Physical activity for individuals living with a physical disability in Quebec: Issues and opportunities of access.

BACKGROUND: Individuals living with a physical disability have reported difficulty in meeting their healthy living and leisure needs which could be a result of poor accessibility. OBJECTIVE: This qualitative study aimed to understand the relative accessibility of physical activity from the perspective of individuals living with a physical disability in Quebec, Canada. METHODS: Twenty semi-structured interviews were conducted with current, past, non-members, and staff members of an adapted physical activity program. A qualitative approach with an inductive thematic analysis was used to interpret the data. RESULTS: We identified five overarching themes focusing on participants' experiences related to access: (i) physical activity opportunities; (ii) social interactions; (iii) relationships; (iv) infrastructure; (v) policies and public services. Participants highlighted that access to physical activity programming is shaped by a complex interaction of these overarching themes and their sub-themes. CONCLUSIONS: Access to physical activity opportunities for individuals living with a physical disability cannot be understood in isolation from the broader public policies, infrastructure, social interactions, and relationships that shape their experiences. Policy makers and other health and recreational professionals must consider these broader factors when recommending or creating physical activity opportunities for individuals with physical disabilities.

Sudden Cardiac Death in End-Stage Renal Disease.

The challenge presented by sudden cardiac death in dialysis patients is to better define risk factors and delineate multiple etiologies. Only then can therapy be tailored to the highest risk patients and the incidence of sudden cardiac death be reduced. This article details the many possible etiologies and presents a brief overview of more recent research that may in the future prove of great benefit in improving the mortality of our patients with end-stage renal disease.

Indicators of self-rated health in the Canadian population with diabetes.

AIMS: Self-rated health is a widely used measure of general health assessing risk factors and poor health outcomes in health surveys and clinical settings. The characteristics of self-rated health may be different in populations with specific chronic conditions, such as populations with diabetes. This study investigates the characteristics of self-rated health in a Canadian community sample of people with diabetes. METHODS: Self-rated health was obtained from 1837 adults with Type 2 diabetes participating in the Montreal Diabetes Health and Well-Being Study. Global disability and depression were assessed using the World Health Organization Disability Assessment Schedule II and the Patient Health Questionnaire, respectively. Logistic regressions studied the association between self-rated health and depression, disability, diabetes-related characteristics, socio-demographic factors, social support and lifestyle-related behaviours in both men and women. RESULTS: Participants' answers were dichotomized into excellent/very good/ good (78%) and fair/poor (22%) self-rated health. Both depression (men: odds ratio 1.9, 95% CI 1.4-2.6; women: odds ratio 1.5, 95% CI 1.2-1.9) and disability (men: odds ratio 1.7, 95% CI 1.4-1.9; women: odds ratio 1.7, 95% CI 1.5-1.9) were associated with fair/poor self-rated health. The associations remained unchanged even after controlling for diabetes characteristics. After controlling for confounding variables, chronic conditions were associated with fair/poor self-rated health in both men and women. Obesity was associated with fair/poor self-rated health in women only, while lifestyle behaviours such as being physically active and alcohol consumption were associated with good/very good/excellent self-rated health in men. CONCLUSIONS: In men and women, depression and disability are important factors that are associated with self-rated health in a large sample of individuals with Type 2 diabetes.

Nutritional vitamin D supplementation in haemodialysis: A potential vascular benefit?

