Frédéric Mauny

Medication adherence in type 2 diabetes: the ENTRED study 2007, a French Population-Based Study.

Background Adherence to prescribed medications is a key dimension of healthcare quality. The aim of this large population-based study was to evaluate self-reported medication adherence and to identify factors linked with poor adherence in patients with type 2 diabetes in France. Methodology The ENTRED study 2007, a French national survey of people treated for diabetes, was based on a representative sample of patients who claimed reimbursement for oral hypoglycaemic agents and/or insulin at least three times between August 2006 and July 2007, and who were randomly selected from the database of the two main National Health Insurance Systems. Medication adherence was determined using a six-item self-administered questionnaire. A multinomial polychotomous logistic regression model was used to identify factors associated with medication adherence in the 3,637 persons with type 2 diabetes. Principal Findings Thirty nine percent of patients reported good medication adherence, 49% medium adherence and 12% poor adherence. The factors significantly associated with poor adherence in multivariate analysis were socio-demographic factors: age <45 years, non-European geographical origin, financial difficulties and being professionally active; disease and therapy-related factors: HbA1c>8% and existing diabetes complications; and health care-related factors: difficulties for taking medication alone, decision making by the patient only, poor acceptability of medical recommendations, lack of family or social support, need for information on treatment, reporting no confidence in the future, need for medical support and follow-up by a specialist physician. Conclusions In a country with a high level of access to healthcare, our study demonstrated a substantial low level of medication adherence in type 2 diabetic patients. Better identification of those with poor adherence and individualised suitable recommendations remain essential for better healthcare management.

Relationship between Spread of Methicillin-Resistant Staphylococcus aureus and Antimicrobial Use in a French University Hospital

The objective of our study was to determine whether antibiotic pressure in the units of a teaching hospital affects the acquisition of methicillin-resistant Staphylococcus aureus (MRSA), independently of the other collective risk factors previously shown to be involved (MRSA colonization pressure, type of hospitalization unit, and care workload). The average incidence of acquisition of MRSA during the 1-year study period was 0.31 cases per 1000 days of hospitalization, and the use of ineffective antimicrobials reached 504.54 daily defined doses (DDDs) per 1000 days of hospitalization. Univariate analysis showed that acquisition of MRSA was significantly correlated with the use of all antimicrobials, as well as correlated with the use of each class of antimicrobial and with colonization pressure. Multivariate analysis with a Poisson regression model showed that the use of antimicrobials was associated with the incidence of acquisition of MRSA, independently of the other variables studied, but it did not allow us to determine the hierarchy of the different antimicrobial classes with respect to the effect.

Dioxin emissions from a solid waste incinerator and risk of non-Hodgkin lymphoma.

Background It is not clear whether low environmental doses of dioxin affect the general population. We previously detected a cluster of patients with non-Hodgkin lymphoma around a French municipal solid waste incinerator with high dioxin emissions. To explore the environmental route suggested by these findings, we carried out a population-based case-control study in the same area. Methods We compared 222 incident cases of non-Hodgkin lymphoma diagnosed between 1980 and 1995 and controls randomly selected from the 1990 population census, using a 10-to-1 match. Dioxin ground-level concentrations were modeled with a second-generation Gaussian-type dispersion model, yielding four dioxin exposure categories. The latter were linked to individual places of residence, using Geographic Information System technology. Results The risk of developing non-Hodgkin lymphoma was 2.3 times higher (95% confidence interval = 1.4–3.8) among individuals living in the area with the highest dioxin concentration than among those living in the area with the lowest dioxin concentration. No increased risk was found for the intermediate dioxin exposure categories. Adjustment for a wide range of socioeconomic characteristics at the block group level did not alter the results. Conclusion Although emissions from incinerators are usually not regarded as an important source of exposure to dioxins compared with other background sources, our findings support the hypothesis that environmental dioxins increase the risk of non-Hodgkin lymphoma among the population living in the vicinity of a municipal solid waste incinerator.

Negligible risk for epidemics after geophysical disasters

Short-term risk for epidemics after geophysical disasters is very low.

