The impact of COVID-19 on the experiences of patients and their family caregivers with medical assistance in dying in hospital.

BACKGROUND: The COVID-19 pandemic and its containment measures have drastically impacted end-of-life and grief experiences globally, including those related to medical assistance in dying (MAiD). No known qualitative studies to date have examined the MAiD experience during the pandemic. This qualitative study aimed to understand how the pandemic impacted the MAiD experience in hospital of persons requesting MAiD (patients) and their loved ones (caregivers) in Canada. METHODS: Semi-structured interviews were conducted with patients who requested MAiD and their caregivers between April 2020 and May 2021. Participants were recruited during the first year of the pandemic from the University Health Network and Sunnybrook Health Sciences Centre in Toronto, Canada. Patients and caregivers were interviewed about their experience following the MAiD request. Six months following patient death, bereaved caregivers were interviewed to explore their bereavement experience. Interviews were audio-recorded, transcribed verbatim, and de-identified. Transcripts were analyzed using reflexive thematic analysis. RESULTS: Interviews were conducted with 7 patients (mean [SD] age, 73 [12] years; 5 [63%] women) and 23 caregivers (mean [SD] age, 59 [11] years; 14 [61%] women). Fourteen caregivers were interviewed at the time of MAiD request and 13 bereaved caregivers were interviewed post-MAiD. Four themes were generated with respect to the impact of COVID-19 and its containment measures on the MAiD experience in hospital: (1) accelerating the MAiD decision; (2) compromising family understanding and coping; (3) disrupting MAiD delivery; and (4) appreciating rule flexibility. CONCLUSIONS: Findings highlight the tension between respecting pandemic restrictions and prioritizing control over the dying circumstances central to MAiD, and the resulting impact on patient and family suffering. There is a need for healthcare institutions to recognize the relational dimensions of the MAiD experience, particularly in the isolating context of the pandemic. Findings may inform strategies to better support those requesting MAiD and their families during the pandemic and beyond.

A Race to the End: Family Caregivers' Experience of Medical Assistance in Dying (MAiD)-a Qualitative Study.

BACKGROUND: The June 2016 legalization of medical assistance in dying (MAiD) provided an added layer of choice to end-of-life care in Canada. Family caregivers play an important role in patient end-of-life decision-making. They may experience unique psychological burden or distress associated with their role. However, we know little about the caregiver experience associated with patient MAiD requests and the nature of psychosocial supports caregivers require before, during, and following MAiD intervention. OBJECTIVE: The objective of this study is to better understand the caregiver experience of MAiD within the Canadian legal landscape following Bill C-14. DESIGN: Caregiver experience was examined based on qualitative, semi-structured interviews. PARTICIPANTS: A total of 22 caregivers of patients who had requested MAiD were interviewed. APPROACH: Transcripts were recorded, transcribed, and analyzed based on grounded theory methodology. KEY RESULTS: The caregiver experience of MAiD within the legal framework was found to be understood as a "race to the end," with the ultimate goal of creating an ideal dying experience for the patient while balancing a threat to capacity that would undermine their access to MAiD. Caregivers can be described within the overarching framework as either co-runners or onlookers. Sources of caregiver distress were linked to these roles. CONCLUSIONS: The "race to the end" theoretical model contributes new knowledge and understanding that can inform the development of tailored support services for caregivers, the impact of legislative changes on this population, and future research examining decision-making near end of life and the caregiver experience.

The balloon impasse sign in percutaneous transvenous mitral valvuloplasty.

