"The needle is already ready to go": communities' and health care professionals' perceptions of routine vaccination in Nunavik, Canada.

Inuit living in the northern region of Nunavik continue to experience significant health inequalities, which are rooted in colonialism that still have repercussions on their health-related perceptions and practices, including vaccination. This study aimed to explore the perceptions and determinants of routine vaccination among the Inuit of Nunavik by describing factors influencing vaccination decisions from the perspective of community members and health professionals. Semi-structured interviews focusing on the perception of vaccination and experience with vaccination and health services were conducted with 18 Inuit and 11 non-Inuit health professionals. Using the socio-ecological model, factors acting at the community and public policy (e.g. rumours and misinformation about vaccination, language barrier), organisational (e.g. complexity of the vaccination process, staff turnover, lack of specialised vaccination workers and interpreters), and intrapersonal and interpersonal (e.g. past experiences with vaccination, vaccine attitudes, social norms) levels were identified as having an impact on vaccination decisions. Improving vaccination coverage in Nunavik requires a more global reflection on how to improve and culturally adapt the health care and services offered to the Inuit population.

Improving delivery of care in rural emergency departments: a qualitative pilot study mobilizing health professionals, decision-makers and citizens in Baie-Saint-Paul and the Magdalen Islands, Québec, Canada.

BACKGROUND: Emergency departments (EDs) in rural and remote areas face challenges in delivering accessible, high quality and efficient services. The objective of this pilot study was to test the feasibility and relevance of the selected approach and to explore challenges and solutions to improve delivery of care in selected EDs. METHODS: We conducted an exploratory multiple case study in two rural EDs in Québec, Canada. A survey filled out by the head nurse for each ED provided a descriptive statistical portrait. Semi-structured interviews were conducted with ED health professionals, decision-makers and citizens (n = 68) and analyzed inductively and thematically. RESULTS: The two EDs differed with regards to number of annual visits, inter-facility transfers and wait time. Stakeholders stressed the influence of context on ED challenges and solutions, related to: 1) governance and management (e.g. lack of representation, poor efficiency, ill-adapted standards); 2) health services organization (e.g. limited access to primary healthcare and long-term care, challenges with transfers); 3) resources (e.g. lack of infrastructure, limited access to specialists, difficult staff recruitment/retention); 4) and professional practice (e.g. isolation, large scope, maintaining competencies with low case volumes, need for continuing education, teamwork and protocols). There was a general agreement between stakeholder groups. CONCLUSIONS: Our findings show the feasibility and relevance of mobilizing stakeholders to identify context-specific challenges and solutions. It confirms the importance of undertaking a larger study to improve the delivery of care in rural EDs.

Organisation des services dans une urgence rurale éloignée : réflexions autour du cas de Fermont, Québec.

INTRODUCTION: The goal of this study was to meet a small, remote emergency department's need to reflect on the minimum threshold of services to offer. The study's main objectives were to 1) provide a statistical profile of the emergency services in Fermont, Quebec, 2) assess the staff's and users' perception of the threshold of services offered and 3) propose solutions for improving care and services. METHODS: This case study was conducted with a participatory approach and a mixed methodology. We compared the results from a questionnaire on the emergency services that was validated during a previous study with the results concerning the other rural emergency services in Quebec as well as with national and provincial recommendations. The questionnaire concerned users' sociodemographic characteristics, the hospital's and the emergency services' descriptors, the services available locally, and the physician and nurse staff. Interviews were also carried out with 33 people (health care professionals, policy-makers and citizens). RESULTS: Fermont's emergency department is smaller than the average rural emergency department in Quebec. They have resources that are in some respects comparable to those of other emergency departments and in line with the recommendations; in other respects, their resources are rather limited. Respondents emphasized how important it is to take into account the environment's specific features when establishing the minimum threshold of services. The proposed solutions would promote collaboration, break down silos within professional practice and focus on training. CONCLUSION: Fermont's case aside, this exploratory case study highlights how important it is to adopt a pluralistic, participatory and local approach in order to support reflection on the minimum threshold of services in remote emergency departments and to improve their overall performance.

