Prevalence and patterns of chronic disease multimorbidity and associated determinants in Canada.

INTRODUCTION: Multimorbidity is increasingly recognized as a key issue in the prevention and management of chronic diseases. We examined the prevalence and correlates of chronic disease multimorbidity in the general adult Canadian population in relation to age and other key determinants. METHODS: We extracted data from the Canadian Community Health Survey 2011/12 on 105 416 Canadian adults. We analysed the data according to the number of multimorbidities (defined as 2+ or 3+ diseases from a list of 9) and examined the determinants of multimorbidity using regression analyses. RESULTS: Our findings show that 12.9% of Canadians report 2+ chronic diseases and 3.9% report 3+ chronic diseases. Those reporting 3 or more chronic diseases were more likely to be female, older, living in the lowest income quintile and to have not completed high school. In the overall population, social deprivation is associated with a 3.7 odds of multimorbidity, but when examined across age groups, the odds of multimorbidity were notably higher in middle age, 7.5 for those aged 35 to 49 years and 5.4 for those aged 50 to 64 years. DISCUSSION: As the proportion of Canadians living with multiple chronic diseases increases, we need to assess chronic disease from a holistic perspective that captures multimorbidity and upstream factors, to facilitate broader and more context-appropriate associations with healthy living, quality of life, health care costs and mortality. Special consideration should be given to the role that social deprivation plays in the development of multimorbidity. Canadians living in the lowest socioeconomic group are not only more likely to develop multimorbidity, but the onset of multimorbidity is also likely to be significantly earlier.

TITRE: Prévalence et profils de la multimorbidité au Canada et déterminants associés. INTRODUCTION: La prise en compte de la multimorbidité est de plus en plus reconnue comme un élément fondamental de la prévention et de la prise en charge des affections chroniques. Cette étude porte sur la prévalence et les corrélats de la multimorbidité chez les adultes canadiens en fonction de l'âge et de certains autres déterminants clés. MÉTHODOLOGIE: Nous avons extrait des données portant sur 105 416 adultes canadiens ayant répondu à l'Enquête sur la santé dans les collectivités canadiennes de 2011-2012. Nous les avons analysées en fonction du nombre d'affections concomitantes présentes (deux ou plus ou trois ou plus, sur une liste de neuf) et nous avons cherché à caractériser les déterminants de la multimorbidité à l'aide de régressions. RÉSULTATS: D'après notre analyse, 12,9 % des Canadiens souffraient de deux affections chroniques ou plus et 3,9 % de trois ou plus. Les répondants ayant déclaré souffrir de trois affections chroniques ou plus étaient plus susceptibles d'être des femmes, d'être plus âgés, de faire partie d'un ménage dont le revenu fait partie du quintile le plus faible et dont le niveau de scolarité le plus élevé de l'un des membres était inférieur aux études secondaires. La multimorbidité en lien avec le dénuement social était associée à une cote de 3,7 dans la population en général, mais de 7,5 chez les 35 à 49 ans et de 5,9 chez les 50 à 64 ans, soit la population d'âge moyen. ANALYSE: La proportion de Canadiens atteints de multiples affections chroniques étant en augmentation, nous devons adopter, pour étudier les affections chroniques et leurs facteurs en amont, une approche globale qui tienne compte de la multimorbidité, afin d'agir de manière globale et adaptée au contexte pour favoriser une vie saine et une meilleure qualité de vie et pour réduire les coûts des soins de santé et la mortalité. On devrait particulièrement tenir compte du rôle joué par le dénuement social dans l'apparition de la multimorbidité, car non seulement les Canadiens du groupe socioéconomique le plus démuni sont plus susceptibles de souffrir de multimorbidité, mais celle-ci surgira aussi probablement beaucoup plus précocement.

Monitoring chronic diseases in Canada: the Chronic Disease Indicator Framework.

INTRODUCTION: The Public Health Agency of Canada developed the Chronic Disease Indicator Framework (the Framework) with the goal of systematizing and enhancing chronic disease surveillance in Canada by providing the basis for consistent and reliable information on chronic diseases and their determinants. METHODS: Available national and international health indicators, frameworks and national health databases were reviewed to identify potential indicators. To make sure that a comprehensive and balanced set of indicators relevant to chronic disease prevention was included, a conceptual model with "core domains" for grouping eligible indicators was developed. Specific selection criteria were applied to identify key measures. Extensive consultations with a broad range of government partners, non-governmental organizations and public health practitioners were conducted to reach consensus and refine and validate the Framework. RESULTS: The Framework contains 41 indicators organized in a model comprised of 6 core domains: social and environmental determinants, early life / childhood risk and protective factors, behavioural risk and protective factors, risk conditions, disease prevention practices, and health outcomes/status. Also planned is an annual release of updated data on the proposed set of indicators, including national estimates, breakdowns by demographic and socioeconomic variables, and time trends. CONCLUSIONS: Understanding the evidence related to chronic diseases and theirdeterminants is key to interpreting trends and crucial to the development of public health interventions. The Framework and its related products have the potential of becoming an indispensable tool for evidence-informed decision making in Canada.

