Medical assistance in dying for mental illness: a complex intervention requiring a correspondingly complex evaluation approach.

Medical assistance in dying for mental illness as a sole underlying medical condition (MAiD MI-SUMC) is a controversial and complex policy in terms of psychosocial and ethical medical practice implications. We discuss the status of MAiD MI-SUMC in Canada and argue for the use of the UK Medical Research Council's framework on complex interventions in programme evaluations of MAiD MI-SUMC. It is imperative to carefully and rigorously evaluate the implementation of MAiD MI-SUMC to ensure an understanding of the multiple facets of implementation in contexts permeated by unique social, economic, cultural and historical influences, with a correspondingly diverse array of outcomes. This requires a complexity-informed programme evaluation focused on context-dependent mechanisms and stakeholder experiences, including patients, service providers and other people affected by the policy. It is also important to consider the economic impact on health and social welfare systems. Such evaluations can provide the data needed to guide evidence-informed decision-making that can contribute to safer implementation and refinement of MAiD MI-SUMC.

Care considerations in medical assistance in dying for persons with mental illness as the sole underlying medical condition: a qualitative study of patient and family perspectives.

BACKGROUND: Persons with mental illness as their sole underlying medical condition are eligible to access medical assistance in dying (MAiD) in a small number of countries, including Belgium, the Netherlands, Luxemburg and Switzerland. In Canada, it is anticipated that people experiencing mental illness as their sole underlying medical condition (MI-SUMC) will be eligible to request MAiD as of March 17th 2024. To date, few studies have addressed patient and family perspectives on MAiD MI-SUMC care processes. This study aimed to address this gap and qualitatively explore the perspectives of persons with lived experience of mental illness and family members on care considerations during MI-SUMC implementation. METHODS: Thirty adults with lived experience of mental illness and 25 adult family members residing in Ontario participated in this study. To facilitate participant engagement, the semi-structured interview used a persona-scenario exercise to discuss perspectives on MAiD MI-SUMC acceptability and care considerations. Framework analysis was used to inductively analyze data using NVivo 12 Pro. Steps, processes, or other care considerations suggested by the participants were charted in a framework matrix after familiarization with the narratives. Key themes were further identified. A lived-experience advisory group participated in every aspect of this study. RESULTS: Six themes were developed from the patient and family narratives: (1) Raising MAiD MI-SUMC awareness; (2) Sensitive Introduction of MAiD MI-SUMC in goals of care discussions; (3) Asking for MAiD MI-SUMC: a person-focused response; (4) A comprehensive circle of MAiD MI-SUMC care; (5) A holistic, person-centered assessment process; and (6) Need for support in the aftermath of the decision. These themes highlighted a congruence of views between patient and family members and described key desired process ingredients, including a person-centred non-judgmental stance by care providers, inter-professional holistic care, shared decision making, and the primacy of patient autonomy in healthcare decision making. CONCLUSIONS: Family and patient perspectives on the implementation of MAiD MI-SUMC offer important considerations for service planning that could complement existing and emerging professional practice standards. These stakeholders' perspectives will continue to be essential in MAiD MI-SUMC implementation efforts, to better address the needs of diverse communities and inform improvement efforts.

Medical Assistance in Dying for Mental Illness as a Sole Underlying Medical Condition and Its Relationship to Suicide: A Qualitative Lived Experience-Engaged Study: Aide Médicale à Mourir Pour Maladie Mentale Comme Seule Condition Médicale Sous-Jacente et Son Lien Avec le Suicide: Une Etude Qualitative Engagée Dans l'Expérience Vécue.

