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The purpose of this research was to explore parental perspectives on the impact of parent restrictions imposed in response to the COVID-19 pandemic across Canadian Neonatal Intensive Care Units (NICUs). A co-designed online survey was conducted targeting parents (n = 235) of infants admitted to a Canadian NICU from March 1, 2020, until March 5, 2021. Parents completed the survey from 38 Canadian NICUs. Large variation in the severity of policies regarding parental presence was reported. Most respondents (68.9%) were classified as experiencing high restrictions, with one or no support people allowed in the NICU, and felt that policies were less easy to understand, felt less valued and respected, and found it more challenging to access medicine or health care. Parents reported gaps in care related to self-care, accessibility, and mental health outcomes. There is significant variation in parental restrictions implemented across Canadian NICUs. National guidelines are needed to support consistent and equitable care practices. [ABSTRACT FROM AUTHOR]

Increasingly, ICD implantation is performed without defibrillation testing (DT). To determine the current frequency of DT, the risks associated with DT, and to understand how physicians select patients to have DT. Between January 2007 and July 2008, all patients in Ontario, Canada who received an ICD were enrolled in this prospective registry. A total of 2,173 patients were included; 58% had new ICD implants for primary prevention, 25% for secondary prevention, and 17% had pulse generator replacement. DT was carried out at the time of ICD implantation or predischarge in 65%, 67%, and 24% of primary, secondary, and replacement cases respectively (P = <0.0001). The multivariate predictors of a decision to conduct DT included: new ICD implant (OR = 13.9, P < 0.0001), dilated cardiomyopathy (OR = 1.8, P < 0.0001), amiodarone use (OR = 1.5, P = 0.004), and LVEF > 20% (OR = 1.3, P = 0.05). A history of atrial fibrillation (OR = 0.58, P = 0.0001) or oral anticoagulant use (OR = 0.75, P = 0.03) was associated with a lower likelihood of having DT. Age, gender, NYHA class, and history of stroke or TIA did not predict DT. Perioperative complications, including death, myocardial infarction, stroke, tamponade, pneumothorax, heart failure, infection, wound hematoma, and lead dislodgement, were similar among patients with (8.7%) and without (8.3%) DT (P = 0.7) DT is performed in two-thirds of new ICD implants but only one-quarter of ICD replacements. Physicians favored performance of DT in patients who are at lower risk of DT-related complications and in those receiving amiodarone. DT was not associated with an increased risk of perioperative complications. (J Cardiovasc Electrophysiol, Vol. 21, pp. 1344-1348, December 2010) [ABSTRACT FROM AUTHOR]

The article presents a study on the use of remote sensing technology to obtain quantitative topographic data for the digital imagery of the dynamics of the South Saskatchewan River, Canada. The study used a methodology that involves coupling image processing methods and archival photogrammetric techniques with image processing to quantify inundated areas of the river channel. Results show that the ground control transfer did not affect the precision of the data obtained photogrammetrically.

Bone marrow examination (BME) in paediatric Hodgkin lymphoma (HL) was evaluated, as evidence from adult HL suggests it may be unnecessary. An internet-based survey was used to examine the practice of Canadian paediatric oncologists regarding BME in children and the impact of routine BME was evaluated in patients with HL treated at our institution. Sixteen of 17 paediatric oncology centres were represented. Forty-three percent of eligible doctors completed the survey. Routine BME for stages III and IV disease was consistent nationally. By contrast, 54% and 70% of respondents reported performing routine BME for stages I and II HL respectively. Respondents were more likely to report performing routine BME in low-stage HL if trained outside Canada ( P = 0·04, stage I; P = 0·07, stage II) or practicing at smaller centres ( P = 0·05, stage I; P = 0·03, stage II). At our institution, 62 patients were eligible for analysis. Only four patients (6·5%) had a positive BME. Anaemia was the only significant risk factor ( P = 0·006). No patient with otherwise low stage was found to have marrow involvement. Comparison of staging with and without BME demonstrated no significant difference to final risk classification. BME in paediatric patients with low-stage HL has extremely low yield and may be unnecessary. [ABSTRACT FROM AUTHOR]

