Age and duration of follow-up as modulators of the risk for ischemic heart disease associated with high plasma C-reactive protein levels in men.

BACKGROUND: Plasma C-reactive protein (CRP) levels recently have been identified as an emerging risk factor for ischemic heart disease (IHD). However, whether plasma CRP levels predict an increased risk for future IHD beyond traditional risk factors has yet to be evaluated in a large prospective, population-based study. METHODS: The association between elevated plasma CRP levels and the risk for future IHD was investigated in the prospective, population-based cohort of 2037 IHD-free middle-aged men from the Quebec Cardiovascular Study. During a 5-year follow-up, 105 first IHD events were recorded. Baseline plasma CRP levels were measured using a highly sensitive assay. RESULTS: High plasma CRP concentrations (equal to or above vs below the median level of 1.77 mg/L) were associated with a significant 1.8-fold increase in IHD risk (95% confidence interval [CI], 1.2-2.7). This association remained significant after adjustment for lipid risk factors but not when the simultaneous contribution of nonlipid traditional risk factors was taken into account. Multivariate analyses indicated that CRP level predicted short-term risk for IHD (events that occurred < or =2 years after the baseline evaluation), but not long-term risk (>2 years). Moreover, high plasma CRP levels predicted an increased risk for IHD, independent of any other confounder, in younger (< or =55 years) but not in older (>55 years) individuals. CONCLUSION: Plasma CRP levels may provide independent information on IHD risk only in younger middle-aged men and in the case of IHD events that may occur relatively soon after the baseline evaluation.

Comparison of various electrophoretic characteristics of LDL particles and their relationship to the risk of ischemic heart disease.

BACKGROUND: Several cross-sectional studies and 3 prospective, nested, case-control studies have indicated that individuals with small, dense low density lipoprotein (LDL) particles are at increased risk for ischemic heart disease (IHD). However, whether LDL particle size is an independent risk factor for future IHD events remains controversial. The objective of the present study was to further analyze the cardiovascular risk associated with various electrophoretic characteristics of LDL particles in men. METHODS AND RESULTS: LDL particles were characterized by polyacrylamide gradient gel electrophoresis (PAGGE) in a cohort of 2034 men of the Quebec Cardiovascular Study. All men were initially free of IHD and were followed up for a period of 5 years, during which 108 first IHD events were recorded. Among all LDL characteristics investigated by PAGGE, including LDL peak particle size, the cholesterol concentration in LDL particles with a diameter smaller than 255 A showed the strongest association with the risk of IHD (relative risk=4.6 in men in the third vs first tertile of the distribution, P<0.001). Multivariate logistic and survival models indicated that the relationship between LDL cholesterol levels in particles with a diameter <255 A and IHD risk was independent of all nonlipid risk factors and of LDL cholesterol, high density lipoprotein cholesterol, triglyceride, and lipoprotein(a) levels. CONCLUSIONS: Results from this large, population-based, prospective study suggest that further characterization of LDL particles by PAGGE, in addition to the traditional lipid profile, may improve our ability to predict IHD events in men.

[Normal confidence interval for a summary measure]. / Intervalle de confiance normal pour une mesure pondérée.

This paper proposes an approach for calculating the normal confidence interval of a weighted summary measure which requires a particular continuous transformation for its variance estimation. By using the transformation properties and applying the delta method, the variance of transformed measure is easily expressed in terms of the transformed specific measure variances and the squared weights. The confidence limits of the summary measure are easily deduced by inverse transformation of those of transformed measure. The method is illustrated by applying it to some well known epidemiological measures. It seems appropriate for application in stratified analysis context where size allows normal approximation.

Mucosal oncogenic human papillomaviruses and extragenital Bowen disease.

