Health indicators in the European regions: expanding regional comparisons to the new countries of the European Union - ISARE III.

OBJECTIVES: Most comparisons of health in Europe take place at the national level. However, there is increased interest in looking at health data at a sub-national level. This study aimed to establish the availability of health data at a regional level and to develop a methodology for the comparisons of health indicators at a sub-national level. In previous work on indicators at a regional level in the European Union, the authors recommended the development of such indicators. This paper takes into account the expansion of the European Union which took place in 2004. STUDY DESIGN: Observational study using routinely available data. METHODS: Similar to previous projects, a network of country correspondents was used and data were collected on a similar range of topics. In addition, a supplementary list of data was collected from one region of each country. RESULTS: Twenty-three countries out of the 25 member states of the European Union participated in the study. Where available, data were of relatively good quality. Data on mortality were most readily available, but data on important public health topics such as obesity were much more difficult to obtain. CONCLUSIONS: A database and a set of indicators for relevant sub-national areas of countries in the European Union, including new countries, were constructed. Data collection from the new countries was more straightforward due to the requirement for them to adhere to the nomenclature of territorial units for statistics (NUTS) levels. The lack of adherence to NUTS levels in the 'old' countries of the European Union continues to create problems. There remains an urgent need to introduce comprehensive sub-national data collection on important public health topics such as obesity and smoking.

What clinical characteristics of children with autism influence their inclusion in regular classrooms?

BACKGROUND: This study took place in the context of recent legislation enacted in several countries--including France--and aimed at promoting inclusion of children with intellectual disabilities. It focuses on young children with autism and examines the links between the children's characteristics and their weekly hours of regular-classroom inclusion and intervention in specialised setting. METHOD: Standardised clinical and sociodemographic data were collected for 77 children with autism, along with data about their interventional programmes. RESULTS: The study showed that the number of hours of inclusion at school was influenced by the children's behavioural and adaptive characteristics, as well as by the socioprofessional category of their parents, although these factors did not affect the number of hours spent in specialised setting. Moreover, the total amount of time per week spent in interventional services of any kind was very small for some of the children. CONCLUSION: The time spent in special-intervention services and regular classrooms combined did not add up to an adequate number of weekly hours for these children, particularly those exhibiting at least one of the following characteristics: low adaptation level, major behavioural problems or low socioprofessional category of parents.

[Regionalization of perinatal care helps to reduce neonatal mortality and morbidity in very preterm infants and requires updated information for caregivers]. / La régionalisation des soins en périnatalité permet d'améliorer le pronostic néonatal des grands prématurés nés en région Languedoc-Roussillon et nécessite une actualisation des informations fournies aux professionnels.

UNLABELLED: In 1997 a large French epidemiological study (Epipage) showed increased mortality and morbidity in Languedoc Roussillon when compared to other regions of France. In order to update information, we set up a regional database about very preterm infants born in Languedoc-Roussillon since 2003. Our objective was to analyze the evolution of mortality and of the morbidity in very preterm infants between 1997 and 2003-2005. METHODS: We analyzed mortality and the morbidity (respiratory, neurological, digestive) of the very preterm infants born alive between 22 and 32 weeks amenorrhea and admitted alive in neonatology included in Epipage study in 1997 and of those included in the regional database in 2003-2005. Between these 2 periods, professional practices were significantly improved as the perinatal network was set up and perinatal care was regionalized. RESULTS: We analyzed the data collected in 3121 subjects of Epipage study and 1111 subjects of the regional database. We observed a significant reduction (P<0.05) of neonatal mortality (8% versus 23%), rate of bronchopulmonary dysplasia (9% versus 19%) and of periventricular leukomalacia (9% versus 18%). During this period, there were significant increases (P<0.05) in the rates of antenatal corticotherapy (87% versus 61%) and caesarean section (72% versus 38%). CONCLUSION: We observed a significant improvement of morbidity of very preterm infants and a decreased mortality for the youngest subjects which was concomitant of an improvement of the professional's practices. It is necessary to take into account these results to propose relevant informations to the professionals with and thus indirectly to the parents.

Survival of very preterm infants: Epipage, a population based cohort study.