Percutaneous transvenous mitral valvuloplasty (PTMV) is an established therapy for rheumatic mitral stenosis (MS). While the Wilkins score standardizes the description of valve anatomy and predicts successful PTMV, echocardiographic assessment has some limitations. The 'balloon impasse' sign is the inability to cross a stenotic valve with a deflated Inoue balloon. This sign was described in the 1990s as an indicator of severe subvalvular thickening (regardless of the echocardiographic findings), portending an increased risk of severe mitral regurgitation (MR) post-PTMV. Despite its implications for management, it has been seldom reported. A 57-year-old woman with symptomatic, severe MS and a Wilkins score of 7 underwent PTMV. The 'balloon impasse' sign was observed when attempting to cross the stenotic valve. When the balloon was fully inflated, severe MR was noted, and the patient required mitral valve replacement. This case demonstrates the continued importance of the 'balloon impasse' sign and its implications for the therapeutic efficacy of PTMV.

The impact of driving time, distance, and socioeconomic factors on outcomes of patients with locally advanced rectal cancer.

Objectives: Cancer patients experience disparities due to socioeconomic status (SES) factors. We assessed the impact of SES factors on outcomes in patients with locally advanced rectal cancer (LARC) who received neoadjuvant chemoradiation (nCRT) and surgery (Sx) in 3 Canadian provinces. Study design: This study was a multi-institutional retrospective chart review. Methods: Associations among community characteristics (2016 Canadian Census data), distance and time to the cancer center (mapping software), and outcomes were evaluated using the CHORD multi-institutional database. Results: 1,064 patients were included. Median age 62, 68% male, 15% lived in a rural community, 19% with median community household income >$50,000 CAD, median community proportion with post-secondary education 66%, 12% lived >100km away, and 18% lived >1 â€‹h away.Factors predictive of worse disease-free survival (DFS) and overall survival (OS) in univariate analysis included driving time >1 â€‹h, median community income ≤$50,000 CAD, driving distance >100km, and lower median community proportion with post-secondary education. Driving time >1 â€‹h remained significant in multivariate analysis for worse DFS (HR 1.47; 95% CI 1.14-1.90; p â€‹= â€‹0.003) and OS (HR 1.60, 95% CI 1.19-2.16; p â€‹= â€‹0.002). Conclusion: Outcomes of patients with LARC undergoing nCRT are negatively associated with increased driving time to the cancer centre.

In Search of a Simple and Reliable Method of Measuring Intra-abdominal Pressure in Peritoneal Dialysis Patients.

BACKGROUND: Patients treated with peritoneal dialysis (PD) are at increased risk of developing mechanical complications such as dialysate leaks and hernias thought to be partially related to an increase in intra-abdominal pressure (IAP) secondary to dialysate in the abdomen. However, measurement of IAP requires specialized equipment that is not readily available in the home dialysis unit. OBJECTIVES: To develop a reliable method of measuring IAP in PD patients that could be easily used in the home dialysis unit. We hypothesized that the handheld Stryker pressure monitor would be suitable for this purpose via connection to the PD catheter. DESIGN: Cross-sectional. SETTING: Tertiary Care Hospital, Ottawa, Ontario, Canada. PATIENTS: Patients who were having a PD catheter inserted via laparoscopic surgery at The Ottawa Hospital were recruited for the study. MEASUREMENTS: With the patients at end-expiration, the IAP measured with the Stryker monitor connected to the PD catheter was compared with the insufflator pressures of 15, 10, and 5 mm Hg. METHODS: Bland-Altman plots were constructed and intraclass correlation coefficients were calculated for each pressure. RESULTS: Twelve patients participated in the study: 9 men and 3 women. They were on average 53 ± 15 years old and 81 ± 13.4 kg. Two patients had to be excluded from the analysis due to difficulties zeroing the Stryker pressure monitor at the time of surgery. There were also rapid fluctuations in the insufflator pressure recording, creating additional challenges in comparing the 2 measurements at end-expiration. The 95% limits of agreement for the Bland-Altman plots ranged from 7.9 (@15 mm Hg) to 12.2 (@10 mm Hg). The intraclass correlation coefficients for reliability of the individual measurements ranged from 0.015 (10 mm Hg) to 0.634 (15 mm Hg). LIMITATIONS: Small sample size and lack of a gold standard comparator may have affected our results. CONCLUSIONS: In our study, we used the operating room insufflator as the gold standard for measuring IAP. By Bland-Altman plots and intraclass correlation coefficients, the pressure values obtained with the Stryker pressure monitor were not a reliable estimate of insufflator IAP especially at lower pressures. Further studies are needed to identify an ideal tool for measurement of IAP to guide PD management.