BACKGROUND: Genital Bowen disease is known to have a strong association with human papillomavirus (HPV) type 16. On the other hand, previous studies of extragenital Bowen disease (EBD) that have used different hybridization techniques have produced discordant results in the detection of mucosal oncogenic HPV. METHODS: Ninety-four samples of EBD from 78 patients were investigated clinicopathologically. DNA extracted from fixed and embedded tissues was analyzed for the presence of the main mucosal oncogenic HPV types 16, 18, 31, and 33 using polymerase chain reaction (PCR) with specific primers described in 1996 by Baay et al., which are particularly well adapted to fixed tissues and give small amplimers. Moreover, 11 EBD of the hands were investigated by in situ hybridization (ISH). RESULTS: Of the 94 extragenital BD obtained from 78 patients, HPV DNA type 16 was detected in 78 cases (83%) from 65 patients (83.3%) by PCR. Nine patients with EBD of the hands (90%) had HPV type 16, and ISH displayed a diffuse hybridization pattern that corresponded to the episomal viral form of HPV DNA. CONCLUSIONS: The current retrospective study of 94 samples clearly demonstrates the high prevalence of HPV type 16 infection in EBD, especially in EBD of the hands. In this study, no specific clinical, topographic, or histopathologic features of any lesions were found to be indicative of the presence or absence of HPV.

Profile of handicap situations in children with cerebral palsy.

The purposes of this study were to establish a profile of handicap situations in children with cerebral palsy and to identify some variables associated with the occurrence of these situations. Ninety-eight children with a diagnosis of cerebral palsy (mean age +/- 1 SD, 10.5 +/- 3.5 years) were recruited on a voluntary basis. The Life Habits Assessment (LIFE-H, version 1.0) was used to measure the degree of accomplishment in 12 categories of life situations (activities of daily living and social roles). Significant disruptions in the accomplishment of all life habit categories were revealed. The highest disruptions were observed in the following categories: recreation, community, personal care, education, mobility, housing and nutrition. Disruption progressed significantly with increased severity of cerebral palsy. Impairment type, severity, speech and language disorders, and comprehension difficulties explained a high percentage of the total variance (> 60%) in the accomplishment of life habits. The results suggest that life habits related to school and social integration are greatly disturbed.

Prediction of preterm delivery by fetal fibronectin: a meta-analysis.

OBJECTIVE: To assess the cervicovaginal fetal fibronectin test to predict preterm delivery. DATA SOURCES: We searched MEDLINE, Current Contents, Index Medicus, and proceedings of meetings for studies published between 1991 and June 1997. METHODS OF STUDY SELECTION: Inclusion criteria were prospective cohort study; test performed between 20 and 36 weeks' gestation; fetal fibronectin measured by a previously described assay, with a cutoff level set at 50 ng/mL; test results not disclosed to women or physicians; and fewer than 20% of study participants excluded from the analysis. TABULATION, INTEGRATION, AND RESULTS: Twenty-nine relevant studies were stratified according to the prevalence of preterm delivery, the number of tests performed, and delivery before 34, 35, or 37 weeks. Sensitivities, specificities, and likelihood ratios were calculated in each study. The summary estimates of the likelihood ratio for tests yielding positive results or tests yielding negative results along with their 95% confidence intervals (CIs) were computed in each stratum according to a random-effects model. All summary likelihood ratios for a test yielding positive results indicated a significant association with preterm delivery. The strongest association was found between a single test with positive results and delivery before 37 weeks in a low-risk population (likelihood ratio 7.5; 95% CI 4.6, 12.3). This association also was found in high-risk women (likelihood ratio 3.5; 95% CI 2.6, 4.6). In high-risk women, a test yielding negative results was associated with a reduction in risk of preterm delivery (likelihood ratio 0.4; 95% CI 0.3, 0.5). CONCLUSION: Fetal fibronectin in cervicovaginal secretions is associated with preterm delivery in both high-risk and low-risk women.

Screening for diabetic retinopathy. Do family physicians know the Canadian guidelines?

OBJECTIVE: To assess whether family physicians and family medicine residents know what the Canadian guidelines for screening for diabetic retinopathy are, and to assess whether they believe they can perform this screening. DESIGN: Mailed survey with two mailed reminders. PARTICIPANTS: All general practitioners (N = 1038) listed in two health catchment areas, Québec and Chaudière-Appalaches administrative regions in the province of Québec, and all family medicine residents (N = 125) at Laval University Medical School. Response rate was 62% among general practitioners and 77% among residents. MAIN OUTCOME MEASURES: Knowledge of screening guidelines for diabetic retinopathy in type I and type II diabetes, including timing of the initial screening examination, risk factors, natural history, and treatment of ocular complications; and perception of ability to screen for diabetic retinopathy. RESULTS: Among GPs, 80% of respondents correctly chose the statement with the current guideline for first screening for diabetic retinopathy to be performed shortly after diagnosis of type II diabetes. Only 13% of respondents were familiar with the guideline for first screening 5 years after diagnosis of type I diabetes. Agreement with other correct guideline statements was also low. Overall, residents had higher scores than GPs. Most respondents were not confident in the accuracy of their eye examinations. CONCLUSIONS: General practitioners and family medicine residents have varying levels of knowledge about the Canadian guidelines for screening for diabetic retinopathy. These results will be useful in designing and improving educational programs for GPs in diabetic retinopathy screening.

