Stress in Parents of Children With Genetically Determined Leukoencephalopathies: A Pilot Study.

Genetically determined leukoencephalopathies comprise a group of rare inherited white matter disorders. The majority are progressive diseases resulting in early death. We performed a cross-sectional pilot study including 55 parents from 36 families to assess the level of stress experienced by parents of patients with genetically determined leukoencephalopathies, aged 1 month to 12 years. Thirty-four mothers and 21 fathers completed the Parenting Stress Index-4th Edition. One demographic questionnaire was completed per family. Detailed clinical data was gathered on all patients. Statistical analysis was performed with total stress percentile score as the primary outcome. Mothers and fathers had significantly higher stress levels compared with the normative sample; 20% of parents had high levels of stress whereas 11% had clinically significant levels of stress. Mothers and fathers had comparable total stress percentile scores. We identified pediatric behavioral difficulties and gross motor function to be factors influencing stress in mothers. Our study is the first to examine parental stress in this population and highlights the need for parental support early in the disease course. In this pilot study, we demonstrated that using the Parenting Stress Index-4th Edition to assess stress levels in parents of patients with genetically determined leukoencephalopathies is feasible, leads to valuable and actionable results, and should be used in larger, prospective studies.

Induced sputum markers of fibrosis and decline in pulmonary function in asbestosis and silicosis: a pilot study.

OBJECTIVE: To evaluate the usefulness of fibrogenic cytokines and mediators in the analysis of induced sputum and determine if their levels correlated with previous decline in lung function in asbestosis and silicosis. DESIGN: In a pilot study for the evaluation of 19 workers with asbestosis and 15 with silicosis, all workers had chart reviews and records of previous lung function tests. Fourteen healthy control subjects were also included in the study. All subjects attended the laboratory for a clinical evaluation, pulmonary function tests and induced sputum sampling. Differential cell counts were performed and the following mediators and cytokines were measured: matrix metalloproteinase 9 (MMP-9), tissue inhibitor of metalloproteinases 1 (TIMP-1), fibronectin, interleukin 1 beta (IL-1beta), IL-6, IL-8, IL-12, transforming growth factor beta (TGF-beta) and tumor necrosis factor-alpha (TNF-alpha). RESULTS: Levels of IL-1beta were higher in the sputum of subjects with asbestosis and silicosis than in controls. Eosinophils, neutrophils and IL-1beta levels were significantly correlated with the rate of decline in pulmonary function. CONCLUSION: The induced sputum levels of certain inflammatory cells and IL-1beta correlate with the decline in pulmonary function associated with asbestosis and silicosis. It remains to be established if these markers can help predict the clinical outcome of workers exposed to these mineral particles or fibers in a prospective study.

Increasing incidence of primary malignant brain tumors: influence of diagnostic methods.

BACKGROUND: The incidence of brain cancer has increased dramatically over the last decades in most developed countries. Whether these trends can be attributed to improved diagnosis is not clear. PURPOSE: To determine the effect of new imaging technology on increased rates of brain cancer, we assessed the level of detection for neurological disorders when computed tomography (CT) and magnetic resonance imaging (MRI) results were not available. METHODS: A neurologist performed a blind review of hospital charts from 356 randomly selected patients, hospitalized between 1985 and 1989 for neurological disorders, including brain cancer. All prediagnosis information except CT and MRI results was used as a basis for diagnostic re-evaluation. Also, a random sample of 151 brain cancer patients diagnosed between 1960 and 1965 was selected for a description of diagnostic methods used during that period. RESULTS: A comparison between the original diagnoses and the re-evaluations for patients in the 1985-1989 sample indicated that there was, among the diseases selected, a 24% misclassification when CT scans and MRI were not available. In particular, 20% of brain tumors were undetected (95% confidence interval = 15%-25%), and 10% of non-tumor disorders were inaccurately labeled as brain tumors in the absence of these tests. The repeatability of the re-evaluations was 86%. CONCLUSIONS: Among elderly North Americans, at least twofold increases in brain cancer incidence were observed over the last two decades. Since our findings show that CT scans and MRI are responsible for the detection of about 20% of brain tumors, we conclude that other factors also are responsible for the observed trends.

Report Summary--Rio Political Declaration on Social Determinants of Health: A Snapshot of Canadian Actions 2015.