CONTEXTE: Les patients traités par dialyse péritonéale (DP) sont plus sujets aux complications mécaniques (hernies, fuites de dialysat) attribuées en partie à une augmentation de la pression intra-abdominale (PIA) due à l'accumulation de dialysat dans l'abdomen. La mesure de la PIA requiert toutefois de l'équipement spécialisé difficilement accessible en contexte de dialyse à domicile. OBJECTIF: Développer une méthode fiable, et facile à utiliser en contexte de dialyse à domicile, pour mesurer la PIA chez les patients traités par DP. Nous avons émis l'hypothèse qu'un tensiomètre portatif Stryker raccordé au cathéter de DP pourrait convenir à cet usage. TYPE D'ÉTUDE: Étude transversale. CADRE: Un centre de soins tertiaires d'Ottawa (Ontario) au Canada. SUJETS: Des patients de l'hôpital d'Ottawa à qui on avait inséré un cathéter de DP par chirurgie laparoscopique. MESURES: La pression intra-abdominale, mesurée en fin d'expiration à l'aide d'un tensiomètre Stryker raccordé au cathéter de DP, a été comparée aux pressions de 15, 10 et 5 mm Hg de l'insufflateur. MÉTHODOLOGIE: Des courbes de Bland-Altman ont été établies et des coefficients de corrélation intraclasse ont été calculés pour chaque mesure de pression. RÉSULTATS: Douze patients, soit neuf hommes et trois femmes, âgés de 53 ± 15 ans et pesant 81 ±13,4 kg en moyenne, ont participé à l'étude. Deux patients ont été exclus de l'analyse en raison de difficultés à remettre le tensiomètre Stryker à zéro au moment de l'intervention. On a observé de rapides fluctuations dans l'enregistrement de la pression avec l'insufflateur, ce qui a compliqué davantage la comparaison des deux mesures en fin d'expiration. Les limites de concordance à 95 % pour les courbes de Bland-Altman se situaient entre 7,9 (15 mm Hg) et 12,2 (10 mm Hg). Les coefficients de corrélation intraclasses pour la fiabilité des mesures individuelles s'échelonnaient entre 0,015 (10 mm Hg) et 0,634 (15 mm Hg). LIMITES: Les résultats sont limités par la faible taille de l'échantillon et l'absence d'étalon-or pour la comparaison. CONCLUSION: Pour cette étude, l'insufflateur de la salle d'opération a servi d'étalon-or pour la mesure de la PIA. Selon les courbes de Bland-Altman et les coefficients de corrélation intraclasses, les valeurs de pression obtenues avec le tensiomètre Stryker n'ont pas constitué une estimation fiable de la PIA de l'insufflateur, particulièrement pour les faibles valeurs de pression. Des études supplémentaires sont nécessaires pour proposer un outil de mesure fiable de la PIA afin de guider la gestion de la DP.

Physical Activity in Patients Treated With Peritoneal Dialysis: A Systematic Review and Meta-analysis.

