To determine whether extrauterine growth is associated with neurologic outcomes and if this association varies by prenatal growth profile.For 1493 preterms from the EPIPAGE (Étude Épidémiologique sur les Petits Âges Gestationnels [Epidemiological Study on Small Gestational Ages]) cohort, appropriate for gestational-age (AGA) was defined by birth weight >-2 SD and small for gestational-age (SGA) by birth weight ≤-2 SD. Extra-uterine growth was defined by weight gain or loss between birth and 6 months by z-score change. Growth following-the-curve (FTC) was defined as weight change -1 to +1 SD, catch-down-growth (CD) as weight loss ≥1 SD, and catch-up-growth (CU) as weight gain ≥1 SD. At 5 years, a complete medical examination (n = 1305) and cognitive evaluation with the Kauffman Assessment Battery for Children (n = 1130) were performed. Behavioral difficulties at 5 years and school performance at 8 years were assessed (n = 1095).Overall, 42.5% of preterms were AGA-FTC, 20.2% AGA-CD, 17.1% AGA-CU, 5.6% SGA-FTC, and 14.5% SGA-CU. Outcomes did not differ between CU and FTC preterm AGA infants. Risk of cerebral palsy was greater for AGA-CD compared with AGA-FTC (aOR 2.26 [95% CI 1.37-3.72]). As compared with children with SGA-CU, SGA-FTC children showed no significant increased risk of cognitive deficiency (aOR 1.41[0.94-2.12]) or school difficulties (aOR 1.60 [0.84-3.03]). Compared with AGA-FTC, SGA showed increased risk of cognitive deficiency (SGA-FTC aOR 2.19 [1.25-3.84]) and inattention-hyperactivity (SGA-CU aOR 1.65 [1.05-2.60]).Deficient postnatal growth was associated with poor neurologic outcome for AGA and SGA preterm infants. CU growth does not add additional benefits. Regardless of type of postnatal growth, SGA infants showed behavioral problems and cognitive deficiency.

In 1997 a large French epidemiological study (Epipage) showed increased mortality and morbidity in Languedoc Roussillon when compared to other regions of France. In order to update information, we set up a regional database about very preterm infants born in Languedoc-Roussillon since 2003. Our objective was to analyze the evolution of mortality and of the morbidity in very preterm infants between 1997 and 2003-2005.Methods. We analyzed mortality and the morbidity (respiratory, neurological, digestive) of the very preterm infants born alive between 22 and 32 weeks amenorrhea and admitted alive in neonatology included in Epipage study, in 1997 and of those included in the regional database in 2003-2005. Between these 2 periods, professional practices were significantly improved as the perinatal network was set up and perinatal care was regionalized.Results. We analyzed the data collected in 3121 subjects of Epipage study and 1111 subjects of the regional database. We observed a significant reduction (P < 0.05) of neonatal mortality (8% versus 23%), rate of bronchopulmonary dysplasia (9% versus 19%) and of periventricular leukomalacia (9% versus 18%). During this period, there were significant increases (P < 0.05) in the rates of antenatal corticotherapy (87% versus 61%) and caesarean section (72% versus 38%).Conclusion. We observed a significant improvement of morbidity of very preterm infants and a decreased mortality for the youngest subjects which was concomitant of an improvement of the professional's practices. It is necessary to take into account these results to propose relevant informations to the professionals with and thus indirectly to the parents. (C) 2008 Elsevier Masson SAS. All rights reserved.

