Biomedical subjects

H Grandjean

Publications and source records attributed to H Grandjean.

At least 19 recordsLinked to original sources

PubMed2006

Caesarean section on request: a comparison of obstetricians' attitudes in eight European countries.

OBJECTIVE: To explore the attitudes of obstetricians to perform a caesarean section on maternal request in the absence of medical indication. DESIGN: Cluster sampling cross-sectional survey. SETTING: Neonatal Intensive Care Unit (NICU) associated maternity units in eight European countries. POPULATION: Obstetricians with at least 6 months clinical experience. METHODS: NICU-associated maternity units were chosen by census in Luxembourg, Netherlands and Sweden and by geographically stratified random sampling in France, Germany, Italy, Spain and UK. An anonymous, self-administered questionnaire was used for data collection. MAIN OUTCOME MEASURES: Obstetricians' willingness to perform a caesarean section on maternal request. RESULTS: One hundred and five units and 1,530 obstetricians participated in the study (response rates of 70 and 77%, respectively). Compliance with a hypothetical woman's request for elective caesarean section simply because it was 'her choice' was lowest in Spain (15%), France (19%) and Netherlands (22%); highest in Germany (75%) and UK (79%) and intermediate in the remaining countries. Using weighted multivariate logistic regression, country of practice (P<0.001), fear of litigation (P= 0.004) and working in a university-affiliated hospital (P= 0.001) were associated with physicians' likelihood to agree to patient's request. The subset of female doctors with children was less likely to agree (OR 0.29, 95% CI 0.20-0.42). CONCLUSIONS: The differences in obstetricians' attitudes are not founded on concrete medical evidence. Cultural factors, legal liability and variables linked to the specific perinatal care organisation of the various countries play a role. Greater emphasis should be placed on understanding the motivation, values and fears underlying a woman's request for elective caesarean delivery.

Adult↗

PubMed2005

[Social and demographic characteristics and perinatal risks for highly deprived mothers].

OBJECTIVE: To assess the frequency of deprivation in pregnant women and estimate the associated medical risks. MATERIAL: and methods. A retrospective study of the hospital's computerised data (6149 women) and two prospective studies with health staff (n=534) and social workers (n=85) in two maternity hospitals. RESULTS: In the retrospective study, 17.5% of mothers were deprived. Deprivation was associated both with more difficulties during pregnancy and the perinatal period and with longer hospital stays. The prospective studies confirmed the prevalence of deprivation and gave a more detailed idea of the associated social and demographic characteristics. Deprivation was related with a combination of risk factors with a particularly important influence of economic risk. A quarter of deprived mothers had unwanted pregnancies and according to the social workers approximately 10% of them were not in a position to take care of their baby. CONCLUSION: This study emphasizes the importance of deprivation as a perinatal medical risk factor. Screening should take place in early pregnancy in order to find the best way to help such families.

Adolescent↗

PubMed2005

[Socioeconomical status, health behaviors and health status of French adolescents: Health Behavior in School-aged Children (HBSC) survey].

BACKGROUND: The impact of living conditions on health is not well known, but health inequalities observed in adults seem partly determined by behaviours and health status at an earlier stage, and more particularly during adolescence. So, our aim was to study adolescents' health and their health behaviours function to family socioeconomic status. METHODS: We analysed French data from the international survey "Health Behavior in School-aged Children" carried out in a representative sample of adolescents aged 13 and 15 years in 1998. A self-administered questionnaire was completed by the adolescents who answered questions concerning their health, health behaviours, and their families' socio-economic status. RESULTS: Adolescents from blue-collar families were more numerous to report to be in "fairly good health" or "not very good health" (OR = 1.40, CI 95% = 1.12-1.74) and to be overweight or obese (OR = 1.85, CI 95% = 1.25-2.24) than those from executive families. They were also more numerous to have bad health behaviours than those from executive families. CONCLUSION: This study has established that, in adolescents, differences in health, health behaviours, types of consumption and physical activities depended on the families' socio-economic status.

Adolescent↗

PubMed2005

Prevalence and main characteristics of schoolchildren diagnosed with food allergies in France.