TITRE: Surveillance des maladies chroniques au Canada : Cadre conceptuel d'indicateurs des maladies chroniques. INTRODUCTION: L'Agence de la santé publique du Canada a conçu le Cadre conceptuel d'indicateurs des maladies chroniques (le Cadre) dans le but de systématiser et d'améliorer la surveillance des maladies chroniques au Canada en instaurant les fondements d'une information uniforme et fiable sur les maladies chroniques et leurs déterminants. MÉTHODOLOGIE: Des indicateurs de santé nationaux et internationaux, des cadres conceptuels ainsi que des bases de données sur la santé nationale ont été examinés pour identifier les indicateurs potentiels. Pour s'assurer d'obtenir un ensemble complet et équilibré d'indicateurs pertinents en matière de prévention des maladies chroniques, nous avons élaboré un modèle conceptuel comprenant des « champs de référence ¼ pour le regroupement des indicateurs. Plusieurs critères de sélection ont été appliqués pour le choix des mesures clés. Des consultations approfondies avec un large éventail de partenaires du gouvernement, d'organismes non gouvernementaux et de professionnels de la santé publique ont été réalisées pour en arriver à un consensus et pour perfectionner et valider le Cadre. RÉSULTATS: Le Cadre comprend 41 indicateurs structurés autour de 6 champs de référence : les déterminants sociaux et environnementaux, les facteurs de risque et de protection en bas âge, les facteurs de risque et de protection comportementaux, les conditions à risque, les pratiques de prévention des maladies, l'état de santé global et les impacts sur la santé. Nous avons aussi prévu une mise à jour annuelle des données touchant l'ensemble des indicateurs proposés, que ce soit les estimations nationales, les ventilations par variables démographiques et socioéconomiques ou les tendances temporelles. CONCLUSION: Comprendre les données probantes liées aux maladies chroniques et leurs déterminants est nécessaire pour interpréter les tendances et crucial pour élaborer des interventions efficaces en matière de santé publique. Le Cadre et ses produits connexes sont susceptibles de devenir un outil indispensable d'aide à la décision axée sur des données probantes au Canada.

Magnetographic assessment of fetal hiccups and their effect on fetal heart rhythm.

Fetal hiccups emerge as early as nine weeks post-conception, being the predominant diaphragmatic movement before 26 weeks of gestation. They are considered as a programmed isometric inspiratory muscle exercise of the fetus in preparation for the post-natal respiratory function, or a manifestation of a reflex circuitry underlying the development of suckling and gasping patterns. The present paper provides the first evidence of non-invasive biomagnetic measurements of the diaphragm spasmodic contractions associated with fetal hiccups. The magnetic field patterns generated by fetal hiccups exhibit well-defined morphological features, consisting of an initial high frequency transient waveform followed by a more prolonged low frequency component. This pattern is consistent across recordings obtained from two fetal subjects, and it is confirmed by signals recorded in a neonatal subject. These results demonstrate that fetal biomagnetometry can provide insights into the electrophysiological mechanisms of diaphragm motor function in the fetus. Additionally, we study the correlation between hiccup events and fetal cardiac rhythm and provide evidence that hiccups may modulate the fetal heart rate during the last trimester of pregnancy.

Neuropsychological evaluation in rehabilitation planning and evaluation of functional skills.

This paper focuses on the benefits of neuropsychological assessment for evaluating a brain-injured person's functional abilities and rehabilitation needs. The importance of early assessment in addressing these goals is discussed. Strengths and weaknesses of neuropsychological assessment for predicting a person's ability to participate in normal activities of daily living are considered. Test data taken alone often lack ecological validity, but nevertheless, specific test findings can be used to predict functional skills. The ecological validity of neuropsychological testing can be extended by observing the patient's approach to tasks in the assessment environment and by observing the patient in his or her normal activities. Evaluation information obtained by allied rehabilitation professionals, including occupational and speech and language therapies, can be integrated with neuropsychological test data to both extend the generalizability of our findings and to validate hypotheses generated from our test data. The use of neuropsychological test data in planning a cognitive rehabilitation program is also considered.

Simultaneous measurement of adenosine and hypoxanthine in human umbilical cord plasma using reversed-phase high-performance liquid chromatography with photodiode-array detection and on-line validation of peak purity.

