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Standing, sitting and associated working conditions in the Quebec population in 1998.

Working posture is an important determinant of musculoskeletal and vascular health. Knowledge of the context and type of postures is necessary in order to examine their associations with health-related outcomes. This study describes self-reported usual working postures in a population and their associations with other working conditions and demographic variables. The 1998 Quebec Health and Social Survey is a population-based survey of 11,986 private households in the province of Quebec. It contained a self-administered questionnaire, including an extensive occupational health section. The analyses in this study were limited to respondents with paid employment who had at least 6 months seniority in their current job, comprising 9,425 subjects. The overall prevalence of usual work in a standing posture is 58%; it is more common among men, workers under 25 years, those in the two lowest educational quintiles and those with incomes under 20,000 Canadian dollars. Only one person in six who works standing reports being able to sit at will. Women and men differ in the types of usual standing and sitting postures at work. Those who work standing and/or who work in more constrained postures are more likely to be exposed to other physical work demands, such as handling heavy loads, repetitive work, forceful exertion and low job decision latitude. The association between decision latitude and constrained postures is an important link between psychosocial and physical stressors in the workplace. In epidemiological studies, exposure covariation and interactions should be considered in the generation and interpretation of the associations between work postures and musculoskeletal disorders.

Decision Making↗

Abstinence versus nonabstinence: the objectives of alcoholism rehabilitation programs in Quebec.

Since the end of the nineteenth century, various attitudes toward alcoholism--from moralistic and legalistic to those rooted in medicine and psychology--have been adopted. Some of these have persisted and continue to influence the treatment programs available to alcoholics. One of the most popular explanatory models today is the traditional model, which prescribes abstinence as a treatment objective. However, more and more studies are showing that controlled drinking can be a viable alternative for many alcoholics. The aim of the present study is to determine the type of treatment goal preferred by alcoholism rehabilitation centers in the province of Quebec. As of March 31, 1987, the general directors of 78 of the 81 rehabilitation centers operating in Quebec were contacted and interviewed. The data most relevant to the present study came from the response to the following question: "Is a treatment goal other than complete abstinence acceptable for every client who registers in your program to resolve a problem of alcoholism?" The results indicate that most centers will not allow their clients to work toward any goal other than abstinence.

Alcohol Drinking↗

Geographic distribution of 18 autosomal recessive disorders in the French Canadian population of Saguenay-Lac-Saint-Jean, Quebec.

We analysed the geographic distribution of 770 patients and 1084 obligate carriers of 18 autosomal recessive disorders that have a high incidence in Saguenay-Lac-Saint-Jean (SLSJ) (Quebec). The places of birth of the patients and the obligate carriers were found to be unevenly distributed in SLSJ. A statistically significant higher number of places of birth than expected (p < or = 0.05) was observed in Saguenay and Lac-Saint-Jean (LSJ) East, where the immigration was mainly the fact of individuals coming from Charlevoix. A significantly lower number of places of birth than expected was found in LSJ West, and in some municipalities in which the immigration and the contribution of the ancestors from Charlevoix was low. The geographic distribution of inbreeding and kinship only partially explained the geographic distribution of the disorders. The individuals who had both parents and all four grandparents born in SLSJ were at a higher risk of having a recessive disorder. While the genes of these disorders are still being introduced in SLSJ, they are also being dispersed in other regions and outside Quebec by emigrants from SLSJ.

Emigration and Immigration↗

Effectiveness of serogroup C meningococcal polysaccharide vaccine: results from a case-control study in Quebec.

