End-of-Life Care Among Patients With Kidney Failure on Maintenance Dialysis: A Retrospective Population-Based Study.

Background: Nephrologists routinely provide end-of-life care for patients with kidney failure (KF) on maintenance dialysis. Involvement of primary care and palliative care physicians may enhance this experience. Objective: The objective was to describe outpatient care patterns in the last year of life and the end-of-life acute care utilization for patients with KF on maintenance dialysis. Design: Retrospective cohort study using population-level health administrative data. Setting & Participants: Outpatient and inpatient care during the last year of life among patients who died between 2017 and 2019, receiving maintenance dialysis in Ontario, Canada. Measurements: The primary exposure is patterns of physician specialties providing outpatient care in the last year of life. Outcomes include outpatient encounters in the last year of life, acute care visitation in the last month of life, and place of death. Methods: We reported the count and percentage of categorical outcomes and the median (interquartile range) for numeric outcomes. We produced time series plots of the mean monthly percentage of encounters to different specialties stratified by physician specialty patterns. We evaluated differences in outcomes by physician specialty patterns using analysis of variance (ANOVA) and Pearson's chi-square tests (P < .05, two-tailed). Results: Among 6866 patients, the median age at death was 73, 36.1% were female, and 87.8% resided in urban regions. Three patterns emerged: a primary care, nephrology, and palliative care triad (25.5%); a primary care and nephrology dyad (59.3%); and a non-primary care pattern (15.2%). Palliative care involvement is concentrated near death. Of all, 81.4% spent at least 1 day in hospital or emergency department in the last month, but those with primary care, palliative care, and nephrology involvement had the fewest acute care deaths (65.8%). Limitations: Outpatient care patterns were defined using physician billing codes, potentially missing care from other providers. Conclusions: Nephrology and primary care predominantly manage outpatient care in the last year of life for patients with KF on maintenance dialysis, with consistent acute care use across care patterns except for the place of death. Future research should explore associations between patterns of care and end-of-life outcomes to identify the most optimal model of care for patients with KF on maintenance dialysis.

Contexte: Il est courant pour les néphrologues de prodiguer des soins de fin de vie aux patients souffrant d'insuffisance rénale (IR) sous dialyse d'entretien. Cette expérience pourrait être enrichie par la participation des médecins des unités de soins primaires et de soins palliatifs. Objectif: Cette étude visait à décrire les modèles de soins ambulatoires prodigués au cours de la dernière année de vie et l'utilisation des soins aigus en fin de vie chez les patients atteints d'IR sous dialyse d'entretien. Conception: Étude de cohorte populationnelle rétrospective réalisée à partir des données administratives du système de santé. Cadre et sujets de l'étude: Les soins ambulatoires et hospitaliers au cours de la dernière année de vie chez les patients décédés sous dialyse d'entretien entre 2017 et 2019 en Ontario (Canada). Mesures: La principale mesure est le profil des spécialités médicales qui fournissent des soins ambulatoires dans la dernière année de vie. Les données recueillies comprennent les consultations externes au cours de la dernière année de vie, les visites en soins aigus au cours du dernier mois de vie et le lieu du décès. Méthodologie: Nous avons rapporté le nombre et le pourcentage de résultats catégoriels, ainsi que la médiane (écart interquartile) des résultats numériques. Nous avons produit des graphiques chronologiques du pourcentage mensuel moyen de consultations avec différentes spécialités, stratifiées selon les spécialités médicales. Nous avons évalué les différences dans les résultats selon les profils de spécialités médicales en utilisant les tests ANOVA et Chi-Square de Pearson (P <,05; bilatéral). Résultats: Des 6 866 patients inclus (âge médian au décès: 73 ans), 36,1% étaient des femmes et 87,8% vivaient en région urbaine. Trois modèles sont apparus: une triade soins primaires, néphrologie et soins palliatifs (25,5%); une dyade soins primaires et néphrologie (59,3%); et un modèle de soins non primaires (15,2%). La participation des soins palliatifs est concentrée autour du moment du décès. Une grande majorité des patients (81,4%) avait passé au moins une journée à l'hôpital ou aux urgences au cours du dernier mois, mais les personnes qui avaient bénéficié d'une triade de soins (primaires, néphrologie et soins palliatifs) présentaient une moins grande proportion de décès en soins aigus (65,8%). Limites: Les modèles de soins ambulatoires ont été définis à l'aide des codes de facturation des médecins, ce qui pourrait avoir exclu les soins dispensés par d'autres prestataires. Conclusion: Les soins ambulatoires au cours de la dernière année de vie des patients atteints d'IR sous dialyse d'entretien sont principalement prodigués par la néphrologie et les soins primaires, avec une utilisation constante des soins aigus dans tous les modèles de soins, sauf pour le lieu du décès. Les futures recherches devraient explorer les liens entre les modèles de soins et les résultats en fin de vie afin d'identifier le modèle de soins le plus optimal pour les patients atteints d'IR sous dialyse d'entretien.