Underprivileged immigrants from endemic areas cumulate risk factors for infections by HIV-AIDS and hepatitis B and C. Free primary care consultations are available to them in the four health centers of the city of Paris. The objective of our study was to identify socio-demographic and medical factors related to the lack of screening proposition for HIV-AIDS and hepatitis B and C to new immigrant patients in these centers in 2003.For each disease, the absence of screening proposition was analyzed according to geographical origin, length of stay in France, type of accommodation, type of health insurance and symptom motivating the encounter in logistic mixed models adjusted on sex and age.About 500 patients were included in the analysis. Three-quarters of them were male and from Sub-Saharan Africa. They were 36 years old on average. Half of them lived in shelters for homeless or immigrants. Their median stay lasted two years. They rarely came for screening (1%), sometimes for asthenia (6%) and two-thirds of them for uro-genito-digestive signs. The results were similar for the three screenings. The lack of screening proposition was about 45% and varied significantly between physicians. Factors significantly associated with the lack of screening proposition were: coming from non-Sub-Saharan Africa (especially from North Africa and Middle East; OR = 1.7 to 3.6) and having a health insurance (OR = 2.4 to 2.6) regardless of the disease; being a female (OR = 2.0 to 2.3) in the case of hepatitis; and having a length of stay in France greater than or equal to five years (OR = 1.9) for hepatitis B.Our results should encourage practitioners to provide more screening to underprivileged immigrants and draws attention to immigrants from non-Sub-Saharan origin and those with health insurance. Factors that might explain doctor and gender-related variability observed in hepatitis are highlighted.Les immigrés issus des zones d'endémie et en situation de précarité cumulent les facteurs de risque d'infection par le virus de l'immunodéficience humaine (VIH-sida) et les hépatites B et C. Des consultations de premier recours gratuites leur sont accessibles dans quatre centres médicosociaux (CMS) parisiens. L'objectif de cette étude était d'identifier les facteurs sociodémographiques et médicaux liés à l'absence de proposition de dépistage du VIH-sida et des hépatites B et C aux immigrés primo-consultants dans ces centres en 2003.Pour chaque virose, l'absence de proposition de dépistage a été analysée en fonction de l'origine géographique, de la durée de séjour, du type d'hébergement, de la couverture sociale et du motif de consultation, dans des modèles logistiques mixtes ajustés sur le sexe et l'âge.Les quelque 500 patients inclus dans l'analyse étaient pour les trois-quarts de sexe masculin et d'origine subsaharienne. Âgés de 36 ans en moyenne et hébergés pour moitié en foyers de sans domicile fixe ou de migrants, ils avaient une durée médiane de séjour en France de deux ans et consultaient rarement pour dépistage (1 %), parfois pour asthénie (6 %) et dans un tiers des cas pour des signes abdo-génito-urinaires. Les résultats étaient similaires pour les trois dépistages. L'absence de proposition de dépistage s'élevait à environ 45 % et variait significativement entre les médecins. Les facteurs significativement liés à l'absence de proposition de dépistage étaient : l'origine non subsaharienne (en particulier d'Afrique du Nord et du Moyen-Orient ; OR = 1,7 à 3,6,) et le fait d'avoir une couverture sociale (OR = 2,4 a 2,6) quelle que soit la virose ; le sexe féminin (OR = 2,0 à 2,3) dans le cas des hépatites et la durée de séjour supérieure ou égale à cinq ans (OR = 1,9) pour l'hépatite B.Nos résultats doivent encourager les praticiens à proposer davantage de dépistages aux immigrés précaires, en ayant une attention particulière à ceux d'origine non subsaharienne et à ceux ayant une couverture sociale. Ils invitent à réfléchir aux facteurs médecins qui pourraient expliquer la variabilité inter-médecin et aux inégalités de sexe observées dans le dépistage des hépatites.

Objective: The purpose of this study was to examine the relationships between different causes of preterm delivery (eg, maternal hypertension, small-for-gestational age [SGA], other) and cerebral damage (eg, cystic periventricular leukomalacia [c-PVL], grade III intraventricular hemorrhage [IVH], and intra-parenchymal hemorrhage [IPH]).Study design: This study included 1902 very preterm singletons who were transferred to neonatal intensive care units in 9 French regions. We used logistic regression models to compare the risk of. cerebral injury associated with maternal hypertension, SGA, and all other causes of preterm delivery.Results: We found that the risk of c-PVL and grade III IVH was higher in infants born after preterm premature rupture of membranes (PPROM) with short latency or idiopathic preterm labor than in infants born to hypertensive mothers. We show that SGA and antepartum maternal hemorrhage significantly increase the risk of IPH.Conclusion: Our results show that infants born to hypertensive mothers have a lower risk of cerebral injuries than infants born following idiopathic preterm labor and PPROM because they are less exposed to prenatal infection. (c) 2005 Elsevier Inc. All rights reserved.

