L'utilisation de services de santé et de médicaments par des personnes agées de Montréal qui re?oivent des soins maintien à domicile.

A survey was conducted among 160 persons aged 64 year or more in Montreal who were receiving home care. They answered at home a questionnaire on their use of health care services and drugs, and showed the interviewer all the drugs they were taking. In comparison with similar data from elsewhere, the use of health care services (an average of 8.0 encounters with a physician per person per year) and of drugs (an average of 5.3 per person) by this group seems high. Perhaps this group of people was obviously sicker than others of the same age, but this remains to be shown. Moreover, despite the reported frequency of health problems, it is uncertain whether such use of services and drugs was necessary. The question is raised whether the home care system is doing for the patient what it was intended to do.     

Projecting the number of patients with first ever strokes and patients newly handicapped by stroke in England and Wales.

The common assumption that future increases in the number of elderly people will result in a parallel increase in the burden of care of long term disabled survivors of stroke was examined. The number of patients with first ever strokes and the net number of people handicapped after these strokes in England and Wales every five years until 2023 have been projected. Between the base year 1983 and the year 2023 an increase in population of about 5% will occur; first ever strokes are projected to increase by about 30% and deaths within six months of first ever strokes by about 40%. The net number of severely handicapped people six months after a first ever stroke is projected to increase by only about 8%, however, and the net number of people who are moderately or severely handicapped by only 4%. This paradox occurs because first ever stroke often kills people who have been handicapped by other causes, particularly if they are elderly. It is concluded that despite the limitations of these data they strongly suggest that the increased burden of health care of patients with first ever strokes in the next 40 years will be primarily that of caring for those in the acute stages of stroke and not with the management of chronic handicap after a stroke.     

Helping disabled people--the user's view.

The main needs for most people with physical disabilities are housing and help with daily living. Thus, many of them will find the new emphasis on social aspects of community care particularly relevant. Peter Swain is a disabled man who leads a project in east Devon which ensures that disabled people have a voice in helping to shape the services they need. In this article he explains how the project, Living Options East Devon, works and how the new legislation for community care might affect disabled people.     

Is the money following the clients with learning disabilities?

For the past decade patients with learning disabilities living in long stay mental handicap hospitals have been resettled in the community. Local authorities have also taken on the care of new patients who would once have been long stay residents. The imperfect data that are available suggest that in England about half the residents in mental handicap hospitals in 1981 are now the responsibility of local authorities; the figures for Wales and Northern Ireland are 38% and 33%. Data on revenue suggest that the savings to the health service are much less--perhaps 9% in Northern Ireland and 3.6% in England, although there have also been capital gains through the sale of hospitals. Existing methods of transferring money from health to local authorities--joint finance and "dowries" for individual patients--do not seem adequately to have compensated local authorities. Moreover, as patients still to be transferred are more severely disabled local authorities will require larger sums--about 26 000 pounds per patient per year plus 39 200 pounds in capital. If the government chooses not to transfer these resources from health authorities it will be switching funds away from learning disabled people to other care groups.     

Disabled access to information technology — a protable adaptable,multipurpose device

The technology exists to allow severely physically disabled people to have a far more indepentdent lifestyle than many handicapped people enjoy today. To use an ever increasing range of sophisticated domestic equipment, without special modifications, an individually tailored control system and a universal accessing device are required. A portable multipurpose device allows multiply handicapped, non-speaking people a means of operating a variety of general-purpose or specialized pieces of electronic equipment at home and elsewhere, safely and independently. The device also provides a means of communication through the medium of computer-computer communication over telephone lines and will interface to a powered chair for independent mobility. Various features are provided which are not available from conventional environmental control systems. Through a specialized adjustable multipurpose switch system and a universal control device the handicapped person should be able to enjoy the independence afforded by the intelligent home of the future.     

