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To evaluate the scale-up of the OPUS-AP program to improve the care of residents at long-term care (LTC) centers through the systematic implementation of resident-centered approaches to care, the application of nonpharmacologic interventions for the management of behavioral and psychological symptoms of dementia (BPSD), and the deprescribing of antipsychotics where these are not clinically indicated.Prospective, closed cohort.Residents with major neurocognitive disorder (MNCD) from 24 (phase 1) and 129 (phase 2) publicly funded LTC centers in Quebec, Canada.The primary outcome was antipsychotic deprescribing (cessation or dose reduction). Secondary outcomes included changes in benzodiazepine and antidepressant prescriptions, BPSD, and falls. Comparisons were made between assessments at baseline and after 9 months.OPUS-AP phase 2 was conducted from March to December 2019 in 329 clinical wards at 129 LTC centers. At baseline, the 10,601 included residents had a mean age of 82.9: 64.6% were of female sex, 73.7% had a diagnosis of MNCD, and 47.0% had an antipsychotic prescription. These characteristics were similar to those of the 1054 residents at the 24 LTC centers in phase 1. In phase 2, successful antipsychotic deprescribing was achieved for 77.1% of residents in whom this approach was attempted, compared to 85.5% in phase 1. Phase 1 and 2 showed statistically significant improvements in the Cohen-Mansfield Agitation Inventory score and reduced use of benzodiazepines in residents with successful antipsychotic deprescribing. These improvements were of a smaller magnitude in phase 2. Statistically significant reductions in falls were observed in phase 2.The scale-up of the OPUS-AP program from 24 to 129 LTC centers was successful and resulted in a significant reduction in antipsychotic use, as well as improvement in BPSD, and reductions in benzodiazepine use and falls in residents with successful antipsychotic deprescribing.

(1) Background: This article discusses the first two phases of development and validation of the Three Domains of Judgment Test (3DJT). This computer-based tool, co-constructed with users and capable of being administered remotely, aims to assess the three main domains of judgment (practical, moral, and social) and learn from the psychometric weaknesses of tests currently used in clinical practice. (2) Method: First, we presented the 3DJT to experts in cognition, who evaluated the tool as a whole as well as the content validity, relevance, and acceptability of 72 scenarios. Second, an improved version was administered to 70 subjects without cognitive impairment to select scenarios with the best psychometric properties in order to build a future clinically short version of the test. (3) Results: Fifty-six scenarios were retained following expert evaluation. Results support the idea that the improved version has good internal consistency, and the concurrent validity primer shows that 3DJT is a good measure of judgment. Furthermore, the improved version was found to have a significant number of scenarios with good psychometric properties to prepare a clinical version of the test. (4) Conclusion: The 3DJT is an interesting alternative tool for assessing judgment. However, more studies are needed for its implementation in a clinical context.

Background: Nursing home (NH) residents with severe dementia use many medications, sometimes inappropriately within a comfort care approach. Medications should be regularly reviewed and eventually deprescribed. This pragmatic, controlled trial assessed the effect of an interprofessional knowledge exchange (KE) intervention to decrease medication load and the use of medications of questionable benefit among these residents. Methods: A 6-month intervention was performed in 4 NHs in the Quebec City area, while 3 NHs, with comparable admissions criteria, served as controls. Published lists of “mostly”, “sometimes” or “exceptionally” appropriate medications, tailored for NH residents with severe dementia, were used. The intervention included 1) information for participants’ families about medication use in severe dementia; 2) a 90-minute KE session for NH nurses, pharmacists, and physicians; 3) medication reviews by NH pharmacists using the lists; 4) discussions on recommended changes with nurses and physicians. Participants’ levels of agitation and pain were evaluated using validated scales at baseline and follow-up. Results: Seven (7) NHs and 123 participants were included for study. The mean number of regular medications per participant decreased from 7.1 to 6.6 in the intervention, and from 7.7 to 5.9 in the control NHs (p-value for the difference in differences test: < 0.05). Levels of agitation decreased by 8.3% in the intervention, and by 1.4% in the control NHs (p=0.026); pain levels decreased by 12.6% in the intervention and increased by 7% in the control NHs (p=0.049). Proportions of participants receiving regular medications deemed only exceptionally appropriate decreased from 19% to 17% (p=0.43) in the intervention and from 28% to 21% (p=0.007) in the control NHs (p=0.22). The mean numbers of regular daily antipsychotics per participant fell from 0.64 to 0.58 in the intervention and from 0.39 to 0.30 in the control NHs (p=0.27). Conclusions: This interprofessional intervention to reduce inappropriate medication use in NH residents with severe dementia decreased medication load in both intervention and control NHs, without important concomitant increase in agitation, but mixed effects on pain levels. Practice changes and heterogeneity within these 7 NHs, and a ceiling effect in medication optimization likely interfered with the intervention. The study is registered at ClinicalTrials.gov : # NCT05155748 (first registration 14-12-2021)