Background Little is known about the clinical significance of mild extrapyramidal signs (EPS) in elderly individuals. We investigated whether EPS are associated with functional impairment in older people with cognitive decline.Methods A sub-group of 105 participants from the EUGERIA Study of Cognitive Ageing without Parkinson's disease or dementia, but with informant evidence of cognitive decline, were followed across three years and underwent neurological examination and assessment of mental health, cognition and functional capacity.Results 28.6% had at least one EPS (resting tremor, muscular rigidity or akinesia, of which rigidity was the most frequent). EPS presence was significantly associated with functional impairment after controlling for age and cognitive impairment (AAMI), although the association was reduced to borderline significance after further adjustment for depression and psychotropic medication use. There was evidence of colinearity between EPS and depression, possibly suggesting similar underlying mechanisms.Conclusions There is an association between mild EPS and functional impairment in older persons with evidence of cognitive decline, but free of dementia or Parkinson's disease. Copyright (C) 2002 John Wiley Sons, Ltd.

BACKGROUND:Anaesthesia could provoke persistent alterations in specific cognitive domains in the elderly where ageing-related neuronal changes may exacerbate pharmacotoxic effects.AIMS:To evaluate anaesthesia effects on the incidence of cognitive dysfunction after orthopaedic surgery in elderly patients.METHOD:A total of 140 patients over the age of 64 years completed a full range of computerised cognitive tests. The study takes into account effects of pre-operative cognitive dysfunction, depressive symptomatology and ability to perform activities of daily living.RESULTS:Postoperative cognitive decline persisted for up to 3 months in 56% of subjects. Dysfunction was limited to verbal, visuo-spatial and semantic abilities and secondary and implicit memory. Age, low educational level, pre-operative cognitive impairment or depression are risk factors.CONCLUSIONS:Cognitive functions are not equally affected, type of impairment being determined by the risk factors described above and anaesthesia type.

Subclinical cognitive impairment is commonly reported in elderly populations, but its clinical significance is largely undetermined. It is commonly perceived as a normal feature of the aging process or a separate nosological entity, The clinical status of this disorder is explored herein by reference to longitudinal observations. It is concluded that persons with subclinical cognitive impairment constitute a highly heterogeneous group, There is an elevated risk in this group for senile dementia, with an estimated 18% incidence rate over 3 years, but in the majority of cases, this problem is more commonly associated with depressive symptomatology and physical illness. Only 13% of persons with recent observable change in cognitive functioning appear to have a totally benign and transient syndrome. Caution should be exercised in applying single unifying nosological entities such as age-associated memory impairment to this group of the elderly. Copyright (C) 2000 by W.B. Saunders Company.

BACKGROUND Evidence relating to the potentially protective effect of smoking and alcohol consumption in relation to senescent cognitive decline and Alzheimer's disease is inconclusive. METHODS The relationship between wine and tobacco consumption and cognitive change was assessed within a longitudinal study of normal elderly people showing recent instability in cognitive functioning using an extensive battery of cognitive tests. RESULTS While moderate wine consumption was found to be associated with a fourfold diminishing of the risk of Alzheimer's disease (OR = 0.26), as found in other studies, this effect was found to disappear when institutionalization was taken into account. Wine consumption was associated with an increased risk of decline over time in attention and in secondary memory. No protective effect for Alzheimer's disease was found for smoking, although smoking was associated with a decreased risk for decline over time in attentional and visuospatial functioning. No clear combined effect of smoking and drinking was found, even though smoking was found to increase the risk of decline in language performance when adjusted on wine consumption. CONCLUSIONS There is no evidence to suggest that wine and tobacco consumption may protect against Alzheimer's disease.

Background. Two sets of research diagnostic criteria, age-associated memory impairment (AAMI) and ageing-associated cognitive decline (AACD), are widely used to describe mild cognitive decline in ageing. However, the extent to which the nosological entities they represent are similar or distinct is unclear.Methods. A sample of 111 participants without dementia but with informant evidence of cognitive decline were drawn from the EUGERIA Study of Cognitive Ageing, a population-based study in southern France. These participants were classified as either normal or with AAMI according to the criteria of Crook ct nl. (1986), then reclassified as normal or with AACD according to criteria recommended by Levy et al. (1994). Neuropsychological test scores were then compared in these two pairs of groups.Results. Particpants were classified as either normal (N = 74) or with AAMI(N = 37), then reclassified as normal (N = 72) or with AACD (N = 39). Only 20 (54%) of participants with AAMI simultaneously met criteria for AACD, and those with AACD showed more extensive cognitive impairment than those with AAMI.Conclusions. Although there is a large overlap between AAMI and AACD, these findings suggest that AAMI and AACD refer to distinct clinical entities, the latter delineating a more severe state of impairment. This may be largely because AAMI is defined as impairment with reference to young normals, whereas AACD refers to impairment with respect to normal contemporaries. Copyright (C) 1999 John Wiley & Sons, Ltd.