BACKGROUND: After a mass-immunization campaign in the province of Quebec, Canada, from 1992 to 1993, a case-control study was conducted to evaluate the effectiveness of the polysaccharide vaccine, while controlling for the potential confounding effects of selected risk factors for serogroup C meningococcal disease. METHODS: The case patient group comprised 74 individuals with confirmed serogroup C meningococcal disease reported after the beginning of the campaign until 31 March 1998. Four control subjects, matched for age and place of residence, were randomly selected from the Quebec health insurance registry. Information on case patients was obtained from regional public health departments. Case patients and control subjects (or a family member) were interviewed by telephone. The analyses were conducted by using conditional logistic regression models. RESULTS: Although the 95% confidence intervals (CIs) were large as a result of the small sample sizes, a high level of protection was found among children aged >or=6 years, during the first 2 years after vaccination (vaccine effectiveness, 95%; 95% CI, 68%-99%; P<.002), and protection remained high during the following 3 years (77%; 95% CI, -364% to 99%; P=.34). For children aged 2-5 years, the estimated effectiveness was positive during the first 2 years (62%; 95% CI, -403% to 97%; P=.47) but was negative during the following period (-74%; 95% CI, -1956% to 85%; P=.66). Among children aged <2 years, there was no evidence of protection. Household crowding and disadvantaged socioeconomic conditions were associated with increased risk of disease. CONCLUSIONS: The polysaccharide vaccine remains a cost-effective option for the short-term protection of school-aged children and adults; however, conjugate vaccines are needed for younger children.

Adult↗

Increasing risk of relapse after treatment of Clostridium difficile colitis in Quebec, Canada.

BACKGROUND: Clinicians who treat patients with Clostridium difficile-associated diarrhea (CDAD) in Quebec, Canada, have noted an apparent increase in the proportion of patients who experience relapse. METHODS: To determine whether there was an increase in the frequency of treatment failure and of recurrence of CDAD after treatment, we reviewed data on cases that had been diagnosed in a hospital in the province of Quebec during the period 1991-2004. The frequency of recurrences within 60 days after the initial diagnosis was measured using Kaplan-Meier analysis, and Cox regression was used for multivariate analysis. RESULTS: Among patients who had initially been treated with metronidazole, the proportion whose regimens were switched to vancomycin or for whom vancomycin was added because of a disappointing response did not vary between 1991 and 2002 (66 [9.6%] of 688 patients overall) but more than doubled in 2003-2004 (112 [25.7%] of 435; P < .001). Among 845 patients treated with metronidazole only, the 60-day probability of recurrence increased dramatically in 2003-2004 (47.2%), compared with 1991-2002 (20.8%; P < .001). During 1991-2002, the probabilities of recurrence were 20.0%, 13.8%, and 28.9% among individuals aged 0-17, 18-64, and > or = 65 years, respectively; during 2003-2004, the probabilities were 25.0%, 27.1%, and 58.4%, respectively. CONCLUSION: In 2003-2004, there was an increase in the proportion of patients with CDAD believed, by their attending physicians, to have experienced metronidazole treatment failure, as well as an increase in the frequency of post-metronidazole therapy recurrences, especially among elderly persons.

Adolescent↗

Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec.

BACKGROUND: Since 2002, an epidemic of Clostridium difficile-associated-diarrhea (CDAD) associated with a high case-fatality rate has involved >30 hospitals in the province of Quebec, Canada. In 2003, a total of 55% of patients with CDAD at our hospital had received fluoroquinolones in the preceding 2 months. It has been suggested that massive use of proton pump inhibitors might have facilitated this epidemic. METHODS: To delineate the risk of CDAD associated with specific classes of antibiotics and whether this is modulated by concomitant use of proton pump inhibitors and other drugs altering gastric acidity or gastrointestinal motility, we conducted a retrospective cohort study of patients hospitalized in a teaching hospital in Sherbrooke, Canada, during the period of January 2003 through June 2004. We obtained data on 7421 episodes of care corresponding to 5619 individuals. Patients were observed until they either developed CDAD or died or for 60 days after discharge from the hospital. Adjusted hazard ratios (AHRs) were calculated using Cox regression. RESULTS: CDAD occurred in 293 patients. Fluoroquinolones were the antibiotics most strongly associated with CDAD (AHR, 3.44; 95% confidence interval [CI], 2.65-4.47). Almost one-fourth of all inpatients received quinolones, for which the population-attributable fraction of CDAD was 35.9%. All 3 generations of cephalosporins, macrolides, clindamycin, and intravenous beta-lactam/beta-lactamase inhibitors were intermediate-risk antibiotics, with similar AHRs (1.56-1.89). Proton pump inhibitors (AHR, 1.00, 95% CI, 0.79-1.28) were not associated with CDAD. CONCLUSIONS: Administration of fluoroquinolones emerged as the most important risk factor for CDAD in Quebec during an epidemic caused by a hypervirulent strain of C. difficile.

