Sturgeon Community Hospital

...increased demand has recently driven the price of black market smoked sturgeon as high as $ 26 a kilogram. With poachers standing to gain roughly a third of this price [besides the much higher price of caviar], a large fish could be worth thousands of dollars. Gary Hamilton in Canadian Geographic, July/August 1996, p. 62

Abstract Clubroot, caused by Plasmodiophora brassicae, was detected for the first time on canola in Alberta. Galling, typical of the disease, was observed on the roots of canola (Brassica napus) plants in a dozen fields near St. Albert, Alberta. The presence of resting spores of the pathogen was confirmed by light and electron microscopy. Pathogen spores were isolated from diseased tissue and used to inoculate roots of B. napus 'Westar', on which they produced symptoms similar to those observed in the field. Resting spores were recovered from galls on inoculated plants. The identification of clubroot on the Alberta canola crop is a matter of concern, as the disease is associated with appreciable yield losses and can only be managed with extended intervals between host crops because other management strategies may be too expensive to implement or are of limited effectiveness. Further studies are underway to determine the extent of the problem. Keywords: clubroot Plasmodiophora brassicae canolacrucifers

Abstract Several hypotheses explain the prevalence of undifferentiated sex chromosomes in poikilothermic vertebrates. Turnovers change the master sex determination gene, the sex chromosome or the sex determination system (e.g. XY to WZ). Jumping master genes stay main triggers but translocate to other chromosomes. Occasional recombination (e.g. in sex-reversed females) prevents sex chromosome degeneration. Recent research has uncovered conserved heteromorphic or even homomorphic sex chromosomes in several clades of non-avian and non-mammalian vertebrates. Sex determination in sturgeons (Acipenseridae) has been a long-standing basic biological question, linked to economical demands by the caviar-producing aquaculture. Here, we report the discovery of a sex-specific sequence from sterlet (Acipenser ruthenus). Using chromosome-scale assemblies and pool-sequencing, we first identified an approximately 16 kb female-specific region. We developed a PCR-genotyping test, yielding female-specific products in six species, spanning the entire phylogeny with the most divergent extant lineages (A. sturio, A. oxyrinchus versus A. ruthenus, Huso huso), stemming from an ancient tetraploidization. Similar results were obtained in two octoploid species (A. gueldenstaedtii, A. baerii). Conservation of a female-specific sequence for a long period, representing 180 Myr of sturgeon evolution, and across at least one polyploidization event, raises many interesting biological questions. We discuss a conserved undifferentiated sex chromosome system with a ZZ/ZW-mode of sex determination and potential alternatives. This article is part of the theme issue ‘Challenging the paradigm in sex chromosome evolution: empirical and theoretical insights with a focus on vertebrates (Part I)’.

PURPOSE: To compare the effect of early mobilization (EM) with standard rehabilitation (SR) over the initial 24 months following arthroscopic rotator cuff (RC) repair. METHODS: A total of 206 patients with full-thickness RC tears undergoing arthroscopic repair were randomized following preoperative assessment of shoulder range of motion (ROM), pain, strength, and health-related quality of life (HRQOL) to either EM (n = 103; self-weaned from sling and performed pain-free active ROM during the first 6 weeks) or SR (n = 103; wore a sling for 6 weeks with no active ROM). Shoulder ROM, pain, and HRQOL were reassessed at 6 weeks and 3, 6, 12, and 24 months postoperatively by a blinded assessor. At 6, 12, and 24 months, strength was reassessed. At 12 months, ultrasound verified RC integrity. Independent t tests assessed 6-week group differences and 2-way repeated measures analysis of variance assessed changes over time between groups. RESULTS: The groups were similar preoperatively (P > .12). The mean age of participants was 55.9 (minimum, 26; maximum, 79) years, and 131 (64%) were men. A total of 171 (83%) patients were followed to 24 months. At 6 weeks postoperatively, EM participants had significantly better forward flexion and abduction (P < .03) than the SR participants; no other group differences were noted. Over 24 months, there were no group differences in ROM after 6 weeks (P > .08), and pain (P > .06), strength (P = .35), or HRQOL (P > .20) at any time. Fifty-two (25%) subjects (30% EM; 33% SR) had a full-thickness tear present at 12-month postoperative ultrasound testing (P > .8). CONCLUSIONS: EM did not show significant clinical benefits, but there was no compromise of postoperative ROM, pain, strength, or HRQOL. Repair integrity was similar at 12 months postoperatively between groups. Consideration should be given to allow pain-free active ROM within the first 6 weeks following arthroscopic RC repair. LEVEL OF EVIDENCE: Level I, high-quality randomized controlled trial.

The International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) COVID-19 dataset is one of the largest international databases of prospectively collected clinical data on people hospitalized with COVID-19. This dataset was compiled during the COVID-19 pandemic by a network of hospitals that collect data using the ISARIC-World Health Organization Clinical Characterization Protocol and data tools. The database includes data from more than 705,000 patients, collected in more than 60 countries and 1,500 centres worldwide. Patient data are available from acute hospital admissions with COVID-19 and outpatient follow-ups. The data include signs and symptoms, pre-existing comorbidities, vital signs, chronic and acute treatments, complications, dates of hospitalization and discharge, mortality, viral strains, vaccination status, and other data. Here, we present the dataset characteristics, explain its architecture and how to gain access, and provide tools to facilitate its use.