BACKGROUND The latest global figures show that 55 million persons lived with major neurocognitive disorders (MNCDs) worldwide in 2021. In Quebec, Canada, most of these seniors are cared for by family physicians in interdisciplinary primary care clinics such as family medicine groups (FMG). When a person suffers from a MNCD, taking potentially inappropriate medications or polypharmacy (five different medications or more) increases their vulnerability to serious adverse events. With the recent arrival of pharmacists working in FMGs and their expanded scope of practice and autonomy, new possibilities for optimizing seniors' pharmacotherapy are opening. OBJECTIVE This project aims to evaluate the impact of involving these pharmacists in the care trajectory of older adults living with MNCD, in an interdisciplinary collaboration with the FMG team, as well as home care nurses and physicians. Pharmacists will provide medication reviews, interventions, and recommendations to improve the pharmacotherapy and education provided to these patients and their caregivers. METHODS This 2-step mixed methods study will include a quasi-experimental controlled trial (step 1) and semi-structured interviews (step 2). Seniors undergoing cognitive assessment, recently diagnosed with MNCD or receiving care for this at home, will be identified and recruited in FMGs in two Quebec regions. FMGs implementing the intervention will involve pharmacists in these patients’ care trajectory. Training and regular mentoring will be offered to these FMGs, especially to pharmacists. In control FMGs, no FMG pharmacist will be involved with these patients, and usual care will be provided. RESULTS Medication use (including appropriateness) and burden, satisfaction of care received, and quality of life will be assessed at study beginning and after six months of follow-up and compared between groups. At the end of the intervention study, we will conduct semi-structured interviews with FMG care team members (pharmacists, nurses, physicians) who have experienced the intervention. We will ask about the feasibility of integrating the intervention into practice, their satisfaction with and their perception of the intervention impacts for seniors and their families. We will assess the effect of improved pharmaceutical care for seniors with or at risk of MNCDs through the involvement of FMG pharmacists and a reorganization of pharmaceutical care. CONCLUSIONS The inclusion of pharmacists in interdisciplinary care teams is recent and rising, strengthened by more significant pharmacist practice roles. Results will inform the processes required to successfully involve pharmacists and implement developed tools and procedures transposable to other care settings to improve patient care. CLINICALTRIAL NCT04889794

Background and Objectives: Many clinical supervisors in family medicine feel ill-equipped to teach senior care to their family medicine residents (trainees). We therefore sought to explore their preferred learning strategies for improving their clinical and teaching skills with regard to senior care. Methods: In this qualitative study, we conducted focus groups and interviews with supervisors from four family medicine clinics, to explore their preferred educational strategies. We selected four clinics using a maximum-variation strategy, based on a survey assessing continuing professional development (CPD) needs. The qualitative thematic analysis followed an inductive/deductive approach based on McGuire’s attributes of persuasive communication. Results: The four focus groups and nine interviews with 53 supervisors (37 physicians, 9 nurses, 4 psychologists, 1 social worker, 1 nutritionist, 1 sexologist) revealed that supervisors preferred being trained by experienced trainers specialized in senior care, from various professional backgrounds, and knowledgeable about local community resources. They valued practical training the most, such as clinical case discussions based on real cases, clinical tools, and mentoring. The findings also suggest that training in senior care should be adapted to the supervisors’ experience, profession, workload, and scope of intervention. Supervisors valued repeated CPD with longitudinal follow-up and easy access to trainers and to up-to-date training content. Conclusions: The findings of this project will allow those who design CPD activities to adapt such activities to the preferences of supervisors, so as to improve their clinical and teaching skills in senior care. This, in turn, may help supervisors to embody an appealing professional role model for learners.

Background the aim of this study was to evaluate the impact of emergency department (ED) stay-associated delirium on older patient’s functional and cognitive status at 60 days post ED visit. Methods this study was part of the multi-centre prospective cohort INDEED study. This project took place between March 2015 and July 2016 in five participating EDs across the province of Quebec. Independent non-delirious patients aged ≥65, with an ED stay ≥8 hours, were monitored for delirium until 24 hours post ward admission. A 60-day follow-up phone assessment was conducted. Participants were screened for delirium using the Confusion Assessment Method. Functional and cognitive statuses were assessed at baseline and at the 60-day follow-up using OARS and TICS-m. Results a total of 608 patients were recruited, 393 of which completed the 60-day follow-up. The Confusion Assessment Method was positive in 69 patients (11.8%) during ED stay or within the first 24 hours following ward admission. At 60 days, delirium patients experienced an adjusted loss of −2.9/28 [95%CI: −3.9, −2.0] points on the OARS scale compared to non-delirious patients who lost −1.6 [95%CI: −1.9, −1.3] (P = 0.006). A significant adjusted difference in cognitive function was also noted at 60 days, as TICS-m scores in delirious patients decreased by −1.6 [95%CI: −3.5, 0.2] compared to non-delirious patients, who showed a minor improvement of 0.5 [95%CI: −0.1, 1.1] (P = 0.03). Conclusion seniors who developed ED stay-associated delirium have lower baseline functional and cognitive status than non-delirious patients, and they will experience a more significant decline at 60 days post ED visit.

Background It is documented that health professionals from various settings fail to detect > 50% of delirium cases. Objective This study aimed to describe the proportion of unrecognized incident delirium in five emergency departments (EDs). Secondary objectives were to compare the two groups (recognized/unrecognized) and assess the impact of unrecognized delirium at 60 days regarding 1) unplanned consultations and 2) functional and cognitive decline. Method This is a sub-analysis of a multicenter prospective cohort study. Independent patients aged ≥ 65 years who tested negative for delirium on the initial interview with an ED stay ≥ 8 h were enrolled. Patients were assessed twice daily using the Confusion Assessment Method (CAM) and the Delirium Index up to 24 h into hospital admission. Medical records were reviewed to assess whether delirium was recognized or not. Results The main study reported a positive CAM in 68 patients. Three patients’ medical files were incomplete, leaving a sample of 65 patients. Delirium was recognized in 15.4% of our participants. These patients were older (p = 0.03) and female (p = 0.01) but were otherwise similar to those with unrecognized delirium. Delirium Index scores were higher in patients with recognized delirium (p = 0.01) and they experienced a more important functional decline at 60 days (p = 0.02). No association was found between delirium recognition and health care services utilization or decline in cognitive function. Conclusions This study confirms reports of high rates of missed or unrecognized delirium (84.6%) in ED patients compared to routine structured screening using the CAM performed by a research assistant. Patients with recognized delirium were older women with a greater severity of symptoms and experienced a more significant functional decline at 60 days.

