Closely related strains of Escherichia coli have been shown to cause extraintestinal infections in unrelated persons. This study tests whether a food reservoir may exist for these E. coli. Isolates from three sources collected over the same time period and geographic area were compared. The sources comprised E. coli isolates from women with urinary tract infection (UTI) (n = 353); retail meat (n = 417); and restaurant/ready-to-eat foods (n = 74). E. coli were evaluated for antimicrobial susceptibility and O:H serotype and compared by using six different genotyping methods. We identified 17 clonal groups that contained E. coli isolates (n = 72) from more than one source. E. coli from retail chicken (O25:H4-ST131 and O114:H4-ST117) and honeydew melon (O2:H7-ST95) were indistinguishable from or closely related to E. coli from human UTIs. This study provides strong support for the role of food reservoirs in the dissemination of E. coli causing community-acquired UTIs. / Il a été démontré que des souches de Escherichia coli étroitement reliées causaient des infections extraintestinales chez des personnes non-reliées. Cette étude teste l'hypothèse selon laquelle il existerait un réservoir alimentaire pour ces souches d'E. coli. Des isolats provenant de trois sources différentes et récoltés durant les mêmes périodes et régions géographiques ont été comparés. Les sources incluaient des isolats d'E. coli provenant de femmes soufrant d'infection urinaire (IU) (n=353); de viande vendue au détail (n = 417); et d'aliments de restauration/prêts-à-manger (n =74). Les E. coli ont été évalués pour leur susceptibilité aux agents antimicrobiens et leur sérotype O:H, et ont été comparés par l'intermédiaire de six différentes méthodes de génotypage. Nous avons identifié 17 groupes clonaux contenant des isolats d'E. coli (n = 72) provenant de plus d'une source. Des E. coli provenant de viande de poulet (O25:H4-ST131 et O114:H4-ST117) et de melon au miel (O2:H7-ST95) étaient indistinguables ou étroitement reliés à des E. coli provenant d'IUs. Cette étude supporte fortement le rôle des réservoirs alimentaires dans la dissémination du E. coli causant des IUs acquises dans la communauté.

Previous reports have identified the need of a quality-of-life measure for use with persons with low back pain (LBP) in order to verify treatment efficacy. The Spitzer Quality-of-Life Index (QL-Index) has proven to be valid and reliable in various clinical studies. However, it has shown a lack of responsiveness when used with low back pain patients. In an attempt to improve responsiveness, a disease specific module was developed to complement the QL-Index. Patients, their significant others, and health professionals were interviewed to determine the contents of the LBP-Module, A prospective design was employed in the preliminary psychometric study (n = 31). This study demonstrated good internal consistency ($ alpha$ = 0.818) and high test-retest reliability (ICC = 0.91) for the combined use of the QL-Index and LBP-Module. It also showed strong evidence supporting construct validity. Effect size (ES = 1.42) and standardized response mean (SRM = 1.24) calculations demonstrated high responsiveness for the combined use of the quality-of-life measures. The LBP-Module presented in this thesis seems to be the first quality-of-life measure developed for persons with this disorder. It should therefore be a useful outcome measure in future studies.

Available evidence from RCTs shows that GPs' counselling can be effective in reducing smoking prevalence and that some specific features of the intervention (for example the offer of follow-up visits) may enhance its effectiveness. The impact of such preventive activity, however, is dependent not only on intervention characteristics, but also on factors related to the recipients (smokers) and the providers (physicians). Paper 1 explores the role of pre-treatment factors in predicting quitting following GPs' counselling among 861 smokers enrolled in the Turin smoking cessation trial. Social support and smoke free environment reinforce the impact of GPs' counselling, which is less effective for more addicted smokers and for women. Counselling might be more effective, if GPs would take advantage of information on individuals' experience of behavioral change to tailor their message. Paper 2 compares a group of smokers (N = 965), who were invited to participate in the Turin smoking 1 cessation trial, to a matched sample of smokers (N = 277), listed in the files of 42 GPs collaborating in the trial. The patients in the second set were potentially eligible for recruitment, but were not invited to participate. Estimates of the effect of individual characteristics on patient recruitment indicate that GPs focused their efforts on heavier and diseased smokers. As this tendency may dilute the impact of their anti-smoking action, more effective educational strategies should be implemented when planning preventive interventions.