In their paper in this volume Bemis et al. (1997) ask: ‘How many valid species of Acipenser should we recognize-’ Although a partial answer to this question is presented in their Table 5, we discovered in the course of preparing this volume that sonic additional commentary is needed. In fact, there are two questions: (1) how many species should be recognized? and (2) what scientific names should be used for some of the species? The sympatric distributions of most species of sturgeons set the stage for much confusion about species boundaries, but the situation is actually much more complicated. Confusion about the number of species of sturgeons living within the same basin can result from the often close morphological and meristic similarities of certain species of Acipenser, particularly during juvenile period. Moreover, westill have remarkably inadequate knowledge of the comparative anatomy of thespeciesof Acipener: no modern study has ever attempted a comprehensive examination of all species, and it is impossible to rely on literature for the sorts of comparisons that must be made (for more on this general problem, see Grande & Bemis 1991,1997). Most classical descriptions and comparativean atomical studies relieduponsmall sample sizes. Voucher specimens of large sturgeons areespecially rare in mosthistorical collections, and type specimens (if available at all) are seldom prepared in ways that are suitable for making detailed anatomical comparisons (e.g., many skins are simply overstuffed with straw, so that all internal structures are lost). Intraspecific morphological and meristic polymorphisms occur in all species of acipenserids, and in most cases we have very poor knowledge of differences that develop during ontogeny, particularly changes in such features as the shape of the rostrum (Bemis et al. 1997). Another problem is the ease of hybridization between different species of sturgeons (reviewed in Birstein et al. 1997 this volume). In many of these cases, it is not easy to discriminate between parental species and the hybrids.