Background Antipsychotics are often used for the first-line management of behavioral and psychological symptoms of dementia despite their limited efficacy and the risk of serious adverse drug events, compounded with disregard for guidelines recommending prioritizing non-pharmacological interventions. Some innovative interventions promote the deprescription of antipsychotics in long term care (LTC) settings. Objective The objective of this article is to present the conditions leading to the scale-up of an innovative program on the appropriate use of antipsychotics in LTC centers. Methods The Optimizing Practices, Use, Care and Services-Antipsychotics (OPUS-AP) program is a mixed-method project that aims to improve LTC residents’ care through increased knowledge and competency among staff, resident-centered approaches, nonpharmacologic interventions, and by deprescribing antipsychotics when appropriate. This article consists of a qualitative study focused on exploring the implementation conditions of the OPUS-AP program. This study was carried out in an integrated health area of Quebec. It consisted of 46 semi-structured interviews with staff members and managers involved in the implementation of OPUS-AP. The qualitative data analysis was inspired by a realistic evaluation approach, which shed light on the causal chain between context, mechanisms, and perceived effects. Results This study identified certain conditions conducive to scaling up the OPUS-AP program: an integrated, collaborative and evidence-based approach; communications in support of the process; stakeholder engagement at the strategic, tactical and operational levels; an implementation climate conducive to change; and an integrated knowledge translation strategy. Conclusion Despite evidence of clinical efficacy, deprescribing programs require great deal of scaling up efforts. Hence, this study underscores the need to further examine conditions for scaling up medication usage programs in real life contexts.

The objective of this study was to identify the predictors of incident delirium in this high-risk population.This study was a planned sub-analysis of the INDEED multicentre cohort study. We recruited patients aged ≥ 65, independent/semi-independent, with an emergency department (ED) length of stay ≥ 8 h and admitted to any hospital ward. Patients were followed up during their ED stay up to 24 h after ward admission. Sociodemographic characteristics, comorbidities, functional status (OARS), illness severity, level of frailty, cognitive status (TICS-m) and ED/patient environment evaluation were collected during initial interview. Patients were screened for delirium twice a day using the Confusion Assessment Method. Multivariate logistic regression was performed to identify the predictors of delirium.Incident delirium was detected in 68 patients of the 612 patients included (11%). Initially, seven candidate predictors were included in a regression model, of which four were retained using a stepwise selection procedure. Presence of cognitive impairment at baseline (OR 3.6, p 0.001), absence of mobilization during the whole ED length of stay (OR 3.3, p = 0.002), longer ED length of stay (OR 1.02, p = 0.006) were associated with a higher risk of incident delirium while higher functional status was associated with a lower risk (OR 0.8, p 0.001).More work is needed to determine which tool(s) are most appropriate for the ED use to increase delirium screening compliance among health professionals working in this department. It is really the first step to be able to suggest interventions to decrease delirium incidence.RéSUMé: OBJECTIF: L'objectif de cette étude était d'identifier les prédicteurs du délirium incident dans cette population à hautrisque. MéTHODES: Cette étude était une sous-analyse planifiée de l'étude de cohorte multicentrique INDEED. Nous avons recruté des patients âgés de ≥ 65 ans, indépendants/semi-indépendants, ayant une durée de séjour au département d'urgence (DU) ≥ 8 h et admis dans n'importe quel service. Les patients ont été suivis pendant leur séjour aux urgences jusqu'à 24 h après leur admission. Les caractéristiques sociodémographiques, les comorbidités, l'état fonctionnel (OARS), la gravité de la maladie, le niveau de fragilité, l'état cognitif (TICS-m) et l'évaluation de l'environnement des urgences/patients ont été recueillis lors de l'entretien initial. Les patients ont été soumis à un dépistage du délirium deux fois par jour à l'aide de la méthode d'évaluation de la confusion. Une régression logistique multivariée a été effectuée pour identifier les prédicteurs de délirium. RéSULTATS: Le délirium incident a été détecté chez 68 des 612 patients inclus (11%). Au départ, sept prédicteurs candidats ont été inclus dans un modèle de régression, dont quatre ont été retenus par une procédure de sélection par étapes. La présence d'un déficit cognitif initial (RC 3,6, p0,001), l'absence de mobilisation pendant toute la durée du séjour à l'urgence (RC 3,3, p = 0,002), une durée de séjour plus longue à l'urgence (RC 1,02, p = 0,006) étaient associées à un risque plus élevé de délirium incident, tandis qu'un état fonctionnel plus élevé était associé à un risque plus faible (RC 0,8, p0,001). CONCLUSIONS: Des travaux supplémentaires sont nécessaires pour déterminer quel(s) outil(s) sont les plus appropriés au DU afin d'accroître le dépistage du délirium par les professionnels de santé travaillant dans ce service. C'est vraiment la première étape pour pouvoir proposer des interventions visant à diminuer l'incidence du délirium.