Background. Daycare centres play a role in hepatitis A infection epidemiology; however, there is little information on this infection among daycare educators in Canada. / Objective. To determine hepatitis A seroprevalence and risk factors among daycare educators. / Methods. Directors and educators from randomly selected daycare centres in Montreal completed questionnaires on daycare-level and educator-level characteristics. Sera were collected during on-site visits. / Results. The seroprevalence of hepatitis A among the 492 participating educators was 35.6% (15.9% among Canadian-born educators). Risk factors included: region of birth by income-level (OR = 20.8; 95% CI: 9.4, 46.0); report of previous hepatitis A vaccination (OR = 6.1; 95% CI: 2.9, 13.0); travel to endemic areas (OR = 2.4; 95% CI: 1.3, 4.2); and age (OR5-yr = 1.5; 95% CI: 1.3, 1.7). For Canadian-born educators, a further association was found between seropositivity and years worked in daycare (OR5-yr = 1.3; 95% CI: 1.0, 1.8). / Conclusion. In a non-outbreak situation, daycare educators share similar risk factors for seropositivity with the general population. Canadian-born educators appear to be placed at additional risk by working in daycare centres, and may benefit from vaccination.

A definition of difficult labour was developed after reviewing the literature, consulting with experts, and examining alternatives. Difficult labour, in primiparas, was defined as either prolonged labour with vaginal delivery, longer than 15 hours from admission to full dilatation, or cesarean section after admission for uncomplicated labour. This measure proved, to a satisfactory degree, practical, reliable and valid. / A study of predisposing factors, measured prior to labour onset, was conducted in 1,125 primiparas at two hospitals, a community hospital and a high-risk referral hospital. Analysis was restricted to 781 primiparas, admitted to hospital for uncomplicated (spontaneous) labour. Rates of difficult labour were 17% at the community hospital and 24% at the high-risk referral hospital. Rates of cesarean section were in keeping with high rates reported elsewhere, but rates of prolonged labour were higher than expected. Anxiety about childbirth, as self reported prior to labour onset, was not found to predispose to difficult labour, nor was lack of attendance at childbirth education classes. Factors predisposing to difficult labour, at both hospitals, were short maternal height (p = 0.01) and heavy body mass index, kg/m('2) (p = 0.01). Further research is needed, using a reliable measure of difficult labour, to clarify reasons for labour differences between women and hospitals.

As of September 1999, all donated units of blood in Canada undergo a process known as pre-storage leukoreduction. This process removes a significant proportion of white blood cells from blood at the time of donation. The decision to implement universal leukoreduction was based on fairly strong evidence that leukoreduction was beneficial in some adult populations such as cardiac and colorectal surgical patients. However, very little information exists on its effectiveness in other populations such as the neonatal population. The purpose of this thesis was three fold: (1) to conduct a systematic review of the literature to assess the effectiveness of leukoreduction; (2) to undertake a methods paper outlining the optimal design to study the effectiveness of leukoreduction given its universal nature; and (3) to conduct a study assessing the effectiveness of leukoreduction in the neonatal population. / The results of the systematic review elucidate the paucity of well-conducted, methodologically sound studies evaluating the effectiveness of leukoreduction in the neonatal population. The current evidence suggests that leukoreduction may be effective. However, further studies are needed especially with respect to clinically important outcomes. The lack of convincing data and the significant cost of leukoreduction mandate evaluations to determine its clinical and economic impact. / The methods manuscript describes important methodological issues confronted in the design of the before/after evaluation. Because of the universal application of many transfusion interventions, one has to consider, carefully, the methodological rigor with which these interventions are evaluated. The methodological considerations discussed are: (1) threats to internal validity; (2) precision; and (3) generalizability. Properly conceived, designed, conducted, and analyzed, such a before/after study design can yield informative associations. / The final paper presents the results of the before/after study. The study included a total of 515 infants <1250 grams from three sites across Canada. The effect of leukoreduction on our primary outcome of nosocomial bacteremia was an odds ratio of 0.59 (95%CI: 0.34--1.01). Crude and adjusted rates for all major neonatal morbidities suggest that leukoreduction improved all outcomes. The adjusted odds ratio for a composite measure of any major neonatal morbidity was 0.31 (95%CI: 0.17--.56). Based on the results of this study, it is concluded that the implementation of universal prestorage leukoreduction significantly improved clinical outcomes in premature infants requiring blood transfusions.

