: 15% (95%CI, 13.6-16.5) of the newborns with CHD were PTB and the odds of PTB was more than two fold higher than for general population (OR 2.3 95%CI, 1.8-2.8). The higher risk of PTB, and particulary very PTB (< 32 weeks), associated with CHD persisted after exclusion of cases associated with chromosomal anomalies and/or non-cardiac defects and adjustement for maternal age, sociodemographic characteristics and diabetes. There were wide variations in PTB across the ten groups examined.Conclusion: In this population-based study, the risk of PTB and particulary very PTB was substancially higher for newborn with CHD. Risk of PTB varied highly for subcategories of CHD and the specific associations oberved may be helpful for generating hypotheses about the developemental links between CHD and PTB.

Enduring large use of acetaminophen suppositories for fever management in children: a national survey of French parents and healthcare professionals’ practices

AbstractThe pharmacological specificities of the rectal formulation of acetaminophen led to a debate on its appropriateness for managing fever in children, but few data are available on the formulation’s current use and determinants of use. In a national cross-sectional study between 2007 and 2008, healthcare professionals were asked to include five consecutive patients with acute fever. Among the 6255 children (mean age 4.0xa0yearsu2009±u20092.8 SD) who received acetaminophen given by parents or prescribed/recommended by healthcare professionals, determinants of suppository use were studied by multilevel models. A suppository was given by 27xa0% of parents and prescribed/recommended by 19xa0% of healthcare professionals, by 24 and 16xa0%, respectively, for children 2 to 5xa0years old, and by 13 and 8xa0%, respectively, for those 6 to 12xa0years old. Among children who received suppositories from parents and healthcare professionals, 83 and 84xa0%, respectively, did not vomit. Suppository use was independently associated with several patient- and healthcare professional-level characteristics: young age of children, presence of vomiting, or lack of diarrhea.n Conclusion: We report an enduring large use of suppositories in France for the symptomatic management of fever in children, including in non-vomiting and/or older children. The rational for such use should be questioned.What is Known:• The pharmacological specificities of the rectal formulation of acetaminophen have led to a debate on its appropriateness for managing fever in children. Few data are available on the formulation’s current use and determinants of the use.What is New:• In a national cross-sectional study, we observed a large use of suppositories in France for symptomatic management of fever in children. Suppositories were frequently used for the youngest children but also for older and/or non-vomiting children.

Relation between the quality of the ultrasound image acquisition and the precision of the measurement of the crown-rump length in the late first trimester: what are the consequences?

OBJECTIVEnTo assess the extent to which the distribution of crown-rump length (CRL) values may be correlated with different criteria for the quality of the CRL images.nnnSTUDY DESIGNnThis is a retrospective analysis of a series of 977 CRL images, by two independent observers, for the presence or the absence of 14 quality hallmarks. Inter-observer agreement for the hallmarks was assessed by the proportion of agreement and Cohens kappa. The association between the quantiles of the CRL distribution and the presence or absence of the 14 quality hallmarks was modeled using quantile regression.nnnRESULTSnThe overall inter-observer agreement across the 14 hallmarks was 91.7%, kappa=0.81, 95% CI [0.80-0.82]. Distribution of CRL measurements varied considerably as a function of image quality: when the fetus was in extension, the mean CRL was +5.7mm (vs. not in extension, p<0.001), when the fetus was in flexion (vs. not), the mean CRL was -4.7mm (p<0.001) and when the image magnification was <65% (vs. >65%), the mean CRL was -4.2mm (p<0.001). There was a global trend to over-estimate the CRL for the higher deciles and to under-estimate the CRL for the lower deciles when the sagittal quality hallmarks were absent. No significant impact on CRL distribution was observed in association with the precise placement of the calipers nor with the horizontal orientation of the fetus.nnnCONCLUSIONnDistribution of CRL measurements was influenced by the quality of CRL images. In particular, inadequate position of the fetus (flexion/extension) and insufficient image magnification were associated with systematic changes in the values of CRL. Our results show that as the quality of CRL images decreases, the associated variations in the distribution of CRL can have an impact on the chromosomal risk assessment and may lead to inappropriate obstetrical decisions.

64 Risk of Congenital Heart Defects for Children Conceived Following Assisted Reproductive Technologies. A Population Based Evaluation

64 Risk of Congenital Heart Defects for Children Conceived Following Assisted Reproductive Technologies. A Population Based Evaluation

National cross-sectional study of nonsteroidal anti-inflammatory drugs use highlights differences between parents and professionals and prompts safety concerns.

Controversy surrounding the safety of nonsteroidal anti‐inflammatory drugs (NSAIDs) provides an opportunity to study parents’ and healthcare professionals’ differential use of over‐the‐counter drugs.