Background Elderly patients discharged from hospital experience fragmented care, repeated and lengthy emergency department (ED) visits, relapse into their earlier condition, and rapid cognitive and functional decline. The Acute Care for Elders (ACE) program at Mount Sinai Hospital in Toronto, Canada uses innovative strategies, such as transition coaches, to improve the care transition experiences of frail elderly patients. The ACE program reduced the lengths of hospital stay and readmission for elderly patients, increased patient satisfaction, and saved the health care system over Can $4.2 million (US $2.6 million) in 2014. In 2016, a context-adapted ACE program was implemented at one hospital in the Centre intégré de santé et de services sociaux de Chaudière-Appalaches (CISSS-CA) with a focus on improving transitions between hospitals and the community. The quality improvement project used an intervention strategy based on iterative user-centered design prototyping and a “Wiki-suite” (free web-based database containing evidence-based knowledge tools) to engage multiple stakeholders. Objective The objectives of this study are to (1) implement a context-adapted CISSS-CA ACE program in four hospitals in the CISSS-CA and measure its impact on patient-, caregiver-, clinical-, and hospital-level outcomes; (2) identify underlying mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly; and (3) identify underlying mechanisms by which the Wiki-suite contributes to context-adaptation and local uptake of knowledge tools. Methods Objective 1 will involve staggered implementation of the context-adapted CISSS-CA ACE program across the four CISSS-CA sites and interrupted time series to measure the impact on hospital-, patient-, and caregiver-level outcomes. Objectives 2 and 3 will involve a parallel mixed-methods process evaluation study to understand the mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly and by which our Wiki-suite contributes to adaptation, implementation, and scaling up of geriatric knowledge tools. Results Data collection started in January 2019. As of January 2020, we enrolled 1635 patients and 529 caregivers from the four participating hospitals. Data collection is projected to be completed in January 2022. Data analysis has not yet begun. Results are expected to be published in 2022. Expected results will be presented to different key internal stakeholders to better support the effort and resources deployed in the transition of seniors. Through key interventions focused on seniors, we are expecting to increase patient satisfaction and quality of care and reduce readmission and ED revisit. Conclusions This study will provide evidence on effective knowledge translation strategies to adapt best practices to the local context in the transition of care for elderly people. The knowledge generated through this project will support future scale-up of the ACE program and our wiki methodology in other settings in Canada. Trial Registration ClinicalTrials.gov NCT04093245; https://clinicaltrials.gov/ct2/show/NCT04093245. International Registered Report Identifier (IRRID) DERR1-10.2196/17363

RÉSUMÉNous avons évalué les besoins de formation des cliniciens qui supervisent les résidents dans les cliniques d’enseignement de médecine familiale au Québec. Nous avons utilisé une méthodologie mixte comprenant: un balayage environnemental des programmes de formation des Départements de médecine familiale, un consensus d’experts pour sélectionner des situations cliniques prioritaires pour les soins aux aînés, un questionnaire pour connaître la perception des superviseurs de leurs besoins de formation, et des entrevues pour comprendre les raisons des besoins. Partant du balayage, les experts ont identifié 13 situations cliniques prioritaires. Les 352 participants au sondage (taux de réponse : 36 %) ont rapporté des besoins plus importants pour gérer les symptômes comportementaux et psychologiques de la démence, la polymédication, la dépression, et les troubles cognitifs. Les entrevues ont révélé que ces situations cliniques étaient parfois complexes à diagnostiquer et à gérer en raison de leurs aspects psychosociaux, de la communication avec les patients et les familles, et de la coordination des équipes interprofessionnelles. Les superviseurs ont également rapporté des besoins plus important en milieu soins de longue durée et à domicile par rapport aux soins ambulatoires, dû à la complexité des soins aux aînés dans ces milieux et à la présence de proches aidants.

To improve the care of seniors living with dementia, current initiatives typically target better identification and treatment of the patient. Our recent survey, however, shows we should also focus more on the needs of the informal caregivers who care for this population in primary care settings. This three-round Delphi survey sought caregivers’ views on the most frequent and difficult decisions that seniors with dementia, their informal caregivers, and health care providers face in primary care settings in the province of Quebec. Respondents consisted of 31 health care professionals, informal caregivers, managers, representatives of community-based organizations devoted to these seniors, and clinical researchers involved in the organization of care or services to seniors with dementia. When we asked respondents to rank 27 common but difficult decisions involving benefit/harm trade-offs, 83% ranked the decision to choose an option to reduce the burden of informal caregivers as one of the five most important decisions. Choosing a treatment to manage agitation, aggression or psychotic symptoms followed closely, with 79% of respondents selecting it as one of the five most important decisions. Our results point to the importance of attending to the needs of informal caregivers and improving the management of behavioural and psychological symptoms of dementia.

