RESUMEN
BACKGROUND: Population health management (PHM) by hospital groups is not yet defined nor implemented in France. However, in 2019, the French Hospitals Federation launched a pilot program to experiment PHM in five territories around five Territorial Hospital Groups (GHT's). In order to implement PHM, it is necessary to firstly define the population which healthcare facilities (hospitals) have responsibility for. In the French healthcare system, mapping of health territories however relies mainly on administrative data criteria which do not fit with the actual implementation of GHT's. Mapping for the creation of territorial hospital groups (GHTs) also did not include medical criteria nor all healthcare offers particularly in private hospitals and primary care services, who are not legally part of GHT's but are major healthcare providers. The objective of this study was to define the French population groups for PHM per hospital group. METHODS: A database study based on DRG (acute care, post-acute and rehabilitation, psychiatry and home care) from the French National Hospitals Database was conducted. Data included all hospital stays from 1 January 2016 to 31 December 2017. The main outcome of this study was to create mutually exclusive territories that would reflect an accurate national healthcare service consumption. A six-step method was implemented using automated analysis reviewed manually by national experts. RESULTS: In total, 2840 healthcare facilities, 5571 geographical zones and 31,441,506 hospital stays were identified and collated from the database. In total, 132 GHTs were included and there were 72 zones (1.3%) allocated to a different GHTs. Furthermore, 200 zones were manually reviewed with 33 zones allocated to another GHT. Only one area did not have a population superior to 50,000 inhabitants. Three were shown to have a population superior to 2 million. CONCLUSIONS: Our study demonstrated a feasible methodology to define the French population under the responsibility of 132 hospital groups validated by a national group of experts.
Asunto(s)
Gestión de la Salud Poblacional , Francia/epidemiología , Hospitales Privados , Humanos , Tiempo de Internación , Grupos de PoblaciónRESUMEN
BACKGROUND: Deathbed wills by their nature are susceptible to challenge. Clinicians are frequently invited to give expert opinion about a dying testator's testamentary capacity and/or vulnerability to undue influence either contemporaneously, when the will is made, or retrospectively upon a subsequent challenge, yet there is minimal discourse in this area to assist practice. METHODS: The IPA Capacity Taskforce explored the issue of deathbed wills to provide clinicians with an approach to the assessment of testamentary capacity at the end of life. A systematic review searching PubMed and Medline using the terms: "deathbed and wills," "deathbed and testamentary capacity," and "dying and testamentary capacity" yielded one English-language paper. A search of the individual terms "testamentary capacity" and "deathbed" yielded one additional relevant paper. A focused selective review was conducted using these papers and related terms such as "delirium and palliative care." We present two cases to illustrate the key issues here. RESULTS: Dying testators are vulnerable to delirium and other physical and psychological comorbidities. Delirium, highly prevalent amongst terminal patients and manifesting as either a hyperactive or hypoactive state, is commonly missed and poorly documented. Whether the person has testamentary capacity depends on whether they satisfy the Banks v Goodfellow legal criteria and whether they are free from undue influence. Regardless of the clinical diagnosis, the ultimate question is can the testator execute a specific will with due consideration to its complexity and the person's circumstances? CONCLUSIONS: Dual ethical principles of promoting autonomy of older people with mental disorders whilst protecting them against abuse and exploitation are at stake here. To date, there has been scant discourse in the scientific literature regarding this issue.