[Malaria control in tropical Africa. 1956]. / La lutte contre le paludisme en Afrique tropicale.

Although spraying with insecticides has caused a spectacular regression in malaria in many parts of Africa, it cannot be said that the transmission of the disease has been definitely interrupted in any large area on the mainland. There is therefore some uneasiness regarding the methods so far adopted and doubts as to whether the very considerable expenditure involved is justified. There is, moreover, acute anxiety about the possible development of resistance to insecticides by the vector anopheles. Fortunately, so far there does not appear to be any in Africa, and the author considers that logical aim should be complete eradication of malaria before resistance does appear to the powerful insecticides now available. Control measures must inevitably be continued indefinitely, but if the aim of eradication is achieved, operations could cease and it would be possible for anopheles to co-exist with man without transmitting malaria. The author points out that before any continent-wide campaign can be begun, there are, in addition to the problem of funds, a number of other problems which must be carefully studied. Among these are the lack of trained specialized staff at all levels, transport difficulties, shortage of water over vast areas in the dry season and floods during the rains, the differing habits of the various African populations, and the biology of the vector mosquitos. Despite these problems, however, the time for concerted action to achieve eradication in Africa draws nearer with each succeeding day.

Association between characteristics of locomotion and accomplishment of life habits in children with cerebral palsy.

BACKGROUND AND PURPOSE: "Handicap situation" is defined in the literature as "a disruption in the accomplishment of a person's life habits (activities of daily living and social roles)." The purpose of this study was to determine the strength of association between various types of locomotion and the accomplishment of life habits, which is an indicator of the occurrence of handicap situations in children with cerebral palsy. SUBJECTS: Ninety-eight children with cerebral palsy, aged 5 to 17.8 years (mean = 10.5, SD = 3.5), were recruited. METHODS: The Life Habits Assessment was used to evaluate handicap situations in activities of daily living and social roles. Types of locomotion, the Pediatric Functional Independence Measure (locomotion section), and 2 tests representing functional activities (walking speed and stair climbing) were used as characteristics of locomotion. RESULTS: Locomotion capabilities were associated with the accomplishment of activities of daily living and social roles. Performance in variables related to locomotion, number of associated problems, and type of cerebral palsy explained 17% to 74% of the total variance in accomplishment of life habits in children who walked without technical aids. CONCLUSION AND DISCUSSION: The results suggest that locomotion might influence the accomplishment of life habits. Other factors, however--such as environmental barriers--should also be examined to determine their impact on the occurrence of handicap situations.

[Relationship between preoperative delay in hip fractures, postoperative complications and risk of death]. / Relation entre le délai pré-opératoire pour une fracture de hanche, les complications post-opératoires et le risque de décès.

The objective was to describe the relationship between preoperative delay, postoperative complications, and risk of death at 6 months. The population is constituted of 200 subjects aged 65 years or older who were living at home and treated for a hip fracture in any of three of Québec's hospitals between April, 1st, 1987 and March, 31, 1989. Chi-square or F-test, and linear and logistic regression were used to test the relationship between the variables. Preoperative delays varied from 2 to 403 h (median, 45 h). Variations between hospitals were particularly important; median delay at hospital 1 was 109 h, at hospital 2, 36 h, at hospital 3, 30.5 h. Only 5% of the variance of the delay was explained by the subjects' characteristics before the fracture. The relationships between delay and postoperative complications are not significant. However, the risk of death at 6 months increased with the length of operative delay; the observed increase tends to be linear (p = 0.03). These results suggest first, that surgery for hip fracture had to be consider as an urgency, second, that it could be done 36 hours or less after the arrival at hospital.

Apolipoprotein A-I and B levels and the risk of ischemic heart disease during a five-year follow-up of men in the Québec cardiovascular study.

