Publications by authors named "Stephanie Thompson"

143 Publications

Addressing feasibility challenges to delivering intradialytic exercise interventions: A theory-informed qualitative study.

Nephrol Dial Transplant 2021 Aug 20. Epub 2021 Aug 20.

Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba.

Background: Intradialytic exercise (IDE) may improve physical function and health-related quality of life. However, incorporating IDE into standard hemodialysis care has been slow due to feasibility challenges. We conducted a multicenter qualitative feasibility study to identify potential barriers and enablers to IDE and generate potential solutions to these factors.

Methods: We conducted 43 semi-structured interviews with healthcare providers and patients across twelve hospitals in Ontario, Canada. We used the Theoretical Domains Framework and directed content analysis to analyze the data.

Results: We identified eight relevant domains (knowledge, skills, beliefs about consequences, beliefs about capabilities, environmental context and resources, goals, social/professional role and identity, and social influences) represented by three overarching categories: 1) Knowledge, skills and expectations: lack of staff expertise to oversee exercise, uncertainty regarding exercise risks, benefits, and patient interest, lack of knowledge regarding exercise eligibility; 2) Human, material and logistical resources: staff concerns regarding workload, perception that exercise professionals should supervise IDE; space, equipment, and scheduling conflict concerns; 3) Social dynamics of the unit: local champions and patient stories contribute to IDE sustainability.We developed a list of actionable solutions by mapping barriers and enablers to behavior change techniques. We also developed a feasibility checklist of 47 questions identifying key factors to address prior to IDE launch.

Conclusions: Evidence-based solutions to identified barriers and enablers to IDE and a feasibility checklist may help recruit and support units, staff, and patients and address key challenges to the delivery of IDE in diverse clinical and research settings.
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http://dx.doi.org/10.1093/ndt/gfab228DOI Listing
August 2021

Global Policy Barriers and Enablers to Exercise and Physical Activity in Kidney Care.

J Ren Nutr 2021 Aug 12. Epub 2021 Aug 12.

Alberta Kidney Care - South, Calgary, Alberta, Canada.

Objective: Impairment in physical function and physical performance leads to decreased independence and health-related quality of life in people living with chronic kidney disease and end-stage kidney disease. Physical activity and exercise in kidney care are not priorities in policy development. We aimed to identify global policy-related enablers, barriers, and strategies to increase exercise participation and physical activity behavior for people living with kidney disease.

Design And Methods: Guided by the Behavior Change Wheel theoretical framework, 50 global renal exercise experts developed policy barriers and enablers to exercise program implementation and physical activity promotion in kidney care. The consensus process consisted of developing themes from renal experts from North America, South America, Continental Europe, United Kingdom, Asia, and Oceania. Strategies to address enablers and barriers were identified by the group, and consensus was achieved.

Results: We found that policies addressing funding, service provision, legislation, regulations, guidelines, the environment, communication, and marketing are required to support people with kidney disease to be physically active, participate in exercise, and improve health-related quality of life. We provide a global perspective and highlight Japanese, Canadian, and other regional examples where policies have been developed to increase renal physical activity and rehabilitation. We present recommendations targeting multiple stakeholders including nephrologists, nurses, allied health clinicians, organizations providing renal care and education, and renal program funders.

Conclusions: We strongly recommend the nephrology community and people living with kidney disease take action to change policy now, rather than idly waiting for indisputable clinical trial evidence that increasing physical activity, strength, fitness, and function improves the lives of people living with kidney disease.
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http://dx.doi.org/10.1053/j.jrn.2021.06.007DOI Listing
August 2021

Voicing Individual Concerns for Engagement in Hemodialysis (VOICE-HD): A Mixed Method, Randomized Pilot Trial of Digital Health in Dialysis Care Delivery.

Can J Kidney Health Dis 2021 27;8:20543581211032857. Epub 2021 Jul 27.

Department of Internal Medicine, Health Sciences, Health Sciences Centre, University of Manitoba, Winnipeg, Canada.

Background: People receiving in-center hemodialysis (HD) have prioritized the need for more individualized health information and better communication with nephrologists. The most common setting for patient-nephrologist interactions is during the HD treatment, which is a time pressured setting that lacks privacy.

Objective: To facilitate effective communication in the hemodialysis (HD) unit, we evaluated the usability of a web application (web app) from both the patient and physician perspective. The main aim of the web app was to support patients in prioritizing their dialysis concerns outside of the clinical HD encounter.

Design: Mixed method, parallel arm, multi-site, pilot randomized controlled trial.

Setting: Two outpatient Canadian HD centers.

Participants: Adult patients receiving in-center HD and their attending nephrologists.

Methods: Patients were randomized to either a web application or an active control (paper form) for logging concerns to be addressed at weekly encounters with the nephrologist over 8 weeks. Topics included: HD treatment, symptoms, modality, and medications. The primary outcome was usability, defined as effectiveness (engagement with the tool, frequency of submitted concerns, whether the concern was satisfactorily addressed) and satisfaction with the tool using a priori thresholds and explored in interviews with patients and nephrologists.

Results: 77 patients (30 women, median age 61, interquartile range [53,67], median 2 years [1,4] on dialysis) and 19 nephrologists (4 women, median age 46 [36,65]) were enrolled. Patient use of a digital device at baseline was low (20%). Engagement with the tool was 70% (web app) and 100% (paper) with a lower proportion of patients in the web app group submitting at least one concern over 8 weeks compared to the paper form group: 56.7% vs 87.9%. Weekly concerns were satisfactorily addressed in both groups and ≥70% of patients would continue to use the tools. For patients, both tools promoted preparation and participation in the encounter; however, only the web app facilitated greater privacy in relaying concerns. For most nephrologists, the tools were disruptive to their workflow and were perceived as unnecessary given existing processes and familiarity with patients. For future versions of the app, patients suggested more features to facilitate self-management and nephrologists suggested integration with health databases and multidisciplinary teams.

Limitations: Tertiary setting may limit generalizability.

Conclusions: Both tools promoted fundamental components of self-management; however, patients in the paper form group submitted concerns more often and this tool was easier to remember to use. Although modifications would likely enhance web app usability, successful future adoption is limited by physician acceptance. ClinicalTrials.gov NCT03605875.
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http://dx.doi.org/10.1177/20543581211032857DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8323421PMC
July 2021

Physical Activity and Health in Chronic Kidney Disease.

Contrib Nephrol 2021 Aug 3;199:1-13. Epub 2021 Aug 3.

Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China.