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Delirio/psicología , Testimonio de Experto , Competencia Mental/legislación & jurisprudencia , Enfermo Terminal , Testamentos , Delirio/etiología , Ética Clínica , Testimonio de Experto/ética , Testimonio de Experto/legislación & jurisprudencia , Humanos , Cuidado Terminal/ética , Cuidado Terminal/legislación & jurisprudencia , Cuidado Terminal/psicología , Enfermo Terminal/legislación & jurisprudencia , Enfermo Terminal/psicología , Testamentos/legislación & jurisprudencia , Testamentos/psicologíaRESUMEN
BACKGROUND: Since 2001, the French hospital stay databases (Programme de médicalisation des systèmes d'information, PMSI) have included a unique and anonymous identifier in order to cross-link discharge abstracts from a given patient, within and across hospitals. These data could be used to estimate prevalence for some diseases at a territorial level provided that linkage quality is good enough. Few morbidity data are available at this scale. This study analyzes the link between linkage quality and hospitalization rates in three French regions (Picardy, Brittany and Provence-Alpes-Côte d'Azur-Paca). METHODS: We studied short stays in medicine-chirurgical-obstetrical units for the 2004-2005 period (all stays, and stays with mention of cancer or asthma). To study linkage quality, the percentage of linkable stays (no error during the production of the anonymous identifier) was calculated at regional and territorial levels (areas used by regional health authorities). The interquartile range (IQR=third quartile-first quartile) of the percentage of linkable stays was calculated and the link between this percentage and standardized rates of people hospitalized at least once in 2004 or 2005 tested by Spearman correlation coefficients. RESULTS: For all stays, percentages of linkable stays were 94.4%, 96.6% and 97.0% in Picardy, Paca and Brittany respectively in 2004-2005. Geographical variation at the territorial level was higher in Picardy (IQR between 4 and 6) than in the two other regions (IQR between 1 and 2). The percentage of linkable stays was positively and significantly associated with the hospitalization rate for all stays and those with mention of cancer in Picardy only. CONCLUSION: According to these results, PMSI data earlier than 2006 should be used with precaution; linkage quality should be analyzed before making geographical or time comparisons of hospitalization rates. Comparisons cannot always be made. Other studies should be carried out in other regions, and to analyze recent trends in linkage quality.
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Recolección de Datos/normas , Bases de Datos Factuales , Hospitalización/estadística & datos numéricos , Factores Epidemiológicos , Estudios de Factibilidad , Francia/epidemiología , Humanos , Control de CalidadRESUMEN
BACKGROUND: As people live longer, there is increasing potential for mental disorders to interfere with testamentary distribution and render older people more vulnerable to "undue influence" when they are making a will. Accordingly, clinicians dealing with the mental disorders of older people will be called upon increasingly to advise the courts about a person's vulnerability to undue influence. METHOD: A Subcommittee of the IPA Task Force on Testamentary Capacity and Undue Influence undertook to establish consensus on the definition of undue influence and the provision of guidelines for expert assessment of risk factors for undue influence. RESULTS: International jurisdictions differ in their approach to the notion of undue influence. Despite differences in legal systems, from a clinical perspective, the subcommittee identified some common "red flags" which might alert the expert to risk of undue influence. These include: (i) social or environmental risk factors such as dependency, isolation, family conflict and recent bereavement; (ii) psychological and physical risk factors such as physical disability, deathbed wills, sexual bargaining, personality disorders, substance abuse and mental disorders including dementia, delirium, mood and paranoid disorders; and (iii) legal risk factors such as unnatural provisions in a will, or provisions not in keeping with previous wishes of the person making the will, and the instigation or procurement of a will by a beneficiary. CONCLUSION: This review provides some guidance for experts who are requested by the courts to provide an opinion on the risk of undue influence. Whilst international jurisdictions require different thresholds of proof for a finding of undue influence, there is good international consensus on the clinical indicators for the concept.
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Coerción , Abuso de Ancianos/legislación & jurisprudencia , Voluntad en Vida/legislación & jurisprudencia , Competencia Mental/legislación & jurisprudencia , Anciano , Humanos , Cooperación InternacionalRESUMEN
Understanding the mechanisms controlling the generation and maintenance of biodiversity provides some of the planet's greatest and most pressing challenges. Variation in resource concentration, which varies widely at multiple scales, may cause biodiversity to increase, decrease, or exhibit a unimodal response and underlying mechanisms remain obscure. We established experimental cultures of long-term stationary phase (LTSP) Escherichia coli to test whether per capita heterozygosity varies with resource concentration, and, if so, whether population sizes associated with different resource concentrations contributed to these patterns. Our results provide the clearest example to date of increasing per capita heterozygosity with increasing resource concentration. Further, our experimental manipulations of population size, independent of resource concentration, provide the first unequivocal evidence that population size is one of the underlying factors controlling per capita heterozygosity along such resource gradients. Specifically, we show that cultures with higher maximum population sizes, associated with higher resource concentrations, have higher per capita heterozygosity. These experiments provide the first experimental evidence for an underappreciated factor controlling biodiversity along resource gradients--population size. This direct evidence of population size influencing diversification rates has implications for regional and global scale patterns of biodiversity.
