Lateral condyle fracture of the humerus in children treated with bioabsorbable materials.

The aim of this study was to compare clinical and radiological outcome of lateral condyle fracture of the elbow in children treated with bioabsorbable or metallic material. From January 2008 to December 2009, 16 children with similar fractures and ages were grouped according to the fixation material used. Children were seen at 3, 6, and 12 months and more than 4 years (mean 51.8 months) postoperatively. The clinical results were compared using the Mayo Elbow Performance Score (MEPS). Radiographic studies of the fractured and opposite elbow were assessed at last follow-up control. Twelve children had a sufficient followup and could be included in the study. Seven could be included in the traditional group and 5 in the bioabsorbable group. At 12 months, the MEPS was 100 for every child in both groups. Asymptomatic bony radiolucent visible tracks and heterotopic ossifications were noted in both groups. There were no significant differences in terms of clinical and radiological outcome between the two groups. The use of bioabsorbable pins or screws is a reasonable alternative to the traditional use of metallic materials for the treatment of lateral condyle fracture of the elbow in children.

Endoscopic subureteral collagen injection for the treatment of vesicoureteral reflux in infants and children.

Between June 1988 and September 1994, 100 girls and 32 boys 2 months to 15.5 years old (average 4.9 years) with 204 refluxing ureteral units were treated by endoscopic subureteral collagen injection. The collagen injected was of bovine origin and cross-linked with glutaraldehyde (Zyplast*). Followup ranged from 3 to 75 months (mean 33). Reflux was absent in 62.7% of cases 3 months after 1 endoscopic subureteral injection. Improvement to reflux grades I and II, generally not requiring further treatment, occurred in a further 15.2% of cases. A total of 66 ureters was injected twice. The overall cure rate after 1 or 2 injections was 79.4% 3 months after injection. There was no correlation between the risk of recurrent reflux and initial degree of reflux. Late recurrence of reflux following a reflux-free period occurred in 11.3% of the 204 units during the observation period, which varied from 3 months to 6 1/4 years. Reflux was absent after 1 or 2 injections, including late recurrence, in 70.6% of cases and in an additional 13.2% recurrent reflux was grade I or II, not necessitating any further treatment. Considering these results, subureteral collagen injection remains an adequate method of treatment for vesicoureteral reflux in children.

Epidemiology of pulmonary hypertension: new data from the Swiss registry.

since 1999 data from pulmonary hypertension (PH) patients from all PH centres in Switzerland were prospectively collected. We analyse the epidemiological aspects of these data. PH was defined as a mean pulmonary artery pressure of >25 mm Hg at rest or >30 mm Hg during exercise. Patients with pulmonary arterial hypertension (PAH), PH associated with lung diseases, PH due to chronic thrombotic and/or embolic disease (CTEPH), or PH due to miscellaneous disorders were registered. Data from adult patients included between January 1999 and December 2004 were analysed. 250 patients were registered (age 58 +/- 16 years, 104 (41%) males). 152 patients (61%) had PAH, 73 (29%) had CTEPH and 18 (7%) had PH associated with lung disease. Patients <50 years (32%) were more likely to have PAH than patients >50 years (76% vs. 53%, p <0.005). Twenty-four patients (10%) were lost to followup, 58 patients (26%) died and 150 (66%) survived without transplantation or thrombendarterectomy. Survivors differed from patients who died in the baseline six-minute walking distance (400 m [300-459] vs. 273 m [174-415]), the functional impairment (NYHA class III/IV 86% vs. 98%), mixed venous saturation (63% [57-68] vs. 56% [50-61]) and right atrial pressure (7 mm Hg [4-11] vs. 11 mm Hg [4-18]). PH is a disease affecting adults of all ages. The management of these patients in specialised centres guarantees a high quality of care. Analysis of the registry data could be an instrument for quality control and might help identify weak points in assessment and treatment of these patients.

Collaboration entre médecin de famille et psychiatre pour les problèmes de santé mentale [Family physicians and psychiatrists' collaborative care for mental health problems].