From intervention to impact: modelling the potential mortality impact achievable by different longlasting, insecticide-treated net delivery strategies

ABSTRACT: BACKGROUND: The current target of universal access to long-lasting, insecticide-treated nets (LLIN) is 80% coverage to reduce malaria deaths by 75% by 2015. So far, campaigns have been the main channel for large-scale delivery of LLINs, however the World Health Organization has recommended that equal priority should be given to delivery via routine antenatal care (ANC) and immunization systems (EPI) to target pregnant women and children from birth. These various channels of LLIN delivery are targeted to children of different ages. Since risk of mortality varies with child age and LLIN effectiveness declines with net age, it was hypothesized that the age at which a child receives a new LLIN, and therefore the delivery channel, is important in optimizing the health impact of a net. METHODS: A simple dynamic mathematical model was developed of delivery and impact of LLINs among children under five years of age and their household members, incorporating data on age-specific malaria death rates, net use by household structure, and net efficacy over time. RESULTS: The presented analysis finds that supplementing a universal mass campaign with extra ANC delivery would achieve a 1.4 times higher mortality reduction than campaign delivery alone, reflecting that children born in the years between campaigns would otherwise have access to old nets or no nets at an age of high risk. The relative advantage of supplementary ANC delivery is still present though smaller if malaria transmission levels are lower or if there is a strong mass effect achieved by mass campaigns. CONCLUSION: These results indicate that LLIN delivery policies must take into account the age of greatest malaria risk. Emphasis should be placed on supporting routine delivery of LLINs to young children as well as campaigns. Lucy C Okell and Lucy Smith Paintain contributed equally.     

The Yad Sarah geriatric dental clinic, a different model

Introduction: There are not sufficient dental services for elderly people around the world. Yad Sarah is an Israel‐wide network of volunteers aiding sick, elderly, isolated and housebound people with an array of services aimed at making home care possible. It provides medical and social services to more than 380 000 elderly persons per year and in addition, lends medical equipment free of charge, has day rehabilitation centres, legal aid council for seniors, provides transportation for the disabled, meal deliveries and geriatric dental services. Materials and methods: The latter are equipped with five dental units (one mobile unit) and a dental laboratory. During the 5 years from 2000 to 2004 the dental services provided dental care for 3890 elderly patients with the main clinic located in Jerusalem. Patients pay an average of 70% of the cost price of their dental care, with the difference being subsidised by Yad Sarah. Of the 515 patients who applied for treatment in 2004, 54% possessed natural teeth in both jaws, 28% were fully edentulous, 12% were edentulous in the maxilla and 6% were edentulous in the mandible. Females applied for dental treatment more often than the male population. Older patients (75–101 years old) required oral care at their homes or at old age residences, more frequently than the younger age groups (60–74 years old). Conclusion: Dental treatment was administered by 70 volunteer dental surgeons, two certified dental hygienists and dental hygienist students. The clinical staff was provided with a comprehensive in‐service training in geriatric dentistry during the 3‐year service learning period. A survey in 2004 showed that 83% of the selected patients were satisfied, compared with 14% who were not. The reasons for satisfaction were, mainly, the personal relationship with the attending staff (41%) and the professional ability of the dental team (46%).     

Leprosy and mortality in the Medieval Danish village of Tirup

Leprosy was a well-recognized and dreaded disease in Denmark in the Middle Ages (AD 1000-1536). A large fraction of the population was affected by leprosy in the 13th century. This paper analyzes the correlation between signs of leprosy and risk of dying in the small Danish village of Tirup (AD 1150-1350). Seven different dichotomous osteological lesions indicative of leprosy are analyzed, and it is possible to score at least one of these conditions on 135 skeletons of adult or adolescent people (aged 14 or more). Scores were transformed to a statistic, lambda, indicating the likelihood that the person to whom the skeleton belonged suffered from leprosy. The analyses indicate that the prevalence of leprosy among adult people in Tirup was 26% (95% confidence interval, 17-35%). The lambda statistic indicates that people who died with signs of leprosy did not differ in the distribution of age at death from those who did not have such signs. Skeletons showing dental enamel hypoplasia were less likely to come from skeletons with high lambda-values. The association between lambda and dental enamel hypoplasia indicates a relationship between stress in early childhood (ages 1-6 years) and subsequent development of signs of leprosy.     

We need to address ableism in science

In science, technology, engineering, and mathematics (STEM) fields, disabled people remain a significantly underrepresented part of the workforce. Recent data suggests that about 20% of undergraduates in the United States have disabilities, but representation in STEM fields is consistently lower than in the general population. Of those earning STEM degrees, only about 10% of undergraduates, 6% of graduate students, and 2% of doctoral students identify as disabled. This suggests that STEM fields have difficulty recruiting and retaining disabled students, which ultimately hurts the field, because disabled scientists bring unique problem-solving perspectives and input. This essay briefly explores the ways in which ableism—prejudice against disabled people based on the assumption that they are “less than” their nondisabled peers—in research contributes to the exclusion of disabled scientists and suggests ways in which the scientific community can improve accessibility and promote the inclusion of disabled scientists in academic science.     

