Four steps to standardize reporting of peritoneal dialysis technique failure: A proposed approach.

BACKGROUND: Technique failure is an important outcome measure in research and quality improvement in peritoneal dialysis (PD) programs, but there is a lack of consistency in how it is reported. METHODS: We used data collected about incident dialysis patients from 10 Canadian dialysis programs between 1 January 2004 and 31 December 2018. We identified four main steps that are required when calculating the risk of technique failure. We changed one variable at a time, and then all steps, simultaneously, to determine the impact on the observed risk of technique failure at 24 months. RESULTS: A total of 1448 patients received PD. Selecting different cohorts of PD patients changed the observed risk of technique failure at 24 months by 2%. More than one-third of patients who switched to hemodialysis returned to PD-90% returned within 180 days. The use of different time windows of observation for a return to PD resulted in risks of technique failure that differed by 16%. The way in which exit events were handled during the time window impacted the risk of technique failure by 4% and choice of statistical method changed results by 4%. Overall, the observed risk of technique failure at 24 months differed by 20%, simply by applying different approaches to the same data set. CONCLUSIONS: The approach to reporting technique failure has an important impact on the observed results. We present a robust and transparent methodology to track technique failure over time and to compare performance between programs.

How Attending Physician Preceptors Negotiate Their Complex Work Environment: A Collective Ethnography.

PURPOSE: To generate an empiric, detailed, and updated view of the attending physician preceptor role and its interface with the complex work environment. METHOD: In 2013, the authors conducted a modified collective ethnography with observations of internal medicine medical teaching unit preceptors from two university hospitals in Canada. Eleven observers conducted 32 observations (99.5 hours) of 26 preceptors (30 observations [93.5 hours] of 24 preceptors were included in the analysis). An inductive thematic approach was used to analyze the data with further axial coding to identify connections between themes. Four individuals coded the main data set; differences were addressed through discussion to achieve consensus. RESULTS: Three elements or major themes of the preceptor role were identified: (1) competence or the execution of traditional physician competencies, (2) context or the extended medical teaching unit environment, and (3) conduct or the manner of acting or behaviors and attitudes in the role. Multiple connections between the elements emerged. The preceptor role appeared to depend on the execution of professional skills (competence) but also was vulnerable to contextual factors (context) independent of these skills, many of which were unpredictable. This vulnerability appeared to be tempered by preceptors' use of adaptive behaviors and attitudes (conduct), such as creativity, interpersonal skills, and wellness behaviors. CONCLUSIONS: Preceptors not only possess traditional competencies but also enlist additional behaviors and attitudes to deal with context-driven tensions and to negotiate their complex work environment. These skills could be incorporated into role training, orientation, and mentorship.

How evidence from observing attending physicians links to a competency-based framework.

CONTEXT: Competency-based medical education frameworks are often founded on a combination of existing research, educational principles and expert consensus. Our objective was to examine how components of the attending physician role, as determined by observing preceptors during their real-world work, link to the CanMEDS Physician Competency Framework. METHODS: This is a sub-study of a broader study exploring the role of the attending physician by observing these doctors during their working day. The parent study revealed three overarching elements of the role that emerged from 14 themes and 123 sub-themes: (i) Competence, defined as the execution of traditional physician competencies; (ii) Context, defined as the environment in which the role is carried out, and (iii) Conduct, defined as the manner of acting, or behaviours and attitudes in the role that helped to negotiate the complex environment. In this sub-study, each sub-theme, or 'role-related component', was mapped to the competencies described in the CanMEDS 2005 and 2015 frameworks. RESULTS: Many role-related components from the Competence element were represented in the 2015 CanMEDS framework. No role-related components from the Context element were represented. Some role-related components from the Conduct element were represented. These Conduct role-related components were better represented in the 2015 CanMEDS framework than in the 2005 framework. CONCLUSIONS: This study shows how the real-world work of attending physicians links to the CanMEDS framework and provides empirical data identifying disconnects between espoused and observed behaviours. There is a conceptual gap where the contextual influences of physicians' work and the competencies required to adjust to these influences are missing from the framework. These concepts should be incorporated into learning both broadly, such as through an emphasis on context within curriculum development for the workplace (e.g. entrustable professional activities), and explicitly, through the introduction of novel competencies (e.g. the Conduct role-related components described in this study).

