Pleural penetration of amoxicillin and metronidazole during pleural infection: An ambispective cohort study.

OBJECTIVES: The pharmacokinetics of antibiotics in pleural fluid during pleural infections has been poorly described. This study aimed to explore amoxicillin and metronidazole diffusion into the pleural space. METHODS: This was an ambispective, single-centre study that included patients with complicated parapneumonic effusion or pleural empyema managed with repeated therapeutic thoracentesis as first-line treatment between 2014 and 2022. Pleural steady-state or trough concentrations of amoxicillin and metronidazole were measured, with a lower limit of quantification of 5 mg/L. RESULTS: Seventy paired blood and pleural samples were analysed from 40 patients. The median (interquartile range) patient age was 55 years (45-67 years) and 88% were male. The median patient weight was 65.8 kg (57.3-82 kg) and median plasma albumin concentration was 29.7 g/L (23.7-33.9 g/L). Median creatinine clearance was 106 mL/min (95-117 mL/min). Median amoxicillin pleural concentrations in patients treated with oral, bolus and continuous intravenous administrations (6 g/day) were, respectively, 5.2 (<5-6.4), 9.4 (8-13.1) and 10.8 (7.1-13.1) mg/L. Pleural concentrations were <5 mg/L in 5/11 samples (45%) with oral treatment and 6/59 (10%) with intravenous treatment. Median metronidazole pleural concentrations were 18.4 (15.7-22.8) mg/L, with all patients being treated orally (1.5 g/day). CONCLUSIONS: Oral metronidazole (1.5 g/day) and intravenous amoxicillin (6 g/day) achieved therapeutic targets in pleural fluid in most cases, but oral amoxicillin did not.

Benralizumab for eosinophilic granulomatosis with polyangiitis.

BACKGROUND: Benralizumab is effective in the treatment of eosinophilic asthma and is being investigated for the treatment of other eosinophil-associated diseases. Reports on the use of benralizumab for the treatment of eosinophilic granulomatosis with polyangiitis (EGPA) are limited to case reports and small case series. METHODS: We conducted a multicentre, retrospective study including EGPA patients treated with off-label benralizumab. The primary endpoint was the rate of complete response defined as no disease activity (Birmingham Vasculitis Activity Score=0) and a prednisone dose ≤4 mg/day. Partial response was defined as no disease activity and a prednisone dose ≥4 mg/day. RESULTS: Sixty-eight patients were included, including 31 (46%) who had previously received mepolizumab. The use of benralizumab was warranted by uncontrolled asthma in 54 (81%), persistent ear, nose and throat (ENT) manifestations in 27 (40%) and persistent glucocorticoids (GCs) use in 48 (74%) patients. Median (IQR) follow-up after starting benralizumab was 23 (9-34) months. Thirty-three patients (49%) achieved a complete response, 24 (36%) achieved a partial response and 10 (15%) did not respond. Among the 57 patients who initially responded, 10 (18%) eventually required further line treatments. GCs were discontinued in 23 patients (38%). Prior mepolizumab use was associated with a higher rate of primary failure (26.7% vs 5.4%, p=0.034) and less frequent GCs discontinuation (14.8% vs 55.9%, p=0.001). Vasculitis flares occurred in 7 patients (11%) and were associated with histological evidence of vasculitis and/or antineutrophil cytoplasmic antibodies positivity at benralizumab initiation (p=0.004). CONCLUSIONS: Benralizumab appears to be an effective treatment for refractory asthma or ENT manifestations in EGPA and allows GC-sparing. However, its efficacy was lower after prior failure of mepolizumab.

A case report of Covid-19 in an autoimmune pulmonary alveolar proteinosis: An association in tune with the times!