BACKGROUND: Personal health records (PHRs) are tools that allow individuals to access, share and manage their health information online. PHRs have received considerable interest and investment in recent years, because they are thought to have the potential to promote patient self-management and greater involvement in their own care. Despite apparent public interest and a proliferation of available options, adoption rates remain low. There is a gap in our understanding as to why people are choosing to use or not use PHRs, and what different populations of users might want from such a tool. In particular, young adults could be a potential group to target with preventative strategies using a PHR, since technology is much more integrated in their everyday life.OBJECTIVE: This qualitative descriptive study therefore aimed to explore the views and expectations of young healthy adults about using an online personal health record. METHODS: Four focus groups were conducted with a total of 29 participants (18-34 years old) from a community setting in Montreal, Canada. Interviews were transcribed and analyzed with inductive thematic analysis. RESULTS: With respect to how young adults viewed PHRs, three broad themes were identified: perceived advantages to using a PHR; future PHR users; and concerns about PHRs. In terms of what they themselves expected from using a PHR, different themes were elaborated: characteristics of an “ideal” PHR; using the PHR for preventative health; taking more control over their health; and making the PHR worthwhile. A conceptual framework of factors influencing expectations of PHR use in this population is proposed.CONCLUSION: The findings suggest that what young adults perceive as benefits of a PHR may not be the same things that motivate them to actually use a PHR. The results emphasize the fact that more research is needed to understand the expectations and anticipated use of different populations in designing a patient-centered tool. The proposed framework can be used as a basis and tested in future research on PHR adoption. / CONTEXTE: Les dossiers de santé personnels (DSP) sont des outils qui permettent aux individus d'accéder, de partager et de gérer l'information sur leur santé en ligne. Ils ont obtenu beaucoup d'intérêt et des investissements considérables ces dernières années puisqu'on considère que les DSP ont le potentiel de promouvoir une plus grande implication des patients dans la gestion de leurs propres soins. Malgré l'intérêt public apparent et une prolifération des options, les taux d'adoption des DSP restent faibles. Notre compréhension des raisons pour lesquelles les gens choisissent d'utiliser ou non les DSP et de ce que les différentes populations d'utilisateurs pourraient vouloir d'un tel outil est limitée. En particulier, les jeunes adultes pourraient être un bon groupe à cibler en ce qui concerne les possibilités de prévention avec un DSP puisque la technologie est beaucoup plus intégrée dans leur vie quotidienne.OBJECTIF: Cette étude qualitative descriptive vise donc à explorer les points de vue et les attentes des jeunes adultes en bonne santé à propos de l'utilisation d'un dossier de santé personnel. METHODES: Quatre tables rondes ont été menées avec un total de 29 participants (18-34 ans) dans un milieu communautaire de Montréal, au Canada. Les entrevues ont été transcrites et ensuite analysées avec la méthode d'analyse thématique inductive. RÉSULTATS: En ce qui concerne ce que les jeunes adultes pensent à propos des DSP, trois grands thèmes ont été identifiés: les avantages perçus, les futurs utilisateurs et les préoccupations au sujet des DSP. En terme de ce qu'eux-mêmes attendaient d'un DSP, différents thèmes ont été élaborés: les caractéristiques d'un DSP «idéal»; la contribution des DSP à la santé préventive en prenant plus de contrôle sur leur santé, et l'aspect pratique des DSP. Un cadre conceptuel des facteurs ayant une influence sur les attentes des participants à propos des DSP est proposé. CONCLUSION: Les résultats suggèrent que ce que les jeunes adultes perçoivent comme avantages d'un DSP ne sont pas les mêmes choses qui les motivent à se servir d'une PHR. Cela souligne l'importance de comprendre l'utilisation prévue et les attentes des populations d'utilisateurs spécifiques dans la conception d'un outil centré sur le patient. Le cadre proposé peut constituer une base pour de plus amples recherches sur l'adoption des DSP.