Longitudinal study of respiratory health in dairy farmers: influence of artificial barn fodder drying

Factors influencing respiratory consequences of dairy farming have not been extensively investigated to date. To evaluate the effects of barn fodder drying on respiratory symptoms and lung function, a 5 yr follow-up study was performed in the Doubs (France). A cohort of male dairy farmers was analysed in 1990. The initial cross-sectional results suggested that barn-drying fodder may protect dairy farmers from lung function impairment. In 1995, 113 barn-drying farmers (92%) and 231 traditional-drying farmers (84%) were re-analysed. Barn and traditional fodder-drying farmers were compared for prevalence of symptoms and spirometric measures of lung function. After controlling for age, smoking status, altitude and cumulative exposure, barn-drying farmers compared to traditional-drying farmers had a lower prevalence of chronic bronchitis (4 versus 10%; p<0.05) and slightly higher values of forced expiratory volume in one second (FEV1) (p=0.06) and FEV1/vital capacity (VC) (p<0.01). Nevertheless, decline of the respiratory function parameters was not significantly different between the two groups. Variables positively and significantly associated to longitudinal decline of lung function parameters were: age (FEV1, FEV1/VC); altitude (VC, FEV1) and chronic bronchitis and dyspnoea at the initial survey (FEV1/VC). Persistence and emergence of chronic bronchitis, dyspnoea and symptoms at exposure were also significantly associated to an acceleration in the annual decline of the respiratory function. In conclusion, the mode of fodder drying does not seem to significantly influence the decline in lung function. Nevertheless, this study confirms the results of the initial cross-sectional analysis and supports the hypothesis that barn drying fodder may have a protective effect on respiratory health in dairy farming.

Prevalence and risk factors for COPD in farmers: a cross-sectional controlled study

There are conflicting data regarding the magnitude and determinants of chronic obstructive pulmonary disease (COPD) risk in farmers. In a cross-sectional study of 917 nonfarming working controls and 3787 farmers aged 40–75 years, we assessed respiratory symptoms, tobacco exposure, job history (without direct exposure measurement) and lung function. COPD was defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criterion (post-bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) <0.70) and by the Quanjer reference equation (post-bronchodilator FEV1/FVC <lower limit of normal (LLN)). The prevalence (95% CI) of COPD according to the GOLD criterion was 5.1% (4.4–5.8%) and 2.9% (1.8–4.0%) in farmers and controls, respectively (p=0.005), and 3.1% (2.5–3.6%) and 1.5% (0.7–2.3%), respectively, for the LLN criterion (p<0.01). For both COPD criteria after adjustment for age, sex and smoking status, COPD prevalence was similar in controls and crop farmers. Compared to controls, four job categories had a higher prevalence of COPD according to the GOLD criterion, namely, cattle breeders, swine breeders, poultry breeders and breeders of two or more livestock types. Among cattle breeders, only those from Franche-Comté had higher prevalence of COPD according to both GOLD and LLN criteria. The prevalence of COPD in farmers is higher than in nonfarming working controls, and depends on the farming activity, the region and the criterion used to define COPD. Prevalence of COPD is higher in agricultural workers than in nonfarming working control subjects http://ow.ly/RUYe8

Assessing residential exposure to urban noise using environmental models: does the size of the local living neighborhood matter?

Environmental epidemiological studies rely on the quantification of the exposure level in a surface defined as the subject’s exposure area. For residential exposure, this area is often the subject’s neighborhood. However, the variability of the size and nature of the neighborhoods makes comparison of the findings across studies difficult. This article examines the impact of the neighborhood’s definition on environmental noise exposure levels obtained from four commonly used sampling techniques: address point, façade, buffers, and official zoning. A high-definition noise model, built on a middle-sized French city, has been used to estimate LAeq,24 h exposure in the vicinity of 10,825 residential buildings. Twelve noise exposure indicators have been used to assess inhabitants’ exposure. Influence of urban environmental factors was analyzed using multilevel modeling. When the sampled area increases, the average exposure increases (+3.9 dB), whereas the SD decreases (−1.6 dB) (P<0.01). Most of the indicators differ statistically. When comparing indicators from the 50-m and 400-m radius buffers, the assigned LAeq,24 h level varies across buildings from –9.4 to +22.3 dB. This variation is influenced by urban environmental characteristics (P<0.01). On the basis of this study’s findings, sampling technique, neighborhood size, and environmental composition should be carefully considered in further exposure studies.