Results of the 2014-2015 Canadian Society of Nephrology workforce survey.

BACKGROUND: Nephrology was previously identified as a subspecialty with few Canadian employment opportunities, and in recent years, fewer trainees are choosing nephrology. OBJECTIVE: The objective of this study is to better understand the current Canadian adult nephrology workforce and the expected workforce trends over the next 5 years. DESIGN: This is an online self-administered survey. SETTING: This study is set in Canada. SURVEY PARTICIPANTS: Survey participants are Canadian adult nephrologists, including self-identified division heads. MEASUREMENTS: The measurements of this study are demographics, training, current practice characteristics, work hours, and projected workforce needs. METHODS: Survey questions were based on previous workforce surveys. Ethics approval was obtained through the University of Saskatchewan. The survey was piloted in both English and French and modified based on the feedback to ensure that responses accurately reflected the information desired. It was circulated to all identified Canadian nephrologists via an anonymous e-mail link for self-administration. Categorical data was aggregated, and free-text answers were thematically analyzed. Additional descriptive analysis was conducted by all authors. RESULTS: Five hundred ninety-two Canadian nephrologists were contacted and 48 % responded, with representation from all Canadian provinces. One third of the respondents were female, and the largest age cohort was 41-50 years. Most nephrologists are trained in Canada and 61 % completed additional training. The majority of the respondents (69.1 %) began working as a nephrologist immediately upon completion of fellowship training. Younger nephrologists reported more challenges in finding a job. Eighty percent of responding nephrologists were satisfied with their current work hours, 13.1 % will reduce work hours within 3 years, an additional 8.2 % will reduce work hours within 5 years, and a further 14.2 % will reduce work hours within 10 years. Nephrology division heads forecasted the number of clinical and academic nephrologists needed for the next 3 and 5 years. LIMITATIONS: The response rate was 48 %. Forecasted workforce needs are not indicative of guaranteed future positions. CONCLUSIONS: This Canadian Society of Nephrology workforce survey demonstrated the current workforce demographics, individual nephrologist future workforce plans, and projected nephrology division requirements for the next 3 and 5 years. Further work will need to be done to refine Canadian nephrology workforce planning with the development of a robust strategy that encompasses both societal and nephrologists' needs with the realities of employment.