The burden of disease linked to mental disorders represents more than one-fifth of years lived with disability in the world. Less than half of people suffering from mental disorders are adequately treated. Three quarter of those who receive treatment are followed by primary care. Collaborative care aims to increase the efficiency of direct general practitioner's treatment. Main components are sustainable and individualized consultation-liaison relationship (1/2 day of psychiatrist by 15 days for 10-15 general practitioners), and support of a clinical case manager for complex situations. Collaboration is bidirectional: early or crisis access to specialist care and long-term followup by general practitioner. This model is a challenge for the doctor-patient dual relationship and requires incentives in a public health perspective.

Preliminary results of venlafaxine exposure in pregnancy, a multicenter prospective cohort ENTIS study

Introduction: Venlafaxine (Efexor®) is a serotonin and noradrenaline reuptake inhibitor (SNRI) used for the treatment of depression and anxiety disorders. The limited data on the use of venlafaxine in human pregnancy do not indicate an increased risk of congenital malformations. The main purpose of the study is to assess the rate of major malformations after first trimester exposure to venlafaxine. Methods: This multicenter, prospective cohort study was performed using data from nine centers who are member of the European Network of Teratology Information Services (ENTIS). Data on pregnancy and pregnancy outcome of women who used venlafaxine in pregnancy were collected during individual risk counseling. Standardized procedures for data collection and followup were used by each center. Results: Follow up data were collected on 744 pregnancies of womenwhoused venlafaxine during gestation. In 583 (78.4%) cases the exposure had occurred at least in the first trimester. In total, there were 600 live births (5 twins), 85 spontaneous abortions, 57 elective terminations of pregnancy, 5 fetal deaths, and 2 ectopic pregnancies. The overall rate of major malformations after first trimester exposure and excluding chromosomal and genetic disorders was 3.2% (16/500) in all pregnancies ending in delivery, pregnancy terminations or fetal deaths with fetal-pathological examination. Among live births the malformation rate was 2.7% (13/490). We observed no increased risk for organ specific malformations. Conclusions: The present study indicates that venlafaxine is not a major human teratogen.

2008 Cancer in Iowa Report, 2008

Cancer is a reportable disease as stated in the Iowa Administrative Code. Cancer data are collected by the State Health Registry of Iowa, located at The University of Iowa in the College of Public Health’s Department of Epidemiology. The staff includes more than 50 people. Half of them, situated throughout the state, regularly visit hospitals, clinics, and medical laboratories in Iowa and neighboring states to collect cancer data. A follow-up program tracks more than 99 percent of the cancer survivors diagnosed since 1973. This program provides regular updates for followup and survival. The Registry maintains the confidentiality of the patients, physicians, and hospitals providing data. In 2008 data will be collected on an estimated 16,000 new cancers among Iowa residents. Noninvasive cases of bladder cancer are included in the estimates for bladder cancer, to be in agreement with the definition of reportable cases of the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute. Since 1973 the Iowa Registry has been funded primarily by the SEER Program of the National Cancer Institute. Iowa represents rural and Midwestern populations and provides data included in many National Cancer Institute publications. Beginning in 1990 a small percent of the Registry’s annual operating budget has been provided by the state of Iowa. Beginning in 2003, the University of Iowa has also been providing cost-sharing funds. The Registry also receives funding through grants and contracts with university, state, and national researchers investigating cancer-related topics.

Spine bone texture assessed by trabecular bone score (TBS) predicts osteoporotic fractures in men: The Manitoba Bone Density Program.

