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Introduction: Low acuity patients have been controversially tagged as a source of emergency department (ED) misuse. Authorities for many Canadian health regions have set up policies so these patients preferably present to walk-in clinics (WIC). We compared the cost and quality of the care given to low acuity patients in an academic ED and a WIC of Québec City during fiscal year 2015-16. Methods: We conducted an ambidirectional (prospective and retrospective) cohort study using a time-driven activity-based costing method. This method uses duration of care processes (e.g., triage) to allocate to patient care all direct costs (e.g., personnel, consumables), overheads (e.g., building maintenance) and physician charges. We included consecutive adult patients, ambulatory at all time and discharged from the ED or WIC with a diagnosis of upper respiratory tract infection (URTI), urinary tract infection (UTI) or low back pain. Mean cost [95%CI] per patient per condition was compared between settings after risk-adjustment for age, sex, vital signs, number of regular medications and co-morbidities using generalized log-gamma regression models. Proportions [95%CI] of antibiotic prescription and chest X-Ray use in URTI, compliance with provincial guidelines on use of antibiotics in UTI, and column X-Ray use in low back pain were compared between settings using a Pearson Chi-Square test. Results: A total of 409 patients were included. ED and WIC groups were similar in terms of age, sex and vital signs on presentation, but ED patients had a greater burden of comorbidities. Adjusted mean cost (2016 CAN$) of care was significantly higher in the ED than in the WIC (p < 0.0001) for URTI (78.42[64.85-94.82] vs. 59.43[50.43-70.06]), UTI (78.88[69.53-89.48] vs. 53.29[43.68-65.03]), and low back pain (87.97[68.30-113.32] vs. 61.71[47.90-79.51]). For URTI, antibiotics were more frequently prescribed in the WIC (44.1%[34.3-54.3] vs. 5.8%[1.2-16.0]; p < 0.0001) and chest X-Rays, more frequently used in the ED (26.9%[15.6-41.0] vs. 13.7%[7.7-22.0]; p = 0.05). No significant differences were observed in the compliance with guidelines on use of antibiotics in UTI and in the use of column X-Ray in low back pain. Conclusion: Total cost of care for low acuity patients is lower in walk-in clinics than in EDs. However, our results suggest that quality-of-care issues should be considered in determining the best alternate setting for treating ambulatory emergency patients.
Our Hospital-based Health Technology Assessment unit (HB-HTA) was founded in 2011 following the nomination of Louis-H. Lafontaine hospital as the Montreal University Mental Health Institute (IUSMM). From the beginning, the HB-HTA has been supporting and advising the Chief Executive Officer of IUSMM in the decision-making process concerning the implementation of new technologies and practices in mental health. Since 2015, the HB-HTA is part of the East of Montreal Regional Integrated Health and Social Services Centre (CIUSSS de l'Est-de-l’Île de Montréal), continuing to support decisions in mental health. Currently, the HB-HTA unit is nested in the Quality, Performance and Ethics department.
Formed by a coordinator, a scientific advisor and a manager, the HB-HTA team plans, organizes and sets up the evaluation activities. The unit benefits from the support of a Steering Committee which consists of representatives of clinical, administrative and research directions, as well as of health users and families. This committee determine the strategic orientation of the HB-HTA unit, prioritize the projects, approves the evaluation products and gives indications on the knowledge transfer process.
To answer the decision questions, our HB-HTA unit employs two types of products: evaluation reports and informative notes. Based on an exhaustive literature search and consultations with stakeholders, the evaluation reports offer recommendations to support the decision-making process. The informative notes are rapid responses based on a partial literature search. The nature of this type of analysis does not allow the formulation of recommendations, however, a conclusion of the consulted literature is offered.
Based on the work of our HB-HTA unit, some important decisions were made by the IUSMM. As an example, the systematic screening of psychiatric patients for drug and alcohol was not favored by our institution; rather than this, priority was given to staff training, in order to better identify and treat psychiatric patients with substance abuse comorbidity.
In order to support service planning of the youth program of the East of Montreal Health and Social Services Board, and potentially of the other twenty-five programs across the Quebec province, our hospital-based Health Technology Assessment (HTA) unit was asked to bring evidence of the effective interventions for five most common mental disorders in children and young populations, namely anxio-depressive disorders, attention deficit and hyperactivity disorder, oppositional and conduct disorders, substance abuse disorders, and suicide attempts.
