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ObjectivesRamadan fasting is an Islamic religious practice involving abstinence from food and drink from dawn to sunset. Its consequences on kidney-relevant outcomes in patients with chronic kidney disease (CKD) and kidney transplant recipients remain unclear.DesignSystematic review and meta-analysis.Data sourcesMEDLINE, Embase, Global Health, CINAHL (EBSCOhost), Scopus, Web of Science and Google Scholar were searched up to 18 September 2023.Eligibility criteriaWe included observational studies among non-dialysis CKD and kidney transplant recipients who fasted during Ramadan and examined changes in kidney function.Data extraction and synthesisStandardised methods were used by two independent reviewers to screen, select and extract data. Outcomes included changes in serum creatinine (SCr), estimated glomerular filtration rate (eGFR), proteinuria, blood pressure, electrolytes and adverse events—all pre- and post-Ramadan. Results were pooled using random effects modelling.ResultsWe included 32 observational studies with a total of 2592 participants. 21 studies reported on participants with CKD and 11 studies reported on kidney transplant recipients (studies variably including non-fasting control arms). Meta-analysis of 25 studies revealed that Ramadan fasting was not associated with changes to SCr for the following groups according to study design: CKD with a non-fasting arm (mean difference (MD)=0.82 µmol/L; 95% CI −7.22, 8.86; I2=38%); transplant with a non-fasting arm (MD=−0.17 µmol/L; 95% CI −2.50, 2.15; I2=0%) and CKD without a non-fasting arm (post–pre MD=13.84 µmol/L; 95% CI −3.78, 31.47; I2=88%). For transplant studies without a non-fasting arm, lower SCr was associated with the post-Ramadan period (post–pre MD=−5.40 µmol/L; 95% CI –10.78, –0.02; I2=0%). In the 18 studies that reported on eGFR, fasting during Ramadan was not associated with an effect on eGFR for any of the groups.ConclusionWe report inconsistent effects of Ramadan fasting on kidney function in CKD or kidney transplantation. Results should be interpreted with caution due to the significant limitations of the underlying studies.

Although patients with chronic kidney disease (CKD) are routinely managed in primary care settings, no nationally representative study has assessed the quality of care received by these patients in Canada. To evaluate the current state of CKD management in Canadian primary care practices to identify care gaps to guide development and implementation of national quality improvement initiatives. This cross-sectional study leveraged Canadian Primary Care Sentinel Surveillance Network data from January 1, 2010, to December 31, 2015, to develop a cohort of 46 162 patients with CKD managed in primary care practices. Data analysis was performed from August 8, 2018, to July 31, 2019. The study examined the proportion of patients with CKD who met a set of 12 quality indicators in 6 domains: (1) detection and recognition of CKD, (2) testing and monitoring of kidney function, (3) use of recommended medications, (4) monitoring after initiation of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), (5) management of blood pressure, and (6) monitoring for glycemic control in those with diabetes and CKD. The study also analyzed associations of divergence from these quality indicators. The cohort comprised 46 162 patients (mean [SD] age, 69.2 [14.0] years; 25 855 [56.0%] female) with stage 3 to 5 CKD. Only 4 of 12 quality indicators were met by 75% or more of the study cohort. These indicators were receipt of an outpatient serum creatinine test within 18 months after confirmation of CKD, receipt of blood pressure measurement at any time during follow-up, achieving a target blood pressure of 140/90 mm Hg or lower, and receiving a hemoglobin A1c test for monitoring diabetes during follow-up. Indicators in the domains of detection and recognition of CKD, testing and monitoring of kidney function (specifically, urine albumin to creatinine ratio testing), use of recommended medications, and appropriate monitoring after initiation of treatment with ACEIs or ARBs were not met. Only 6529 patients (18.4%) with CKD received a urine albumin test within 6 months of CKD diagnosis, and 3954 (39.4%) had a second measurement within 6 months of an abnormal baseline urine albumin level. Older age (≥85 years) and CKD stage 5 were significantly associated with not satisfying the criteria for the quality indicators across all domains. Across age categories, younger patients (aged 18-49 years) and older patients (≥75 years) were less likely to be tested for albuminuria (314 of 1689 patients aged 18-49 years [18.5%], 1983 of 11 919 patients aged 75-84 years [61.6%], and 614 of 5237 patients aged ≥85 years [11.7%] received the urine albumin to creatinine ratio test within 6 months of initial estimated glomerular filtration rate <60 mL/min per 1.73 m2; P < .001). Patients aged 18 to 49 years were less commonly prescribed recommended medications (222 of 2881 [7.7%]), whereas patients aged 75 to 84 years were prescribed ACEIs or ARBs most frequently (2328 of 5262 [44.2%]; P < .001). The findings suggest that management of CKD across primary care practices in Canada varies according to quality indicator. This study revealed potential priority areas for quality improvement initiatives in Canadian primary care practices.