Autoimmune pulmonary alveolar proteinosis (PAP) is a rare disease characterized by the alveoli accumulation of surfactants proteins and lipids, which diagnosis is confirmed by the presence of GM-CSF antibodies in serum. PAP can be evoked when its characteristic images on chest computed-tomography (CT) are present: bilateral and multifocal ground-glass opacities and crazy-paving appearance. Patients with PAP are at an increased risk of opportunistic infections caused by Nocardia, mycobacteria and fungal pathogens due to impaired processing of pulmonary surfactant. We here report a typical case of newly diagnosed autoimmune PAP, with initial indication to realize a whole-lung lavage. Despite this treatment the patient presented a marked clinical worsening, with increasing need for oxygen and finally the need for mechanical ventilation. The chest CT was controlled and found to be typical of PAP, while the search for opportunistic infections remained negative. Finally, SARS-CoV-2 PCR was performed on bronchoalveolar lavage fluid, and was positive, whereas it had previously been negative twice. Our case report highlights the difficulty of distinguishing SARS-CoV-2 infection in the context of PAP, as the chest CT features are similar. We believe that a SARS-CoV-2 RT-PCR should be systematically realized in case of respiratory deterioration in PAP patients.

Construction and Validation of an Individual Deprivation Index: a Study Based on a Representative Cohort of the Paris Metropolitan Area.

The association between health status and deprivation is well established. However, it is difficult to measure deprivation at an individual level and already-existing indices in France are not validated or do not meet the needs of health practitioners. The aim of this work was to establish a validated, easy-to-use, multidimensional, relevant index that was representative of the population in the Paris metropolitan area. From the SIRS 2010 cohort study, 14 socio-economic characteristics were selected: health insurance, educational background, socio-professional category, professional status, feelings of loneliness, emotional situation, household type, income, perceived financial situation, social support (support in daily life, financial and emotional), housing situation, and migration origin. In addition, a total of 12 health status, healthcare use, and nutrition-related variables were also selected. Content validity and internal validity of the index were explored. The 14 socio-economic indicators were associated to varying degrees with poorer health status, less use of healthcare, and poorer nutrition and were distributed across the 14 multiple-choice questions of the index. Each answer was rated from 0 to 2. The index value of 10 that isolates 20% of the most deprived individuals was used as threshold. "Being deprived," as defined with this value, was significantly associated with 9 of the 12 studied health variables. This index could be a relevant instrument in the assessment of deprivation and social inequalities of health.

Determinants of human papillomavirus (HPV) vaccine uptake among girls in France: A population-based telephone survey.

INTRODUCTION: The uptake of human papillomavirus (HPV) vaccination in France remains low. The aim of this study was to identify factors associated with the uptake of the HPV vaccine in girls aged 11-14 years in France. METHODS: We conducted a telephone survey among a quota sample of 1102 mothers of 11-14-year-old daughters residing in mainland France, using the French Survey Questionnaire for the Determinants of HPV Vaccine Hesitancy (FSQD-HPVH). The dependent variable was the uptake of at least one dose of the HPV vaccine in the daughter. The independent variables included the FSQD-HPVH item variables, the Global Vaccine Confidence Index item variables, the daughter's age, and the mother's socioeconomic status. RESULTS: Overall, 38.6% of the mothers indicated that their daughter received at least one dose of the HPV vaccine. The multivariate analysis revealed that agreeing with the statement that doctors/health care providers believe vaccinating girls against HPV was a good idea, and having asked questions to the attending doctor about HPV vaccines were associated with a higher HPV vaccine uptake (OR = 4.99 , 95% CI [2.09-11.89]; and OR = 3.44, 95% CI [2.40-4.92]). Mother's belief that her daughter was too young to be vaccinated against HPV (OR = 0.16 , 95% CI [0. 09-0.29]) and lower daughter's age (OR = 0.17 , 95% CI [0.10-0.28] for girls aged 11 compared to those aged 14) were found strongly inversely associated with HPV vaccination, followed by agreeing with the statement that the HPV vaccine was unsafe (OR = 0.42 , 95% CI [0.26-0.67]), identifying as true the statement that HPV was very rare (OR = 0.49 , 95% CI [0.31-0.77]), and the mother's refusal of own vaccination (OR = 0.57 , 95% CI [0.40-0.80]). CONCLUSION: We have identified important determinants associated with HPV vaccine uptake in France. Interventions designed to improve HPV vaccine uptake should be tailored to address these determinants.

Malnutrition and decreased food intake at diagnosis are associated with hospitalization and mortality of idiopathic pulmonary fibrosis patients.