OBJECTIVE: This lived experience-engaged study aims to understand patient and family perspectives on the relationship between suicidality and medical assistance in dying when the sole underlying medical condition is mental illness (MAiD MI-SUMC). METHOD: Thirty individuals with mental illness (age M = 41.8 years, SD = 14.2) and 25 family members (age M = 47.5 years, SD = 16.0) participated in qualitative interviews examining perspectives on MAiD MI-SUMC and its relationship with suicide. Audio recordings were transcribed and analysed using reflexive thematic analysis. People with lived experience were engaged in the research process as team members. RESULTS: Four main themes were developed, which were consistent across individuals with mental illness and family members: (a) deciding to die is an individual choice to end the ongoing intolerable suffering of people with mental illness; (b) MAiD MI-SUMC is the same as suicide because the end result is death, although suicide can be more impulsive; (c) MAiD MI-SUMC is a humane, dignified, safe, nonstigmatized alternative to suicide; and (4) suicidality should be considered when MAiD MI-SUMC is requested, but suicidality's role is multifaceted given its diverse manifestations. CONCLUSION: For patient-oriented mental health policy and treatment, it is critical that the voices of people with lived experience be heard on the issue of MAiD MI-SUMC. Given the important intersections between MAiD MI-SUMC and suicidality and the context of suicide prevention, the role that suicidality should play in MAiD MI-SUMC is multifaceted. Future research and policy development are required to ensure that patient and family perspectives guide the development and implementation of MAiD MI-SUMC policy and practice.

Walking Alongside: Views of Family Members on Medical Assistance in Dying for Mental Illness as the Sole Underlying Medical Condition.

Medical assistance in dying (MAiD) was introduced into Canadian federal legislation in 2016. Mental illness as the sole underlying medical condition (MI-SUMC) is currently excluded from eligibility; such exclusion is scheduled to expire on March 17, 2024. Irremediability, capacity, quality of life, autonomy, family involvement, and healthcare system constraints have been debated intensively. Recent studies have not explored the views of family members of persons with mental illness on MAiD MI-SUMC. This study aimed to fill this knowledge gap. Twenty-five Ontario residents who had a loved one with mental illness participated. A persona-scenario exercise was designed to explore participants' views on MAiD MI-SUMC in hypothetical situations. Reflexive thematic analysis was used to analyze the data. A lived experience-advisory panel was engaged throughout the study. Seven themes were developed: Witnessing suffering; A road with barriers and limitations; Societal barriers; The unknowns of mental illness; Individual choices: the life or death that a person wants; MAiD MI-SUMC as an acceptable choice when suffering cannot be relieved with available treatments and supports; and The emotional outcome. Participants constructed their views based on their experience of supporting a loved one with mental illness. MAiD MI-SUMC was perceived as a multifaceted issue, whose acceptability and potential introduction required a concurrent exploration and discussion of the challenges arising due to limitations of the healthcare system, the opportunities and limits to family involvement, and the value of patient autonomy.

Searching for relief from suffering: A patient-oriented qualitative study on medical assistance in dying for mental illness as the sole underlying medical condition.

Medical assistance in dying (MAiD) was introduced into Canadian legislation in 2016. Mental illness as the sole underlying medical condition (MI-SUMC) is excluded from eligibility; this is expected to change in 2024. Incurability, intolerable suffering, capacity to make healthcare decisions, and suicidality have been publicly debated in connection with mental illness. Few studies have explored the views of persons with mental illness on the introduction and acceptability of MAiD MI-SUMC; this study aimed to fill this gap. Thirty adults, residing in Ontario, Canada, who self-identified as living with mental illness participated. A semi-structured interview including a persona-scenario exercise was designed to discuss participants' views on MAiD MI-SUMC and when it could be acceptable or not. Reflexive thematic analysis was used to inductively analyze data. Codes and themes were developed after extensive familiarization with the dataset. A lived-experience advisory group was engaged throughout the study. We identified six themes: The certainty of suffering; Is there a suffering threshold to be met? The uncertainty of mental illness; My own limits, values, and decisions; MAiD MI-SUMCas acceptable when therapeutic means, and othersupports, have been tried to alleviate long-term suffering; and Between relief and rejection. These themes underline how the participants' lived experience comprised negative impacts caused by long-term mental illness, stigma, and in some cases, socioeconomic factors. The need for therapeutic and non-therapeutic supports was highlighted, along with unresolved tensions about the links between mental illness, capacity, and suicidality. Although not all participants viewed MAiD MI-SUMC as acceptable for mental illness, they autonomously embraced limits, values, and decisions of their own along their search for relief. Identifying individual and contextual elements in each person's experience of illness and suffering is necessary to understand diverse perspectives on MAiD MI-SUMC.