MISE EN CONTEXTE: La néphrologie a été identifiée dans le passé comme une sous-spécialité pour laquelle les perspectives d'emploi se faisaient rares au Canada. Une conséquence de cette constatation a été la diminution du nombre de stagiaires qui l'ont choisie comme spécialité dans les dernières années. OBJECTIFS DU SONDAGE: On a cherché à mieux connaître la nature des effectifs actuels en néphrologie adulte au Canada et à mesurer l'évolution de la main-d'œuvre pour les cinq prochaines années. TYPE D'ÉTUDE: Le plan de l'enquête reposait sur un questionnaire autoadministré auquel les participants accédaient en ligne. PARTICIPANTS: Le sondage s'est tenu auprès des néphrologues canadiens traitant des adultes et incluait des répondants s'identifiant comme chefs de division. MESURES: On a recueilli des données sur les effectifs actuels la formation, les caractéristiques des pratiques en vigueur, le nombre d'heures travaillées et les besoins anticipés à moyen terme en fait de main d'œuvre. MÉTHODOLOGIE: Les questions de la présente enquête ont été établies à partir de sondages réalisés antérieurement au sujet des effectifs. L'Université de la Saskatchewan a fourni les approbations déontologiques nécessaires à la conduite de l'enquête. Le questionnaire modifié sur la base des commentaires reçus dans les sondages précédents pour s'assurer que les réponses tenaient compte de l'information souhaitée, était disponible en anglais et en français. Le questionnaire a été distribué à tous les néphrologues canadiens par le biais d'un lien de courrier électronique anonyme afin que ceux-ci puissent le remplir de façon autonome. Les données catégorielles ont été comptabilisées et les réponses aux questions ouvertes ont fait l'objet d'une analyse thématique. Enfin, les auteurs du présent article ont procédé à des analyses descriptives supplémentaires. RÉSULTATS: Le questionnaire a été envoyé à 592 néphrologues ceux-ci ont répondu dans une proportion de 48 % et celle-ci comptait des représentants de toutes les provinces canadiennes. Le tiers des répondants étaient des femmes, et le groupe d'âge prédominant était celui des 41 à 50 ans. La plupart des néphrologues questionnés avaient reçu leur formation au Canada, une proportion de 61 % avait suivi une formation supplémentaire. La majorité des répondants (69,1 %) ont mentionné avoir trouvé un emploi dans leur domaine de spécialité dès la fin de leur formation postdoctorale, mais les plus jeunes ont rapporté avoir rencontré plus de difficultés au moment de leur recherche d'un poste de néphrologue. La grande majorité des répondants (80 %) se disait satisfaite du nombre d'heures travaillées actuellement. Cependant, 13,1 % des néphrologues en poste ont l'intention de réduire leurs heures de travail au cours des trois prochaines années, 8,2 % prévoient de le faire dans les cinq ans alors que 14,2 % envisagent de le faire d'ici dix ans. Quant aux besoins d'effectifs en néphrologie clinique ainsi que pour le volet académique, les chefs de division ont fait des prévisions pour les prochains trois et cinq ans. LIMITES DE L'ÉTUDE: Le taux de participation au sondage ne s'élevait qu'à 48 %. De plus les prévisions concernant les besoins de main-d'œuvre mentionnés dans cette publication ne reflètent pas nécessairement de futures affectations. CONCLUSIONS: Cette enquête sur la situation des effectifs menée par la Société Canadienne de Néphrologie dresse le portrait de la situation actuelle des plans d'avenir individuels des néphrologues, de même que des besoins d'effectifs anticipés par les chefs de division pour les prochains trois et cinq ans. Des travaux ultérieurs devront être réalisés pour mieux arrimer la planification de la main-d'œuvre en néphrologie au Canada au développement de stratégies solides se penchant à la fois sur les besoins sociétaux et ceux des néphrologues concernant les réalités du marché du travail.

A real-time locating system observes physician time-motion patterns during walk-rounds: a pilot study.

BACKGROUND: Walk-rounds, a common component of medical education, usually consist of a combination of teaching outside the patient room as well as in the presence of the patient, known as bedside teaching. The proportion of time dedicated to bedside teaching has been declining despite research demonstrating its benefits. Increasing complexities of patient care and perceived impediments to workflow are cited as reasons for this declining use. Research using real-time locating systems (RTLS) has been purported to improve workflow through monitoring of patients and equipment. We used RTLS technology to observe and track patterns of movement of attending physicians during a mandatory once-weekly medical teaching team patient care rounding session endorsed as a walk-rounds format. METHODS: During a project to assess the efficacy of RTLS technology to track equipment and patients in a clinical setting, we conducted a small-scale pilot study to observe attending physician walk-round patterns during a mandatory once-weekly team rounding session. A consecutive sample of attending physicians on the unit was targeted, eight agreed to participate. Data collected using the RTLS were pictorially represented as linked points overlaying a floor plan of the unit to represent each physician's motion through time. Visual analysis of time-motion was independently performed by two researchers and disagreement resolved through consensus. Rounding events were described as a sequence of approximate proportions of time engaged within or outside patient rooms. RESULTS: The patient care rounds varied in duration from 60 to 425 minutes. Median duration of rounds within patient rooms was approximately 33% of total time (range approximately 20-50%). Three general time-motion rounding patterns were observed: a first pattern that predominantly involved rounding in ward hallways and little time in patient rooms; a second pattern that predominantly involved time in a ward conference room; and a third balanced pattern characterized by equal proportions of time in patient rooms and in ward hallways. CONCLUSIONS: Observation using RTLS technology identified distinct time-motion rounding patterns that hint at differing rounding styles across physicians. Future studies using this technology could examine how the division of time during walk-rounds impacts outcomes such as patient satisfaction, learner satisfaction, and physician workflow.