BACKGROUND: A cross-sectional, descriptive, questionnaire-based survey was conducted in Toulouse schools to determine the prevalence of food allergies among schoolchildren. OBJECTIVES: The first goal of the survey was to estimate the prevalence of food allergies. The second goal was to determine the main characteristics of the allergies. METHODS: The questionnaires (3500) were distributed in 150 classes in eight schools. The return rate was 77.6% (2716). RESULTS: Of the 192 (7.0%) questionnaires with a 'Yes' response (report of a food allergy), 182 were retained as reporting true food allergies (6.7%). The cumulative and point prevalences were 6.7% [95% confidence interval (CI) 5.8-7.6] and 4.7% [95% CI 3.9-5.5], respectively. The point prevalences were 4.0% for the children aged 2-5 years, 6.8% for the children aged 6-10 years, and 3.4% for the children aged 11-14 years. The main foods reported as causing adverse reactions were cow milk (n = 29, 11.9%), eggs (n = 23, 9.4%), kiwis (n = 22, 9.0%), peanuts (n = 20, 8.2%), fish (n = 19, 7.8%), tree nuts (n = 19, 7.8%), and shrimp (n = 13, 5.3%). The average age at which the allergies were detected was 3.4+/-2.8 years (with a range of 0.1-12 years). The clinical signs of the food allergies were cutaneous (n=153, 62.7%), digestive (n = 74, 30.3%), respiratory (n = 17, 6.9%), and anaphylactic shock (n = 12, 4.9%). CONCLUSION: While well aware of the biases inherent in this type of study, we estimated the cumulative and point prevalences of food allergies in a population of school-age children in Toulouse at 6.7% and 4.7%, respectively. Cow milk, eggs, and peanuts were the main foods reported as causing allergies. Exotic fruits, shellfish, and tree nuts appeared to be relatively new allergens.

Actinidia↗

PubMed2005

Does smoking in pregnancy modify the impact of antenatal steroids on neonatal respiratory distress syndrome? Results of the Epipage study.

OBJECTIVES: To assess the relation between cigarette smoking during pregnancy and neonatal respiratory distress syndrome (RDS) in very preterm birth, and to analyse the differential effect of antenatal steroids on RDS among smokers and non-smokers. DESIGN: A population based cohort study (the French Epipage study). SETTING: Regionally defined births in France. METHODS: A total of 858 very preterm liveborn singletons (27-32 completed weeks of gestation) of the French Epipage study were included in this analysis. The odds ratio for RDS in relation to smoking in pregnancy was estimated using a logistic regression to control for gestational age. The odds ratio for RDS in relation to antenatal steroids was estimated taking into account an interaction between antenatal steroids and cigarette smoking, using multiple logistic regression to control for gestational age, birthweight ratio, main causes of preterm birth, mode of delivery, and sex. RESULTS: The odds ratio for RDS in relation to smoking in pregnancy adjusted for gestational age (aOR) was 0.59 (95% confidence interval (CI) 0.44 to 0.79). The aOR for RDS in relation to antenatal steroids was 0.31 (95% CI 0.19 to 0.49) in babies born to non-smokers and 0.63 (95% CI 0.38 to 1.05) in those born to smokers; the difference was significant (p = 0.04). CONCLUSIONS: Cigarette smoking during pregnancy is associated with a decrease in the risk of RDS in very preterm babies. Although antenatal steroids reduce the risk of RDS in babies born to both smokers and non-smokers, the reduction is smaller in those born to smokers.

Female↗

PubMed2005

[Self-evaluation of the quality of life of children aged 6 to 12 years old: analysis of the concept and development of a prototype tool].

The objective of this work was to assess the quality of life of children aged 6 to 12 years old. The authors present the different conceptual and operational steps which lead to the construction of a prototype tool. It was a generic tool composed of 63 items which covered the classically described areas of life. Its originality was due to the method of construction used which included children's involvement, to the pictorial representation of real-life situations for children, and to its adaptation for gender. The evaluation of this tool showed a good level of acceptability but statistical analysis revealed some metrological inadequacies leading to the reconsideration of the initial concepts and their methods of exploration. Therefore a new tool was constructed whose validation is presented in a second article in the next issue.

Child↗

PubMed2005

[Self-evaluation of the quality of life of children aged 6 to 12 years old: construction and first steps in the validation of kidlQol, a generic computer-based tool].