A new, robust and sensitive reversed-phase high-performance liquid chromatographic method was developed for concomitant measurement of plasma concentrations of the ATP catabolites adenosine and hypoxanthine in human umbilical cord blood. Deproteinized cord plasma was chromatographed on Hypersil C18 columns, using UV photodiode-array detection, spectral analysis of peaks and on-line confirmation of peak purity. Elution with a gradient of acetonitrile-tetrahydrofuran in ammonium dihydrogen phosphate buffer pH 4.7, yielded sharp, well-resolved peaks of adenosine and hypoxanthine within 16 min. Peak areas were quantified from external calibration curves and converted to plasma concentrations via cord blood hematocrits. In seven deliveries, gestational ages 32-40 weeks, adenosine (range, 0.1-2.1 microM) was less than hypoxanthine (range, 1.6-18.5 microM) in the same cord plasma sample. Arteriovenous levels of each purine were similar, except in an abruptio placenta delivery.

Information processing deficits and brain injury: preliminary results.

Information processing deficits are often reported in individuals who have sustained a brain injury. These deficits interfere with the patient's rehabilitation progress because of the brain's inability to efficiently process information. This article describes specific aspects of information processing (i.e. etiology, assessment, rehabilitation). A systematic treatment approach is further discussed using both a controlled group study and a single case design. The results, while tentative, suggest that a systematic approach toward the rehabilitation of information processing deficits was as qualitatively effective, and likely more cost-effective than traditional approaches.

Mild brain injury: an overview.

This special issue of Applied Neuropsychology focuses on mild brain injury. This article provides an overview of mild brain injury, including its epidemiology, etiology, diagnostic criteria, and clinical symptoms. The contributing authors discuss various issues related to this topic, and divergent views are presented. Specifically, these include causes, symptoms, assessment, and recovery from mild brain injury. In addition, rehabilitation and forensic aspects of mild brain injury are discussed. Collectively, it is anticipated that this special issue will help to clarify the nature of mild brain injury and stimulate additional interest and research into this phenomenon.

Emotional consequences and psychotherapy for individuals with mild brain injury.

It is well documented that even mild brain injury can manifest with significant cognitive and emotional symptoms. Undoubtedly, these alterations may result in career, social, and personal consequences. In this article we discuss and summarize psychotherapeutic approaches to be used for individuals with mild brain injury. The primary focus is on providing education and assistance for developing coping strategies. Once an individual recognizes, accepts, and adjusts to the limitations resulting from the brain injury, then a more favorable level of adjustment can occur.

Efficacy of neuropsychological rehabilitation for mild-moderate traumatic brain injury.

The growing literature on cognitive rehabilitation is increasingly demanding more evaluation related to the validity of such therapy. The current research addresses some of the criticisms of previous efficacy studies and provides support for the effectiveness of cognitive rehabilitation according to a specific treatment protocol employed at an outpatient rehabilitation program. Stringent subject selection criterion were utilized to maximize the validity of the statistical comparisons of selected pre- and post- rehabilitation neuropsychological test scores and cognitive level of functioning. Results supported improvement in performance on selected neuropsychological test scores and cognitive functioning following cognitive rehabilitation. Limited validating evidence for behavioral indicators of level of cognitive functioning were obtained through correlations of behavioral ratings to their corresponding neuropsychological test scores. Results suggest that traditional measures of efficacy of cognitive rehabilitation may be insensitive to the cognitive sequalae of mild head injury due, in part, to compensatory strategies invoked by the subjects.

Rehabilitation of visual processing deficits following brain injury.

Visual processing deficits are a common sequelae in individuals who have sustained a brain injury, Visual processing includes the acquisition of visual information and the appropriate use and manipulation of that information based upon task or environmental demands, Following brain injury, visual processing deficits can manifest in various ways, and will likely interfere with the patient's progress and rehabilitation outcome, This article describes the importance of understanding and accurately identifying visual processing deficits and implementing specific rehabilitation strategies to maximize functional independence.

Resolution of unilateral fetal hydrothorax with associated non-immune hydrops after intrauterine thoracentesis.

Congenital hydrothorax has been successfully managed in utero by two different treatment modalities: thoracentesis and pleuroamniotic shunting. Unfortunately, there is a paucity of data as to which method is better for the management of this problem. This case report supports the use of thoracentesis as the initial procedure for primary fetal hydrothorax. We report a pregnancy complicated by primary fetal hydrothorax with non-immune hydrops that completely resolved after two thoracenteses in the early third trimester. Complete resolution was maintained throughout pregnancy without the need for further antenatal or neonatal intervention, i.e. further thoracentesis, pleuroamniotic shunt placement, intubation, or chest and/or abdominal tube placement. The child was delivered at 42 weeks and is doing well without problems at 1 year of age. We believe that intrauterine thoracentesis should be the initial procedure of choice for the treatment of primary fetal hydrothorax with mediastinal shift, and pleuroamniotic shunting should be reserved for cases that require repetitive thoracenteses.