Likeability of Garden Birds: Importance of Species Knowledge & Richness in Connecting People to Nature

Interacting with nature is widely recognised as providing many health and well-being benefits. As people live increasingly urbanised lifestyles, the provision of food for garden birds may create a vital link for connecting people to nature and enabling them to access these benefits. However, it is not clear which factors determine the pleasure that people receive from watching birds at their feeders. These may be dependent on the species that are present, the abundance of individuals and the species richness of birds around the feeders. We quantitatively surveyed urban households from towns in southern England to determine the factors that influence the likeability of 14 common garden bird species, and to assess whether people prefer to see a greater abundance of individuals or increased species richness at their feeders. There was substantial variation in likeability across species, with songbirds being preferred over non-songbirds. Species likeability increased for people who fed birds regularly and who could name the species. We found a strong correlation between the number of species that a person could correctly identify and how connected to nature they felt when they watched garden birds. Species richness was preferred over a greater number of individuals of the same species. Although we do not show causation this study suggests that it is possible to increase the well-being benefits that people gain from watching birds at their feeders. This could be done first through a human to bird approach by encouraging regular interactions between people and their garden birds, such as through learning the species names and providing food. Second, it could be achieved through a bird to human approach by increasing garden songbird diversity because the pleasure that a person receives from watching an individual bird at a feeder is dependent not only on its species but also on the diversity of birds at the feeder.     

Children in an ageing society

This paper explores the implications of demographic aging for children and pediatric practice in the Western society. It focuses on the social class differences in childbearing patterns, specific issues related to disability, and distribution of resources between age groups. Women in the Western world are now having children at an older age than at any time in the past 50 years. Voluntary childlessness or deliberate delay in childbearing is common among highly educated women. This changing pattern in childbearing may increase and polarize health and wealth inequalities. With advancements in neonatal and pediatric care which prolong life expectancy and survival of disabled children, it is projected that there will be an increasing number of very old parents caring for severely disabled offspring. Meanwhile, there are also many children who are carrying considerable burdens of caring for their disabled parents. The community burden of disability will continue to rise. The needs of the elderly population may drain resources from child health services. Despite this demographic pattern, care for the children is still important. Health care authorities must not become contented with the existing pediatric care services just because demographic changes require that the nation should invest more in care of the older population.     

Rural-Urban Differences in the Long-Term Care of the Disabled Elderly in China

Background

In China, the rapid rate of population aging and changes in the prevalence of disability among elderly people could have significant effects on the demand for long-term care. This study aims to describe the urban-rural differences in use and cost of long-term care of the disabled elderly and to explore potential influencing factors.

Methods

This study uses data from a cross-sectional survey and a qualitative investigation conducted in Zhejiang province in 2012. The participants were 826 individuals over 60 years of age, who had been bedridden or suffered from dementia for more than 6 months. A generalized linear model and two-part regression model were applied to estimate costs, with adjustment of covariates.

Results

Pensions provide the main source of income for urban elderly, while the principal income source for rural elderly is their family. Urban residents spend more on all services than do rural residents. Those who are married spend less on daily supplies and formal care than the unmarried do. Age, incapacitation time, comorbidity number, level of income, and bedridden status influence spending on medical care (β=-0.0316, -0.0206, 0.1882, 0.3444, and -0.4281, respectively), but the cost does not increase as the elderly grow older. Urban residents, the married, and those with a higher income level tend to spend more on medical equipment. Urban residence and living status are the two significant factors that affect spending on personal hygiene products.

Conclusions

The use of long-term care services varies by living area. Long-term care of the disabled elderly imposes a substantial burden on families. Our study revealed that informal care involves huge opportunity costs to the caregivers. Chinese policy makers need to promote community care and long-term care insurance to relieve the burden of families of disabled elderly, and particular attention should be given to the rural elderly.     

Recording of Severe Mental Illness in United Kingdom Primary Care, 2000–2010

Background

There is increasing emphasis on primary care services for individuals with severe mental illnesses (SMI), including schizophrenia, bipolar disorder, and other non-organic psychotic disorders. However we lack information on how many people receive these different diagnoses in primary care. Primary care databases offer an opportunity to explore the recording of new SMI diagnoses in representative general practices.

Methods

We used data from The UK Health Improvement Network (THIN) primary care database including longitudinal patient records for individuals aged over 16 years from 437 general practices. We determined the annual GP recorded rate of first diagnosis of SMI by age, gender, social deprivation and urbanicity between 2000 and 2010.

