Healthcare interactions prior to first hospital admission with alcohol-related liver disease.

BACKGROUND AND AIMS: To examine the healthcare contacts of patients in the year before an index admission to hospital with alcohol-related liver disease (ArLD) to identify where opportunities for earlier identification of alcohol use disorders (AUD) and ArLD and intervention may occur. METHODS: A retrospective cohort study using the regional database encompassing NHS organisations across North West London (344 general practitioner [GP] practices, 4 acute hospital trusts and 2 mental health and community health trusts). Patients who had an index admission with ArLD were identified through healthcare coding and compared with a control cohort. Healthcare contacts, blood tests and AUD testing in the year preceding admission were measured. RESULTS: The ArLD cohort had 1494 participants with an index hospital admission with ArLD. The control cohort included 4462 participants. In the year preceding an index admission with ArLD, 91% of participants had at least one contact with primary care with an average of 2.97 (SD 2.45) contacts; 80% (n = 1199/1494) attended ED, 68% attended an outpatient clinic, and 42% (n = 628/1494) had at least one inpatient admission. Only 9% of the ArLD (137/1494) had formal testing for AUD. Abnormal bilirubin and platelets were more common in the ArLD than the control cohort 25% (138/560) and 28% (231/837), respectively, v 1% (12/1228) and 1% (20/1784). CONCLUSIONS: Prior to an index admission with ArLD patients have numerous interactions with all healthcare settings, indicating missed opportunities for early identification and treatment.

How an electronic health record became a real-world research resource: comparison between London's Whole Systems Integrated Care database and the Clinical Practice Research Datalink.

BACKGROUND: In the UK, several initiatives have resulted in the creation of local data warehouses of electronic patient records. Originally developed for commissioning and direct patient care, they are potentially useful for research, but little is known about them outside their home area. We describe one such local warehouse, the Whole Systems Integrated Care (WSIC) database in NW London, and its potential for research as the "Discover" platform. We compare Discover with the Clinical Practice Research Datalink (CPRD), a popular UK research database also based on linked primary care records. METHODS: We describe the key features of the Discover database, including scope, architecture and governance; descriptive analyses compare the population demographics and chronic disease prevalences with those in CPRD. RESULTS: As of June 2019, Discover held records for a total of 2.3 million currently registered patients, or 95% of the NW London population; CPRD held records for over 11 million. The Discover population matches the overall age-sex distribution of the UK and CPRD but is more ethnically diverse. Most Discover chronic disease prevalences were comparable to the national rates. Unlike CPRD, Discover has identifiable care organisations and postcodes, allowing mapping and linkage to healthcare provider variables such as staffing, and includes contacts with social, community and mental health care. Discover also includes a consent-to-contact register of over 3000 volunteers to date for prospective studies. CONCLUSIONS: Like CPRD, Discover has been a number of years in the making, is a valuable research tool, and can serve as a model for other areas developing similar data warehouses.

Antidepressant and antipsychotic prescribing in primary care for people with dementia.

OBJECTIVE: To use data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) to evaluate the prevalence of antidepressant and antipsychotic prescriptions among patients with no previous depression or psychosis diagnoses, and to identify the factors associated with the use of these drugs in this population. DESIGN: Retrospective cohort study using data derived from CPCSSN. SETTING: Primary care practices associated with CPCSSN. PARTICIPANTS: Patients who were born before 1949; who were associated with a CPCSSN primary care practitioner between October 1, 2007, and September 30, 2013; and whose electronic medical records contained data from at least 6 months before and 12 months after the date of dementia diagnosis. MAIN OUTCOME MEASURES: Prescription for an antidepressant or antipsychotic medication in the absence of a depression or psychosis diagnosis. Multivariable models were fitted to determine estimated odds ratios (ORs) and were adjusted for age and sex. RESULTS: Of the 3252 patients without a depression diagnosis, 8.5% received a new prescription for an antidepressant in the 12 months following their diagnosis of dementia. Prescribing was reduced in association with older age (OR of 0.86 per 5-year age increase, P=.001) and male sex (OR=0.77, P=.056), and prescribing increased in association with prescription of cholinesterase inhibitor medications (OR=1.57, P=.003). Of the 4262 patients without a diagnosis of psychosis, 6.1% received a new prescription for an antipsychotic in the 12 months following their diagnosis of dementia. Higher rates of antipsychotic prescriptions were reported in men (OR=1.31, P=.046), those receiving a prescription for steroids (OR=1.90, P=.037), and those diagnosed with Parkinson disease (OR 1.58, P=.051). CONCLUSION: A substantial number of patients with dementia are being prescribed antidepressant or antipsychotic medications by their primary care practitioners without evidence of depression or psychosis in their electronic medical records.