Background Medication regimens in nursing home (NH) residents with severe dementia should be frequently reviewed to avoid inappropriate medication, overtreatment and adverse drug events, within a comfort care approach. This study aimed at testing the feasibility of an interdisciplinary knowledge exchange (KE) intervention using a medication review guidance tool categorizing medications as either “generally”, “sometimes” or “exceptionally” appropriate for NH residents with severe dementia. Methods A quasi-experimental feasibility pilot study with 44 participating residents aged 65 years or over with severe dementia was carried out in three NH in Quebec City, Canada. The intervention comprised an information leaflet for residents’ families, a 90-min KE session for NH general practitioners (GP), pharmacists and nurses focusing on the medication review guidance tool, a medication review by the pharmacists for participating residents with ensuing team discussion on medication changes, and a post-intervention KE session to obtain feedback from team staff. Medication regimens and levels of pain and of agitation of the participants were evaluated at baseline and at 4 months post-intervention. A questionnaire for team staff explored perceived barriers and facilitators. Statistical differences in measures comparing pre and post-intervention were assessed using paired t-tests and Cochran’s-Q tests. Results The KE sessions reached 34 NH team staff (5 GP, 4 pharmacists, 6 heads of care unit and 19 staff nurses). Forty-four residents participated in the study and were followed for a mean of 104 days. The total number of regular medications was 372 pre and 327 post-intervention. The mean number of regular medications per resident was 7.86 pre and 6.81 post-intervention. The odds ratios estimating the risks of using any regular medication or a “sometimes appropriate” medication post-intervention were 0.81 (95% CI: 0.71–0.92) and 0.83 (95% CI: 0.74–0.94), respectively. Conclusion A simple KE intervention using a medication review guidance tool categorizing medications as being either “generally”, “sometimes” or “exceptionally” appropriate in severe dementia was well received and accompanied by an overall reduction in medication use by NH residents with severe dementia. Levels of agitation were unaffected and there was no clinically significant changes in levels of pain. Staff feedback provided opportunities to improve the intervention. Electronic supplementary material The online version of this article (10.1186/s12877-018-0895-z) contains supplementary material, which is available to authorized users.

Personalized medicine is based on: 1) improved clinical or non-clinical methods (including biomarkers) for a more discriminating and precise diagnosis of diseases; 2) targeted therapies of the choice or the best drug for each patient among those available; 3) dose adjustment methods to optimize the benefit-risk ratio of the drugs chosen; 4) biomarkers of efficacy, toxicity, treatment discontinuation, relapse, etc. Unfortunately, it is still too often a theoretical concept because of the lack of convenient diagnostic methods or treatments, particularly of drugs corresponding to each subtype of pathology, hence to each patient. Stratified medicine is a component of personalized medicine employing biomarkers and companion diagnostics to target the patients likely to present the best benefit-risk balance for a given active compound. The concept of targeted therapy, mostly used in cancer treatment, relies on the existence of a defined molecular target, involved or not in the pathological process, and/or on the existence of a biomarker able to identify the target population, which should logically be small as compared to the population presenting the disease considered. Targeted therapies and biomarkers represent important stakes for the pharmaceutical industry, in terms of market access, of return on investment and of image among the prescribers. At the same time, they probably represent only the first generation of products resulting from the combination of clinical, pathophysiological and molecular research, i.e. of translational research.

Resume La medecine personnalisee repose sur : 1) des methodes cliniques et paracliniques (y compris des biomarqueurs) pour un diagnostic plus discriminant et plus precis des maladies ; 2) des therapies ciblees ou le choix du meilleur traitement parmi ceux possibles pour chaque patient ; 3) des methodes d’ajustement de posologie pour maximiser le rapport benefice/risque des medicaments choisis ; 4) des biomarqueurs d’efficacite, de toxicite, d’arret de traitement, de rechute, etc. Malheureusement, c’est encore trop souvent un concept theorique faute de methodes diagnostiques et de traitements adaptes, en particulier des medicaments correspondant a chaque sous-type pathologique et donc pour chaque patient. La medecine stratifiee en est une composante, utilisant des biomarqueurs et des tests diagnostiques compagnons pour cibler les patients susceptibles de presenter la meilleure balance benefice-risque pour un principe actif donne. Le concept de therapie ciblee, surtout utilise en oncologie, repose sur l’existence d’une cible moleculaire definie, impliquee ou non dans le processus pathologique, et/ou sur l’existence d’un biomarqueur permettant d’identifier la population cible, qui devrait etre logiquement restreinte par rapport a la population atteinte de la pathologie consideree. Therapies ciblees et biomarqueurs representent des enjeux importants pour l’industrie pharmaceutique, en termes d’acces au marche, de retour sur investissement et d’image aupres des prescripteurs. En meme temps, ils ne representent probablement que la premiere generation de produits issus de la combinaison de la recherche clinique et de la recherche physiopathologique et moleculaire, c’est-a-dire de la recherche translationnelle.

ObjectivesIn the fast pace of the Emergency Department (ED), clinicians are in need of tailored screening tools to detect seniors who are at risk of adverse outcomes. We aimed to explore the usefulness of the Bergman-Paris Question (BPQ) to expose potential undetected geriatric syndromes in community-living seniors presenting to the ED.MethodsThis is a planned sub-study of the INDEED multicentre prospective cohort study, including independent or semi-independent seniors (≥65 years old) admitted to hospital after an ED stay ≥8 hours and who were not delirious. Patients were assessed using validated screening tests for 3 geriatric syndromes: cognitive and functional impairment, and frailty. The BPQ was asked upon availability of a relative at enrolment. BPQ’s sensitivity and specificity analyses were used to ascertain outcomes.ResultsA response to the BPQ was available for 171 patients (47% of the main study’s cohort). Of this number, 75.4% were positive (suggesting impairment), and 24.6% were negative. To detect one of the three geriatric syndromes, the BPQ had a sensitivity of 85.4% (95% CI [76.3, 92.0]) and a specificity of 35.4% (95% CI [25.1, 46.7]). Similar results were obtained for each separate outcome. Odds ratio demonstrated a higher risk of presence of geriatric syndromes.ConclusionThe Bergman-Paris Question could be an ED screening tool for possible geriatric syndrome. A positive BPQ should prompt the need of further investigations and a negative BPQ possibly warrants no further action. More research is needed to validate the usefulness of the BPQ for day-to-day geriatric screening by ED professionals or geriatricians.