Champlain BASE™ (Building Access to Specialists through eConsultation) is a web-based asynchronous electronic communication service that allows primary-care- practitioners (PCPs) to submit \"elective\" clinical questions to a specialist. For adults, PCPs have reported improved access and timeliness to specialist advice, averted face-to-face specialist referrals in up to 40% of cases and high provider satisfaction. To determine whether the expansion of eConsult to a pediatric setting would result in similar measures of improved healthcare system process and high provider acceptance reported in adults. Prospective observational cohort study. Single Canadian tertiary-care academic pediatric hospital (June 2014-16) servicing 1.2 million people. 1. PCPs already using eConsult. 2.Volunteer pediatric specialists provided services in addition to their regular workload. 3.Pediatric patients (< 18 years-old) referred for none-acute care conditions. Specialty service utilization and access, impact on PCP course-of-action and referral-patterns and survey-based provider satisfaction data were collected. 1064 eConsult requests from 367 PCPs were answered by 23 pediatric specialists representing 14 specialty-services. The top three specialties represented were: General Pediatrics 393 cases (36.9%), Orthopedics 162 (15.2%) and Psychiatry 123 (11.6%). Median specialist response time was 0.9 days (range <1 hour-27 days), most consults (63.2%) required <10minutes to complete and 21/21(100%) specialist survey-respondents reported minimal workload burden. For 515/1064(48.4%) referrals, PCPs received advice for a new or additional course of action; 391/1064(36.7%) referrals resulted in an averted face-to-face specialist visit. In 9 specialties with complete data, the median wait-time was significantly less (p<0.001) for an eConsult (1 day, 95%CI:0.9-1.2) compared with a face-to-face referral (132 days; 95%CI:127-136). The majority (>93.3%) of PCPs rated eConsult as very good/excellent value for both patients and themselves. All specialist survey-respondents indicated eConsult should be a continued service. Similar to adults, eConsult improves PCP access and timeliness to elective pediatric specialist advice and influences their care decisions, while reporting high end-user satisfaction. Further study is warranted to assess impact on resource utilization and clinical outcomes.

IntroductionElectronic consultation (eConsult)—provider-to-provider electronic asynchronous exchanges of patient health information at a distance—is emerging as a potential tool to improve the interface between primary care providers and specialists. Despite growing evidence that eConsult has clinical benefits, it is not widely adopted. We investigated factors influencing the adoption and implementation of eConsult services.MethodsWe applied established methods to guide the review, and the recently published Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews to report our findings. We searched five electronic databases and the grey literature for relevant studies. Two reviewers independently screened titles and full texts to identify studies that reported barriers to and/or facilitators of eConsult (asynchronous (store-and-forward) use of telemedicine to exchange patient health information between two providers (primary and secondary) at a distance using secure infrastructure). We extracted data on study characteristics and key barriers and facilitators were analysed thematically and classified using the Quadruple Aim framework taxonomy. No date or language restrictions were applied.ResultsAmong the 2579 publications retrieved, 130 studies met eligibility for the review. We identified and summarised key barriers to and facilitators of eConsult adoption and implementation across four domains: provider, patient, healthcare system and cost. Key barriers were increased workload for providers, privacy concerns and insufficient reimbursement for providers. Main facilitators were remote residence location, timely responses from specialists, utilisation of referral coordinators, addressing medicolegal concerns and incentives for providers to use eConsult.ConclusionThere are multiple barriers to and facilitators of eConsult adoption across the domains of Quadruple Aim framework. Our findings will inform the development of practice tools to support the wider adoption and scalability of eConsult implementation.