AIM: Vitamin D deficiency is highly prevalent in end-stage renal disease and has been associated with atherosclerosis, endothelial dysfunction and left ventricular hypertrophy. Although activated vitamin D has shown to be cardioprotective, the cardiovascular benefits of nutritional vitamin D (i.e. ergocalciferol or cholecalciferol) have not been explored in the dialysis population. The aim of this investigation was to evaluate the effect of ergocalciferol therapy on vascular adhesion molecules, markers of inflammation and atherosclerosis among haemodialysis patients. METHODS: This was a pilot study of matched haemodialysis patients. For every patient enrolled taking ergocalciferol, an age and race matched control was recruited. Predialysis blood samples were collected and assayed for adhesion molecules (soluble vascular cell adhesion molecule-1 (sVCAM-1), soluble intercellular adhesion molecule-1 (sICAM-1), E-selectin and P-selectin), inflammatory cytokines (interleukin-6 (IL-6) and tumour necrosis factor-α (TNF-α)), oxLDL-ß(2) GPI and IgG anticardiolipin. RESULTS: A total of 40 haemodialysis patients were studied (20 on ergocalciferol therapy, 20 not receiving ergocalciferol therapy). Patients taking ergocalciferol had higher 25-hydroxyvitamin D levels compared with those not taking ergocalciferol. Even though doxercalciferol usage and dosing was similar between groups, plasma sVCAM-1, sICAM-1 and P-selectin concentrations were lower among ergocalciferol treated patients. No significant differences in E-selectin, IL-6, TNF-α, oxLDL-ß(2) GPI or anticardiolipin antibody levels were observed. CONCLUSION: Patients receiving ergocalciferol had lower plasma levels of vascular adhesion molecules despite equivalent use of activated vitamin D therapy. Future investigations should confirm the role of nutritional vitamin D therapy, in addition to activated D therapy, in haemodialysis patients and the potential vascular benefits of these agents.

A national survey of the management of delirium in UK intensive care units.

BACKGROUND: Delirium is an acute organ dysfunction common amongst patients treated in intensive care units. The associated morbidity and mortality are known to be substantial. Previous surveys have described which screening tools are used to diagnose delirium and which medications are used to treat delirium, but these data are not available for the United Kingdom. AIM: This survey aimed to describe the UK management of delirium by consultant intensivists. Additionally, knowledge and attitudes towards management of delirium were sought. The results will inform future research in this area. METHODS: A national postal survey of members of the UK Intensive Care Society was performed. A concise two page questionnaire survey was sent, with a second round of surveys sent to non-respondents after 6 weeks. The questionnaire was in tick-box format. RESULTS: Six hundred and eighty-one replies were received from 1308 questionnaires sent, giving a response rate of 52%. Twenty-five percent of respondents routinely screen for delirium, but of these only 55% use a screening tool validated for use in intensive care. The majority (80%) of those using a validated instrument used the Confusion Assessment Method for the Intensive Care Unit. Hyperactive delirium is treated pharmacologically by 95%; hypoactive delirium is treated pharmacologically by 25%, with haloperidol the most common agent used in both. Over 80% of respondents agreed that delirium prolongs mechanical ventilation and hospital stay and requires active treatment. CONCLUSION: This UK survey demonstrates screening for delirium is sporadic. Pharmacological treatment is usually with haloperidol in spite of the limited evidence to support this practice. Hypoactive delirium is infrequently treated pharmacologically.

Detection of multiregion objects embedded in nonoverlapping noise.

The concept of a statistical filter for objects that comprise several regions is introduced. The process is optimal in the presence of nonoverlapping noise for the target and may perform independently of variations in the mean value in every region. The basic performance of the filter is described, and a comparison with other types of processing is made.

Improved robustness of target location in nonhomogeneous backgrounds by use of the maximum-likelihood ratio test location algorithm.

We address the problem of localizing small targets with random gray levels that appear in random background clutter. We consider the recently proposed maximum-likelihood ratio test (MLRT) algorithm, which scans the observed scene with an estimation window in which the local statistics are estimated. In the presence of a spatially homogeneous background, we show that if the estimation window is a few times larger than the target itself, the MLRT is quasi-equivalent to the optimal maximum-likelihood (ML) algorithm, which uses the whole scene for estimating the background statistics. The MLRT thus constitutes an efficient alternative to the ML algorithm and is more robust in dealing with spatially nonhomogeneous clutter since it utilizes a small estimation window.

The interstellar chemistry of PAH cations.