INTRODUCTION AND AIMS: Malnutrition is frequent in patients with idiopathic pulmonary fibrosis (IPF). We examined the relationship between malnutrition at diagnosis and all-cause hospitalization, survival, and acute exacerbation in newly diagnosed IPF patients. METHODS: In this prospective cohort study, the nutritional status of 153 consecutive newly-diagnosed IPF outpatients was evaluated by measuring body mass index (BMI), fat-free mass index (FFMI) with bioelectrical impedance analysis, and food intake with the Self Evaluation of Food Intake (SEFI)®. Diagnosis was taken as the baseline date and malnutrition was defined as an FFMI below 17 (men) or 15 kg/m2 (women). To determine the factors associated with all-cause hospitalization and mortality, univariate Cox regression analyses were performed and variables with P < 0.2 were included in a stepwise multivariable analysis. RESULTS: A quarter (26%; 40/153) of the patients were suffering from malnutrition at baseline, which was more frequent (62%) in patients whose BMI was <25 kg/m2. Patients whose baseline FFMI was low were more likely to be hospitalized (Hazard Ratio (HR) = 1.98 [95% confidence interval, 1.15; 3.41], P = 0.0139) and/or die (HR = 1.79 [1.11; 2.89], P = 0.0165), but their acute exacerbation rate was similar to that of patients with normal FFMIs. Decreased food intake (SEFI®<7) at baseline was associated with all-cause hospitalization (P = 0.003) and mortality (P < 0.0001) during follow-up. Baseline higher gender-age-physiology (GAP) scores (HR = 1.24 [1.01; 1.52], P = 0.0434; HR = 1.71 [1.37; 2.14], P < 0.0001, respectively), lower BMI (HR = 0.89 [0.83; 0.96], P = 0.003; HR = 0.89 [0.82; 0.96], P = 0.003), and decreased food intake (SEFI® score) (HR = 0.81 [0.71; 0.93], P = 0.003; HR = 0.72 [0.64; 0.81], P < 0.0001), but not FFMI, were independently associated with all-cause hospitalization and mortality rates during follow-up. CONCLUSIONS: Malnutrition and decreased food intake at IPF diagnosis are associated with all-cause hospitalization and mortality. Future studies will determine whether dedicated interventions to improve food intake and nutritional status could improve outcomes for IPF patients.

Soluble CD163 is produced by monocyte-derived and alveolar macrophages, and is not associated with the severity of idiopathic pulmonary fibrosis.

The soluble form of the membrane hemoglobin scavenger receptor CD163 (sCD163), released by shedding, is a strong marker for macrophage activation. Serum sCD163 levels rise in several acute inflammatory states and some fibrosing diseases. Monocyte-derived macrophages (MoDM) differentiated by macrophage colony-stimulating factor (M-MoDM) contribute to the pathophysiology of idiopathic pulmonary fibrosis (IPF), an irreversible and rapidly fatal interstitial lung disease. Since M-MoDM express high membrane CD163 levels, we thus postulated that sCD163 could be a relevant biomarker for macrophage activation in IPF. We found that M-MoDM constitutively released higher amounts of sCD163 (49.5 ± 24.5 ng/ml) than monocytes (0.45 ± 0.32 ng/ml) or MoDM differentiated with granulocyte macrophage-stimulating factor (2.24 ± 0.98 ng/ml). The basal production of sCD163 by M-MoDM was increased following stimulation with lipopolysaccharide (123.4 ± 54.9 ng/ml) or ATP (168.9 ± 41.8 ng/ml). The sCD163 release was controlled by metalloproteases but not through ADAM17 activation. Moreover, CD163-positive macrophages and sCD163 were detected in pulmonary tissues and alveolar fluids of Caucasian patients with IPF, respectively. IPF alveolar macrophages constitutively secreted sCD163 amounts (67.6 ± 44.6 ng/µg RNA) which were significantly higher than those released by alveolar macrophages isolated from controls (19.2 ± 7.6 ng/µg RNA) or patients with other interstitial lung disease (31.5 ± 16.6 ng/µg RNA). However, the concentrations of sCD163 in blood serum collected from 155 patients with IPF did not correlate with the severity of their disease. In conclusion, our results show that M-MoDM constituted a pertinent model to study the regulation of sCD163 production. Yet, serum sCD163 values could not provide a prognostic biomarker for IPF in our cohort.