Clinical Background and Epidemiology: Low physical activity is a common phenotype in individuals living with chronic kidney disease (CKD). It increases as renal function declines and is associated with adverse clinical outcomes and a poor quality of life (QOL). Both behavioral and disease-related factors contribute to the low physical activity levels in CKD. CKD has profound negative effects on skeletal muscle structure and function that are related to impairments in mitochondrial function, inflammation, oxidative stress, metabolic acidosis, and other uremia-related factors. These factors promote muscle protein catabolism and wasting, and impair strength, physical performance, and cardiorespiratory fitness. Moreover, the high burden of comorbid disease contributes to patient fatigue, fear of injury, and poor exercise self-efficacy. All of these factors reinforce patient's sedentary behavior, leading to a vicious cycle of disease and disability that further compromises their health and QOL. Data from both observational studies and exercise interventions indicate that increasing levels of physical activity may provide a range of benefits in CKD patients, including attenuating declines in renal function, and improving markers of physical function, cardiovascular disease risk, and QOL. Unfortunately, these results have not led to widespread implementation of exercise programs in CKD, and physical inactivity and poor physical function remain hallmarks of the disease worldwide. Challenges and Solutions: There are many frequently cited barriers to implementing exercise programs in CKD. These include: a lack of training and knowledge about physical activity/exercise prescriptions and interventions among health professionals; inadequate time to implement exercise programs due to other clinical responsibilities; a lack of specific funding and incentives to develop these programs; and a poor quality of the data demonstrating efficacy of exercise. Many CKD patients also are unmotivated to incorporate exercise into their daily lives due to time constraints, depression, and other comorbid diseases, and poor self-efficacy for exercise. Given these barriers, it is not surprising that physical activity/exercise programs have not become a component of standard of care for CKD patients. We discuss several potential solutions to address these barriers, including: (1) providing better education and training for healthcare professionals who provide exercise advise and counselling to individuals with CKD; (2) providing incentives to reimburse payers to develop and maintain exercise programs in CKD; and (3) providing more personalized approaches to exercise prescription and implementation of exercise programs that consider the unique circumstances of individual CKD patients. In summary, low physical activity levels in CKD patients result from a combination of many factors that adversely impact patient's health and QOL. Addressing this problem will require comprehensive intervention strategies that consider both the unique pathophysiology of CKD and the individual circumstances of those living with the disease.
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http://dx.doi.org/10.1159/000517696DOI Listing
August 2021

Exploring Proteomes of Robust Yarrowia lipolytica Isolates Cultivated in Biomass Hydrolysate Reveals Key Processes Impacting Mixed Sugar Utilization, Lipid Accumulation, and Degradation.

mSystems 2021 Aug 3;6(4):e0044321. Epub 2021 Aug 3.

Department of Chemical and Biomolecular Engineering, University of Tennessee, Tennessee, USA.

Yarrowia lipolytica is an oleaginous yeast exhibiting robust phenotypes beneficial for industrial biotechnology. The phenotypic diversity found within the undomesticated Y. lipolytica clade from various origins illuminates desirable phenotypic traits not found in the conventional laboratory strain CBS7504 (or W29), which include xylose utilization, lipid accumulation, and growth on undetoxified biomass hydrolysates. Currently, the related phenotypes of lipid accumulation and degradation when metabolizing nonpreferred sugars (e.g., xylose) associated with biomass hydrolysates are poorly understood, making it difficult to control and engineer in Y. lipolytica. To fill this knowledge gap, we analyzed the genetic diversity of five undomesticated Y. lipolytica strains and identified singleton genes and genes exclusively shared by strains exhibiting desirable phenotypes. Strain characterizations from controlled bioreactor cultures revealed that the undomesticated strain YB420 used xylose to support cell growth and maintained high lipid levels, while the conventional strain CBS7504 degraded cell biomass and lipids when xylose was the sole remaining carbon source. From proteomic analysis, we identified carbohydrate transporters, xylose metabolic enzymes, and pentose phosphate pathway proteins stimulated during the xylose uptake stage for both strains. Furthermore, we distinguished proteins involved in lipid metabolism (e.g., lipase, NADPH generation, lipid regulators, and β-oxidation) activated by YB420 (lipid maintenance phenotype) or CBS7504 (lipid degradation phenotype) when xylose was the sole remaining carbon source. Overall, the results relate genetic diversity of undomesticated Y. lipolytica strains to complex phenotypes of superior growth, sugar utilization, lipid accumulation, and degradation in biomass hydrolysates. Yarrowia lipolytica is an important industrial oleaginous yeast due to its robust phenotypes for effective conversion of inhibitory lignocellulosic biomass hydrolysates into neutral lipids. While lipid accumulation has been well characterized in this organism, its interconnected lipid degradation phenotype is poorly understood during fermentation of biomass hydrolysates. Our investigation into the genetic diversity of undomesticated Y. lipolytica strains, coupled with detailed strain characterization and proteomic analysis, revealed metabolic processes and regulatory elements conferring desirable phenotypes for growth, sugar utilization, and lipid accumulation in undetoxified biomass hydrolysates by these natural variants. This study provides a better understanding of the robust metabolism of Y. lipolytica and suggests potential metabolic engineering strategies to enhance its performance.
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http://dx.doi.org/10.1128/mSystems.00443-21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8407480PMC
August 2021

Prevalence of polypharmacy and associated adverse health outcomes in adult patients with chronic kidney disease: protocol for a systematic review and meta-analysis.

Syst Rev 2021 07 4;10(1):198. Epub 2021 Jul 4.

Department of Medicine, University of Alberta, Edmonton, AB, Canada.

Background: Polypharmacy, often defined as the concomitant use of ≥ 5 medications, has been identified as a significant global public health threat. Aging and multimorbidity are key drivers of polypharmacy and have been linked to a broad range of adverse health outcomes and mortality. Patients with chronic kidney disease (CKD) are particularly at high risk of polypharmacy and use of potentially inappropriate medications given the numerous risk factors and complications associated with CKD. The aim of this systematic review will be to assess the prevalence of polypharmacy among adult patients with CKD, and the potential association between polypharmacy and adverse health outcomes within this population.

Methods/design: We will search empirical databases such as MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science, and PsycINFO and grey literature from inception onwards (with no language restrictions) for observational studies (e.g., cross-sectional or cohort studies) reporting the prevalence of polypharmacy in adult patients with CKD (all stages including dialysis). Two reviewers will independently screen all citations, full-text articles, and extract data. Potential conflicts will be resolved through discussion. The study methodological quality will be appraised using an appropriate tool. The primary outcome will be the prevalence of polypharmacy. Secondary outcomes will include any adverse health outcomes (e.g., worsening kidney function) in association with polypharmacy. If appropriate, we will conduct random effects meta-analysis of observational data to summarize the pooled prevalence of polypharmacy and the associations between polypharmacy and adverse outcomes. Statistical heterogeneity will be estimated using Cochran's Q and I index. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., sex, kidney replacement therapy, multimorbidity).

Discussion: Given that polypharmacy is a major and a growing public health issue, our findings will highlight the prevalence of polypharmacy, hazards associated with it, and medication thresholds associated with adverse outcomes in patients with CKD. Our study will also draw attention to the prognostic importance of improving medication practices as a key priority area to help minimize the use of inappropriate medications in patients with CKD.

Systematic Review Registration: PROSPERO registration number: [ CRD42020206514 ].
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http://dx.doi.org/10.1186/s13643-021-01752-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8256607PMC
July 2021

Effectiveness and Utilization of Cardiac Rehabilitation Among People With CKD.