A review of reviews was conducted for the five disorders in young populations aged 6 to 25 years. This was based exclusively on systematic reviews and meta-analysis of a minimum two randomized-controlled trials. The review was completed with examples of Quebec's good practices in youth mental health gathered from personal research experience of clinical researchers involved in the project. The project involved collaboration with three other hospital units and provincial HTA agencies.
No review supporting screening and early detection for the five disorders was identified. Prevention, however, was better covered in the literature, and a clear distinction was made between universal, targeted and indicated interventions. In general, targeted and indicated prevention interventions were effective in the case of anxio-depressive (1) and substance use disorders, while universal prevention strategies seemed to reduce suicide attempts and suicide ideation (2). Effective treatments also exist for these mental disorders. In general, psychotherapies dominated for anxio-depressive and substance use disorders; parental skills dominated in oppositional disorders, whilst pharmacological treatment dominated in attention deficit and hyperactivity disorder (3). Evidence was limited for suicide attempts. The overview of Quebec's good practices allowed identification of interventions or practices already in use in the province.
The review summarized effective interventions for five most common mental disorders in young populations. It also permitted to identify several research gaps, and therefore research recommendations were formulated for the province's health research agency.
Soil CO2 flux measurement is a key method that can be used to monitor the hazards in an active volcanic area. In order to determine accurately the variations of the CO2 soil emission we propose an approach based on the radiocarbon (14C) deficiency recorded in the plants grown in and around the Solfatara (Naples, Italy). We twice sampled selected poaceae plants in 17 defined sites around the Solfatara volcano. 14C measurements by liquid scintillation counting (LSC) were achieved on the grass samples. The 14C deficiency determined in the sampled plants, compared to the atmosphere 14C activity, ranged from 6.6 to 51.6%. We then compared the proportion of magmatic CO2 inferred to the instantaneous measurements of CO2 fluxes from soil performed by the accumulation chamber CO2 degassing measurement at the moment of the sampling at each site. The results show a clear correlation (r=0.88) between soil CO2 fluxes and 14C activity. The determination of the plants 14C deficiency provides an estimate of the CO2 rate within a few square meters, integrating CO2 soil degassing variations and meteorological incidences over a few months. It can therefore become an efficient bio-sensor and can be used as a proxy to cartography of the soil CO2 and to determine its variations through time
The rapid pace of economic, political, and social change over the past 150 years has framed and reframed archaeological practice in Ontario. Indigenous groups have become increasingly involved in and critical of archaeological research. Indigenous peoples who value archaeological investigation of ancestral sites, but also desire to protect their buried ancestors, have restricted archaeological excavation and the analysis of remains. Over the last decade, research and consulting archaeologists in Ontario, Canada, have worked collaboratively with Indigenous peoples with an eye to developing sustainable archaeology practices. In the spirit of sustainable archaeology, a comprehensive research project and field school run by Wilfrid Laurier University is training the next generation of archaeologists to adopt investigative techniques that minimize disturbance of ancestral sites. Here we present the results of our surface, magnetic susceptibility, and metal detecting surveys of a Huron-Wendat village site, which pose minimally invasive solutions for investigating village sites in wooded areas. The water-sieving of midden soils in an attempt to recover 100 percent of cultural materials, and the analysis of archived collections also honor the values of Indigenous descendant communities by limiting additional invasive excavation.
Archaeological evidence of the ancestral Huron-Wendat Nation of Southern Ontario, Canada, shows a population increase from the thirteenth through sixteenth centuries, suggesting high fertility. Birth timing and infant survival are influenced by mothers' decisions about weaning. This study explores trophic enrichment of δ15N in horizontal dentine slices from 35 deciduous molars (n = 33 dm1, n = 2 dm2) and 39 permanent first molars (M1) representing five Huron-Wendat ossuaries, dating from the fourteenth through seventeenth centuries. Weaning was normally incomplete at the end of dm formation, at an age of about 2.5 years. Post-weaning dentine values appear by the end of crown formation of M1. The weaning process began between 8 and 18 months and was complete in all cases by 3.5 years. Timing of the weaning process does not support the idea that Huron-Wendat population increase was associated with early weaning of infants. Communities from the sixteenth century and thereafter show earlier completion of weaning. Reasons for earlier cessation of breastfeeding may be found in the social and biological disruptions of the era of European contact. Values from permanent teeth of mandibles with sex attributed suggest a more homogeneous, possibly venison-oriented, post-weaning diet among males.