Background: depressive illness in dementia is often assumed to be a unitary clinical phenomenon.Aim: to describe changes in patterns of depressive symptomatology with time, and associated changes in cerebral blood flow to the frontal and temporal regions.Method and results: 397 elderly people with sub-clinical cognitive dysfunction were observed over 3 years. Sixteen percent of them developed dementia during the study. The prevalence of depressive symptomatology was higher in this group than in the general population, especially in women, who also had higher recovery rates. A changing profile of depressive symptoms was found in depressed elderly people progressing to dementia, with fewer affective symptoms and increases in agitation and motor slowing. These changes were paralleled by greater reductions in left temporal regional cerebral blood flow than in non-depressed subjects with Alzheimer's disease.Conclusion: in dementia, there may be two separate and interacting depressive syndromes whose differentiation may be clinically important.

Cognitive disorder is a primary cause of disability in the elderly. In some cases, the problem is exacerbated by co-existing affective disorders which may make community care more difficult and, through its effect on self-control and motivation, also increase disability levels. The present study examines the evolution of disabilities as defined by the International Classification of Impairments, Disabilities and Handicaps, in a cohort of 397 elderly persons with sub-clinical cognitive deficits. Over the three years of the study, 11 % of this cohort developed dementia without depression and 5 % dementia with depression. Dementia alone was found to produce an increased prevalence in the final year of the study of difficulties in dressing, sleeping, walking, continence, bathing and dental care. Rates were higher for all functions except sleeping in cases of dementia with depression. Significant decrements over time were found in dressing, putting on shoes, use of telephone and continence. Additionally, elderly persons with dementia and depression showed decline in ability to wash. These preliminary results suggest that dementia-related disability may be reduced, if an associated affective illness is treated.

Objectives. To assess the extent to which loss of ability to perform everyday activities in early stage senile dementia is worsened by the presence of depressive illness.Methods. The evolution of disabilities is measured by an activity scale permitting observation of small changes in everyday performance in a cohort of 397 elderly persons with subclinical cognitive deficit. Over the 3 years of the study, 11% of the cohort developed dementia without depression and 5% dementia with depression.Results. Progressive disablement was found to be greater in persons with senile dementia as compared to normal subjects. Depression alone had no significant effect over the time period. Persons with both senile dementia and depression had significantly higher rates of disability at 3 years than persons with senile dementia alone. Significantly greater decrements across the observation period were observed in dressing, washing, use of telephone and continence in the senile dementia-depression group only.Conclusion. Depression does not in itself engender significant disability but interacts with senile dementia to accelerate loss of functioning. Effective treatment of depressive illness in senile dementia may have significant impact on the prevalence and severity of disability. (C) 1998 John Wiley & Sons, Ltd.

BACKGROUND:Research into ageing-related pathology relies not only on exploration of disease aetiology, but also a clear understanding of the normal ageing process. The present study aims to examine the characteristics of elderly subjects who lie on the borderline between normal and pathological ageing.METHOD:Cognitive functioning is examined using computerized neuropsychometric assessment in a population of 833 normal elderly from which a cohort of 397 subjects with sub-clinical cognitive impairment are followed over three years. Subjects receive a standardized neurological examination and ApoE genotypes are established.RESULTS:Analysis of covariance revealed no cross-sectional age differences for syntax comprehension (p = 0.19), articulation (p = 0.46), semantic matching (p = 0.12), reading (p = 0.79), and implicit memory (p = 0.21) while explicit memory, language skills and visuospatial skills were found to deteriorate both in the cross-sectional age comparisons and across time. An overall intellectual ability factor, derived from Principal Components Analysis, was found by regression to decline principally in persons with low education, and a high initial IQ level was observed to provide a protective effect over age 75. Persons with higher levels of education show relative stability over time on language and secondary memory tasks but deteriorate as rapidly as persons with low education on visuospatial tasks. Five separate patterns of sub-clinical cognitive deficit were isolated by cluster analysis. Two groups, with differing clinical profiles (of which only one manifested the ApoE4 allele), were found to have an increased risk of developing senile dementia (OR = 4.4 and 3.9). A third group had a high prevalence of depressive illness, and the remaining two showed very little change.CONCLUSION:Ageing does not affect all cognitive functions uniformly: a high initial education level slowing rate of decline for certain tasks. Separate patterns of cognitive change are observed in early senile dementia, benign change and changes related to depressive illness. Results suggest the need for more stringent selection of normal control groups.