Kidney Int Rep 2021 Jun 30;6(6):1537-1547. Epub 2021 Mar 30.

Department of Medicine, University of Calgary, Calgary, Alberta, Canada.

Introduction: Cardiac rehabilitation (CR) is a proven therapy for reducing cardiovascular death and hospitalization. Whether CR participation is associated with improved outcomes in patients with chronic kidney disease (CKD) is unknown.

Methods: We obtained data on all adult patients in Calgary, Alberta, Canada with angiographically proven coronary artery disease from 1996 to 2016 referred to CR from The Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease and TotalCardiology Rehabilitation. An estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m or kidney replacement therapy defined CKD. Predictors of CR use were estimated with multinomial logistic regression. The association between starting versus not starting and completion versus noncompletion of CR and clinical outcomes were estimated using multivariable Cox proportional hazards models.

Results: Of 23,215 patients referred to CR, 12,084 were eligible for inclusion. Participants with CKD (N = 1322) were older, had more comorbidity, lower exercise capacity on graded treadmill testing, and took longer to be referred and to start CR than those without CKD. CKD predicted not starting CR: odds ratio 0.73 (95% confidence interval [CI] 0.64-0.83). Over a median 1 year follow-up, there were 146 deaths, 40 (0.3%) from CKD and 106 (1.0%) not from CKD. Similar to those without CKD, the risk of death was lower in CR completers (hazard ratio [HR] 0.24 [95% CI 0.06-0.91) and starters (HR 0.56 [95% CI 0.29- 1.10]) with CKD.

Conclusion: CR participation was associated with comparable benefits in people with moderate CKD as those without who survived to CR. Lower rates of CR attendance in this high-risk population suggest that strategies to increase CR utilization are needed.
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http://dx.doi.org/10.1016/j.ekir.2021.03.889DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8207316PMC
June 2021

An Evidence-Based Theory About PRO Use in Kidney Care: A Realist Synthesis.

Patient 2021 Jun 10. Epub 2021 Jun 10.

Sociology and Social Policy, University of Leeds, Leeds, UK.

Background: There is international interest on the use of patient-reported outcomes (PROs) in nephrology.

Objectives: Our objectives were to develop a kidney-specific program theory about use of PROs in nephrology that may enhance person-centered care, both at individual and aggregated levels of care, and to test and refine this theory through a systematic review of the empirical literature. Together, these objectives articulate what works or does not work, for whom, and why.

Methods: Realist synthesis methodology guided the electronic database and gray literature searches (in January 2017 and October 2018), screening, and extraction conducted independently by three reviewers. Sources included all nephrology patients and/or practitioners. Through a process of extraction and synthesis, each included source was examined to assess how contexts may trigger mechanisms to influence specific outcomes.

Results: After screening 19,961 references, 84 theoretical and 34 empirical sources were used. PROs are proposed to be useful for providing nephrology care through three types of use. The first type is use of individual-level PRO data at point of care, receiving the majority of theoretical and empirical explorations. Clinician use to support person-centered care, and patient use to support patient engagement, are purported to improve satisfaction, health, and quality of life. Contextual factors specific to the kidney care setting that may influence the use of PRO data include the complexity of kidney disease symptom burden, symptoms that may be stigmatized, comorbidities, and time or administrative constraints in dialysis settings. Electronic collection of PROs may facilitate PRO use given these contexts. The second type is use of aggregated PRO data at point of care, including public reporting of PROs to inform decisions at point of care and improve quality of care, and use of PROs for treatment decisions. The third type is use of aggregated PRO data by organizations, including publicly available PRO data to compare centers. In single-payer systems, regular collection of PROs by dialysis centers can be achieved through economic incentives. Both the second and third types of PRO use include pressures that may trigger quality improvement processes.

Conclusion: The current state of the evidence is primarily theoretical. There is pressing need for empirical research to improve the evidence-base of PRO use at individual and aggregated levels of nephrology care.
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http://dx.doi.org/10.1007/s40271-021-00530-2DOI Listing
June 2021

Impact of home telemonitoring and management support on blood pressure control in non-dialysis CKD: a systematic review protocol.

BMJ Open 2021 05 25;11(5):e044195. Epub 2021 May 25.

Medicine, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada

Introduction: Hypertension is a common public health problem and a key modifiable risk factor for cardiovascular (CV) and chronic kidney disease (CKD). Home blood pressure (BP) telemonitoring (HBPT) and management is associated with improved BP control, accelerated delivery of care and decision-making strategies that can reduce adverse outcomes associated with hypertension. The aim of this paper is to describe the protocol for a systematic review to assess the impact of HBPT interventions used for improving BP control and reducing CV and kidney outcomes in non-dialysis CKD patients.

Methods: We developed this protocol using the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015. We will search empirical databases such as MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science and PsycINFO and grey literature for studies conducted in non-dialysis CKD patients on interventions using HBPT and reporting outcomes related to BP control and other outcomes such as CV events and kidney disease progression. All studies meeting these criteria, in adults and published from inception until 2020 with no language barrier will be included.

Ethics And Dissemination: Ethical approval will not be required for this review as the data used will be extracted from already published studies with publicly accessible data. As this study will assess the impact of HBPT on BP control in non-dialysis CKD patients, evidence gathered through it will be disseminated using traditional approaches that includes open-access peer-reviewed publication, scientific presentations and a report. We will also disseminate our findings to appropriate government agencies.

Prospero Registration Number: CRD42020190705).
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http://dx.doi.org/10.1136/bmjopen-2020-044195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8154939PMC
May 2021

Temperament as a moderator of the association of cumulative risk with preadolescent appraisal and coping style.

Anxiety Stress Coping 2021 Sep 26;34(5):513-529. Epub 2021 Apr 26.

Department of Psychology, University of Washington, Seattle, WA, USA.

Background: Children exposed to cumulative risk (CR) are more likely to have poor physical and psychological health across the lifespan. CR may contribute to children's adjustment, in part through its effects on appraisal and coping. Further, child temperament may alter the effects of CR on appraisal and coping.

Objective: This study investigated the interactive and prospective effects of CR and temperament on children's appraisal and coping strategies.

Design And Method: In this secondary data analysis using a community sample (N=306) of preadolescents (M age = 9.5 at T1), structural equations models were conducted to examine temperament negative emotionality (NE) and effortful control (EC) as moderators of the effect of CR on both levels and proportional use of positive and threat appraisals, and active and avoidant coping.

Results: Children higher in NE used more threat appraisal and avoidant coping, whereas children higher in EC used less threat appraisal concurrently and decreased in their use of threat appraisal across 1 year. Both NE and EC altered the prospective effect of CR on appraisal and coping.

Conclusions: Findings suggest temperament alters the effect of CR on appraisal and coping, implicating EC as a resource and NE as a vulnerability in changes in appraisal and coping during preadolescence.
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http://dx.doi.org/10.1080/10615806.2021.1918681DOI Listing
September 2021

Qualitative Research in Clinical Epidemiology.