Results

We identified 10,520 individuals with a first record of schizophrenia, bipolar disorder or other non-organic psychosis among 4,164,794 patients. This corresponded to a rate of first diagnosis of 46.4 per 100,000 person years at risk (PYAR) (95% CI 45.4 to 47.4) in the 16–65 age group. The rate of first record of schizophrenia was 9.2 per 100,000 PYAR (95% CI 8.7 to 9.6) in this age group, bipolar disorder was 15.0 per 100,000 PYAR (95% CI 14.4 to 15.5) and other non-organic psychotic disorder was 22.3 per 100,000 PYAR (95% CI 21.6 to 23.0).

Conclusions

The rates of GP recorded SMI in primary care records were broadly comparable to incidence rates from previous epidemiological studies of SMI and show similar patterns by socio-demographic characteristics. However there were some differences by specific diagnoses. GPs may be recording rates that are higher than those used to commission services.     

The younger disabled unit at Fazakerley Hospital.

The activities of a new younger disabled unit reflect the changing pattern of care now being provided for severely physically disabled young people. A co-ordinated team approach to their rehabilitation has enabled all but a few of the severely disabled to continue living at home. This represents a considerable saving on the cost of hospital-based care and has afforded them the best opportunity for developing their lives to the full and enjoying a satisfactory life in the community.     

Leprosy in the early medieval Lauchheim community

Leprosy was a well-recognized and dreaded disease in medieval Europe (5th-15th century AD). It is reported to have reached Germany with the Roman invasion. A much larger fraction than previously assumed appears to have been affected by leprosy in the medieval period. This article estimates the frequency (i.e., the prevalence at death) of leprosy among adult people buried in the Lauchheim early medieval cemetery. Seven different dichotomous osteological lesions indicative of leprosy are analyzed, and it is possible to score at least one of these conditions on 110 adult skeletons (aged 15 or more). The scores were transformed to a statistic--lambda (lambda)--indicating the likelihood that the person to whom the skeleton belonged suffered from leprosy. The analyses indicate that 16% (95% confidence interval: 9-23%) of adult people in Lauchheim died with osteological signs of leprosy. Leprosy was significantly more prevalent among men than women. The lambda statistic indicates that people who died with signs of leprosy did not differ in the distribution of age at death from those who did not have such signs. Some of the leprosy-related lesions had a statistically significant nonrandom dispersal on the cemetery; but there is no clear pattern to this and the significant results could be easily attributed to a type-1 error in the statistical analysis.     

Ageism in cardiology

This article supports the argument that ageism exists in health care, particularly on the equity of access to cardiological services. Rates of use of potentially life saving and life promoting interventions and investigations decline as the patient gets older. Higher rates of cardiological interventions occur among younger people, despite the high incidence of the condition among older individuals. Any ageism in clinical medicine and policy is simply a reflection of the presence of ageist attitudes in wider society, where the youth receives a higher priority over age. Ageism in medicine needs to be addressed to preserve or recapture this trust within an aging population. A wide ranging approach is necessary if equity in the provision of health care services is to be ensured which includes improvement of clinical guidelines and more specific monitoring of health care. Educational efforts to raise awareness that age stereotyping and ageist attitudes are unethical should be initiated. Research initiatives, which cover large numbers of older people, should be developed and older people should be empowered to influence choices and standards of treatments. Finally, legislation may be required to eradicate ageism in society.     

