Population health management in France: specifying population groups through the DRG system.

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.

Deathbed wills: assessing testamentary capacity in the dying patient.

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.

[Evaluation of hospital stays linkage quality to study health spatial variation. a feasibility study in three French regions]. / Évaluation de la qualité du chaînage des séjours hospitaliers pour l'étude des variations spatiales de santé à partir des données du PMSI. Étude de faisabilité dans trois régions françaises.

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.

Diversification rates increase with population size and resource concentration in an unstructured habitat.

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.

Can artificial reefs mimic natural reef communities? The roles of structural features and age.

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.

Variable structures of Fis-DNA complexes determined by flanking DNA-protein contacts.

The Fis protein from Escherichia coli and Salmonella typhimurium regulates many diverse reactions including recombination, transcription, and replication and is one of the most abundant DNA binding proteins present in the cell under certain physiological conditions. As a specific regulator, Fis binds to discrete sites that are poorly related in primary sequence. Analysis of DNA scission by a collection of Fis conjugates to 1,10-phenanthroline-copper combined with comparative gel electrophoresis has shown that the structures of Fis-DNA complexes are highly variable, displaying overall DNA curvatures that range from < or = 50 degrees to > or = 90 degrees. This variability is primarily determined by differential wrapping of flanking DNA around Fis. By contrast, DNA bending within the core recognition regions appears similar among the binding sites that were analyzed. Flanking DNA contacts by Fis depend on the nucleotide sequence and are mediated by an electrostatic interaction with arginine 71 and a hydrogen bond with asparagine 73, both of which are located outside of the helix-turn-helix DNA binding motif. These contacts strongly influence the kinetics of binding. These data, combined with the crystal structure of Fis, have enabled us to generate new models for Fis-DNA complexes that emphasize the variability in DNA structures within the flanking regions.

Recruitment of benthic organisms onto a planned artificial reef: shifts in community structure one decade post-deployment.

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.

Selection of lambda Spi- transducing phages using the P2 old gene cloned onto a plasmid.

The old gene product of the P2 prophage interferes with plaque formation by lambda wild type phage but allows lambda phages whose red and gam genes have been deleted to form small, visible plaques (the lambda Spi- phenotype). The old gene product also kills Escherichia coli recB or recC mutants. We have cloned the old gene into the high-copy-number plasmid pBR322, where it prevents plaque formation by both lambda Spi+ and lambda Spi- phages. We transferred a DNA fragment that carries the old gene to the low-copy-number plasmid pSC101 and found that lambda Spi- phages can be selected on strains that carry this plasmid. The plasmid-borne old gene kills E. coli recB mutants, providing a selection for old- mutants.

Geriatric psychiatry training for the general psychiatric resident.

Although there is a real need in variety of settings for psychiatrists trained in working with older people, a large proportion of psychiatric residency programs do not offer the opportunity for clinical experience with this age group. The author stresses the need to include this subject in the curriculum of residency training programs. He describes the features of one program that offers comprehensive training in this area.

Daily social and physical activity increases slow-wave sleep and daytime neuropsychological performance in the elderly.

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.

Antianxiety effects of lorazepam in patients with cardiovascular symptomatology.

Lorazepam was administered to 38 patients with moderate to severe anxiety associated with cardiovascular symptomatology. A comparable group of patients on placebo (35) served as controls in this 4-week study. Average dosage was 3 mg/day given as 2 mg in the evening and 1 mg in the morning. The Global response, Hamilton Anxiety Rating Scale scores, and 35-Item Self-Rating Scale scores showed lorazepam to be significantly more effective in relieving anxiety than placebo, both clinically and statistically. Adverse reactions were transient and tolerable, and were reported in only 2 patients on lorazepam.

Efficacy and tolerability of antidepressant therapy in the old-old.

As the number of elderly increases worldwide, there will be a concurrent increase in the absolute number of people over 70 years of age who suffer from major depressive disorders. There is a paucity of research in this old-old population, although each of the following drugs has been studied in at least one clinical drug trial: amitriptyline, bupropion, dothiepin, fluoxetine, mianserin, nortriptyline, paroxetine, and sertraline. The results to date, though limited, suggest similar efficacy and greater tolerability of serotonin selective reuptake inhibitors compared with tricyclic antidepressants in the elderly.