Environmental Light Controls the Daily Organization of Breathing by Activating Brn3b-expressing Intrinsically Photosensitive Retinal Ganglion Cells in Mice.

Rhythmic, daily fluctuations in minute ventilation are controlled by the endogenous circadian clock located in the suprachiasmatic nucleus (SCN). While light serves as a potent synchronizer for the SCN, it also influences physiology and behavior by activating Brn3b-expressing, intrinsically photosensitive retinal ganglion cells (ipRGCs). It is currently unclear the extent to which the external light environment shapes daily ventilatory patterns independent of the SCN. To determine the relative influence of environmental light versus circadian timing on the organization of daily rhythms in minute ventilation, we used whole-body plethysmography to measure the breathing of mice housed on a non-entraining T28 cycle (14 h light:14 h dark). Using this protocol, we found that minute ventilation exhibits a ~28-h rhythm with a peak at dark onset that coincides with the light:dark cycle and the animals' locomotor activity. To determine if this 28-h rhythm in minute ventilation was mediated by Brn3b-expressing ipRGCs, we measured the breathing of Brn3bDTA mice housed under the T28 cycle. Brn3bDTA mice lack the Brn3b-expressing ipRGCs that project to many non-SCN brain regions. We found that despite rhythmic light cues occurring on a 28-h basis, Brn3bDTA mice exhibited 24-h rhythms in minute ventilation, locomotor activity, and core body temperature consistent with organization by the SCN. The 24-h minute ventilation rhythm of Brn3bDTA mice was found to be driven predominantly by tidal volume rather than respiratory rate. These data indicate that the external light:dark cycle can directly drive daily patterns in minute ventilation by way of Brn3b-expressing ipRGCs. In addition, these data strongly suggest that the activation of Brn3b-expressing ipRGCs principally organizes daily patterns in breathing and locomotor activity when light:dark cues are presented in opposition to endogenous clock timing.

Characteristics of family physicians with additional training or focused practices in caring for older adults: Population-based retrospective cohort study.

OBJECTIVE: To identify FPs with additional training and focused practice activities relevant to the needs of older patients within health administrative data and to describe their medical practices and service provision in community-based primary care settings. DESIGN: Retrospective cohort study. SETTING: Ontario. PARTICIPANTS: Family physicians with Certificates of Added Competence in care of the elderly from the College of Family Physicians of Canada or focused practice billing designations in care of the elderly. MAIN OUTCOME MEASURES: Evidence of additional training or certification in care of the elderly or practice activities relevant to the care of older adults. RESULTS: Of 14,123 FPs, 242 had evidence of additional scope to better support older adults. These FPs mainly practised in team-based care models, tended to provide comprehensive care, and billed for core primary care services. In an unadjusted analysis, factors statistically significantly associated with greater likelihood of having additional training or focused practices relevant to the care of older patients included physician demographic characteristics (eg, female sex, having completed medical school in Canada, residential instability at the community level), primary care practice model (ie, focused practice type), primary care activities (eg, more likely to provide consultations, practise in long-term care, refer patients to psychiatry and geriatrics, bill for complex house call assessments, bill for home care applications, and bill for long-term care health report forms), and patient characteristics (ie, older average age of patients). CONCLUSION: The FP workforce with additional training or focused practices in caring for older patients represents a small but specialized group of providers who contribute a portion of the total primary care activities for older adults. Health human resource planning should consider the contributions of all FPs who care for older adults, and enhancing geriatric competence across the family medicine workforce should be emphasized.

Implementing a National Nursing and Midwifery Digital Health Capability Framework: Exploring Knowledge, Experience in Informatics and Barriers and Enablers.

A National Nursing and Midwifery Digital Health Capability Framework was developed in 2020 to define and complement digital health knowledge and skills for professional practice. This mixed-methods study explored nurses' and midwives' Framework knowledge and its applicability, types and extent of nursing and midwifery informatics roles, and barriers and enablers to working in informatics. Survey respondents reported familiarity with the Framework, with content analysis identifying three themes - informatics as part of nursing or midwifery roles, descriptions and variability of informatics roles, and the need for informatics role development and recognition. Framework knowledge can be improved through standardised and defined roles and a career pathway that includes national, organisational, local, and individual support.