Online mis/disinformation and vaccine hesitancy in the era of COVID-19: Why we need an eHealth literacy revolution.

The quality of online health information is cause for concern in general, and the spread of mis/disinformation on the benefits and risks of vaccines has certainly been fueling vaccine hesitancy. In the wake of the COVID-19 pandemic, we have entered an era of unprecedented "infodemic." There has never been a more urgent time to address the long-standing question of how to overcome the deleterious influence of exposure to online mis/disinformation on vaccine uptake. eHealth literacy, a skill set including media literacy, is key to navigating the web in search for health information and processing the one encountered through social media. Studies assessing the impact of increasing eHealth literacy on behavioral attitudes and health outcomes in the general population are relatively scarce to date. Yet for many reasons, leveraging eHealth literacy skills, and more specifically, media literacy, could be of great value to help mitigate the detrimental effects of erroneous information on vaccination decision-making. In this paper, we make the case that eHealth and media literacies should be viewed as fundamental skills that have the potential to empower citizens to better recognize online mis/disinformation and make informed decisions about vaccination as any other health matters.

Intrapleural use of urokinase and DNase in pleural infections managed with repeated thoracentesis: A comparative cohort study.

INTRODUCTION: Evacuation of infected fluid in pleural infections is essential. To date, the use of an intrapleural fibrinolytic agent such as urokinase and DNase has not yet been assessed in infections managed by repeated therapeutic thoracentesis (RTT). METHODS: We performed a retrospective comparative study of two successive cohorts of consecutive patients with pleural infections from 2001 to 2018. Between 2001 and 2010, patients had RTT with intrapleural urokinase (RTT-U). After 2011, patients received intrapleural urokinase and DNase with RTT (RTT-UD). Data were collected through a standardized questionnaire. RESULTS: One hundred and thirty-three patients were included: 93 were men and the mean age was 59 years (standard deviation 17.2). Eighty-one patients were treated with a combination of intrapleural urokinase and DNase, and 52 were treated with intrapleural urokinase only. In the RTT-UD, RTT failure occurred in 14 patients (17%) compared to 10 (19%) in the RTT-U group (P = 0.82). There was no difference between the two groups in intensive care unit admission, surgical referrals or in-hospital mortality. RTT-UD was associated with faster time to apyrexia (aOR = 0.51, 95%CI [0.37-0.72]), a reduced length of hospital stay (aOR = 0.61, 95%CI [0.52-0.73]) and a higher volume of total pleural fluid retrieved (aOR = 1.38, 95%CI [1.02-1.88]). Complications were rare with only one hemothorax in the RTT-UD group and no pneumothorax requiring drainage in either group. CONCLUSION: Compared to urokinase only, intrapleural use of urokinase and DNase in RTT was associated with quicker defervescence, shorter hospital stay and increased volumes of pleural fluid drained. Randomized controlled trials evaluating urokinase and DNase with RTT technique would be required to confirm these results.

Effect of Internet use for searching information on vaccination on the uptake of human papillomavirus vaccine in France: A path-analysis approach.

Internet is a popular source of information regarding vaccination. This study aimed to determine whether there is a negative association between Internet use among French vaccine-hesitant mothers and HPV vaccine uptake by their daughters, and to gain insight into the pathways that would link Internet use to the lack of HPV vaccine uptake. We conducted a pooled cross-sectional analysis across the 2015, 2016, 2017 and 2018 Vaccinoscopie® Survey. Multivariate logistic regression and path models were used in the analysis. The study sample included a total of 2038 respondent mothers. Of those, 89 (4.4%) declared having never been in the situation of searching for information regarding a vaccination they had hesitated about, leaving 1949 mothers for the present analysis. Approximately 24% (466/1949) of the mothers declared using the Internet as a source of vaccine information. In multivariate logistic regression adjusted for physician recommendation of HPV vaccination, attitudes towards vaccines in general, perception of HPV vaccine usefulness, maternal level of education, region of residence, and the survey year, the use of Internet by the mothers was significantly associated with a lower HPV vaccination among their daughters (adjusted odds ratio (aOR), 0.66; 95% confidence interval (CI), 0.47-0.91). Path analysis further confirmed the negative effect of Internet use (ß = -0.10, standard error (SE) = 0.02, P < 0.0001), highlighting how the Internet plays a detrimental role in HPV vaccine uptake through a lower perceived level of HPV vaccine usefulness, a lower perceived level of information on childhood vaccination, and unfavorable attitudes towards vaccination in general.

