Equi-caloric bouts of interval (INT: 5x 2:2 min at 85 and 40% VO2max) and continuous (21 minutes at 60% VO2max) exercise were performed by 13 older prehypertensive males on separate days, at equivalent times of day, to assess the influence of exercise mode on post-exercise hypotension (PEH). Cardiovascular measures were collected for 30 min pre and 60 min post-exercise. PEH as measured by mean post-exercise systolic blood pressure (SBP) decrease, area under the SBP curve, and minimum SBP achieved, was equivalent after both conditions. SV was significantly reduced and HR was significantly elevated post-exercise after both conditions. No significant reductions in CO or TPR were observed. INT exercise provided a larger perturbation to the autonomic nervous system as measured by Baroreflex sensitivity and Heart Rate Variability. The responses elicited by acute INT exercise, with repeated exposure, may lead to greater improvements in blood pressure regulation than those associated with continuous aerobic training.

Background: Infant immunization pain is not currently well managed despite effective strategies. Objective: To determine the effectiveness of tactile stimulation when added to a combination of pain-reducing interventions in infants undergoing immunization. Methods: Healthy infants aged 4-6 months undergoing immunization in primary care were randomized to tactile stimulation or usual care. All infants also received pain-relieving interventions. A validated measure of acute pain in infants, the Modified Behavioral Pain Scale (MBPS), was the primary outcome. Results: Altogether, 120 infants participated. Characteristics did not differ (p > 0.05) between those allocated to tactile stimulation and usual care groups. Mean MBPS pain scores did not differ between groups: 8.2 (1.1) vs. 8.0 (1.3); p = 0.57, respectively. Conclusions: Parent-led tactile stimulation did not improve pain relief in infants when added to other interventions. Parental attention could have been focused on tactile stimulation, preventing parents from performing appropriate soothing activities. Additional investigation of the effectiveness of clinician-led tactile stimulation is recommended.

Inflammatory bowel disease (IBD), characterized by chronic gastrointestinal inflammation, represents a significant childhood chronic disease. In this thesis, a case ascertainment definition of paediatric-onset IBD was validated using administrative data and developed the Ontario Crohn’s and Colitis Cohort (OCCC). The epidemiology of paediatric IBD in Ontario was described, demonstrating that Ontario has one of the highest worldwide incidence rates. Statistically significant increases in incidence were noted in 0-4 year olds (5.0%/year, p=0.03) and 5-9 year olds (7.6%/year, p<0.0001), but not in other age groups. Lower income children were more likely to be hospitalized at least once (hazard ratio (HR) 1.17, 95% confidence intervals (CI) 1.05-1.30) or visit the ED (HR 1.21, 95% CI 1.09-1.35) and had more IBD-related physician visits (odds ratio (OR) 3.73, 95% CI 1.05-13.27). Lower income children with Crohn's disease (CD) (not ulcerative colitis [UC]) were more likely to undergo intra-abdominal surgery within 3 years of diagnosis (OR 1.22, 95% CI 1.01-1.49), especially if diagnosed after 2000 (OR 1.79, 95% CI 1.27-2.53). Finally, changes in health services utilization and surgical rates were described, as were changes in specialist care provision and immunomodulator use in children with IBD between 1994-2007. The changes to care included increased outpatient care provided by paediatric gastroenterologists, and increased immunomodulator use. Children diagnosed with CD, but not UC, in recent years had lower surgical rates. In CD patients, intra-abdominal surgical rates within three years of diagnosis decreased from 18.8% in children diagnosed in 1994-1997 to 13.6% in those diagnosed in 2001-2004 (P = 0.035). When stratified by age at diagnosis, this decrease was significant in children diagnosed ≥10 years old (OR 0.67, 95% CI 0.48-0.93). The OCCC will continue to be used to investigate the epidemiology and burden of paediatric IBD and to improve the care received by children with IBD in Ontario.