Early Palliative Care for the Geriatric Patient with Cancer.

Older adults with cancer present with complex multidimensional problems. Therefore, early integration of palliative care for the older adult with cancer is important, and a multidisciplinary team approach is critical for optimum care. The importance of incorporating geriatric and palliative concerns in assessment, as well as early involvement of the multidisciplinary team, is discussed as a manner of addressing the needs of older adults with cancer. Concerns related to metabolic changes that can occur with aging, as well as risk for polypharmacy and inappropriate prescribing for older adults, are also reviewed.

Associations between symptoms with healthcare utilization and death in advanced cancer patients.

INTRODUCTION: There is limited data about assessments that are associated with increased utilization of medical services among advanced oncology patients (AOPs). We aimed to identify factors related to healthcare utilization and death in AOP. METHODS: AOPs at a comprehensive cancer center were enrolled in a Center for Medicare and Medicaid Innovation program. Participants completed the Edmonton Symptom Assessment Scale (ESAS) and the Functional Assessment of Cancer Therapy-General (FACT-G) scale. We examined factors associated with palliative care (PC), acute care (AC), emergency room (ER), hospital admissions (HA), and death. RESULTS: In all, 817 AOPs were included in these analyses with a median age of 69. They were generally female (58.7%), white (61.4%), stage IV (51.6%), and represented common cancers (31.5% GI, 25.2% thoracic, 14.3% gynecologic). ESAS pain, anxiety, and total score were related to more PC visits (B=0.31, 95% CI [0.21, 0.40], p<0.001; B=0.24 [0.12, 0.36], p<0.001; and B=0.038 [0.02, 0.06], p=0.001, respectively). Total FACT-G score and physical subscale were related to total PC visits (B=-0.021 [-0.037, -0.006], p=0.008 and B=-0.181 [-0.246, -0.117], p<0.001, respectively). Lower FACT-G social subscale scores were related to more ER visits (B=-0.03 [-0.53, -0.004], p=0.024), while increased tiredness was associated with fewer AC visits (B=-0.039 [-0.073, -0.006], p=0.023). Higher total ESAS scores were related to death within 30 days (OR=0.87 [0.76, 0.98], p=0.027). CONCLUSIONS: The ESAS and FACT-G assessments were linked to PC and AC visits and death. These assessments may be useful for identifying AOPs that would benefit from routine PC.

Learning about psychiatric aspects of medical assistance in dying: a pilot survey of self-perceived educational needs among assessors in a Canadian academic hospital.

BACKGROUND: Medical assistance in dying (MAiD) was legalized in Canada in 2016, although it has been accessible as an end-of-life option in the province of Quebec since 2015. Before its implementation in clinical settings, few physicians had received formal training on requests assessments. New data indicate MAiD requesters have high rates of psychiatric comorbidities. Hence, assessment and management of psychiatric and psychosocial issues among MAiD requesters are important competencies to develop for assessors, although few training programs address them. The aim of our study was to explore physicians' self-perceived educational needs on psychiatric aspects related to MAiD in the province of Quebec. METHODS: We conducted a cross-sectional online survey and used a non-probability sampling design in one academic tertiary care center. A descriptive analysis was performed, and responders were compared on different variables. RESULTS: From twenty-five physician assessors, nineteen responded anonymously to an online survey (n=19). The findings of our pilot study revealed that participants felt highly competent in most psychiatric aspects at end-of-life and related to MAiD practice, except for psychotherapy and psychopharmacology as well as depression identification. Most indicated strong interest in further training. No statistical differences were found among responders regarding previous experience or training in palliative care. CONCLUSIONS: Based on our study, MAiD assessors reported high level of competency in managing psychiatric issues among requesters, but that they also expressed a strong desire for additional education.

The perspectives of oncology healthcare providers on the role of palliative care in a comprehensive cancer center.