Based on the Developmental Origin of Health and Disease concept, maternal undernutrition has been shown to sensitize adult offspring to metabolic pathologies such as obesity. Using a model of maternal 70% food restriction in pregnant female rats throughout gestation (called FR30), we previously reported that obesity-prone adult male rat offspring displayed hyperleptinemia with modifications in leptin and leptin receptor messenger RNA (mRNA) levels in white adipose tissue (WAT). Apelin is a member of the adipokine family that regulates various aspects of energy metabolism and WAT functionality. We investigated whether apelin and its receptor APJ could be a target of maternal undernutrition. Adult male rat offspring from FR30 dams showed increased plasma apelin levels and apelin gene expression in WAT. Post-weaning high-fat diet led to marked increase in APJ mRNA and protein levels in offspring’s WAT. We demonstrate that maternal undernutrition and post-weaning diet have long-term consequences on the apelinergic system of adult male rat offspring.
Information is crucial in mental healthcare, yet it remains undervalued by stakeholders. Its absence undermines rationality in planning, makes it difficult to monitor service quality improvement, impedes accountability and human rights monitoring. For international organizations (e.g., WHO, OECD), information is indispensable for achieving better outcomes in mental health policies, services and programs. This article reviews the importance of developing system level information with reference to inputs, processes and outputs, analyzes available tools for collecting and summarizing information, highlights the various goals of information gathering, discusses implementation issues and charts the way forward.
Relevant publications and research were consulted, including WHO studies that purport to promote the use of information systems to upgrade mental health care in high- and low-middle income countries.
Studies have shown that once information has been collected by relevant systems and analyzed through indicator schemes, it can be put to many uses. Monitoring mental health services, represents a first step in using information. In addition, studies have noted that information is a prime resource in many other areas such as evaluation of quality of care against evidence based standards of care. Services data may support health services research where it is possible to link mental health data with other health and non-health databases. Information systems are required to carefully monitor involuntary admissions, restrain and seclusion, to reduce human rights violations in care facilities. Information has been also found useful for policy makers, to monitor the implementation of policies, to evaluate their impact, to rationally allocate funding and to create new financing models.
Despite its manifold applications, Information systems currently face many problems such as incomplete recording, poor data quality, lack of timely reporting and feedback, and limited application of information. Corrective action is needed to upgrade data collection in outpatient facilities, to improve data quality, to establish clear rules and norms, to access adequate information technology equipment and to train health care personnel in data collection. Moreover, it is necessary to shift from mere administrative data collection to analysis, dissemination and use by relevant stakeholders and to develop a “culture of information” to dismantle the culture of intuition and mere tradition. Clinical directors, mental health managers, patient and family representatives, as well as politicians should be educated to operate with information and not just intuition.
We extend the full wavefield modeling with forward scattering theory and Volterra Renormalization to a vertically varying two-parameter (velocity and density) acoustic medium. The forward scattering series, derived by applying Born-Neumann iterative procedure to the Lippmann-Schwinger equation (LSE), is a well known tool for modeling and imaging. However, it has limited convergence properties depending on the strength of contrast between the actual and reference medium or the angle of incidence of a plane wave component. Here, we introduce the Volterra renormalization technique to the LSE. The renormalized LSE and related Neumann series are absolutely convergent for any strength of perturbation and any incidence angle. The renormalized LSE can further be separated into two sub-Volterra type integral equations, which are then solved noniteratively. We apply the approach to velocity-only, density-only, and both velocity and density perturbations. We demonstrate that this Volterra Renormalization modeling is a promising and efficient method. In addition, it can also provide insight for developing a scattering theory-based direct inversion method.
