A process-based approach to health-related quality of life as a "way of living".

INTRODUCTION: There is an historical initiative to establish common theoretical ground to support a framework for assessing health-related quality of life (HRQL). Our aim was to add to this effort with an analysis of theoretical/philosophical themes embedded in HRQL questionnaires and patient reports. METHODS AND RESULTS: We reviewed recent developments in HRQL assessment. This included analyzing a representative sample of psychometric measures of HRQL to schematically summarize core theoretical/philosophical themes that are embedded in questionnaire items. This analysis indicated a state-based framework for HRQL that was characterized by themes of hedonic and eudaimonic well-being, and desire-satisfaction. In contrast, a review of patient reports of HRQL indicated a process-based framework where goal-directed activities aimed to secure aspirational life goals while striving to accept the reality of declining health. Given this difference in HRQL themes we used a meta-philosophical approach, based on Hadot's idea of philosophy as a way of living, to identify a process-based theoretical framework for HRQL assessment that addressed patient-reported themes. The Stoic modification of eudaimonic well-being was examined where HRQL and well-being are viewed as a process (vs. state) aimed at transforming the experience of loss or grief in response to adversity through goal-directed activities/exercises (euroia biou, good flow in life). We then introduced a complementary research agenda for HRQL assessment that incorporates self-reported, goal-directed activities that are initiated or maintained to promote HRQL. CONCLUSION: A process-based approach to HRQL assessment may increase the spectrum of clinically relevant features that currently comprise operational measures of this patient-reported appraisal.

Chrysotile and chrysophosphate chemical modification of the chrysotile surface and its effect on biological behavior.

Chrysotile asbestos was reacted with phosphorus oxychloride (POC) gas to produce a chemically modified fiber referred to as chrysophosphate. The presence of phosphorus and chlorine on the fiber surface and in small fiber bundles was verified by means of energy dispersive x-ray spectrometry and laser mass spectrometry. The altered fiber exhibits different physical-chemical properties when compared with the unaltered precursor material. In addition to marked surface changes, fibrils of the reacted material appear to be cross-linked increasing the size of particulates, fiber bundles and increasing their mechanical stability. The reacted specimens exhibit fewer fibrils reducing their surface area. In vitro testing using the human erythrocyte model showed the membranolytic activity of the reacted fiber to be substantially reduced to the background level measured for mechanical membrane breakage during manipulation. Membranolytic activity of unreacted chrysotile displayed values reported previously in the literature. These data support the observation made in other studies that fiber surface modification by means of an industrial process may be a method for reducing the biological potential of mineral particles. The membrane model is considered a useful and preliminary examination. These materials will require further testing in more complex in vivo systems. Some in vivo assays were performed on chrysophosphate with results that appeared to differ from our membrane tests. These differences are described and the variation of batch chemistry, stability of the reacted surface, and the resulting surface chemistry, are discussed.

Methodology of the 2009 Survey on Living with Chronic Diseases in Canada--hypertension component.

INTRODUCTION: The Survey on Living with Chronic Diseases in Canada--hypertension component (SLCDC-H) is a 20-minute cross-sectional telephone survey on hypertension diagnosis and management. Sampled from the 2008 Canadian Community Health Survey (CCHS), the SLCDC-H includes Canadians (aged ≥ 20 years) with self-reported hypertension from the ten provinces. METHODS: The questionnaire was developed by Delphi technique, externally reviewed and qualitatively tested. Statistics Canada performed sampling strategies, recruitment, data collection and processing. Proportions were weighted to represent the Canadian population, and 95% confidence intervals (CIs) were derived by bootstrap method. RESULTS: Compared with the CCHS population reporting hypertension, the SLCDC-H sample (n = 6142) is slightly younger (SLCDC-H mean age: 61.2 years, 95% CI: 60.8-61.6; CCHS mean age: 62.2 years, 95% CI: 61.8-62.5), has more post-secondary school graduates (SLCDC-H: 52.0%, 95% CI: 49.7%-54.2%; CCHS: 47.5%, 95% CI: 46.1%-48.9%) and has fewer respondents on hypertension medication (SLCDC-H: 82.5%, 95% CI: 80.9%-84.1%; CCHS: 88.6%, 95% CI: 87.7%-89.6%). CONCLUSION: Overall, the 2009 SLCDC-H represents its source population and provides novel, comprehensive data on the diagnosis and management of hypertension. The survey has been adapted to other chronic conditions--diabetes, asthma/chronic obstructive pulmonary disease and neurological conditions. The questionnaire is available on the Statistics Canada website; descriptive results have been disseminated by the Public Health Agency of Canada.