Patterns of gynaecological check-up and their association with body mass index within the CONSTANCES cohort.

OBJECTIVES: To investigate the relationship between patterns of gynaecological check-up and body mass index while accounting for various determinants of health care use. METHODS: Sequence analysis and clustering were used to highlight patterns of gynaecological check-up, which included the regularity of breast and cervical cancer screening and visits to the gynaecologist over four years, among 6182 women aged 54-65 included in the CONSTANCES cohort between 2013 and 2015 in France. Multinomial logistic regressions were used to study the association between these patterns and women's body mass index. RESULTS: We identified four patterns of gynaecological check-up, from (A) no or inappropriate check-up (20%) to (D) almost one visit to the gynaecologist every year, overscreening for cervical cancer and frequent use of opportunistic breast cancer screening (12%). From patterns A to D, the proportion of obese women decreased and that of women with normal body mass index increased. Obese and overweight women underwent more breast than cervical cancer screening and were less often overscreened than normal weight women. These differences were only partly explained by the lower socioeconomic situation of overweight and obese women. Beyond the financial barrier, the screening modality and the type of exam may play a role. Among women who were screened for cervical cancer, obese and overweight women were less often screened by a gynaecologist. CONCLUSION: Further efforts should be made to enhance the take-up of screening among obese women who are deterred by the healthcare system.

Acceptability of on-site rapid HIV/HBV/HCV testing and HBV vaccination among three at-risk populations in distinct community-healthcare outreach centres: the ANRS-SHS 154 CUBE study.

BACKGROUND: HIV, HBV and HCV infections continue to represent major health concerns, especially among key at-risk populations such as men who have sex with men (MSM), people who inject drugs (PWIDs), transgender women (TGW) and sex workers (SW). The objective of the ANRS-CUBE study was to evaluate the acceptability of a healthcare, community-based strategy offering a triple rapid HIV-HBV-HCV testing, and HBV vaccination, targeted at three priority groups (MSM, PWIDs and TGW/SWs), in three community centers, in the Paris area. METHODS: This longitudinal multicentric non-randomized study included all adult volunteers attending one of the three specialized community centers in Paris, between July 2014 and December 2015. HIV, HBV and HCV status and acceptability of HBV vaccination were evaluated. RESULTS: A total of 3662, MSM, 80 PWIDs and 72 TGW/SW were recruited in the three centers respectively. Acceptability of rapid tests was 98.5% in MSM and 14.9% in TGW/SWs, but could not be estimated in PWIDs since the number of users attending and the number of proposals were not recorded. User acceptability of HBV vaccination was weak, only 17.9% of the eligible MSM (neither vaccinated, nor infected) agreed to receive the first dose, 12.2% two doses, 5.9% had a complete vaccination. User acceptability of HBV vaccination was greater in PWIDs and TGW/SWs, but decreased for the last doses (66.7 and 53.3% respectively received a first dose, 24.4 and 26.7% a second dose and 6.7 and 0% a third dose). Fifty-three participants (49 MSM and 4 PWIDs) were discovered HIV positive, more than half with a recent infection. All but two HIV positive participants were linked to appropriate care in less than one month. CONCLUSIONS: Rapid HIV-HCV-HBV screening showed a very high level of acceptability among MSM. Efforts need to be made to improve immediate acceptability for HBV vaccination, especially among MSM, and follow-up doses compliance. Our results show the important role of community centers in reaching targets, often fragile, populations, while also suggesting the need to reinforce on-site human support in terms of testing and vaccination, especially when addressing PWIDs.