Methods Mol Biol 2021 ;2249:369-388

Faculty of Nursing, University of Alberta, Edmonton, AB, Canada.

This chapter provides an overview of qualitative research approaches in the study of health, disease, and health service delivery and summarizes important considerations when designing research studies to address questions that ask the "how," "why," or "what" of a particular issue. As qualitative research encompasses distinct methodologies, brief descriptions of the main approaches and examples from the literature are provided. Guidance on how to evaluate quality in the design and reporting of qualitative studies is also discussed.
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http://dx.doi.org/10.1007/978-1-0716-1138-8_20DOI Listing
June 2021

An International Delphi Survey on Exercise Priorities in CKD.

Kidney Int Rep 2021 Mar 18;6(3):657-668. Epub 2020 Dec 18.

Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada.

Introduction: Defining the role of exercise in chronic kidney disease (CKD) is a top research priority for people with CKD. We aimed to achieve consensus on specific research priorities in exercise and CKD among an international panel of stakeholders.

Methods: Using the Delphi method, patients/caregivers, researchers, clinicians, and policymakers submitted their top research priorities in round 1 and ranked their importance in rounds 2 and 3 using a 9-point Likert scale. The mean, median, and proportion of scores ranked 7 to 9 were calculated. Consensus was defined as priorities that scored above the overall mean and median score within each stakeholder panel. Qualitative description was used to understand participants' rankings.

Results: Seventy participants (78% response) completed round 1: 15 (21.4%) clinicians, 33 (47.1%) researchers, 13 (18.6%) policymakers, and 9 (12.9%) patients; (85.7%) completed round 3. The top research priorities were defining exercise-related outcomes meaningful to patients, identifying patients' motivation and perspective towards exercise, understanding the effect of exercise on the risk of institutionalization, mortality, and mobility, and understanding the effect of pre- and post-transplant exercise on postoperative recovery. Themes from the qualitative analysis were individualization, personal experience, and holistic approach to exercise (patients), the need to address common clinical problems (clinicians), developing targeted interventions (researchers), and the importance of evidence-based development versus implementation (policymakers).

Conclusions: Preventing physical disability was a common priority. Policymakers emphasized that more efficacy studies were needed. Other panels expressed the need for holistic and targeted exercise interventions and for outcomes that address common clinical problems.
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http://dx.doi.org/10.1016/j.ekir.2020.12.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7938076PMC
March 2021

Reducing Ethnic and Geographic Inequities to Optimise New Zealand Stroke Care (REGIONS Care): Protocol for a Nationwide Observational Study.

JMIR Res Protoc 2021 Jan 12;10(1):e25374. Epub 2021 Jan 12.

Nelson-Malborough District Health Board, Neslon-Malborough, New Zealand.

Background: Stroke systems of care differ between larger urban and smaller rural settings and it is unclear to what extent this may impact on patient outcomes. Ethnicity influences stroke risk factors and care delivery as well as patient outcomes in nonstroke settings. Little is known about the impact of ethnicity on poststroke care, especially in Māori and Pacific populations.

Objective: Our goal is to describe the protocol for the Reducing Ethnic and Geographic Inequities to Optimise New Zealand Stroke Care (REGIONS Care) study.

Methods: This large, nationwide observational study assesses the impact of rurality and ethnicity on best practice stroke care access and outcomes involving all 28 New Zealand hospitals caring for stroke patients, by capturing every stroke patient admitted to hospital during the 2017-2018 study period. In addition, it explores current access barriers through consumer focus groups and consumer, carer, clinician, manager, and policy-maker surveys. It also assesses the economic impact of care provided at different types of hospitals and to patients of different ethnicities and explores the cost-efficacy of individual interventions and care bundles. Finally, it compares manual data collection to routine health administrative data and explores the feasibility of developing outcome models using only administrative data and the cost-efficacy of using additional manually collected registry data. Regarding sample size estimates, in Part 1, Study A, 2400 participants are needed to identify a 10% difference between up to four geographic subgroups at 90% power with an α value of .05 and 10% to 20% loss to follow-up. In Part 1, Study B, a sample of 7645 participants was expected to include an estimated 850 Māori and 419 Pacific patients and to provide over 90% and over 80% power, respectively. Regarding Part 2, 50% of the patient or carer surveys, 40 provider surveys, and 10 focus groups were needed to achieve saturation of themes. The main outcome is the modified Rankin Scale (mRS) score at 3 months. Secondary outcomes include mRS scores; EQ-5D-3L (5-dimension, 3-level EuroQol questionnaire) scores; stroke recurrence; vascular events; death; readmission at 3, 6, and 12 months; cost of care; and themes around access barriers.

Results: The study is underway, with national and institutional ethics approvals in place. A total of 2379 patients have been recruited for Part 1, Study A; 6837 patients have been recruited for Part 1, Study B; 10 focus groups have been conducted and 70 surveys have been completed in Part 2. Data collection has essentially been completed, including follow-up assessment; however, primary and secondary analyses, data linkage, data validation, and health economics analysis are still underway.

Conclusions: The methods of this study may provide the basis for future epidemiological studies that will guide care improvements in other countries and populations.

International Registered Report Identifier (irrid): DERR1-10.2196/25374.
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http://dx.doi.org/10.2196/25374DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7838000PMC
January 2021

New Zealand hospital stroke service provision.

N Z Med J 2020 12 4;133(1526):18-30. Epub 2020 Dec 4.

Associate Professor of Neurology and Head of Department, Department of Medicine, University of Otago, Wellington; Consultant Neurologist, Department of Neurology, Capital and Coast District Health Board, Wellington.

Aim: To describe stroke services currently offered in New Zealand hospitals and compare service provision in urban and non-urban settings.

Method: An online questionnaire was sent to stroke lead clinicians at all New Zealand District Health Boards (DHBs). Questions covered number and location of stroke inpatients, stroke service configuration, use of guidelines/protocols, staffing mix, access to staff education, and culture appropriate care.

Results: There were responses from all 20 DHBs. Differences between urban and non-urban hospitals included: access to acute stroke units (55.6% non-urban vs 100% urban; p=0.013), stroke clinical nurse specialists (50% vs 90%; p=0.034), stroke clot retrieval (38.9% vs 80%; p=0.037) and Pacific support services (55.6% vs 100%; p=0.030). There were also differences in carer training (66.7% non-urban vs 100% urban; p=0.039) and goal-specific rehabilitation plans in the community (61.1% vs 100%; p=0.023). Access to TIA services, stroke rehabilitation units, early supported discharge, psychologists, continuing staff education, and culturally responsive stroke care were suboptimal irrespective of hospital location.

Conclusion: Hospital location is associated with differences in stroke services provision across New Zealand and ongoing work is required to optimise consistent access to best practice care. These results, in conjunction with an ongoing (REGIONS Care) study, will be used to determine whether this affects patient outcomes.
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December 2020

Patient, Caregiver, and Provider Perspectives on Challenges and Solutions to Individualization of Care in Hemodialysis: A Qualitative Study.