OBJECTIVE: To evaluate the outcome for all infants born before 33 weeks gestation until discharge from hospital. DESIGN: A prospective observational population based study. SETTING: Nine regions of France in 1997. PATIENTS: All births or late terminations of pregnancy for fetal or maternal reasons between 22 and 32 weeks gestation. MAIN OUTCOME MEASURE: Life status: stillbirth, live birth, death in delivery room, death in intensive care, decision to limit intensive care, survival to discharge. RESULTS: A total of 722 late terminations, 772 stillbirths, and 2901 live births were recorded. The incidence of very preterm births was 1.3 per 100 live births and stillbirths. The survival rate for births between 22 and 32 weeks was 67% of all births (including stillbirths), 85% of live births, and 89% of infants admitted to neonatal intensive care units. Survival increased with gestational age: 31% of all infants born alive at 24 weeks survived to discharge, 78% at 28 weeks, and 97% at 32 weeks. Survival among live births was lower for small for gestational age infants, multiple births, and boys. Overall, 50% of deaths after birth followed decisions to withhold or withdraw intensive care: 66% of deaths in the delivery room, decreasing with increasing gestational age; 44% of deaths in the neonatal intensive care unit, with little variation with gestational age. CONCLUSION: Among very preterm babies, chances of survival varies greatly according to the length of gestation. At all gestational ages, a large proportion of deaths are associated with a decision to limit intensive care.

[Study of drug prescribing in patients older than 65 in Languedoc-Roussillon]. / Analyse de la prescription médicamenteuse chez les plus' de 65 ans en Languedoc-Roussillon.

PURPOSE: To analyse the medical prescriptions reimbursed by the Languedoc-Roussillon health care to the patient above 65 years old and analyse potential drugs interactions. To deduct the presenting actual educational modalities and information needed to ameliorate the quality of prescriptions for the elderly. METHODS: The data from the second trimester 1999 were taken from the LR health care data base on pharmaceutical agents which records the prescriptions dispensed in the pharmacies by teletransmission of codes CIP (Club International Pharmaceutique). The drug interactions of the prescriptions for the elderly of 65 or above in January 1999 by the LR health care Gard region. RESULTS: The prescriptions differ according to the sex and age. The drugs of psychotrope family and veinotonics (10% more) laxatives and NSAID's (2 to 3% more) for women. The majority of prescribed drugs diminish after a pick at the age of 85. The antihyperlipidemic drugs are an exception because their prescription diminishes immediately after 70's. The analyse of medical interactions shows lots of problem: sulfonylureas with fibrates (533 prescriptions), oral anticoagulant and fibrates (23), between sulfomylureas (273), or NSAID's (174) and a lot of contraindicated drugs (Ozidia 37). CONCLUSIONS: Some medical treatments because of their large number of prescription need to be continually educated to the practitioners. Some drugs which are inadvisable because of their adverse effects have had an individual treatment. This database is a good way to analyse the drug iatrogeny and its prevention.

[Evaluation of measles, mumps and rubella vaccine coverage in 3 year old children in twelve French counties. Time-trends and related factors]. / Evaluation de la couverture vaccinale rougeole-oreillons-rubéole chez les enfants de trois ans dans douze départements français. Evolution temporelle et facteur associés.

BACKGROUND: The aims of our study were to estimate the measle-mumps-rubella (MMR) vaccine coverage in 3 years old children in 12 French countees, to document the evolution between 1997 and 1999 in two groups of 6 countees (pilot group and control group) before and after the implementation of promotion programmes in the pilot group, and to identify factors related to measle-mumps-rubella vaccination. METHODS: Two telephone surveys were carried out in 1997 and 1999 among children randomly selected in the birth rolls of 12 French countees. Parents of 3 years old children were interviewed on measle-mumps-rubella vaccination, knowledge and opinions on vaccinations, utilisation of health care and socio-demographic characteristics. RESULTS: The participation rate was 97% in both surveys. Among the 7382 respondent parents, 98% had immediate access to the child's medical file and could document the vaccine status. The vaccine coverage did not increase significantly between 1997 and 1999 (86.7% versus 87.2%), both in control (89.3% vs. 90.2%) and pilot groups (84.3% vs. 84.3%). A logistic regression model showed that several factors were independently and significantly related to measle-mumps-rubella vaccination (utilisation of homeopathic medicines, mother's age, number of children, physician speciality (general practitioner or pediatrician) and opinion on vaccinations). CONCLUSION: Our study shows that there is a stagnation of vaccine coverage in several French countees, which makes unlikely the national objective of viruses eradication. This epidemiological situation makes very likely outbreaks of measles, mumps and rubella in these countees. National and local pilot programmes did not succeed to promote vaccination in countees with a low measle-mumps-rubella vaccine coverage. Our study identified sub-groups of parents who should be targeted by promotion programmes.