The KidlQol is a self-evaluation computer-based instrument to assess the quality of life of children aged 6 to 12 years old. This self-evaluation comprises three areas of their subjective quality of life: physical, psychological and social. A computer-assisted tool, composed of 62 items, was developed and set up based upon the results from the evaluation of the initial prototype tool which underwent a series validation steps, tested among children with and without psychological problems. This evaluation lead to the production of a final tool called KidlQuol, which is composed of 44 items. This tool, which utilises computer images to represent real-life situations, is adapted for and accessible to children with a French cultural background aged between 6 and 12 years old. As a generic tool, it could be used among a population of children with various types of handicaps, chronic diseases or psycho-social difficulties.

Child↗

PubMed2005

Impact of nutritional status on the evolution of Alzheimer's disease and on response to acetylcholinesterase inhibitor treatment.

BACKGROUND: Weight loss is frequently observed in patients with Alzheimer's disease (AD), as observed in clinical practice and reported in the literature. However, information on the evolution of nutritional status and its impact on the prognosis of AD is still scarce. OBJECTIVE: Our aim was to determine the impact of nutritional status on the evolution of AD and on the response to treatment with acetylcholinesterase inhibitors (AChEI) by prospective one-year follow-up of AD patients living at home. METHODS: We studied a cohort of 523 patients with Alzheimer's disease referred from 1994 to 2002 to an Alzheimer centre. After diagnosis, they were followed for one year in a prospective observational study in clinical practice. At entry and every 6 months, patients underwent standardised neurocognitive and geriatric evaluation (MMSE, ADAS-cog, IADL, MNA, caregiver burden). These evaluations were accompanied by complete clinical examination, standard paraclinical investigations and recording of treatment received. RESULTS: Of our patients, 25.8% presented at inclusion a risk of undernutrition with an MNA score of 23.5 or less. During follow-up, the number of patients with rapid loss on the MMSE (3 points or more in one year) was higher in subjects who presented a risk of undernutrition at inclusion (53.6%) than in well-nourished subjects (43.2%) (P = 0.07). Similarly, increased dependence at one year was more frequent in subjects at risk of undernutrition at inclusion (57.7% versus 44.4%, P = 0.0219). The beneficial effect of AChEI treatment on cognitive function was not influenced by initial nutritional status; on the contrary, among the subjects at risk of undernutrition at inclusion, the risk of rapid loss on the MMSE in one year was decreased in subjects treated during follow-up compared with untreated subjects (43.9% versus 73.1% ; OR = 0.29; 95% CI = 0.10-0.83; P = 0.0219). This relationship was not found in subjects whose initial MNA score was greater than 23.5. CONCLUSION: Our work indicates that AD patients living at home with a caregiver are frequently at risk of undernutrition. Undernourished patients seem to present more rapid aggravation of the disease, but paradoxically, these patients appear to be those who best respond to AChEI treatment.

Aged↗

PubMed2004

Survival of very preterm infants: Epipage, a population based cohort study.

OBJECTIVE: To evaluate the outcome for all infants born before 33 weeks gestation until discharge from hospital. DESIGN: A prospective observational population based study. SETTING: Nine regions of France in 1997. PATIENTS: All births or late terminations of pregnancy for fetal or maternal reasons between 22 and 32 weeks gestation. MAIN OUTCOME MEASURE: Life status: stillbirth, live birth, death in delivery room, death in intensive care, decision to limit intensive care, survival to discharge. RESULTS: A total of 722 late terminations, 772 stillbirths, and 2901 live births were recorded. The incidence of very preterm births was 1.3 per 100 live births and stillbirths. The survival rate for births between 22 and 32 weeks was 67% of all births (including stillbirths), 85% of live births, and 89% of infants admitted to neonatal intensive care units. Survival increased with gestational age: 31% of all infants born alive at 24 weeks survived to discharge, 78% at 28 weeks, and 97% at 32 weeks. Survival among live births was lower for small for gestational age infants, multiple births, and boys. Overall, 50% of deaths after birth followed decisions to withhold or withdraw intensive care: 66% of deaths in the delivery room, decreasing with increasing gestational age; 44% of deaths in the neonatal intensive care unit, with little variation with gestational age. CONCLUSION: Among very preterm babies, chances of survival varies greatly according to the length of gestation. At all gestational ages, a large proportion of deaths are associated with a decision to limit intensive care.

Birth Weight↗

PubMed2003

Short-term outcome of isolated and associated congenital heart defects in relation to antenatal ultrasound screening.

