Ambulatory health services utilization in patients with dementia - Is there an urban-rural difference?

<p>Abstract</p> <p>Background</p> <p>Due to demographic changes and an un-equal distribution of physicians, regional analyses of service utilization of elderly patients are crucial, especially for diseases with an impact like dementia. This paper focuses on dementia patients. The aim of the study is to identify differences in service utilization of incident dementia patients in urban and rural areas.</p> <p>Methods</p> <p>Basis for the analysis were all insured persons of a German Health Insurance fund (the GEK) aged 65 years and older living in rural and urban areas. We focussed on physician contacts in the outpatient sector during the first year after an incidence diagnosis of dementia. Special attention was given to contacts with primary care physicians and neurologists/psychiatrists. The dementia cohort was analyzed together with a non-dementia control group drawn according to age, gender and amount of physician contacts. Uni- and bivariate as well as multivariate analysis were performed to estimate the influences on service utilization.</p> <p>Results</p> <p>Results show that the provision of primary care seems to be equally given in urban and rural areas. For specialists contacts however, rural patients are less likely to consult neurologists or psychiatrists. This trend can already be seen before the incident diagnosis of dementia. All consultations rise in the quarter of the incident dementia diagnosis compared to the control group. The results were also tested in a linear and a logistic regression, showing a higher chance for persons living in urban areas to visit a specialist and an overall higher rate in service utilization for dementia patients.</p> <p>Conclusions</p> <p>Because of a probable increase in the number of dementia patients, service provision has to be accessible even in rural areas. Due to this and the fact that demographic change is happening at different paces in different regions, regional variations have to be considered to ensure the future service provision.</p

Towards an holistic account on residual stresses in full-forward extruded rods

An holistic view is attempted towards prediction of the effect of residual stresses induced by full-forward extrusion on fatigue life of workpieces during operation. To study the effect of constitutive model on the accuracy of forming simulations, a combined nonlinear isotropic/kinematic hardening model as well as the isotropic hardening part of the same model are calibrated based on five compression-tension-compression uniaxial stress experiments. A full-forward extrusion finite element model is developed adapting both the aforementioned hardening plasticity models and the predicted residual stress states at the surface of the workpiece are compared against that of a corresponding forming experiment. Results show residual stress predictions of remarkable accuracy by the FE-models with the isotropic hardening model. The effect of residual stresses on fatigue life of the workpiece is qualitatively studied by uncoupled multiscale simulations featuring gradient crystal plasticity at the microscale. While the effective (homogenized) macroscale response indicates elastic response during a macroscopically cyclic loading, plasticity accompanying reduction of residual stresses is still present at the microscale within, e.g. grain boundaries

Specialist involvement and referral patterns in ambulatory medical care for patients with dementia in Germany: results of a claims data based case-control study.

Background: To analyze the referral processes from general practitioners to specialists and among specialists for dementia patients in the time periods before, during and after the diagnosis in Germany. Methods: In this case-control study claims data from 1,848 insurants with incident dementia aged 65 years and more and 7,392 matched controls were compared over a two-year period covering the pre-incidence, incidence and post-incidence time periods. Results: We found an increase in referrals of 30% in the incidence quarter, mainly from general practice to neuropsychiatry and from there to radiology. Referrals to clinical chemistry and other disciplines for dementia-specific reasons were negligible in amount. 34% of incident cases had at least one contact with a neuropsychiatrist during the year of incidence, and the majority of them visited this specialist repeatedly during that year. Only a minority (13.5%) of patients was referred to radiology for imaging. Referrals to other specialists declined whereas self-referrals did not increase. Conclusions: The referral rates to relevant specialists (neuropsychiatry, radiology and clinical chemistry) are far less frequent than proposed in German guidelines. More research is needed to explain the gape between guidelines and daily care and to find ways for a better implementation of guidelines in ambulatory care. Guidelines should not only deal with diagnostic procedures and therapeutic options but also consider questions of applicability in daily clinical practice and propose effective organizational models of care provision

Association between footwear use and neglected tropical diseases: a systematic review and meta-analysis

BACKGROUND The control of neglected tropical diseases (NTDs) has primarily focused on preventive chemotherapy and case management. Less attention has been placed on the role of ensuring access to adequate water, sanitation, and hygiene and personal preventive measures in reducing exposure to infection. Our aim was to assess whether footwear use was associated with a lower risk of selected NTDs. METHODOLOGY We conducted a systematic review and meta-analysis to assess the association between footwear use and infection or disease for those NTDs for which the route of transmission or occurrence may be through the feet. We included Buruli ulcer, cutaneous larva migrans (CLM), leptospirosis, mycetoma, myiasis, podoconiosis, snakebite, tungiasis, and soil-transmitted helminth (STH) infections, particularly hookworm infection and strongyloidiasis. We searched Medline, Embase, Cochrane, Web of Science, CINAHL Plus, and Popline databases, contacted experts, and hand-searched reference lists for eligible studies. The search was conducted in English without language, publication status, or date restrictions up to January 2014. Studies were eligible for inclusion if they reported a measure of the association between footwear use and the risk of each NTD. Publication bias was assessed using funnel plots. Descriptive study characteristics and methodological quality of the included studies were summarized. For each study outcome, both outcome and exposure data were abstracted and crude and adjusted effect estimates presented. Individual and summary odds ratio (OR) estimates and corresponding 95% confidence intervals (CIs) were calculated as a measure of intervention effect, using random effects meta-analyses. PRINCIPAL FINDINGS Among the 427 studies screened, 53 met our inclusion criteria. Footwear use was significantly associated with a lower odds of infection of Buruli ulcer (OR=0.15; 95% CI: 0.08-0.29), CLM (OR=0.24; 95% CI: 0.06-0.96), tungiasis (OR=0.42; 95% CI: 0.26-0.70), hookworm infection (OR=0.48; 95% CI: 0.37-0.61), any STH infection (OR=0.57; 95% CI: 0.39-0.84), strongyloidiasis (OR=0.56; 95% CI: 0.38-0.83), and leptospirosis (OR=0.59; 95% CI: 0.37-0.94). No significant association between footwear use and podoconiosis (OR=0.63; 95% CI: 0.38-1.05) was found and no data were available for mycetoma, myiasis, and snakebite. The main limitations were evidence of heterogeneity and poor study quality inherent to the observational studies included. CONCLUSIONS/SIGNIFICANCE Our results show that footwear use was associated with a lower odds of several different NTDs. Access to footwear should be prioritized alongside existing NTD interventions to ensure a lasting reduction of multiple NTDs and to accelerate their control and elimination. PROTOCOL REGISTRATION PROSPERO International prospective register of systematic reviews CRD42012003338