Can J Kidney Health Dis 2020 12;7:2054358120970715. Epub 2020 Nov 12.

Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada.

Background: Clinical settings often make it challenging for patients with kidney failure to receive individualized hemodialysis (HD) care. Individualization refers to care that reflects an individual's specific circumstances, values, and preferences.

Objective: This study aimed to describe patient, caregiver, and health care professional perspectives regarding challenges and solutions to individualization of care in people receiving in-center HD.

Design: In this multicentre qualitative study, we conducted focus groups with individuals receiving in-center HD and their caregivers and semi-structured interviews with health care providers from May 2017 to August 2018.

Setting: Hemodialysis programs in 5 cities: Calgary, Edmonton, Winnipeg, Ottawa, and Halifax.

Participants: Individuals receiving in-center HD for more than 6 months, aged 18 years or older, and able to communicate in English were eligible to participate, as well as their caregivers. Health care providers with HD experience were recruited using a purposive approach and snowball sampling.

Methods: Two sequential methods of qualitative data collection were undertaken: (1) focus groups and interviews with HD patients and caregivers, which informed (2) individual interviews with health care providers. A qualitative descriptive methodology guided focus groups and interviews. Data from all focus groups and interviews were analyzed using conventional content analysis.

Results: Among 82 patients/caregivers and 31 health care providers, we identified 4 main themes: session set-up, transportation and parking, socioeconomic and emotional well-being, and HD treatment location and scheduling. Particular challenges faced were as follows: (1) session set-up: lack of preferred supplies, machine and HD access set-up, call buttons, bed/chair discomfort, needling options, privacy in the unit, and self-care; (2) transportation and parking: lack of reliable/punctual service, and high costs; (3) socioeconomic and emotional well-being: employment aid, finances, nutrition, lack of support programs, and individualization of treatment goals; and (4) HD treatment location and scheduling: patient displacement from their usual spot, short notice of changes to dialysis time and location, lack of flexibility, and shortages of HD spots.

Limitations: Uncertain applicability to non-English speaking individuals, those receiving HD outside large urban centers, and those residing outside of Canada.

Conclusions: Participants identified challenges to individualization of in-center HD care, primarily regarding patient comfort and safety during HD sessions, affordable and reliable transportation to and from HD sessions, increased financial burden as a result of changes in functional and employment status with HD, individualization of treatment goals, and flexibility in treatment schedule and self-care. These findings will inform future studies aimed at improving patient-centered HD care.
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http://dx.doi.org/10.1177/2054358120970715DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7672734PMC
November 2020

Facilitators and Barriers to Care in Rural Emergency Departments in Alberta for Patients on Peritoneal Dialysis (PD): An Interpretive Descriptive Study.

Can J Kidney Health Dis 2020 4;7:2054358120970098. Epub 2020 Nov 4.

Faculty of Nursing, University of Alberta, Edmonton, Canada.

Background: Home dialysis offers many advantages to patients, but they require support to manage a home-based therapy such as peritoneal dialysis (PD). A rural emergency department provides an important safety net for patients requiring medical care, including managing complications of PD, such as peritonitis. Patients living in northern Alberta are spread out geographically and can be far from a PD training center, yet anecdotally, many rural sites do not provide care for these patients.

Objective: Our aim was to identify the facilitators and barriers to nursing care in rural emergency departments in northern Alberta for patients receiving PD.

Design: A qualitative interpretive descriptive approach was used.

Setting: Rural emergency departments across northern Alberta.

Participants: Purposeful sampling was used to seek participants from 1 of 4 rural acute care hospital emergency departments in northern Alberta. Six registered nurses and 1 licensed practical nurse agreed to participate in the study. They ranged in experience from 2 to 18 years. Two of the participants were unit managers, 2 were clinical nurse educators (CNEs), and the other 3 were staff nurses with 1 of them in a leadership position.

Methods: Individual semistructured interview were conducted over the telephone. The interview guide was developed based on a review of the literature. Interviews continued until no new information was obtained, that is, data were saturated. Interviews were audio recorded and transcribed verbatim. Field notes were recorded. A constant comparative approach was used for analysis. The coding process was both deductive (drawing from the literature) and inductive.

Results: Seven participants were interviewed, and there were 4 main themes and 1 subtheme that emerged from the analysis: was seen as both facilitators and barriers; ; ; and Continuing education about PD was a facilitator, and the lack of education was a barrier to provision of PD care. Similarly, availability of resource materials about PD and access to a CNE were facilitators, while lack of these resources was a barrier to offering PD care. As PD was not always seen regularly, infrequent exposure was a barrier to offering PD care. Lack of physician supports, both from the locum physicians who were sometimes reluctant to care for these patients and the delays in reaching nephrologists were barriers.

Limitations: The findings represent the perceptions of the emergency department nurses who participated. These perceptions may differ from those of nurses who work in other regions of the country. Furthermore, most participants were in a leadership role, and it may be that their perspectives differ from those of front-line nurses.

Conclusions: The findings from our study highlight the need for availability of education and resource materials/persons to care for these patients. There is also a need for greater physician support from both local physicians as well as nephrologists to offer high-quality PD care.

Trial Registration: Not applicable. This study is not a clinical trial. It did not involve prospective assignment of participants to a treatment group.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7649850PMC
November 2020

A Higher Concentration of Dialysate Magnesium to Reduce the Frequency of Muscle Cramps: A Narrative Review.

Can J Kidney Health Dis 2020 22;7:2054358120964078. Epub 2020 Oct 22.

Division of Nephrology, Department of Medicine, Health Sciences Centre, University of Calgary, Calgary, AB, Canada.

Purpose Of Review: Strategies to mitigate muscle cramps are a top research priority for patients receiving hemodialysis. As hypomagnesemia is a possible risk factor for cramping, we reviewed the literature to better understand the physiology of cramping as well as the epidemiology of hypomagnesemia and muscle cramps. We also sought to review the evidence from interventional studies on the effect of oral and dialysate magnesium-based therapies on muscle cramps.

Sources Of Information: Peer-reviewed articles.

Methods: We searched for relevant articles in major bibliographic databases including MEDLINE and EMBASE. The methodological quality of interventional studies was assessed using a modified version of the Downs and Blacks criteria checklist.

Key Findings: The etiology of muscle cramps in patients receiving hemodialysis is poorly understood and there are no clear evidence-based prevention or treatment strategies. Several factors may play a role including a low concentration of serum magnesium. The prevalence of hypomagnesemia (concentration of <0.7 mmol/L) in patients receiving hemodialysis ranges from 10% to 20%. Causes of hypomagnesemia include a low dietary intake of magnesium, use of medications that inhibit magnesium absorption (eg, proton pump inhibitors), increased magnesium excretion (eg, high-dose loop diuretics), and a low concentration of dialysate magnesium. Dialysate magnesium concentrations of ≤0.5 mmol/L may be associated with a decrease in serum magnesium concentration over time. Preliminary evidence from observational and interventional studies suggests a higher dialysate magnesium concentration will raise serum magnesium concentrations and may reduce the frequency and severity of muscle cramps. However, the quality of evidence supporting this benefit is limited, and larger, multicenter clinical trials are needed to further determine if magnesium-based therapy can reduce muscle cramps in patients receiving hemodialysis. In studies conducted to date, increasing the concentration of dialysate magnesium appears to be well-tolerated and is associated with a low risk of symptomatic hypermagnesemia.