INTRODUCTION: One quarter of osteoporotic fractures occur in men. TBS, a gray-level measurement derived from lumbar spine DXA image texture, is related to microarchitecture and fracture risk independently of BMD. Previous studies reported the ability of spine TBS to predict osteoporotic fractures in women. Our aim was to evaluate the ability of TBS to predict clinical osteoporotic fractures in men. METHODS: 3620 men aged ≥50 (mean 67.6years) at the time of baseline DXA (femoral neck, spine) were identified from a database (Province of Manitoba, Canada). Health service records were assessed for the presence of non-traumatic osteoporotic fracture after BMD testing. Lumbar spine TBS was derived from spine DXA blinded to clinical parameters and outcomes. We used Cox proportional hazard regression to analyze time to first fracture adjusted for clinical risk factors (FRAX without BMD), osteoporosis treatment and BMD (hip or spine). RESULTS: Mean followup was 4.5years. 183 (5.1%) men sustain major osteoporotic fractures (MOF), 91 (2.5%) clinical vertebral fractures (CVF), and 46 (1.3%) hip fractures (HF). Correlation between spine BMD and spine TBS was modest (r=0.31), less than correlation between spine and hip BMD (r=0.63). Significantly lower spine TBS were found in fracture versus non-fracture men for MOF (p<0.001), HF (p<0.001) and CVF (p=0.003). Area under the receiver operating characteristic curve (AUC) for incident fracture discrimination with TBS was significantly better than chance (MOF AUC=0.59, p<0.001; HF AUC=0.67, p<0.001; CVF AUC=0.57, p=0.032). TBS predicted MOF and HF (but not CVF) in models adjusted for FRAX without BMD and osteoporosis treatment. TBS remained a predictor of HF (but not MOF) after further adjustment for hip BMD or spine BMD. CONCLUSION: We observed that spine TBS predicted MOF and HF independently of the clinical FRAX score, HF independently of FRAX and BMD in men. Studies with more incident fractures are needed to confirm these findings.

Operative Treatment of Ovarian Cancer and Borderline Tumors in Different Hospital Categories in Finland

Surgery is the cornerstone of ovarian cancer treatment and maximal cytoreduction is important. In the early 1980’s primary surgical treatment of ovarian cancer was performed in over 80 hospitals in Finland. The significance of the operative volume of the hospital, of the training of the surgeons and of centralization of surgical treatment has been widely discussed. The aim of the present study was to evaluate the outcome of surgical treatment of ovarian cancer in different hospital categories retrospectively and prospectively, and to analyze if any differences are reflected in survival. The retrospective study included 3851 ovarian cancer patients operated between 1983 and 1994 in Finland. The data was analyzed according to hospital category (university, central, and other) and by quartiles of the hospital operative volume. The results showed that patients operated in the highest operative volume hospitals had the best relative survival. When stratifying the analysis by the period of diagnosis (1983-1988 and 1989-1994), the university hospitals improved their performance the most. The prospective part of the thesis was initiated in 1999 and included 307 patients with invasive ovarian cancer and 65 patients with an ovarian borderline tumor. The baseline and 5-year surveys used a questionnaire that was filled in by the operating surgeons. For analysis of the 5-year followup data, the hospitals were divided into three categories (<10, 10-20, or >20 patients operated in 1999). The effect of the surgical volume was analyzed also as a continuous variable (1-47 operations per year). In university hospitals, pelvic lymphadenectomy was performed in 88 %, and para-aortic lymphadenectomy in 73 %, of the patients with stage I disease. The corresponding figures ranged from 11 % to 21 % in the other hospitals. For stage III ovarian cancer patients operated by gynecological oncologists, the estimated odds ratio for no macroscopic residual tumor was 3.0 times higher (95 % CI 1.2-7.5) than for those operated by general gynecologists. In the university and other hospitals 82% of the patients received platinum-based chemotherapy. Platinum + taxane combination was given to 63 % of the patients in the university and in 49 % in the other hospitals (p = 0.0763). Only a minority of the patients with tumors of borderline malignancy were staged according to recommendations, most often multiple peritoneal biopsies and omentectomy were neglected. FIGO stage, patient age, and residual tumor were independent prognostic factors of cancer-specific 5-year survival. A higher hospital operative volume was also a significant prognostic factor for better cancer-specific survival (p = 0.036) and disease-free survival (p = 0.048). In conclusion, ovarian cancer patients operated in high-volume university hospitals were more often optimally debulked and had a significantly better cancer-specific survival than patients operated in other hospitals. These results favor centralization of primary surgical treatment of ovarian cancer.

The use of telomerase activity for the detection of prostatic cancer cells after prostatic massage.