TITRE: Méthodologie de l'Enquête sur les personnes ayant une maladie chronique au Canada ­ composante de l'hypertension de 2009. INTRODUCTION: L'Enquête sur les personnes ayant une maladie chronique au Canada ­ composante de l'hypertension (EPMCC-H) est une enquête téléphonique transversale de 20 minutes sur le diagnostic et la prise en charge de l'hypertension. L'échantillon de l'EPMCC-H, sélectionné à partir des répondants à l'Enquête sur la santé dans les collectivités canadiennes (ESCC) de 2008, était composé de Canadiens (de 20 ans et plus) des dix provinces ayant déclaré avoir reçu un diagnostic d'hypertension. MÉTHODOLOGIE: Le questionnaire a été élaboré au moyen de la technique Delphi et a fait l'objet d'un examen externe ainsi que de tests qualitatifs. Statistique Canada s'est chargé des stratégies d'échantillonnage, du recrutement, de la collecte et du traitement des données. Les proportions ont été pondérées afin de représenter la population canadienne et les intervalles de confiance (IC) à 95 % ont été calculés au moyen de la méthode de rééchantillonnage bootstrap. RÉSULTATS: Si on le compare à la population de l'ESCC ayant déclaré souffrir d'hypertension, l'échantillon de l'EPMCC-H (n = 6 142) est légèrement plus jeune (âge moyen des répondants à l'EPMCC-H : 61,2 ans, IC à 95 % : 60,8 à 61,6; âge moyen des répondants à l'ESCC : 62,2 ans, IC à 95 % : 61,8 à 62,5), comporte plus de détenteurs d'un diplôme d'études postsecondaires (EPMCC-H : 52,0 %, IC à 95 %: 49,7 % à 54,2 %; ESCC : 47,5 %, IC à 95 % : 46,1 % à 48,9 %) et moins de répondants prenant un médicament pour l'hypertension (EPMCC-H : 82,5 %, IC à 95 % : 80,9 % à 84,1 %; ESCC : 88,6 %, IC à 95 % : 87,7 % à 89,6 %). CONCLUSION: Dans l'ensemble, l'EPMCC-H de 2009 est représentatif de sa population source et fournit des données nouvelles et exhaustives sur le diagnostic et la prise en charge de l'hypertension. L'enquête a été adaptée à d'autres maladies chroniques ­ diabète, asthme/maladie pulmonaire obstructive chronique et troubles neurologiques. Le questionnaire est accessible à partir du site Web de Statistique Canada; des résultats descriptifs ont été publiés par l'Agence de la santé publique du Canada.

Behavioural modification of the cholinergic anti-inflammatory response to C-reactive protein in patients with hypertension.

OBJECTIVES: A central hypothesis of the cholinergic anti-inflammatory reflex model is that innate immune activity is inhibited by the efferent vagus. We evaluated whether changes in markers of tonic or reflex vagal heart rate modulation following behavioural intervention were associated inversely with changes in high-sensitivity C-reactive protein (hsCRP) or interleukin-6 (IL-6). DESIGN: Subjects diagnosed with hypertension (n = 45, age 35-64 years, 53% women) were randomized to an 8-week protocol of behavioural neurocardiac training (with heart rate variability biofeedback) or autogenic relaxation. Assessments before and after intervention included pro-inflammatory factors (hsCRP, IL-6), markers of vagal heart rate modulation [RR high-frequency (HF) power within 0.15-0.40 Hz, baroreflex sensitivity and RR interval], conventional measures of lipoprotein cholesterol and 24-h ambulatory systolic and diastolic blood pressure. RESULTS: Changes in hsCRP and IL-6 were not associated with changes in lipoprotein cholesterol or blood pressure. After adjusting for anti-inflammatory drugs and confounding factors, changes in hsCRP related inversely to changes in HF power (ß = -0.25±0.1, P = 0.02), baroreflex sensitivity (ß = -0.33±0.7, P = 0.04) and RR interval (ß = -0.001 ± 0.0004, P = 0.02). Statistically significant relationships were not observed for IL-6. CONCLUSIONS: Changes in hsCRP were consistent with the inhibitory effect of increased vagal efferent activity on pro-inflammatory factors predicted by the cholinergic anti-inflammatory reflex model. Clinical trials for patients with cardiovascular dysfunction are warranted to assess whether behavioural interventions can contribute independently to the chronic regulation of inflammatory activity and to improved clinical outcomes.

