Age-specific information resources to address the needs of young people with stroke: a scoping review protocol

BACKGROUND AND AIMS

Young people with stroke (YPwS) persistently experience challenges with disability, social reintegration, employment, and financial stability to provide for themselves and their families. The aims of this scoping review are to (1) identify and collate information resources for YPwS and evidence-based self-managements programs and (2) identify gaps in age-specific resources available for YPwS after traditional rehabilitation services have ended and/or who are returning to live in the community.

METHODS

We will include both qualitative and quantitative studies, including all study designs. Participants will be community-dwelling adults aged between 18 and 65 years with a clinical diagnosis of stroke. We will include information resources and evidence-based self-managements programs for YPwS. Search terms will include stroke, young people, and community dwelling. We will search electronic databases such as MEDLINE. The reference lists of included studies, systematic reviews, and stroke guidelines and stroke-specific websites will also be searched. We will also contact Stroke Support Organizations and international/national allied health professional organisations to gather information resources about YPwS. We will also conduct a comprehensive environmental scan of additional resources using the search engine Google. The titles, abstracts, full-text articles, and contents of the resources identified by the search will be assessed against the inclusion and exclusion criteria to identify potentially relevant resources.

RESULTS AND CONCLUSIONS

Existing resources and self-management programs will be collated and categorized according to the type of needs addressed such as physical, emotions, activities of daily living, information, relationships, and social needs as well as the key gaps identified.

Efanesoctocog alfa elicits functional clot formation that is indistinguishable to that of recombinant factor VIII

BACKGROUND

Factor VIII (FVIII) binding to endogenous von Willebrand factor (VWF) has constrained half-life extension of recombinant FVIII (rFVIII) products for hemophilia A. Efanesoctocog alfa (rFVIIIFc-VWF-XTEN; BIVV001) is a novel fusion protein designed to decouple FVIII from VWF in circulation and maximize half-life prolongation by XTEN® polypeptides and Fc fusion. FVIII, VWF, and platelets interact to achieve normal hemostasis. Thus, bioengineered FVIII replacement products, such as efanesoctocog alfa, require comprehensive assessment of their hemostatic potential.

OBJECTIVES

We compared functional clot formation and injury-induced platelet accumulation between efanesoctocog alfa and rFVIII.

PATIENTS/METHODS

The hemostatic potential of efanesoctocog alfa and rFVIII were assessed by measuring their dose-dependent effects on in vitro fibrin generation in hemophilic plasma and in vivo injury-induced platelet accumulation using intravital microscopy and repeat saphenous vein laser-induced injuries in hemophilia A mice.

RESULTS

Equal concentrations of efanesoctocog alfa or rFVIII (up to 1 IU/ml) added to plasma from patients with hemophilia A elicited similar kinetics for dose-dependent fibrin polymerization between factor products. In the presence of tissue plasminogen activator (tPA), clots formed had similar stability between products. Single intravenous doses (50, 100, or 150 IU/kg) of efanesoctocog alfa or rFVIII shortly before repeat saphenous vein laser-induced injuries increased platelet accumulation over time in a dose-dependent manner in hemophilia A mice. Platelet deposition kinetics were similar between products.

CONCLUSIONS

Equivalent doses of efanesoctocog alfa and rFVIII had similar efficacy in promoting fibrin clot formation and injury-induced platelet accumulation. The hemostatic potential of efanesoctocog alfa was indistinguishable from that of rFVIII.

Solid peripheral tumor leads to systemic inflammation, astrocyte activation and signs of behavioral despair in mice

Prevalence of depression is higher in patients with cancer than in the general population. Sustained systemic inflammation has been associated with depressive behavior and it has been reported that depressed patients commonly display alterations in their immune system. We previously showed that cancer in mice induces a systemic environment that promotes neutrophil activation and leukocytosis. We thus hypothesized that the peripheral systemic response to a solid tumor leads to endothelial activation, which may promote inflammatory changes in the brain with behavioral consequences. Using the Lewis lung carcinoma (LLC) model, we show that tumor growth induces a progressive increase in peripheral inflammation as observed by elevated interleukin-6 (IL-6). In behavioral studies, tumor-bearing mice showed no sign of motor, coordination or short term working memory deficits as assessed by rotarod, balance-beam, and novel object recognition tests. However, there was an impairment in the grip strength test and interestingly, an anxious and despair-like phenotype in the elevated plus-maze, and tail suspension tests, respectively. Immunostaining of perfused brains revealed fibrin accumulation in the vasculature with some leakage into the parenchyma, a process known to activate endothelial cells. Taken together, our results suggest that the inflamed and prothrombotic systemic environment created by the growth of a peripherally-located solid tumor induces endothelial activation, accumulation of fibrin in the brain and astrocyte activation, perhaps leading to depressive-like behavior.