La nouvelle Loi handicap

Although, over the centuries, disabled persons have been successively considered to be an image of evil, pity, or sin, what image and what rights are provided by the French law of 11/02/2005 on equal rights, participation and citizenship of disabled persons? Isn’t there still an enormous gap between written laws and what really happens in everyday life, as dozens of laws have been added since the first law voted in the 19th century? The vocabulary has also changed over the years from mutilated, to handicapped, to disabled. The marked differences between official figures and figures derived from the HID (Handicap Independence Incapacity) survey conducted between 1998 and 2001, clearly illustrates the difficulty of defining disability. With ageing of the French population aging and improvement of technologies, the number of disable persons will increase considerably over the years to come. Does the new law of 11/02/2005 provide a solution to this urgent situation? Has it identified all of the problems concerning accessibility, human assistance, schooling, rights of the disabled or is it just another law on disability, which is more useful to the legislator than to the people concerned? The new law focuses on four points. First of all, the right to compensation by creating a disability pension, which replaces third party benefits and professional fees benefits and adult disability pension, the right to schooling for all disabled children, the right to employment, and finally the creation of departmental disability centres, staffed by the various actors currently involved in the care of the disabled (Conseil Général, DDASS, CPAM, CAF, etc...). Creation of the disability pension is now based on five main types of assistance: human assistance, technical assistance, adaptation of the home and the vehicle as well as excess transport costs, animal assistance, and finally exceptional and specific aids. Apart from direct assistance to disabled persons, the new law is also designed to improve accessibility (law and decrees already in application since 1991 and 1994) to transport, public places, etc. However, the law also gives another definition of accessibility by extending its scope to all aspects of disability (motor, sensory, cognitive, mental, etc.). This accessibility must be implemented within defined deadlines: 3 years for transport, 5 years for universities and prefectures, and 10 years for other public buildings. Another innovation of this law is that of the initial training and continuing education of healthcare professionals of the medical and social sector (cause of disability, therapeutic innovations, educational innovations, reception and supportive care of disabled persons, announcement of disability, etc.). However, as so little progress has been made the over the centuries, many disabled people will be left by the wayside. Although politicians have now become aware of the problem, the errors, delays, and imperfections of this new law will allow tolerance rather than insertion of the disabled in the years to come. We must develop a different vision of disability, as illustrated by the creation, in 2002, of a European Commission network called “Design for All” to develop systems that can be used by healthy as well as disabled persons. Disabled persons are also trying to find solutions concerning parenthood and childbirth, as although the law has defined “all” aspects for healthy parents with a disabled child, no measures have been taken for disabled parents. The Mother-Child Department of the Institut Mutualiste Montsouris is developing a programme for these future parents with the help of ESCAVIE (Espace Conseil pour l’autonomie en milieu ordinaire de vie) in collaboration with the occupational therapist and social worker. A disabled parents association has also been formed in the Mother-Child Department. A last point does not directly concern the new law, but the bioethics law of August 2004 and preimplantation diagnosis, which was the subject of a recent debate concerning its revision. The old myth of birth control has resurfaced. Unfortunately politicians collude with the media to present this stereotyped image of the perfect, beautiful, normal baby.     

Combining simple blood tests to identify primary care patients with unexpected weight loss for cancer investigation: Clinical risk score development,internal validation,and net benefit analysis

BackgroundUnexpected weight loss (UWL) is a presenting feature of cancer in primary care. Existing research proposes simple combinations of clinical features (risk factors, symptoms, signs, and blood test data) that, when present, warrant cancer investigation. More complex combinations may modify cancer risk to sufficiently rule-out the need for investigation. We aimed to identify which clinical features can be used together to stratify patients with UWL based on their risk of cancer.Methods and findingsWe used data from 63,973 adults (age: mean 59 years, standard deviation 21 years; 42% male) to predict cancer in patients with UWL recorded in a large representative United Kingdom primary care electronic health record between January 1, 2000 and December 31, 2012. We derived 3 clinical prediction models using logistic regression and backwards stepwise covariate selection: Sm, symptoms-only model; STm, symptoms and tests model; Tm, tests-only model. Fifty imputations replaced missing data. Estimates of discrimination and calibration were derived using 10-fold internal cross-validation. Simple clinical risk scores are presented for models with the greatest clinical utility in decision curve analysis. The STm and Tm showed improved discrimination (area under the curve ≥ 0.91), calibration, and greater clinical utility than the Sm. The Tm was simplest including age-group, sex, albumin, alkaline phosphatase, liver enzymes, C-reactive protein, haemoglobin, platelets, and total white cell count. A Tm score of 5 balanced ruling-in (sensitivity 84.0%, positive likelihood ratio 5.36) and ruling-out (specificity 84.3%, negative likelihood ratio 0.19) further cancer investigation. A Tm score of 1 prioritised ruling-out (sensitivity 97.5%). At this threshold, 35 people presenting with UWL in primary care would be referred for investigation for each person with cancer referred, and 1,730 people would be spared referral for each person with cancer not referred. Study limitations include using a retrospective routinely collected dataset, a reliance on coding to identify UWL, and missing data for some predictors.ConclusionsOur findings suggest that combinations of simple blood test abnormalities could be used to identify patients with UWL who warrant referral for investigation, while people with combinations of normal results could be exempted from referral.

Dr. Brian D Nicholson and colleagues investigate whether combinations of routine blood tests could be used to stratify patients in UK with unexpected weight loss based on their risk of cancer.