Limitations: Few interventional studies have examined the effect of magnesium-based therapy on muscle cramps in patients receiving hemodialysis and most were nonrandomized, pre-post study designs.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7585892PMC
October 2020

A Mixed Method Investigation to Determine Priorities for Improving Information, Interaction, and Individualization of Care Among Individuals on In-center Hemodialysis: The Triple I Study.

Can J Kidney Health Dis 2020 19;7:2054358120953284. Epub 2020 Oct 19.

Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.

Background: Current health systems do not effectively address all aspects of chronic care. For better self-management of disease, kidney patients have identified the need for improved health care information, interaction with health care providers, and individualization of care.

Objective: The Triple I study examined challenges to exchange of between patients and health care providers and of care in in-center hemodialysis with the aim of identifying the top 10 challenges that individuals on in-center hemodialysis face in these 3 areas.

Design: We employed a sequential mixed methods approach with 3 phases:1. A qualitative study with focus groups and interviews (Apr 2017 to Aug 2018);2. A cross-sectional national ranking survey (Jan 2019 to May 2019);3. A prioritization workshop using a modified James Lind Alliance process (June 2019).

Setting: In-center hemodialysis units in 7 academic centers across Canada: Vancouver, Calgary, Edmonton, Winnipeg, Ottawa, Montreal, and Halifax.

Participants: Individuals receiving in-center hemodialysis, their caregivers, and health care providers working in in-center hemodialysis participated in each of the 3 phases.

Methods: In Phase 1, we collected qualitative data through (1) focus groups and interviews with hemodialysis patients and their caregivers and (2) individual interviews with health care providers and decision makers. Participants identified challenges to in-center hemodialysis care and potential solutions to these challenges. In Phase 2, we administered a pan-Canadian cross-sectional ranking survey. The survey asked respondents to prioritize the challenges to in-center hemodialysis care identified in Phase 1 by ranking their top 5 topics/challenges in each of the 3 "I" categories. In Phase 3, we undertook a face-to-face priority setting workshop which followed a modified version of the James Lind Alliance priority setting workshop process. The workshop employed an iterative process incorporating small and large group sessions during which participants identified, ranked, and voted on the top challenges and innovations to hemodialysis care. Four patient partners contributed to study design, implementation, analysis, and interpretation.

Results: Across the 5 participating centers, we conducted 8 focus groups and 44 interviews, in which 113 participants identified 45 distinct challenges to in-center hemodialysis care. Subsequently, completion of a national ranking survey (n = 323) of these challenges resulted in a short-list of the top 30 challenges. Finally, using small and large group sessions to develop consensus during the prioritizing workshop, 38 stakeholders used this short-list to identify the top 10 challenges to in-center hemodialysis care. These included individualization of dialysis-related education; improved information in specific topic areas (transplant status, dialysis modalities, dialysis-related complications, and other health risks); more flexibility in hemodialysis scheduling; better communication and continuity of care within the health care team; and increased availability of transportation, financial, and social support programs.

Limitations: Participants were from urban centers and were predominately English-speaking. Survey response rate of 31.5% in Phase 2 may have led to selection bias. We collected limited information on social determinants of health, which could confound our results.

Conclusion: Overall, the challenges we identified demonstrate that individualized care and information that improves interaction with health care providers is important to patients receiving in-center hemodialysis. In future stages of this project, we will aim to address these challenges by trialing innovative patient-centered solutions.

Trial Registration: Not applicable.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7580147PMC
October 2020

Expanding the clinical and genetic spectrum of PCYT2-related disorders.

Brain 2020 09;143(9):e76

Neurometabolic Diseases Laboratory, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.

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September 2020

Predicting Successful Laparoendoscopic Transhiatal Esophagectomy (THE) by Mediastinal Height Measurement.

Am Surg 2020 Aug 6;86(8):1032-1035. Epub 2020 Aug 6.

24041 Department of Surgery, West Virginia University, Charleston Division, Charleston, WV, USA.

Background: Laparoendoscopic transhiatal esophagectomy (THE) provides advantages over traditional THE by not only avoiding laparotomy but by also allowing more precise esophageal mobilization. Occasionally, the length of the gastric conduit is insufficient to allow delivery into the neck after laparoscopic mobilization and requires laparotomy to complete the procedure. We hypothesize that the need for laparotomy will correlate with the measurement of mediastinal height (distance from thoracic vertebrae T1-T12) on chest CT.

Methods: Medical records of all patients who underwent attempted laparoendoscopic-assisted THE at a tertiary referral center between March 1, 2003 and January 31, 2019 were reviewed. Patients' mediastinal height was measured using computed tomography (CT) imaging of the chest by investigators and analyzed for correlation between mediastinal height and successful completion of a totally laparoendoscopic procedure.

Results: A total of 21 cases met inclusion criteria: 9 successful laparoendoscopic THE procedures and 12 failed laparoendoscopic THE procedures (those requiring addition of a mini-laparotomy or thoracotomy). The mean mediastinal length for successful laparoendoscopic surgery was 23.5 cm, whereas the mean mediastinal length for failed laparoscopic surgeries was 24.8 cm (P = .03). Patient's overall height was not found to correlate with the need for conversion.

Conclusions: Shorter mediastinal length is associated with successful laparoendoscopic or laparoscopic THE. This information is readily available to clinicians from routine preoperative staging studies (chest CT) and may be used to potentially predict the success rate of a totally laparoendoscopic approach and aid in patient selection. Further prospective evaluation of these findings is warranted.
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August 2020

The Provision of Acute Pediatric Surgical Care by Adult Acute Care General Surgeons : Is There a Learning Curve?

Am Surg 2020 Dec 26;86(12):1640-1646. Epub 2020 Jun 26.

12355Department of Surgery, West Virginia University/Charleston Division, Charleston, WV, USA.

Background: At our hospital, acute surgical care of children aged 6 and older is managed by adult acute care surgeons. Previously published data from a 10-year experience with this model demonstrated no differences in outcomes when compared with pediatric surgical benchmark data. This study assesses for the effects of a learning curve in the care of pediatric patients by comparing outcomes of patients treated in the first three years with those treated in the last 3 years during a 10-year experience with this model.

Design: This was a retrospective study of pediatric patients aged 6 and older who underwent an emergent or urgent, nontrauma surgical procedure by a general surgeon. Data was obtained via chart review and descriptive statistics were compared between patients operated on between January 1, 2009-January 1, 2012 and January 1, 2016-January 1, 2019.