PURPOSE: Prostate cancer is the most commonly diagnosed cancer in the United States. The diagnosis or followup of prostate cancer in men older than 50 years is based on digital rectal examination, measurement of the free-to-total prostatic specific antigen ratio and transrectal ultrasound assisted needle biopsy of the prostate. We developed and evaluated a noninvasive method for diagnosing prostate cancer based on the measurement of telomerase activity after prostatic massage in fresh voided urine or after urethral washing. MATERIALS AND METHODS: We obtained 36 specimens of cells after prostatic massage in the fresh voided urine of 16 patients who subsequently underwent radical prostatectomy and after urethral washing in 20 who underwent prostate needle biopsies. Ethylenediaminetetraacetic acid was immediately added to the collected urine or washing to a final concentration of 20 mM. After protein extraction by CHAPS buffer each specimen was tested for telomerase activity in a 2-step modified telomeric repeat amplification protocol assay. The 2 prostate cancer cell lines PC-3 and LNCaP with high telomerase activity were used as a positive control. RESULTS: Telomerase activity was detected in 14 of 24 samples with known prostate cancer (sensitivity 58%). In contrast, no telomerase activity was found in the 12 cases without histological evidence of prostate tumor (specificity 100%). Eight of 9 poorly differentiated cancers expressed telomerase activity (89%), while only 6 of 15 well and moderately differentiated cancers showed telomerase activity (40%). CONCLUSIONS: Our data illustrate that telomerase activity may be detected in voided urine or washing after prostatic massage in patients with prostate cancer. Sensitivity was higher for poorly differentiated tumors. This approach is not currently available for detecting prostate cancer in clinical practice. However, these results are promising and further studies are ongoing.

Clinically occult metastases in patients with cutaneous melanoma. Detection with sentinel lymph node biopsy and whole body positron emission tomography

Objective: The aim of this study was to investigate the use of sentinel lymph node biopsy (SLNB) and whole body positron emission tomography (PET), with emphasis on surgical treatment and prognosis, in the detection of clinically occult metastases in patients with clinically localized cutaneous melanoma. Patients and methods: The study population consisted of 1255 patients with clinical stage I–II cutaneous melanoma, operated at Turku University Hospital between 1983 and 2007. 334 patients underwent SLNB and they were compared to 921 retrospective patients. A subgroup of 30 symptom-free patients with high risk melanoma underwent prospectively whole body PET 6–24 months postoperatively. Results: Overall, the disease-specific survival rate was 84.4 % at five years. Sex, Breslow thickness, age and nodal status were independent prognostic factors for survival. SLNB revealed occult nodal metastases in 17 % of the patients. There was no significant difference in disease-specific overall survival between SLNB patients and controls, but the nodal disease-free time was significantly longer suggesting better local control after SLNB and subsequent completion lymph node dissection. The followup time was different between the study cohorts and initial surgery was performed during different time periods. SLNB detected micrometastases in seven of 155 patients (4.5 %) with thin T1 primary melanoma and in four of 25 patients (16 %) with head and neck melanoma. In six of 30 asymptomatic patients with high risk melanoma (20 %), whole body PET detected occult distant metastases. Conclusion: Both SLNB and whole body PET were reliable methods to detect clinically occult metastases in patients with cutaneous melanoma. This upstaging altered the treatment in each case.

Patterns of impact resulting from a 'sit less, move more' web-based program in sedentary office employees