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Biodiversidad , Escherichia coli/citología , Ecosistema , Escherichia coli/genética , Heterocigoto , Densidad de Población , Dinámica PoblacionalRESUMEN
In light of the deteriorating state of coral reefs worldwide, the need to rehabilitate marine environments has greatly increased. Artificial reefs (ARs) have been suggested as a tool for reef conservation and rehabilitation. Although successions of AR communities have been thoroughly studied, current understanding of the interactions between artificial and natural reefs (NRs) is poor and a fundamental question still to be answered is that of whether AR communities can mimic adjacent NR communities. We suggest three alternative hypotheses: Neighboring ARs and NRs will (1) achieve a similar community structure given sufficient time; (2) be similar only if they possess similar structural features; (3) always differ, regardless of age or structural features. We examined these hypotheses by comparing the community structure on a 119-year old shipwreck to a neighboring NR. Fouling organisms, including stony and soft corals, sponges, tunicates, sea anemones and hydrozoans were recorded and measured along belt transects. The ahermatypic stony coral Tubastrea micrantha dominated vertical AR regions while the soft corals Nephthea sp. and Xenia sp. dominated both artificial and natural horizontal surfaces. Our results support the second hypothesis, indicating that even after a century an AR will mimic its adjacent NR communities only if it possesses structural features similar to those of the natural surroundings. However, if the two differ structurally, their communities will remain distinct.
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Antozoos/fisiología , Biodiversidad , Conservación de los Recursos Naturales/métodos , Ecosistema , Animales , Antozoos/clasificación , Antozoos/crecimiento & desarrollo , Ambiente , Océanos y Mares , Densidad de Población , NavíosRESUMEN
Man-made submerged structures, including shipwrecks, offering substrata for fouling organisms and fish, have been classified secondarily as artificial reefs (ARs). The current approach in AR design is that of low-profile structures placed on the seabed and attempting to mimic natural reef (NR) communities with the aim of mitigating degraded marine ecosystems. To examine the validity of this concept, a long-term comparison of the developing AR fouling communities to those of nearby NRs is required. A survey of the fouling reefal organisms was conducted on seven shipwrecks (Red Sea, Egypt), comprising three young (ca 20 years old) and four old (>100 years old) unplanned ARs, in comparison to nearby NR communities. The hypothesis tested was that the age of the ARs shapes the structure of their fouling coral communities. The results demonstrated distinct differences between ARs and NRs and between young and old ARs. While the species composition on ARs may resemble that of NRs after approximately 20 years, obtaining a similar extent of coral cover may require a full century. Moreover, differences in structural features between ARs and NRs may lead to differences in species composition that persist even after 100 years.
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Antozoos/fisiología , Ecosistema , Navíos , Animales , Egipto , Océano Índico , Factores de TiempoRESUMEN
Most artificial reef (AR) studies have examined the early colonization stages of benthic communities, while only a few have monitored the development of AR communities beyond the initial successional phases and evaluated the time scale needed for such development. In addition, despite the proliferation of AR studies, comparative studies between artificial and natural reefs (NRs) are scarce. We present here the monitoring results of initial (1-2 year) and progressed (10 year) stages of the developing benthic communities of a purpose-planned AR submerged at Eilat, Israel (Red Sea), and compare them to its adjacent NR. Visual surveys of macro-invertebrates were conducted on the initial stages and coral communities were characterized at the progressed stage, using belt transects. The results demonstrate a distinct shift in species composition of the AR communities along the monitoring periods: from a soft coral dominated community, comprised mainly of Dendronephthya hemprichi, in initial developmental stages of up to two years post-deployment, to a community dominated by the sponge Crella cyatophora at year 10. Distinct differences in coral species count, living cover and diversity were found between the AR and its neighboring NR. We estimate the time frame required to develop a progressed diverse AR community to be well over a decade, even in tropical ecosystems. The factors shaping the species composition of purpose-designed ARs in a coral reef environment, including structural design, spatial orientation, depth and age, are discussed.