Background: Immigrants and refugees have increased morbidity and mortality from liver disease compared to host populations largely due to undetected chronic hepatitis B virus (HBV) infection. We conducted a systematic review of the seroprevalence of chronic HBV and prior immunity in migrants arriving in immigrant-receiving countries to identify the proportion who would benefit from HBV screening and vaccination programs. We then performed a cost-effectiveness analysis to identify the optimal intervention for adult immigrants and refugees arriving in Canada. Methods: Four electronic databases were searched to identify studies that reported HBV surface antigen (HBsAg) and HBV surface antibodies (anti-HBs) in international migrants. Proportions for chronic HBV and prior immunity were transformed using the logit transformation and pooled using a random-effects model. A decision-analysis model was then developed to examine the cost-effectiveness of four screening and vaccination strategies, compared to no screening or vaccination: a) universal vaccination, b) anti-HBs screening and vaccination of susceptibles, c) HBsAg screening and antiviral treatment, d) combined HBsAg and anti-HBs screening. Model parameters for the seroprevalence of infection and immunity were obtained from the systematic review. Estimates for disease progression, medical costs and utilities were obtained from the published literature.Results: The overall pooled seroprevalence of infection in international migrants was 7.2% (95% CI: 6.3% – 8.2%) and the proportion with prior immunity was 39.7% (95% CI: 35.7% – 43.9%). HBV seroprevalence differed significantly by region of origin with migrants from East Asia and Sub-Saharan Africa at highest risk of infection and migrants from Eastern Europe at intermediate risk. None of the strategies were found to be cost-saving, but screening for HBsAg to identify chronically infected immigrants was found to be the most cost-effective strategy and would cost $37,675 per quality-adjusted life year (QALY) gained, compared to no intervention. Results were sensitive to the cost and effectiveness of antiviral therapy. A probabilistic sensitivity analysis demonstrated that the screen and treat strategy would have an 84% chance of having an incremental cost-effectiveness ratio of < $50,000 per QALY gained.Conclusions: The seroprevalence of chronic HBV is high in migrants from most world regions, particularly among those from East Asia, Sub-Saharan Africa and Eastern Europe. Screening adult immigrants soon after arrival would be cost-effective and would reduce morbidity and mortality from HBV. / Contexte: Les immigrants et les réfugiés ont un taux élevé de mortalité par la maladie du foie par rapport aux populations d'accueil en grande partie en raison de la présence d'une infection par le virus de l'hépatite B (VHB) chroniquenon détectée. Nous avons effectué une révision systématique de la séroprévalence de l'hépatite B chronique et d'une immunité préalable aux migrants qui arrivent dans les pays qui accueillent des immigrants afin d'identifier ceux qui bénéficieraient d'un dépistage du VHB et des programmes de vaccination. Nous avons ensuite effectué une analyse coût-efficacité pour identifier l'intervention optimale pour les immigrants et les réfugiés adultes qui arrivent au Canada.Méthodes: Des recherches ont été effectuées sur quatre bases de données afin d'identifier les études indiquant la prévalence de l'antigène de surface du VHB (AgHBs) et des anticorps du VHB (anti-HBs) chez les migrants internationaux. Les estimations de l'hépatite B chronique et de l'immunité préalable ont été transformées en utilisant la transformation logit et regroupées à l'aide d'un modèle à effets aléatoires. Un modèle d'analyse décisionnelle a ensuite été développé afin d'examiner le rapport coût-efficacité de quatre stratégies de dépistage et de vaccination: a) la vaccination universelle, b) le dépistage AgHBs et le traitement antiviral, c) le dépistage anti-HBs et la vaccination des sujets réceptifs, d) le dépistage combiné de AgHBs et anti-HBs, par rapport à l'absence de dépistage ou de vaccination. Les paramètres du modèle pour la séroprévalence de l'infection et l'immunité ont été obtenus à partir de la révision systématique. Les estimations pour la progression de la maladie, les frais médicaux et les services publics ont été obtenues à partir de la littérature publiée.Résultats: La séroprévalence globale de l'infection était de 7.2% (IC 95%: 6.3% - 8.2%) et la proportion de l'immunité préalable était de 39.7% (IC 95%: 35.7% - 43.9%). La séroprévalence du VHB était considérablement différente par région d'origine. Les migrants de l'Asie de l'Est et de l'Afrique sub-saharienne étaient les plus à risque et les migrants de l'Europe de l'Est étaient à risque intermédiaire. Aucune de ces stratégies ne s'est avérée réduire les coûts, mais le dépistage AgHBs pour identifier les immigrants infectés chroniquement a été jugé le plus rentable et coûterait $37,675 par année de vie ajustée sur la qualité (QALY) gagnée, par rapport au status quo. Les résultats ont été sensibles au coût et à l'efficacité de la thérapie antivirale. Une analyse de sensibilité probabiliste a démontré que le dépistage et la stratégie de traitement aurait une chance de 84% d'avoir un rapport coût-efficacité de < $50,000 par QALY gagnée.Conclusions: La séroprévalence de l'hépatite B chronique est élevée chez les migrants originaires de la plupart des régions du monde, en particulier pour ceux de l'Asie de l'Est, de l'Afrique subsaharienne et d'Europe de l'Est. Le dépistage d'AgHBs après l'arrivée des immigrants serait le plus rentable, quelle que soit la région d'origine des immigrants, et permettrait de réduire la morbidité et la mortalité causées par le VHB.