Exposure to anaesthetic agents, cognitive functioning and depressive symptomatology in the elderly.

BACKGROUND: Anaesthesia could provoke persistent alterations in specific cognitive domains in the elderly where ageing-related neuronal changes may exacerbate pharmacotoxic effects. AIMS: To evaluate anaesthesia effects on the incidence of cognitive dysfunction after orthopaedic surgery in elderly patients. METHOD: A total of 140 patients over the age of 64 years completed a full range of computerised cognitive tests. The study takes into account effects of pre-operative cognitive dysfunction, depressive symptomatology and ability to perform activities of daily living. RESULTS: Postoperative cognitive decline persisted for up to 3 months in 56% of subjects. Dysfunction was limited to verbal, visuo-spatial and semantic abilities and secondary and implicit memory. Age, low educational level, pre-operative cognitive impairment or depression are risk factors. CONCLUSIONS: Cognitive functions are not equally affected, type of impairment being determined by the risk factors described above and anaesthesia type.

Subclinical cognitive impairment: epidemiology and clinical characteristics.

Subclinical cognitive impairment is commonly reported in elderly populations, but its clinical significance is largely undetermined. It is commonly perceived as a normal feature of the aging process or a separate nosological entity. The clinical status of this disorder is explored herein by reference to longitudinal observations. It is concluded that persons with subclinical cognitive impairment constitute a highly heterogeneous group. There is an elevated risk in this group for senile dementia, with an estimated 18% incidence rate over 3 years, but in the majority of cases, this problem is more commonly associated with depressive symptomatology and physical illness. Only 13% of persons with recent observable change in cognitive functioning appear to have a totally benign and transient syndrome. Caution should be exercised in applying single unifying nosological entities such as age-associated memory impairment to this group of the elderly.

Depressive illness, depressive symptomatology and regional cerebral blood flow in elderly people with sub-clinical cognitive impairment.

BACKGROUND: Depressive illness in dementia is often assumed to be a unitary clinical phenomenon. AIM: To describe changes in patterns of depressive symptomatology with time, and associated changes in cerebral blood flow to the frontal and temporal regions. METHOD AND RESULTS: 397 elderly people with sub-clinical cognitive dysfunction were observed over 3 years. Sixteen percent of them developed dementia during the study The prevalence of depressive symptomatology was higher in this group than in the general population, especially in women, who also had higher recovery rates. A changing profile of depressive symptoms was found in depressed elderly people progressing to dementia, with fewer affective symptoms and increases in agitation and motor slowing. These changes were paralleled by greater reductions in left temporal regional cerebral blood flow than in non-depressed subjects with Alzheimer's disease. CONCLUSION: In dementia, there may be two separate and interacting depressive syndromes whose differentiation may be clinically important.

Cognitive decline in ageing: are AAMI and AACD distinct entities?

BACKGROUND: Two sets of research diagnostic criteria, age-associated memory impairment (AAMI) and ageing-associated cognitive decline (AACD), are widely used to describe mild cognitive decline in ageing. However, the extent to which the nosological entities they represent are similar or distinct is unclear. METHODS: A sample of 111 participants without dementia but with informant evidence of cognitive decline were drawn from the EUGERIA Study of Cognitive Ageing, a population-based study in southern France. These participants were classified as either normal or with AAMI according to the criteria of Crook et al. (1986), then reclassified as normal or with AACD according to criteria recommended by Levy et al. (1994). Neuropsychological test scores were then compared in these two pairs of groups. RESULTS: Particpants were classified as either normal (N=74) or with AAMI (N=37), then reclassified as normal (N=72) or with AACD (N=39). Only 20 (54%) of participants with AAMI simultaneously met criteria for AACD, and those with AACD showed more extensive cognitive impairment than those with AAMI. CONCLUSIONS: Although there is a large overlap between AAMI and AACD, these findings suggest that AAMI and AACD refer to distinct clinical entities, the latter delineating a more severe state of impairment. This may be largely because AAMI is defined as impairment with reference to young normals, whereas AACD refers to impairment with respect to normal contemporaries.

The effects of wine and tobacco consumption on cognitive performance in the elderly: a longitudinal study of relative risk.