ADAMTS13 Deficiency Worsens Colitis and Exogenous ADAMTS13 Administration Decreases Colitis Severity in Mice

Background  Inflammatory bowel disease (IBD) affects 1.6 million people in the United States. IBD is associated with an increased risk of thrombosis, which rises with disease activity. The pathogenesis of IBD and its increased thrombotic risk is not completely understood. Ultra large von Willebrand factor (ULVWF) multimers are secreted from activated endothelium, leading to recruitment of platelets and leukocytes. A disintegrin and metalloproteinase with thrombospondin type I repeats motif 13 (ADAMTS13) cleaves highly adhesive ULVWF into smaller, less bioactive, multimers, releasing them into circulation. Mice deficient in ADAMTS13 (ADAMTS13 ^−/− ) have heightened inflammatory and thrombotic responses.

Objectives  We hypothesized that upon colitis induction, ADAMTS13 ^−/− mice would have more severe symptoms compared with wild-type (WT) mice, and rhADAMTS13 administration to mice with colitis would improve their condition.

Results  Dextran sodium sulfate–induced colitis was worse in ADAMTS13 ^−/− mice than WT. ADAMTS13 ^−/− showed increased weight loss, worse anemia, and increased clinical and histologic colitis severity, compared with WT mice. ADAMTS13 ^−/− mice had increased VWF release, with accumulation at inflamed colonic sites. Also, the majority of mice showed one or more submucosal colonic thrombi. ADAMTS13 deficiency worsened colitis and propagated intestinal inflammation, most likely through increased platelet–leukocyte recruitment by VWF. Treatment of WT mice with rhADAMTS13 decreased colitis severity without worsening anemia. Additionally, several immune-mediated chronic murine colitis models, and inflamed colon tissue specimens from IBD patients, showed increased VWF release at inflamed sites, suggesting a generalizability of our findings.

Conclusion  Measuring VWF/ADAMTS13 levels could have clinical utility. When applicable, the administration of ADAMTS13, in addition to primary treatment, may improve outcomes for IBD patients.

Diabetes primes neutrophils to undergo NETosis, which impairs wound healing

Wound healing is impaired in diabetes, resulting in significant morbidity and mortality. Neutrophils are the main leukocytes involved in the early phase of healing. As part of their anti-microbial defense, neutrophils form extracellular traps (NETs) by releasing decondensed chromatin lined with cytotoxic proteins. NETs, however, can also induce tissue damage. Here we show that neutrophils isolated from type 1 and type 2 diabetic humans and mice were primed to produce NETs (a process termed NETosis). Expression of peptidylarginine deiminase 4 (PAD4, encoded by Padi4 in mice), an enzyme important in chromatin decondensation, was elevated in neutrophils from individuals with diabetes. When subjected to excisional skin wounds, wild-type (WT) mice produced large quantities of NETs in wounds, but this was not observed in Padi4(-/-) mice. In diabetic mice, higher levels of citrullinated histone H3 (H3Cit, a NET marker) were found in their wounds than in normoglycemic mice and healing was delayed. Wound healing was accelerated in Padi4(-/-) mice as compared to WT mice, and it was not compromised by diabetes. DNase 1, which disrupts NETs, accelerated wound healing in diabetic and normoglycemic WT mice. Thus, NETs impair wound healing, particularly in diabetes, in which neutrophils are more susceptible to NETosis. Inhibiting NETosis or cleaving NETs may improve wound healing and reduce NET-driven chronic inflammation in diabetes.

ADAMTS13 Endopeptidase Protects against Vascular Endothelial Growth Factor Inhibitor-Induced Thrombotic Microangiopathy

Thrombotic microangiopathy (TMA) is a life-threatening condition that affects some, but not all, recipients of vascular endothelial growth factor (VEGF) inhibitors given as part of chemotherapy. TMA is also a complication of preeclampsia, a disease characterized by excess production of the VEGF-scavenging soluble VEGF receptor 1 (soluble fms-like tyrosine kinase 1; sFlt-1). Risk factors for VEGF inhibitor-related TMA remain unknown. We hypothesized that deficiency of the VWF-cleaving ADAMTS13 endopeptidase contributes to the development of VEGF inhibitor-related TMA. ADAMTS13(-/-) mice overexpressing sFlt-1 presented all hallmarks of TMA, including thrombocytopenia, schistocytosis, anemia, and VWF-positive microthrombi in multiple organs. Similar to VEGF inhibitor-related TMA in humans, these mice exhibited severely impaired kidney function and hypertension. In contrast, wild-type mice overexpressing sFlt-1 developed modest hypertension but no other features of TMA. Recombinant ADAMTS13 therapy ameliorated all symptoms of TMA in ADAMTS13(-/-) mice overexpressing sFlt-1 and normalized BP in wild-type mice. ADAMTS13 activity may thus be a critical determinant for the development of TMA secondary to VEGF inhibition. Administration of recombinant ADAMTS13 may serve as a therapeutic approach to treat or prevent thrombotic complications of VEGF inhibition.