BACKGROUND: Results obtained largely from case-control studies have suggested that an elevated plasma concentration of apolipoprotein (apo) B may be considered an important risk factor for ischemic heart disease (IHD). Prospective data on the relevance of measuring apo A-I and apo B levels in the assessment of IHD risk, however, remain sparse as well as controversial. METHODS AND RESULTS: Plasma lipid, apo B, and apo A-I levels as well as other risk factors were evaluated at baseline in 1985 in a sample of 2155 men (45 to 76 years old) who were followed for a period of 5 years for clinical signs of IHD. Proportional-hazards analyses indicated that plasma apo B concentrations measured at entry were strongly associated with onset of IHD (relative rate, 1.4; 95% confidence interval [CI], 1.2 to 1.7), independent of covariables such as age, smoking, diabetes mellitus, and systolic blood pressure. Controlling for triglycerides, HDL cholesterol, and total/HDL cholesterol ratio did not eliminate the relationship between plasma apo B levels and IHD. The association between apo A-I and IHD was of lower magnitude (relative rate, 0.85; 95% CI, 0.7 to 1.0), and adjustment for selected plasma lipid and lipoprotein levels eliminated this association. Stepwise logistic regression analysis revealed that, among metabolic variables, apo B was the strongest correlate of IHD. CONCLUSIONS: These prospective results emphasize the importance of apo B as a risk factor for IHD. Apo B may be regarded as a relevant tool in the assessment of IHD risk in men, because it may provide information that would not be obtained from the conventional lipid-lipoprotein profile.

Postprandial appearance of dietary deuterated cholesterol in the chylomicron fraction and whole plasma in healthy subjects.

This study examined the appearance of dietary cholesterol in the chylomicron fraction (chylomicrons plus chylomicron remnants) and whole plasma in healthy normolipidemic subjects during a 0-7-h postprandial period. Six adult males were given two diet sequences in random order: a low-fiber diet (standard Western diet for 14 d) followed by a labeled low-fiber test meal or a fiber-supplemented diet (40 g oat bran/d for 14 d) followed by a labeled oat bran (40 g) test meal. The test meals provided 192.5 mg cholesterol, including 80.1 mg octadeuterated cholesterol. Fasting and hourly postmeal blood samples were obtained for 7 h. Isotopic cholesterol ratios [tracer:(tracer+native cholesterol)] were determined by gas chromatography-mass spectrometry. Chylomicron triacylglycerol and cholesterol concentrations peaked after 2-3 h and returned to baseline after 7 h. After the low-fiber test meal, the isotopic cholesterol ratio continuously increased until 7 h in the chylomicron fraction (4.2 +/- 1.2 x 10(-3)) and whole plasma (1.04 +/- 0.39 x 10(-3)). At 7 h postprandial, the maximum dietary cholesterol concentration in the chylomicron fraction and plasma cholesterol was 1 in 99 and 1 in 397 cholesterol molecules, respectively. No marked differences were obtained after the high-fiber sequence compared with the low-fiber one; there was a comparable isotopic cholesterol ratio and concentration in the chylomicron fraction and a slightly lower (-44%, P < 0.10) 0-7 h area under the curve whole-plasma deuterated cholesterol concentration. Thus, dietary cholesterol supplied as a single meal does not simultaneously appear in the chylomicron fraction postprandially with endogenous cholesterol and triacylglycerols and fiber feeding does not markedly alter this process in healthy normolipidemic humans.

[Anti-influenza vaccination in a family medicine department]. / Vaccination anti-influenza dans une unité de médecine familiale (1988-1992).

This study describes the anti-influenza vaccination coverage of persons aged 65 or over who presented at the family medicine unit (FMU) of the Saint-Sacrement Hospital (Quebec City), between January 1988 and December 1992. All individuals were classified according to their anti-influenza vaccination status for each vaccination period. In general, the proportion of vaccinated persons increased by 14.1% during the five-year vaccination period. The mean increase in the proportion of vaccinated persons is 22.6% for those seen at least once a year at the FMU and 52.6% for those who were vaccinated at the FMU the previous year. The study results indicate that regular medical examination and previous vaccination increase the likelihood of subsequent vaccination in persons aged 65 or over.

Child and adolescent psychiatry placement in specialist psychiatric training: a regional study.