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Antozoos , Conservación de los Recursos Naturales , Invertebrados , Animales , Ecosistema , Ambiente , Arquitectura y Construcción de Instituciones de Salud , Dinámica Poblacional , Clima TropicalRESUMEN
The uptake and stable maintenance of extracellular DNA, genetic transformation, is universally recognized as a major force in microbial evolution. We show here that extracellular DNA, both homospecific and heterospecific, can also serve as the sole source of carbon and energy supporting microbial growth. Mutants unable to consume DNA suffer a significant loss of fitness during stationary-phase competition. In Escherichia coli, the use of DNA as a nutrient depends on homologs of proteins involved in natural genetic competence and transformation in Haemophilus influenzae and Neisseria gonorrhoeae. Homologs of these E. coli genes are present in many members of the gamma subclass of Proteobacteria, suggesting that the mechanisms for consumption of DNA may have been widely conserved during evolution.
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ADN Bacteriano/metabolismo , Escherichia coli/crecimiento & desarrollo , Escherichia coli/genética , Genes Bacterianos , Recuento de Colonia Microbiana , Medios de Cultivo , Medios de Cultivo Condicionados , Escherichia coli/metabolismo , Evolución Molecular , Gammaproteobacteria/genética , Haemophilus influenzae/genética , Mutación , Homología de Secuencia de Aminoácido , Transformación BacterianaRESUMEN
Behavioral and psychological symptoms of dementia are an important aspect of dementing illness. They represent a growing burden to caregivers and health care institutions and an increasing financial burden as the proportion of elderly patients, and consequently those with dementia, increases throughout the world. Behavioral and psychological symptoms of dementia can be recognized and assessed using a number of rating scales. Management of the symptoms is then possible for the benefit of patients, family members, caregivers, and the health care system.
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Demencia/diagnóstico , Demencia/psicología , Escalas de Valoración Psiquiátrica/estadística & datos numéricos , Anciano , Enfermedad de Alzheimer/diagnóstico , Enfermedad de Alzheimer/epidemiología , Enfermedad de Alzheimer/psicología , Antipsicóticos/administración & dosificación , Antipsicóticos/uso terapéutico , Cuidadores , Deluciones/diagnóstico , Deluciones/epidemiología , Deluciones/psicología , Demencia/epidemiología , Trastorno Depresivo/diagnóstico , Trastorno Depresivo/epidemiología , Trastorno Depresivo/psicología , Alucinaciones/diagnóstico , Alucinaciones/epidemiología , Alucinaciones/psicología , Humanos , Psiquiatría , Agitación Psicomotora/diagnóstico , Agitación Psicomotora/epidemiología , Agitación Psicomotora/psicología , Investigadores , Esquizofrenia/diagnóstico , Esquizofrenia/epidemiologíaRESUMEN
BACKGROUND: Activities of daily living (ADL) deficits are integral components of dementia disorders, and ADL measures are among the most robust markers of the course of Alzheimer's disease (AD). Despite this acknowledged importance, no clearly useful ADL instrument for cross-cultural application in pharmacologic trials in the early stages of AD had been available. METHOD: An international effort was launched to develop an ADL scale for pharmacologic trials in early AD. Steps taken from 1990 to the present included: (1) international scientific working group meetings and reviews, (2) reviews of existing measures, (3) collating of existent, nonredundant items, (4) querying experts for new items, (5) interviews with informants and subjects in the USA, France, and Germany, toward the identification of potential new items, (6) identification of an item pool based upon these procedures, (7) creation of a trial instrument, (8) piloting of this instrument, and (9) refinement of the scale based upon statistical analysis of the pilot data. Final item selection was based upon: (1) relevance for > or = 80% of subjects in severity-stratified USA and German samples; (2) absence of gender and national biases; (3) significant (p <.05) discrimination between (a) normal versus mildly impaired and (b) mildly impaired versus moderately to moderately severely impaired subjects; and (4) Global Deterioration Scale (GDS) scores accounting for > or = 12% of variance in the item after controlling for age and gender. RESULTS: An ADL scale consisting of 40 items that correlate with the global and cognitive progress of AD is developed for international usage in pharmacologic trials in incipient, mild, moderate, and moderately severe AD. The scale contains 40 items falling within 13 ADL categories. The 40-item scale is shown to have .81 correlation with GDS staging, .81 with mental status assessment (Mini-Mental State Examination), and .81 with a psychometric test (the SKT) (p values < .001). CONCLUSION: This scale can be used to measure therapeutic response in AD.