Evaluation and Optimisation of a Patient Portal Implementation: An Action Research Approach.

Patient portals can support care delivery and have demonstrated mixed impacts on patients, clinicians and health services. These variable impacts are primarily due to barriers to uptake and challenges associated with successfully implementing patient portals. As little is currently known about how implementation barriers can be addressed in practice, this project used an action research approach to evaluate and optimise the implementation of a patient portal in a real-world setting. Whilst the study is ongoing, the preliminary findings are reported in this paper, along with plans to use the findings to improve the portal in the next round of the action research cycle.

Loss of endogenous circadian clock function in mice alters respiratory cycle timing in a time of day- and sex-specific manner.

Resting breathing and ventilatory chemoreflexes are regulated in a 24-hr manner by the endogenous circadian clock. However, it is unclear how circadian biology influences different phases of the breath-to-breath respiratory cycle which are predominantly controlled by pontomedullary regions of the brainstem. Here, we performed whole-body plethysmography during quiet wakefulness in young adult male and female mice lacking the core clock gene Brain and Muscle Arnt-like 1 (BMAL1) to determine the extent to which the molecular clock affects respiratory cycle timing and ventilatory airflow mechanics. Breath waveform analysis revealed that male BMAL1 knockout (KO) mice exhibit time of day-specific differences in inspiratory and expiratory times, total cycle length, end inspiratory pause, relaxation time, and respiratory rate compared to wild-type littermates. Notably, changes in respiratory pattern were not observed in female BMAL1 KO mice when compared to wild-type females. Additionally, BMAL1 deficiency did not disrupt overall minute ventilation or peak airflow in either sex, suggesting total ventilatory function during quiet wakefulness is preserved. Taken together, these findings indicate that genetic disruption of the circadian clock in mice elicits sex-specific changes in respiratory cycle timing.

Length of Postpartum Hospital Stays During COVID-19: Findings From a Convergent Parallel Mixed-Methods Study.

OBJECTIVES: We examined the length of postpartum hospitalization for live births during the COVID-19 pandemic and explored how pandemic circumstances influenced postpartum hospital experiences. METHODS: We conducted a cross-provincial, convergent parallel mixed-methods study in Ontario (ON) and British Columbia (BC), Canada. We included birthing persons (BPs) with an in-hospital birth in ON from 1 January to 31 March 2019, 2021, and 2022 (quantitative), and BPs (≥18 years) in ON or BC from 1 May 2020 to 1 December 2021 (qualitative). We linked multiple health administrative datasets at ICES and developed multivariable linear regression models to examine the length of hospital stay (quantitative). We conducted semi-structured interviews using qualitative descriptive to understand experiences of postpartum hospitalization (qualitative). Data integration occurred during design and interpretation. RESULTS: Relative to 2019, postpartum hospital stays decreased significantly by 3.29 hours (95% CI -3.58 to -2.99; 9.2% reduction) in 2021 and 3.89 hours (95% CI -4.17 to -3.60; 9.0% reduction) in 2022. After adjustment, factors associated with shortened stays included: giving birth during COVID-19, social deprivation (more ethnocultural diversity), midwifery care, multiparity, and lower newborn birth weight. Postpartum hospital experiences were impacted by risk perception of COVID-19 infection, clinical care and hospital services/amenities, visitor policies, and duration of stay. CONCLUSIONS: Length of postpartum hospital stays decreased during COVID-19, and qualitative findings described unmet needs for postpartum services. The integration of large administrative and interview data expanded our understanding of observed differences. Future research should investigate the impacts of shortened stays on health service outcomes and personal experiences.

Prevalence and population attributable fractions of potentially modifiable risk factors for dementia in Canada: A cross-sectional analysis of the Canadian Longitudinal Study on Aging.