Objective: This thesis aimed to advance the study of sustainability through the exploratory use of a conceptual framework for the investigation of a collaborative project. Methods: A qualitative case study design, utilizing document analysis and key informant interviews, was used to conduct a three-year follow-up of a collaborative mental health project. The study design and directed content analysis were informed by the Scheirer and Dearing (2011) conceptual framework. Results: The sustained outcomes identified by the six participating agencies included: institutionalized project components, maintained client benefits, continued collaboration and sustained attention to the issue. The sustainability of project components was associated with complex interactions between the innovation, organization, and community factors investigated. Conclusions: The study illustrated the importance of evaluating multiple aspects of sustainability to fully capture a project’s long-term effect. Complex systems theory was proposed to describe the interactions observed and as a direction for further development of the conceptual framework.

Objective: This thesis aimed to advance the study of sustainability through the exploratory use of a conceptual framework for the investigation of a collaborative project. Methods: A qualitative case study design, utilizing document analysis and key informant interviews, was used to conduct a three-year follow-up of a collaborative mental health project. The study design and directed content analysis were informed by the Scheirer and Dearing (2011) conceptual framework. Results: The sustained outcomes identified by the six participating agencies included: institutionalized project components, maintained client benefits, continued collaboration and sustained attention to the issue. The sustainability of project components was associated with complex interactions between the innovation, organization, and community factors investigated. Conclusions: The study illustrated the importance of evaluating multiple aspects of sustainability to fully capture a project’s long-term effect. Complex systems theory was proposed to describe the interactions observed and as a direction for further development of the conceptual framework.

En dépit du nombre croissant d’études cliniques sur le canal artériel (CA), des failles méthodologiques entretiennent plusieurs incertitudes concernant l’efficacité et la sécurité des traitements chez les bébés nés prématurés. L’objectif de cette recherche était de comparer les concentrations de prostaglandine E2 (PGE2) et les mesures du flux mésentérique par échographie Doppler chez les enfants nés prématurément et ayant un canal artériel traité à l’ibuprofène par voie intraveineuse ou entérale, en utilisant la méthodologie randomisée contrôlée et à double insu. Dans notre étude pilote, 20 nouveau-nés prématurés de moins de 34 semaines ayant un CA symptomatique confirmé par échocardiographie, furent randomisés au traitement à l’ibuprofène par voie intraveineuse ou entérale. La voie d’administration fut maintenue à l’insu de l’équipe traitante, des cardiologues et des investigateurs. Des dosages des prostaglandines plasmatiques ont été mesurés avant le début du traitement ainsi que 3, 24 et 48 h après le début du traitement. Les mesures du flux mésentérique ont été effectuées avant le traitement à l’ibuprofène ainsi que 1 h et 3 h après le traitement. Nous avons démontré à partir de nos observations que les niveaux plasmatiques de prostaglandines E2 diminuent chez les patients ayant répondu au traitement à l’ibuprofène, indépendamment de la voie d’administration. Nous n’avons pas observé de changement dans l’évolution des dosages de PGE2 chez les patients qui n’ont pas répondu au traitement. Les paramètres mesurés par échographie Doppler au niveau de l’artère mésentérique supérieure n’étaient pas affectés par la voie d’administration du traitement à l’ibuprofène, intraveineuse ou entérale. La présente étude suggère ainsi que le traitement du CA par ibuprofène intraveineux ou entéral n’influe pas sur le flux sanguin mesuré par échographie Doppler. La baisse de la prostaglandine E2 coïncide avec la fermeture du CA, et son dosage pourrait jouer un rôle dans la gestion du traitement. Nous avons démontré la faisabilité d’une étude clinique randomisée à double insu dans le traitement du canal artériel; une méthodologie qui devrait désormait être employé dans la recherche clinique sur les traitements de la persistance du CA. / Despite the growing body of research on the patent ductus arteriosus (PDA), issues with clinical research methodology impairs much of our understanding regarding treatment efficacy and safety in the preterm population. The purpose of this study was to determine plasma prostaglandin E2 (PGE2) concentrations in preterm infants with symptomatic persistence of the ductus arteriosus treated with IV and oral ibuprofen, and measure Doppler flow parameters in the superior mesenteric artery, utilizing randomized controlled and double-blind methodology. Twenty patients age < 34 wks with a symptomatic PDA confirmed by echocardiography randomized to oral vs intravenous ibuprofen regimen. Treating physician, cardiologists and study investigators were blinded to treatment allocation. Plasma PGE2 levels were measured prior to ibuprofen treatment and at 3, 24 and 48 h after treatment. Mesenteric Doppler measurements were taken prior to ibuprofen treatment, and 1 h and 3 h after treatment. Our results showed that plasma PGE2 levels decreased over time in patients that exhibited ductal closure after IV or oral ibuprofen treatment; no time-dependent changes in PGE2 were seen in subjects that failed to respond to ibuprofen. Superior mesenteric artery Doppler flow measurements were not affected by ibuprofen treatment (IV or oral), regardless of efficacy on ductal closure and of PGE2 changes. We conclude that treatment with oral or intravenous ibuprofen does not impact on superior mesenteric artery blood flow measured by Doppler ultrasound. Decreases in plasma PGE2 concentrations coincide with ibuprofen efficacy, and may be more cost-effective to monitor than ultrasound. This study also demonstrated the successful use of double blinded randomized controlled research methodology, which should be more strictly applied in future clinical research on PDA treatment.