Introduction: While negative consequences of incident delirium on functional and cognitive decline have been widely studied, very limited data is available regarding functional and cognitive outcomes in Emergency Department (ED) patients. The aim of this study was therefore to evaluate the impact of ED stay-associated delirium on older patient's functional and cognitive status at 60 days post-ED visit. Methods: This study is a planned sub-analysis of a large multicentre prospective cohort study (the INDEED study). This project took place between March and July of the years 2015 and 2016 within 5 participating EDs across the province of Quebec. Independent non-delirious patients aged □65, with an ED stay at least 8hrs were monitored until 24hrs post-ward admission. A 60-day follow-up phone assessment was also conducted. Participants were screened for delirium using the validated Confusion Assessment Method (CAM) and the severity of its symptoms was measured using the Delirium Index. Functional and cognitive status were assessed at baseline as well as at the 60-day follow-up using the validated OARS and TICS-m. Results: A total of 608 patients were recruited, 393 of which completed the 60-day follow-up. Sixty-nine patients obtained a positive CAM during ED-stay or within the first 24 hours following ward admission. At 60-days, those patients experienced a loss of 3.1 (S.D. 4.0) points on the OARS scale compared to non-delirious patients who lost 1.6 (S.D. 3.0) (p = 0.03). A significant difference in cognitive function was also noted at 60-days, as delirious patients’ TICS-m score decreased by 2.1 (S.D. 6.2) compared to non-delirious patients, who showed a minor improvement of 0.5 (S.D. 5.8) (p = 0.01). Conclusion: People who developed ED stay-associated delirium have lower baseline functional and cognitive status than non-delirious patients and they will experience a more significant decline at 60 days post-ED visit.

INTRODUCTION:Since the 1990s in France, based on contemporary French consensus conferences, for Hepatitis B (HBV) or Hepatitis C (HCV), diagnosis is acknowledged when detection of Hepatitis B surface antigen or anti-HCV antibody is positive on a 1st test line and further replicated on an independent blood sample.The replication was introduced to alleviate the low performance of immunoassay and avoid false positive results.Currently, the Haute Autorité de santé (HAS) is managing an update of diagnostic tests reimbursed for HBV and HCV to fully cover diagnostic needs.Our aim is to assess the clinical relevance of this repetition.METHODS:The assessment involves a critical analysis of national and international guidelines identified by a systematic literature search, and stakeholders’ views (professionals and public authorities).RESULTS:Since the 1990s, new tools were introduced (that is, polymerase chain reaction (PCR) for diagnosis and follow-up), and performances were improved for both enzyme immunoassay tests and PCR. Despite those change, replications are still performed nowadays in France.Neither guidelines nor stakeholders’ contributions mentioned any replication tests’ clinical relevance.The Ministry of Health confirms that replications have not any legal basis contrary to HIV diagnosis procedures. Also the French National agency for health products safety confirms there are neither technological pitfalls nor reagent vigilance signals involving HBV or HCV in vitro diagnostic tests. Furthermore, after 1st line positive results, a second blood sample is always collected to test other markers such as HBV DNA or HCV RNA which represent the best 2nd proof of infection.CONCLUSIONS:This work has enlightened a lack of clinical relevance for the replication of the same serological makers’ detection. It may obliterate soon this French medical dogma. This work has illustrated that short assessment based on critical guideline analysis linked with stakeholders’ views allows a rapid answer without assessment quality reduction. This HAS work will contribute to medical practice rationalization and cost reduction.

INTRODUCTION:The increase in travelers and refugees combined with global warming may soon lead to the development of tropical diseases such as Schistosoma or Strongyloides infections in some European countries.Those intestinal parasites may persist for decades with subclinical infections or low-grade disease with nonspecific manifestations. In the presence of immunosuppression, strongyloidiasis can rapidly evolve into life-threatening disseminated disease, whereas chronic schistosomiasis can lead to complications causing future morbidity and death.Currently in France, an update of diagnostic tests reimbursed for those tropical diseases is ongoing to fully cover diagnostic needs.Our aim was to assess the clinical relevance of tests used in schistosomiasis’ or strongyloidiasis’ diagnosis and include the most relevant in the national list of reimbursed tests.METHODS:The assessment involves a critical analysis of national and international guidelines identified by a systematic literature search, and stakeholders’ views.RESULTS:This work identifies several autochthonous outbreaks of those diseases in France; such as urogenital schistosomiasis that occurred in Corsica, in summer 2013. Also it enlightens the increase of strongyloides serological tests performed in the past years. Those facts prove the potential development of those infections in Europe.It underlines that, serology is the first diagnostic test line for most cases and is more sensitive than stool microscopy which represents however the final diagnostic investigation to confirm the intestinal infection.It confirms the main indications of those two diagnostic tools.It relies on a tropical infectious disease expert network including the French army health service. They have brought further clarification of diagnostic tests clinical relevance for travelers or autochthonous cases.CONCLUSIONS:This new use of Health Technology Assessment has allowed updating and listing the relevant diagnostic tools which might be crucial to better follow those diseases and it may help the health system to face the increase of tropical infections.