OBJECTIVES: We investigated the prevalence and population attributable fraction (PAF) of 12 potentially modifiable risk factors for dementia in middle-aged and older Canadians. METHODS: We conducted a cross-sectional study of 30,097 adults aged 45 to 85 with baseline data from the Canadian Longitudinal Study on Aging (2011‒2015). Risk factors and associated relative risks were taken from a highly cited systematic review. We calculated the prevalence of each risk factor using sampling weights. Individual PAFs were calculated both crudely and weighted for communality, and combined PAFs were calculated using both multiplicative and additive assumptions. Analyses were stratified by household income and repeated at CLSA's first follow-up (2015‒2018). RESULTS: The most prevalent risk factors were physical inactivity (63.8%; 95% CI, 62.8-64.9), hypertension (32.8%; 31.7-33.8), and obesity (30.8%; 29.7-31.8). The highest crude PAFs were physical inactivity (19.9%), traumatic brain injury (16.7%), and hypertension (16.6%). The highest weighted PAFs were physical inactivity (11.6%), depression (7.7%), and hypertension (6.0%). We estimated that the 12 risk factors combined accounted for 43.4% (37.3‒49.0) of dementia cases assuming weighted multiplicative interactions and 60.9% (55.7‒65.5) assuming additive interactions. There was a clear gradient of increasing prevalence and PAF with decreasing income for 9 of the 12 risk factors. CONCLUSION: The findings of this study can inform individual- and population-level dementia prevention strategies in Canada. Differences in the impact of individual risk factors between this study and other international and regional studies highlight the importance of tailoring national dementia strategies to the local distribution of risk factors.

RéSUMé: OBJECTIFS: Nous avons étudié la prévalence et la fraction attribuable dans la population (FAP) de 12 facteurs de risque de démence potentiellement modifiables chez les Canadiens d'âge moyen et plus âgés. MéTHODE: Nous avons mené une étude transversale de 30 097 adultes de 45 à 85 ans à l'aide des données de référence de l'Étude longitudinale canadienne sur le vieillissement (ELCV) (2011‒2015). Les facteurs de risque et les risques relatifs associés ont été extraits d'une revue systématique fréquemment citée. Nous avons calculé la prévalence de chaque facteur de risque à l'aide de poids d'échantillonnage. Les FAP individuelles ont été calculées à la fois sous forme brute et pondérées selon leurs points communs; les FAP combinées ont été calculées à l'aide d'hypothèses multiplicatives et additives. Les analyses ont été stratifiées selon le revenu du ménage et répétées au premier suivi de l'ELCV (2015‒2018). RéSULTATS: Les facteurs de risque les plus prévalents étaient la sédentarité (63,8 %; IC de 95%, 62,8­64,9), l'hypertension artérielle (32,8 %; 31,7­33,8) et l'obésité (30,8 %; 29,7­31,8). Les FAP brutes les plus élevées étaient la sédentarité (19,9 %), les traumatismes cranio-cérébraux (16,7 %) et l'hypertension artérielle (16,6 %). Les FAP pondérées les plus élevées étaient la sédentarité (11,6 %), la dépression (7,7 %) et l'hypertension artérielle (6,0 %). Selon nos estimations, les 12 facteurs de risque combinés représentaient 43,4 % (37,3‒49,0) des cas de démence en supposant des interactions multiplicatives pondérées et 60,9 % (55,7‒65,5) en supposant des interactions additives. Il y avait clairement un gradient d'accroissement de la prévalence et de la FAP avec la diminution du revenu pour 9 des 12 facteurs de risque. CONCLUSION: Les constats de l'étude peuvent éclairer les stratégies individuelles et populationnelles de prévention de la démence au Canada. Les différences d'impact des facteurs de risque individuels entre cette étude et d'autres études internationales et régionales montrent l'importance d'adapter les stratégies nationales de prévention de la démence à la répartition locale des facteurs de risque.

Trends of Peanut-Induced Anaphylaxis Rates Before and After the 2017 Early Peanut Introduction Guidelines in Montreal, Canada.