Pilot studies of supervised injecting facilities (SIF) are under consideration in Canada, but it is elemental to first establish acceptability among the injecting drug use (IDU) population that are potential attendees. This study aimed to assess SIT acceptability and to determine factors associated with the willingness of public injectors to use SIF in a city considering their establishment. From April 2001--February 2002, qualitative, key informant interviews and survey data collection methods were employed. Questions were appended to a study monitoring HIV risk among Montreal IDU. Univariate and bivariate analyses preceded logistic regression. 11 key informants and 251 IDU participated in the study. Key informants generated specific SIT models subsequently presented to IDU. Overall, SIF acceptability was high. Two logistic regression models presented factors independently predictive of potential SIF use including drug use characteristics and SIF attributes. Initial community and user consultations are essential in assessing relevance and planning of SIF.

Abstract How do physicians perceive and respond to low income patients? BACKGROUND: People with low socio-economic status have many health problems and relatively low access to medical and dental services. The dentists' attitudes, perceptions and ideas towards the low income patients have been shown to be significant determinants in accessing care. However, we have little information with respect to physicians. OBJECTIVES: The objective of this study was thus to determine the physicians' experiences with low income patients and in particular to identify the difficulties they encounter when dealing with deprived patients. We also wanted to identify the strategies and proposals suggested by physicians to improve health care for the deprived. METHOD: The study involved qualitative methodology using 7 open-ended interviews with physicians practicing in Quebec. The interviews were recorded on audiotapes and transcribed. The analyses consisted of debriefing the sessions, coding and interpreting the results. RESULTS: Three types of physicians were identified. The empathic physician looks beyond the physical problem of the deprived patient and tries to determine strategies to help on the social, psychosocial, financial and medical level. The blaming physician, on the contrary, tends to blame deprived patients for their laziness and abuse of the system. Its blaming attitude creates a communication and confidence barrier with the patients and complicates access to proper treatment. Finally, the indifferent physician treats the physical problems of all patients equally without concern about their social or socio-economic status. CONCLUSION: Like for dentists, the physicians' perc / Résumé Quel est la perception et la réponse des médecins aux patients démunis? LITTERATURE : Les personnes démunies ont beaucoup de problèmes de santé et un accès relativement faible aux services médicaux et dentaires. Les attitudes, perceptions et idées des dentistes vers les patients de faible revenu sont des déterminants significatifs dans l'accès aux soins. Cependant, nous avons peu d'information par rapport aux médecins. OBJECTIFS : L'objectif de cette étude est ainsi de déterminer les expériences des médecins avec les patients de faible revenu et d'identifier en particulier les difficultés rencontrées quand ils traitent des patients démunis. Nous voulions aussi identifier les stratégies et les propositions suggérées par les médecins pour améliorer les services de santé pour les personnes pauvres. METHODE : L'étude a consisté en 7 entretiens avec des médecins pratiquant au Québec utilisant la méthodologie qualitative. Les entretiens ont été enregistrés sur des bandes sonores et transcrits. L'analyse a consisté en une retranscription des données, un codage de l'information et une interprétation des résultats. RESULTATS : Trois types de médecins ont été identifiés : Le médecin empathique regarde au-delà du problème physique du patient pauvre et essaie de déterminer des stratégies pour l'aider sur les plans social, psychosocial, financier et médical. Le médecin qui blâme, au contraire, a tendance à blâmer les patients pauvres pour leur paresse et leur abus du système. Son attitude crée une barrière de communication et de confiance avec les patients et complique ainsi l'accès au traitement. Enfin, le médecin in