Diffuse interstellar bands (DIBs) are mysterious absorption lines in the optical spectra of stars, and have been known for 75 years. Although it is widely believed that they arise from gas-phase organic molecules (rather than from dust grains) in the interstellar medium, no consensus has been reached regarding their precise cause. The realization that many emission features in astronomical infrared spectra probably arise from polycyclic aromatic hydrocarbons (PAHs), which may themselves be very abundant in the interstellar medium, has led to the suggestion that ionized PAHs might be the source of the DIBs. Laboratory investigations have revealed that small, positively charged PAHs in matrices have absorption features that bear some resemblance to DIBs, but no clear identification of any DIB with any specific PAH cation has yet been made. Here we report a laboratory study of the chemical reactivity of PAH cations (C6H6+, C10H8+ and C16H10+) in the gas phase. We find that these PAH cations are very reactive, and are therefore unlikely to survive in high abundances in the interstellar medium. Rather, such molecules will react rapidly with hydrogen, and we therefore suggest that the resulting protonated PAH cations (and species derived from them) should become the focus of future searches for a correspondence between molecular absorption features and the DIBs.

Long-term survival and functional status in the elderly after cardiac surgery.

BACKGROUND: Hospital mortality and morbidity of cardiac surgery have been well described in the elderly, but there is a paucity of data regarding long-term functional status. OBJECTIVE: To evaluate long-term survival and functional status of patients aged 70 years or older after cardiac surgery. DESIGN: Retrospective observational study. SETTING: University-affiliated tertiary care hospital. PATIENTS: Three hundred and twenty-nine consecutive patients aged 70 or older who had undergone cardiac surgery from January 1990 to December 1993. INTERVENTIONS: Besides postoperative mortality and morbidity, data regarding long-term survival and functional status and preoperative variables affecting these outcomes were analyzed. MAIN RESULTS: Mean age at surgery was 73.9 +/- 2.9 years, and 70.2% of the procedures were performed on an urgent basis. Postoperative mortality was 9.4%. Five-year Kaplan-Meier survival in postoperative survivors was 85.9% and is comparable with the survival of the general sex- and age-matched Quebec population. Preoperative variables affecting long-term survival were atrial fibrillation (RR 3.8; 95% CI 1.4 to 10.0), smoking status on admission (RR 3.6; CI 1.6 to 8.1), peripheral vascular disease (RR 2.9; CI 1.4 to 6.2) and low creatinine clearance (RR 1.4; CI 1.1 to 1.7). Functional status evaluated by the Karnofsky score showed a successful functional outcome in 84.6% of patients at follow-up (mean 2.6 +/- 1.1 years). Preoperative variables unfavourably influencing a successful functional outcome were hypertension (OR 0.34; CI 0.15 to 0.76), cerebrovascular disease (OR 0.35; CI 0.15 to 0.87) and low creatinine clearance (OR 0.73; CI 0.55 to 0.96). CONCLUSIONS: Despite severe cardiovascular and often urgent conditions, sustained functional improvement and good long term survival can be objectively documented in most elderly patients after cardiac surgery.

Metoclopramide reduces the induction dose of propofol.

BACKGROUND: Metoclopramide has been shown to reduce the dose of thiopentone required for induction of anaesthesia. When propofol is used, there have been conflicting results with one small study showing a reduction in the anaesthetic dose and one study failing to demonstrate any effect. METHODS: Two groups of 30 patients were studied. The patients were randomised to receive either saline 0.03 ml/mg or metoclopramide 0.15 mg/kg 5 min before a manual injection of propofol at a set rate. RESULTS: This study shows a reduction in the dose of propofol required for the induction of general anaesthesia following an intravenous dose of metoclopramide. The induction dose of propofol was reduced by 24%. CONCLUSION: The mechanism of reduction of propofol dose by metoclopramide is unknown; it may involve GABA or result from a more complex interaction involving dopamine blockade by metoclopramide.

Management of new symptoms of dyspepsia in the elderly in Quebec.