Caring takes a toll on family caregivers throughout the care trajectory (Steppacher & Kissler, 2018). Family caregivers often report worsening health and stress/distress (Bauer & Sousa-Poza, 2015; Richardson, Lee, Berg-Weger, & Grossberg, 2013). Family caregiving has become more onerous as illness, frailty and impairments become more severe, but in the last two decades medical advances, increased longevity, shorter hospital stays and the push for community care have made caregiving even more complex and longer lasting (Health Quality Ontario, 2016; Schulz et al., 2018; Sinha, 2018). In 2016, over a third (34%) of caregivers to long-term home care clients in Canada were stressed and distressed (Health Quality Ontario, 2016), up from 16.6% in 2010 (Canadian Institutes for Health Information [CIHI], 2010). Furthermore, primary family caregivers at the greatest risk of distress are those who live with the care recipient, provide more than 20 hr of care, care for a person with moderate to severe impairments (functional, cognitive) and/or depression, and coordinate care or provide medical treatments (Pauley, Chang, Wojtak, Seddon, & Hirdes, 2018; Sinn et al., 2018). Given that primary care physicians have the potential to reach the majority of caregivers throughout the care trajectory (Pindus et al., 2016), an opportunity exists for caregivers to benefit from care and support from primary care teams (Afram, Verbeek, Bleijlevens, & Hamers, 2015; Richardson et al., 2013). Primary care is credited for better population health, more health equity and better use of resources (Starfield, 2012). Four key domains are associated with high-quality primary care: first-contact access for each need, person focused (not disease) over time, comprehensiveness and coordination of care (Hochman & Asch, 2017). Vulnerable populations benefit most from quality primary care (Starfield, 2012) and family caregivers are a vulnerable population (Centers for Disease Control [CDC], 2018). They have high rates of stress and depression, impaired ability to recover from an illness and often neglect their own health because they are providing care. In fact, caregiver's poor health or mortality is frequently the reason for the client's LTC admission (CDC, 2018). Family caregivers believe family physicians are well positioned to support them (Brotman & Yaffe, 1994). Indeed, family physicians were the only sources of formal support associated with reduction of burden for family caregivers of long-term care clients (Shiba, Kondo, & Kondo, 2016). However, primary care physicians may regard supporting caregivers as outside the purview of their role. In Australia, Bulsara and Fynn (2006) found physicians saw their role as to the patient only. As such, they were unable or unwilling to provide emotional or psychological support for caregivers. However, the vast majority of physicians (96%) did think they had a role in referring caregivers to services. Similarly, 91% of Canadian family physicians (n = 142) believed they could only respond to the non-medical needs of caregivers as they were not the patient (Yaffe & Klvana, 2002). Over 80% of physicians in this same study reported that interactions with caregivers were stressful and three-quarters (75.5%) believed they were not adequately remunerated for the stress and time involved to meet caregivers needs. Similarly, general practitioners in the United Kingdom (n = 211) found they lacked the time, resources and training to meet caregivers needs (Simon & Kendrick, 2001). These results suggest that the existing primary care system needs to be adapted to support family caregivers. The demand for system changes to support caregivers primarily comes from bottom-up pressure from academic researchers or top-down in glossy reports from national or provincial agencies (Byrne, 2016). For example, Romanow (2002) in Building on Values: The Future of Healthcare in Canada and Schulz and Eden (2016) Families Caring for an Aging America both recommend that health systems should support caregivers. In addition, editorials and think pieces theorise that primary care should play a central role in caregiver support (Collins & Swartz, 2011; Frisch, 2013; Massoud, Lysy, & Bergman, 2010; Schulz & Czaja, 2018), but primary care is a complex system. Practices are already stretched by growing workloads and decreasing resources (Okunogbe et al., 2018; Steinglass, 2006). Yet, the perspective of primary care physicians is essential to meaningful health system change (Pawson, Greenhalgh, Brennan, & Glidewell, 2014). As such, an important question to ask is: What do primary care physicians think about supporting caregivers? We conducted a scoping review to understand what is known about support for caregivers in primary care by family physicians. The initial literature search of the interface between family physicians or primary care and family caregivers revealed numerous studies on caregivers’ perceptions of interactions with physicians, but only a limited number on physicians’ perceptions on supporting family caregivers. Hence, we decided to do a scoping review to enable a broader exploration of what is known about the topic at hand rather than a systematic review/detailed analysis of a specific research question. A scoping review summarises and synthesises the extent, range and nature of the literature to inform research, practice, programmes and policy by mapping key concepts, types of evidence and gaps in a defined field (Arksey & O'Malley, 2005; Levac, Colquhoun, & O'Brien, 2010). We followed Arksey and O'Malley's (2005) protocols for scoping reviews and Thomas and Harden (2008) guidance for thematic synthesis. We restricted the search to English language and to the last decade (2009–2019) in the electronic databases Scopus, Medline, PubMed and CINAHL using the search terms related to physicians and family caregivers (see Table 1 for search terms). We searched for grey literature on Google using the same terms and Google's search guidance (Google, ND; see Table 1 for search terms and strategy). We sought a broad range of literature, including original research, review articles, systematic reviews, international, national and provincial reports, conceptual/theoretical papers and opinion papers that explored physicians’ perspectives on caregiver support or provided context on physician's role in caregiver support (see Figure 1). Conducted title, abstract and subject headings search for terms related to Physicians: ‘primary care’ OR ‘family care’ AND physician OR doctor OR ‘general practitioner’ OR ‘primary care Physician’ OR ‘family physician’ OR ‘medical home’ AND Family caregivers: Caregiver OR carer OR ‘family caregiver’ OR ‘unpaid caregiver’ OR ‘informal caregiver’ Limited to years: 2009–2019 Title, Abstract and Subject Heading searches were adapted for databases. *Boolean search: Title (Intitle), Abstract (InAB), Subject Heading (InSW) We excluded literature that included only patients, caregivers or staff perceptions of physician's care or primary care physician's roles. In the initial keyword searches, we screened titles and abstracts for inclusion and inclusion criteria. The search results were imported into EndNote and duplicates removed (see Figure 1). Full texts of titles and abstracts remaining after duplicates were removed were retrieved and read in their entirety by the second author. The first and second authors reviewed the included and excluded articles and agreed on the final articles to be included (n = 27). Their results and findings were entered into an extraction table (Table 2). As recommended by Arksey and O’ Malley's (2005) scoping review protocol, we did not assess quality. We imported the papers into NVivo for data management. We coded the text in three stages: line-by-line, for descriptive themes, and then generated analytical themes (Thomas & Harden, 2008). In line-by-line coding, we began adding conceptual codes that would ‘translate’ the content from one study to another. The first and second authors began collating the initial codes into descriptive themes in the second stage. We developed these themes by staying close to the primary studies. We checked back and forth to ensure that the themes reflected the intent within and across the primary studies. Lastly, we identified the key points within these themes through examining the coding frequencies and discussing the storylines in the themes. In all, 27 studies met the broad criteria we set for this 10-year scoping review. In total, 23 papers were from the peer-reviewed literature and four published by associations in the grey literature. Peer-reviewed literature included the following: three papers reviewing the ethics of physicians engagement with caregivers (Barnard & Yaffe, 2014; Gitlin & Hodgson, 2016; Mitnick, Leffler, & Hood, 2010); three literature reviews on the role of physicians in care of the dementia caregivers (O'Connor, 2011; Robinson et al., 2011; Sunne & Huntington, 2017); a report on the development of a survey on physician's perceptions of care for caregivers (Bedard, Gibbons, Lambert-Belanger, & Riendeau, 2014), a policy paper (Moore, Frank, & Chambers, 2018), 12 qualitative investigations (Burridge, Mitchell, Jiwa, & Girgis, 2017; Burridge, Mitchell, Jiwa, & Girgis, 2011; Carduff et al., 2014; Doekhie, Strating, Buljac-Samardzic, Bovenkamp, & Paauwe, 2018; Foley, Boyle, Jennings, & Smithson, 2017; Gill et al., 2014; Greenwood, Mackenzie, Harris, Fenton, & Cloud, 2011; Hum et al., 2014; Kiceniuk et al., ND; Krug et al., 2018; Leu, Frech, & Jung, 2018; Wang et al., 2018); and three reports on two surveys (Greenwood, MacKenzie, Habibi, Atkins, & Jones, 2010; Jones, Mackenzie, Greenwood, Atkins, & Habibi, 2012; Thyrian & Hoffmann, 2012). A policy paper Doctors of BC 2016a,2016b), two guides to developing caregiver-centred care practice (Doctors of BC 2016a,2016b; Princess Royal Trust, 2011), and a survey (Skufca, 2019) were published by organisations. In all, 16 primary studies sought physicians’ perspectives with 800 physician informants overall (range = 2–335; mean = 53, median = 13). One study did not report on the number of physicians participating (Gill et al., 2014). The papers were, in order of number of papers, from Canada (n = 8), the United Kingdom (n = 6), the United States (n = 4), Australia (n = 2); Ireland (n = 2), Germany (n = 2), the Netherlands (n = 1), Switzerland (n = 1) and China (n = 1). More detailed characteristics of the included studies are provided in Table 2. We defined three main themes: (a) Primary care is the ideal context for reaching most caregivers and overwhelming recognition that caregivers would benefit from support; (b) collaborative, integrated care models were the recommended designs for caregiver-centred care practices and (c) actualising consistent support for caregivers within primary care practices remains elusive. Therefore, we identified the facilitators and barriers to caregiver-centred care at the practice, health system and policy levels. We delineate the subthemes from these main themes in the sections that that family caregivers support and that primary care is the ideal context for reaching caregivers included primary care is the of a for reaching the most caregivers. The primary care physician's in supporting family caregivers could as caregiver health, better care for the care and with care. However, is about the physician's role in supporting family the caregiver the For example, et reported that in both family physicians and caregivers that discussing family caregivers’ needs not the patient Carduff et reported because were rather than Doctors caregivers to ask they The three this on health that on the patient and patient (Barnard & Yaffe, 2014; Gitlin & Hodgson, 2016; et al., 2010). recommended