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The road to legalization of Medical Assistance in Dying (MAID) across Canada has largely focused on legislative details such as eligibility and establishment of regulatory clinical practice standards. Details on how to implement high-quality, person-centered MAID programs at the institutional level are lacking. This study seeks to understand what improvement opportunities exist in the delivery of the MAID process from the family caregiver perspective.
This multi-methods study design used structured surveys, focus groups, and unstructured e-mail/phone conversations to gather experiential feedback from family caregivers of patients who underwent MAID between July 2016 and June 2017 at a large academic hospital in Toronto, Canada. Data were combined and a qualitative, descriptive approach used to derive themes within family perspectives.
Improvement themes identified through the narrative data (48% response rate) were grouped in two categories: operational and experiential aspects of MAID. Operational themes included: process clarity, scheduling challenges and the 10-day period of reflection. Experiential themes included clinician objection/judgment, patient and family privacy, and bereavement resources.
Significance of results
To our knowledge, this is the first time that family caregivers’ perspectives on the quality of the MAID process have been explored. Although practice standards have been made available to ensure all legislated components of the MAID process are completed, detailed guidance for how to best implement patient and family centered MAID programs at the institutional level remain limited. This study provides guidance for ways in which we can enhance the quality of MAID from the perspective of family caregivers.
Once on a plane to New Orleans I chanced to half overhear a conversation between two passengers who shared the same row of seats with me. Somewhere between wakefulness and drowsiness, my ear caught a telltale accent that betrayed one of my seatmates as an Orleanian as they chatted animatedly about the Crescent City, Louisiana, and the ways that both diverged from the rest of the country. The native noted reverently the influence of the Roman Catholic Church, he remarked grandly on the extraordinary cuisine, he waxed pridefully about the city as the birthplace of jazz, and he spoke warmly about the manifold ethnic origins of his fellow Louisianians. Then, as if to fortify his contention that he hailed from a truly unusual place, he pointedly observed that Louisiana was the only state in the nation whose legal system rested upon the Napoleonic Code, even as he confessed to an uncertainty about why that difference existed or what it meant precisely.
In response to concerns about acetolactate synthase (ALS) inhibitor–resistant weeds in wheat production systems, we explored the efficacy of managing Bromus spp., downy and Japanese bromes, in a winter wheat system using alternative herbicide treatments applied in either fall or spring. Trials were established at Lethbridge and Kipp, Alberta, and Scott, Saskatchewan, Canada over three growing seasons (2012–2014) to compare the efficacy of pyroxasulfone (a soil-applied very-long-chain fatty acid elongase inhibitor; WSSA Group 15) and flumioxazin (a protoporphyrinogen oxidase inhibitor; WSSA Group 14) against industry-standard ALS-inhibiting herbicides for downy and Japanese brome control. Winter wheat injury from herbicide application was minor, with the exception of flucarbazone application at Scott. Bromus spp. control was greatest with pyroxsulam and all herbicide treatments containing pyroxasulfone. Downy and Japanese bromes were controlled least by thiencarbazone and flumioxazin, respectively, whereas Bromus spp. had intermediate responses to the other herbicides tested. Herbicides applied in fall resulted in reduced winter wheat yield relative to the spring applications. Overall, pyroxasulfone or pyroxsulam provided the most efficacious Bromus spp. control compared with the other herbicides and consistently maintained optimal winter wheat yields. Therefore, pyroxasulfone could facilitate management of Bromus spp. resistant to ALS inhibitors in winter wheat in the southern growing regions of western Canada. Improved weed control and delayed herbicide resistance may be achieved when pyroxasulfone is applied in combination with flumioxazin.
To report the introduction and impact of non-medical prescribing, initiated to improve patient pathways for those presenting with dizziness and balance disorders.
The Southport and Ormskirk physiotherapy-led vestibular clinic sees and treats all patients with dizziness and balance disorders referred to the ENT department. Letters are triaged by an audiologist, who also performs an otological examination and hearing test; this is followed by an assessment with the independent prescriber physiotherapist. An ENT consultant is nearby if joint consultation is needed. Diagnoses, treatments and patient satisfaction were studied, with an analysis of the impact of medication management (stopping or starting medicines) on patients and service.
In 12 months, 413 new patients with dizziness and balance disorders had appointments. The most common diagnoses were benign paroxysmal positional vertigo and vestibular migraine. Eighty-four per cent of patients required self-management strategies, 50 per cent exercise therapy, 48 per cent medication management and 24 per cent a particle repositioning manoeuvre. Patient satisfaction was high (99 per cent).
Having an independent prescriber physiotherapist leading the balance clinic has reduced the number of hospital visits and onward referrals. Nearly half of all patients required medication management as part of their dizziness or balance treatment.