Relationship between social support and autonomic function during a stress protocol in ulcerative colitis patients in remission.

BACKGROUND: The relationship of psychological stress to relapse in ulcerative colitis (UC) is inconsistent. This may be due to a failure to identify patient characteristics, such as social support, which moderate the transduction of stress from the central nervous system to the immune system. In this study we tested the hypothesis that social support enhances parasympathetic modulation of heart rate in UC. METHODS: An indirect measure of autonomic function (heart rate variability; HRV) was measured in 108 patients with UC in remission during a standard protocol involving periods of stress, paced breathing, and relaxation. Social support was measured with the Social Support Questionnaire. RESULTS: After controlling for age, which is strongly related to HRV, both satisfaction with social support (F = 5.7, significance = 0.002) and its interaction with age (F = 7.8, significance <0.001) were associated with high-frequency HRV, which measures parasympathetic modulation of heart rate. Social support was associated with higher levels of high-frequency HRV at almost all points in the stress protocol. Neither age nor social support was associated with differences in the LF/HF ratio, which measures sympathetic modulation of heart rate. CONCLUSIONS: Social support is related to parasympathetic activity in UC. Given previous evidence of an antiinflammatory role for the parasympathetic nervous system, this suggests that autonomic function could serve as a mediating link between social support and reduced inflammatory activity.

Biobehavioral factors in the context of ischemic cardiovascular diseases.

OBJECTIVE: We set out to examine the development of current thinking on the relationship between behavioral factors and ischemic heart disease, with the latter being viewed as an epidemic. METHODS: The present work is a nonsystematic review of the subject. RESULTS: Atherogenic components of the coronary-prone or type A behavior pattern (TABP), including hostility, cynicism, and suppression of anger, as well as stress reactivity, depression, and social isolation, are emerging as particularly significant behavioral characteristics, although their pathophysiology is not yet fully understood. Effective patient management, particularly for lifestyle modification, requires an appreciation of an individual's stage in their readiness to change. CONCLUSION: The control and prevention of cardiovascular diseases depend on a multidisciplinary approach that recognizes the importance and intricacies of lifestyle behaviors.

A risk assessment for exposure to glass wool.

Synthetic vitreous fibers (SVFs) have been widely used as insulation material in places where asbestos was used many years ago and therefore the hazards have been compared. Since the three principal types of asbestos fibers types have caused lung cancer at high exposures, there is a widely held belief that all fibers are carcinogenic if inhaled in large enough doses. Hence, on a morphological basis, SVFs have been studied for their carcinogenic potential. However, there is considerable evidence that differences exist among fibers in their potency to produce a carcinogenic response. In this attempt to carry out a numerical risk assessment for the installers of blown glass wool (fiber) insulation, we start with a characterization of the material; then we review the exposures both in manufacturing and installation. Neither the epidemiological studies of human exposure nor the animal studies have shown a marked hazardous effect from glass wool and we can therefore be sure that any effect that might exist is small. But in this case, as in many other situations where there is a potential hazard, society desires further reassurance and therefore we have made a mechanistic calculation. There are good estimates of the risk associated with exposure to chrysotile asbestos at high exposures and doses. We have therefore taken these numbers and discussed how much less risky an exposure to glass wool fibers might be. We conclude that for a given fiber count, glass wool is five to ten times less risky (and of course the risk might be zero). The risk for a nonsmoking installer of glass wool fiber insulation who wears a respirator is about 6 in a million (and might be zero) per year. This means that out of a million installers there might be six lung cancers from this cause every year or out of 10,000 installers there might be one in 16 years. The low risk of 6 in a million per year of a worker blowing glass wool is consistent with the fact that no one has found any of cancer attributable to the manufacture or installation of glass wool fibers in spite of diligent searches. This is compared with several other occupational risks. Nonetheless common prudence suggests that any installer of blown glass wool fiber insulation wear a respirator.

Readiness to perform cardiopulmonary resuscitation: an emerging strategy against sudden cardiac death.