Behavioral and psychological symptoms of dementia: a current focus for clinicians, researchers, and caregivers.

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.

A brief agitation rating scale (BARS) for nursing home elderly.

OBJECTIVE: To determine the effectiveness of a brief agitation rating scale (BARS) derived from the Cohen-Mansfield Agitation Inventory (CMAI). DESIGN: Test of reliability and validity of a new test. SETTING: The Lieberman Geriatric Health Centre, a skilled nursing facility. PARTICIPANTS: Forty members of the Lieberman Geriatric Health Centre nursing staff, 232 residents, and a sample of 40 randomly selected residents. MEASUREMENTS: Observational agitation ratings by registered nurses and certified nurses' assistants; item to total correlations for the CMAI on each of the three shifts; Pearson correlations between the 10-item BARS and the BEHAVE-AD and the BSSAD scales. RESULTS: Internal consistency reliability for the BARS was .74 (for the day shift), .82 (evening shift), and .80 (night shift), compared with .86, .91, and .87 for the full CMAI. Each of the 232 residents' scores on the BARS was correlated with a total score from the CMAI separately on each shift. Correlations were of .95, .94, and .95. Thus, across all shifts, the BARS accounted for approximately 90 percent of the variance of the total score of the CMAI. Concurrent validity of the BARS was supported by significant correlation with BEHAVE-AD and BSSD. CONCLUSIONS: The BARS represents a brief and effective mechanism to assess the presence and severity of physically aggressive, physically non-aggressive, and verbally agitated behaviors in elderly nursing home residents.

Nimodipine potentiates the light-induced suppression of melatonin.

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.

Managing the behavioral and psychological signs and symptoms of dementia.

As the world's population ages, increasing numbers of patients with dementia can be expected, the signs and symptoms of which can be extremely disruptive. In particular, behavioral and psychological signs and symptoms of dementia reduce the quality of life of carers (usually family members) and increase the cost of care. Conventional neuroleptics have been used for many years in the management of disturbed and disruptive demented patients, although there are few well-controlled clinical trials demonstrating their efficacy. The use of the low-potency neuroleptics is associated with orthostatic hypotension, cardiac toxicity, anticholinergic side effects and daytime sedation. The high-potency neuroleptics tend to cause extrapyramidal side effects and akathisia. Clozapine although less likely to cause extrapyramidal symptoms than conventional neuroleptics, can cause orthostatic hypotension and requires continual blood monitoring. Early-phase open trials suggest that risperidone is efficacious in patients with behavioral and psychological signs and symptoms of dementia and that it has a low side-effects profile. Further trials are needed to confirm this, but it is likely that the newer antipsychotics, as typified by risperidone, will lead to safer and more effective management of patients with the disruptive and costly behavioral and psychological signs and symptoms of dementia. Non-pharmacologic interventions may also provide benefit, though controls are rare.

Psychotherapeutic agents in older adults. Antipsychotics: old and new.

As the number of older adults worldwide continues to increase markedly, the absolute increase in their numbers means that there also will be a substantial increase in the number of older people with mental disorders. These disorders include several that manifest psychotic symptoms. Many credit the substantial reduction in the number of older people in state mental hospitals over the past 40 years primarily to the advent of antipsychotic (neuroleptic) medication. Although the traditional neuroleptic medications often are effective, they also are associated with troublesome side effects. Newer neuroleptic medications appear to be just as effective but have fewer adverse side effects.

Aging and mental health: primary care of the healthy older adult. A roundtable discussion: Part I.

Dementia, depression, alcoholism, and suicide are some of the most important mental health issues for the aging population. Among the factors that affect the physician's ability to evaluate and manage these disorders are drug-induced side effects, the ability and willingness of patients to communicate their feelings, the level of caregiver cooperation, and limitations imposed by federal regulations and reimbursement policies. In this first of three installments of a panel discussion, experts in geriatrics and geropsychiatry discuss healthy aging, age-related memory and sensory loss, changes in mentation postanesthesia, sexuality in the elderly, and side effects of common psychoactive medications.

Aging and mental health: diagnosis of dementia and depression.

In this second segment of a panel discussion on aging and mental health, panelists focus on the primary care evaluation and management of the patient with dementia, including differential diagnosis of depression. Other topics of discussion include the roles of psychiatric referral and psychotherapy in patient management, suicide prevention, and alcoholism in elderly patients.