that the on the patient but that physicians do have an to family caregivers. Gitlin and (2016) the of to family that not reaching to family caregivers is and to patient the to the family caregiver's health is et a They recommend for and should but physicians should the family caregiver's for of and care The physician's should on patient and caregiver quality of caregiver and health, providing and emotional and referring caregivers to and/or were for primary care but physicians had perspectives on their role with caregivers. a survey found interactions focused on medical (Skufca, physicians over they should on a role et al., and general practitioners in the United Kingdom they had in providing emotional support and but to support and to an staff et al., 2012). to be for caregivers within primary care In the survey of general practitioners in the United Kingdom (n = did not respond to the question practice for et al., 2010; et al., 2012). caregivers’ or and identified the caregiver in their to were an important of their but physicians were by the nature of the health system care for and caregivers their role et al., 2014; et al., 2017; et al., 2011; Doctors of BC 2016a,2016b; et al., 2018; et al., 2017; Gill et al., 2014; & Mackenzie, 2010; et al., 2010; Hum et al., 2014; et al., 2012; Kiceniuk et al., ND; Krug et al., 2018; et al., 2018; Robinson et al., 2010; Sunne & Huntington, 2017; Thyrian & Hoffmann, 2012; Wang et al., 2018). of of resources and Hum et provided this should be of that and should be published Canadian physicians were by or to and by as that did not meet caregivers needs and et al., 2014; Kiceniuk et al., that of their or community could be more at providing and caregivers to et al., 2017; et al., 2011; Carduff et al., Doctors of et al., 2017; et al., 2011; et al., 2010; Hum et al., 2014; et al., 2012; et al., 2018; Krug et al., et al., 2018; Princess Royal Trust, 2011; Sunne & Huntington, 2017; Thyrian & 2012; Wang et al., 2018). integrated care models were recommended as the to primary care to meet caregivers’ needs et al., 2014; et al., 2017; Doctors of BC 2016a,2016b; et al., 2018; et al., 2017; Gill et al., 2014; & Mackenzie, 2010; et al., 2010; Hum et al., 2014; et al., 2012; Kiceniuk et al., ND; Krug et al., 2018; et al., 2018; Robinson et al., 2010; Sunne & Huntington, 2017; Thyrian & Hoffmann, 2012; Wang et al., 2018). medical associations (Doctors of BC 2016a,2016b; Princess Royal Trust, have developed to physicians their practices to support caregivers. These (Doctors of BC that primary care care practices provide care and support to caregivers. primary they that a caregiver's practice or should be to coordinate care and caregivers to health and community that to and community could be and that caregiver or community could to provide support and However, in the policy paper that the of Family in BC Doctors of BC 2016a,2016b), recommended that and to to and a and caregivers as in care’ The and to actualising consistent support for caregivers within primary care practices remains et al., 2014; et al., 2017; Carduff et al., 2014; Doctors of BC 2016a,2016b; et al., 2018; et al., 2017; Gill et al., 2014; & Mackenzie, 2010; et al., 2011; Hum et al., 2014; et al., 2012; Kiceniuk et al., ND; Krug et al., 2018; et al., 2018; 2011; Sunne & Huntington, 2017; Thyrian & Hoffmann, 2012; Wang et al., 2018). As Krug et that primary care physicians to practices to support caregivers is and that existing to be and Robinson et that for caregivers in primary care the same systematic as the of long-term However, they that are facilitators and barriers at practice, system and policy that be we are to primary care potential to care and support caregivers. We on thematic analysis to provide on the facilitators and barriers that to be we are to enable primary care physicians and practices to provide caregiver-centred care. the caregiver as a patient in the practice and practice protocols to support caregivers care for caregivers. and physicians were more supporting caregivers the caregiver a patient in their For example, Canadian family physicians agreed or agreed that caregiver needs and providing support or the caregiver their patient but were or the caregiver not a patient et al., 2014). physician recognition and caregiver protocols as a person to coordinate care for and care increased benefit from and to support and that takes of both and medical needs (Doctors of BC 2016a,2016b; Princess Royal Trust, a caregivers as key in care of the care as well as with needs of their own et al., 2018). Caregiver about and of time and were practice barriers to supporting caregivers. to not ask for for physicians to them as caregivers et al., 2017; Carduff et al., 2014). physicians (n = caregivers and not of who the caregiver is as the barriers to supporting caregivers (Skufca, as on the caregivers on the needs and to their own caregivers do not their of the interactions may physicians from about their health et al., because of the complex caregivers may not be to the home to or of physician's to or caregiver may more about caregiver and but are In a study of in general practitioners they had training and lacked that they were needs et al., 2010; et al., 2012). In a report of the Primary for study in Kiceniuk et one physician's about think we about dementia or caregiver burden would be of a at the of a to for caregiver burden or that is caregiver a but In a survey of primary care = were or in with caregivers and were or with caregivers (Skufca, The for the time with caregivers may be the caregiver is not the patient et al., 2014; et al., 2017; Carduff et al., 2014; Doctors of BC 2016a,2016b; et al., 2018; et al., 2017; Gill et al., 2014; & Mackenzie, 2010; et al., 2011; Hum et al., 2014; et al., 2012; Kiceniuk et al., ND; Krug et al., 2018; et al., 2018; 2011; Sunne & Huntington, 2017; Thyrian & Hoffmann, 2012; Wang et al., 2018). in results from an Primary for Kiceniuk et reported that in physicians for time to caregiver the caregiver is a patient and had an from the Similarly, in Ontario, et that physicians reported they do not have time to with caregivers and that they are not adequately for supporting caregivers’ In results from this literature caregiving be and for physicians. is that primary care practices provide the support caregivers need, to caregivers for is In the in about one of survey provided about or to and agencies et al., 2010; et al., 2012). and of and by caregivers is and onerous for health are a system that should between primary care, and (Gill et al., 2014). should be to and with as electronic health are We identified three systems barriers in the papers included in this (a) the health system to on care, (b) health and community systems are complex and and (c) to support caregivers are or to to the first system the health system to on patient care, support for caregivers In addition, ethics for physicians on with caregivers provide (Barnard & Yaffe, 2014; Gitlin & Hodgson, 2016; et al., 2010). to health and community an identified is that these systems to in collaborative, integrated care that to community is the for health to and the community are not well in with health and care the and caregivers may are not Caregiver as well as a or a to care are often in only that these may not be to caregivers who do not the access to or or for the they are physicians to assess and support caregivers with could the ability of the primary care physicians to their practices to support time and caregivers. The Quality and general practitioners for caregiver care et al., 2010; et al., 2011; et al., 2012; Princess Royal Trust, However, Canada has Canadian caregivers. have at the provincial For example, in the the that for caregivers should be and but is guidance as to who should provide support is addition, this not or that are in or ethics are a ethics do not provide for caregiver support (Barnard & Yaffe, 2014; Gitlin & Hodgson, 2016; et al., 2010). Doctors of have a policy of Family in BC and a for to their practices to support family caregivers. They recommend that the BC caregiver to caregivers in and health (see Table Family caregiver is patient in the were more supporting caregivers as in their with family recognition and about caregiver practice protocols to support caregivers. protocols for family person to coordinate caregiver's care and Caregiver Family caregivers do not as caregivers ask for They to on the health their own those for needs may not be to home to of time and for caregivers is often complex and may not be codes for time with caregivers. on the and on the needs. health and community integrated care that to community is recommended but systems are not and to may access to and for care Primary care physicians that caregivers would benefit from support from primary care integrated care models that physicians, a caregiver or and community support are as the most this are barriers to primary care physician's ability to and support caregivers (see and the physician's role in caregiver-centred care is not well defined and do not to or ask for is an that family physicians and to the and and from physicians is but may not be in a & Family caregivers of their time health and care and then the care and from health and care & 2017). health and community systems in onerous for physicians to across systems and caregivers to the services. is not as a medical caregivers needs to be complex and they lacked the time to the caregivers and remunerated for the caregiver care they provide (see Table Schulz et and Schulz and to barriers as a of and authors to caregivers for as a (see Table 2). and have primary care practices do not to have to In the United for example, the family Caregiver and on are to In the United general practices with access to However, physicians did were the most caregiver resources (Skufca, support and care for family caregivers systematic and support throughout the care and in the of both health and community systems et al., 2018; Schulz & Czaja, 2018). As family caregivers do not or a or who is or is recommended Royal Trust, is to primary care physicians to support family caregivers. are at the practice, health and community and policy levels. pressure for caregivers’ has from the research community and as the of or (Byrne, 2016; 2011; Schulz et al., 2018). support is as physicians report to assess and support family system and policy changes are and medical should training to to assess and support family caregivers. policy changes that caregiver support in of care, and for time for caregivers are and the of and are to complex system change & 2017; & 2018). as the for caregivers & et al., and inclusion of specific in the for the Health 2019) are of changes to support for family caregivers in primary care. In to primary care practices the first of and support from are & their family physician's perspectives & 2014). in is associated with increased to and of care et al., 2014), of should caregivers’ review is limited by the of on primary care support for caregivers from the perspective of primary care physicians. of the reports in this review included perspectives of only a physicians. of primary care physicians and primary is to provide data about their of barriers and perceptions of the support that caregivers et al., 2014; et al., 2010). The findings are limited by of research in primary care teams have change and do not physicians perspectives of they enable practice and policy to support family caregivers. is increased that caregivers Primary teams are well positioned to caregivers to both primary care practices and their but the policy and to change has perspectives about caregiver interactions are to inform health and community Future to these is to support caregivers throughout their care