Before beginning higher professional training in one of the subspecialties, all psychiatry trainees must complete a general professional psychiatric training. At this stage, some but not all will undertake a clinical placement in child and adolescent psychiatry. Fifty-seven trainees who had completed one of the 15 child and adolescent psychiatry placements in a Regional Health Authority, took part in a semi-structured telephone interview. The trainees were asked to compare the child and adolescent psychiatry placement with a general adult psychiatry placement with respect to the training received in a number of areas. These areas were considered to be important to psychiatrists of all future subspecialties and included: assessment, communication, psychological interventions and psychological theories. In addition, subjects were asked about their general professional training as a whole and the role that child and adolescent psychiatry placements should play. The interview included quantitative and qualitative components. The findings suggest that child and adolescent psychiatry placements can make a significant contribution to a number of important areas of general professional development and that there would be considerable support for strengthening the role of such placements in psychiatry training.

Chronic oat bran intake alters postprandial lipemia and lipoproteins in healthy adults.

This study evaluates the possible interaction between chronic oat bran intake and the postmeal metabolic response. Six normolipidemic men consumed three different diets for 14 d, at the end of which they consumed a test meal. The diets were C (control), basal low-fiber diet (15.6 g fiber/d) and a low-fiber (2.8 g fiber) test meal; OB (oat bran), basal low-fiber diet and a 40-g oat bran-enriched test meal (12.8 g fiber); and OB-A (oat bran-adaptation), 14-d oat bran (40 g/d) supplemented diet (23.8 g fiber/d) and an oat bran test meal (12.8 g fiber). The diets were fed in a random order. Fasting and postmeal blood samples were obtained for 7 h and lipoproteins were isolated. Adding oat bran to the test meals markedly reduced the postmeal insulin rise (P < 0.05). Compared with the low-fiber control diet, the effects elicited postprandially by adding oat bran to a single meal were enhanced after 14 d of oat bran feeding, ie, increased plasma triglycerides, phospholipids, and free cholesterol; decreased plasma esterified cholesterol; increased chylomicron and small-sized triglyceride-rich lipoprotein triglycerides; increased LDL and HDL free cholesterol; and decreased HDL esterified cholesterol. Thus, chronic oat bran feeding alters the postmeal response in human subjects.

Outbreak of glutaraldehyde-induced proctocolitis.

BACKGROUND: An outbreak of hemorrhagic proctocolitis occurred after the introduction of 2% glutaraldehyde as a disinfectant for colonoscopes. An inadequate rinsing procedure was detected. Recent studies have pointed to glutaraldehyde as an irritant potentially capable of inducing colitis. This study aimed to measure retrospectively the occurrence of proctocolitis after colonoscopy in persons exposed to glutaraldehyde used as a disinfectant for colonoscopes, and to compare this rate with that in patients exposed to the previous cleaning procedure. METHODS: Colonoscopic procedures were randomly selected during the period when glutaraldehyde was used, as well as during the previous period, when a detergent was used. Patients were asked to respond to a questionnaire during a telephone interview, in search of symptoms compatible with proctocolitis after colonoscopy. RESULTS: Of the 400 colonoscopic procedures selected during each of the glutaraldehyde and the detergent periods, respectively 299 and 242 were evaluable. According to different nonexclusive definitions, we observed in the glutaraldehyde period higher frequencies of proctocolitis (at least five stools/day; 14/299 vs 3/242, p = 0.02), severe proctocolitis (> 10 stools/day; 10/299 vs 1/242, p = 0.04), and severe hemorrhagic proctocolitis (6/299 vs 0/242, p = 0.04). Younger age was associated with proctocolitis only during the glutaraldehyde period (p = 0.0008). No pathogen was demonstrated in the only two patients who had stool cultures. The median incubation after colonoscopy was 4 hours (range 0 to 24 hours) and the symptoms lasted 30 hours (range 6 to 216 hours). No patient had fever, and the illness resolved spontaneously in all cases. CONCLUSION: Inadequate rinsing of colonoscopes after immersion in glutaraldehyde may result in proctocolitis, presumably caused by direct action on the mucosa.

Effects of increasing amounts of dietary cholesterol on postprandial lipemia and lipoproteins in human subjects.