Single versus composite score discriminative validity with the Halstead-Reitan Battery and the Stroop Test in mild brain injury.

The predictive validity of single measures from the Halstead-Reitan Neuropsychological Test Battery and Stroop Neuropsychological Screening Test were evaluated in a sample of 25 mild traumatic brain-injured and 25 neurologically normal subjects and compared to the accuracy of composite score measures, specifically the General Neuropsychological Deficit Scale and the Halstead Impairment Index. Whereas several measures from the Halstead Impairment Index achieved significantly better than chance prediction, the two summary measures from the Halstead-Reitan Neuropsychological Test Battery predicted the neurological status of the subjects with the most accuracy. The Stroop Neuropsychological Screening Test did not perform well as a single predictor. Together, these results suggest that single-measure screening tests do not predict mild brain-injury as well as composite neuropsychological measures. The results also give credence to the argument of comprehensive testing for brain-injured patients whose injuries are deemed medically mild.

Metacognition as the ultimate executive: Techniques and tasks to facilitate executive functions.

It has been well-documented that executive function deficits are a common consequence of brain injury. Metacognitive processes, in close alliance with executive functions, are viewed as integral components of learning and awareness. Combining all of these areas may be necessary to achieve a beneficial treatment plan for improving executive functions. This article provides a definitional analysis of executive functions and metacognitive processes and it discusses the role of learning, internal mediation, and strategy development. A specific executive functions program is described and suggested as a framework for establishing a metacognitive-learning routine.

Laparoscopic cholecystectomy in the second trimester of pregnancy. A case report.

Laparoscopic cholecystectomy was performed at 19 weeks' gestation for recurrent cholecystitis. The procedure was completed without complications, and the patient was discharged on the second postoperative day. Thereafter, the pregnancy progressed uneventfully.

Terminal deletion of 7q presenting in utero with a truncus arteriosus and nonimmune hydrops.

Terminal deletion of 7q presents with variable anatomical and developmental findings. This case is the first reported in utero diagnosis based on cytogenetic findings and in utero demonstration of resolving congestive heart failure due to a truncus arteriosus.

Development of the Eagle-Barrett (prune belly) syndrome and a thickened, poorly functional bladder wall after early second-trimester decompression of fetal megacystis.

The management of bladder outlet obstruction in the fetus remains a debated issue. Recent data suggest the use of cystocentesis for the possible relief of the bladder neck obstruction or for the opening of posterior urethral valves. This case report adds further support for the use of cystocentesis and observation prior to the placement of an indwelling bladder shunt. The case further demonstrates that relief of the megacystis may not prevent prune belly syndrome, bladder dysfunction or renal damage. Finally, the case demonstrates that severe oligohydramnios in the second trimester need not invariably result in pulmonary hypoplasia.

Cortisol effect on atrial natriuretic factor response to hypertonic saline in fetal sheep.

Atrial natriuretic factor (ANF) is released following a variety of stimuli including hypertonicity in the fetus. To study the effect that cortisol has on fetal ANF release, seven chronically instrumented fetal sheep at gestational ages ranging from 110-132 days were studied in two experiments. In one experiment (CORTISOL), a continuous cortisol (with EtOH vehicle) infusion was maintained. In the other experiment (CONTROL), the vehicle was infused alone. Ninety minutes from the start of this infusion, a hypertonic saline bolus (12 meg/kg) was given. Osmolality, ANF, cortisol, pH, PO2, PCO2, mean arterial pressure (MAP), heart rate (HR), and hematocrit (HCT) were followed over a 120-min period. Following hypertonic saline, serum osmolality increased from 290.6 +/- 2.3 mOsm/kg to 310.4 +/- 2.5 mOsm/kg (P < 0.01). Baseline values for pH, PO2, and HCT were 7.37 +/- 0.01, 22.5 +/- 1.6 mmHg, and 33.9 +/- 1.2 respectively. Each of these variables fell following hypertonic saline infusion. MAP rose from 40.6 +/- 1.7 mmHg to 47.0 +/- 2.4 mmHg (P < 0.01). However, there were no differences between CONTROL and CORTISOL experiments in any of the above changes. Cortisol levels in the CONTROL group did not change during the course of the experiment, but in the CORTISOL group rose from 8.2 +/- 4.4 ng/ml to 33.0 +/- 9.9 ng/ml (P = 0.02). Plasma ANF levels prior to hypertonic saline were similar (124.8 +/- 17.7 pg/ml and 127.6 +/- 26.1 pg/ml) in the CONTROL and CORTISOL groups respectively and rose following hypertonic saline to a maximum of 155.3 +/- 16.6 pg/ml and 189.2 +/- 42.7 pg/ml (P = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)