Exposure to general anesthesia has been suggested as a possible cause of long-term cognitive impairment in elderly subjects. The present study reviews the literature in this field in order to describe postoperative cognitive impairment in elderly populations, to determine to what extent this may be attributed to anesthetic agents, and to consider evidence of a causal relationship between anesthesia and onset of senile dementia. A systematic literature search was conducted using five bibliographic databases (PASCAL, Medline, Excerpta Medica, Psychological Abstracts, and Science Citation Index). Significant cognitive dysfunction was found to be common in elderly persons 1 to 3 days after surgery, but reports of longer-term impairment are inconsistent due to the heterogeneity of the procedures used and populations targeted in such studies. Incidence rates vary widely according to type of surgery, suggesting that factors other than anesthesia explain a significant proportion of the observed variance. Anesthesia appears to be associated with longerterm cognitive disorder and the acceleration of senile dementia, but only in a small number of cases, suggesting the existence of other interacting etiological factors.

BackgroundCognitive impairment without dementia is commonly observed in ageing populations. The present study aims to describe types of impairment and evolution over a one-year period.MethodThree hundred and ninety-seven normal French elderly persons demonstrating recent, observable change in cognitive performance were examined annually using a computerised cognitive examination.ResultsFive subtypes were differentiated by cluster analysis. Two of the groups were predicted by logistic regression to be at high risk of senile dementia. Of 16 incident cases of senile dementia diagnosed in the following year, 13 were found to have derived from these two groups. The typology was also found to be useful in the description of age-associated memory impairment.ConclusionsSubclinical cognitive impairment was found to not constitute a unitary phenomenon and heterogeneous subgroups could be differentiated. The concept of ‘normality’ in elderly cohorts is reconsidered in the light of these findings.

Many studies have implicated low education as a risk factor for cognitive impairment in elderly people. Findings are, however, inconsistent and the mechanism by which education level may intervene in senescent cognitive change is uncertain. The present study examines cognitive change over a 1-year period in 283 elderly persons manifesting recent subclinical deterioration in at least one area of cognitive functioning. The results suggest that the impact of both education level and young adult IQ on the degree of cognitive change over the year is greater in the older age groups. Secondary memory and language functions were found to be more resistant to decline in the high-education group, while attention, implicit memory and visuospatial skills are found to decline irrespective of education level.

Although the efficacy of hormonal replacement therapy (HRT) regarding numerous consequences of menopause is proven, its prevalence of use is low, as is compliance with the prescribed treatment. The aim of this work was to study the factors influencing a woman's decision to take HRT by analyzing the determinants of HRT use of at least 6 months' duration among postmenopausal women working for a French company and enrolled in a cohort study. Special attention was paid to the women's expectations of HRT. We compared two groups of women: 113 current HRT users who had been users for at least 6 months and 101 never users. Among the 113 current users, the most frequent treatment was a combination of oestrogen and progestin (86%). The determinants of HRT use for at least 6 months included a prior spinal radiograph, which showed a significant relationship with the use of hormone treatment (odds ratio (OR) 2.4; 95% confidence interval (CI) 1.2-4.7), a current marriage (OR 2.5; 95% CI 1.3-5.1) and previous hot flushes (OR 2.4; 95% CI 1.2-4.9). The strongest determinant was an expectation that HRT would prevent osteoporosis (OR 5.0; 95% CI 2.2-11.6). In this population concern about osteoporosis appears to be an important determinant of HRT use. Our results underline the importance of the diffusion of information among physicians and women about HRT's benefits, especially its efficacy in preventing osteoporosis.