In 2012, Canada and other United Nations (UN) Member States endorsed the "Rio Political Declaration on Social Determinants of Health" (Rio Declaration), a non-binding pledge which calls on World Health Organization (WHO) Member States to improve/influence the working and living conditions that affect health and well-being. The Rio Declaration sets out actions to address health inequities in five themes: to adopt better governance for health and development; to promote participation in policy making and implementation; to further reorient the health sector towards reducing health inequities; to strengthen global governance and collaboration; and to monitor and increase accountability. In 2013, following the endorsement of the Rio Declaration, the Government of Canada released a report to begin to document Canadian actions related to its five themes. Building on this first report, and in anticipation of WHO reporting on Member State implementation of the Rio Declaration at the May 2015 World Health Assembly, the Government of Canada developed the report, Rio Political Declaration on Social Determinants of Health: A Snapshot of Canadian Actions 2015, which showcases Canada's recent actions since 2013 contributing to the advancement of the five Rio Declaration themes. The report provides a current picture of the diverse spectrum of activities undertaken across levels of government and sectors to advance health equity and address social determinants of health in Canada, and intends to stimulate global and domestic exchange and uptake of promising practices to advance health equity.

TITRE: Note de synthèse - Déclaration politique de Rio sur les déterminants sociaux de la santé : aperçu des mesures canadiennes de 2015. INTRODUCTION: En 2012, le Canada et d'autres États membres des Nations unies ont adopté la Déclaration politique de Rio sur les déterminants sociaux de la santé (Déclaration de Rio), un engagement non contraignant par lequel les États membres de l'Organisation mondiale de la santé (OMS) promettent d'améliorer les conditions de travail et de vie qui influent sur la santé et le bien-être. La Déclaration de Rio énonce plus précisément cinq engagements visant à réduire les inégalités en santé : adopter une meilleure gouvernance pour la santé et le développement, promouvoir la participation à l'élaboration et à la mise en oeuvre des politiques, réorienter davantage le secteur de la santé pour réduire les inégalités en santé, renforcer la gouvernance et la collaboration mondiales et enfin suivre les progrès et accroître la responsabilisation. En 2013, à la suite de l'adoption de la Déclaration de Rio, le gouvernement du Canada a publié un premier rapport pour rendre compte des mesures prises. En 2015, en prévision de la présentation d'un rapport par l'OMS sur la mise en oeuvre de la Déclaration de Rio par les États membres à l'Assemblée mondiale de la santé en mai et en s'appuyant sur ce premier rapport, le gouvernement du Canada a rédigé le rapport Déclaration politique de Rio sur les déterminants sociaux de la santé : aperçu des mesures canadiennes de 2015, qui présente les mesures relevant des cinq engagements de la Déclaration et prises depuis 2013 par le Canada. Ce rapport donne un aperçu des activités entreprises par les différents ordres de gouvernement et secteurs pour promouvoir l'équité en santé et agir sur les déterminants sociaux de la santé. Il vise de plus à encourager la mise en commun et l'adoption de pratiques prometteuses visant à promouvoir l'équité en santé à l'échelle nationale et internationale.

Survival experience among elderly end-stage renal disease patients. A controlled comparison of transplantation and dialysis.

Renal transplantation is a relatively recent treatment option among the elderly with end-stage renal disease (ESRD). Since little is known regarding the clinical benefits of transplantation relative to dialysis in this age group, this study compares transplantation and dialysis among the elderly with respect to patient survival. Data utilized in this investigation were obtained from the Canadian Organ Replacement Register (CORR). The study population consisted of the 6400 patients aged 60 and over at registration, diagnosed between 1987 and 1993, for whom data on comorbid conditions were available. Survival probability, death rates, age-standardized mortality ratios (SMRs) and Cox regression analysis were employed to evaluate the survival experience among the transplant and dialysis groups. Transplant recipients were matched (by age, underlying diagnosis leading to ESRD, and number of comorbid conditions) to 2 randomly selected patients who did not undergo transplantation. Using Cox regression, the time-dependent hazard ratio for transplantation versus dialysis patients was estimated at 0.47 (P < 0.0001), indicating that even after adjusting for other known prognostic factors, elderly patients who received a transplant experienced significantly greater survival probability than those who remained on dialysis. When transplant patients were matched to randomly selected dialysis patients with the constraint that the corresponding dialysis patient have at least as much follow-up time as the transplant patient had waiting time, five-year survival rates were 81% and 51% for the transplant and dialysis groups, respectively (P < 0.0001). These results support the potential advantage of transplantation among the elderly, and may have important implications for renal care in this age group.