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Actividades Cotidianas , Enfermedad de Alzheimer/diagnóstico , Escalas de Valoración Psiquiátrica/normas , Anciano , Anciano de 80 o más Años , Comparación Transcultural , Femenino , Francia , Alemania , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Psicometría , Índice de Severidad de la Enfermedad , Estados UnidosRESUMEN
With detailed cost information, home and community-based services (HCBS) providers can make intelligent choices that reduce costs without compromising quality and outcomes. Using cost and utilization data from a large HCBS program, monthly costs are estimated and related to demographic and clinical variables. HCBS costs are positively related to disability and cognitive impairment, but not to available social support. Costs vary significantly across the nursing home-eligible population, indicating that caution is warranted when seeking to capitate HCBS services. Per capita costs are strongly related to program volume and experience, falling from $508 to $423 (16.7 percent) over the course of the program.
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Servicios de Salud Comunitaria/economía , Anciano Frágil , Costos de la Atención en Salud , Servicios de Atención de Salud a Domicilio/economía , Anciano , Humanos , IllinoisRESUMEN
The enhanced stress resistance exhibited by starved bacteria represents a central facet of virulence, since nutrient depletion is regularly encountered by pathogens in their natural in vivo and ex vivo environments. Here we explore the notion that the regular stress responses, which are mediated by enzymatically catalyzed chemical transactions and promote endurance during the logarithmic growth phase, can no longer be effectively induced during starvation. We show that survival of bacteria in nutrient-depleted habitats is promoted by a novel strategy: finely tuned and fully reversible intracellular phase transitions. These non-enzymatic transactions, detected and studied in bacteria as well as in defined in vitro systems, result in DNA sequestration and generic protection within tightly packed and highly ordered assemblies. Since this physical mode of defense is uniquely independent of enzymatic activity or de novo protein synthesis, and consequently does not require energy consumption, it promotes virulence by enabling long-term bacterial endurance and enhancing antibiotic resistance in adverse habitats.
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Cromatina/metabolismo , Citoprotección , Escherichia coli/genética , Escherichia coli/metabolismo , Proteínas Bacterianas/metabolismo , Colesterol/metabolismo , Cromatina/genética , Cromatina/ultraestructura , Cristalización , Daño del ADN/efectos de los fármacos , Proteínas de Unión al ADN/metabolismo , Escherichia coli/citología , Escherichia coli/ultraestructura , Iones , Magnesio/farmacología , Microscopía Electrónica , Dispersión de Radiación , Rayos XAsunto(s)
Demencia/historia , Demencia/psicología , Anciano , Anciano de 80 o más Años , Antipsicóticos/historia , Antipsicóticos/uso terapéutico , Ensayos Clínicos como Asunto/historia , Demencia/tratamiento farmacológico , Historia del Siglo XX , Hogares para Ancianos , Humanos , Casas de Salud , Estados UnidosRESUMEN
Decreased levels of physical and social activity associated with aging can be particularly pronounced in residents of assisted living facilities. Reduced exposure to important behavioral and time-giving cues may contribute to the age-related changes in circadian rhythmicity and sleep. The present study was conducted to test the hypothesis that an enforced schedule of structured social and physical activity (0:900 to 10:30 and 19:00 to 20:30 daily for two weeks) can have beneficial effects on circadian rhythmicity, nocturnal sleep, daytime functioning, mood, and vigor. The subjects were 14 elderly residents of continued-care retirement facilities while a similar group of 9 elderly residents served as controls. The group exposed to structured activities had increased amounts of slow-wave sleep and demonstrated improvement in memory-oriented tasks following the intervention. Conversely, no significant changes were noted in the amplitude and phase of the body temperature rhythm or in subjective measures of vigor and mood. These results indicate that short-term exposure to structured social intervention and light physical activity can significantly improve memory performance and enhance slow-wave sleep in older adults without alterations to the circadian phase or amplitude of body temperature. This is the first report to demonstrate that low intensity activity in an elderly population can increase deep sleep and improve memory functioning. The high degree of interest in these activities paired with the simple nature of the tasks makes this a potentially practical intervention which can be adapted for both community dwelling and assisted-living elders.