Substitute consent practices in the face of uncertainty: a survey of Canadian researchers in aging.

BACKGROUND: In Canada and elsewhere, research policies require researchers to secure consent from a legally authorized representative (LAR) for prospective participants unable to consent. Few jurisdictions, however, offer a clear legislative basis for LAR identification. We investigated Canadian researchers' practices regarding the involvement of decisionally incapacitated participants and tested whether reported practices were associated with (1) researchers' understanding of the law on third-party authorization of research and (2) their comfort with allowing a family member to consent on behalf of an incapacitated relative. METHODS: We surveyed researchers in aging from four Canadian provinces about their practices with prospective participants deemed incapable of consent, their understanding of relevant law, and comfort with family consent for research purposes. Understanding and comfort were measured with research vignettes that briefly described hypothetical studies in which an adult who lacks the capacity to consent was invited to participate. RESULTS: Many respondents reported soliciting consent from a family member (45.7% for low-risk studies and 10.7% for serious risks studies), even in jurisdictions where such authority is uncertain at law. Researchers' tendency to solicit family consent was associated with their comfort in doing so, but not with their understanding of the law on substitute consent for research. CONCLUSIONS: Findings underscore the need to clarify who may authorize an incapacitated adult's participation in research. Meanwhile, people should inform their relatives of their desire to participate or not in research in the event of incapacity, given researchers' tendency to turn to family for consent, even where not supported by law.

Implementation of neonatal phototherapy with the BiliCocoon Bag® device in the maternity ward and impact on mother-infant separation.

BACKGROUND: Free bilirubin jaundice is a frequent pathology in the neonatal period. The major complication is neurological toxicity, the most severe form of which is kernicterus. Overall, 5%-10% of jaundiced neonates require treatment. The first-line treatment is phototherapy, with intensive phototherapy being the gold standard. Other equipment is also available, including the BiliCocoon Bag®. It is a safe and controlled therapy that can be performed in the mother's room in the maternity ward, thereby avoiding separation and allowing for breast- or bottle-feeding during treatment. It is easy to install and does not require protective glasses, thus no scope or hospitalization. In our maternity ward, all neonates requiring intensive phototherapy are hospitalized in the neonatology ward. OBJECTIVE: The objective of our study was to evaluate the number of avoided hospitalizations in neonatology for free bilirubin jaundice since the introduction, according to a strict protocol, of the BiliCocoon Bag® device. MATERIAL AND METHOD: This was a single-center retrospective cohort study using data of newborns usually collected as part of standard care. Children born in our maternity ward during an 18-month period (August 1, 2020 to January 31, 2022) were included. Causes of jaundice, age at the beginning and mode of treatment, number of sessions for each device, and length of stay were compared. Results are presented as number and percentage with median (25th-75th) or mean (extremes) values for categorical and continuous variables, respectively. A t-test was used to compare the means of the independent groups. RESULTS: A total of 316 newborns were included. Physiological jaundice was the main cause of jaundice. The median age for the first phototherapy treatment was 54.5 h (30-68). The 316 neonates needed 438 phototherapy sessions: 235 (74%) neonates required only one phototherapy session, 85 (36%) of them were treated with the BiliCocoon Bag®. For the 81 children who needed two or more phototherapy sessions, 19 children (23.5%) were treated by tunnel phototherapy and then the BiliCocoon Bag®, and eight children (10%) by BiliCocoon Bag® alone. The BiliCocoon Bag® enabled a relative reduction in the hospitalization rate of 38% and avoided hospitalization for approximately one third of the newborns treated. The BiliCocoon Bag® failure rate was 3.6% and the average length of stay was comparable between the two types of treatment. CONCLUSION: Following a strict protocol of use, the BiliCocoon Bag® is a reliable method and a good alternative to intensive phototherapy for newborns in the maternity ward, as it avoids hospitalization and mother-infant separation.