BACKGROUND: Evidence relating to the potentially protective effect of smoking and alcohol consumption in relation to senescent cognitive decline and Alzheimer's disease is inconclusive. METHODS: The relationship between wine and tobacco consumption and cognitive change was assessed within a longitudinal study of normal elderly people showing recent instability in cognitive functioning using an extensive battery of cognitive tests. RESULTS: While moderate wine consumption was found to be associated with a fourfold diminishing of the risk of Alzheimer's disease (OR = 0.26), as found in other studies, this effect was found to disappear when institutionalization was taken into account. Wine consumption was associated with an increased risk of decline over time in attention and in secondary memory. No protective effect for Alzheimer's disease was found for smoking, although smoking was associated with a decreased risk for decline over time in attentional and visuospatial functioning. No clear combined effect of smoking and drinking was found, even though smoking was found to increase the risk of decline in language performance when adjusted on wine consumption. CONCLUSIONS: There is no evidence to suggest that wine and tobacco consumption may protect against Alzheimer's disease.

Progressive disability in senile dementia is accelerated in the presence of depression.

OBJECTIVES: To assess the extent to which loss of ability to perform everyday activities in early stage senile dementia is worsened by the presence of depressive illness. METHODS: To evolution of disabilities is measured by an activity scale permitting observation of small changes in everyday performance in a cohort of 397 elderly persons with subclinical cognitive deficit. Over the 3 years of the study, 11% of the cohort developed dementia without depression and 5% dementia with depression. RESULTS: Progressive disablement was found to be greater in persons with senile dementia as compared to normal subjects. Depression alone had no significant effect over the time period. Persons with both senile dementia and depression had significantly higher rates of disability at 3 years than persons with senile dementia alone. Significantly greater decrements across the observation period were observed in dressing, washing, use of telephone and continence in the senile dementia-depression group only. CONCLUSION: Depression does not in itself engender significant disability, but interacts with senile dementia to accelerate loss of functioning. Effective treatment of depressive illness in senile dementia may have significant impact on the prevalence and severity of disability.

[Renal replacement therapy for chronic renal failure patients in the Languedoc-Roussillon region in 1994]. / Les insuffisants rénaux chroniques en traitement de suppléance dans la région Languedoc-Roussillon en 1994.

BACKGROUND: Unbiased and reliable data are presently required for health planning concerning end stage renal diseases (ESRD) in Languedoc-Roussillon region of France. METHODS: A comprehensive retrospective study has been carried out on patients with ESRD in 1994 in this area. Information was collected from medical and social documents by physicians. The present report describes the management of patients and their demographic and epidemiologic characteristics. Multiple correspondence analysis was carried out to estimate to what extent mode of renal replacement therapy is determined by patient characteristics. RESULTS: An incidence of 11.4 for new cases of renal replacement therapy was found per 100,000 inhabitants. This represents an increase of 4.8% in the total number of patients. The patients were found to be elderly (25% being over 72 years) and to present with multiple pathologies (32.5% severe cardiac pathology; 20.7% arteritis of the lower limbs; 15.1% diabetes; 11.2% manifesting malignant tumors). Only 57.5% received dialysis within a hospital setting; 30.1% received dialysis at home; 13% perform autodialysis; 1.2% were being trained for home dialysis in December. The renal transplantation rate was 5.5%. No significant relationship was found between choice of therapy and age, renal disease, comorbidities and place of dwelling. CONCLUSIONS: This study demonstrates the great variety in the modes of treatment used, the facilities provided and the evolutive trend, which together make programming planning difficult.

Establishing the limits and characteristics of normal age-related cognitive decline.