Spatial and space-time scan statistics to detect low rate clusters of sex ratio

Whether general environmental exposures to endocrine disrupting chemicals (including pesticides and dioxin) might induce decreased sex ratios (male/female ratio at birth) is discussed. To address this issue, the authors looked for a space-time clustering test which could detect local areas of significantly low risk, assuming a Bernoulli distribution. As a matter of fact, if the endocrine disruptor hypothesis holds true, and if the sex ratio is a sentinel health event indicative of new reproductive hazards ascribed to environmental factors, then in a given region, either a cluster of low male/female ratio among newborn babies would be expected in the vicinity of polluting municipal solid waste incinerators (MSWIs) (supporting the dioxin hypothesis), or local clusters would be expected in some rural areas where large amounts of pesticides are sprayed. Among cluster detection tests, the spatial scan statistic has been widely used in various applications to scan for areas with high rates, and rarely (if ever) with low rates. Therefore, the goal of this paper was to check the properties of the scan statistics under a given scenario (Bernoulli distribution, search for clusters with low rates) and to assess its added value in addressing the sex ratio issue. This study took place in the Franche-Comté region (France), mainly rural, comprising three main MSWIs, among which only one had high dioxin emissions level in the past. The study population consisted of 192,490 boys and 182,588 girls born during the 1975–1999 period. On the whole, the authors conclude that: (i) spatial and space-time scan statistics provide attractive features to address the sex ratio issue; (ii) sex ratio is not markedly affected across space and does not provide a reliable screening measure for detecting reproductive hazards ascribed to environmental factors.

Indoor noise exposure at home: a field study in the family of urban schoolchildren.

This article aims at evaluating indoor noise levels at home and investigating the factors that may influence their variability. An 8-day noise measurement campaign was conducted in the homes of 44 schoolchildren attending the public primary schools of Besançon (France). The presence of the inhabitants in the dwelling and the noisy events occurring indoors and outdoors was daily collected using a time-location-activity diary (TLAD); 902 time periods were analyzed. The indoor noise level increased significantly with the outdoor noise level, along with the duration of the presence or level of activity of the inhabitants at home. However, this effect may vary according to the period of day and the day of the week. Moreover, a significant part of the day and evening indoor noise level variability was explained when considering the TLAD variables: 46% and 45% in the bedroom, 54% and 39% in the main room, respectively. Our results highlight the complexity of the indoor environment in the dwellings of children living in an urban area. Combining the inhabitant presence and indoor noise source descriptors with outdoor noise levels and other dwelling or inhabitant characteristics could improve large-scale epidemiological studies. However, additional efforts are still needed, particularly during the night period.

Dispersion Modelling as a Dioxin Exposure Indicator in the Vicinity of a Municipal Solid Waste Incinerator: a Validation Study

Whether low environmental doses of dioxin affect the general population is the matter of intense debate and controversy. In a previous study, we found a 2.3-fold risk for non-Hodgkin lymphoma associated with residence in areas classified as highly exposed to dioxin emitted from a municipal solid waste incinerator (MSWI) (Besançon, France). The main limitation lay within the use of a first-generation Gaussian-type dispersion model as a proxy for dioxin exposure, since its accuracy had not been assessed before. The aim of this study was to validate this geographic-based exposure through PCDD/F measurements from soil samples. PCDD/F concentration, pH, organic carbon concentration, cation exchange capacity, and geomorphology and ecology features were assessed for 75 sampling points. In simple terrain (i.e. northeast of the MSWI), a significant association was highlighted between modeled dioxin ground-level air concentrations and log-transformed measured dioxin soil concentrations with a strong gradient across exposure categories. Conversely, in a complex topography situation (i.e. southwest of the MSWI), the model overpredicted ground-level air concentrations, particularly in the high exposure zone. First-generation modeling provided a reliable proxy for dioxin exposure in simple terrain, reinforcing the results of our case-control study. However, a more advanced atmospheric diffusion model should have been used for refined assessment in complex terrain.