Purpose Encouraging office workers to ‘sit less and move more’ encompasses two public health priorities. However, there is little evidence on the effectiveness of workplace interventions for reducing sitting, even less about the longer term effects of such interventions and still less on dual-focused interventions. This study assessed the short and mid-term impacts of a workplace web-based intervention (Walk@WorkSpain, W@WS; 2010-11) on self-reported sitting time, step counts and physical risk factors (waist circumference, BMI, blood pressure) for chronic disease. Methods Employees at six Spanish university campuses (n=264; 42±10 years; 171 female) were randomly assigned by worksite and campus to an Intervention (used W@WS; n=129; 87 female) or a Comparison group (maintained normal behavior; n=135; 84 female). This phased, 19-week program aimed to decrease occupational sitting time through increased incidental movement and short walks. A linear mixed model assessed changes in outcome measures between the baseline, ramping (8 weeks), maintenance (11 weeks) and followup (two months) phases for Intervention versus Comparison groups.A significant 2 (group) × 2 (program phases) interaction was found for self-reported occupational sitting (F[3]=7.97, p=0.046), daily step counts (F[3]=15.68, p=0.0013) and waist circumference (F[3]=11.67, p=0.0086). The Intervention group decreased minutes of daily occupational sitting while also increasing step counts from baseline (446±126; 8,862±2,475) through ramping (+425±120; 9,345±2,435), maintenance (+422±123; 9,638±3,131) and follow-up (+414±129; 9,786±3,205). In the Comparison group, compared to baseline (404±106), sitting time remained unchanged through ramping and maintenance, but decreased at follow-up (-388±120), while step counts diminished across all phases. The Intervention group significantly reduced waist circumference by 2.1cms from baseline to follow-up while the Comparison group reduced waist circumference by 1.3cms over the same period. Conclusions W@WSis a feasible and effective evidence-based intervention that can be successfully deployed with sedentary employees to elicit sustained changes on “sitting less and moving more”.

The effectiveness of vocationally oriented multidisciplinary rehabilitation (ASLAK®) amongst public sector employees

In Finland, vocationally oriented medical rehabilitation (ASLAK®) is a common preventive rehabilitation measure with the primary goal of preserving and improving work ability. The ASLAK® programme has been used for almost 30 years, although limited data exist on its effectiveness. The aims of this study were to determine whether the increased risk of work disability predicts the participants’ likelihood to be granted ASLAK® rehabilitation and to assess the effectiveness of the programme in decreasing the risk of work disability and modifying health-risk behaviours. This study is a part of the on-going Finnish Public Sector Study conducted by the Finnish Institute of Occupational Health. Data on 53 416 employees (81% women) were gathered from employers’ records, national health registers and repeated survey responses. During the 5-year follow-up, increased levels of the risk factors for work disability did not predict participation in the rehabilitation programme. During the 2.8-year followup (range 0.04–5.0 years), the risk of long-term work disability (sick leave >90 days or retirement) overall or, more specifically, due to musculoskeletal or mental diseases did not differ between the rehabilitants who participated in ASLAK® in 1997–2005 and their propensity score matched controls. There was no evidence of ASLAK® being effective in changing participants’ health-risk behaviours or in improving perceived general or mental health. The results suggest that potential participant recognition, mainly taking place in occupational health care, may fail to identify those with a higher risk of work disability. No evidence on the effectiveness of the programme was found in the study cohort when measured by the selected indicators.

Multiple sclerosis and pregnancy: clinical and immunological aspects

Background: Multiple Sclerosis (MS) is an autoimmune disease of the central nervous system that affects most commonly young women in their childbearing age. Previous studies have shown that MS relapse rate usually reduces during pregnancy and increases again after delivery. Patients with MS and their treating physicians are interested to know more about the risks the disease can cause to pregnancy and how pregnancy affects the disease. The reasons for increased relapse rate after delivery are not entirely clear, but loss of pregnancy related immune tolerance and changes in the hormonal status at the time of delivery seem to be of relevance. Aims and methods: The aims of this study were to follow the natural course of MS during and after pregnancy, evaluate pregnancy related risks among MS patients, follow the inflammatory response of MS patients during and after pregnancy and clarify the risk of relevant co-morbidities known to affect other autoimmune diseases after pregnancy and compare these results to healthy controls. This study was a part of a prospective nation-wide follow-up study of 60 Finnish MS patients. All eligible MS patients were enrolled in the study during the years 2003-2005. A prospective followup continued from early pregnancy until six months postpartum. MS relapses, EDSS scores and obstetric details were recorded. Blood samples were obtained from the patients at early, middle, and late pregnancy, after delivery and one month, three months and six months postpartum. Results: MS patients were no more likely to experience pregnancy or delivery complications than the Finnish mothers in general. The need of instrumental assistance, however, was higher among mothers with MS. Disease activity followed the course seen in previous studies. The majority of mothers (90.2%) breastfed their babies. Contrary to previous results, breastfeeding did not protect MS patients from disease worsening after delivery in present study. Mothers with active pre-pregnancy disease chose to breastfeed less frequently and started medication instead. MS patients presented with higher prevalence of elevated thyroid autoantibodies postpartum than healthy controls, but the rate of thyroid hormonal dysfunction was similar as that of healthy controls. The mode of delivery nor the higher rate of tissue damage assessed with C-reactive protein concentration were not predictive of postpartum relapses. The prevalence of gestational diabetes was slightly higher among mothers with MS compared to Finnish mothers in general, but postpartum depression was observed in similar rates. MS patients presented with significantly lower serum concentrations of vitamin D during pregnancy and postpartum than healthy controls. Conclusions: Childbearing can be regarded as safe for mothers with MS as it is for healthy mothers in general. Breastfeeding can be recommended, but it should be done only after careful evaluation of the individual risk for postpartum disease activation. Considering MS patients tend to develop thyroid antibody positivity after delivery more often than healthy controls and that certain treatments can predispose MS patients to thyroid hormonal dysfunction, we recommend MS mothers to be screened for thyroid abnormalities during pregnancy and after delivery. Increased risk for gestational diabetes should be kept in mind when following MS mothers and glucose tolerance test in early pregnancy should be considered. Adequate vitamin D supplementation is essential for MS mothers also during pregnancy and postpartum period.