Since the da Vinci surgical system was approved by the Food and Drug Administration (FDA) in 2000, the development and deployment of various robot-assisted minimally invasive surgery (MIS) systems have been largely expedited and boomed. With the rapid advancement of robotic techniques in recent decades, robot-assisted systems have been widely used in various surgeries including orthopedics. These robot-related techniques are transforming the conventional ways to conduct surgical procedures. Robot-assisted orthopedic surgeries have become more and more popular due to their potential benefits of increased accuracy and precision in surgical outcomes, enhanced reproducibility, reduced technical variability, decreased pain, and faster recovery time. In this paper, robotic systems and navigation techniques in typical orthopedic surgeries are reviewed, especially for arthroplasty. From the perspective of robotics and engineering, the systems and techniques are divided into two main categories, i.e., robotic systems (RSs), and computer-aided navigation systems (CANSs). The former is further divided into autonomous RS, hands-on RS, and teleoperated RS. For the latter, three key elements in CANS are introduced, including 3D modeling, registration, and navigation. Lastly, the potential advantages and disadvantages of the RS and CANS are summarized and discussed. Future perspectives on robotics in orthopedics, as well as the challenges, are presented.

BACKGROUND: Many Canadian adolescents and young adults with mental health problems face delayed detection, long waiting lists, poorly accessible services, care of inconsistent quality and abrupt or absent inter-service transitions. To address these issues, ACCESS Open Minds, a multi-stakeholder network, is implementing and systematically evaluating a transformation of mental health services for youth aged 11 to 25 at 14 sites across Canada. The transformation plan has five key foci: early identification, rapid access, appropriate care, the elimination of age-based transitions between services, and the engagement of youth and families. METHODS: The ACCESS Open Minds Research Protocol has multiple components including a minimum evaluation protocol and a stepped-wedge cluster randomized trial, that are detailed in this paper. Additional components include qualitative methods and cost-effectiveness analyses. The services transformation is being evaluated at all sites via a minimum evaluation protocol. Six sites are participating in the stepped-wedge trial whereby the intervention (a service transformation along the key foci) was rolled out in three waves, each commencing six months apart. Two sites, one high-population and one low-population, were randomly assigned to each of the three waves, i.e., randomization was stratified by population size. Our primary hypotheses pertain to increased referral numbers, and reduced wait times to initial assessment and to the commencement of appropriate care. Secondary hypotheses pertain to simplified pathways to care; improved clinical, functional and subjective outcomes; and increased satisfaction among youth and families. Quantitative measures addressing these hypotheses are being used to determine the effectiveness of the intervention. DISCUSSION: Data from our overall research strategy will help test the effectiveness of the ACCESS Open Minds transformation, refine it further, and inform its scale-up. The process by which our research strategy was developed has implications for the practice of research itself in that it highlights the need to actively engage all stakeholder groups and address unique considerations in designing evaluations of complex healthcare interventions in multiple, diverse contexts. Our approach will generate both concrete evidence and nuanced insights, including about the challenges of conducting research in real-world settings. More such innovative approaches are needed to advance youth mental health services research. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov, ISRCTN23349893 (Retrospectively registered: 16/02/2017).