Mechanisms of the effectiveness of continuous positive airway pressure in obstructive sleep apnea.

Nasal continuous positive airway pressure (NCPAP) is considered the most effective treatment of obstructive sleep apnea. Its beneficial effects are related to the normalization of breathing during sleep and to the prevention of nocturnal desaturations. NCPAP interacts with the pathophysiologic mechanisms of sleep apnea onset and with the consequences of these apneas. Upper airway patency is maintained with NCPAP by a pneumatic splinting effect while changes in lung volume and pre-apnea SaO2 level may be implicated in the improvement of apnea-related desaturations. An improvement in central chemosensitivity could account for the improvement in diurnal oxygenation observed with long term NCPAP therapy.

End-stage renal disease projections for Canada to 2005 using Poisson and Markov models.

BACKGROUND: End-stage renal disease (ESRD) incidence and prevalence are increasing in many countries worldwide. Due to the high cost of therapy, predicting future numbers of patients requiring dialysis and transplantation is necessary for health care planners. Projecting therapy-specific chronic disease prevalence is inherently problematic, and examples of suitable models and their application are sparse. When applied, rarely was the adequacy of such models evaluated. METHODS: We describe and illustrate a method for projecting therapy-specific ESRD prevalence in Canada for 1995-2005 using data obtained from the Canadian Organ Replacement Register. The projections combine the Poisson model for incidence rates and a Markov model for patient follow-up. Model adequacy is empirically validated by data-splitting. RESULTS: Large increases in ESRD prevalence are expected in Canada, with an average annual increase of 6.9% projected for 1995-2005. Upon validation, the projection model based on 1981-1987 data was able to predict 1994 prevalence within 1%, while projected therapy-specific prevalences closely approximated those observed. CONCLUSIONS: Therapy-specific ESRD prevalence was successfully projected using Poisson and Markov models. Where multistate prevalence forecasts are required, the method could be augmented for application to various other chronic diseases.

Influence of passive changes of lung volume on upper airways.

The total upper airway resistances are modified during active changes in lung volume. We studied nine normal subjects to assess the influence of passive thoracopulmonary inflation and deflation on nasal and pharyngeal resistances. With the subjects lying in an iron lung, lung volumes were changed by application of an extrathoracic pressure (Pet) from 0 to 20 (+Pet) or -20 cmH2O (-Pet) in 5-cmH2O steps. Upper airway pressures were measured with two low-bias flow catheters, one at the tip of the epiglottis and the other in the posterior nasopharynx. Breath-by-breath resistance measurements were made at an inspiratory flow rate of 300 ml/s at each Pet step. Total upper airway, nasal, and pharyngeal resistances increased with +Pet [i.e., nasal resistance = 139.6 +/- 14.4% (SE) of base-line and pharyngeal resistances = 189.7 +/- 21.1% at 10 cmH2O of +Pet]. During -Pet there were no significant changes in nasal resistance, whereas pharyngeal resistance decreased significantly (pharyngeal resistance = 73.4 +/- 7.4% at -10 cmH2O). We conclude that upper airway resistance, particularly the pharyngeal resistance, is influenced by passive changes in lung volumes, especially pulmonary deflation.

Changes in upper airway resistance with lung inflation and positive airway pressure.