BACKGROUND: Food allergies, particularly peanut, represent the predominant cause of anaphylaxis. Whereas early allergen introduction has emerged as a potential preventive strategy, the precise impact of recent guidelines on peanut-induced anaphylaxis rates in Canada remains unclear. OBJECTIVE: To assess the impact of the 2017 Addendum Guidelines for the Prevention of Peanut Allergy on peanut-induced anaphylaxis rates in Canada. METHODS: Using a comprehensive longitudinal registry capturing pediatric anaphylaxis presentations to the Montreal's Children's Hospital, we compared children with and without known peanut allergy who presented with peanut-induced anaphylaxis between 2011 and 2019 inclusive, excluding data beyond 2019 owing to the Coronavirus disease 2019 (COVID-19) pandemic. We calculated rates of peanut-induced anaphylaxis presentations per 100,000 age-adjusted all-cause emergency department visits using 4-month intervals. Interrupted time series analysis was used to compare anaphylaxis rate trends before and after 2017 for children ages 0 to 2 and 3 to 17 years. RESULTS: We examined 2,011 cases of pediatric anaphylaxis, including 429 (21%) triggered by peanuts. Compared with pre-guideline estimates, the yearly rate of change of peanut anaphylaxis rates decreased by 7.96 (95% confidence interval -14.57 to -1.36; P = .018) after 2017 among patients with new-onset anaphylaxis in children 2 years of age or younger (n = 109). No significant changes were identified for older patients ages 3 to 17, or in patients with known peanut allergy. CONCLUSIONS: Early introduction guidelines in Canada are associated with a reduced risk of new-onset peanut-induced anaphylaxis in young children within a single center in Montreal. Further research is required to assess the impact on a wider population and other food allergens.

Time-restricted feeding reveals a role for neural respiratory clocks in optimizing daily ventilatory-metabolic coupling in mice.

The master circadian clock, located in the suprachiasmatic nuclei (SCN), organizes the daily rhythm in minute ventilation (V̇e). However, the extent that the daily rhythm in V̇e is secondary to SCN-imposed O2 and CO2 cycles (i.e., metabolic rate) or driven by other clock mechanisms remains unknown. Here, we experimentally shifted metabolic rate using time-restricted feeding (without affecting light-induced synchronization of the SCN) to determine the influence of metabolic rate in orchestrating the daily V̇e rhythm. Mice eating predominantly at night exhibited robust daily rhythms in O2 consumption (V̇o2), CO2 production (V̇co2), and V̇e with similar peak times (approximately ZT18) that were consistent with SCN organization. However, feeding mice exclusively during the day separated the relative timing of metabolic and ventilatory rhythms, resulting in an approximately 8.5-h advance in V̇co2 and a disruption of the V̇e rhythm, suggesting opposing circadian and metabolic influences on V̇e. To determine if the molecular clock of cells involved in the neural control of breathing contributes to the daily V̇e rhythm, we examined V̇e in mice lacking BMAL1 in Phox2b-expressing respiratory cells (i.e., BKOP mice). The ventilatory and metabolic rhythms of predominantly night-fed BKOP mice did not differ from wild-type mice. However, in contrast to wild-type mice, exclusive day feeding of BKOP mice led to an unfettered daily V̇e rhythm with a peak time aligning closely with the daily V̇co2 rhythm. Taken together, these results indicate that both daily V̇co2 changes and intrinsic circadian time-keeping within Phox2b respiratory cells are predominant orchestrators of the daily rhythm in ventilation.NEW & NOTEWORTHY The master circadian clock organizes the daily rhythm in ventilation; however, the extent that this rhythm is driven by SCN regulation of metabolic rate versus other clock mechanisms remains unknown. We report that metabolic rate alone is insufficient to explain the daily oscillation in ventilation and that neural respiratory clocks within Phox2b-expressing cells additionally optimize breathing. Collectively, these findings advance our mechanistic understanding of the circadian rhythm in ventilatory control.

Using Patient-Specific 3D Modeling and Simulations to Optimize Microwave Ablation Therapy for Liver Cancer.

Microwave ablation (MWA) of liver tumors presents challenges like under- and over-ablation, potentially leading to inadequate tumor destruction and damage to healthy tissue. This study aims to develop personalized three-dimensional (3D) models to simulate MWA for liver tumors, incorporating patient-specific characteristics. The primary objective is to validate the predicted ablation zones compared to clinical outcomes, offering insights into MWA before therapy to facilitate accurate treatment planning. Contrast-enhanced CT images from three patients were used to create 3D models. The simulations used coupled electromagnetic wave propagation and bioheat transfer to estimate the temperature distribution, predicting tumor destruction and ablation margins. The findings indicate that prolonged ablation does not significantly improve tumor destruction once an adequate margin is achieved, although it increases tissue damage. There was a substantial overlap between the clinical ablation zones and the predicted ablation zones. For patient 1, the Dice score was 0.73, indicating high accuracy, with a sensitivity of 0.72 and a specificity of 0.76. For patient 2, the Dice score was 0.86, with a sensitivity of 0.79 and a specificity of 0.96. For patient 3, the Dice score was 0.8, with a sensitivity of 0.85 and a specificity of 0.74. Patient-specific 3D models demonstrate potential in accurately predicting ablation zones and optimizing MWA treatment strategies.