NETosis: a new factor in tumor progression and cancer-associated thrombosis

Neutrophils have long been known as innate immune cells that phagocytose and kill pathogens and mount inflammatory responses protecting the host from infection. In the past decades, new aspects of neutrophils have emerged unmasking their importance not only in inflammation but also in many pathological conditions including thrombosis and cancer. The 2004 discovery that neutrophils, upon strong activation, release decondensed chromatin to form neutrophil extracellular traps (NETs), has unveiled new avenues of research. Here, we review current knowledge regarding NETs in thrombosis, with a special focus on cancer-associated thrombosis as well as their potential role in cancer growth and metastasis. We discuss the prospective use of NET-specific biomarkers, such as citrullinated histone H3 and NET inhibitors, as tools to anticipate and fight cancer-associated thrombosis. We propose that the rapid developments in the field of NETosis may provide new targets to combat the thrombotic consequences of cancer and perhaps even help to contain the disease itself.

Abstract 54: Peptidylarginine Deiminase 4-dependent Generation of Neutrophil Extracellular Traps is Crucial for Deep Vein Thrombosis in Mice

Introduction

Histone hypercitrullination by the enzyme peptidylarginine deiminase 4 (PAD4) leads to nuclear chromatin decondensation that is needed for neutrophil extracellular trap (NET) formation. NETs consist of chromatin and granule proteins that are released into the extracellular environment. NETs were shown to be involved in thrombosis by promoting coagulation and platelet adhesion and were identified in the thrombus scaffold in animal models of deep vein thrombosis (DVT).

Objective

Whether NETs are involved in the pathogenesis of DVT or whether they are merely a consequence of neutrophil recruitment to the thrombus is unknown. We hypothesized that NET formation would be impaired in PAD4-deficient mice during deep vein thrombosis and that this may affect thrombus formation and/or stability.

Methods

PAD4-deficient mice are incapable of citrullinating histones and therefore fail to decondense chromatin during NETosis. We performed the inferior vena cava stenosis model of DVT in wild-type or PAD4-/- mice. Intravital microscopy was done to assess leukocyte vessel wall interaction in PAD4 deficiency.

Results

We induced NET formation in isolated peripheral blood mouse neutrophils with ionomycin and found that PAD4-/- neutrophils had a complete inability to produce NETs (WT, 20.65±2.61% NETs; PAD4-/-, not detected. n=4). Leukocyte-endothelial interactions in PAD4-/- mice were not impaired upon induction of systemic Weibel-Palade body release (WT, 55.2±11.8; PAD4-/-, 62.0±17.5 cells/min, n=5-6). In the DVT model, while a majority (9/10) of wild-type mice formed a thrombus 48 hours after stenosis, only 1 of 11 PAD4-/- mice formed a thrombus. Thrombus formation could be rescued by infusions of isolated WT bone marrow neutrophils into PAD4-/- mice, and extracellular H3Cit+ areas were seen within these thrombi. This data suggests that neutrophil PAD4 was essential for thrombus formation in deep veins.

Conclusion

NETs comprise a crucial part of the pathologic thrombus scaffold, and here we report that the lack of NETs inhibits pathological thrombosis. Chromatin decondensation initiated by PAD4 in neutrophils is a key player in the formation of deep vein thrombi and targeting neutrophil histone modification could be a new way to prevent DVT.

Isoflurane inhibits neutrophil recruitment in the cutaneous Arthus reaction model

PURPOSE

Neutrophil recruitment to the inflammatory sites is regulated by a variety of adhesion molecules including β2 integrins. The dependency of neutrophil recruitment on β2 integrins is variable in different tissues, but has not yet been verified in the cutaneous passive reverse Arthus reaction. We examined this question and also evaluated the impact of isoflurane on neutrophil recruitment to the skin because we previously showed in vitro that isoflurane binds and inhibits β2 integrins.

METHODS

The dependency on β2 integrins in neutrophil recruitment to the skin in the Arthus reaction was examined using αL, αM and β2 knockout mice. Then, we evaluated the effect of isoflurane on neutrophil recruitment to the skin. In addition, the effects of isoflurane on neutrophil binding to intercellular adhesion molecule-1 (ICAM-1), one of the β2 integrin ligands, were studied in vitro using cell adhesion assays.

RESULTS

Neutrophil recruitment to the skin in the Arthus reaction model was totally dependent on β2 integrins, as β2 knockout mice completely abolished it. However, the defect of only one of the β2 integrins was not sufficient to abolish neutrophil recruitment. Isoflurane reduced neutrophil recruitment to the skin by approximately 90 %. Also, isoflurane inhibited neutrophil adhesion to β2 integrin ligand ICAM-1.

CONCLUSIONS

We demonstrated that (1) neutrophil recruitment to the skin was totally dependent on β2 integrins, and (2) isoflurane significantly impaired neutrophil recruitment. Based on the previous studies on the contribution of other adhesion molecules in neutrophil recruitment, it is likely that isoflurane at least partially affects on β2 integrins in this model.