Statement of the issue: Facing large HIV-infected populations, Sub-Saharan African countries are producing antiretroviral (ARV) drugs under provisions of the World Trade Organization’s Agreement on the Trade-Related Aspects of Intellectual Property (TRIPS). Article 7 states that the protection of intellectual property should increase technology transfer to developing countries. This clause and the debate over domestic manufacturers’ ability to provide low-cost ARVs need examination. Methods: Case studies from ARV manufacturing initiatives in Tanzania and South Africa analyzed conditions affecting two outcomes: the type of technology transfer arrangement entered (voluntary license or imitation) and the affordability of ARVs. Data were collected and analyzed from documents, key-informant interviews, and observation. Chi-squared and phi correlation statistics were then conducted across developing countries to test the association of voluntary ARV licensure with TRIPS-compliant patents and domestic firm ownership (state or private). Results: Tanzania’s weak patent system and poorly-financed, partially state-owned firm dissuaded industry investment, but attracted a non-government organization to transfer technology through imitation. Donor-financed ARV tenders, however, restrict competition to international quality-accredited products not produced by the firm. Without large volumes and manufacturing capacity, it cannot achieve economies of scale to reduce prices below imported ARVs. In South Africa, civil society challenged the strong patent system and poor government commitment that inhibited an ARV rollout. This and a well-financed, publicly-traded firm leveraged voluntary licenses. With international quality approval, the firm increased first-line ARV affordability; however, limited domestic competition keeps treatment prices above those of neighbouring countries. A multi-country analysis found 321 generic ARV manufacturing initiatives in 86 firms across 25 developing countries. Voluntary ARV licenses had a strong positive association with TRIPS-patent compliance (ф=.56, p<.0001) and a weak negative association with state-ownership (ф=.19, p<.0001). Firms in South Africa and India were granted 77% of licenses and accounted for most quality accredited generic ARVs. Conclusion: Despite positive association, technology transfer does not readily result from patent protection, particularly to state-owned firms. Developing countries must enact policies to enable affordable ARVs; yet, they must be cautious using local production to increase ARV access, as most initiatives cannot compete with high-volume generic manufacturers.