Adolescent↗

Investigation of determinants of past and current exposures to formaldehyde in the reconstituted wood panel industry in Quebec.

OBJECTIVES: Past and present formaldehyde measurements made in facilities manufacturing reconstituted wood panels in Quebec have been collected in order to assess formaldehyde exposure and its determinants in this industry. METHODS: All 12 plants manufacturing Oriented-strand board (OSB), Medium density fibreboard (MDF) and Particle board (PB) in Quebec were visited by a research team which took area and personal measurements. Past measurements taken by governmental occupational health teams in these plants were also collected. Log-transformed formaldehyde concentrations were analysed with extended linear mixed-effects models. RESULTS: During 2001-2002, 275 measurements were taken by the research team, while 590 measurements dating back to 1984 were collected from governmental files. The area measurements had a global geometric mean (GM) of 0.28 p.p.m. [geometric standard deviation (GSD): 3.1]. The GM of the personal measurements was 0.17 p.p.m. (GSD: 2.3). The fixed-effects of the models for personal and area measurements explained 61 and 57% of the variance, respectively. Job (working area for area concentrations), process (PB, MDF, OSB), season of sampling, origin of the data (research, governmental) and year of sampling were significant determinants of exposure. Proximity to the press, winter conditions, PB and MDF processes and governmental data resulted in the highest exposures. Significant within-sampling campaign correlation was found for both personal and area models. The final models include different residual variances by process for personal measurements and by working area for area measurements. CONCLUSIONS: Several determinants of exposure to formaldehyde in the reconstituted wood panel industry were successfully identified. Higher levels found in governmental data as compared to research data may be explained by a 'worst-case' strategy bias. The observed intra-sampling campaign correlation supports existing results suggesting that measurements taken in a small time frame tend to be correlated. Exposures in this sector are low compared to most 8 h-TWA occupational exposure limits (e.g. 1 p.p.m.) but close to the most demanding ones (e.g. 0.3 p.p.m.).

Data Collection↗

Cancer in asbestos-mining and other areas of Quebec.

Employing incidence data from the Quebec Tumor Registry, we examined the relative risks of cancer of all sites for the years 1969-73 in the asbestos-mining, rural, and metropolitan counties of Quebec Province, Canada. Generally, rates for males exceeded those for females, and the relative risks in the asbestos-mining counties for 7-10 different sites of cancer, all of low incidence, were from 1.50 to 8.08 times those of other rural counties of the Province for both sexes. Metropolitan counties exhibited equally high risk for many of these sites. We discovered higher risks among males in asbestos-mining counties for cancer of the pleura, peritoneum, lip, tongue, salivary gland, mouth, and small intestine and higher risks among females for cancer of the pleura, lip, kidney, salivary gland, and for melanoma. Because of the likelihood of a long latent period for asbestos-related cancers, the risks we observed were possibly the product of since-altered occupational and environmental conditions existing 20-30 years ago in the asbestos-mining areas. The similarities in risks for most cancers in asbestos-mining and urban areas were noteworthy.

Asbestos↗

Methyl mercury exposure in northern Quebec. II. Neurologic findings in children.

The relationship between prenatal exposure to methyl mercury and neurologic and developmental abnormalities was ascertained among 234 Cree Indian children aged 12 to 30 months from four northern Quebec communities. A pediatric neurologist, "blinded" to the children's level of exposure, assessed neurologic, physical, mental, and psychosocial development. Methyl mercury exposure was estimated from maternal hair segments representing the period of pregnancy. Abnormality of the tendon reflexes, observed in 13 boys (11 per cent) and in 14 girls (12 per cent), was positively associated with methyl mercury exposure only in boys and there was no consistent dose-response relationship. Other neurologic disorders were less prevalent and none was positively associated with exposure; indeed, incoordination was negatively associated with exposure in girls. The mild, isolated neurologic abnormalities found after prenatal exposure to methyl mercury in northern Quebec were different from the effects of prenatal exposure described in other areas, and their clinical importance can be determined only by continued medical surveillance.