Are Canadians providing advance directives about health care and research participation in the event of decisional incapacity?

OBJECTIVE: Advance planning for health care and research participation has been promoted as a mechanism to retain some control over one's life, and ease substitute decision making, in the event of decisional incapacity. Limited data are available on Canadians' current advance planning activities. We conducted a postal survey to estimate the frequency with which Canadians communicate their preferences about health care and research should they become incapacitated. METHOD: We surveyed 5 populations (older adults, informal caregivers, physicians, researchers in aging, and research ethics board members) from Nova Scotia, Ontario, Alberta, and British Columbia. We asked respondents whether they had expressed their preferences regarding a substitute decision maker, health care, and research participation in the event of incapacity. RESULTS: Two out of 3 respondents (62.0%; 95% CI 59.1% to 64.8%) had been advised to communicate their health care preferences in advance. Oral expression of wishes was reported by 69.1% of respondents (95% CI 66.8% to 71.3%), and written expression by 46.7% (95% CI 44.3% to 49.2%). Among respondents who had expressed wishes in advance (orally or in writing), 91.2% had chosen a substitute decision maker, 80.9% had voiced health care preferences, and 19.5% had voiced preferences regarding research participation. Having been advised to communicate wishes was a strong predictor of the likelihood of having done so. CONCLUSIONS: Advance planning has increased over the last 2 decades in Canada. Nonetheless, further efforts are needed to encourage Canadians to voice their health care and research preferences in the event of incapacity. Physicians are well situated to promote advance planning to Canadians.

Comfort with proxy consent to research involving decisionally impaired older adults: do type of proxy and risk-benefit profile matter?

BACKGROUND: Dementia research often requires the participation of people with dementia. Obtaining informed consent is problematic when potential participants lack the capacity to provide it. We investigated comfort with proxy consent to research involving older adults deemed incapable of this decision, and examined if comfort varies with the type of proxy and the study's risk-benefit profile. METHODS: We surveyed random samples of five relevant groups (older adults, informal caregivers, physicians, researchers in aging, and Research Ethics Board members) from four Canadian provinces. Respondents were presented with scenarios involving four types of proxies (non-assigned, designated in a healthcare advance directive with or without instructions specific to research participation, and court-appointed). Given a series of risk-benefit profiles, respondents indicated whether they were comfortable with proxy consent to research for each scenario. RESULTS: Two percent of the respondents felt proxy consent should never be allowed. In all groups, comfort depended far more on the risk-benefit profile associated with the research scenario than with type of proxy. For research involving little or no risk and potential personal benefits, over 90% of the respondents felt comfortable with substitute consent by a designated or court-appointed proxy while 80% were at ease with a non-assigned proxy. For studies involving serious risks with potentially greater personal benefits, older adults and informal caregivers were less comfortable with proxy consent. CONCLUSIONS: A large majority of Canadians are comfortable with proxy consent for low-risk research. Further work is needed to establish what kinds of research are considered to be low risk.

Suicide Attempt After Determination of Ineligibility for Assisted Death: A Case Series.