ADAMTS13 exerts a thrombolytic effect in microcirculation

Recombinant tissue plasminogen activator (r-tPA) is the drug of choice for thrombolysis, but it is associated with a significant risk of bleeding and is not always successful. By cleaving von Willebrand factor (VWF), the metalloprotease ADAMTS13 (a disintegrin-like and metalloprotease with thrombospondin type I repeats-13) down-regulates thrombus formation in injured vessels. We investigated whether recombinant ADAMTS13 (r-ADAMTS13) induces thrombolysis in vivo in mice. Thrombosis was produced by ferric chloride-induced (FeCl(3)) injury in the venules of a dorsal skinfold chamber. Phosphate-buffered saline (PBS, vehicle), r-tPA or r-ADAMTS13, supplemented with hirudin (to stop on-going thrombin generation), was directly applied onto the occluded vessel, and thrombus dissolution was evaluated by intravital microscopy. The incidence of blood flow restoration significantly increased 30 minutes (min) after r-ADAMTS13 vs. PBS treatment (60% vs. 0%, p<0.05) and 60 min after r-tPA treatment (75% vs. 17%, p<0.05). Both r-tPA and r-ADAMTS13 significantly reduced thrombus size 60 min after their superfusion (53.2% and 62.3% of the initial thrombus size, p<0.05 and p<0.01, respectively). Bleeding occurred in all r-tPA-treated chambers, while it was absent in mice treated with r-ADAMTS13 or PBS. We observed that, similar to r-tPA, r-ADAMTS13 can dissolve occlusive thrombi induced by FeCl(3) injury in venules. In contrast to r-tPA, the in vivo thrombolytic effect of ADAMTS13 was not associated with any signs of haemorrhage. ADAMTS13 could represent a new therapeutic option for thrombolysis.

How platelets safeguard vascular integrity

The haemostatic role of platelets was established in the 1880s by Bizzozero who observed their ability to adhere and aggregate at sites of vascular injury. It was only some 80 years later that the function of platelets in maintaining the structural integrity of intact blood vessels was reported by Danielli. Danielli noted that platelets help preserve the barrier function of endothelium during organ perfusion. Subsequent studies have demonstrated further that platelets are continuously needed to support intact mature blood vessels. More recently, platelets were shown to safeguard developing vessels, lymphatics, as well as the microvasculature at sites of leukocyte infiltration, including inflamed organs and tumours. Interestingly, from a mechanistic point of view, the supporting role of platelets in these various vessels does not necessarily involve the well-understood process of platelet plug formation but, rather, may rely on secretion of the various platelet granules and their many active components. The present review focuses on these nonconventional aspects of platelet biology and function by presenting situations in which platelets intervene to maintain vascular integrity and discusses possible mechanisms of their actions. We propose that modulating these newly described platelet functions may help treat haemorrhage as well as treat cancer by increasing the efficacy of drug delivery to tumours.

Active transportation as a way to increase physical activity among children

BACKGROUND

This study examines how active transportation could help increase the daily physical activity volume of school-aged children.

METHODS

Using data from the 2003 Origin-Destination Survey carried out among 5% of the 3.5 million residents of the Greater Montreal Area, we determined the proportion of short motorized trips made daily by children 5-14 years old (16 837 children sampled) and estimated the number of steps these trips would account for if they were travelled by foot, taking into account variables such as age, sex and height of children. Modal choice and trip purpose were also examined.

RESULTS

In 2003, 31.2% of the daily trips made by children aged 5-14 years in the Greater Montreal Area were 1 km or less (0.6 mile). Of these, 33.0% were motorized trips. Overall, 13.1% of the children in the area had 'steps in reserve', an average of 2238 steps per child per day. If they were performed, these steps would account for 16.6% of the daily recommended volume of physical activity for children.

CONCLUSION

Replacing short motorized trips with walking could increase the physical activity level of children and contribute to meet the recommended guidelines, as long as these walking trips add to their daily physical activity volume. It could also reduce their dependence towards adults for moving around.

Triggering of T-cell leukemia and dissemination of T-cell lymphoma in MMP-9-deficient mice

Previous studies have shown that high levels of MMP-9 can be detected in the serum of patients with various lymphoid malignancies and in leukemia/lymphoma culture supernatants. Indeed, aggressive forms of lymphoma constitutively produce MMP-9 and its elevated levels in the serum or in tissues correlate with advanced stage and poor patient survival. In vitro, MMP-9, which is also produced by the host peritumoral cells in response to the presence of tumors, plays an important role in migration of tumor cells through artificial basement membranes or endothelial cells. In this study, using MMP-9-deficient mice, we show that absence of MMP-9 does not prevent the development of primary T-cell leukemia. Furthermore, MMP-9-deficient cell lines retained their tumorigenic potential, as shown by their ability to induce thymic lymphoma in young syngeneic wild-type animals. In addition, these MMP-9-deficient tumor cells disseminate in normal mice, or mice that are deficient for MMP-9, indicating that tumor growth and dissemination can occur in total absence of MMP-9. These results show for the first time than lymphoma growth can occur in total absence of MMP-9 and have consequences for therapy of invasive cancers with inhibitors of MMPs.