BACKGROUND: Palliative care (PC) is an essential part of oncologic care, but its optimal role within a cancer center remains unclear. This study examines oncology healthcare providers' perspectives about the role of PC at a comprehensive cancer center (CCC). METHODS: Physicians, nurses, and other oncology healthcare providers at a CCC were surveyed for their opinions about the role of inpatient and outpatient PC, preferences for PC services, and barriers to referral. Chi-squared tests and multiple regression analyses were performed to explore associations. RESULTS: We received 137/221 completed questionnaires (61% response rate). Respondents were generally female (78%), had ≤ 10 years of service (69%), and included physicians (32%), nurses (32%), and advanced practice providers (17%). Most respondents (82%) agreed that more patients could benefit from PC. They also agreed that PC is beneficial for both outpatient and inpatient management of complex pain (96 and 88%), complex symptoms (84 and 74%), and advanced cancer patients (80 and 64%). Transition to hospice (64 vs. 42%, p = 0.007) and goals of care (62 vs. 49%, p = 0.011) provided by PC services were more valued by respondents for the inpatient than for the outpatient setting. Barriers to utilizing PC included lack of availability, unsure of when to refer, and poor communication. The majority of respondents (83%) preferred a cancer focused PC team to provide high-quality care. CONCLUSIONS: Overall, the majority of oncology health care providers believe that more patients could benefit from PC, but opinions vary regarding the roles of inpatient and outpatient PC. Barriers and areas for improvement include availability, referral process, and improved communication.

Screening of biosynthesized zinc oxide nanoparticles for their effect on Daucus carota pathogen and molecular docking.

Herein, we investigate the phytogenic synthesis of zinc oxide nanoparticles (ZnO-NPs) by using aqueous extract of seed coat of almond as a novel resource which can acts as a stabilizing and reducing agents. Successful biosynthesis of ZnO-NPs was observed by Ultraviolet-visible spectroscopy (UV-vis) showing peak at ~272 nm. The scanning electron microscopy (SEM) and transmission electron microscopy (TEM) techniques confirm the circular shape with an average size of ~20 nm. Applications of ZnO-NPs were observed on carrot (Daucus carota) plant infected with pathogenic fungus Rhizoctonia solani. Spray with 50 ppm and 100 ppm ZnO-NPs caused significant increase in plant growth attributes and photosynthetic pigments of carrot plants. It has been reported that the synthesized ZnO-NPs demonstrated an inhibitory activity against plant pathogenic fungus R. solani and reduces disease in carrot plants. Scanning electron microscopy and confocal microscopy indicated adverse effect of ZnO-NPs on pathogens. Antifungal efficiency of ZnO-NPs was further explained with help of molecular docking analysis. Conformation with highest negative binding energy was used to predict binding site of receptor with NPs to know mechanistic approach. ZnO-NPs are likely to interact with the pathogens by mechanical enfolding which may be one of the major toxicity actions against R. solani by ZnO-NPs. RESEARCH HIGHLIGHTS: ZnO nanoparticles were synthesized using waste material from the coat of almond seeds. Images from SEM, TEM, and related techniques like EDS and SAED revealed the irregularity of the ZnO NPs as well as their atom composition. FTIR and XRD analyses confirmed the formation and the presence of crystalline ZnO NPs in nature. Biogenic ZnONPs were found to be effective against the plant pathogenic fungus R. solani. A spray of 50 ppm and 100 ppm ZnO-NPs significantly increased carrot plant growth characteristics and photosynthetic pigments.

Trajectory of patients consulting the emergency department for high blood pressure values.