BACKGROUND: Research into ageing-related pathology relies not only on exploration of disease aetiology, but also a clear understanding of the normal ageing process. The present study aims to examine the characteristics of elderly subjects who lie on the borderline between normal and pathological ageing. METHOD: Cognitive functioning is examined using computerized neuropsychometric assessment in a population of 833 normal elderly from which a cohort of 397 subjects with sub-clinical cognitive impairment are followed over three years. Subjects receive a standardized neurological examination and ApoE genotypes are established. RESULTS: Analysis of covariance revealed no cross-sectional age differences for syntax comprehension (p = 0.19), articulation (p = 0.46), semantic matching (p = 0.12), reading (p = 0.79), and implicit memory (p = 0.21) while explicit memory, language skills and visuospatial skills were found to deteriorate both in the cross-sectional age comparisons and across time. An overall intellectual ability factor, derived from Principal Components Analysis, was found by regression to decline principally in persons with low education, and a high initial IQ level was observed to provide a protective effect over age 75. Persons with higher levels of education show relative stability over time on language and secondary memory tasks but deteriorate as rapidly as persons with low education on visuospatial tasks. Five separate patterns of sub-clinical cognitive deficit were isolated by cluster analysis. Two groups, with differing clinical profiles (of which only one manifested the ApoE4 allele), were found to have an increased risk of developing senile dementia (OR = 4.4 and 3.9). A third group had a high prevalence of depressive illness, and the remaining two showed very little change. CONCLUSION: Ageing does not affect all cognitive functions uniformly: a high initial education level slowing rate of decline for certain tasks. Separate patterns of cognitive change are observed in early senile dementia, benign change and changes related to depressive illness. Results suggest the need for more stringent selection of normal control groups.

Impact of anesthesia on the cognitive functioning of the elderly.

Exposure to general anesthesia has been suggested as a possible cause of long-term cognitive impairment in elderly subjects. The present study reviews the literature in this field in order to describe postoperative cognitive impairment in elderly populations, to determine to what extent this may be attributed to anesthetic agents, and to consider evidence of a causal relationship between anesthesia and onset of senile dementia. A systematic literature search was conducted using five bibliographic databases (PASCAL, Medline, Excerpta Medica, Psychological Abstracts, and Science Citation Index). Significant cognitive dysfunction was found to be common in elderly persons 1 to 3 days after surgery, but reports of longer-term impairment are inconsistent due to the heterogeneity of the procedures used and populations targeted in such studies. Incidence rates vary widely according to type of surgery, suggesting that factors other than anesthesia explain a significant proportion of the observed variance. Anesthesia appears to be associated with longerterm cognitive disorder and the acceleration of senile dementia, but only in a small number of cases, suggesting the existence of other interacting etiological factors.

Does education level determine the course of cognitive decline?

Many studies have implicated low education as a risk factor for cognitive impairment in elderly people. Findings are, however, inconsistent and the mechanism by which education level may intervene in senescent cognitive change is uncertain. The present study examines cognitive change over a 1-year period in 283 elderly persons manifesting recent subclinical deterioration in at least one area of cognitive functioning. The results suggest that the impact of both education level and young adult IQ on the degree of cognitive change over the year is greater in the older age groups. Secondary memory and language functions were found to be more resistant to decline in the high-education group, while attention, implicit memory and visuospatial skills are found to decline irrespective of education level.

A typology of sub-clinical senescent cognitive disorder.

BACKGROUND: Cognitive impairment without dementia is commonly observed in ageing populations. The present study aims to describe types of impairment and evolution over a one-year period. METHOD: Three hundred and ninety-seven normal French elderly persons demonstrating recent, observable change in cognitive performance were examined annually using a computerised cognitive examination. RESULTS: Five subtypes were differentiated by cluster analysis. Two of the groups were predicted by logistic regression to be at high risk of senile dementia. Of 16 incident cases of senile dementia diagnosed in the following year, 13 were found to have derived from these two groups. The typology was also found to be useful in the description of age-associated memory impairment. CONCLUSIONS: Subclinical cognitive impairment was found to not constitute a unitary phenomenon and heterogeneous subgroups could be differentiated. The concept of 'normality' in elderly cohorts is reconsidered in the light of these findings.

Menopause and perceived health status among the women of the French GAZEL cohort.

The aim of this study was to evaluate the effect of menopause on women's quality of life. Women (1171) aged from 45-52 years who work for the French national gas and electricity company volunteered for this study (response rate 75%). They completed a self-administered questionnaire pertaining to general health. Quality of life was measured by the Nottingham Health Profile (NHP). Within this group 289 women were postmenopausal. After controlling for age, those women were more likely to show a lower quality of life than women still menstruating for 4 of the 6 sections of the NHP: social isolation (odds ratio 1.4; 95% confidence interval 1.1-1.9), pain, sleep and energy (odds ratios 1.5; 95% confidence intervals 1.1-2.0). Those alterations of quality of life are explained by the climacteric complaints the women report. Those findings suggest that the treatment of menopausal symptoms with medication of proven efficacy may prevent lowering of quality of life due to menopause.