Raisonner sur l’absence. Prospections géophysiques croisées au prieuré grandmontain d’Époisses à Bretenière (Côte-d’Or)

International audienceIn 2017, while a reorganisation project of the INRAE’s experimental unit in Époisses-Bretenières (Côte-d’Or) was under study, the former priory belonging to the order of Grandmont has been the object of a research campaign crossing medieval and modern archives, built remains and geophysical surveys. The main purpose aimed the reconstruction of the medieval priory and the different spaces organized around the cloister, starting from the only preserved remains of its chapter house. Finally, the surveys have led to a reflection on the lack of buried structures, considered as the possible sign of a practice rather than of an artefact.Les travaux engagés en 2017 dans l’unité expérimentale de l’INRAE du domaine d’Époisses à Bretenière (Côte-d’Or) ont été l’occasion de mettre en place une petite étude croisant sources médiévales et modernes, vestiges bâtis et prospections géophysiques sur le prieuré grandmontain d’Époisses. Partant des vestiges préservés de l’aile des moines, l’ambition première visait la caractérisation de l’emprise du prieuré médiéval disparu et la restitution des différents espaces organisés autour du cloître. L’opération a surtout été l’occasion de réfléchir sur l’absence de vestiges enfouis, envisagée comme le signe éventuel d’une pratique plutôt que celui d’un artefact

Vorbereitung der Studierenden auf die interprofessionelle Praxis durch nachhaltige Implementierung interprofessionell gestalteter Lernsettings zur Förderung interprofessioneller Kompetenzen

Hintergrund: Die Förderung und Forderung einer effektiveren und effizienteren interprofessionellen Zusammenarbeit im Gesundheits- und Sozialwesen sowie die konsequente Umsetzung kompetenzorientierter Curricula in der Ausbildung der verschiedenen Gesundheits- und Sozialberufe sind die dominierenden Themen der letzten Jahre, die Kliniker*innen, Bildungsexpert*innen und Wissenschaftler*innen gleichermassen beschäftigen. Ziel und Fragestellung: Ziel war, die Interprofessionelle Lehre im Departement Gesundheit der ZHAW sowohl strukturell wie inhaltlich neu auszurichten und nachhaltig in den Bachelorprogrammen zu verankern, basierend auf theoretischen Rahmenmodellen und orientiert am gesetzlich geforderten Praxisbezug. Doch wie ist ein Prozess zu gestalten, der mit Fokus auf die Ausbildung kommunikativer und kooperativer Skills im interprofessionellen Kontext all diesen Ansprüchen gerecht wird? Methode: Ein eigens hierfür zusammengesetztes interprofessionelles Fachgremium analysierte die gesetzlichen Vorgaben und Rahmenmodelle, legte in einem iterativen Konsensverfahren die von den Studierenden zu erwerbenden Kompetenzen fest und konzeptualisierte die Ausbildungselemente über die gesamte Ausbildung. Weiter wurden die Inhalte, Lern- und Lehrmethoden bestimmt sowie festgelegt, wie der Kompetenzerwerb überprüft werden soll. Ergebnisse: Ein Grobkonzept zur Gestaltung des interprofessionellen Lernens mit Fokus auf kommunikative Skills und Kompetenzen zur professionsübergreifenden Zusammenarbeit liegt vor und wird derzeit im Detail ausgearbeitet. Sowohl in der Konzipierung, der inhaltlichen Ausgestaltung und der Umsetzung wurden und werden neue Wege beschritten. Die Ausbildung als auch Ermittlung des Kompetenzzugewinns sollen sowohl am Lernort «Hochschule» wie auch am Lernort «Praxis» durch den Einsatz von neuen, innovativen Lehr- und Lernmethoden in unterschiedlichen, interprofessionellen Lehr- und Lernsettings erreicht werden. Diskussion: Die konsequente interprofessionelle Auseinandersetzung und die Notwendigkeit interprofessionellen Zusammenarbeitens auf Ebene der verantwortlichen Bildungsexpert*innen und relevanten Stakeholdern im Rahmen der curricularen Entwicklung kann als ein Organisationsentwicklungsprozess gedeutet werden, welcher die interprofessionelle Ausbildung als verbindendes, gemeinsam zu verantwortendes Element ins Zentrum rückt - zentral für deren Akzeptanz und erfolgreiche Implementierung und Umsetzung am Lernort «Hochschule» wie am Lernort «Praxis»