Obesity in Canada: where and how many?

CONTEXT

Obesity rates are rising sharply among all industrialized countries; the situation seems to be worse in English speaking countries. Taking into account genetic predisposition, excess of caloric intake combined with low energy expenditure will usually result in obesity.

OBJECTIVES

To describe and compare regional obesity rates across Canada and assess the ecological relationship between regional rates of obesity, low level of leisure-time physical activity, and low fruit and vegetable consumption.

DESIGN

Cross-sectional population-based analysis from the 2003 Canadian Community Health Survey. MEASURES AND DATA ANALYSES: Canadian population distributions of body mass index (BMI), leisure-time physical activity and daily fruit and vegetable consumption were obtained from Statistics Canada. All these measures were based on the respondent's self-reported answers to a computer-assisted personal or telephone interview. Obesity rates (BMI> or =30), rates of low level of leisure-time physical activity (less than 1.5 kcal of energy expenditure per day), and rates of low fruit and vegetable consumption (less than five times a day) for the 106 Canadian Health regions were mapped to illustrate their geographical distribution. Cartograms were used in addition to traditional mapping to take into account the differences in population density between these small areas.

RESULTS

In 2003, 15.2% of Canadian individuals aged 20 years and older were considered obese. The rates of obesity varied substantially between the 106 Canadian health regions: from 6.2% in Vancouver to 47.5% in aboriginal population area. At the health region level, low leisure-time physical activity and low fruit and vegetable consumption are both good predictors of obesity (odds ratio of 9.2 and positive predictive value of 93% when considered simultaneously).

CONCLUSION

There is a strong gradient in obesity prevalence between Canadian health regions. At the regional level, high rates of low level of physical activity, and high rates of low fruit and vegetable consumption were both found good predictors of high rates of obesity.

Upregulation of galectin-7 in murine lymphoma cells is associated with progression toward an aggressive phenotype

We have previously shown that ICAM-1-deficient mice were resistant to lymphoma dissemination of intravenously injected 164T2 lymphoma cells. Highly aggressive variants of this cell line, however, could overcome this resistance. To discern the complex pattern of gene expression involved in the evolution of aggressiveness in lymphoma cells, we compared the transcriptome of 164T2 cells with that of their aggressive variants using cDNA arrays. We identified several genes that were differentially expressed in nonmetastatic lymphoma cells and their metastatic variants. Galectin-7, associated with the development of chemically induced mammary carcinoma, was one such gene whose expression was significantly upregulated. We showed that it was constitutively expressed in aggressive variants, at both mRNA and protein levels. Galectin-7 expression in aggressive lymphoma cells was induced upon in vivo selection in several organs, including the thymus, the spleen and kidneys. We also showed that treatment of nonaggressive lymphoma cells with 5-aza-2'-deoxycytidine was sufficient to induce galectin-7 gene expression. This report is the first to show that galectin-7 is expressed in aggressive lymphoma.

Effect of dietary fiber on endogenous nitrogen flows in lactating dairy cows

The effect of dietary fiber on endogenous N secretion was studied using a 15N isotope dilution technique in four fistulated Holstein cows. Two isonitrogenous diets differing only in fiber (NDF and ADF) content were used in a crossover design. One diet (HF) contained 37.4% NDF, while the other (LF) contained 23.3%. A new model was developed to estimate endogenous N secretions and losses for the preintestinal, intestinal, and the total sections of the gastrointestinal tract. Three precursor pools: TCA-soluble fraction of plasma, intestinal mucosa, and milk were compared. Although endogenous losses estimated with the model were numerically different for each precursor pool selected (TCA-soluble fraction > mucosa > milk), treatment effects were similar. As intestinal mucosa is probably closest to the precursor pool, these data are discussed. Non-urea N endogenous secretions contributed 13% of the duodenal N flow but were not affected by the fiber content of the diet. The nonurea N endogenous flow at the duodenum was comprised of approximately equal inputs from endogenous N direct, and that incorporated into the microbial biomass. Total endogenous N flows at the duodenum exceeded, by nearly twofold, estimated inputs of urea-N to microbial biomass. Metabolic fecal output averaged 17% of fecal N and was not affected by level of dietary fiber, but net losses from secretions occurring in the small intestine were higher with the low fiber diet. Overall, endogenous N secretions represented 30% of total digestive tract protein synthesis.

Stimulus-control: nonpharmacologic treatment for insomnia

OBJECTIVES

To evaluate the efficacy and applicability of a behavioural treatment for insomnia that can be administered by family physicians in various clinical settings.

DESIGN

Efficacy of the treatment was evaluated by single-case experimental designs (multiple baseline across subjects). Applicability was assessed through semistructured interviews with physicians.

SETTING

Two private offices, two offices in community health centres, and one office in a family medicine unit.