The influence of pulmonary inflation and positive airway pressure on nasal and pharyngeal resistance were studied in 10 normal subjects lying in an iron lung. Upper airway pressures were measured with two low-bias flow catheters while the subjects breathed by the nose through a Fleish no. 3 pneumotachograph into a spirometer. Resistances were calculated at isoflow rates in four different conditions: exclusive pulmonary inflation, achieved by applying a negative extra-thoracic pressure (NEP); expiratory positive airway pressure (EPAP), which was created by immersion of the expiratory line; continuous positive airway pressure (CPAP), realized by loading the bell of the spirometer; and CPAP without pulmonary inflation by simultaneously applying the same positive extrathoracic pressure (CPAP + PEP). Resistance measurements were obtained at 5- and 10-cmH2O pressure levels. Pharyngeal resistance (Rph) significantly decreased during each measurement; the decreases in nasal resistance were only significant with CPAP and CPAP + PEP; the deepest fall in Rph occurred with CPAP. It reached 70.8 +/- 5.5 and 54.8 +/- 6.5% (SE) of base-line values at 5 and 10 cmH2O, respectively. The changes in lung volume recorded with CPAP + PEP ranged from -180 to 120 ml at 5 cmH2O and from -240 to 120 ml at 10 cmH2O. Resistances tended to increase with CPAP + PEP compared with CPAP values, but these changes were not significant (Rph = 75.9 +/- 6.1 and 59.9 +/- 6.6% at 5 and 10 cmH2O of CPAP + PEP). We conclude that 1) the upper airway patency increases during pulmonary inflation, 2) the main effect of CPAP is related to pneumatic splinting, and 3) pulmonary inflation contributes little to the decrease in upper airways resistance observed with CPAP.

Effects of respiratory drive on upper airways in sleep apnea patients and normal subjects.

We compared the changes in nasal and pharyngeal resistance induced by modifications in the central respiratory drive in 8 patients with sleep apnea syndrome (SAS) with the results of 10 normal men. Upper airway pressures were measured with two low-bias flow catheters; one was placed at the tip of the epiglottis and the other above the uvula. Nasal and pharyngeal resistances were calculated at isoflow. During CO2 rebreathing and during the 2 min after maximal voluntary hyperventilation, we continuously recorded upper airway pressures, airflow, end-tidal CO2, and the mean inspiratory flow (VT/TI); inspiratory pressure generated at 0.1 s after the onset of inspiration (P0.1) was measured every 15-20 s. In both groups upper airway resistance decreased as P0.1 increased during CO2 rebreathing. When P0.1 increased by 500%, pharyngeal resistance decreased to 17.8 +/- 3.1% of base-line values in SAS patients and to 34.9 +/- 3.4% in normal subjects (mean +/- SE). During the posthyperventilation period the VT/TI fell below the base-line level in seven SAS patients and in seven normal subjects. The decrease in VT/TI was accompanied by an increase in upper airway resistance. When the VT/TI decreased by 30% of its base-line level, pharyngeal resistance increased to 319.1 +/- 50.9% in SAS and 138.5 +/- 4.7% in normal subjects (P less than 0.05). We conclude that 1) in SAS patients, as in normal subjects, the activation of upper airway dilators is reflected by indexes that quantify the central inspiratory drive and 2) the pharyngeal patency is more sensitive to the decrease of the central respiratory drive in SAS patients than in normal subjects.

Influence of respiratory drive on upper airway resistance in normal men.

The variations in nasal and pharyngeal resistance induced by changes in the central inspiratory drive were studied in 10 normal men. To calculate resistances we measured upper airway pressures with two low-bias flow catheters; one was placed at the tip of the epiglottis and the other in the posterior nasopharynx, and we measured flow with a Fleisch no. 3 pneumotachograph connected to a tightly fitting mask. Both resistances were obtained continuously during CO2 rebreathing (Read's method) and during the 2 min after a 1-min voluntary maximal hyperventilation. The inspiratory drive was estimated by measurements of inspiratory pressure generated at 0.1 s after the onset of inspiration (P0.1) and by the mean inspiratory flow (VT/TI). In each subject both resistances decreased during CO2 rebreathing; these decreases were correlated with the increase in P0.1. During the posthyperventilation period, ventilation fell below base line in seven subjects; this was accompanied by an increase in both nasal and pharyngeal resistances. These resistances increased exponentially as VT/TI decreased. Parallel changes in nasal and pharyngeal resistances were seen during CO2 stimulus and during the period after the hyperventilation. We conclude that 1) the indexes quantifying the inspiratory drive reflect the activation of nasopharyngeal dilator muscles (as assessed by the changes in upper airway resistance) and 2) both nasal and pharyngeal resistances are similarly influenced by changes in the respiratory drive.

Limitation of lower limb VO(2) during cycling exercise in COPD patients.