Results: In all, 208 cases were performed in the early cohort and 192 cases in the late cohort. Appendectomy was the most common procedure in both intervals (88% early, 94.8% late). Although there was a significant decrease in open procedures in the later cohort (22.6% vs 4.7%, < .001), there was no significant change in disease-specific complications or negative appendectomies. No consults to a fellowship-trained pediatric surgeon were required during either time period, although one was available if needed.

Conclusions: Our data demonstrated a decrease in the number of open procedures in the later cohort. This may be due to an increased comfort level with pediatric laparoscopy over time. However, no significant changes in outcomes were observed. This study supports that acute care general surgeons can provide comparable care to pediatric patients within this age demographic and that although a learning curve, appears to exist with respect to pediatric laparoscopy, it is insignificant in terms of its effect on overall outcomes.
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December 2020

An empirical test of the model of socialization of emotion: Maternal and child contributors to preschoolers' emotion knowledge and adjustment.

Dev Psychol 2020 Mar;56(3):418-430

Department of Psychology, University of Washington.

This study tested child characteristics (temperamental executive control and negative reactivity) and maternal characteristics (parenting behaviors and maternal depressive symptoms) as predictors of a mother's emotion-related socialization behaviors (ERSBs). Further, parenting behaviors and ERSBs were examined as predictors of children's emotion knowledge, social competence, and adjustment problems. ERSBs and children's emotion knowledge were tested as mediators of the effects of child and parent characteristics on adjustment. A community sample (N = 306) of mothers and children (36-40 months at T1) were assessed 4 times, once every 9 months, and assessments included maternal reports of depressive symptoms, observed temperament, observational ratings of general parenting at T1, maternal report of ERSBs at T1 & T2, behavioral measures of emotion knowledge at T3, and teacher ratings of children's adjustment at T4. There were no predictors of ERSBs above prior levels. Higher executive control and lower maternal depressive symptoms predicted greater child emotion knowledge, highlighting the roles of maternal and child contributors to emotion knowledge. Greater emotion knowledge and positive affective quality in parenting predicted children's adjustment, with emotion knowledge mediating the effects of executive control on children's adjustment. In addition, lower levels of maternal supportive ERSBs predicted greater adjustment problems. This study highlights the roles of key variables in Eisenberg, Cumberland, and Spinrad's (1998) heuristic model of emotion socialization and the importance of emotion socialization and emotion knowledge in children's adjustment. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/dev0000860DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7041859PMC
March 2020

A prospective, randomized study comparing ultrasound versus fluoroscopic guided femoral arterial access in noncardiac vascular patients.

J Vasc Surg 2020 07 21;72(1):259-267. Epub 2020 Jan 21.

Charleston Area Medical Center Health Education and Research Institute, Charleston, WV.

Objective: The aim of our prospective, single-center, randomized study was to compare the procedural outcomes and complication rates of ultrasound (US)-guided common femoral artery (CFA) access to fluoroscopic guidance in noncardiac procedures.

Methods: A total of 635 patients undergoing femoral access for noncardiac diagnostic or interventional procedures were randomized 1:1 to receive either fluoroscopic or US-guided access. The primary end point of the study was successful CFA cannulation. Secondary end points included the first-pass success rate, time to sheath insertion, and accidental venipunctures rate. Both short (24 hours) and midterm (30-90 days postprocedure) access complications were assessed by practitioners blinded to patient randomization.

Results: Successful CFA cannulation occurred in 93% of US-guided procedures compared with 86% of fluoroscopy-guided access (P = .002). US guidance was associated with increased rates of first-attempt success (74% vs 42%; P < .001), fewer inadvertent venipunctures (2% vs 10 %; P < .001), and decreased median time to cannulation (80 vs 100 seconds; P < .001) compared with fluoroscopy. Rates of complications did not differ at 24 hours (1% vs 1%; P = .99) or 30 to 90 days (2% vs 4%; P = .15) in fluoroscopy vs US-guided access. When access was performed by vascular surgery trainees (residents and fellows), US guidance retained superior rates of successful CFA cannulation compared to fluoroscopy guided access (n = 298; 96% vs 89%; P = .03). Trainees' time to achieve CFA cannulation was similar to attendings' when using US guidance (median, 85 vs 77 seconds; P = .14); however, with fluoroscopy, trainees' times were significantly longer than those of attendings (137 vs 86 seconds; P = .001).

Conclusions: In comparison to fluoroscopy, US-guided CFA cannulation had a higher rate of success, faster cannulation, and fewer venipunctures in the absence of increased complications.
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July 2020

Physical activity for people with chronic kidney disease: an international survey of nephrologist practice patterns and research priorities.

BMJ Open 2019 12 18;9(12):e032322. Epub 2019 Dec 18.

Department of Medicine, University of Alberta, Edmonton, Alberta, Canada

Objectives: People with chronic kidney diseases (CKD) have identified exercise as a research priority. To inform the research agenda, we surveyed nephrologists on their practice patterns, available resources and research priorities for exercise and physical activity (PA) in CKD.

Design: Cross-sectional international survey.

Setting And Participants: 19-item electronic survey was administered to practising nephrologists with publicly available email addresses in Canada (n=354) and Australia and New Zealand (ANZ) and via newsletters for the Australian and New Zealand Society of Nephrology (n=598).

Outcomes: Frequency and predictors of exercise and PA counselling in practice and research priorities.

Results: 189 respondents (20% response) completed the survey. Eighty-one per cent of ANZ and 42% of Canadian respondents reported that their renal programmes did not have any exercise programmes or resources. The most frequently reported barrier for exercise programme implementation was a lack of funding (77%). Ninety per cent of respondents thought regular exercise provides 'health benefits' for all CKD stages; 59% reported that exercise counselling was within the nephrologists' scope of practice and 47% reported 'frequently' or 'always' counselling patients. In multivariable analysis, female gender (OR 2.31; 95% CI 1.16 to 4.58) and older age (OR 1.94 per age category increase; 95% CI 1.15 to 3.26) were associated with exercise counselling. Out of 194 research priorities, 65 (34%) were clinical outcomes (cardiovascular parameters) and 30% were patient-reported outcomes (quality of life).

Conclusions: Most nephrologists consider exercise and PA counselling as within their scope of practice and beneficial but, due to competing priorities, do not regularly counsel patients. This suggests a need for the evaluation of effective and efficient counselling strategies and a role for the routine involvement of exercise specialists in kidney care. Cardiovascular parameters and quality of life were identified as important outcomes for future exercise trials.
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http://dx.doi.org/10.1136/bmjopen-2019-032322DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6936996PMC
December 2019

Prevalence and Correlates of Accelerometer-Based Physical Activity and Sedentary Time Among Kidney Transplant Recipients.

Can J Kidney Health Dis 2019 29;6:2054358119882658. Epub 2019 Oct 29.

Faculty of Medicine, Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, Canada.

Background: Physical activity is recommended for kidney transplant recipents as it may improve outcomes including mortality, exercise capacity, muscle strength, and health-related quality of life.