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.

Systematic challenges in providing culturally responsive mental health and addictions services have produced widespread inequities for racialized service providers, clients, and communities. There is a pressing need for coordinated system-level change. In this article, we present findings from a cross-sectional mixed methods study examining current organizational practices in advancing racial equity in the child and youth mental health and addictions sector in Ontario. To understand current efforts and identify a path forward, we surveyed executive leaders from 102 agencies and conducted case studies with 10 agencies on their practices along five domains: organizational leadership, intersectoral partnerships, workforce diversity and development, client and community engagement, and continuous improvements. Leaders shared a strong desire to advance racial equity and had begun this work to varying degrees. Fifty-one percent of agencies had made a public commitment to racial equity; however, few had developed written plans to support these efforts. Over 60% of agencies had developed relationships with cross-sectoral and community partners to facilitate this work. Seventy-five percent of agencies had offered racial equity training to staff, and some had implemented targeted recruitment efforts for racialized staff. Over 69% of agencies provided translation services and referrals to other agencies, whereas only 39% provided clients the option to request service providers who reflected their cultural identity. Less than 29% of agencies collected and used race-based data routinely to inform their work. Our findings, in particular the domains examined and barriers and facilitators, can inform parallel efforts in related sectors across Canada and internationally. Les difficultés systématiques à fournir des services de santé mentale et de toxicomanie adaptés à la culture ont entraîné des inégalités généralisées pour les fournisseurs de services, communautés et client racialisés. Il y a un besoin urgent de changements coordonnés à l'échelle du système. Dans cet article, nous présentons les résultats d'une étude transversale à méthodes mixtes portant sur les pratiques organisationnelles actuelles en matière de promotion de l'équité raciale dans le secteur de la santé mentale et de la toxicomanie des enfants et des jeunes en Ontario. Afin de comprendre les efforts actuels et d'identifier une voie à suivre, nous avons interrogé les dirigeants de 102 agences et mené des études de cas auprès de 10 agences sur leurs pratiques dans cinq domaines : leadership organisationnel, partenariats intersectoriels, diversité et développement de la main-d'œuvre, engagement des clients et de la communauté, et améliorations continues. Les dirigeants partageaient un fort désir de faire progresser l'équité raciale et avaient commencé ce travail à des degrés divers. Cinquante et un pour cent des agences s'étaient engagées publiquement en faveur de l'équité raciale; cependant, peu d'entre elles avaient élaboré des plans écrits pour soutenir ces efforts. Plus de 60 % des agences avaient développé des relations avec des partenaires intersectoriels et communautaires pour faciliter ce travail. Soixante-quinze pour cent des agences avaient offert une formation sur l'équité raciale à leur personnel, et certaines avaient mis en place des efforts de recrutement ciblés pour le personnel racialisé. Plus de 69 % des agences fournissent des services de traduction et d'orientation vers d'autres agences, alors que seulement 39 % offrent aux clients la possibilité de demander des fournisseurs de services qui reflètent leur identité culturelle. Moins de 29 % des organismes ont recueilli et utilisé régulièrement des données fondées sur la race pour orienter leur travail. Nos conclusions, en particulier les domaines examinés et les obstacles et facilitateurs, peuvent orienter des efforts parallèles dans des secteurs connexes au Canada et à l'étranger. Public Significance Statement This study identifies current efforts underway to advance racial equity in the child and youth mental health and addictions sector in Ontario. We believe leaders can learn from the early successes and challenges of these agencies outlined in this article to create more innovative and culturally responsive mental health services for all.