Patients with chronic obstructive pulmonary disease (COPD) usually stop exercise before reaching physiological limits in terms of O(2) delivery and extraction. A plateau in lower limb O(2) uptake (VO(2)) and blood flow occurs despite progression of the imposed workload during cycling in some patients with COPD, suggesting that maximal capacity to transport O(2) had been reached and that it had been extracted in the peripheral exercising muscles. This study addresses this observation. Symptom-limited incremental cycle exercise was performed by 14 men [62 +/- 11 (SD) yr] with severe COPD (forced expiratory volume in 1 s = 35 +/- 7% of predicted value). Leg blood flow was measured at each exercise step with a thermodilution catheter inserted in the femoral vein. This value was multiplied by two to account for both working legs (Q(LEGS)). Arterial and femoral venous blood was sampled at each exercise step to measure blood gases. Leg O(2) consumption (VO(2LEGS)) was calculated according to the Fick equation. Total body VO(2) (VO(2TOT)) was measured from expired gas analysis, and tidal volume (VT) and minute ventilation (VE) were derived from the flow signal. In eight patients, VO(2LEGS) kept increasing in parallel with VO(2TOT) as external work rate was increasing. In six subjects, a plateau in VO(2LEGS) and Q(LEGS) occurred during exercise (increment of <3% between 2 consecutive increasing workloads) despite the increase in workload and VO(2TOT) [corresponding mean was 110 +/- 38 ml (11 +/- 4%)]. These six patients also exhibited a plateau in O(2) extraction during exercise. Peak exercise work rate was higher in the eight patients without a plateau than in the six with a plateau (51 +/- 10 vs. 40 +/- 13 W, P = 0.043). VT, VE, and dyspnea were significantly greater at submaximal exercise in patients of the plateau group compared with those of the nonplateau group. These results show that, in some patients with COPD, blood flow directed to peripheral muscles and O(2) extraction during exercise may be limited. We speculate that redistribution of cardiac output and O(2) from the lower limb exercising muscles to the ventilatory muscles is a possible mechanism.

Metabolic and hemodynamic responses of lower limb during exercise in patients with COPD.

Premature lactic acidosis during exercise in patients with chronic obstructive pulmonary disease (COPD) may play a role in exercise intolerance. In this study, we evaluated whether the early exercise-induced lactic acidosis in these individuals can be explained by changes in peripheral O2 delivery (O2). Measurements of leg blood flow by thermodilution and of arterial and femoral venous blood gases, pH, and lactate were obtained during a standard incremental exercise test to capacity in eight patients with severe COPD and in eight age-matched controls. No significant difference was found between the two groups in leg blood flow at rest or during exercise at the same power outputs. Blood lactate concentrations and lactate release from the lower limb were greater in COPD patients at all submaximal exercise levels (all P < 0.05). Leg D02 at a given power output was not significantly different between the two groups, and no significant correlation was found between this parameter and blood lactate concentrations. COPD patients had lower arterial and venous pH at submaximal exercise, and there was a significant positive correlation between venous pH at 40 W and the peak O2 uptake (r = 0.91, P < 0.0001). The correlation between venous pH and peak O2 uptake suggests that early muscle acidosis may be involved in early exercise termination in COPD patients. The early lactate release from the lower limb during exercise could not be accounted for by changes in peripheral O2. The present results point to skeletal muscle dysfunction as being responsible for the early onset of lactic acidosis in COPD.

Transaxillary pleurectomy for treatment of spontaneous pneumothorax.

In the 16-year period 1962 to 1978, 409 transaxillary apical pleurectomies were carried out for definitive treatment of spontaneous pneumothorax in 362 patients. Surgical indications included recurrence (336), bilaterality of the disease (23), persistent air leak (22), and nonexpansion of the lung (10). There was 1 operative death (unsuspected brain tumor), and 3 patients required reexploration for clot removal. The average postoperative period of hospitalization was 6 days. Three hundred ten patients (86% of all patients) were contacted for follow-up 1 to 16 years after operation (average, 4.5 years). There were two documented episodes of recurrent ipsilateral pneumothorax (0.6%). Postoperative pulmonary function studies were done in 40 patients (unilateral, 29; bilateral, 11) 2 to 5 years after operation. The results indicate that there are no significant abnormalities compared with predicted values.