PARTICIPANTS

Six general practitioners and 24 chronic insomniac patients recruited through media advertisements and from physicians' practices. Of an initial 38 subjects screened, six were excluded for sleep-onset latency less than 30 minutes, five for psychological conditions, one for physical handicaps, and two for other reasons.

INTERVENTIONS

Physicians used stimulus-control treatment during individual therapeutic sessions. Patients using hypnotics were encouraged to taper off their medications after treatment was initiated.

MAIN OUTCOME MEASURES

Time it took patients to get to sleep (sleep-onset latency), amount of hypnotic use, and practitioners' evaluation of the treatment.

RESULTS

Fifteen patients completed the treatment; 80% of them reduced their sleep-onset latency. Six of the seven patients using hypnotics at the beginning of the study reduced or stopped their medications. All therapeutic gains were maintained at 3 and 6 months. Physicians thought stimulus-control treatment could be used in medical practice, but specified that it was most useful for highly motivated patients.

CONCLUSION

Family physicians can use stimulus-control treatment effectively for patients with chronic insomnia. This nonpharmacologic approach could help motivated patients reduce their use of hypnotics.

Factors explaining the increase in cost for physician care in Quebec's elderly population

OBJECTIVE

To examine what role demographic factors and increases in physician fees and utilization played in the rise in costs of physician services provided for elderly people in Quebec between 1982 and 1992, and to investigate changes in patterns of care (type and amount of services) related to utilization.

DESIGN

Retrospective study of population-based data.

SETTING

Province of Quebec.

SUBJECTS

Elderly people (65 years of age and over) in Quebec in 1982 (n = 589,800) and in 1992 (n = 803,600).

OUTCOME MEASURES

Proportion of the increase in physician care costs attributable to (a) aging (defined as a shift in the age distribution) of the elderly population, (b) the increase in the size of the elderly population, (c) the increase in physician fees and (d) the increase in utilization of physician services; proportion of care provided by general practitioners (GPs) and by specialists; proportion of minor and complete examinations provided by GPs; and rates of hospital admissions and surgery.

RESULTS

Aging was responsible for 0.5% of the increase in physician care costs between 1982 and 1992, population growth for 27.0% and the increase in physician fees for 25.5%. The increased utilization accounted for 47.0% of the total cost increase. Analyses of the utilization data revealed a shift toward more costly services, more visits to specialists and higher rates of hospital admissions and surgery in 1992 than in 1982.

CONCLUSIONS

Aging and population growth had minor effects on the increase in physician care costs between 1982 and 1992. Increased utilization was the most important factor. The appropriateness of this trend needs to be verified.

Cell-specific heat-shock induction of Hsp23 in the eye of Drosophila melanogaster

The expression of two small heat shock proteins (sHsp), Hsp23 and Hsp27, was examined by immunological approaches in the eye of Drosophila melanogaster. Neither Hsp23 nor Hsp27 is detectable in unstressed (23 degrees C) eyes but both proteins are induced by heat shock (35 degrees C). In response to heat stress, Hsp27 is expressed in all cells of the ommatidium including the cone, pigment and photoreceptor cells. However, the heat-induced expression of Hsp23 is restricted to a single cell type of the ommatidium, the cone cells, suggesting that Hsp23 is regulated by specific mechanisms acting to inhibit the expression of this polypeptide in some ommatidial cells. The cell-specific induction of Hsp23 under stress conditions does not seem to be regulated by the Drosophila melanogaster heat shock transcriptional factor (DmHSF). In both unstressed and stressed conditions, DmHSF is detected in all the different types of ommatidial cells where it is found associated with the nucleus. These observations suggest that factors, other than the heat shock transcriptional factor, are involved in regulating the expression of the hsp23 gene under stress conditions.

[Study on insomnia treatment by family physicians]

OBJECTIVES

To describe treatment of insomnia in general practice and to identify family physicians' training needs in this area.

DESIGN

Mail survey using Dillman's total design method.

PARTICIPANTS

A sampling of 484 general practitioners in the Quebec City area was done to provide roughly equal representation of six practice settings. The response rate was 65%; 295 of the 315 questionnaires returned were selected for analysis.

RESULTS

Most physicians reported treating insomnia with general advice and lifestyle changes; 25% reported prescribing hypnotics frequently; 56% reported they prescribed them occasionally. Although 58% often recommend relaxation techniques, only 8% taught these techniques to their patients. Other cognitive and behavioral approaches are rarely used. Most felt that training in treating insomnia should be offered.

CONCLUSION

Cognitive and behavioral approaches are very effective approaches are very effective nonpharmacological treatments for insomnia. General practitioners make little use of these treatments that could be easily integrated into clinical practice. Strategies for increasing their use discussed.