IntroductionElectronic consultations (eConsult), asynchronous exchanges of patient health information at a distance, are increasingly used as an option to facilitate patient care and collaboration between primary care providers and specialists. Although eConsult has demonstrated success in increasing efficiency in the referral process and enhancing access to care, little is known about the factors influencing its wider adoption and implementation by end users. In this paper, we describe a protocol to conduct a scoping review of the literature on the barriers and facilitators to a wider adoption and implementation of eConsult service.Methods and analysisThis scoping review will be based on the framework pioneered by Arksey and O’Malley and later developed by Levac et al. We will use the guidance for scoping reviews developed by the Joanna Briggs Institute to report our findings. In addition to several electronic databases (Medline, Embase, Cochrane Library, CINAHL, EBSCOhost and PsycINFO) studies will be identified by including relevant grey literature. Two reviewers will independently screen titles and full texts for inclusion. Studies reporting on barriers and/or facilitators in settings similar to eConsult will be included. Data on study characteristics and key barriers and facilitators will be extracted. Data will be analysed thematically and classified using the Quadruple Aim framework.Ethics and disseminationApproval by research ethics board is not required since the review will only include published and publicly accessible data. Review findings will be used to inform future studies and the development of practice tools to support the wider adoption and success of eConsult implementation. We plan to publish our findings in a peer-reviewed journal and develop a useful and accessible summary of the results.

In the aftermath of high-profile incidents involving Black, Indigenous and People of Color (BIPOC) in North America, there is a growing awareness of the pervasiveness of systemic racism and the role that agencies play in perpetuating racism and racial inequities. In the child and youth mental health sector, the journey to improving racial equity is impeded by a lack of consistent frameworks or guidelines. In this commentary, we explore five domains of organizational practices that are prominent in the literature and support diverse clients, communities and staff, including: (1) organizational leadership and commitment, (2) inter-organizational and multisectoral partnerships, (3) workforce diversity and development, (4) client and community needs and engagement, and (5) continuous improvement. As we highlight these domains, we urge researchers, policy makers, and child and youth mental health service providers to work together to advance racial equity in meaningful ways.

IntroductionFasting during the month of Ramadan is a significant Islamic religious practice that involves abstinence from food, drink and medication from dawn to dusk. As just under a quarter of the world’s population identifies as Muslim, the effect of fasting on chronic conditions, such as chronic kidney disease (CKD) is a topic of broad relevance. To date, the information in this area has been mixed, with many limitations of previous studies. This study aims to synthesise the evidence of the effect of Ramadan fasting on changes on kidney function, risk factors, episodes of acute kidney injury and impact on the quality of life in patients with CKD or kidney transplant.Methods and analysisA systematic review of the literature will be conducted, using electronic databases such as MEDLINE, Embase, Global Health, CINAHL and Scopus. Original research and grey literature on the effect of Ramadan fasting in adult patients with CKD or renal transplantation will be included. Two reviewers will independently screen articles for inclusion in the review and independently assess the methodology of included studies using a customised checklist. Mean difference or risk ratio will be reported for continuous or dichotomous outcomes and results will be pooled using a random-effects model where heterogeneity is reasonable. If possible, subgroups (CKD status, setting, season and risk of bias) will be analysed for effect modification with fasting and the outcomes of interest. Risk of bias will be assessed using the Downs and Black checklist.Ethics and disseminationThe results will be disseminated using a multifaceted approach to engage all stakeholders (patients, practitioners and community leaders). Research ethics board approval is not required as this is a systematic review of previously published research.PROSPERO registration numberCRD42018088973.

Contractile actomyosin networks are responsible for the production of intracellular forces. There is increasing evidence that bundles of actin filaments form interconnected and interconvertible structures with the rest of the network. In this study, we explored the mechanical impact of these interconnections on the production and distribution of traction forces throughout the cell. By using a combination of hydrogel micropatterning, traction force microscopy and laser photoablation, we measured the relaxation of traction forces in response to local photoablations. Our experimental results and modelling of the mechanical response of the network revealed that bundles were fully embedded along their entire length in a continuous and contractile network of cortical filaments. Moreover, the propagation of the contraction of these bundles throughout the entire cell was dependent on this embedding. In addition, these bundles appeared to originate from the alignment and coalescence of thin and unattached cortical actin filaments from the surrounding mesh. The mechanism of stress fibre assembly by the coalescence of actin filaments in the cell cortex has now been found to account for the transmission of mechanical forces throughout the entire cell along stress fibres.