Effects of oxygen on lower limb blood flow and O2 uptake during exercise in COPD.

PURPOSE: To quantify the effects of acute oxygen supplementation on lower limb blood flow (QLEG), O2 delivery (QO2LEG), and O2 uptake (VO2LEG) during exercise and to determine whether the metabolic capacity of the lower limb is exhausted at peak exercise during room air breathing in patients with COPD. METHODS: Oxygen (FIO2 = 0.75) and air were randomly administered to 14 patients with COPD (FEV1: 35 +/- 2% pred, mean +/- SEM) during two symptom-limited incremental cycle exercise tests. Before exercise, a cannula was installed in a radial artery and a thermodilution catheter inserted in the right femoral vein. At each exercise step, five-breath averages of respiratory rate, tidal volume, and ventilation (VE), dyspnea and leg fatigue scores, arterial and venous blood gases, and QLEG were obtained. From these measurements, VO2LEG was calculated. RESULTS: Peak exercise capacity increased from 46 +/- 3 W in room air to 59 +/- 5 W when supplemental oxygen was used (P < 0.001). QLEG, QO2LEG, and VO2LEG were greater at peak exercise with O2 than with air (P < 0.05). During submaximal exercise, dyspnea score and VE were significantly reduced with O2 (P < 0.05), whereas QLEG, VO2LEG, and leg fatigue were similar under both experimental conditions. The improvement in peak exercise work rate correlated with the increase in peak QO2LEG (r = 0.66, P < 0.01), peak VO2LEG (r = 0.53, P < 0.05), and reduction in dyspnea at iso-exercise intensity (r = 0.56, P < 0.05). CONCLUSION: The improvement in peak exercise capacity with oxygen supplementation could be explained by the reduction in dyspnea at submaximal exercise and the increases in QO2LEG and VO2LEG, which enabled the exercising muscles to perform more external work. These data indicate that the metabolic capacity of the lower limb muscles was not exhausted at peak exercise during room air breathing in these patients with COPD.

New and prevalent patients with end-stage renal disease in Canada. A portrait of the year 2000.

The number of patients initiating treatment for end-stage renal disease (ESRD) has increased dramatically in Canada and other countries. To assist healthcare planners, the prevalence of ESRD in Canada has been projected to the year 2000 using a Markov modelling technique. Significant increases in ESRD are expected in Canada during the next decade, particularly among the elderly and diabetic populations: estimated increases in prevalence rates of ESRD between 1992 and the year 2000 were 78% and 154% for non diabetic and diabetic populations respectively. These expected increases did not differ significantly between the treatment groups, except among patients with diabetes, in whom projected increases in the prevalence of functioning transplant was smaller than for hemodialysis or peritoneal dialysis. Because the current Canadian prevalence rates are lower than those of some other countries, such as the United States and Japan, these expected trends in prevalence appear reasonable, and illustrate the growing healthcare needs of the ESRD population in Canada during the next decade.

[Hard-to-reach young mothers: study of the implementation of a pre and postnatal intervention for a clientele at risk]. / Les jeunes mères difficiles à rejoindre: étude d'implantation d'une intervention pré et postnatale auprès d'une clientèle à risque.

This paper describes the implementation of a project to prevent the negative biopsychosocial outcomes of teenage pregnancy. The purposes of this project were 1) to reach, as early as possible, young women under 20 years, either pregnant or already young mothers, living in the downtown area of Quebec city on the fringe of society, and perceived to be at risk, and 2) to develop their capacities to take care of themselves and their children, by helping them to recognize their needs, to use adequately the available resources, and to break out of their isolation. A team from Le Centre jeunesse de Québec worked with 25 young pregnant women and 3 young mothers, over a period of 21 months. This team provided the women and their children with a continued and individualized follow-up, which allowed them to develop their autonomy.