OBJECTIVES: Emergency department (ED) visits for high blood pressure are increasing in frequency. We aimed to map those patients' trajectory, from referral sources to the type of care received at the ED to anticipated actions for future high blood pressure concerns, and to better understand their reasons for consulting the ED for high blood pressure values. METHODS: Between 2018 and 2020, patients who presented to the Montreal Heart Institute's ED for elevated blood pressure were recruited in a prospective observational study including a post hoc structured telephone interview and medical chart review. Five possible referral sources were predetermined. We provided proportions and 95% confidence intervals. RESULTS: A total of 100 patients were recruited (female: 59%, mean age: 69 ± 12). A majority (93%, 95% CI 88-98%) possessed a home blood pressure device, among which 46% (95% CI 36-56%) remembered receiving advice for its use. The main referral sources for high blood pressure to the ED were self-reference (53%, 95% CI 43-63%), advice of a lay person (19%, 95% CI 11-27%) or a nurse (13%, 95% CI 6-20%). Mainly, patients reported being concerned by concomitant symptoms or experiencing acute medical consequences (44%, 95% CI 34-54%), having followed the recommendation of a third party (33%, 95% CI 24-42%), or having concerns about their medication (6%, 95% CI 1-11%). Two weeks following their ED visits, consulting ED remained the main choice for future concerns about high blood pressure for 27% of participants. When specifically asked if they would return to the ED for elevated blood pressure, 73% (95% CI 64-83%) said yes. CONCLUSIONS: Most patients who consulted the ED for elevated blood pressure values were self-referred. More can be done to promote blood pressure education, effective use of personal blood pressure devices, and recommendations for patients and health professionals when confronted with high blood pressure results.

RéSUMé: OBJECTIFS: Les visites aux services d'urgence pour hypertension artérielle (TA) sont de plus en plus fréquentes. Nous avons cherché à cartographier le parcours de ces patients, depuis les sources d'orientation jusqu'au type de soins reçus aux urgences, en passant par les mesures prévues en cas de problèmes futurs de tension artérielle élevée, et à mieux comprendre les raisons pour lesquelles ils consultent les urgences pour des valeurs de tension artérielle élevées. MéTHODES: Entre 2018 et 2020, les patients qui se sont présentés aux urgences de l'Institut de cardiologie de Montréal pour une TA élevée ont été recrutés dans le cadre d'une étude observationnelle prospective comprenant une entrevue téléphonique structurée post-hoc et un examen des dossiers médicaux. Cinq sources de référence possibles ont été prédéterminées. Nous avons fourni des proportions et des intervalles de confiance à 95 %. RéSULTATS: Au total, 100 patients ont été recrutés (femmes : 59 %, âge moyen : 69 ± 12). Une majorité (93%, IC à 95% 88-98%) possédait un tensiomètre à domicile, parmi lesquels 46% (IC à 95% 36-56%) se souvenaient avoir reçu des conseils pour son utilisation. Les principales sources d'orientation vers les urgences en cas de tension artérielle élevée étaient l'auto-référence (53 %, IC 95 % 43-63 %), le conseil d'un tiers non-professionnel de la santé (19 %, IC à 95 % 11-27 %) ou d'une infirmière (13 %, IC à 95 % 6-20 %). Principalement, les patients ont déclaré être préoccupés par des symptômes concomitants ou des conséquences médicales aiguës (44 %, IC à 95 %, 34-54 %), avoir suivi la recommandation d'un tiers (33 %, IC à 95 %, 24-42 %) ou avoir des préoccupations au sujet de leurs médicaments (6 %, IC à 95 %, 1-11 %). Deux semaines après leur visite au service d'urgence, la consultation du service d'urgence est restée le principal choix en cas de préoccupations futures concernant l'hypertension artérielle pour 27 % des participants. À la question spécifique de savoir s'ils retourneraient aux urgences pour une TA élevée, 73% (IC à 95% 64-83%) ont répondu oui. CONCLUSIONS: La plupart des patients qui ont consulté les urgences pour des valeurs élevées de la tension artérielle se sont adressés d'eux-mêmes. Il y a place à l'amélioration pour promouvoir l'éducation sur la TA, l'utilisation efficace des appareils de pression artérielle personnels et les recommandations aux patients et aux professionnels de la santé lorsqu'ils sont confrontés à des résultats élevés en matière de TA.

Assistance in dying: A comparative look at legal definitions.