Long-Term Functional Limitations and Predictors of Recovery After COVID-19: A Multicenter Prospective Cohort Study.

BACKGROUND: Limited data exist on post-severe COVID-19 functional trajectory, particularly considering premorbid status. We characterized 1-year functional recovery post-hospitalization for COVID-19, highlighting predictors of long-term recovery. METHODS: We enrolled adult patients with lab-confirmed SARS-CoV-2 infection and hospitalized for COVID-19 sequelae, from five major Ontario, Canada hospitals in a prospective cohort study. Assessments included telephone interviews on admission followed by telephone and in-person assessments at 3-, 6-, 9-, and 12-months post-discharge. The Activity-Measure for Post-Acute Care (AM-PAC) Mobility and Cognition scales were administered at baseline and every 3 months for 1 year. Secondary outcomes included symptoms, spirometry, physical performance, dyspnea, fatigue, distress, anxiety and depression, and quality of life. RESULTS: A total of 254 patients (57.1% male) with a mean age of 60.0 (±13.1) years and an average hospital stay of 14.3 (±19.7) days agreed to participate. At 12 months, 55.3% demonstrated clinically important deficits in mobility and 38.8% had cognitive deficits compared to premorbid levels. Fatigue was reported in 44.2%, followed by difficulty walking long distances in 35.8% and dyspnea in 33.0%. Almost 40% of patients had an FEV1(% Pred) < 80% at 12 months, 60.3% had impairments in physical performance, and 44.5% had problems with anxiety or depression. Predictors of better mobility at 12 months included higher premorbid mobility status, male sex, shorter hospital stay, fewer comorbidities, and higher FEV1 (% pred) at the 3-month follow-up. CONCLUSIONS: Our study provides compelling evidence of the long-term impact of COVID-19 on functional and cognitive status 1-year post-infection.

Evaluating the Association between the Implementation of the PoET (Prevention of Error-Based Transfers) Southwest Spread Project and Palliative Care Provision: A Quasi-Experimental Matched Cohort Study Using Population-Level Health Administrative Data.

OBJECTIVES: The PoET (Prevention of Error-based Transfers) project seeks to align long-term care (LTC) home informed consent practices to existing legislation, thereby reducing consent-related error-based transfers to acute care. We sought to measure changes in resident-level palliative care provision after participating in the PoET Southwest Spread Project (PSSP), and to identify patient and LTC home characteristics associated with palliative care provision. DESIGN: Quasi-experimental matched (1:1 ratio) cohort study design using linked population-based health administrative data. SETTING: Sixty LTC homes (PSSP = 30; Control = 30) in Ontario, Canada, from November 2019 to December 2021. METHODS: We matched 30 PSSP to 30 control homes and described incidence rates for resident-level palliative care provision (ie, physician palliative care encounters and palliative medication prescriptions) during the 7-month postimplementation period. We used generalized linear mixed models to evaluate the association between PSSP implementation and palliative care provision during the postimplementation period. We adjusted for resident-level characteristics (ie, age, sex, comorbidity status) and home-level characteristics (ie, rurality status, profit model, COVID-19 impact). We identified a decedent subcohort to measure palliative care provision patterns during the last 2 months of life. RESULTS: We captured a matched cohort of 8894 residents (PSSP = 4103; Control = 4791). Incidence rates of palliative care encounters increased during the postimplementation period for PSSP (82.6 to 85.4 per 100 person-months) but not for control residents (68.8 to 65.3 per 100 person-months). After adjusting for key covariates, PSSP exposure was associated increased palliative care provision (incidence rate ratio 2.47, 95% CI 2.31-2.64) and palliative care medication prescription (1.16, 95% CI 1.12-1.20). Larger home size, certain health regions, and higher number of comorbidities were associated with increased physician palliative care encounters. CONCLUSIONS AND IMPLICATIONS: By promoting correct informed consent practices in LTC, PSSP participation increased palliative care provision for PSSP LTC residents across all settings.

A Case of Tizanidine Withdrawal and Road to Recovery.

This case report highlights the complexities of tizanidine withdrawal in a 68-year-old woman with chronic pain. Tizanidine, a widely used imidazole-derived muscle relaxant, poses challenges due to the absence of standardized withdrawal protocols. The patient's presentation included hypertension and tachycardia following a gradual reduction in her outpatient tizanidine dose. During the de-escalation of tizanidine, the patient experienced withdrawal symptoms, including severe body aches, hypertension, and tachycardia. Management during withdrawal involved a unique approach using a one-time dose of phenobarbital, a measure that allowed the resolution of hemodynamic instability and pain with complete discontinuation of tizanidine. The ultimate decision to transition the patient to methocarbamol and stop taking tizanidine for pain control highlights the importance of individualized care. The patient has responded to this therapy upon follow-up.