As Canada’s population ages, frailty – with its increased risk of functional decline, deterioration in health status, and death – will become increasingly common. The physiology of frailty reflects its multisystem, multi-organ origins. About a quarter of Canadians over age 65 are frail, increasing to over half in those older than 85. Our health care system is organized around single-organ systems, impairing our ability to effectively treat people having multiple disorders and functional limitations. To address frailty, we must recognize when it occurs, increase awareness of its significance, develop holistic models of care, and generate better evidence for its treatment. Recognizing how frailty impacts lifespan will allow for integration of care goals into treatment options. Different settings in the Canadian health care system will require different strategies and tools to assess frailty. Given the magnitude of challenges frailty poses for the health care system as currently organized, policy changes will be essential.
Much of what is known about how Appalachians cope with chronic poverty is the result of the landmark Beech Creek studies, a series of investigations of an impoverished, geographically isolated group of neighborhoods in eastern Kentucky (Brown 1952a, 1952b, 1988 ; Schwarzweller et al. 1971; McCoy 1986). In 1942 James Brown purposefully selected a remote, nonmining area in rural Clay County, Kentucky, to document a way of life that was less deeply affected by the penetration of commodity, labor, and consumer markets than were Appalachian coalfield communities at the time. Brown’s detailed ethnographic observations of subsistence farming, social stratification, and family and community life, together with subsequent studies of residents and out-migrants from Beech Creek, provide the best empirical record of the strategies by which Appalachian persisters and migrants have coped with chronic, intergenerational poverty.
The declining inflammatory immune competence of acute (i.e. wasting) pre-pubescent protein–energy malnutrition has been regarded as reflecting an unregulated immunological disintegration. Recent evidence, however, suggests that malnutrition stimulates a regulated immunological reconfiguration to achieve a non-inflammatory form of competence, perhaps offering protection against autoimmune reactions – the ‘Tolerance Model’. Our objective was to determine the influence of acute pre-pubescent malnutrition on the expression of genes critical to tolerogenic regulation. Male and female C57BL/6J mice, initially 19 d old, consumed a complete purified diet either ad libitum (age-matched controls) or in restricted daily quantities (mimicking marasmus), or consumed an isoenergetic low-protein diet ad libitum (mimicking incipient kwashiorkor) for 14 d (six animals per dietary group). Gene expression in the spleen, typically an inflammatory organ, and in the small intestine, a site designed for non-inflammatory defence, was assessed by real-time quantitative RT-PCR, and normalised to β-actin. In the spleen of the malnourished groups, both IL-10 and transforming growth factor-β1 mRNA expression increased compared with controls (P < 0·05), whereas mRNA expression of IL-12p40 decreased (P < 0·05). Conversely, malnutrition exerted no influence on the expression of mRNA for these cytokines in the small intestine (P>0·05). Moreover, forkhead box P3 mRNA expression, indicative of cell-based tolerogenic potential, was sustained in both the spleen and intestine of the malnourished groups (P>0·05). Thus, despite limited supplies of energy and substrates, the spleen shifted towards a non-inflammatory character and the intestine was sustained in this mode in advanced pre-pubescent weight loss. These findings provide the first support for the Tolerance Model at the level of mRNA transcript expression.
Steady-state space-charge limited current (SCLC) measurements are used to investigate the density of states (DOS) in the mobility gap of hydrogenated amorphous silicon (a-Si:H). The density of states is calculated by different methods based on both continuous DOS and discrete traps assumptions. The density of states found by the SCLC measurements is used to set the trap densities and trap energy levels to model a vertical a-Si:H thin-film transistor (TFT) using the Medici device simulation package. The effect of different sets of traps in the bulk of a-Si:H and variation of the physical dimensions of the device on the characteristics of the vertical TFT is studied. The simulation on the space-charge limited current is performed to verify the validity and accuracy of the SCLC method.
Advanced rapid thermal processing (RTP) equipment and sensors have been developed for in-situ fabrication of semiconductor devices. High-performance multi-zone lamp modules have been applied to various processes including rapid thermal oxidation (RTO), chemicalvapor deposition (CVD) of tungsten and amorphous/polycrystalline silicon, silicide formation, as well as high-temperature rapid thermal annealing (RTA). Concurrent use of multizone lamps and multi-point temperature sensors allows real-time wafer temperature control and process uniformity optimization. Specific experimental results will be presented on the multi-zone lamp modules, in-situ process control sensors, and single-wafer fabrication processes.
A recently developed method for producing triaxial alignment of single crystalline grains may be applicable to ceramics other than the high-Tc cuprate superconductors for which it was designed as a means of reducing the grain boundary weak links due to grain orientational misfit. This technique uses a suitable combination of a mechanical force and a magnetic field acting on the moment of a rare earth element incorporated into the ceramic; a "granular single crystal" is thus formed. A detailed step-by-step procedure is presented here to facilitate use of the new approach.