OBJECTIVES: This investigation assessed motivational factors and psychosocial barriers that affect individual readiness to perform cardiopulmonary resuscitation (CPR). This is the first study to use the Transtheoretical model in assessing readiness to perform CPR. METHODS: A sample of 786 subjects, > or = 45 years of age and who resided in a private residence, were randomly selected to participate in a structured telephone interview. Data on motivational readiness, emotional state, perceived psychosocial barriers, and perceived efficacy in performing CPR were collected using dichotomous and Likert-type ratings. RESULTS: Subjects with greater motivational readiness expected to experience significantly fewer symptoms of emotional distress during a cardiac emergency and to encounter fewer psychosocial barriers. This group also reported greater efficacy in their ability to perform CPR. These findings were independent of gender, medical history, age, and educational level. CONCLUSIONS: Meaningful differences are apparent in individual readiness to perform CPR. These findings provide additional support for the need to tailor CPR training strategies using behavioral methods that enhance motivational readiness and decrease apprehension about anticipated emotional distress and psychosocial barriers.

A risk assessment for exposure to grunerite asbestos (amosite) in an iron ore mine.

The potential for health risks to humans exposed to the asbestos minerals continues to be a public health concern. Although the production and use of the commercial amphibole asbestos minerals-grunerite (amosite) and riebeckite (crocidolite)-have been almost completely eliminated from world commerce, special opportunities for potentially significant exposures remain. Commercially viable deposits of grunerite asbestos are very rare, but it can occur as a gangue mineral in a limited part of a mine otherwise thought asbestos-free. This report describes such a situation, in which a very localized seam of grunerite asbestos was identified in an iron ore mine. The geological occurrence of the seam in the ore body is described, as well as the mineralogical character of the grunerite asbestos. The most relevant epidemiological studies of workers exposed to grunerite asbestos are used to gauge the hazards associated with the inhalation of this fibrous mineral. Both analytical transmission electron microscopy and phase-contrast optical microscopy were used to quantify the fibers present in the air during mining in the area with outcroppings of grunerite asbestos. Analytical transmission electron microscopy and continuous-scan x-ray diffraction were used to determine the type of asbestos fiber present. Knowing the level of the miner's exposures, we carried out a risk assessment by using a model developed for the Environmental Protection Agency.

Asbestos in the lungs of persons exposed in the USA.

Tissues obtained at autopsy or biopsy from 81 workers and 2 household persons, were chemically digested. The asbestos fibres recovered were characterized by analytical transmission electron microscopy. Among the 83 causes of death were 33 mesotheliomas, 35 lung cancers, 12 asbestosis and 3 from other cancers. Of the three major commercial asbestos fibre types, amosite was found to be the most prevalent fibre, occurring in approximately 76% of the cases, followed by chrysotile in approximately 60% and crocidolite in approximately 24%. Amosite and chrysotile were observed as the single commercial fibre in approximately 22 and approximately 17% of the cases respectively, whereas crocidolite and tremolite were found as the single fibre type in only approximately 2.5% of the cases. Among the fifteen cases where chrysotile and tremolite occurred together, the amount of chrysotile fibre always exceeded tremolite. However, tremolite was also found in ten additional cases where chrysotile was not detected. Amosite was present in four, amosite plus crocidolite in three, and crocidolite alone in one. Amosite was present in all of the insulation workers' lungs studied and was found in the highest concentration in this exposure category. The highest chrysotile concentration was found among workers in general trades. Although most prevalent in shipyard workers lungs, crocidolite concentration is not statistically different among the exposure groups studied. Although crocidolite was found in twenty cases, amosite accompanied it in eighteen of these. Eleven of the 20 cases were from shipyard workers. Of the 8 mesothelioma cases, 7 also contained amosite. Crocidolite alone only occurred in 1 of the 33 mesothelioma cases analysed. We concluded the following: crocidolite exposure occurred among USA insulators and a large percentage of other workers as well; insulation workers are primarily exposed to amosite; mixed fibre exposures are associated with more mesotheliomas than single fibre exposures; chrysotile only exposure is associated with approximately 12% of the mesothelioma cases studied; and if tremolite exposure is associated with chrysotile exposure, the chrysotile amount exceeds that for the associated tremolite.

Preliminary investigation of associations of illness schemata and treatment-induced reduction in headaches.