Evaluating methods for risk prediction of Covid-19 mortality in nursing home residents before and after vaccine availability: a retrospective cohort study.

BACKGROUND: SARS-CoV-2 vaccines are effective in reducing hospitalization, COVID-19 symptoms, and COVID-19 mortality for nursing home (NH) residents. We sought to compare the accuracy of various machine learning models, examine changes to model performance, and identify resident characteristics that have the strongest associations with 30-day COVID-19 mortality, before and after vaccine availability. METHODS: We conducted a population-based retrospective cohort study analyzing data from all NH facilities across Ontario, Canada. We included all residents diagnosed with SARS-CoV-2 and living in NHs between March 2020 and July 2021. We employed five machine learning algorithms to predict COVID-19 mortality, including logistic regression, LASSO regression, classification and regression trees (CART), random forests, and gradient boosted trees. The discriminative performance of the models was evaluated using the area under the receiver operating characteristic curve (AUC) for each model using 10-fold cross-validation. Model calibration was determined through evaluation of calibration slopes. Variable importance was calculated by repeatedly and randomly permutating the values of each predictor in the dataset and re-evaluating the model's performance. RESULTS: A total of 14,977 NH residents and 20 resident characteristics were included in the model. The cross-validated AUCs were similar across algorithms and ranged from 0.64 to 0.67. Gradient boosted trees and logistic regression had an AUC of 0.67 pre- and post-vaccine availability. CART had the lowest discrimination ability with an AUC of 0.64 pre-vaccine availability, and 0.65 post-vaccine availability. The most influential resident characteristics, irrespective of vaccine availability, included advanced age (≥ 75 years), health instability, functional and cognitive status, sex (male), and polypharmacy. CONCLUSIONS: The predictive accuracy and discrimination exhibited by all five examined machine learning algorithms were similar. Both logistic regression and gradient boosted trees exhibit comparable performance and display slight superiority over other machine learning algorithms. We observed consistent model performance both before and after vaccine availability. The influence of resident characteristics on COVID-19 mortality remained consistent across time periods, suggesting that changes to pre-vaccination screening practices for high-risk individuals are effective in the post-vaccination era.

Potentially Modifiable Risk Factors for Dementia and Mild Cognitive Impairment: An Umbrella Review and Meta-Analysis.

INTRODUCTION: The prevalence of mild and major neurocognitive disorders (NCDs), also referred to as mild cognitive impairment and dementia, is rising globally. The prevention of NCDs is a major global public health interest. We sought to synthesize the literature on potentially modifiable risk factors for NCDs. METHODS: We conducted an umbrella review using a systematic search across multiple databases to identify relevant systematic reviews and meta-analyses. Eligible reviews examined potentially modifiable risk factors for mild or major NCDs. We used a random-effects multi-level meta-analytic approach to synthesize risk ratios for each risk factor while accounting for overlap in the reviews. We further examined risk factors for major NCD due to two common etiologies: Alzheimer's disease and vascular dementia. RESULTS: A total of 45 reviews with 212 meta-analyses were synthesized. We identified fourteen broadly defined modifiable risk factors that were significantly associated with these disorders: alcohol consumption, body weight, depression, diabetes mellitus, diet, hypertension, less education, physical inactivity, sensory loss, sleep disturbance, smoking, social isolation, traumatic brain injury, and vitamin D deficiency. All 14 factors were associated with the risk of major NCD, and five were associated with mild NCD. We found considerably less research for vascular dementia and mild NCD. CONCLUSION: Our review quantifies the risk associated with 14 potentially modifiable risk factors for mild and major NCDs, including several factors infrequently included in dementia action plans. Prevention strategies should consider approaches that reduce the incidence and severity of these risk factors through health promotion, identification, and early management.

Measures of retention in HIV care: A protocol for a mixed methods study.