BACKGROUND: Exercise has been shown to be of benefit in the general population and in patients with chronic diseases. Despite a lack of compelling evidence, patients with end-stage kidney disease (ESKD) treated with peritoneal dialysis (PD) are often discouraged from participating in exercise programs that include weight lifting due to concerns about the development of hernias and leaks. The actual effects of physical activity with or without structured exercise programs for patients on PD remain unclear. OBJECTIVE: To determine the risks and benefits of physical activity in the ESKD population treated with PD. DESIGN: Systematic review and meta-analysis. SETTING: Included all studies that met our criteria regardless of country of origin. PATIENTS: Adult patients with ESKD treated with PD. MEASUREMENTS: Descriptive and quantitative analysis of our primary and secondary outcome variables. METHODS: We searched MEDLINE, Embase, CINAHL, and Cochrane Central Register of Controlled Trials for observational and interventional studies examining the effects of physical activity in patients on PD. A systematic review and meta-analysis was conducted of the identified studies. The primary outcomes of interest included patient-centered outcomes of mental health, physical functioning, fatigue, quality of life, and adverse events. Secondary outcomes included nutritional measures, lipid profile, blood pressure changes, maximum heart rate, resting heart rate, maximal oxygen consumption, muscle development, cognitive function, and markers of inflammation. RESULTS: Of 1828 studies identified by the literature search, 12 met the inclusion criteria including 6 interventional and 6 observational studies. There was limited information on the patient important outcomes. However, there is some evidence for improvements in burden of kidney disease, physical function, and some mental health measures with physical activity. LIMITATIONS: Lack of well-designed randomized controlled trials impaired our ability to determine the benefits and risks of increasing physical activity. CONCLUSIONS: There is limited evidence of benefit with increased levels of physical activity in PD patients. Further research is needed to define the exercise program that is likely to be of most benefit to patients treated with PD.

CONTEXTE: Les bienfaits procurés par la pratique d'une activité physique sont démontrés tant dans la population générale que chez les patients souffrant de maladies chroniques. Pourtant, malgré un manque de données probantes à ce sujet, on déconseille souvent aux patients atteints d'insuffisance rénale terminale (IRT) et traités par dialyse péritonéale (DP) de prendre part à un programme d'entraînement incluant des exercices en résistance; on invoque notamment des préoccupations sur le développement d'une hernie ou de fuites. De plus, les effets réels de l'activité physique avec ou sans un programme structuré chez ces patients sont encore mal connus. OBJECTIF DE L'ÉTUDE: L'étude visait à mieux définir les risques et les bienfaits de la pratique d'une activité physique chez les patients atteints d'IRT et traités par DP. TYPE D'ÉTUDE: L'étude a été menée sous la forme d'une revue systématique de la littérature scientifique puis d'une méta-analyse. CADRE: Toutes les études satisfaisant nos critères, quel que soit leur pays d'origine, ont été incluses. PATIENTS: Tous les patients atteints d'IRT et traités par DP. MESURES: Nous avons procédé à l'analyse descriptive et quantitative des variables de nos paramètres primaires et secondaires. MÉTHODOLOGIE: Les bases de données MEDLINE, Embase et CINAHL, de même que le registre central Cochrane des essais cliniques randomisés ont été passés en revue afin d'y répertorier les études observationnelles et interventionnelles traitant des effets de l'activité physique chez les patients sous dialyse péritonéale. Une revue systématique et une méta-analyse des études retenues ont été effectuées. On s'est d'abord intéressé aux observations concernant la santé mentale du patient, son bien-être général, son niveau de fatigue et sa qualité de vie, de même qu'aux événements indésirables rapportés. Les résultats secondaires auxquels nous nous sommes attardés incluaient les mesures nutritionnelles, le profil lipidique, les variations dans la pression artérielle, la fréquence cardiaque maximale, la fréquence cardiaque au repos, la consommation maximale d'oxygène, le développement de la masse musculaire, les fonctions cognitives et les marqueurs de l'inflammation. RÉSULTATS: Des 1 828 études recensées par la revue de la littérature, seule une douzaine satisfaisait nos critères d'inclusion, soit 6 études interventionnelles et 6 études observationnelles. Il y avait très peu d'information au sujet des principaux résultats des patients. Néanmoins, on a pu constater l'existence de preuves attestant de l'allègement du fardeau posé par les maladies rénales et de l'amélioration des fonctions physiques et de certains aspects de la santé mentale par la pratique d'une activité physique. LIMITES DE L'ÉTUDE: Le faible nombre d'essais contrôlés, randomisés et bien conçus traitant de notre sujet nous a empêchés de bien mesurer les bienfaits et les risques associés à l'augmentation de l'activité physique. CONCLUSION: À ce jour, il existe encore peu de preuves que l'accroissement de l'activité physique procure des bienfaits aux patients traités par dialyse péritonéale. D'autres recherches sont nécessaires pour mieux définir les programmes d'exercice susceptibles de procurer le plus de bienfaits sur la santé des patients atteints d'IRT et traités par dialyse péritonéale.