Creating better customer experiences: Service Design effects on customer experience

Pro gradu –tutkielman tavoitteena oli tutkia, kuinka palvelumuotoilua voidaan käyttää parempien asiakaskokemusten luomisessa. Tutkimuksen teoreettisessa osuudessa keskityttiin tutkimaan palvelumuotoilun ja asiakaskokemuksen käsitteitä. Tutkielman empiirinen osuus tehtiin laadullisena tutkimuksena, jossa vertailtiin asiakaskokemuksia kahdessa Espoon kaupungin yhteispalvelupisteessä: Leppävaarassa sijaitseva yhteispalvelupiste oli hiljattain suunniteltu uudelleen käyttäen palvelumuotoilun periaatteita; Matinkylän palvelupiste oli alkuperäisessä muodossaan tutkimuksen aikana. Tutkimuksen yhtenä tavoitteena oli myös selvittää, oliko palvelumuotoilun menetelmin tehty muotoiluprojekti Leppävaaran yhteispalvelupisteessä onnistunut, kun sitä arvioitiin asiakaskokemuksen näkökulmasta. Tutkielman aineisto kerättiin suoran havainnoinnin ja haastattelun keinoin. Yhteensä 33 yksittäistä asiakasta havannoitiin ja haastateltiin tutkimusta varten toukokuussa 2015. Vastaajat valikoituivat satunnaisesti havannointipäivien asiakkaista. Heitä havainnoitiin koko asiakaspolun ajan minkä jälkeen heitä haastateltiin. Tutkimuksen tulokset ovat kaksiosaiset. 1) Arvioitaessa asiakkaiden kokemuksia liittyen palvelutilan toimivuuteen ja aineelliseen ympäristöön todettiin, että palvelumuotoilulla saavuttettiin parempi asiakaskokemus, ja täten Leppävaaran muotoiluprojekti oli onnistunut tavoitteissaan. 2) Kun taas tuloksia tarkasteltiin asiakaspalvelutilanteiden näkökulmasta, projekti ei ollut päässyt tavoitteisiin ja palvelumuotoilun menetelmillä ei pystytty parantamaan asiakaskokemuksta. Espoon kaupungin muotoiluprojekti on vielä kesken, tulosten perusteella tutkija ehdotti jatkotoimenpiteenä muun muassa lisäkoulutusta palveluhenkilökunnalle.

A retrospective study of cholinesterase inhibitors for Alzheimer's disease : the effect of cerebrovascular disease on patient outcomes and the impact of biases on the results.