Adult↗

Rates of transcervical and pertrochanteric hip fractures in the province of Quebec, Canada, 1981-1992.

Two distinct subtypes of hip fracture, transcervical and pertrochanteric, can be distinguished on the basis of the anatomical location of the injury. While the epidemiology of hip fractures has been well described, typically, little or no distinction is made between these subtypes. The objective of this study was to compare and contrast age- and sex-specific rates of transcervical and pertrochanteric fractures in Quebec, Canada. The data for this study were obtained from a database containing records of all persons discharged from all hospitals in Quebec from 1981 to 1992. Rates of hip fractures were calculated by using the population aged 50 years and older as the denominator, and changes in rates over time were assessed using Poisson regression. There were no statistically significant trends in the changes in rates over time (i.e., 95 percent confidence intervals overlapped the null value). Among women below age 70 years, transcervical fractures were more common, whereas among older women, pertrochanteric fractures predominated. Among men, pertrochanteric fractures predominated at all ages. There was a marked seasonal variation in the occurrence of all hip fractures combined: Compared with the summer months, the relative risk of all hip fractures during the winter was 1.32 (95 percent confidence interval 1.28-1.36). The results of this study indicate that the two subtypes of hip fracture, transcervical and pertrochanteric, have different patterns of occurrence, suggesting different risk factor profiles. Clearly, a multidisciplinary research approach is needed before it will be possible to untangle the complex relation between the metabolic processes occurring at the level of the individual and the distribution of the disease in the population.

Age Distribution↗

From evidence to community practice in work rehabilitation: the Quebec experience.

BACKGROUND: The causes of prolonged disability due to back pain are multiply determined, involving medical, social, and environmental factors. Possible solutions to the problem of prolonged back pain disability have emerged from recent research but few efforts have been made to transfer evidence-based programs to large community settings. OBJECTIVE: This article describes three phases of the process of transfer of evidence from rehabilitation research to community practice in the province of Quebec. METHODS AND RESULTS: Phase A: Based on literature review and expert knowledge, the Sherbrooke model was developed and assessed through a population-based, randomized clinical trial. Results at 1-year follow-up showed quicker return to regular work and improvement of quality of life; the 6-year follow-up showed the cost-effectiveness of the method. Phase B: Based on the Sherbrooke model experience and recent evidence, a new program addressing the disability paradigm was developed and implemented in the province of Quebec (Canada). Results at 1- and 3-year follow-ups showed that only 24% of workers were not working owing to their musculoskeletal disorder. The program is presently being tested through a population-based, randomized clinical trial in a population of construction workers. Phase C: To implement the program at a provincial level, a network for management, research and education in work rehabilitation was developed. An external assessment is presently planned to evaluate return to work and economic outcomes and quality of implementation of the program in various settings.

Adult↗

Linkage of the Na,K-ATPase alpha 2 and beta 1 genes with resting and exercise heart rate and blood pressure: cross-sectional and longitudinal observations from the Quebec Family Study.

OBJECTIVE: To investigate whether genetic variations in the genes encoding the alpha and beta subunits of the Na,K-ATPase are linked with hemodynamic phenotypes. DESIGN AND PARTICIPANTS: Cross-sectional data based on 533 subjects (no antihypertensive medication) were obtained from 150 families of phase 2 of the Quebec Family Study, together with longitudinal data from 338 subjects (105 families) who had been measured 12 years earlier in phase 1 of the Quebec Family Study. MAIN OUTCOME MEASURES: Restriction fragment length polymorphisms were examined at the alpha 2 (exon 1 and exon 21-22 with BglII) and beta 1 (Msp I and Pvu II) loci of Na,K-ATPase. Hemodynamic phenotypes measured included systolic and diastolic blood pressure, heart rate and rate-pressure product at rest and during low-intensity exercise. RESULTS: Sib-pair analysis revealed relatively strong linkages (P = 0.0003-0.002) between the resting heart rate and rate-pressure product and the alpha 2 exon 21-22 marker and alpha 2 haplotype. Moreover, the alpha 2 exon 21-22 marker showed suggestive linkages (P = 0.01 to 0.043) with resting systolic blood pressure and exercise diastolic blood pressure, heart rate and rate-pressure product, and the alpha 2 haplotype with exercise diastolic blood pressure and rate-pressure product and the 12-year change in resting systolic blood pressure (P = 0.03 to 0.05). Both the beta 1 Msp I marker and the beta 1 haplotype were linked with the resting rate-pressure product (P = 0.007 and 0.003, respectively), and all beta 1 markers showed linkage with the change in resting systolic blood pressure (P = 0.00005 to 0.024). In men, there was a significant (P = 0.01) interaction between the alpha 2 exon 21-22 genotype and the postglucose plasma insulin level with regard to resting systolic blood pressure. CONCLUSIONS: These data suggest that the alpha 2 and beta 1 genes of Na,K-ATPase contribute to the regulation of hemodynamic phenotypes in healthy subjects.