OBJECTIVE: To use the Régie de l'assurance-maladie du Québec (RAMQ) database to study the clinical strategies used by Quebec physicians in the management of dyspepsia in the elderly. DESIGN: A 20% random sample of the RAMQ database for Quebec residents aged 65 years and older for the three years from July 1, 1991 to June 30, 1992 was used. Patients were placed in three cohorts according to the following treatment strategies: endoscopy, x-ray examination or drug therapy. Patients in each cohort were then categorized as either nonsteroidal anti-inflammatory drug (NSAID) users or non-NSAID users. The choice of drug treatment used to manage the dyspepsia in each cohort was recorded. Drug treatments were divided into the following six antidyspeptic categories: H2 blockers, omeprazole, sucralphate, misoprostol, prokinetic drugs or no drugs. The number of duodenal, oesophageal and stomach cancers diagnosed in each cohort was also counted. RESULTS: Drug therapy was the most frequently used strategy in all patients, and was used more frequently in NSAID users (87%) than in non-NSAID users (69%). A total of 22% of NSAID users in each group, and 46% of NSAID users in the drug therapy group, underwent investigation. H2 blockers were the most prescribed drug in all three treatment strategies, and omeprazole was the second most prescribed drug in the endoscopy and x-ray cohorts. Overall omeprazole was the least prescribed drug. There was a higher rate of cancer detection in the endoscopy and x-ray cohorts than in the drug therapy group. CONCLUSIONS: Previous NSAID use greatly influences the way in which physicians treat patients with dyspepsia.

HSP27 locus cosegregates with left ventricular mass independently of blood pressure.

Left ventricular hypertrophy remains a significant clinical problem and a predictor of fatal outcome in hypertension. Blood pressure per se and environmental modifiers including stress affect cardiac mass. Heat shock proteins are involved in the stress response as well as in the regulation of cardiac growth and cytoprotection. The present study evaluates heat shock protein 27 as a locus marker or candidate gene of cardiac hypertrophy in hypertension. The spontaneously hypertensive rat allele of heat shock protein 27 was associated with about a 6% increase in relative left ventricular weight (P = .0112) in 30 recombinant inbred strains from crosses of Brown Norway and spontaneously hypertensive rats. In 336 F2 crosses of spontaneously hypertensive and Wistar-Kyoto rats, the hypertensive allele was dominant and cosegregated with a similar 6% increase in the ratio of left ventricular weight to body weight (P = .0058) in rats fed a normal salt diet, but its contribution to left ventricular weight decreased in rats kept on a high salt diet. The contribution of the heat shock protein 27 allele was independent of blood pressure. We suggest that heat shock protein 27 represents a candidate gene/locus marker of cardiac hypertrophy in hypertension.

Shanghai trial of nifedipine in the elderly (STONE).

OBJECTIVE: To assess the effectiveness of nifedipine treatment in elderly hypertensives. METHODS: A single-blind trial was conducted under the direction of the Shanghai Institute of Hypertension in 1632 subjects aged 60-79 years alternatively allocated to either nifedipine or placebo after a 4-week placebo run-in period between 1987 and 1990 with mean follow-up of 30 months. Clinical events and risk modification were analysed in collaboration with the University of Montreal. Seventy-four patients with severe hypertension were reallocated to active nifedipine treatment after placebo run-in. RESULTS: Cox's proportional hazards model accounting for covariates demonstrated a highly significant decrease in the probability of events: 'original treatment assignment' analysis indicated that 77 events occurred in the placebo and 32 in the nifedipine group. Similar significances were achieved with 'actual treatment' or 'changes excluded' (excluding reallocated subjects) analyses. A significant reduction in relative risk was observed for strokes and severe arrhythmia with an overall decrease from 1.0 to 0.41 (95% confidence interval 0.27-0.61). CONCLUSION: Nifedipine treatment diminished the number of severe clinical outcomes in elderly hypertensives significantly.

Anaesthesia and radiofrequency endometrial ablation.

Radiofrequency endometrial ablation is a new technique for the treatment of functional menorrhagia. A conductive probe is placed in the uterine cavity which selectively destroys the endometrium by heating, using radiofrequency energy. Hence the patient is charged with a high density electric field. ECG electrodes need to be applied with care and patient-metal contact must be avoided to prevent radiofrequency burns. Monitors may require additional filters.