Indicators of masticatory performance among elderly complete denture wearers

The literature on current techniques for evaluating the masticatory capacity leads to categorizing them into two groups: objective masticatory tests and questionnaires that evaluate the subject masticatory capacity. This study examines how a simple questionnaire on the reported capacity to chew certain food can predict the masticatory performance of edentulous elderly patients. The masticatory performance of 367 completely edentulous elderly persons was measured with the Swallowing Threshold Test Index and compared with their reported masticatory capacity previously measured with a questionnaire on the capacity of the individual to chew nine food items. A total of 47.4% of the individuals had a low masticatory performance. This problem was more frequent in women (51.7%) than in men (41.8%). In measuring the reported masticatory performance with seven of the nine food items listed in the questionnaire, this indicator predicted the masticatory performance with a sensitivity of 65.5% and a specificity of 81.9%. However, even though the measure of prosthesis retention/stability is related to the masticatory performance, it was not a good predictor.

Frequent users of ambulatory health care in Quebec: the case of doctor-shoppers

OBJECTIVE

To examine the patterns of use of ambulatory care in Quebec in 1991, with special emphasis on patients who received care from more than 20 physicians.

DESIGN

Retrospective study of population-based data.

SETTING

Province of Quebec.

PARTICIPANTS

All 7,154,591 people eligible for coverage under the Régie de l'assurance-maladie du Québec (RAMQ) (Quebec Health Insurance Plan) in 1991, including 3639 people who received ambulatory care from more than 20 physicians.

DATA EXTRACTION

The databanks of the RAMQ.

OUTCOME MEASURES

Mean number (and standard deviation) of physician visits and services received, place of visit (clinic or private office), mean cost of services, patient's age, diagnosis, type of specialist visited and social assistance status of frequent users.

RESULTS

The patients who obtained ambulatory care from more than 20 physicians received 10 times more medical services than the overall patient population (59.6 v. 5.8), and the mean cost per patient for ambulatory care was also 10 times higher ($1379 v. $136). Almost all of the frequent users visited at least one outpatient clinic, as compared with 37.3% of the overall population. A higher proportion of the frequent users than of the overall population obtained care from specialists (98.9% v. 54.7%), mainly general surgeons and psychiatrists. The most frequent diagnoses among the frequent users were anxiety (36.0%), abdominal pain (24.3%), drug or alcohol dependence (22.2%) and depression (16.4%).

CONCLUSIONS

A small proportion of the population obtained ambulatory care from a high number of physicians during the year, leading to high expenses. Identifying and understanding this type of frequent user may be useful in developing strategies to promote more effective health-care-seeking behaviours and reduce overuse.

[Preliminary validation of instruments used to measure the psychotherapeutic knowledge, skills and attitudes of family physicians]

OBJECTIVE

To examine the validity and the reliability of three measurement instruments used to evaluate mental health training offered to residents in family medicine.

DESIGN

Development and submission of three French-language instruments measuring knowledge, perceived skills, and attitudes of family physicians and residents.

SETTING

Weekly psychotherapy workshop.

PARTICIPANTS

A group of 90 family medicine residents and practising doctors were recruited by the authors and by teaching facilities.

MAIN OUTCOME MEASURE

Reliability index KR20 and an evaluation of error in the instruments were used.

RESULTS

The results satisfactory in terms of the measurement of perceived skills (KR20 = 0.86) and the measurement of attitudes (KR20 = 0.96); the measurement of knowledge (KR20 = 0.70) was clearly unsatisfactory and the instrument will require upgrading. The measurement of perceived skills was the only one to reveal a distinction between the groups; practising doctors and those interested in psychotherapy believed their skills to be superior to those of residents in training (P = 0.005).

CONCLUSION

Instruments measuring attitudes and perceived skills have excellent psychometric potential; however, it remains to be determined whether the measurement of perceived skills is valid and whether these instruments are useful for monitoring family medicine residents during their training or for assessing the impact of mental health training programs.

Effectiveness of a three-month training program in psychotherapeutic intervention for family practice residents

PURPOSE

To evaluate the influence on knowledge, perceived skills, and attitudes of a psychotherapeutic intervention program for family practice residents.

METHODS

Between 1991 and 1993, a nonrandomized controlled study, using a pretest-posttest design, was used to compare a treatment group of 38 residents with a control group of 16 residents at two family medicine clinics affiliated with the Université de Montréal and Laval University Faculties of Medicine. The residents participated in a structured series of 12 seminars dedicated to psychotherapeutic interventions by family doctors. Three instruments were used to measure knowledge, perceived skills, and attitudes. Statistical analysis included two-tailed chi-square with Yates' correction and the Mann-Whitney test.

RESULTS

Ten residents in the treatment group and one in the control group were excluded from analysis because they did not complete all the evaluations. Greater percentages of residents in the treatment group improved their perceived skills (89% versus 56%, p = .003), and their knowledge (82% versus 50%, p = .06).

CONCLUSION

Skills of the "how-to" type improved more than relational skills. No significant effect on attitude was observed.