Mental Healthcare Utilization among Homeless People in the Greater Paris Area.

The healthcare utilization of homeless people is generally considered insufficient, and studies often suffer from methodological bias (institutionalized vs. street samples). To adapt public health policies in France, epidemiological data on this population are scarce. The objective of this study was to analyze the use of psychiatric care by homeless people with mental health problems in the Greater Paris area and to define the factors influencing this use. The data were from the SAMENTA survey performed in 2009 with a representative random street sample of 859 homeless people from the Greater Paris area. The survey studied the use of psychiatric care (lifelong use, current follow-up, discontinuation of follow-up and treatment) and factors potentially associated with this use for people with a diagnosis of a psychotic, mood or anxiety disorder, with the diagnosis established with an original survey device. Because of our complex sampling design, we describe data for only a weighted estimated prevalence, weighted estimation of the number of people in the population (N) and unweighted total subgroup studied in the survey (n). Among 840 homeless people with useable data, 377 (N = 9762) had a psychiatric disorder. The use of whole-life care for these people may seem high, estimated at 68.7%, but few people were followed up for their disorders (18.2%); individuals with a psychotic disorder were more frequently followed up (36.5%) than others were (p < 0.05). Among those followed up (n = 86, N = 1760), 63.0% were taking medication. Access to care for these people seemed preserved, but the maintenance of care seemed problematic; indeed, among people with a lifelong whole use of care (n= 232, N = 6705), 72.3% could be considered to have discontinued care. The factors that improved lifetime health service utilization or follow-up were socio-demographic (age < 42 years, more educated), social (with social security coverage, not living in a hotel), and medical (psychotic disorder, personality disorder, suicide risk, somatic chronic illness, perception of mental suffering). Improving the care of homeless people with psychiatric disorders requires improving access to care for those isolated from the health system (in particular those living in hotels) and to guarantee continuity of care, by adapting the organization of the care system and promoting social rehabilitation.

Design and content validation of a survey questionnaire assessing the determinants of human papillomavirus (HPV) vaccine hesitancy in France: A reactive Delphi study.

INTRODUCTION: This study aimed to develop and undertake a preliminary validation of a French Survey Questionnaire for the Determinants of HPV Vaccine Hesitancy (FSQD-HPVH). METHODS: We undertook an electronic-based Delphi consultation among a panel of Francophone experts in two rounds. Round 1 consisted of the assessment of a structured questionnaire comprising of three parts ((i) Contextual influences, (ii) Individual and group influences, and (iii) Vaccine/vaccination-specific issues), in line with the WHO Strategic Advisory Group of Experts (SAGE) Vaccine Hesitancy (VH) Model of Determinants. Items included in this questionnaire were based on a literature review. Definitions of the factors included in the SAGE model were provided in the questionnaire. The panel of experts was asked to score each item using a 3-point Likert scale, in which 1 meant "Essential", 2 "Useful but not essential", and 3 "Not necessary". The panel was also invited to comment on the clarity/comprehension of the questions and suggest reformulations/additional items. Lawshe's Content Validity Ratio (CVR) was computed to assess the level of consensus for each statement. Only items upon which agreement was not reached in Round 1 (CVR < 0.6) and newly proposed items were submitted for evaluation in Round 2, using the same procedure. RESULTS: Fifteen experts completed the two rounds. Of 83 items evaluated in Round 1, 35 (42%) had a CVR ≥ 0.6 and were accepted without modification. In Round 2, 66 items were submitted to the same panel and consensus was reached for 22 (33%) items using the threshold of 0.6. The final FSQD-HPVH version includes 57 items. CONCLUSION: This study developed a survey instrument for the evaluation of HPV VH in France with good content validity. It will be used to assess the determinants of HPV VH, the first step towards an evidence-based approach to improving HPV vaccination rates in France.

Risk of late cervical cancer screening in the Paris region according to social deprivation and medical densities in daily visited neighborhoods.