Un intérêt grandissant pour le rôle du citoyen dans la prise de décision concernant la vie publique se développe depuis les dernières années. Le développement et la mise en oeuvre de divers mécanismes de participation citoyenne, comme les conférences citoyennes, témoignent de cet intérêt. Nombre de ces expériences ont fait l'objet d'une évaluation, mais essentiellement au niveau de l'efficacité ou du succès de l'exercice. Peut-on les évaluer sur le plan de l’éthique? Quels sont les défis éthiques posés par les mécanismes de participation citoyenne? Ce mémoire évalue une expérience de conférence citoyenne portant sur les avancées de la biologie humaine à l’ère de la génomique mise sur pied par le Groupe de recherche en bioéthique (GREB) de l’Université de Montréal en 2005. À l’aide du concept de l’éthique de la discussion, telle que proposée par quatre auteurs québécois, une analyse qualitative est effectuée sur six documents rédigés dans le cadre de la conférence. Deux catégories de résultats sont discutées. D’abord, les divers éléments relatifs à la conférence citoyenne qui ont soulevé notre attention. Ensuite, les préoccupations des participants en lien avec la science, la société et la participation. Une meilleure compréhension des aspects éthiques auxquels on devrait accorder une attention particulière contribuera à l’amélioration du mécanisme de conférence citoyenne et à son utilisation à long terme. / In recent years, there has been a growing interest in the role of citizens in public decision-making. This interest is reflected in the development and implementation of various citizen participation mechanisms, such as citizen conferences (also known as consensus conferences). Many of these experiences have been evaluated, but mainly in terms of their effectiveness or success. What are the ethical challenges posed by citizen participation mechanisms? This study looks at a citizen conference on advances in human biology in the era of genomics, held by the Groupe de recherche en bioéthique (GREB) of the Université de Montréal in 2005. The concept of discourse ethics, as developed by four Quebec authors, is used to conduct a qualitative analysis of six documents from the conference. Two categories of results are discussed: noteworthy aspects of the citizen conference and participants’ concerns with regard to science, society and their participation. A better understanding of key ethical issues will help to improve citizen conferences and their long-term use.

Introduction : Les personnes âgées vivant à domicile font des chutes qui peuvent entraîner des conséquences graves. La possibilité de les détecter et d’intervenir rapidement grâce à la vidéosurveillance intelligente constitue une avenue prometteuse. Objectif : L’étude vise à explorer la perception et la récep-tivité des acteurs du système de santé face à l’utilisation de cette technologie sous trois aspects : la transmission des images, l’accessibilité de leur clientèle à cette technologie et son introduction dans leur pratique. Méthodologie : Sept groupes de discussion focalisée ont permis de recueillir le point de vue de 31 participants. Une analyse de contenu avec le logiciel N’Vivo a été réalisée. Résultats : Les participants estiment que les images de chute pourraient parve-nir au CLSC, au proche aidant, au 911 ou à une centrale de surveillance. Ils considèrent que des critères d’admissibilité seraient nécessaires pour favoriser l’accessibilité à la vidéosurveillance intelligente qui, croient-ils, pourrait améliorer les interventions en termes de gestion des urgences lors de chutes et de déter-mination de leurs causes. Conclusion : Les participants sont favorables à la technologie proposée, mais ils requerraient une période d’adaptation afin d’ajuster leur pratique. Ils suggèrent la réalisation d’un projet pilote qui validerait cette technologie. / Introduction: Elderly living at home fall and this may result in severe consequences. However, rapid detection and effective intervention using an intel-ligent videomonitoring system is very promising. Objective: The study aims at exploring the perception and receptiveness of healthcare providers regarding this technology from three angles: image transmission, the accessibility of their cli-ents to such a system, and its introduction in their practice. Methodology: Seven focus groups allowed 31 healthcare providers to express their points of view. A content analysis was performed with N’Vivo software. Findings: Participants reckon that CLSC, caregivers, the 911 or a central call center might receive im-ages of falls. They believe that admission criteria might have to be developed in order to ensure accessibility to the videomonitoring system which, they think, could improve their interventions in terms of emergency management when falls occur as well as of cause seeking. Conclusion: The participants are in favour of using the intelligent videomonitoring system, but they might require an adaptation period in order to adjust their practices. They have recommended that a pilot study be carried out to confirm its feasibility in a real-life setting.