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Envejecimiento/fisiología , Ejercicio Físico/fisiología , Pruebas Neuropsicológicas , Fases del Sueño/fisiología , Conducta Social , Adulto , Anciano , Anciano de 80 o más Años , Ritmo Circadiano/fisiología , Femenino , Hogares para Ancianos , Humanos , Masculino , Recuerdo Mental/fisiología , PolisomnografíaAsunto(s)
Enfermedad de Alzheimer/diagnóstico , Trastornos Psicóticos/diagnóstico , Anciano , Enfermedad de Alzheimer/complicaciones , Enfermedad de Alzheimer/psicología , Antipsicóticos/uso terapéutico , Diagnóstico Diferencial , Evaluación Geriátrica , Humanos , Escalas de Valoración Psiquiátrica , Trastornos Psicóticos/tratamiento farmacológico , Trastornos Psicóticos/etiología , Esquizofrenia/diagnóstico , Psicología del Esquizofrénico , SíndromeRESUMEN
The adhE gene of Escherichia coli encodes a multifunctional ethanol oxidoreductase whose expression is 10-fold higher under anaerobic than aerobic conditions. Transcription of the gene is under the negative control of the Cra (catabolite repressor-activator) protein, whereas translation of the adhE mRNA requires processing by RNase III. In this report, we show that the expression of adhE also depends on the Fis (factor for inversion stimulation) protein. A strain bearing a fis::kan null allele failed to grow anaerobically on glucose solely because of inadequate adhE transcription. However, fis expression itself is not under redox control. Sequence inspection of the adhE promoter revealed three potential Fis binding sites. Electrophoretic mobility shift analysis, using purified Fis protein and adhE promoter DNA, showed three different complexes.
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Alcohol Deshidrogenasa/biosíntesis , Aldehído Oxidorreductasas/biosíntesis , Proteínas Portadoras/genética , Proteínas de Escherichia coli , Escherichia coli/enzimología , Regulación Bacteriana de la Expresión Génica , Complejos Multienzimáticos/biosíntesis , Fusión Artificial Génica , Proteínas Bacterianas/genética , Secuencia de Bases , Proteínas Portadoras/biosíntesis , Factor Proteico para Inverción de Estimulación , Factores de Integración del Huésped , Isopropil Tiogalactósido/metabolismo , Datos de Secuencia Molecular , Consumo de Oxígeno/genética , Regiones Promotoras Genéticas , Biosíntesis de Proteínas , Proteínas Represoras/genética , Transcripción Genética , beta-Galactosidasa/metabolismoRESUMEN
In mammals the phase shifting response of the circadian clock to light can be enhanced by administration of the calcium channel antagonist nimodipine. In the present study we assessed the potential for nimodipine to affect the responsiveness of the human circadian clock to light by measuring the light-induced suppression of melatonin levels in plasma. Seven healthy young subjects (3M, 4F, 27.3 +/- 1.8 years old) were admitted on four occasions to the Clinical Research Center at Northwestern University Medical School. Blood was collected during the night to assess the effect of nimodipine (30 mg, orally, 01:30 h) on plasma melatonin levels in the presence or absence of light (500 lux, 2-3 am). Melatonin levels in plasma were measured by radioimmunoassay. Exposure to light for 1 h suppressed melatonin levels in plasma by nearly 38% relative to samples obtained at the same time in the absence of light (P = 0.013). Nimodipine administration did not modify plasma melatonin levels. However, combined treatment with nimodipine and light suppressed melatonin levels in plasma by 59%. Levels of plasma melatonin were significantly lower following treatment with nimodipine and light than following treatment with placebo/light (P = 0.014). Thus, the calcium channel antagonist nimodipine potentiated the suppressive effect of light on melatonin levels in plasma. These results suggest that the calcium channel antagonist nimodipine may also potentiate the response of the human circadian clock to light, and might thus be useful in combination with phototherapy for the treatment of sleep and circadian rhythm disorders.