A student-initiated objective structured clinical examination as a sustainable cost-effective learning experience.

BACKGROUND: The objective structured clinical examination (OSCE) has gained widespread use as a form of performance assessment. However, opportunities for students to participate in practice OSCEs are limited by the financial, faculty and administrative investments required. OBJECTIVES: To determine the feasibility and acceptability of a student-run mock OSCE (MOSCE) as a learning experience for medical students of all 4 years. DESIGN: We conducted a five-station MOSCE for third-year students. This involved fourth-year students as examiners and first-/second-year students as standardized patients (SPs). Each examiner scored examinees using a checklist and global rating scale while providing written and verbal feedback. MOSCE stations and checklists were designed by students and reviewed by a faculty supervisor. Following the MOSCE, participants completed surveys which elucidated their perceptions on the roles they took during the MOSCE. RESULTS: Fifty examinees participated in the MOSCE. Of these, 42 (84%) consented to participate in the study and submitted completed questionnaires. Twenty-four examiners participated in the OSCE and consented to participate in the study, with 22 (92%) submitting completed questionnaires. Fifty-three of 60 SPs (88%) agreed to take part in this study, and 51 (85%) completed questionnaires. The internal consistency of the five-station OSCE was calculated as a Cronbach's alpha of 0.443. Students commented positively on having the opportunity to network and engage in mentorship activities and reinforce clinical concepts. CONCLUSIONS: Examinees, examiners, and SPs all perceived the MOSCE to be a beneficial learning experience. We found the MOSCE to be a feasible and acceptable means of providing additional OSCE practice to students prior to higher-stakes evaluations.

Physical Activity in Patients Treated With Peritoneal Dialysis: A Protocol for a Systematic Review.

BACKGROUND: Patients with chronic diseases are known to benefit from exercise. Despite a lack of compelling evidence, patients with end-stage kidney disease treated with peritoneal dialysis are often discouraged from participating in exercise programs that include resistance training due to concerns about the development of hernias and leaks. The actual effects of physical activity with or without structured exercise programs for these patients remain unclear. The purpose of this study is to more completely define the risks and benefits of physical activity in the end-stage kidney disease population treated with peritoneal dialysis. METHODS/DESIGN: We will conduct a systematic review examining the effects of physical activity on end-stage kidney disease patients treated with peritoneal dialysis. For the purposes of this review, exercise will be considered a purposive subcategory of physical activity. The primary objective is to determine if physical activity in this patient population is associated with improvements in mental health, physical functioning, fatigue and quality of life and if there is an increase in adverse outcomes. With the help of a skilled librarian, we will search MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials for randomized trials and observational studies. We will include adult end-stage kidney disease patients treated with peritoneal dialysis that have participated in an exercise training program or had their level of physical activity assessed directly or by self-report. The study must include an assessment of the association between physical activity and one of our primary or secondary outcomes measures. We will report study quality using the Cochrane Risk of Bias Assessment Tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies. Quality across studies will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. The results of this review may help to inform guideline development for exercise recommendations specific to this patient population. SYSTEMATIC REVIEW REGISTRATION: PROSPERO:CRD42016041695.