Our aim was to determine the effects of increasing amounts of dietary cholesterol (0-710 mg) on the postprandial plasma lipid responses and lipoprotein changes in normolipidemic human subjects. Ten subjects were fed five different test meals in a random order: one meal did not contain fat or cholesterol while the four others contained a fixed amount of lipids (45 g) and 0, 140, 280, and 710 mg cholesterol, respectively. Fasting and post-meal blood samples were obtained for 7 h. Large and small triglyceride-rich lipoproteins (TRL), low density (LDL), and high density (HDL) lipoproteins were isolated. Compared to the no-fat, no-cholesterol meal, the fat-enriched meals raised (P < 0.05) plasma triglycerides, phospholipids, and free cholesterol and lowered cholesteryl esters postprandially. The meals containing zero or 140 mg cholesterol generally elicited comparable postprandial plasma and lipoprotein lipid responses. The meals providing 280 or 710 mg cholesterol significantly increased postprandial plasma phospholipids and large TRL triglycerides and decreased plasma esterified cholesterol. The lipid composition of the large TRLs and the concentrations of the small TRL lipid components were not altered postprandially by cholesterol intake. On the other hand, LDL free cholesterol increased after 3 h, LDL cholesteryl esters dropped after 3 and 7 h, HDL cholesteryl esters dropped after 3 h, and HDL phospholipids increased 7 h after ingesting meals highly enriched in cholesterol. Blood insulin, apoA-I and apoB were not altered postprandially by cholesterol intake. Thus, the data show that ingesting more than 140 mg cholesterol per meal significantly alters the postprandial lipoprotein response in healthy subjects.

[Viewpoint on the methodology of drug trials affecting cognition of elderly patients]. / Point de vue sur la méthodologie des essais de médicaments à visée cognitive chez les sujets âgés.

Clinical trials for cognitive disorders in the elderly require specific methodological guidelines. They must take into account the psychosocial dimension of the patient and his family and must be based on serious neurobiologic knowledge. In degenerative dementias the progress of research concern genetics, molecular intercellular recognition and astrocytic cells. Biology of cognition like hippocampal long term potentiation provides good pharmacologic basis for trials. In normal brain aging several ways must be developed: aminergic systems, free radicals, excitotoxic amino-acid, nerves growth factors. Clinical trials bring informations for pharmacology and epidemiology. Cholinergic neurons are the main pharmacologic target but there are many other ones: GABA-ergic system, Tau protein, amyloid. A rigourous selection of patients allows to precise the nosology of illness responsible of cognitive disorders and to point-out early clinical signs that represent a more sensitive target. Diagnostic criteria are useful in Alzheimer's disease, memory impairment, vascular dementias and other dementias. Evaluation of stage and evolution of dementia, comorbidity, limits of age and caregiver are practical problems. The effects of drugs used to treat cognitive functions are subtle so it is necessary to detect them to choose the best tests in function of each trial. Laboratory investigations can be used to evaluate the response to drug administration. Ethical point of view is represented by the fact that old people with cognitive impairment must not be away from therapeutic progress. In this field we must consider carefully the consequences of cognitive impairment on patient judgment and consent to clinical trial. Legal problems are regulated by supranational rules and French directives of Huriet law.

Effects of moderate amounts of emulsified dietary fat on postprandial lipemia and lipoproteins in normolipidemic adults.

Eight normolipidemic males ingested a meal containing either 42 g fat or 31 g fat in the form of emulsions (9.0 and 9.2 m2) and a fixed amount of retinyl palmitate. Fasting and postmeal blood samples were obtained for 7 h. Serum and chylomicron triglyceride responses were related to the amount of fat ingested and peaked after 2-3 h. The chylomicron retinyl palmitate response was lower (P < or = 0.05) with the 31-g fat supply. After the 42-g fat intake, but not after the 31-g fat intake, serum free cholesterol and phospholipids increased and esterified cholesterol decreased postprandially. Significantly different responses were observed after both meals for low-density-lipoprotein (LDL) free cholesterol, very-low-density-lipoprotein (VLDL) and LDL esterified cholesterol, and high-density-lipoprotein (HDL) phospholipids. These data show that ingesting 31 g instead of 42 g fat in a meal reduces postmeal lipoprotein variations and suggest that a threshold level of dietary fat should be overcome to promote significant postprandial changes in lipoprotein particles.