Risk factors associated with hemodialysis central venous catheter malfunction; a retrospective analysis of a randomized controlled trial.

BACKGROUND: We previously reported a reduction in central venous catheter (CVC) malfunction when using once-weekly recombinant tissue-plasminogen activator (rt-PA) as a locking solution, compared with thrice-weekly heparin. OBJECTIVES: To identify risk factors for CVC malfunction to inform a targeted strategy for rt-PA use. DESIGN: Retrospective analysis. SETTING: Canadian hemodialysis (HD) units. PATIENTS: Adults with newly placed tunnelled upper venous system CVCs randomized to a locking solution of rt-PA(1 mg/mL) mid-week and heparin (5000 u/ml) on the other HD sessions, or thrice-weekly heparin (5000 u/ml). MEASUREMENTS: CVC malfunction (the primary outcome) was defined as: peak blood flow less than 200 mL/min for thirty minutes during a HD session; mean blood flow less than 250 mL/min for two consecutive HD sessions; inability to initiate HD. METHODS: Cox regression was used to determine the association between patient demographics, HD session CVC-related variables and the outcome of CVC malfunction. RESULTS: Patient age (62.4 vs 65.4 yr), proportion female sex (35.6 vs 48.4%), and proportion with first catheter ever (60.7 vs 61.3%) were similar between patients with and without CVC malfunction. After multivariate analysis, risk factors for CVC malfunction were mean blood processed < 65 L when compared with ≥ 85 L in the prior 6 HD sessions (HR 4.36; 95% CI, 1.59 to 11.95), and mean blood flow < 300 mL/min, or 300 - 324 mL/min in the prior 6 HD sessions (HR 7.65; 95% CI, 2.78 to 21.01, and HR 5.52; 95% CI, 2.00 to 15.23, respectively) when compared to ≥ 350 mL/min. LIMITATIONS: This pre-specified post-hoc analysis used a definition of CVC malfunction that included blood flow, which may result in an overestimate of the effect size. Generalizability of results to HD units where trisodium citrate locking solution is used may also be limited. CONCLUSIONS: HD session characteristics including mean blood processed and mean blood flow were associated with CVC malfunction, while patient characteristics were not. Whether targeting these patients at greater risk of CVC malfunction with rt-PA as a locking solution improves CVC longevity remains to be determined.

CONTEXTE: Nous avons précédemment fait rapport d'une réduction du dysfonctionnement du cathéter veineux central (CVC) lors de l'utilisation hebdomadaire de l'activateur tissulaire du plasminogène obtenu par génie génétique (rt-PA) comme solution verrou, plutôt que l'administration d'héparine trihebdomadaire. OBJECTIFS: Déterminer les facteurs de risques de dysfonctionnement du CVC afin d'indiquer une stratégie visée quant à l'utilisation du rt-PA. TYPE D'ÉTUDE: Analyse rétrospective. CONTEXTE: Les services canadiens d'hémodialyse (HD). PARTICIPANTS: Adultes à qui on a nouvellement installé un CVC tunnellisé intravasculaire dans le système veineux supérieur, et qui ont reçu soit une solution verrou de rt-PA (1 mg/ml) en milieu de semaine et de l'héparine (5 000 u/ml) lors des autres séances d'HD, soit de l'héparine trois fois par semaine (5 000 u/ml). MESURES: On a défini le dysfonctionnement du CVC (résultat primaire) comme étant : un débit sanguin de pointe inférieur à 200 mL/min durant trente minutes, au cours d'une séance d'HD; un débit sanguin moyen inférieur à 250 mL/min lors de deux séances d'HD consécutives; l'impossibilité d'entamer l'HD. MÉTHODES: On a eu recours au modèle de régression de Cox pour déterminer l'association entre les données démographiques des participants, les variables relatives au CVC lors des séances d'HD et le résultat d'un dysfonctionnement du CVC. RÉSULTATS: L'âge des participants (62,4 c. 65,4 ans), la proportion des participants de sexe féminin (35,6% c. 48,4%), et la proportion de ceux à qui on a installé un cathéter pour la première fois (60,7% c. 61,3%) étaient similaires entre les patients qui ont subi un dysfonctionnement du CVC et ceux qui n'en ont pas subi. L'analyse multifactorielle révèle que les facteurs de risque liés au dysfonctionnement du CVC sont un traitement moyen du sang < 65 L, comparativement à ≥ 85 L au cours des 6 séances d'HD précédentes (HR 4,36; 95% CI, 1,59 à 11,95), et un débit sanguin moyen < 300 mL/min, ou 300 ­ 324 mL/min lors des 6 séances d'HD précédentes (HR 7,65; 95% CI, 2,78 à 21,01, et HR 5,52; 95% CI, 2,00 à 15,23, respectivement), comparativement à ≥ 350 mL/min. LIMITES DE L'ÉTUDE: Cette analyse prédéterminée et post-hoc reposait sur une définition du dysfonctionnement du CVC qui comprenait le débit sanguin, ce qui pourrait résulter en une surestimation de l'ampleur de l'effet réel. La validité externe des résultats pour les services d'HD qui utilisent le citrate trisodique comme solution verrou pourrait aussi être limitée. CONCLUSIONS: Les caractéristiques des séances d'HD comprenant le traitement moyen du sang et le débit sanguin moyen ont été associées au dysfonctionnement du CVC, alors que les caractéristiques des participants ne l'ont pas été. Il reste à déterminer si le fait de cibler les patients courant un risque accru de dysfonctionnement du CVC avec rt-PA comme solution verrou améliore la longévité du CVC.