Following the entry of Zea mays to northeast North America, Northern Iroquoian populations expanded their numbers and range. Isotopic values from bone collagen have shown fluctuations in reliance on this dietary staple. With permission of the Huron-Wendat Nation of Wendake, Quebec, we measured δ13Cenamel, δ13Cdentine and δ15Ndentine from 167 permanent teeth, retained before reburial of their ancestral skeletons, and δ13Ccollagene and δ15Ncollagene from adhering bone (n = 53). Enamel values encapsulate diet from ca. 1.5 to 4 years of age; dentine values reflect later childhood. Teeth are from 16 ancestral Huron-Wendat sites in southern Ontario. Isotopic values show consistent reliance on maize from early fourteenth to sixteenth centuries, with higher reliance in the seventeenth century—the time of contact with Europeans and disruptive changes. We show a difference between the diets of children and adults; children consumed more maize and less animal protein. Whitetailed deer (Odocoileus virginianus) did not exploit maize fields, reflecting hunters’ exploitation of distant regions. New values from fish species (n = 21) are pooled with prior data, demonstrating diverse C and N stable isotope patterns. American eel (Anguilla rostrata) is particularly variable. Dietary protein sources were variable compared to the stability of maize: a reliable source of carbohydrate food energy across four centuries.
A pair of elytra of the striped flea beetle Phyllotreta striolata (Fabricius) (Coleoptera: Chrysomelidae) was recovered from a sample of sediment dating before 1668 collected in Ville de Québec, Québec, Canada, making it the earliest recorded introduction of the species in North America. It is proposed that its transatlantic voyage took place on crucifers either voluntarily transported as foodstock and animal fodder or involuntarily as weeds.
Introduction: Patients presenting with high grade (HG) subarachnoid hemorrhage (SAH) from aneurysmal rupture may have persisting neurologic deficits which may lead to questioning the decision of treating aggressively. The objective of this study aims at analyzing outcome and long-term quality of life (QOL) of patients with HG SAH treated surgically. Methods: Retrospective study of patients with Hunt Hess (HH) grade IV or V SAH treated surgically at our institution. Long-term outcome was evaluated based on the modified Rankin Scale (mRS) at 3 years. Survivors were evaluated for QOL using various scales. Results: 63 patients (mean age of 52 year-old) were included. Intraparenchymal hemorrhage (IPH) was found in 85% of cases. 19 patients died. Predictive factors of poor prognosis and mortality were initial cerebral ischemia (p=0.003) and IPH (p=0.007). Favourable outcome (mRS 0-3) was found in 41% of patients. QOL questionnaires revealed that 80 % of responders showed more than 50% recovery. Mild or absent depression was observed in 78% of patients. Conclusion: In this surgical series, performed in an endovascular era, nearly all patients presented with SAH-associated IPH at admission. Despite the presence of such negative prognostic factor and the poor condition at admission, a high rate of favourable outcome and QOL was observed, therefore justifying aggressive surgical treatment.
This chapter explores how the global financial crisis of 2008–9 has affected the stability of the ‘new constitutionalism of disciplinary neo-liberalism’ in the realm of international tax policy. New constitutionalism forms a principal institutional component of neo-liberal hegemony. In neo-Gramscian international political economy, neo-liberalism is understood as a political project aimed at restoring capitalist class power after the economic and social crisis of the 1970s (Harvey 2005; van Apeldoorn and Overbeek 2012). This project is undergirded by dialectically intertwined material, ideational and institutional components. In the material realm, the structural power of transnational capital is manifested by the predominance of international finance and transnational corporations in the global political economy. The cross-border mobility of these fractions and the associated ‘exit option’ discipline governments, parliaments and national trade unions to introduce and accept neo-liberal economic policies. Ideationally, neo-liberalism is characterized by the hegemony of pro-market, supply-side and monetarist discourses (van Apeldoorn and Overbeek 2012). However, militant neo-liberalism has to a certain extent been succeeded by the seemingly more politically ‘neutral’ globalization discourse, which pretends that states have lost a considerable deal of their actual sovereignty and that for nations there is no alternative (TINA) to adjusting to the exigencies of internationally mobile capital.
In the institutional sphere, new constitutionalism firmly institutionalizes neo-liberal globalization. Stephen Gill (2008) defines new constitutionalism as the political project designed to anchor neo-liberal policies into national and international legal frameworks, insulating these policies from normal, day-to-day democratic debate and decision-making. As Gill has stated, the central goal of new constitutionalism is to firmly secure the protection of private property rights, and as such to transform public policy in the interests of mobile capital. What is emerging is a social order in which holders of that capital are conferred privileged rights of citizenship and representation, and in which these rights are ‘locked in’. In effect, ‘the mobile investor becomes the sovereign political subject’ (1998b: 25). Consequently, dominant economic forces, in particular wealthy individuals, transnational corporations and financial institutions, are ‘increasingly insulated from democratic rule and popular accountability’ (ibid: 23), and, in the case examined here, from taxation.