Medical assistance in dying (MAID) and similar right-to-die laws are becoming increasingly common in jurisdictions across North America and elsewhere. To be eligible for MAID in Canada, requesters must have a serious illness, intolerable suffering, and a reasonably foreseeable natural death. They must also undergo two assessments to confirm eligibility. Although a growing body of literature now exists to help clinicians understand and support patients around requests for assisted death, a dearth of literature exists on how best to support those patients who are deemed ineligible. Here, we report on a case series of three patients who attempted suicide after being found ineligible for MAID. Two patients were ineligible because they did not appear to have reasonably foreseeable natural death. The third patient was ineligible because of concerns around decisional capacity. All three cases had previous diagnoses of depressive disorders and mild cognitive impairment, and two cases had histories of suicide attempts. In at-risk patients, we speculate that the period surrounding a finding of MAID ineligibility may represent a period of particular vulnerability. Clinicians must be vigilant and prepared for the possibility of heightened risk, including risk of self-harm, after a finding of ineligibility for assisted death.

Family physicians and dementia in Canada: Part 1. Clinical practice guidelines: awareness, attitudes, and opinions.

OBJECTIVE: To assess Canadian family physicians' awareness of, attitudes toward, and use of the 1999 Canadian Consensus Conference on Dementia (CCCD) clinical practice guidelines (CPGs); to explore the barriers and enablers to implementing dementia CPGs in clinical practice; and to identify more effective strategies for future dementia guideline development and dissemination. DESIGN: Qualitative study using focus groups. SETTING: Academic family practice clinics in Calgary, Alta, Ottawa, Ont, and Toronto, Ont. PARTICIPANTS: Eighteen family physicians. METHODS: Using a semistructured interview guide, we conducted 4 qualitative focus groups of 4 to 6 family physicians whose practices we had audited in a previous study. Transcripts were coded using an inductive data analytic strategy, and categories and themes were identified and described using the principles of thematic analysis. MAIN FINDINGS: Four major themes emerged from the focus group discussions. Family physicians 1) were minimally aware of the existence and the detailed contents of the CCCD guidelines; 2) had strong views about the purposes of guidelines in general; 3) expressed strong concerns about the role of the pharmaceutical industry in the development of such guidelines; and 4) had many ideas to improve future dementia guidelines and CPGs in general. CONCLUSION: Family physicians were minimally aware of the 1999 CCCD CPGs. They acknowledged, however, the potential of future CPGs to assist them in patient care and offered many strategies to improve the development and dissemination of future dementia guidelines. Future guidelines should more accurately reflect the day-to-day practice experiences and challenges of family physicians, and guideline developers should also be cognizant of family physicians' perceptions that pharmaceutical companies' funding of CPGs undermines the objectivity and credibility of those guidelines.

Family physicians and dementia in Canada: Part 2. Understanding the challenges of dementia care.

OBJECTIVE: To explore the challenges Canadian family physicians face in providing dementia care. DESIGN: Qualitative study using focus groups. SETTING: Academic family practice clinics in Calgary, Alta, Ottawa, Ont, and Toronto, Ont. PARTICIPANTS: Eighteen family physicians. METHODS: We conducted 4 qualitative focus groups of 4 to 6 family physicians whose practices we had audited in a previous study. Focus group transcripts were analyzed using the principles of thematic analysis. MAIN FINDINGS: Five major themes related to the provision of dementia care by family physicians emerged: 1) diagnostic uncertainty; 2) the complexity of dementia; 3) time as a paradox in the provision of dementia care; 4) the importance of patients' families; 5) and familiarity with patients. Participants expressed uncertainty about diagnosing dementia and a strong need for expert verification of diagnoses owing to the complexity of dementia. Time, patients' family members, and familiarity with patients were seen as both barriers and enablers in the provision of dementia care. CONCLUSION: Family physicians face many challenges in providing dementia care. The results of this study and the views of family physicians should be considered in the development and dissemination of future dementia guidelines, as well as by specialist colleagues, policy makers, and those involved in developing continuing physician education about dementia.