OBJECTIVE: To investigate the outcome of fetuses affected by congenital heart defects (CHD), either detected or undetected at ultrasound screening, according to their complexity and severity. DESIGN: The study group comprised 3633 malformed fetuses entered into the Eurofetus database of which 798 had CHD. We compared the short-term outcome in cases where a CHD was detected by ultrasound screening with that in cases where a CHD was not detected. Isolated and associated CHD (ICHD and ACHD) and the degree of severity of defects were considered separately. Outcome data included termination of pregnancy (TOP), intrauterine fetal death, neonatal death (< 6 days after birth), gestational age at diagnosis and at delivery, mode of delivery and birth weight. RESULTS: Of the 798 fetuses with CHD, 595 had ICHD and 203 had ACHD. The diagnosis of an anomaly was made significantly earlier in ACHD cases. TOP was chosen in 28% of cases with a prenatal diagnosis of CHD, 20% for ICHD and 37% for ACHD (P < 0.001). The survival rate of antenatally diagnosed fetuses was lower in those with ACHD than in those with ICHD (P < 0.001) and lower for fetuses with antenatal diagnosis than with postnatal diagnosis (P < 0.001); this was due to significant differences in the complexity and severity of the defect. Premature delivery (< 32 weeks) was more frequent in fetuses in which an antenatal diagnosis of CHD had been made. Severe CHD were diagnosed earlier and were associated with a higher rate of TOP and spontaneous loss. CONCLUSIONS: The severity of CHD has a positive influence on the sensitivity of screening but a negative influence on the outcome. CHD that are not diagnosed antenatally include a high proportion of benign malformations. This explains the apparent paradox of a poorer outcome in fetuses in which a CHD was detected prenatally compared to those fetuses in which the defect was undetected prenatally. However, prenatal diagnosis provides parents with the option of TOP or of preventive care in specialized centers.

Female↗

PubMed2002

Sensitivity of ultrasound screening for congenital anomalies in unselected pregnancies.

OBJECTIVE: To assess the influence of heart defect frequency and severity on screening sensitivity of the entire spectrum of congenital anomalies (CA) and on detection rate of congenital heart defect (CHD) when performing routine ultrasound screening in unselected pregnant women. STUDY DESIGN: Secondary analysis was performed on data from Eurofetus, a large international collaborative study of ultrasound screening for CA in unselected populations. The present study addressed the relations (i) between the frequency of CHD in the screened population and the global sensitivity of ultrasound in detecting CA; (ii) between frequency of ventricular septum defect (VSD) and detection rate of CA and CHD; and (iii) between seriousness of CHD and CHD sensitivity. RESULTS: A negative correlation (p<0.001) between CHD frequency and CA sensitivity was observed in this study. Likewise, a negative correlation was also found between frequency of VSD and sensitivity for CA or CHD detection (p<0.001). In addition, a positive significant relationship (p<0.001) was observed between sensitivity and severity of CHD. CONCLUSION: A low CHD frequency introduces bias in CA and CHD sensitivity evaluation. Incomplete assessment of fetal and neonatal malformations brings on systematic error, leading to the pre-eminence of severe defects in the studied population sample and artificially improving sensitivity figures. On the other hand, from a clinician's viewpoint, the higher sensitivity for severe defect is welcomed, since their detection is most crucial for appropriate management.

Chi-Square Distribution↗

PubMed2001

Instrumental activities of daily living as a potential marker of frailty: a study of 7364 community-dwelling elderly women (the EPIDOS study).