Objective: The objective of this study was to examine accelerometer-based physical activity and sedentary time profiles among kidney transplant recipients and examine possible demographic and clinical correlates of physical activity and sedentary time.

Design: Cross-sectional.

Setting: Edmonton, Alberta, Canada.

Patients: Kidney transplant recipients were recruited (N = 1,284) from the Northern Alberta Renal Program's Nephrology Information System database (1993-2016).

Measurements: Participants wore an ActiGraph GT3X+ accelerometer on their hip during waking hours for seven consecutive days.

Methods: Kidney transplant recipients (1993-2016) recruited from the Northern Alberta Renal Program's Nephrology Information System database wore an accelerometer and completed a self-reported questionnaire. Multiple linear regression was used to determine associations between activity level, demographic, and clinical characteristics.

Results: Participants' (n = 133; 11% response rate) mean age (SD) was 58 (14) years and 56% were female. Mean total sedentary time was 9.4 (1.4) hours per day; total moderate-to-vigorous physical activity (MVPA) time was 20.7 (19.6) minutes per day. MVPA was significantly associated with age where each additional year was associated with 0.48 fewer min/day (ie, ~30 seconds) (unstandardized beta: = -0.48 min/day, 95% confidence interval [95% CI]: -0.75, -0.22). Sedentary time was significantly associated with age ( = 1.0 min/day, 95% CI: 0.03, 1.9), body mass index ( = 2.7 min/day, 95% CI: 0.2, 5.13), education ( = 39.1 min/day, 95% CI: 12.3, -65.8), and inversely associated with income ( = -44.9 min/day, 95% CI: -73.1, -16.8).

Limitations: Limitations include the cross-sectional design, poor response rate, and limited generalizability of the results.

Conclusions: Kidney transplant recipients showed high volumes of sedentary time and low volumes of health-enhancing physical activity. Understanding correlates of these behaviors may aid in the development of interventions to favorably change these behaviors.
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http://dx.doi.org/10.1177/2054358119882658DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6820169PMC
October 2019

Electronic Advice Request System for Nephrology in Alberta: Pilot Results and Implementation.

Can J Kidney Health Dis 2019 4;6:2054358119879778. Epub 2019 Oct 4.

Division of Nephrology, University of Calgary, AB, Canada.

Background: Residents of rural areas of Alberta face significant barriers regarding access to specialist care, resulting in delays in provision of optimal care. Electronic referral and consultation systems are promising tools for facilitating timely access to specialist care, especially for people living in rural locations.

Objective: To report our initial experience with the launch of an electronic advice request system for ambulatory kidney care in Alberta, Canada.

Methods: We analyzed electronic advice requests for nephrology services in Alberta after the system's pilot launch, from October 2016 to December 2017. Data for province-wide advice request utility by primary care providers (PCPs) were extracted from Alberta Netcare for analysis.

Results: The total number of electronic advice requests directed to nephrology was 118 (mean number of requests: 2 per week). Only 31 (26.3%) of the cases required a face-to-face clinic visit with a nephrologist. Most (87; 73.7%) cases were managed by PCPs with ongoing nephrologist support via the advice request tool. Typical nephrologist response time was 5.7 ± 0.6 (mean ± SEM) days.

Conclusion: These preliminary data suggest that the electronic advice request program has potential to enhance timely access to specialist kidney care and minimize unnecessary nephrologist visits while reducing response time. Broad implementation of this system may have a substantial positive impact on health outcomes and improve cost-effectiveness for nephrology care in the long term, particularly in rural communities of Alberta.
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http://dx.doi.org/10.1177/2054358119879778DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6778992PMC
October 2019

Protocol: Improving Access to Specialist Nephrology Care Among Rural/Remote Dwellers of Alberta: The Role of Electronic Consultation in Improving Care for Patients With Chronic Kidney Disease.

Can J Kidney Health Dis 2019 30;6:2054358119878715. Epub 2019 Sep 30.

Division of Nephrology, University of Calgary, AB, Canada.

Background: As the burden of chronic kidney disease (CKD) continues to increase, many geographically dispersed Canadians have limited access to specialist nephrology care, which tends to be centralized in major urban areas. As a result, many rural/remote-dwellers in Canada experience poor quality of care and related adverse outcomes. It is imperative to develop alternative care delivery mechanisms to ensure optimal health outcomes for all Canadians.

Objective: To investigate the feasibility and effectiveness of electronic consultation (eConsult) as a new model for interactions between specialists and primary care providers (PCPs) to improve access to care for patients with CKD.

Design: This is a sequential, mixed methods study that will be conducted in 3 phases.

Setting: The study will be conducted across the entire province of Alberta, supported by Alberta Kidney Care (formerly, Northern and Southern Alberta Renal Programs [NARP/SARP]).

Patients: Patients suffering from CKD will be included in the study.

Measurements: We will assess the barriers and enablers of implementation and adoption of an e-consultation protocol to facilitate access to care for patients with CKD in Alberta with a focus on rural/remote-dwellers with CKD. We will also evaluate the impact of the eConsult system (eg, improved access to specialist care, reduction in care gaps), assess the feasibility of province-wide implementation, and compare eConsult with practice facilitation versus eConsult alone in terms of access to specialist care, quality of care, and related outcomes.

Methods: The study will be conducted in 3 phases. In phase 1, we will assess the perceptions of stakeholders (ie, PCPs, nephrologists, patients, policymakers, and other care providers) to improve CKD care delivery, quality, and outcomes in Alberta with focus groups and semistructured interviews. Phase 2 will engage specific family physicians for their input on key factors and logistical issues affecting the feasibility of implementing eConsult for the care of patients with CKD. Phase 3 will provide academic detailing including practice facilitation to clinics in Alberta to assess how eConsult with practice facilitation compares with eConsult alone in terms of access to specialist care, quality of care, and related outcomes.

Results: We will assess stakeholder perceptions about potential barriers to and enablers of a new eConsult and decision support system strategy, focusing on elements that are most important for the design of a feasible and implementable intervention. We will develop, pilot test, and assess the impact of the eConsult model in improving access to specialist nephrology care and the feasibility of province-wide implementation. The final phase of the project will address key challenges for optimal care for patients with CKD living in rural, remote, and underserved areas of Alberta, particularly timely referral and disease management as well as the cost-effective benefits of eConsult.

Limitations: Lack of high-speed Internet in many rural and remote areas of Alberta may lead to more time spent in completing the eConsult request online versus faxing a referral the traditional way. Allied health care staff (referral coordinators, administrative staff) require training to the eConsult system, and physicians at many remote sites do not have adequate staff to handle eConsult as an added task.

Conclusions: Implementation of eConsult can favorably influence referral patterns, access to care, care quality, patient outcomes, and health care costs for people with CKD. Results of this study will inform the optimization of care for rural/remote-dwellers with CKD and will facilitate future partnerships with policymakers and provincial renal programs in Alberta to ensure optimal kidney health for all residents.

Trial Registration: Not required.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6769217PMC
September 2019
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