Introduction: It is documented that physicians and nurses fail to detect delirium in more than half of cases from various clinical settings, which could have serious consequences for seniors and for our health care system. The present study aimed to describe the rate of documented incident delirium in 5 Canadian Emergency departments (ED) by health professionals (HP). Methods: This study is part of the multicenter prospective cohort INDEED study. Patients aged 65 years old, initially free of delirium with an ED stay 8hours were followed up to 24h after ward admission. Delirium status was assessed twice daily using the Confusion Assessment Method (CAM) by trained research assistants (RA). HP reviewed patient charts to assess detection of delirium. HP had no specific routine detection of delirious ED patients. Inter-observer agreement was realized among RA. Comparison of detection between RA and HP was realized with univariate analyses. Results: Among the 652 included patients, 66 developed a delirium as evaluated with the CAM by the RA. Among those 66 patients, only 10 deliriums (15.2%) were documented in the patients medical file by the HP. 54 (81.8%) patients with a CAM positive for delirium by the RA were not recorded by the HP, 2 had incomplete charts. The delirium index was significantly higher in the HP reported group compared to the HP not reported, respectively 7.1 and 4.5 (pConclusion: It seems that health professionals missed 81.8% of the potential delirious ED patients in comparison to routine structured screening of delirium. HP could identify patients with a greater severity of symptoms. Our study points out the need to better identify elders at risk to develop delirium and the need for fast and reliable tools to improve the screening of this disorder.

Introduction: Prevalence and incidence of delirium in older patients admitted to acute and long-term care facilities ranges between 9.6% and 89% but little is known in the context of emergency department (ED) incident delirium. Literature regarding the incidence of delirium in the ED and its potential impacts on hospital length of stay (LOS), functional status and unplanned ED readmissions is scant, its consequences have yet to be clearly identified in order to orient modern acute medical care. Methods: This study is part of the multicenter prospective cohort INDEED study. Three Canadian EDs completed the two years prospective study (March-July 2015 and Feb-May 2016). Patients aged 65 years old, initially free of delirium with an ED stay 8hours were followed up to 24h after ward admission. Patients were assessed 2x/day during their entire ED stay and up to 24 hours on hospital ward by research assistants (RA). The primary outcome of this study was incident delirium in the ED or within 24 h of ward admission. Functional and cognitive status were assessed using validated Older Americans’ Resources and Services and the Telephone Interview for Cognitive Status- modified tools. The Confusion Assessment Method (CAM) was used to detect incident delirium. ED and hospital administrative data were collected. Inter-observer agreement was realized among RA. Results: Incident delirium was not different between sites, nor between phases, nor between times from one site to another. All phases confounded, there is between 7 to 11% of ED related incident delirious episodes. Differences were seen in ED LOS between sites in non-delirious patients, but also between some sites for delirious participants (pConclusion: The fact that incidence of delirium was the same for all sites, despite the differences of ED LOS and different time periods suggest that many other modifiable and non-modifiable factors along LOS influenced the incidence of ED induced delirium. Emergency physician should concentrate on improving senior-friendly environment for the ED.

ObjectiveWe aim to determine the incidence of delirium and describe its impacts on hospital length of stay (LOS) among non-delirious community-dwelling older adults with an 8-hour exposure to the emergency department (ED) environment.DesignThis is a prospective observational multicentre cohort study (March–July 2015). Patients were assessed two times per day during their entire ED stay and up to 24 hours on hospital ward.SettingThe study took place in four Canadian EDs.Participants338 included patients: (1) aged ≥65 years; (2) who had an ED stay ≥8 hours; (3) were admitted to hospital ward and (4) were independent/semi-independent.Main outcome(s) and measure(s)The primary outcomes of this study were incident delirium in the ED or within 24 hours of ward admission and ED and hospital LOS. Functional and cognitive status were assessed using validated Older Americans Resources and Services and the modified Telephone Interview for Cognitive Status tools. The Confusion Assessment Method was used to detect incident delirium. Univariate and multivariate analyses were conducted to evaluate outcomes.ResultsMean age was 76.8 (±8.1), 17.7% were aged >85 years old and 48.8% were men. The mean incidence of delirium was 12.1% (n=41). Median IQR ED LOS was 32.4 (24.5–47.9) hours and hospital LOS was 146.6 (75.2–267.8) hours. Adjusted mean hospital LOS was increased by 105.4 hours (4.4 days) (95% CI 25.1 to 162.0, PConclusionsAn incident delirium was observed in one of eight independent/semi-independent older adults after an 8-hour ED exposure. An episode of delirium increases hospital LOS by 4 days and therefore has important implications for patients and could contribute to ED overcrowding through a deleterious feedback loop.

The objective of this literature review was to evaluate the results obtained at vaginal myomectomy. The databases consulted were Medline, Cochrane Library, National Guideline Clearinghouse, and Health Technology Assessment Database. Keywords used for research were colpotomy, myomectomy, and vaginal myomectomy, and then abdominal myomectomy, laparoscopic-assisted vaginal myomectomy, and laparoscopic myomectomy. Eight case series and 2 case reports were analyzed, and included 372 patients. Reported rates of conversion to laparotomy during the operation ranged from 0% to 17.6%. The most frequently described risk factors for conversion to laparotomy were location of the myoma in the fundus and a large volume of myoma to be extracted, although no maximum threshold size can be defined. Performing laparoscopy first does not seem to limit the risk. Reported rates of transfusion during the operation ranged from 0% to 40%. Several cases of pelvic abscess have been described, with reported frequency of 2.2% to 5.7%. Authors mentioned the role of the vaginal drain that is inserted at the end of the procedure. No specific studies have been performed on long-term effectiveness, postoperative adhesions, integrity of the scar, or subsequent fertility. There are no good controlled studies of this technique. Feasibility seems to be acceptable, although the risk of pelvic infection in the postoperative period may be increased. Long-term effectiveness and safety were not assessed. A vaginal approach may be considered an alternative to laparotomy or laparoscopy in surgery to treat accessible myomas, and seems to be the simplest method.