Blood Pressure↗

Persistence of a 1930 swine influenza A (H1N1) virus in Quebec.

Two antigenically distinct H1N1 influenza A viruses were isolated during an outbreak of respiratory disease in Quebec swine in 1990/91. Analysis of haemagglutinin and partial nucleoprotein sequences indicated that one was a variant of the swine H1N1 influenza virus circulating in the American Midwest whereas the other was very similar to virus isolated from swine in 1930. The existence of this latter isolate supports the concept that influenza viruses can be maintained for long periods in swine, perhaps in geographically limited pockets. Serological evidence indicates that these distinct strains continued to circulate widely in south-central Quebec until at least 1993.

Amino Acid Sequence↗

A survey of midwives in Quebec: what are their similarities and differences?

BACKGROUND: Until recently, Canada was the only industrialized country that had not legalized midwifery. In the province of Quebec the government adopted a law to evaluate midwifery in eight pilot projects before generalizing the practice. This study examined the similarities and differences among midwives in Quebec. METHODS: Using data from a 1991 mail survey, we compared 31 nurse-midwives, 12 professional midwives, and 27 lay midwives to assess professional background and opinions about selected maternity care issues and aspects of future midwifery practice, such as midwife training options, responsibilities, setting for midwifery care, relationship to other maternity caregivers, autonomy, and control over their profession. RESULTS: Midwives largely shared the same philosophy of care but had different viewpoints on two main professional aspects: compared with professional midwives and nurse-midwives, lay midwives preferred to deliver antepartum, intrapartum, and postpartum care at a client's home or an independent birthing center; like professional midwives, they rejected nursing as a prerequisite to midwifery training. Other interrelated personal, social, political, and legal factors were also associated with different beliefs. CONCLUSIONS: Despite the differences among the three groups, the process under way in Canada is to recognize a single profession of midwife. Creating a unified profession is a challenge that Canadian midwives with different backgrounds face in the 1990s.

Health Knowledge, Attitudes, Practice↗

Cost-utility of adjuvant high-dose interferon alpha therapy in stage III cutaneous melanoma in Quebec.

OBJECTIVE: To estimate the cost-utility of adjuvant high-dose interferon in high-risk melanoma patients in Quebec compared to a watchful waiting strategy. METHOD: A Markov model was developed that replicates the findings of the pivotal E1684 trial. It was then used to extrapolate survival over a period of 35 years. Costs of medical resources used during the first year were derived through a detailed analysis of a sample (n = 13) of patients treated in a leading academic hospital. Follow-up costs were assessed through a medical decision algorithm. Utilities were derived from a population-based survey (n = 104) in different locations in Quebec using the time trade-off method. RESULTS: The mean incremental cost per quality-adjusted life-year of adjuvant Interferon therapy is equal to 55,090 CAN dollars over a follow-up of 7 years but drops down to 14,003 CAN dollars when extrapolated over 35 years. CONCLUSIONS: Estimates of the cost-effectiveness of high-dose interferon in melanoma patients show an acceptable cost-effectiveness ratio if long-term survival is taken into account. Estimates are, however, strongly influenced by the observed trial differences in survival, the utility associated to health states, and the discount rate.

Adult↗

Determinants of initiation and suboptimal use of anti-ulcer medication: a study of the Quebec older population.