BACKGROUND: Social and physical characteristics of the daily visited neighborhoods have gained an extensive interest in analyzing socio-territorial inequalities in health and healthcare. The objective of the present paper is to estimate and discuss the role of individual and contextual factors on participation in preventive health-care activities (smear screening) in the Greater Paris area focusing on the characteristics of daily visited neighborhoods in terms of medical densities and social deprivation. METHODS: The study included 1817 women involved in the SIRS survey carried out in 2010. Participants could report three neighborhoods they regularly visit (residence, work/study, and the next most regularly visited). Two "cumulative exposure scores" have been computed from household income and medical densities (general practitioners and gynecologists) in these neighborhoods. Multilevel logistic regression models were used to measure association between late cervical screening (> 3 years) and characteristics of daily visited neighborhoods (residential, work or study, visit). RESULTS: One-quarter of the women reported that they had not had a smear test in the previous 3 years. Late smear test was found to be more frequent among younger and older women, among women being single, foreigners and among women having a low-level of education and a limited activity space. After adjustment on individual characteristics, a significant association between the cumulative exposure scores and the risk of a delayed smear test was found: women who were exposed to low social deprivation and to low medical densities in the neighborhoods they daily visit had a significantly higher risk of late cervical cancer screening than their counterparts. CONCLUSIONS: For a better understanding of social and territorial inequalities in healthcare, there is a need for considering multiple daily visited neighborhoods. Cumulative exposure scores may be an innovative approach for analyzing contextual effects of daily visited neighborhoods rather than focusing on the sole residential neighborhood.

Real-world care for individuals aged over fifty with fractures in France: Evidence for a wide care gap-The EPIFRACT Study.

OBJECTIVES: To describe the care trajectories of adults aged ≥50 years with fragility fractures in France. METHODS: A postal questionnaire was sent to 15,000 individuals aged ≥50 years extracted from a representative panel of the French population (METASKOPE) in April-May 2018. Respondents experiencing a single fragility fracture in the previous three years constituted the study population. Information was collected regarding diagnosis, hospitalisations, physician visits and treatment related to the fractures. RESULTS: 13,914 participants returned a questionnaire (92.8%), of whom 436 reported a single fragility fracture. Their mean age was 68.7±10.3 years. 11.9% of this sample had undergone bone densitometry (DXA) prior to the fracture and 11.9% had received a diagnostic of osteoporosis. Following the fracture, a further 17.4% underwent DXA and 8.5% were diagnosed with osteoporosis. 74.3% of fractures were initially managed in an emergency department and 29.6% led to immediate hospitalisation. Prior to fracture, 3.4% received a specific anti-osteoporotic treatment, 10.1% vitamin D and 6.4% calcium supplementation. After the fracture, these figures rose to 10.8%, 26.8% and 19.0% respectively. 86.2% participants made at least one follow-up visit to a physician. CONCLUSIONS: The rate of DXA screening following fragility fractures in subjects over fifty is very low. Most patients with fragility fractures did not receive a diagnosis of osteoporosis. The proportion of patients treated with a specific anti-osteoporotic treatment after a fracture is low even though around half consulted their general practitioner after the fracture. Practice guidelines are thus not being adhered to in everyday clinical practice in France.

Influence of Individual and Contextual Perceptions and of Multiple Neighborhoods on Depression.

The risk of depression is related to multiple various determinants. The consideration of multiple neighborhoods daily frequented by individuals has led to increased interest in analyzing socio-territorial inequalities in health. In this context, the main objective of this study was (i) to describe and analyze the spatial distribution of depression and (ii) to investigate the role of the perception of the different frequented spaces in the risk of depression in the overall population and in the population stratified by gender. Data were extracted from the 2010 SIRS (a French acronym for "health, inequalities and social ruptures") cohort survey. In addition to the classic individual characteristics, the participants reported their residential neighborhoods, their workplace neighborhoods and a third one: a daily frequented neighborhood. A new approach was developed to simultaneously consider the three reported neighborhoods to better quantify the level of neighborhood socioeconomic deprivation. Multiple simple and cross-classified multilevel logistic regression models were used to analyze the data. Depression was reported more frequently in low-income (OR = 1.89; CI = [1.07-3.35]) or middle-income (OR = 1.91; CI = [1.09-3.36]) neighborhoods and those with cumulative poverty (OR = 1.64; CI = [1.10-2.45]). In conclusion, a cumulative exposure score, such as the one presented here, may be an appropriate innovative approach to analyzing their effects in the investigation of socio-territorial inequalities in health.