BACKGROUND: Whether prehospital point-of-care (POC) troponin further accelerates the time to diagnosis in patients with chest pain (CP) is unknown. We conducted a randomized trial of POC-Troponin testing in the ambulance. METHODS AND RESULTS: Patients with chest pain presenting by ambulance were randomized to usual care (UC) or POC-Troponin; ST-elevation myocardial infarction patients or those with noncardiovascular symptoms were excluded. Pre-hospital high-sensitivity troponin was analyzed on a POC device and available to the paramedic and emergency department (ED) staff. The final diagnosis was centrally adjudicated. The primary endpoint was time from first medical contact to discharge from ED or admission to hospital. We randomized 601 patients in 19 months; 296 to UC and 305 to POC-Troponin. After ambulance arrival, the first troponin was available in 38 minutes in POC-Troponin and 139 minutes in UC. In POC-Troponin, the troponin was >0.01 ng/mL in 17.4% and >0.03 ng/mL in 9.8%. Patients spent a median of 9.0 hours from first medical contact to final disposition, and 165 (27.4%) were admitted to the hospital. The primary endpoint was shorter in patients randomized to POC-Troponin (median 8.8 hours [6.2-10.8] compared to UC (median 9.1 hours [6.7-11.2]; P=0.05). There was no difference in the secondary endpoint of repeat ED visits, hospitalizations, or death in the next 30 days. CONCLUSIONS: In this broad population of patients with CP, ambulance POC-Troponin accelerated the time to final disposition. Enhanced and more cost-effective early ED discharge of the majority of patients with CP calling 911 is an unrealized opportunity. CLINICAL TRIAL REGISTRATION: URL: https://www.ClinicalTrials.gov/. Unique identifier: NCT01634425.

Spur cell anemia is an acquired form of hemolytic anemia caused by a structural abnormality of red cell membranes that results in spiculated erythrocytes. These peculiarly shaped red blood cells, called acanthocytes, have a shortened survival and undergo splenic sequestration and destruction. Spur cell anemia has been known to occur in several conditions, including chronic liver disease, and more specifically in alcoholic cirrhosis. Treatment of this disorder has been disappointing and usually indicates end-stage liver disease. Liver transplantation has been reported as the most effective treatment. We herein present a case of severe spur cell hemolytic anemia that successfully reverted after orthotopic liver transplantation and recurred secondary to resumption of alcohol intake and consequent liver graft failure. This case conclusively demonstrates the association among alcoholic cirrhosis, end-stage liver disease, and spur cell hemolytic anemia.

BACKGROUND: Indigenous youth in Canada face profound health inequities which are shaped by the rippling effects of intergenerational trauma, caused by the historical and contemporary colonial policies that reinforce negative stereotypes regarding them. Moreover, wellness promotion strategies for these youth are replete with individualistic Western concepts that excludes avenues for them to access holistic practices grounded in their culture. Our scoping review explored strategies, approaches, and ways health and wellness can be enhanced by, for, and with Indigenous youth in Canada by identifying barriers/roadblocks and facilitators/strengths to enhancing wellness among Indigenous youth in Canada. METHODS: We applied a systematic approach to searching and critically reviewing peer-reviewed literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews [PRISMA-ScR] as a reporting guideline. Our search strategy focused on specific keywords and MeSH terms for three major areas: Indigenous youth, health, and Canada. We used these keywords, to systematically search the following electronic databases published in English between January 01, 2017, to May 22, 2021: Medline [Ovid], PubMed, ERIC, Web of Science, Scopus, and iportal. We also used hand-searching and snowballing methods to identify relevant articles. Data collected were analysed for contents and themes. RESULTS: From an initial 1695 articles collated, 20 articles met inclusion criteria for this review. Key facilitators/strengths to enhancing health and wellness by, for, and with Indigenous youth that emerged from our review included: promoting culturally appropriate interventions to engage Indigenous youth; using strength-based approaches; reliance on the wisdom of community Elders; taking responsibility; and providing access to wellness supports. Key barriers/roadblocks included: lack of community support for wellness promotion activities among Indigenous youth; structural/organizational issues within Indigenous communities; discrimination and social exclusion; cultural illiteracy among youth; cultural discordance with mainstream health systems and services; and addictions and risky behaviours. CONCLUSION: This scoping review extracted 20 relevant articles about ways to engage Indigenous youth in health and wellness enhancement. Our findings demonstrate the importance of promoting health by, and with Indigenous youth, by engaging them in activities reflexive of their cultural norms, rather than imposing control measures that are incompatible with their value systems.