A multivariate model to predict caries increment in Montreal children aged 5 years

A study was carried out in Montreal (Canada) to predict caries development over the period of one year in primary teeth of kindergarten children (mean age 5 years 8 months +/- 4 months) living in a non-fluoridated area. The 302 children were examined at school on two occasions, one year apart. At the first examination selected predictors were collected: caries experience, salivary S. mutans and lactobacilli, buffer capacity, debris index, parents' education, fluoride consumption and family structure (one or two parents). Regression analysis was performed to select the significant factors. A total of 143 children developed new caries over the study period; the mean increment for the whole group was 2.1 dmfs. Sensitivity (Sn) and specificity (Sp) were calculated for each predictor and for the final model. The best model comprised only two factors, caries experience and lactobacillus. This could identify 81.8 per cent of children who would develop new caries during the next 12 months (Sn) and 77.4 per cent of those who would not (Sp). Among the single predictors caries experience alone reached 78.3 per cent for sensitivity and 77.4 per cent for specificity. None of the other predictors, except parents' education, was very good at predicting caries increment over one year.

Factors affecting the ingestion of fluoride dentifrice by children

Several factors affecting the amount of fluoride ingested during toothbrushing by 2- to 7-year-old children were investigated. The specific purpose of this study was to determine the contribution of age, the amount of dentifrice used, and rinsing after brushing to the variation in the ingestion of fluoride dentifrice. Four hundred and five children brushed their teeth in front of a portable sink. The tubes of dentifrice in gel (0.24% NaF) were weighed before and after use to determine the amount of toothpaste used. The fluoride content of the collected liquids was determined with a fluoride-ion-specific electrode. The amount of fluoride ingested was derived by determining the difference between the amounts used and recovered. The amount of dentifrice used, the age, and the rinsing habits, entered in a multiple regression model, explained up to 66 percent of the total variation in the amount of fluoride ingested. The amount of dentifrice used accounted by itself for 60 percent of the total variation. Therefore, these results indicate that the quantity of dentifrice used was the most important factor affecting the ingestion of fluoride through toothbrushing by young children.

Caries predictors suitable for mass-screenings in children: a literature review

This paper reviews the predictors used to identify children and adolescents at high risk of developing dental caries. They are presented with their degree of association with caries, their validity as screening tests and their methods of determination. The most promising predictors are identified and caries prediction models are also briefly reviewed. The article concludes with some comments about weaknesses encountered in the conduct of screening studies and makes some suggestions for improving the validity of the prediction models.

Recruitment and compliance in school-based FMR programs

A study on the effectiveness of a fluoride mouthrinse program was conducted over a 20-month period among 610 children attending grade 5 in two unfluoridated communities. The results showed that the preventive agent had no significant cariostatic effect. Participation and compliance problems were investigated as possible explanations. Comparisons were made between children who refused to participate or dropped out of the program and those who completed it, to see whether group-specific characteristics could be responsible for the low reduction of caries resulting from the mouthrinse. The relationship between compliance and DMFS increment was also examined. The analysis revealed that the children who refused to participate in the study or who dropped out showed sociodemographic characteristics associated with a high caries risk. This suggests that children who need the program most might not benefit because of low participation or failure to remain in the program. Moreover, the DMFS increment over the 20-month period was lower among the children exposed to 50 rinse sessions or more.

Variability in the ingestion of toothpaste by preschool children

The amount of dentifrice used and ingested on three occasions by a group of 48 children aged between 3 and 5 years was measured. The purpose of the present study was to investigate the variability in the amount of dentifrice used and ingested. The quantity of toothpaste ingested was derived from the differences between the amounts used and rejected. On average, the difference in the amount used between any two brushings was less than 0.250 g for 66% of the subjects, and the difference in the amount ingested was less than 0.100 g for 69% of the children. There were no statistically significant differences in the quantities used and ingested between the three brushings.

[Behavior and conditions related to denture wearing in edentulous Quebecers over 60 years of age]

A study was conducted among 367 persons aged 60 and over in order to determine the type and severity of digestive and nutritional problems experienced by edentulous elderly not wearing functional dentures. This article summarizes the information collected through an interview. The data describes the prosthetic status and experience of the elderly, their use of dental services and their methods of hygiene. In addition, information is provided on the level of satisfaction relative to their dentures and the need for repair or replacement of the latter.

The ingestion of fluoride dentifrice by young children

Through the fluoridation of drinking water, fluorides are becoming an increasing part of the human environment in industrialized countries. Fluoridated toothpastes are widely used in the United States and Canada. The younger a subject is, the greater proportion of toothpaste he or she tends to swallow.

[Relation between blood pressure and smoking in a population of Quebec workers]

Relations between blood pressure and cigarette smoking were investigated on the basis of a health survey conducted in a population of 3034 mine workers from Quebec Province. Blood pressure was found to be lower among smokers than among non-smokers, the difference between these two groups being: systolic pressure 2.3 mmHg, diastolic pressure 3.0 mmHg. After adjustment for age and bodyweight this relation persisted but only as far as diastolic pressure was concerned. The prevalence of hypertension was 1.5 times higher in non-smokers than in smokers. On the other hand, the number of cigarette-smoking years and the number of cigarettes smoked per day seemed to have little effect on mean arterial pressure.