Le but de cette étude était de déterminer la contribution de plusieurs facteurs (le design de la tâche, l’orientation d’angle, la position de la tête et du regard) sur la capacité des sujets à percevoir les différences de formes bidimensionnelles (2-D) en utilisant le toucher haptique. Deux séries d'expériences (n = 12 chacune) ont été effectuées. Dans tous les cas, les angles ont été explorés avec l'index du bras tendu. La première expérience a démontré que le seuil de discrimination des angles 2-D a été nettement plus élevé, 7,4°, que le seuil de catégorisation des angles 2-D, 3,9°. Ce résultat étend les travaux précédents, en montrant que la différence est présente dans les mêmes sujets testés dans des conditions identiques (connaissance des résultats, conditions d'essai visuel, l’orientation d’angle). Les résultats ont également montré que l'angle de catégorisation ne varie pas en fonction de l'orientation des angles dans l'espace (oblique, verticale). Étant donné que les angles présentés étaient tous distribués autour de 90°, ce qui peut être un cas particulier comme dans la vision, cette constatation doit être étendue à différentes gammes d'angles. Le seuil plus élevé dans la tâche de discrimination reflète probablement une exigence cognitive accrue de cette tâche en demandant aux sujets de mémoriser temporairement une représentation mentale du premier angle exploré et de la comparer avec le deuxième angle exploré. La deuxième expérience représente la suite logique d’une expérience antérieure dans laquelle on a constaté que le seuil de catégorisation est modifié avec la direction du regard, mais pas avec la position de la tête quand les angles (non visibles) sont explorés en position excentrique, 60° à la droite de la ligne médiane. Cette expérience a testé l'hypothèse que l'augmentation du seuil, quand le regard est dirigé vers l'extrême droite, pourrait refléter une action de l'attention spatiale. Les sujets ont exploré les angles situés à droite de la ligne médiane, variant systématiquement la direction du regard (loin ou vers l’angle) de même que l'emplacement d'angle (30° et 60° vers la droite). Les seuils de catégorisation n’ont démontré aucun changement parmi les conditions testées, bien que le biais (point d'égalité subjective) ait été modifié (décalage aux valeurs inférieurs à 90°). Puisque notre test avec le regard fixé à l’extrême droite (loin) n'a eu aucun effet sur le seuil, nous proposons que le facteur clé contribuant à l'augmentation du seuil vu précédemment (tête tout droit/regard à droite) doit être cette combinaison particulière de la tête/regard/angles et non l’attention spatiale. / The purpose was to determine the contribution of several factors (design of the task, angle orientation, head position and gaze) to the ability of subjects to perceive differences in twodimensional (2-D) shape using haptic touch. Two series of experiments (n=12 each) were carried out. In all cases the angles were explored with the index finger of the outstretched arm. The first experiment showed that the mean threshold for 2-D angle discrimination was significantly higher, 7.4°, than for 2-D angle categorization, 3.9°. This result extended previous work, by showing that the difference is present in the same subjects tested under identical conditions (knowledge of results, visual test conditions, angle orientation). The results also showed that angle categorization did not vary as a function of the orientation of the angles in space (oblique, upright). Given that the angles presented were all distributed around 90°, and that this may be a special case as in vision, this finding needs to be extended to different ranges of angles. The higher threshold with angle discrimination likely reflects the increased cognitive demands of this task which required subjects to temporarily store a mental representation of the first angle scanned, and to compare this to the second scanned angle. The second experiment followed up on observations that categorization thresholds are modified with gaze direction but not head position when the unseen angles are explored in an eccentric position, 60° to the right of midline. This experiment tested the hypothesis that the increased threshold when gaze was directed to the far right might reflect an action of spatial attention. Subjects explored angles located to the right of midline, systematically varying the direction of gaze (away from or to the angles) along with angle location (30° and 60° to the right). Categorization thresholds showed no change across the conditions tested, although bias (point of subjective equality) was changed (shift to lower angle values). Since our testing with far right gaze (away) had no effect on threshold, we suggest that the key factor contributing to the increased threshold seen previously (head forward/gaze right) must have been this particular combination of head/gaze/angles used and not spatial attention.