BACKGROUND: A number of clinical conditions have been shown to be associated with frailty in elderly people. We hypothesized that incapacities on the Instrumental Activities of Daily Living (IADLs) scale could make it possible to identify this population. We investigated the associations between IADL incapacities and the various known correlates of frailty in a cohort of community-dwelling elderly women. METHODS: Cross-sectional analysis was carried out on the data from 7364 women aged over 75 years (EPIDOS Study). The IADL was the dependent variable. Sociodemographic, medical, and psychological performance measures were obtained during an assessment visit. Falls in the previous 6 months and fear of falling were also ascertained. Body composition was measured by dual-energy x-ray absorptiometry. The factors associated with disability in at least one IADL were included in a logistic regression model. RESULTS: Thirty-two percent of the population studied had disability in at least one IADL item. This group was significantly older (81.7 +/- 4.1 yr vs 79.8 +/- 3.4 yr), had more frequent histories of heart disease, stroke, depression or diabetes, and was socially less active (p =.001). These associations persisted after multivariate analysis. Cognitive impairment as assessed by the Pfeiffer test (Pfeiffer score <8) was closely associated with disabilities on the IADL (OR 3.101, 95% confidence interval [CI] 2.19-4.38). Falls and fear of falling were also more frequent in the group of women with an abnormal IADL (p =.001) but only fear of falling remained significantly associated with incapacities on at least one IADL item after logistic regression (OR 1.47, 95% CI 1.28-1.69). Women with disability on at least one IADL item also had lower bone mineral density, this was independent of the other factors. CONCLUSION: Our results confirmed that women with disability on at least one IADL item are frailer because they had more associated disorders, poorer cognitive function and more frequent falls. Disabilities on this scale could be a good tool for identifying individuals at risk of frailty among elderly persons living at home and in apparent good health. This finding requires confirmation by longitudinal studies.

Accidental Falls↗

PubMed2001

Nutritional risk factors for institutional placement in Alzheimer's disease after one year follow-up.

Amongst factors associated with the institutional placement of elderly people with dementia, there has been little study of those related to malnutrition. We followed a cohort of 318 individuals with Alzheimer's disease (AD). Patients, who were all living at home at the start of the study were recruited from the outpatient service of a hospital unit specialising in AD. After one year, 20% of the patients had moved into institutional care. Multivariate analysis showed that a Mini nutritional Assessment score (MNA) of less than 25.5 (median score of the sample) and overeating behavioural problems (p=0.006) were risk factors for institutional placement. Nutritional problems are reversible and patients with a low MNA score could benefit from a thorough geriatric assessment, in order to slow or prevent institutional placement.

Activities of Daily Living↗

PubMed2001

The effect of platelet PlA polymorphism on experimental thrombus formation in man depends on blood flow and thrombogenic substrate.

A number of studies have reported conflicting data on the association of the PlA1/PlA2 polymorphism of the GPIIIa gene and coronary syndromes. We have investigated the effect of this polymorphism on experimental platelet thrombus formation in man. Forty healthy male volunteers were genotyped for the PlA1/PlA2 polymorphism. Thrombus formation was induced ex vivo by exposing a tissue factor (TF) or a collagen-coated coverslip in a parallel plate perfusion chamber to native blood for 2 and 4 min. The shear rates at these surfaces were 650 and 2,600 s(-1). Platelet and fibrin deposition was quantified by immunoenzymatic methods. The frequencies of PlA1/PlA1 and PlA1/PlA2 genotypes were 52.5% and 47.5%, respectively. Ex vivo deposition of fibrin on TF was not affected by the PlA1/PlA2 polymorphism. However, the ex vivo platelet deposition at 650 s(-1) was higher in blood from PlA1/PlA1 individuals than in PlA1/PlA2 individuals (P= 0.008 at 4 min). On collagen, neither fibrin nor platelet deposition was significantly affected by the PlA1/PlA2 polymorphism. Platelet thrombus formation is significantly influenced by genetic variations in the GPIIIa platelet receptor. This effect depends on the blood flow properties and the nature of the thrombogenic stimulus.

Adult↗

PubMed2000

Alzheimer disease: protective factors.

Approximately 6-8% of all persons aged >65 y have Alzheimer disease and the prevalence of the disease is increasing. Any intervention strategy aimed at decreasing risks or delaying the onset of the disease will therefore have a substantial effect on health care costs. Nutrition seems to be one of the factors that may play a protective role in Alzheimer disease. Many studies suggest that oxidative stress and the accumulation of free radicals are involved in the pathophysiology of the disease. Several studies have shown the existence of a correlation between cognitive skills and the serum concentrations of folate, vitamin B-12, vitamin B-6, and, more recently, homocysteine. However, nutritional factors have to be studied not alone but with the other factors related to Alzheimer disease: genetics, estrogen, antiinflammatory drug use, and socioeconomic variables. The objective of this article was to review recent studies in this field.

Aged↗

PubMed2000

Determination of appendicular muscle mass by dual energy X-ray absorptiometry method in women with sarcopenia and Alzheimer's disease.