PIP: Between 1980 and 1993, the pregnancy rate among Quebec teenagers rose from 24.9 to 37.3 per 1000 women aged 15-19 years, a 50% increase. In the heart of the city of Quebec, the rate rose from 43.7/1000 to 74.4/1000 between 1986 and 1994, an increase of 70%. In 1994, 59 young women gave birth to their infants, while 110 opted for abortion. In Quebec during the 1990s, a range of services were offered to pregnant women and young parents, but these services reached out to few disenfranchised women, and still less to pregnant teens and young mothers. This paper describes a project launched in downtown Quebec to prevent the negative biopsychosocial consequences of adolescent pregnancy. The project hoped to reach out to women under age 20 years, who were either pregnant or already mothers, living on the margins of society in downtown Quebec, and help them to develop their capacities to care for themselves and their children. The idea was to make them recognize their needs, use their available resources, and break them out of their isolation. A team from Le Centre jeunesse de Quebec (Quebec Youth Center) worked with 25 young, pregnant women and 3 young mothers from September 1995 to August 1997. The team then provided the young women with an individualized and ongoing follow-up, during which they were helped to become autonomous. One-third of the women were considered to be autonomous by the end of the project.

Dialysis therapy among elderly patients; data from the Canadian Organ Replacement Register, 1981-1991.

Reports of clinical outcomes after commencement of dialysis treatment among elderly patients with end-stage renal disease (ESRD) are not been numerous. This paper describes the demographic and clinical characteristics of the elderly treated for ESRD in Canada using the Canadian Organ Replacement Register data. Comparisons with younger age groups are also presented. Analyses of data for the period 1981-1991 indicated that the elderly (65+) represent an expanding portion of all new ESRD patients in Canada. Distributions of dialysis modalities showed no major differences by age groups (45-54, 55-64, 65-75, 75+). However, the overall usage of intermittent peritoneal dialysis has decreased over time (from 17% of patients in 1981-83 to 7% in 1990-91). Deaths from social causes were slightly more frequent among the elderly (15.9% of all deaths among those aged 65+ vs 10% among those aged 45-64). Moreover, deaths from infections were more common among patients on dialysis for a longer period of time and more common among patients on peritoneal dialysis than among those on hemodialysis. Discontinuations of continuous ambulatory peritoneal dialysis (CAPD) because of the inability to cope increased with age. Patients with comorbid conditions were more likely to receive hemodialysis, and, as expected, the presence of these conditions increased with age and significantly reduced survival. Other determinants of survival included calendar period of registration, renal center size, and treatment modality. This paper illustrates the many changes over time in the elderly population treated for ESRD. Also of importance, however, is the elderly Canadian population with ESRD which is not presently treated.

[Quebec spirometry reference values]. / Valeurs de références spirométriques québécoises.

Lung volumes forced expiratory flow rates and carbon monoxide diffusing capacity (apnea) were measured in 397 non-smoking, nonatopic, asymptomatic subjects (219 women, 178 men). The equipments and methods for measurements met the ATS criteria. The linear regression of the different variables according to age and height allowed the elaboration of a new set of predictive equations (Quebec). When comparing the different reference values used in North America and Europe, it is found that those of Miller and associates as well as those recommended by the CECA provide the best description of the Quebec situation. However, we would eventually prefer the reference values of Miller and associates over those of the CECA, because they better fit the current ATS criteria and also provide references for smokers. Lung volumes and forced expiratory flow rates of 97 non-smoking, nonatopic, asymptomatic manual workers were measured in the same conditions and submitted to the same comparisons. Quebec predictive values as well as those of Miller and associates isolated the same individuals in the so called abnormal zone. We therefore conclude that Quebec's standards should be preferred in the Province of Quebec pulmonary function laboratories.

Patterns of health services utilization in rural Canada.

CONTEXT OF THIS STUDY: Canadians value ease of access to their health services. Although many studies have focused on accessibility to health services in Canada, few have examined rural-urban differences in this aspect, particularly from a national perspective. Yet disparities in access to health services exist between rural and urban populations, as do the challenges of delivering health care to more remote areas or to those with small populations. "Canada's Rural Communities: Understanding Rural Health and Its Determinants" is a three-year research project co-funded by the Canadian Population Health Initiative (CPHI) of the Canadian Institute for Health Information (CIHI) and the Public Health Agency of Canada (PHAC). It involves investigators from the Public Health Agency of Canada, the Centre for Rural and Northern Health Research (CRaNHR) at Laurentian University, and other researchers. The first publication of the research project was How Healthy Are Rural Canadians? An Assessment of Their Health Status and Health Determinants; this, the second publication, is a descriptive analysis of the utilization patterns of a broad range of health services by rural residents compared to their urban counterparts.