This study examined how illness schemata-ways people organize information about illness-change over the course of cognitive-behavioral treatment of chronic headache and the extent to which such changes predict reduction of headache. 73 subjects with chronic migraine, mixed migraine and tension, or tension headache were classified on the basis of outcome from imagery-based treatment as Treatment-responders (n = 24). Treatment nonresponders (n = 27), and Monitoring Controls (n = 22). Self-reported illness schemata related to the seriousness and changeability of headache were assessed at pretreatment and 8-wk. follow-up. While groups did not differ on pretreatment measures of illness schemata, at follow-up the Treatment responder group reported higher Changeability scores than Treatment-nonresponders and Control subjects and lower Seriousness scores than Control subjects. Headache reduction at follow-up was related to follow-up Changeability scores, in-session changes in systolic blood pressure and reported posttreatment expectations of headache activity, but not pretreatment measures of illness schemata. Findings indicate that improvements in headache activity are not influenced by the severity of headaches and may change prior to cognitive-behavioral treatment. Rather, among individuals who show decreases in headache activity, changes in beliefs about illness and headache reduction may have reciprocal relations both of which result from cognitive behavioral treatment.

Preparation, attitudes and behaviour in nonhospital cardiac emergencies: evaluating a community's readiness to act.

OBJECTIVE: To determine how people in a moderately sized Ontario city believe they will react if they witness someone colapsing. DESIGN: Telephone survey. SETTING: The cities of Kitchener and Waterloo, part of the Regional Municipality of Waterloo, Ontario, with a combined population of 378,000. PARTICIPANTS: Households were randomly contacted and a questionnaire was administered, provided the respondent was over 44 years of age and agreed to be interviewed. Of 2479 households with eligible respondents, 811 (33%) completed the questionnaire. OUTCOMES: Age, sex, educational level, cardiac risk factors and cardiopulmonary resuscitation (CPR) training of respondents were determined, as well as actions they would take if cardiac arrest occurred in a family member at home or in stranger in the street, and associated emotions and barriers to implementing actions. RESULTS: Among the first three actions that respondents who were not prompted with possible responses said they would take, 311 (72%) witnessing a collapse at home, compared with 166 (44%) witnessing a collapse on the street, would call 911, the police or an ambulance. Other 'first three actions' in home collapse were checking for breathing (120 [28%]), checking for pulse (91 [21%]) and administering CPR (34 [8%]); these actions were less commonly selected in response to a strangers collapse and when respondents were not prompted. Respondents felt they would be more likely to perform CPR on a friend than on a stranger (OR 1.38, 95% CI 1.10 to 1.58). When asked how likely they would be to perform specific acts when witnessing a collapse, 254 (69%) of respondents thought they would call their family doctor and 179 (48%) thought they were likely to begin chest compressions. Barriers to performing CPR centred around legalities and disease transmission. CONCLUSION: Older people do not know how to act effectively in a cardiac emergency. Traditional CPR and public awareness programs have been ineffective in reaching this population; alternative means are required to help the public respond more effectively to cardiac emergencies.

How can we help patients to initiate change?

This paper presents guidelines to help patients initiate change in risk behaviours for coronary artery disease. Two questions are explored. These address the clinical method and session content, respectively. How might we best conduct the interview, so that the patient's motivation for changing risk behaviour is enhanced? What is the optimal focus for counselling, so that the patient can feel that the activity of exploring or modifying their risk behaviour is meaningfully connected with their personal goals and life priorities? Specific guidelines are presented to guide practitioners in fostering a patient-centred clinical method. Practitioner tasks for structuring session content are derived from motivational theory and the transtheoretical model of readiness for change.

Asbestos in New York City public school buildings--public policy: is there a scientific basis?

The most recent of New York City's asbestos emergencies occurred in the late summer of 1993. It prevented schools from opening that fall, precipitated much media excitement, and caused a flurry of widespread abatement activities. This resulted in large measure from the U.S. Environmental Protection Agency's subjective school building inspection policy concerning identification of asbestos hazards in buildings and the subsequent Asbestos Hazard Emergency Response Act mandate for inspection. Data on concentrations of asbestos in the air, important for the calculation of risk to building occupants, were not required and therefore not obtained, as part of the abatement strategy or priority setting. Based on fiber-in-air measurements obtained elsewhere, the calculated risk to NYC school children, using the most pessimistic models, was less than six excess cancer deaths per million lifetimes equivalent to smoking less than a dozen cigarettes in a lifetime. The NYC administration responded to pressure from parent groups concerned with perceived asbestos risks to their children by closing the schools. The hysteria occurred because much of EPA's policy lacked a scientific basis for risk evaluation and assessment.