Diagnosis and treatment of dementia: 5. Nonpharmacologic and pharmacologic therapy for mild to moderate dementia.

BACKGROUND: Practising physicians frequently seek advice on the most effective interventions for dementia. In this article, we provide practical guidance on nonpharmacologic and pharmacologic interventions for the management of mild to moderate dementia based on recommendations from the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia. METHODS: We developed evidence-based guidelines using systematic literature searches, with specific criteria for the selection and quality assessment of articles, and a clear and transparent decision-making process. We selected articles published from January 1996 to December 2005 that dealt with the management of mild to moderate stages of Alzheimer disease and other forms of dementia. Recommendations based on the literature review were drafted and voted on. Consensus required 80% or more agreement by participants. Subsequent to the conference, we searched for additional articles published from January 2006 to April 2008 using the same major keywords and secondary search terms. We graded the strength of the evidence using the criteria of the Canadian Task Force on Preventive Health Care. RESULTS: We identified 1615 articles, of which 954 were selected for further study. From a synthesis of the evidence in these studies, we made 48 recommendations for the management of mild to moderate dementia (28) and dementia with a cerebrovascular component (8) as well as recommendations for addressing ethical issues (e.g., disclosure of the diagnosis) (12). The updated literature review did not change these recommendations. An exercise program is recommended for patients with mild to moderate dementia. Physicians should decide whether to prescribe a cholinesterase inhibitor on an individual basis, balancing anticipated benefits with the potential for harm. For mild mood and behavioural concerns, nonpharmacologic approaches should be considered first. INTERPRETATION: Although the available therapies for dementia can help with the management of symptoms, there is a need to develop more effective interventions.

Diagnosis and treatment of dementia: 4. Approach to management of mild to moderate dementia.

BACKGROUND: The management of mild to moderate dementia presents complex and evolving challenges. Practising physicians are often uncertain about the appropriate approaches to issues such as the disclosure of the diagnosis, driving and caregiver support. In this article, we provide practical guidance on management based on recommendations from the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia. METHODS: We developed evidence-based guidelines using systematic literature searches, with specific criteria for the selection and quality assessment of articles, and a clear and transparent decision-making process. We selected articles published from January 1996 to December 2005 that dealt with the management of mild to moderate stages of Alzheimer disease and other forms of dementia. Recommendations based on the literature review were drafted and voted on. Consensus required 80% or more agreement by participants. Subsequent to the conference, we searched for additional articles published from January 2006 to April 2008 using the same major keywords and secondary search terms. We graded the strength of evidence using the criteria of the Canadian Task Force on Preventive Health Care. RESULTS: We identified 1615 articles, of which 954 were selected for further study. From a synthesis of the evidence in these studies, we made 48 recommendations for the management of mild to moderate dementia (28) and dementia with a cerebrovascular component (8) as well as recommendations for addressing ethical issues (e.g., disclosure of the diagnosis) (12). The updated literature review did not change these recommendations. In brief, patients and their families should be informed of the diagnosis. Although the specifics of managing comorbid conditions might require modification, standards of care and treatment targets would not change because of a mild dementia. The use of medications with anticholinergic effects should be minimized. There should be proactive planning for driving cessation, since this will be required at some point in the course of progressive dementia. The patient's ability to drive should be determined primarily on the basis of his or her functional abilities. An important aspect of care is supporting the patient's primary caregiver. INTERPRETATION: Much has been learned about the care of patients with mild to moderate dementia and the support of their primary caregivers. There is a pressing need for the development, and dissemination, of collaborative systems of care.

Patient and Public Involvement in Identifying Dementia Research Priorities.