OBJECTIVES: To describe the use of anti-ulcer medication in the Quebec older population; to examine determinants of initiation, suboptimal use, and switches between products. DESIGN: Population-based retrospective cohort study. SETTING: Universal health program for older adults in Quebec. PARTICIPANTS: 5000 users and 5000 non-users of anti-ulcer medications were selected randomly. Use was defined as the presence in the 1991 prescription database of an anti-ulcer prescription. Among users, 1697 (34%) were new users and were considered as the exposure group. Subjects were followed for 365 days after inclusion. MEASUREMENTS: Measured were patient's age, gender, prescribed duration of anti-ulcer medication, concomitant medications, and gastrointestinal diagnostic procedures. RESULTS: A total of 17% of new users had unusually short courses; 18% were long-term users. There was no difference in duration for omeprazole compared with other anti-ulcer medications. First-time use of NSAIDs was the strongest predictor of initiation of anti-ulcer medication (odds ratio = 3.21; 95% CI, 2.66-3.88). Twenty-six percent of users switched brands. Only 9.5% of new users underwent a diagnostic procedure before initiation of therapy, and 49% of long-term users ever underwent such procedure. CONCLUSION: Despite a relatively homogeneous recommended duration of therapy, patterns of use of anti-ulcer medication among older people are highly variable, and treatment is often not accompanied by a diagnostic procedure.

Age Factors↗

Survival after percutaneous endoscopic gastrostomy among older residents of Quebec.

CONTEXT: Percutaneous endoscopic gastrostomy has become a mainstay of nutritional support for individuals with swallowing dysfunction. There is little population-based data to guide the use of this intervention in older individuals. OBJECTIVE: To describe the use of percutaneous endoscopic gastrostomy among older residents of Quebec and to evaluate patient characteristics associated with subsequent survival and hospital discharge. DESIGN: A population-based cohort study. SETTING: Quebec, Canada. PATIENTS: 175 individuals with a billing claim for percutaneous endoscopic gastrostomy performed in 1993. MEASUREMENTS: Billing and hospitalization databases were used to collect patient characteristics, medical diagnoses, discharge destinations, and dates of death. The relationships between demographic and diagnostic variables before gastrostomy, and subsequent survival and discharge home, were evaluated using survival analysis. RESULTS: Median survival after gastrostomy was 210 days. Mortality at 30 days was 18.3%. Decreased survival was associated with a previous diagnosis of malignancy (risk ratio (RR) = 1.71; 95% CI, 1.09-2.68); mortality did not increase with increasing age. Of 163 individuals hospitalized at the time of gastrostomy, 42 (26%) were discharged home. Individuals with a previous diagnosis of stroke (RR = 2.80; 95% CI 1.01-7.77) were more likely to be discharged home than other individuals. CONCLUSIONS: Survival after percutaneous endoscopic gastrostomy is poor; the requirement for such a procedure appears to be a marker for severe underlying disease. The greater likelihood of return home after gastrostomy among individuals with stroke suggests that the use of this intervention as an adjunct to rehabilitation is appropriate in these individuals.

Aged↗

Long-term continuous use of benzodiazepines by older adults in Quebec: prevalence, incidence and risk factors.

OBJECTIVE: To determine the prevalence and incidence of long-term use of benzodiazepines and to assess patient-, prescriber-, and drug-related risk factors. DESIGN: Cohort study. PARTICIPANTS: 1,423 community-dwelling older adults in Quebec who participated in the Canadian Study of Health and Aging (CSHA1). MEASUREMENTS: Patient characteristics were obtained from the CSHA1 database. These were linked to provincial health insurance data to ascertain benzodiazepine use and prescriber characteristics. MAIN OUTCOME MEASURE: Use of benzodiazepines for at least 135 of the first 180 days following initiation of use. RESULTS: Twelve-month prevalence of long-term continuous use, standardized by age and gender to the Quebec population, was 19.8%. Twelve-month cumulative incidence of long-term continuous use was 1.9%. Older patients were more likely to proceed to long-term continuous use. CONCLUSIONS: Risk of long-term continuous use of benzodiazepines seems to increase with age. This association was found to be independent of gender, health status, anxiety, cognitive status, benzodiazepine type, and physician characteristics.

Adult↗