Euthanasia, assisted suicide, medical assistance in dying, death with dignity: these and many other different terms are used around the world to capture various types of assistance in dying. This diversity in terminology can create confusion both in academic debates and in policy-making if it is unclear what type of action or inaction is intended to be captured, by whom, and under what circumstances. By defining and contrasting several terms and legal status of assistance in dying in jurisdictions authorizing it, this comparative glossary aims to lay a foundation that prevents linguistic and conceptual confusion.

Ethical judgment in assessing requests for medical assistance in dying in Canada and Quebec: What can we learn from other jurisdictions?

This paper concerns the ethical judgment that lies at the heart of assessing requests for Medical Assistance in Dying (MAID) in Canada and Quebec, namely is it ethically right to help the person requesting assistance to end his or her life? We address situations in which making this judgment may be challenging despite the person fulfilling legal eligibility requirements. Using three clinical cases that are challenging by virtue of the legal requirement that a person experience intolerable suffering we explore this issue. We review practice guidance provided to providers and assessors in six jurisdictions and discuss potential resources to inform the ethical judgments involved in MAID assessments.

Lessons Learnt during the Implementation of WISN for Comprehensive Primary Health Care in India, South Africa and Peru.

INTRODUCTION: The World Health Organization introduced the workload indicators of staffing needs (WISN) in 1998 to improve country-level health workforce planning. This study presents the primary care health workforce planning experiences of India, South Africa and Peru. METHODS: A case study approach was used to explore the lessons learnt in the implementation of WISN in India and South Africa. It also describes the methods developed and implemented to estimate health workforce in Peru. We identify the barriers and facilitators faced by countries during the implementation phase through the triangulation of literature, government reports and accounts of involved health planners in the three countries. RESULTS: India implemented WISN in a referral pathway of three district health facilities, including a primary health centre, community health centre and district hospital. Implementation was impeded by limited technical support, poor stakeholder consultation and information systems challenges. South Africa implemented WISN for health workforce planning in primary care and found the skills mix and staff determinations to be unaffordable. The Peruvian Ministry of Health considered using WISN but decided to develop a context-specific tool to estimate the health workforce needed using its available resources such as the National Register of Health Personnel. The main challenge in using WISN was the insufficient information on its inputs. CONCLUSION: While India and South Africa had unique experiences with the integration of WISN in their health system, none of the countries has yet benefited from the implementation of WISN due to financial, infrastructure and technical challenges. Since the methodology developed by the Peruvian Ministry of Health is context-specific, its implementation has been promising for health workforce planning. The learnings from these countries' experiences will prove useful in bringing future changes for the health workforce.

Rational Design of Protein-Specific Folding Modifiers.

Protein-folding can go wrong in vivo and in vitro, with significant consequences for the living organism and the pharmaceutical industry, respectively. Here we propose a design principle for small-peptide-based protein-specific folding modifiers. The principle is based on constructing a "xenonucleus", which is a prefolded peptide that mimics the folding nucleus of a protein. Using stopped-flow kinetics, NMR spectroscopy, Förster resonance energy transfer, single-molecule force measurements, and molecular dynamics simulations, we demonstrate that a xenonucleus can make the refolding of ubiquitin faster by 33 ± 5%, while variants of the same peptide have little or no effect. Our approach provides a novel method for constructing specific, genetically encodable folding catalysts for suitable proteins that have a well-defined contiguous folding nucleus.

Role of Ligand Binding Site in Modulating the Mechanical Stability of Proteins with ß-Grasp Fold.