INTRODUCTION:Mechanical thrombectomy (MT) is used in patients with acute ischaemic stroke due to occlusion of a proximal cerebral artery. Over the years endovascular techniques have been used to re-canalise blocked vessels, but are not currently reimbursed by National Health Insurance in France.The aim was to assess the efficacy and safety of MT in combination with intravenous tissue plasminogen activator (IV t-PA), or as an alternative to it, in adults with an acute ischaemic stroke who are not eligible for thrombolysis or in whom thrombolysis has failed; to support the reimbursement decision by National Health Insurance.METHODS:Within the scope of The European Network for Health Technology Assessment (EUnetHTA), a rapid assessment of “Endovascular therapy using devices for acute ischaemic stroke” was jointly produced with Haute Autorité de santé (HAS) as a reviewer.RESULTS:The EUnetHTA report provided a systematic review based on eight randomized controlled trials (RCT) for effectiveness and all available published data for safety.To produce its assessment, HAS has adapted the EUnetHTA report by: 1.Updating the systematic literature review including the latest published trials2.Retaining the subgroup analysis of the five most recent trials considered more relevant in the EUnetHTA report for the assessment of effectiveness3.Analysing specifically the different endovascular interventions studied in the five RCTs4.Taking into account contributions from stakeholders.CONCLUSIONS:This horizontal collaboration among European HTA doers has facilitated and shortened the assessment of the clinical benefit of this technology, confirming the relevance of EUnetHTA cooperation.This clinical assessment of thrombectomy is to be completed by the evaluation of its organizational impact in the management of acute ischemic stroke.

Early prenatal diagnosis of fetal sex is necessary to optimize pregnancy management in families known to be at risk of some heritable disorders. The demonstration of cell-free fetal DNA (cffDNA) in the mother's blood has made it possible to identify Y chromosome sequences in maternal blood and to determine fetal sex noninvasively, during the first trimester. This procedure can significantly reduce the number of invasive procedures for women with fetuses at risk of sex-linked diseases and optimize the management of these pregnancies. Fetal sex can be diagnosed by ultrasound with the same sensitivity and specificity, but later in pregnancy. We performed a review of the published literature evaluating the use of cffDNA and ultrasound for prenatal determination of fetal sex during the first trimester of pregnancy. We present the feasibility of the two methods and their impact on clinical practice. We applied a sensitive search of multiple bibliographic databases including Pubmed (MEDLINE), EMBASE, the Cochrane Library and Web of science between 1998 and 2013. Sixteen reports of the determination of fetal sex in maternal blood and 13 reports of the determination by ultrasound met our inclusion criteria. We found a sensitivity and specificity of nearly 100% from 8 weeks of gestation for cffDNA and from 13 weeks of gestation for ultrasound respectively. Based on this review, we conclude that fetal sex can be determined with a high level of accuracy by analyzing cffDNA and at an earlier gestation than ultrasound. Ten years after the first feasibility study, the French National Authority for Health (HAS) released a technological assessment report on the determination of fetal sex in maternal blood, which has resulted in validating this test for reimbursement by the national health insurance fund for the following indications: X-linked recessive disease and congenital adrenal hyperplasia.

This systematic literature review is intended to clarify and evaluate the results obtained by ovarian drilling as surgical treatment for polycystic ovarian syndrome (PCOS). Four databases were consulted (Medline at the National Library of Medicine, USA; Cochrane Library, UK; National Guideline Clearinghouse, USA; and the Health Technology Assessment Database, Sweden) and searched for ‘polycystic ovary syndrome' plus ‘drilling' in the title or abstract. The assessment criteria used to define the efficacy of the procedure were the rates of ovulation, clinical pregnancy and early miscarriage. Alternatives to surgical ovarian drilling were evaluated. This search produced 147 references, 81 of which met the selection criteria. This review of infertility management in women with PCOS indicates that ovarian drilling is a second-line treatment when treatment with clomiphene citrate fails to lead to conception. The benefits of ovarian drilling are that it does not induce either hyperstimulation syndrome or multiple pregnancies. It is concluded that ovarian drilling is an option in the management of female infertility associated with PCOS, especially as a second-line treatment after the failure of clomiphene citrate treatment.

To evaluate various techniques for restoring tubal patency after sterilisation.A search strategy was designed, and for each subject either thesaurus terms (MeSH descriptors) or terms from the title or summary were used.Mean length of hospital stay following laparoscopy seems to be shorter in comparison with laparotomy (3.3 vs. 6.1 days, P0.05). Rate of conversion to laparotomy is 5%. Pregnancy rates observed are between 54 and 88% for laparotomy and 31-85% for laparoscopy. Mean time to conception was between 2 and 9.6 months. Most pregnancies occurred in the 2 years following restoration of tubal patency (cumulative conception rate 80% at 12 months). Young age (35 years), type of ligature (rings), how recently the ligature was done (8 years), the anastomosis site (in the middle of the tube) and a good length of remaining tube (7 cm) are the factors that govern whether there can be good restoration of tubal patency. Ectopic pregnancy rates observed are between 1.7 and 12% for laparotomy and 0-7% for laparoscopy. There are no randomised or quasi-randomised studies comparing tubal anastomosis and in vitro fertilization.There are few good-quality controlled studies in this area. Results of restoration of tubal patency seem to be comparable, regardless of the route of approach (laparotomy or laparoscopy).