INTRODUCTION: Retention in HIV care is necessary to achieve adherence to antiretroviral therapy, viral load suppression, and optimal health outcomes. There is no standard definition for retention in HIV care, which compromises consistent and reliable reporting and comparison of retention across facilities, jurisdictions, and studies. OBJECTIVE: The objective of this study is to explore how stakeholders involved in HIV care define retention in HIV care and their preferences on measuring retention. METHODS: We will use an exploratory sequential mixed methods design involving HIV stakeholder groups such as people living with HIV, people involved in providing care for PLHIV, and people involved in decision-making about PLHIV. In the qualitative phase of the study, we will conduct 20-25 in-depth interviews to collect the perspectives of HIV stakeholders on using their preferred retention measures. The findings from the qualitative phase will inform the development of survey items for the quantitative phase. Survey participants (n = 385) will be invited to rate the importance of each approach to measuring retention on a seven-point Likert scale. We will merge the qualitative and quantitative findings phase findings to inform a consensus-building framework for a standard definition of retention in care. ETHICAL ISSUES AND DISSEMINATION: This study has received ethics approval from the Hamilton Integrated Research Ethics Board. The findings will be disseminated through peer-reviewed publications, conference presentations, and among stakeholder groups. LIMITATIONS: This study has limitations; we won't be able to arrive at a standard definition; a Delphi technique amongst the stakeholders will be utilized using the framework to reach a consensus globally accepted definition.

Fully automated deep learning based auto-contouring of liver segments and spleen on contrast-enhanced CT images.

Manual delineation of liver segments on computed tomography (CT) images for primary/secondary liver cancer (LC) patients is time-intensive and prone to inter/intra-observer variability. Therefore, we developed a deep-learning-based model to auto-contour liver segments and spleen on contrast-enhanced CT (CECT) images. We trained two models using 3d patch-based attention U-Net ([Formula: see text] and 3d full resolution of nnU-Net ([Formula: see text] to determine the best architecture ([Formula: see text]. BA was used with vessels ([Formula: see text] and spleen ([Formula: see text] to assess the impact on segment contouring. Models were trained, validated, and tested on 160 ([Formula: see text]), 40 ([Formula: see text]), 33 ([Formula: see text]), 25 (CCH) and 20 (CPVE) CECT of LC patients. [Formula: see text] outperformed [Formula: see text] across all segments with median differences in Dice similarity coefficients (DSC) ranging 0.03-0.05 (p < 0.05). [Formula: see text], and [Formula: see text] were not statistically different (p > 0.05), however, both were slightly better than [Formula: see text] by DSC up to 0.02. The final model, [Formula: see text], showed a mean DSC of 0.89, 0.82, 0.88, 0.87, 0.96, and 0.95 for segments 1, 2, 3, 4, 5-8, and spleen, respectively on entire test sets. Qualitatively, more than 85% of cases showed a Likert score [Formula: see text] 3 on test sets. Our final model provides clinically acceptable contours of liver segments and spleen which are usable in treatment planning.

The Viability and Acceptability of a Virtual Wound Care Command Centre in Australia.

The objective of this study was to assess the viability and acceptability of an innovative Virtual Wound Care Command Centre where patients in the community, and their treating clinicians, have access to an expert wound specialist service that comprises a digital wound application (app) for wound analysis, decision-making, remote consultation, and monitoring. Fifty-one patients with chronic (42.6%) wounds were healed, with a median time to healing of 66 (95% CI: 56-88) days. All patients reported high satisfaction with their wound care, 86.4% of patients recommended the Virtual Wound Care Command Centre with 84.1% of patients reporting the app as easy to use. The data revealed that the Virtual Wound Care Command Centre was a viable and acceptable patient-centred expert wound consultation service for chronic wound patients in the community.

Reshaping Wound Care: Evaluation of an Artificial Intelligence App to Improve Wound Assessment and Management.

This study evaluated the usability and effectiveness of an artificial intelligence application for wound assessment and management from a clinician-and-patient perspective. A quasi-experimental design was conducted in four settings in an Australian health service. Data were collected from patients in the standard (n=166,243 wounds) and intervention (n=124,184 wounds) group, at baseline and post-intervention. Clinicians completed a survey (n=10) and focus group (n=13) and patients were interviewed (n=4). Wound documentation were analysed descriptively, bivariate statistics determined between-group differences, and interviews were thematically analysed. Compared with the standard group, wound documentation in the intervention group improved significantly (<2 items documented 24% vs 70%, P < .001). During the intervention, 101/132 wounds improved (mean wound size reduction=53.99%). Positive evaluations included instantaneous objective wound assessment, shared wound plans increased patient adherence and enhanced efficiency in providing virtual care. Application use facilitated remote patient monitoring and reduced patient travel time while maintaining optimal wound care.