OBJECTIVES: The objective was to examine predictors of hospital admission among adults presenting to Canadian emergency departments (EDs) for acute exacerbations of chronic obstructive pulmonary disease (COPD). Current acute treatment approaches and outcomes 2 weeks after the ED visit are also described. METHODS: Subjects, aged > or =35 years presenting with COPD exacerbations to 16 EDs across Canada, underwent a structured in-ED interview and a telephone interview 2 weeks later. RESULTS: Of 501 study patients, 247 (49.3%; 95% confidence interval [CI] = 44.9% to 53.6%) were admitted. Admitted patients were older, were more often former smokers, and had more admissions for COPD during the past 2 years. They also reported more days of activity limitation and use of inhaled beta(2)-agonists in the previous 24 hours. Canadian Triage and Acuity Scale (CTAS), respiratory rate (RR), and airflow obstruction were more severe in the hospitalized group. Most of the patients received inhaled beta(2)-agonists, anticholinergics, oral corticosteroids (CS), and antibiotics; hospitalized patients received more aggressive treatments. The median ED length of stay (LOS) of admitted patients was 13.1 hours (interquartile range [IQR] = 7.4-23.0) compared to 5.6 hours (IQR = 4.2-8.4) in discharged patients. Admission was associated with at least two COPD admissions in the past 2 years (odds ratio [OR] = 2.10; 95% CI = 1.24 to 3.56), receiving oral CS for COPD (OR = 1.72; 95% CI = 1.08 to 2.74), having a CTAS score of 1-2 (OR = 2.04; 95% CI = 1.33 to 3.12), and receiving adjunct ED treatments (OR = 3.95; 95% CI = 2.45 to 6.35). Use of EDs for usual COPD care was associated with a reduced risk of admission (OR = 0.43; 95% CI = 0.28 to 0.66). CONCLUSIONS: Exacerbations of COPD in Canadian EDs result in prolonged ED stays and approximately 50% hospitalization despite aggressive acute treatment approaches. Historical, severity, and treatment-related factors were strongly associated with hospital admission. Validation of these results should be completed prior to widespread use.

Background: The distribution of hepatitis C (HCV) infection in Canada signals a widening gap between Indigenous and non-Indigenous people. Current evidence demonstrates that the rate of HCV infection among Indigenous people is at least five times higher than the rest of Canada. This analysis provides a reconciliatory response, which exposes the colonial etiology of the HCV gap in Canada and proposes potential anti-colonial approaches to HCV wellness and health care for Indigenous people. Methods: This analysis applies Two-Eyed Seeing as a reconciliatory methodology to advance the understanding of HCV burden and identify the key elements of responsive HCV care in the context of Indigenous nations in Canada. Results: The analysis underlines the colonial distribution of HCV burden in Canada, highlights Indigenous perspectives on HCV infection, hypothesizes a clinical pathway for the underlying colonial etiology of HCV infection, and identifies Indigenous healing as a promising anti-colonial conceptual approach to HCV wellness and health care among Indigenous people. Conclusions: In the eyes of Indigenous people, HCV infection is a colonial illness that entails healing as an anti-colonial approach to achieving wellness and gaining health. Future empirical research should elaborate on the colonial HCV pathway hypothesis and inform the development of a framework for HCV healing among Indigenous people in Canada.

INTRODUCTION: Significant evidence in the literature supports case management (CM) as an effective intervention to improve care for patients with complex healthcare needs. However, there is still little evidence about the facilitators and barriers to CM implementation in primary care setting. The three specific objectives of this study are to: (1) identify the facilitators and barriers of CM implementation in primary care clinics across Canada; (2) explain and understand the relationships between the actors, contextual factors, mechanisms and outcomes of the CM intervention; (3) identify the next steps towards CM spread in primary care across Canada. METHODS AND ANALYSIS: We will conduct a multiple-case embedded mixed methods study. CM will be implemented in 10 primary care clinics in five Canadian provinces. Three different units of analysis will be embedded to obtain an in-depth understanding of each case: the healthcare system (macro level), the CM intervention in the clinics (meso level) and the individual/patient (micro level). For each objective, the following strategy will be performed: (1) an implementation analysis, (2) a realist evaluation and (3) consensus building among stakeholders using the Technique for Research of Information by Animation of a Group of Experts method. ETHICS AND DISSEMINATION: This study, which received ethics approval, will provide innovative knowledge about facilitators and barriers to implementation of CM in different primary care jurisdictions and will explain how and why different mechanisms operate in different contexts to generate different outcomes among frequent users. Consensual and prioritised statements about next steps for spread of CM in primary care from the perspectives of all stakeholders will be provided. Our results will offer context-sensitive explanations that can better inform local practices and policies and contribute to improve the health of patients with complex healthcare needs who frequently use healthcare services. Ultimately, this will increase the performance of healthcare systems and specifically mitigate ineffective use and costs.

BACKGROUND: Quantifying glenohumeral bone loss is key in preoperative surgical planning for a successful Bankart repair. HYPOTHESIS: Simple radiographs can accurately measure bone defects in cases of recurrent shoulder instability. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A true anteroposterior (AP) view, alone and in combination with an axillary view, was used to evaluate the diagnostic properties of radiographs compared with computed tomography (CT) scan, the current gold standard, to predict significant bone defects in 70 patients. Sensitivity, specificity, and positive and negative predictive values were evaluated and compared. RESULTS: Detection of glenoid bone loss on plain film radiographs, with and without axillary view, had a sensitivity of 86% for both views and a specificity of 73% and 64% with and without the axillary view, respectively. For detection of humeral bone loss, the sensitivity was 8% and 17% and the specificity was 98% and 91% with and without the axillary view, respectively. Regular radiographs would have missed 1 instance of significant bone loss on the glenoid side and 20 on the humeral side. Interobserver reliabilities were moderate for glenoid detection (κ = 0.473-0.503) and poor for the humeral side (κ = 0.278-0.336). CONCLUSION: Regular radiographs showed suboptimal sensitivity, specificity, and reliability. Therefore, CT scan should be considered in the treatment algorithm for accurate quantification of bone loss to prevent high rates of recurrent instability.