Fragility fractures in France: epidemiology, characteristics and quality of life (the EPIFRACT study).

Between 1 and 2% of people aged 50 years and over living at home in France are likely to experience a fragility fracture each year. Three-quarters of these individuals are not diagnosed with osteoporosis and lose the opportunity for appropriate care. PURPOSE: To estimate the incidence of fragility fractures in France and to describe the characteristics of individuals with such fractures and of their fractures. METHODS: In April-May 2018, a postal survey was performed in France targeting a representative panel of 15,000 individuals aged ≥ 50 years, who were invited to complete a questionnaire. If they reported experiencing a fracture in the previous 3 years, they were asked to provide information on demographics, fracture type, risk factors for fractures and osteoporosis diagnosis. Only fragility fractures were considered, and these were classified as major (associated with increased mortality) or minor, based on the fracture site. RESULTS: Around 13,914 panellists returned an exploitable questionnaire (92.8%). About 425 participants reported ≥ 1 fragility fracture (453 fractures), corresponding to a 12-month incidence rate of 1.4% [95%CI: 1.2, 1.6]. Incidence was higher in women (1.99% [1.87, 2.05]) than in men (0.69% [0.38, 0.86]) and increased with age. Around 157 fractures (34.6%) were classified as major. Participants reporting major fractures were older than those reporting minor fractures (mean age: 72.6 ± 11.3 vs 67.1 ± 10.6) and more likely to report previous corticosteroid use (odds ratio: 1.90 [95%CI: 1.13, 3.18]). No other patient characteristic was associated with fracture severity. About 117 participants with fractures (27.5%) had undergone bone densitometry, and 97 (22.8%) declared having received a diagnosis of osteoporosis. CONCLUSIONS: Around 340,000 people aged ≥ 50 years living at home in France are estimated to experience osteoporotic fractures each year. However, > 75% of panellists reporting fractures were never diagnosed with osteoporosis and thus did not have the opportunity to receive appropriate care.

Non-participation and attrition in a longitudinal study of civilians exposed to the January 2015 terrorist attacks in Paris, France.

BACKGROUND: Non-participation and attrition are rarely studied despite being important methodological issues when performing post-disaster studies. A longitudinal survey of civilians exposed to the January 2015 terrorist attacks in Paris, France, was conducted 6 (Wave 1) and 18 months (Wave 2) after the attacks. We described non-participation in Wave 1 and determined the factors associated with attrition in Wave 2. METHODS: Multivariate logistic regression models were used to compare participants in both waves with those who participated in the first wave only. Analyses were performed taking the following factors into account: socio-demographic characteristics, exposure to terror, peri-traumatic reactions, psychological support, perceived social support, impact on work, social and family life, and mental health disorders. Characteristics of new participants in Wave 2 were compared with participants in both waves using a chi-square test. RESULTS: Of the 390 persons who were eligible to participate in the survey, 190 participated in Wave 1 (participation rate: 49%). The most frequently reported reason for non-participation was to avoid being reminded of the painful event (32%, n = 34/105). In Wave 2, 67 were lost to follow-up, 141 people participated, of whom 123 participated in Wave 1 (re-participation rate: 65%) and 18 were new. Attrition in Wave 2 was associated with socio-demographic characteristics (age, French origin) and location during the attacks, but not with terror exposure or mental health disorders. Compared with those who participated in both waves, new participants declared less social and psychological support since the attacks. CONCLUSIONS: Attrition at 6 months was not associated with exposure to terror or mental health disorders, which indicates that any bias in future analyses on IMPACTS on mental health outcomes will be limited. Our findings suggest the importance of adapting similar surveys for people of foreign origin and of improving strategies to avoid attrition of younger people, for example by using social media, peers, and the educational environment. The present study also revealed that a high level of exposure to terror and a lack of social and psychological support after a terrorist event could impede individuals' participation in similar surveys in the short term.