OBJECTIVES: To engage persons with dementia, friends, family, caregivers, and health and social care providers to identify and prioritize their questions for research related to living with dementia and prevention, diagnosis, and treatment of dementia. DESIGN: The Canadian Dementia Priority Setting Partnership (PSP) followed James Lind Alliance PSP methods. Results were compared with the World Health Organization research prioritization exercise and the United Kingdom Dementia PSP. SETTING: Canada. PARTICIPANTS: In the first survey, 1,217 individuals and groups from across Canada submitted their questions about dementia. 249 participated in the interim prioritization. For the final prioritization workshop, the 28 participants included persons with dementia, friends, family, caregivers, health and social care providers, Alzheimer Society representatives, and members of an organization representing long-term care home residents. RESULTS: The Canadian Dementia PSP top 10 priorities relate to health, quality of life, societal issues, and dementia care. Five priorities overlap with one or both of the other two prioritization initiatives. CONCLUSION: These results provide researchers and research funding agencies with topics that individuals with personal or professional experience of dementia prioritize, but they are not intended to preclude research into other aspects of dementia.

Perceptions of the process of care among caregivers and care recipients in dementia care networks.

The Dementia Care Networks Study investigated 4 community-based, not-for-profit dementia care networks in Ontario, Canada. Investigators examined whether sociodemographic and health characteristics, type of support network, and amount of service use among care recipients and caregivers (n = 267 dyads) were associated with experiences with care processes. The process-of-care constructs were: family physicians' awareness of services; experiences with health care workers, and assessment and placement activities. The findings highlighted that family physicians' understanding of dementia and their ability to work with the dyad to become aware of and accept services, was an important component in the dyad's satisfaction. If caregivers received home support and the care recipients received emotional support from their social support network, they were more likely to be satisfied with their experiences with health care workers. In summary, increased awareness and provision of services were associated with more positive perceptions of network effectiveness.

Management of mild to moderate Alzheimer's disease and dementia.

The authors were charged with making a series of evidence-based recommendations that would provide concrete advice on all aspects of the management of mild to moderate stages of dementia and Alzheimer's disease (AD). The recommendations were primarily targeted to primary care physicians practicing in Canada. The assigned topic area did not include either the assessment of a patient with suspected dementia or the prevention of AD and other dementias. An extensive examination of the available literature was conducted. Explicit criteria for grading the strength of recommendations and the level of evidence supporting them were used. The 28 evidence-based recommendations agreed on are presented in this article.

Management of dementia by family physicians in academic settings.

OBJECTIVE: To determine what proportion of patients with dementia seen by family physicians are assessed and managed according to the recommendations of the Canadian Consensus Conference on Dementia (CCCD). DESIGN: Retrospective medical record review. SETTING: Outpatient services in university-affiliated family practice clinics in Calgary, Alta; Ottawa, Ont; and Toronto, Ont. PARTICIPANTS: One hundred sixty patients who were diagnosed with dementia between January 1, 2000, and June 1, 2004. MAIN OUTCOME MEASURES: Use of the Mini-Mental State Examination (MMSE); collateral history; physical examination maneuvers; initial laboratory tests; diagnostic imaging; caregiver identification, assessment, and referral; driving assessment; specialist referral patterns; and other recommendations of the CCCD. RESULTS: The average age of patients assessed was 83 years; most patients (66.3%) were female. More than half (54.1%) were diagnosed with Alzheimer disease or vascular dementia. More than 25% of patients were not given a specific diagnosis: 13.1% were labeled as "dementia," and 12.5% as "not yet diagnosed." For most patients (69.6%) a collateral history was obtained and a primary caregiver identified (79.4%). Few physicians, however, assessed caregiver stress (33.1%) or referred caregivers for support (12.5%). Most patients (80.6%) seen by their family physicians for cognitive changes underwent at least one MMSE. The average score on the first MMSE was 23.5 (of 30) points. Most physicians ordered appropriate "basic" blood tests as part of their assessment. Forty percent of patients had computed tomographic examinations within 3 months of reporting symptoms of cognitive difficulties to their family physicians. Of these, 25% met the criteria for computed tomographic scan as recommended by the guidelines. Only 36.5% were asked about driving status or safety concerns and had this inquiry documented. Of those, 15.5% were referred for driving evaluations and 12.5% were reported to the Ministry of Transportation. CONCLUSION: There is fair to good compliance with recommendations of the 1999 CCCD guidelines. There is, however, little assessment of caregiver coping and referral of caregivers for support. Similarly, there is little assessment of driver safety and referral for formal driving evaluations. Computed tomographic imaging as part of the evaluation of dementia is overused.