Despite many studies on ligand-modulated protein mechanics, a comparative analysis of the role of ligand binding site on any specific protein fold is yet to be made. In this study, we explore the role of ligand binding site on the mechanical properties of ß-grasp fold proteins, namely, ubiquitin and small ubiquitin related modifier 1 (SUMO1). The terminal segments directly connected through hydrogen bonds constitute the ß-clamp geometry (or mechanical clamp), which confers high mechanical resilience to the ß-grasp fold. Here, we study ubiquitin complexed with CUE2-1, a ubiquitin-binding domain (UBD) from yeast endonuclease protein Cue2, using a combination of single-molecule force spectroscopy (SMFS) and steered molecular dynamics (SMD) simulations. Our study reveals that CUE2-1 does not alter the mechanical properties of ubiquitin, despite directly interacting with its ß-clamp. To explore the role of ligand binding site, we compare the mechanical properties of the ubiquitin/CUE2-1 complex with that of previously studied SUMO1/S12, another ß-grasp protein complex, using SMD simulations. Simulations on the SUMO1/S12 complex corroborate previous experimentally observed enhancement in the mechanical stability of SUMO1, even though S12 binds away from the ß-clamp. Differences in ligand binding-induced structural impact at the transition state of the two complexes explain the differences in ligand modulated protein mechanics. Contrary to previous reports, our study demonstrates that direct binding of ligands to the mechanical clamp does not necessarily alter the mechanical stability of ß-grasp fold proteins. Rather, binding interactions away from the clamp can reinforce protein stability provided by the ß-grasp fold. Our study highlights the importance of binding site and binding modes of ligands in modulating the mechanical stability of ß-grasp fold proteins.

Incidentaloma Discoveries in the Course of Neuroimaging Research.

ABSTRACTAmong healthy volunteers in psychiatric brain functional magnetic resonance imaging (fMRI) research studies, the prevalence of incidentalomas can be as high as 34%, of which 10% show clinical significance. An incidentaloma is a lesion found by coincidence without clinical symptoms or suspicion. Like lesions and other types of accidental findings, it is found in healthy individuals recruited to take part in psychiatric studies. The prevalence of these accidental findings among specific psychiatric populations remains unknown. However, a precise understanding of cerebral neuroanatomy, neuroradiological expertise, and an appropriate choice of fMRI exploration sequences will increase the sensitivity of identifying these accidental findings and enable researchers to address their clinical relevance and nature. We present recommendations on how to appropriately inform patients or participants of the accidental findings. Additionally, we propose specific suggestions pertaining to the clinical research setting aimed for investigators and psychiatrists. Unlike current articles pertaining to incidentaloma, the current report provides a distinct focus on psychiatric issues and specific recommendations for studies involving psychiatric patients.

Palliative care for acute kidney injury patients in the intensive care unit.

Patients with acute kidney injury (AKI) in the intensive care unit (ICU) are often suitable for palliative care due to the high symptom burden. The role of palliative medicine in this patient population is not well defined and there is a lack of established guidelines to address this issue. Because of this, patients in the ICU with AKI deprived of the most comprehensive or appropriate care. The reasons for this are multifactorial including lack of palliative care training among nephrologists. However, palliative care in these patients can help alleviate symptoms, improve quality of life, and decrease suffering. Palliative care physicians can determine the appropriateness and model of palliative care. In addition to shared decision-making, advance directives should be established with patients early on, with specific instructions regarding dialysis, and those advance directives should be respected.

Management of pain in end-stage renal disease patients: Short review.

Pain management in end stage renal disease (ESRD) patients is a complex and challenging task to accomplish, and effective pain and symptom control improves quality of life. Pain is prevalent in more than 50% of hemodialysis patients and up to 75% of these patients are treated ineffectively due to its poor recognition by providers. A good history for PQRST factors and intensity assessment using visual analog scale are the initial steps in the management of pain followed by involvement of palliative care, patient and family counseling, discussion of treatment options, and correction of reversible causes. First line should be conservative management such as exercise, massage, heat/cold therapy, acupuncture, meditation, distraction, music therapy, and cognitive behavioral therapy. Analgesics are introduced according to WHO guidelines (by the mouth, by the clock, by the ladder, for the individual, and attention to detail) using three-step analgesic ladder model. Neuropathic pain can be controlled by gabapentin and pregabalin. Substitution/addition of opioid analgesics are indicated if pain control is not optimal. Commonly used opioids in ESRD patients are tramadol, oxycodone, hydromorphone, fentanyl, methadone, and buprenorphine. Methadone, fentanyl, and buprenorphine are the ideal analgesics in ESRD. However, complex pain syndrome requires multidrug analgesic regimen comprising opioids, non-opioids, and adjuvant medication, which should be individualized to the patient to achieve adequate pain control.