INTRODUCTION: Cette étude visait à répondre au besoin d'une petite urgence éloignée d'assoir sa réflexion autour d'un seuil minimum de services à offrir. Les principaux objectifs de l'étude étaient de : 1) dresser le portrait statistique de l'urgence de Fermont, Québec, 2) évaluer la perception du personnel et des usagers en lien avec le seuil de services offert et 3) énoncer des solutions permettant d'améliorer les soins et les services. METHODS: Cette étude de cas a été réalisée avec une approche participative et une méthodologie mixte. Nous avons comparée les données d'un questionnaire sur l'urgence qui a été validé lors d'une étude précédente aux données des autres urgences rurales québécoises et à des recommandations nationales et provinciales. Le questionnaire portait sur les caractéristiques sociodémographiques des usagers, les descripteurs du centre hospitalier et de l'urgence, les services disponibles localement et les effectifs médicaux et infirmiers. Des entrevues ont aussi été réalisées auprès de 33 personnes (professionnels de la santé, décideurs et citoyens). RESULTS: L'urgence de Fermont est plus petite que la moyenne des urgences rurales québécoises et dotée de ressources à certains égards comparables aux autres urgences et aux recommandations et à d'autres égards limités. Les répondants ont souligné l'importance de tenir compte des particularités du milieu dans l'établissement d'un seuil minimum de services. Les solutions proposées concernent l'importance de favoriser la collaboration, de décloisonner la pratique professionnelle et de miser sur la formation. CONCLUSION: Au-delà du cas de Fermont, cette étude de cas exploratoire a permis de souligner l'importance d'adopter une approche pluraliste, participative et locale pour soutenir la réflexion autour du seuil minimum de services à offrir dans les urgences éloignées et pour améliorer la performance générale des urgences rurales.

Comparative gene expression profiles induced by PPARγ and PPARα/γ agonists in rat hepatocytes.

Species-differential toxic effects have been described with PPARα and PPARγ agonists between rodent and human liver. PPARα agonists (fibrates) are potent hypocholesterolemic agents in humans while they induce peroxisome proliferation and tumors in rodent liver. By contrast, PPARγ agonists (glitazones) and even dual PPARα/γ agonists (glitazars) have caused idiosyncratic hepatic and nonhepatic toxicities in human without evidence of any damage in rodent during preclinical studies. The mechanisms involved in such differences remain largely unknown. Several studies have identified the major target genes of PPARα agonists in rodent liver while no comprehensive analysis has been performed on gene expression changes induced by PPARγ and dual PPARα/γ agonists. Here, we investigated transcriptomes of rat hepatocytes after 24h treatment with two PPARγ (troglitazone and rosiglitazone) and two PPARα/γ (muraglitazar and tesaglitazar) agonists. Although, hierarchical clustering revealed a gene expression profile characteristic of each PPAR agonist class, only a limited number of genes was specifically deregulated by glitazars. Functional analyses showed that many genes known as PPARα targets were also modulated by both PPARγ and PPARα/γ agonists and quantitative differences in gene expression profiles were observed between these two classes. Moreover, most major genes modulated in rat hepatocytes were also found to be deregulated in rat liver after tesaglitazar treatment. Taken altogether, these results support the conclusion that differential toxic effects of PPARα and PPARγ agonists in rodent liver do not result from transcriptional deregulation of major PPAR target genes but rather from qualitative and/or quantitative differential responses of a small subset of genes.

Reproducible chemical-induced changes in gene expression profiles in human hepatoma HepaRG cells under various experimental conditions.

The use of in vitro human liver cell models is an attractive approach in toxicogenomic studies designed to analyze gene expression changes induced by a toxic chemical. However, in such studies, reliability, reproducibility and interlaboratory concordance of microarrays, as well as the choice of the most suitable cell model, remain a matter of debate. This work was aimed at evaluating the robustness of microarray technologies and the suitability of the highly differentiated human HepaRG cell line in the investigation of gene expression changes induced by a toxic compound in human liver. The influence of various experimental conditions including cell cultures grown at different test sites, different generations of microarrays, RNA analysis platforms and softwares, was tested on gene expression profiles induced by a 20h treatment with an 8mM concentration of phenobarbital as the toxic compound. As many as 1099 genes (p-value<0.01 and 1.5-fold-change), representing 74% and 30% of the signature genes detected with Agilent 22 and 44K pangenomic microarrays, respectively, were shown to be modulated in common in six independently performed experiments. The most modulated genes included both those known to be regulated by phenobarbital, such as cytochromes P450 and membrane transporters, and those involved in oxidative stress, inflammation and apoptosis, typifying a toxic insult. These data provide strong support for the use of a toxicogenomic approach for the in vitro prediction of chemical toxicity, and for the choice of human HepaRG cells as a promising model system for human hepatotoxicity testing.