Negotiating access to a diagnosis of dementia: Implications for policies in health and social care.

The 'Pathways to Diagnosis' study captured the experience of the prediagnosis period of Alzheimer's disease and related dementias through indepth interviews with 29 persons with dementia and 34 of their family caregivers across four sites: anglophones in Calgary, francophones in Ottawa, Chinese-Canadians in Greater Vancouver and Indo-Canadians in Toronto. In this cross-site analysis, we use the 'Candidacy' framework to comprehensively explore the challenges to securing a diagnosis of dementia in Canada and to develop relevant health and social policy. Candidacy views eligibility for appropriate medical care as a process of joint negotiation between individuals and health services, which can be understood relative to seven dimensions: identification of need, navigation, appearances at services, adjudication by providers, acceptance of/resistance to offers, permeability of services and local conditions. Interviewees experienced challenges relative to each of the seven dimensions and these varied in form and emphasis across the four ethno-linguistic groups.

Evaluating the effectiveness of community-based dementia care networks: the Dementia Care Networks' Study.

PURPOSE: The Dementia Care Networks' Study examined the effectiveness of four community-based, not-for-profit dementia networks. The study involved assessing the relationship between the types of administrative and service-delivery exchanges that occurred among the networked agencies and the network members' perception of the effectiveness of these exchanges. DESIGN AND METHODS: With the use of a case-study method, the evolution, structure, and processes of each network were documented. Social network analysis using a standardized questionnaire completed by member agencies identified patterns of administrative and clinical exchanges among networked agencies. RESULTS: Differences were found between the four networks in terms of their perceptions of service-delivery effectiveness; perceptions of administrative effectiveness did not factor significantly. Exchanges between groups of agencies (cliques) within each of the four networks were found to be more critical than those between individual agencies within each network. IMPLICATIONS: Integration-measured by the types of exchanges within as opposed to across networks-differentiated the four networks studied. This research contributes to our understanding of the use of multiple measures to evaluate the inner workings of service delivery and their impact on elder health and elder health care.

Quality of life and Economic Aspects of Community Support Programs for Caregivers of Dementia Patients.

This economic analysis of community programs for caregivers of dementia patients first reviews the clinical data on caregiver stress and the effectiveness of a variety of intervention programs. The authors then discuss issues relevant to the measurement of the true costs of specific community support programs and their impact on the quality of life of caregivers. Using cost data derived from other published studies, the authors conducted a cost-utility analysis using incremental costs per quality-adjusted life-year (QALY) gained. A sensitivity analysis of cost: utility ratios reveals a range from $3,333 (1988 US. dollars) to $28,571 per QALY gained. Although this is comparable to other health care programs, community support programs for caregivers of dementia patients present special challenges for evaluation of outcome.

[Gastric interdigitating reticulum cell sarcoma: unusual presentation of a histiocytic tumor]. / Sarcome gastrique à cellules interdigitées: présentation inhabituelle d'une tumeur histiocytaire rare.

Histiocytic sarcoma, proliferation arising from immunoregulatory effector system cells, is a very rare and recently recognized tumor. Diagnosis is based on immunohistochemical and molecular genetic study, which allows to distinguish histiocytic sarcoma from lymphocytic proliferation, such as non-Hodgkin's lymphoma. We report the case of a gastric interdigitating reticulum cell sarcoma, treated by resection and chemotherapy. We review here clinical, histological, immunohistochemical and genotypic features of histiocytic tumors of the digestive tract.