INTRODUCTION: A common reason for frequent use of healthcare services is the complex healthcare needs of individuals suffering from multiple chronic conditions, especially in combination with mental health comorbidities and/or social vulnerability. Frequent users (FUs) of healthcare services are more at risk for disability, loss of quality of life and mortality. Case management (CM) is a promising intervention to improve care integration for FU and to reduce healthcare costs. This review aims to develop a middle-range theory explaining how CM in primary care improves outcomes among FU with chronic conditions, for what types of FU and in what circumstances. METHODS AND ANALYSIS: A realist synthesis (RS) will be conducted between March 2017 and March 2018 to explore the causal mechanisms that underlie CM and how contextual factors influence the link between these causal mechanisms and outcomes. According to RS methodology, five steps will be followed: (1) focusing the scope of the RS; (2) searching for the evidence; (3) appraising the quality of evidence; (4) extracting the data; and (5) synthesising the evidence. Patterns in context-mechanism-outcomes (CMOs) configurations will be identified, within and across identified studies. Analysis of CMO configurations will help confirm, refute, modify or add to the components of our initial rough theory and ultimately produce a refined theory explaining how and why CM interventions in primary care works, in which contexts and for which FU with chronic conditions. ETHICS AND DISSEMINATION: Research ethics is not required for this review, but publication guidelines on RS will be followed. Based on the review findings, we will develop and disseminate messages tailored to various relevant stakeholder groups. These messages will allow the development of material that provides guidance on the design and the implementation of CM in health organisations. TRIAL REGISTRATION NUMBER: Prospero CRD42017057753.

Significant populations of White Sturgeon, Acipenser transmontanus, are restricted to three rivers in northwestern North America, the Sacramento, Columbia and Fraser.While this species can and does enter sea water it is not an obligatory anadromous species.In British Columbia, White Sturgeon are caught by commercial, native, and sports fishermen, especially in the lower Fraser River.The present total B.C. catch is likely from 30 to 40 tonnes/year.White Sturgeon spend most time in main channel areas but move into sloughs and side channels in summer in response to temperature.The species has been reported to spawn upstream in the Sacramento River at temperatures between 7.8 to 17.8°C in spring.Fecundity is high (180 000 to 590 000) and eggs are adhesive, hatching in a week at 15°C.Growth rates are variable and appear to be climatically influenced -Columbia fish reach an average of 167 cm in 20 years.White Sturgeon are carnivorous, feeding on invertebrates and fish.Limiting factors are uncertain but temperature may be important.The White Sturgeon is the largest freshwater fish in Canada.While present populations appear healthy, the distribution in Canada is restricted to south and central British Columbia in the Fraser and Columbia Rivers where they are subject to commercial, native, and increasingly popular sport fisheries.De grandes populations d'Esturgeon blanc, Acipenser transmontanus, sont confinées a trois cours d'eau situés dans la partie nord-ouest de l'Amérique du Nord, soit les fleaves Columbia et Fraser et la riviére Sacramento.Bien que l'espece puisse pénétrer en eau salée et s'y rend effectivement, ce n'est pas une espéce anadrome par nécéssité.En Colombie-Britannique, l'Esturgeon blanc est capturé par des pécheurs commerciaux, autochtones et sportifs, notamment dans le cours inférieur du fleuve Fraser.Les prises totales actuelles dans la province se situent probablement entre 30 et 40 tm par année.L'Esturgeon blanc passe la majeure partie de sa vie dans les chenaux principaux, mais il migre dans les marais et les chenaux secondaires l'été.On a signalé que cette espéce fraie en amont dans la rivi¢re Sacramento, a des températures variant entre 7,8 et 17,8°C au printemps.Le nombre d'oeufs pondus est eleve (entre 180 000 et 590 000), et les oeufs sont adhésifs, l'éclosion ayant lieu au bout d'une semaine, a 15°C.Les taux de croissance sont variables et semblent étre régis par le climat: les poissons de la Colombie-Britannique atteignent une longueur moyenne de 167 cm en vingt ans.L'Esturgeon blanc est carnivore et se nourrit d'invertébrés et de poissons.On ne connait pas avec certitude les facteurs limitatifs, mais la température pourrait jouer un réle important.L'Esturgeon blanc est le plus gros poisson dulcicole du Canada.Bien que les populations actuelles semblent en bonne santé, l'aire de dispersion au Canada est limitée au sud et au centre de la Colombie-Britannique dans les fleuves Fraser et Columbia ou ils sont exposés aux pécheurs commerciaux, autochtones et une péche sportive qui devient plus populaire.

Background: The literature on moral distress highlights the need for hospitals and healthcare organizations to improve the work environment in critical care. However, only few studies delve into the types of intervention programs and administrative processes that can be put into effect to help nurses effectively deal with moral distress. Aim: The aim of this study was to systematically synthesize evidence from published studies of interventions that address moral distress in critical care nurses. The attributes, measures, and outcomes of published interventions were described. Methods: Systemized literature review based on searches in four biomedical sciences databases (CINAHL, MEDLINE, COCHRANE, and SCOPUS). The Cochrane Collaboration's tool was employed for risk of bias. Eligibility criteria included published full-text articles exploring any type of intervention for critical care nurses' moral distress. Results: Based on the selection criteria, seven studies were included in the review (two quasi-experimental, two randomized clinical trials, three mixed method). The majority of studies exhibited high risk of bias. Only two studies had moderate risk of bias. The most common type of interventions were workshops. Conclusion: We identified a small number of overall low-quality intervention studies, which provided weak evidence on the effectiveness of workshops for moral distress. Based on the indications for potentially large effect size of workshops, more well-designed studies are needed in order to elucidate the characteristics, content, and duration of effective workshops for moral distress. The results of this review can inform future efforts to develop and test intervention strategies for moral distress among intensive care unit (ICU) nurses.

Provides a definition of, and a background to, teleworking; points out the advantages to organizations and employees, and the economic and demographic factors which have encouraged its growth. Examines the security threats and vulnerabilities which are inherent in teleworking and assesses the risks associated with employees working on sensitive material from a remote site. Postulates a framework for threat and risk assessment with a generic model, and a specific example using a hypothetical telework situation.