OBJECTIVES: To study appendicular muscle mass in women with Alzheimer's disease (AD) to investigate the association between sarcopenia and AD. To examine the AD associated changes in body fat distribution. DESIGN: a cross-sectional study of 32 women with AD and 32 healthy age and bone mineral density matched women. SETTING: Toulouse, France. RESULTS: No differences were noted in fat free soft tissue mass or Appendicular Skeletal Muscle (ASM) mass between AD women and control women. The difference of ASM (kg) /height2 (m)2, used as an index of relative skeletal muscle mass, was not statistically significative between the two groups. The prevalence of sarcopenia increased from 21.9 % in healthy elderly women to 40.6 % in AD women but the difference was not statistically significant. No statistically significant relationship emerged between sarcopenia and AD (OR= 0.41, CI 0.12-1.4). Moreover, total body fat mass was significantly lower in women with AD than in the age -, sex - and bone mineral density - matched controls. CONCLUSION: AD are not necessary linked to sarcopenia. The decrease in adipose tissue in women with AD could be one more factor involving estrogen deficiency in the etiology of the disease.

Absorptiometry, Photon↗

PubMed1999

Separate and combined value of bone mass and gait speed measurements in screening for hip fracture risk: results from the EPIDOS study. Epidémiologie de l'Ostéoporose.

Based on data from the EPIDOS prospective study, we have shown that femoral bone mineral density (BMD), calcaneal ultrasound measurements and fall-related factors are significant predictors of the risk of hip fracture. The goal of the present investigation, in the same cohort of elderly women, was (1) to assess and compare the value of femoral BMD, calcaneal broadband ultrasound attenuation (BUA), gait speed and age for identifying elderly women at high risk of hip fracture and (2) to determine whether combining two or more of these measurements would improve predictive ability over single measures. A total of 5895 elderly women had baseline measurements of femoral neck BMD by dual-energy X-ray absorptiometry, calcaneal BUA and gait speed. During an average of 33 months of follow-up, 170 women suffered a hip fracture. We compared the sensitivity and specificity of single and combined measures for three specific cutoff levels to define high risk, i.e., the median, the top quartile and the top decile of risk. We found that femoral BMD, calcaneal BUA, gait speed and age have approximatively the same discriminant value to identify women at high risk of hip fracture even though certain measures and combinations of measures have a significantly higher sensitivity for certain cutoff levels. The sensitivity of the available screening tools is low, even when they are combined: to obtain a sensitivity of about 80%, approximately 50% of the population must be considered to be at high risk.

Aged↗

PubMed1999

The performance of routine ultrasonographic screening of pregnancies in the Eurofetus Study.

OBJECTIVES: The purpose of the Eurofetus Study was to evaluate the accuracy of the antenatal detection of malformations by routine ultrasonographic examination in unselected populations. STUDY DESIGN: All ultrasonographic diagnoses of malformations and the outcomes of the fetuses were prospectively recorded in 61 European obstetric units over a 3-year period (1990-1993). Also recorded were all cases of malformation diagnosed after abortion or birth for the mothers who underwent follow-up in these centers. RESULTS: Of 3685 malformed fetuses, 2262 had received diagnoses during pregnancy (sensitivity, 61.4%). Of a total number of 4615 malformations, 2593 were detected (sensitivity, 56.2%). The detection sensitivity was higher for the major than for the minor abnormalities (73.7% vs 45.7%), and the diagnosis was made earlier in the pregnancy (24.2 weeks vs 27.6, P <. 01). Overall, 55% of the major abnormalities were detected within 24 gestational weeks. Within each severity group the accuracy of detection depended on the system. For the major abnormalities it was better for the central nervous system (88.3%) and urinary tract (84. 8%) but lower for the heart and great vessels (38.8%). Detection of minor abnormalities was also effective for the urinary tract (89.1%) but not for the heart and great vessels (20.8%) or the musculoskeletal system (18%). Detection of abnormalities had an influence on the rate of termination of pregnancy. The rate of live births for the mothers bearing fetuses with major abnormalities was lower than that for the mothers in whom no abnormalities were detected, mainly because of the higher rate of elective terminations of pregnancy in the former group. CONCLUSION: Systematic ultrasonographic screening during pregnancy can now detect a large proportion of fetal malformations, although some still escape detection.

Blood Vessels↗