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The objectives of the study were to estimate the current exposure to cadmium (Cd) in Europe, potential differences between the countries and geographic regions, determinants of exposure and to derive European exposure levels. The basis for this work was provided by the European Human Biomonitoring Initiative (HBM4EU) which established a framework for alignment of national or regional HBM studies. For the purpose of Cd exposure assessment, studies from 9 European countries (Iceland, Denmark, Poland, Czech Republic, Croatia, Portugal, Germany, France, Luxembourg) were included and urine of 20-39 years old adults sampled in the years 2014-2021 (n = 2510). The measurements in urine were quality assured by the HBM4EU quality assurance/quality control scheme, study participants' questionnaire data were post-harmonized. Spatially resolved external data, namely Cd concentrations in soil, agricultural areas, phosphate fertilizer application, traffic density and point source Cd release were collected for the respective statistical territorial unit (NUTS). There were no distinct geographic patterns observed in Cd levels in urine, although the data revealed some differences between the specific study sites. The levels of exposure were otherwise similar between two time periods within the last decade (DEMOCOPHES - 2011-2012 vs. HBM4EU Aligned Studies, 2014-2020). The age-dependent alert values for Cd in urine were exceeded by 16% of the study participants. Exceedances in the different studies and locations ranged from 1.4% up to 42%. The studies with largest extent of exceedance were from France and Poland. Association analysis with individual food consumption data available from participants' questionnaires showed an important contribution of vegetarian diet to the overall exposure, with 35% higher levels in vegetarians as opposed to non-vegetarians. For comparison, increase in Cd levels due to smoking was 25%. Using NUTS2-level external data, positive associations between HBM data and percentage of cropland and consumption of Cd-containing mineral phosphate fertilizer were revealed, which indicates a significant contribution of mineral phosphate fertilizers to human Cd exposure through diet. In addition to diet, traffic and point source release were identified as significant sources of exposure in the study population. The findings of the study support the recommendation by EFSA to reduce Cd exposure as also the estimated mean dietary exposure of adults in the EU is close or slightly exceeding the tolerable weekly intake. It also indicates that regulations are not protecting the population sufficiently. The HBM4EU project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 733032. Co-funding for the HBM4EU Aligned Studies has been provided by the national programs: Sant´e Publique France and the French ministries of Health and the Environment (ESTEBAN, France); MEYS (No. LM2018121), and Cetocoen Plus project (CZ.02.1.01/0.0/0.0/15_003/0000469) (CELSPAC:YA, Czech Republic); the Ministry of Science and Higher Education of Poland (contract no.3764/H2020/2017/2) (POALES, Poland); Public Health Fund (Diet_HBM, Iceland); Croatian Institute of Public Health (HBM survey in Croatia); National Institute of Health Dr Ricardo Jorge (INSEF_ExpoQuim, Portugal); German Ministry for the Environment, Nature Conservation, Nuclear Safety and Consumer Protection (BMUV) (ESB, Germany); Luxembourg Institute of Health (LIH), the Laboratoire national de sant´e (human biomonitoring part), the Ministry of Higher Education and Research of Luxembourg and the Ministry of Health of Luxembourg (Oriscav-Lux2, Luxembourg); Candy Foundation (Nos. 2017–224 and 2020–344), Absalon Foundation (No. F-23653-01), The Danish Environmental Protection Agency (Miljøstyrelsen: MST-621-00012 Center on Endocrine Disrupters), The Research council of Capital Region of Denmark (No. E-22717-11), Research council of Rigshospitalet (Nos. E-22717-12, E-22717-07, E-22717-08), Aase og Ejnar Danielsens Fond (No. 10–001874), International Research and Research Training Centre for Male Reproduction and Child Health (EDMaRC, No. 1500321/1604357) (CPHMINIPUB (parents) and DYMS, Denmark). J.Kl. and L.A. thank the CETOCOEN EXCELLENCE project No. CZ.02.1.01/0.0/0.0/17_043/0009632 financed by MEYS for supportive background, and supported from the European Union’s Horizon 2020 research and innovation program under grant agreement No. 857560. This publication reflects only the author’s view, and the European Commission is not responsible for any use that may be made of the information it contains. The authors would like to thank also the participants in the HBM4EU Aligned Studies, the fieldworkers that collected the samples and database managers that made the information available to HBM4EU, the laboratories who performed the analytical measurements and the HBM4EU project partners for the supporting material and organization of the QA/QC scheme. Sí

Resume Objectifs La stimulation medullaire (SM) est une technique antalgique indiquee dans le traitement des douleurs chroniques neuropathiques irreductibles. Elle beneficie d’une prise en charge par l’assurance maladie depuis 2002. Ce travail a pour objectif de presenter un mode original de collaboration public–prive et d’en evaluer l’efficience. Methodes Depuis 2004, trois structures douleur francaises du secteur public collaborent avec un neurochirurgien installe en etablissement de sante prive, selon une procedure organisationnelle bien etablie. Un registre prospectif a ete mis en place pour evaluer l’efficacite et la securite de nos pratiques. Resultats Notre serie porte sur 141 patients ayant beneficie d’une phase test de SM ; 75 % ont ete implantes definitivement. Parmi les patients non perdus de vue, 81,7 % beneficient d’un soulagement superieur a 80 % de la douleur a long terme (12 mois) : ces resultats sont nettement superieurs a ceux de la litterature. Le taux de complications est quant a lui inferieur a celui des series publiees, la grande majorite des complications etant mineures et reversibles. Conclusions Notre mode original de collaboration public–prive a permis de simplifier et de decloisonner les filieres de mise en place de la SM dans notre territoire de sante, au benefice direct des patients. Les resultats de notre serie en termes d’efficacite et de securite viennent confirmer la pertinence d’une telle organisation.