MISE EN CONTEXTE: Les bienfaits procurés par l'exercice physique chez les patients souffrant de maladies chroniques sont connus. Pourtant, malgré l'absence de données probantes, on conseille souvent aux patients atteints d'insuffisance rénale terminale (IRT) et sous dialyse péritonéale d'éviter de prendre part à un programme d'entraînements incluant des exercices en résistance, en raison de préoccupations sur le développement d'une hernie ou de fuites. Les effets réels de l'activité physique avec ou sans un programme structuré chez ces patients sont encore mal connus. L'objectif de cette étude est de mieux définir les risques et les bienfaits de l'activité physique dans la population de patients atteints d'IRT et traités par dialyse péritonéale. MÉTHODOLOGIE/CONCEPTION DE L'ÉTUDE: Nous procèderons à une revue systématique de la littérature examinant les effets de l'activité physique chez les patients atteints d'IRT et traités par dialyse péritonéale. Aux fins de la présente analyse, un entraînement sera considéré comme une sous-catégorie de l'activité physique. L'objectif principal est de déterminer si l'activité physique chez ces patients est associée à une amélioration de la santé mentale, du bien-être physique en général, du niveau de fatigue et de la qualité de vie. On veut également vérifier si la pratique d'une activité physique provoque une augmentation des conséquences indésirables. Avec l'aide d'un bibliothécaire expérimenté, nous consulterons le Cochrane Central Register of Controlled Trials ainsi que les bases de données MEDLINE, EMBASE et CINAHL afin de répertorier les essais cliniques randomisés et les études observationnelles traitant du sujet. Nous inclurons des adultes atteints d'IRT traités par dialyse péritonéale suivant un programme d'exercices ou des patients dont le niveau d'activité physique aura été évalué directement ou par auto-évaluation. L'étude devra inclure une évaluation de l'association entre la pratique d'une activité physique et l'un de nos critères principal ou secondaire. La qualité des études retenues sera évaluée: les essais cliniques contrôlés randomisés seront évalués à l'aide de l'outil Cochrane qui mesure les risques de biais, et les études observationnelles le seront avec l'échelle de Newcastle ­ Ottawa. De même, la qualité des données recueillies au cours de l'étude sera évaluée au moyen de la méthodologie GRADE. Les résultats de cet examen pourront guider l'élaboration de lignes directrices et des recommandations pour la pratique d'une activité physique chez cette population de patients spécifique. ENREGISTREMENT DE LA REVUE SYSTÉMATIQUE: Prospero CRD42016041695.

Caudal Nucleus Accumbens Core Is Critical in the Regulation of Cue-Elicited Approach-Avoidance Decisions.

The nucleus accumbens (NAc) is thought to be a site of integration of positively and negatively valenced information and action selection. Functional differentiation in valence processing has previously been found along the rostrocaudal axis of the shell region of the NAc in assessments of unconditioned motivation. Given that the core region of the NAc has been implicated in the elicitation of motivated behavior in response to conditioned cues, we sought to assess the role of caudal, intermediate, and rostral sites within this subregion in cue-elicited approach-avoidance decisions. Rats were trained to associate visuo-tactile cues with appetitive, aversive, and neutral outcomes. Following the successful acquisition of the cue-outcome associations, rats received microinfusions of GABAA and GABAB receptor agonists (muscimol/baclofen) or saline into the caudal, intermediate, or rostral NAc core and were then exposed to a superimposition of appetitively and aversively valenced cues versus neutral cues in a "conflict test," as well as to the appetitive versus neutral cues, and aversive cues versus neutral cues, in separate conditioned preference/avoidance tests. Disruption of activity in the intermediate to caudal parts of the NAc core resulted in a robust avoidance bias in response to motivationally conflicting cues, as well as a potentiated avoidance of aversive cues as compared with control animals, coupled with an attenuated conditioned preference for the appetitive cue. These results suggest that the caudal NAc core may have the capacity to exert bidirectional control over appetitively and aversively motivated responses to valence signals.