Undernutrition exposure during the perinatal period reduces the growth kinetic of the offspring and sensitizes it to the development of chronic adult metabolic diseases both in animals and in humans. Previous studies have demonstrated that a 50% maternal food restriction performed during the last week of gestation and during lactation has both short- and long-term consequences in the male rat offspring. Pups from undernourished mothers present a decreased intrauterine (IUGR) and extrauterine growth restriction. This is associated with a drastic reduction in their leptin plasma levels during lactation, and exhibit programming of their stress neuroendocrine systems (corticotroph axis and sympatho-adrenal system) in adulthood. In this study, we report that perinatally undernourished 6-month-old adult animals demonstrated increased leptinemia (at PND200), blood pressure (at PND180), food intake (from PND28 to PND168), locomotor activity (PND187) and altered regulation of glycemia (PND193). Cross-fostering experiments indicate that these alterations were prevented in IUGR offspring nursed by control mothers during lactation. Interestingly, the nutritional status of mothers during lactation (ad libitum feeding v. undernutrition) dictates the leptin plasma levels in pups, consistent with decreased leptin concentration in the milk of mothers subjected to perinatal undernutrition. As it has been reported that postnatal leptin levels in rodent neonates may have long-term metabolic consequences, restoration of plasma leptin levels in pups during lactation may contribute to the beneficial effects of cross-fostering IUGR offspring to control mothers. Collectively, our data suggest that modification of milk components may offer new therapeutic perspectives to prevent the programming of adult diseases in offspring from perinatally undernourished mothers.
Genetic variants in the FTO (fat mass- and obesity-associated) gene have the highest association of all obesity-associated genes. Its placental expression was shown to relate to birth weight, suggesting that it may participate in the control of fetal weight gain. To gain more insight into the implication of FTO in fetal growth, we measured its placental expression in samples including extremes of abnormal fetal growth, such as after intrauterine growth restriction (IUGR) or macrosomia in both rats and humans. In rats, fetal growth was modulated by maternal nutritional modifications. In humans, placental villi were collected from pathological pregnancies (i.e. with IUGR or fetal macrosomia). Placental FTO mRNA expression was reduced by IUGR but was not significantly affected by macrosomia in either rats or humans. Our data suggest that placental FTO may participate in interactions between the in utero environment and the control of fetal growth under IUGR conditions by modulating epigenetic processes.
The taxonomy of the Nearctic genus Ophraella Wilcox is revised. Data for all known immature stages are included. Ophraella integra (LeConte) is synonymized with O. notulata (Fabricius). Ophraella dilatipennis (Jacoby) is transferred to the genus Neolochmaea Laboissière.Thirteen species are recognized, of which 6 are new : O. arctica, californiana, communa, macrovittata, nuda, and pilosa. The distribution and host plants of species are as follows : O. americana, eastern North America, on Solidago spp.; O. pilosa, transcontinental along the Canadian border, on Aster, primarily A. macrophyllus; O. cribrata, coast to coast in the United States, on Solidago of the subgenus Virgaurea; O. conferta in northeastern states, on Solidago with preference for S. canadensis and S. rugosa; O. sexvittata in southeastern states, on Solidago spp.; O. notulata in eastern US and Gulf states to Mexico, on Iva oraria; O. notata in eastern portion of the United States, on Eupatorium perfoliatum; O. macrovittata in the Gulf states, host plant unknown; O. communa in North America and Mexico, on Ambrosia artemisiifolia; O. bilineata in the Canadian Prairies and the bordering states, on Chrysopsis villosa; O. californiana in California and Mexico, on Artemisia Douglasiana; O. nuda in Alberta, host plant unknown; and O. arctica in tundra zone, on Solidago multiradiata scopulorum.The life cycles of most species are still unknown but most species probably have only 1 generation per year. The eggs are laid in clusters on the under surface of young leaves. The larvae skeletonize young leaves and live exposed. Before pupation, the larva spins a loose cocoon and attaches it to a leaf tip. Pupation lasts 1–2 weeks. The newly hatched adults are active on host plants until the early fall, when they enter the leaf litter for overwintering.