Assessment of the Siksika chronic disease nephropathy-prevention clinic.

OBJECTIVE: To determine if a community-based multifactorial intervention clinic led by a nurse practitioner would improve management of First Nations people at risk of developing chronic kidney disease. DESIGN: Qualitative descriptive study. SETTING: A nephropathy-prevention clinic in Siksika Nation, Alta. PARTICIPANTS: First Nations people with diabetes, hypertension, or dyslipidemia who were referred to the clinic. MAIN OUTCOME MEASURES: Changes in blood pressure (BP), hemoglobin A(1c), and low-density lipoprotein levels, as well as in use of antiplatelet therapy, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker medications, and statin therapy. RESULTS: Members of the Siksika Nation were treated according to clinical practice guidelines. A total of 78 patients had at least 2 visits to the clinic and were included in this analysis (61.5% were women; mean age 56 years). Among those initially above target, a significant reduction was achieved in mean hemoglobin A(1c) (0.96%; P < .01), systolic BP (15.84 mm Hg; P < .05), diastolic BP (7.16 mm Hg; P < .001), and low-density lipoprotein (0.62 mmol/L; P < .01) levels. There was a significant increase in the proportion of patients with clinical indications who were treated with acetylsalicylic acid (42.4%; P < .01), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker medications (35.9%; P < .01), or statin therapy (35.9%; P < .01). CONCLUSION: A community-based, nurse practitioner-led clinic can improve many clinically relevant factors in patients at risk of developing chronic kidney disease. Studies have shown that achieving treatment targets is associated with a reduced risk of early death and cardiovascular events; the effect in the First Nations population on these hard clinical end points remains to be determined.

X-ray structures of cyclophanes derived from naphtho[1,2-c:5,6-c]difuran and the synthesis, structure, and reaction kinetics of its 1,3,6,8-tetrasilylated derivative.

A silylated derivative of naphtho[1,2-c:5,6-c]difuran, 1,3,6,8-tetrakis(tert-butyldimethylsilyl)naphtho[1,2-c:5,6-c]difuran, has been isolated and its X-ray crystal structure determined. Bond localization confirms the polyene character of this isobenzofuran ring system. This molecule undergoes two successive Diels-Alder reactions with second-order rate constants differing by over 2 orders of magnitude, consistent with predictions based on their structure-count ratios and with the reactivity of the novel 1,3-bis(tert-butyldimethylsilyl)isobenzofuran. Crystal structures of two cyclophanes derived from the reaction of naphtho[1,2-c:5,6-c]difuran and bis(imide) or bis(ester) dienophiles show marked differences in the conformation of the aliphatic chain found in the solid state.