Introduction: La démence peut être causée par la maladie d’Alzheimer (MA), la maladie cérébrovasculaire (MCEREV), ou une combinaison des deux. Lorsque la maladie cérébrovasculaire est associée à la démence, les chances de survie sont considérées réduites. Il reste à démontrer si le traitement avec des inhibiteurs de la cholinestérase (ChEIs), qui améliore les symptômes cognitifs et la fonction globale chez les patients atteints de la MA, agit aussi sur les formes vasculaires de démence. Objectifs: La présente étude a été conçue pour déterminer si la coexistence d’une MCEREV était associée avec les chances de survie ou la durée de la période jusqu’au placement en hebergement chez les patients atteints de la MA et traités avec des ChEIs. Des études montrant de moins bons résultats chez les patients souffrant de MCEREV que chez ceux n’en souffrant pas pourrait militer contre l’utilisation des ChEIs chez les patients atteints à la fois de la MA et la MCEREV. L'objectif d'une seconde analyse était d'évaluer pour la première fois chez les patients atteints de la MA l'impact potentiel du biais de « temps-immortel » (et de suivi) sur ces résultats (mort ou placement en hebergement). Méthodes: Une étude de cohorte rétrospective a été conduite en utilisant les bases de données de la Régie de l’Assurance Maladie du Québec (RAMQ) pour examiner la durée de la période jusqu’au placement en hebergement ou jusqu’au v décès des patients atteints de la MA, âgés de 66 ans et plus, avec ou sans MCEREV, et traités avec des ChEIs entre le 1er Juillet 2000 et le 30 Juin 2003. Puisque les ChEIs sont uniquement indiquées pour la MA au Canada, chaque prescription de ChEIs a été considérée comme un diagnostic de la MA. La MCEREV concomitante a été identifié sur la base d'un diagnostic à vie d’un accident vasculaire cérébral (AVC) ou d’une endartériectomie, ou d’un diagnostic d'un accident ischémique transitoire au cours des six mois précédant la date d’entrée. Des analyses séparées ont été conduites pour les patients utilisant les ChEIs de façon persistante et pour ceux ayant interrompu la thérapie. Sept modèles de régression à risque proportionnel de Cox qui ont varié par rapport à la définition de la date d’entrée (début du suivi) et à la durée du suivi ont été utilisés pour évaluer l'impact du biais de temps-immortel. Résultats: 4,428 patients ont répondu aux critères d’inclusion pour la MA avec MCEREV; le groupe de patients souffrant seulement de la MA comptait 13,512 individus. Pour le critère d’évaluation composite considérant la durée de la période jusqu’au placement en hebergement ou jusqu’au décès, les taux de survie à 1,000 jours étaient plus faibles parmi les patients atteints de la MA avec MCEREV que parmi ceux atteints seulement de la MA (p<0.01), mais les différences absolues étaient très faibles (84% vs. 86% pour l’utilisation continue de ChEIs ; 77% vs. 78% pour la thérapie avec ChEIs interrompue). Pour les critères d’évaluation secondaires, la période jusqu’au décès était plus courte chez les patients avec la MCEREV que sans la MCEREV, mais la période jusqu’au vi placement en hebergement n’était pas différente entre les deux groupes. Dans l'analyse primaire (non-biaisée), aucune association a été trouvée entre le type de ChEI et la mort ou le placement en maison d'hébergement. Cependant, après l'introduction du biais de temps-immortel, on a observé un fort effet différentiel. Limitations: Les résultats peuvent avoir été affectés par le biais de sélection (classification impropre), par les différences entre les groupes en termes de consommation de tabac et d’indice de masse corporelle (ces informations n’étaient pas disponibles dans les bases de données de la RAMQ) et de durée de la thérapie avec les ChEIs. Conclusions: Les associations entre la coexistence d’une MCEREV et la durée de la période jusqu’au placement en hebergement ou au décès apparaissent peu pertinentes cliniquement parmi les patients atteints de la MA traités avec des ChEIs. L’absence de différence entre les patients atteints de la MA souffrant ou non de la MCEREV suggère que la coexistence d’une MCEREV ne devrait pas être une raison de refuser aux patients atteints de la MA l’accès au traitement avec des ChEIs. Le calcul des « personne-temps » non exposés dans l'analyse élimine les estimations biaisées de l'efficacité des médicaments.