Ground penetrating radar (GPR) surveys of unit and compound braid bars in the sandy South Saskatchewan River, Canada, are used to test the influential facies model for sandy braided alluvium presented by Cant & Walker (1978) . Four main radar facies are identified: (1) high-angle (up to angle-of-repose) inclined reflections, interpreted as having formed at the margins of migrating bars; (2) discontinuous undular and/or trough-shaped reflections, interpreted as cross-strata associated with the migration of sinuous-crested dunes; (3) low-angle (< 6°) reflections, interpreted as formed by low-amplitude dunes or unit bars as they migrate onto bar surfaces; and (4) reflections of variable dip bounded by a concave reflection, interpreted as being formed by the filling of channel scours, cross-bar channels or depressions on the bar surface. The predominant vertical arrangement of facies is discontinuous trough-shaped reflections at the channel base overlain by discontinuous undular reflections, overlain by low-angle reflections that dominate the deposits near the bar surface. High-angle inclined reflections are only found near the surface of unit bars, and are of relatively small-scale (< 0·5 m), but can be found at a greater range of depths within compound bars. The GPR data show that a high spatial variability exists in the distribution of facies between different compound bars, with facies variability within a single bar being as pronounced as that between bars. Compound bars evolve as an amalgamation of unit bars and other compound bars, and comprise a facies distribution that is representative of the main bar types in the South Saskatchewan River. The GPR data are compared with the original model of Cant & Walker (1978) and reveal a much greater variability in the scale, proportion and distribution of facies than that presented by Cant & Walker (1978) . Most notably, high-angle inclined strata are over-represented in the model of Cant and Walker, with many bars being dominated by the deposits of low- and high-amplitude dunes. It is suggested that further GPR studies from a range of braided river types are required to properly quantify the full range of deposits. Only by moving away from traditional, highly generalized facies models can a greater understanding of braided river deposits and their controls be established. [ABSTRACT FROM AUTHOR]

Background and Objectives: Relational caring has the capacity to reduce stigma associated with dementia by shifting the focus from dysfunction and behavior management, to attending to the interdependencies and reciprocities that underpin caring relationships, and making explicit the centrality of relationships to quality care, growth, and quality of life. Education, particularly arts-based approaches, has been identified as a key strategy to decrease stigma. Yet rarely are the arts utilized in educational initiatives, and particularly so in community care settings. With an interest in redressing this, our team evaluated the impact of a Canadian filmed research-based drama-Cracked: new light on dementia-about stigma associated with people living with dementia and their families., Research Design and Methods: We conducted interviews with family carers of people living with dementia and formal care providers affiliated with community-based dementia care, and also the general public at 3 and 8 months postscreening., Results: Our analysis of participants' perceptions/experiences illustrates the effectiveness of Cracked in reducing stigma by demonstrating changes in the understanding of dementia and changes in practice. Our analysis also includes attention to how the film, as a form of cultural production, deepened engagement and facilitated transformation., Discussion and Implications: Our evaluation of Cracked demonstrates that it is an effective strategy for decreasing the stigma associated with dementia by promoting relational caring. It also importantly contributes to the theoretical literature that supports film-based approaches to stigma reduction., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: Equitable appointments of departmental leaders in medical schools have lagged behind other Equity, Diversity, and Inclusion (EDI) advancements. The purpose of this research was to 1) analyze how policy documents communicate changing ideas of EDI, employment equity, and departmental leadership; and 2) investigate department heads' (DH) perspectives on EDI policies and practices., Methods: We conducted a critical discourse analysis to examine underlying assumptions shaping EDI and departmental leadership in one Canadian medical school. We created and analyzed a textual archive of EDI documents ( n = 17, 107 pages) and in-depth interviews with past ( n = 6) and current ( n = 12) DH (830 minutes; 177 pages)., Results: Documents framed EDI as: a legal requirement; an aspiration; and historical reparation. In interviews, participants framed EDI as: affirmative action; relationships; numerical representation; and relinquishing privilege. We noted inconsistent definitions of equity-deserving groups., Conclusions: Change is slowly happening, with emerging awareness of white privilege, allyship, co-conspiracy, and the minority tax. However, there is more urgent work to be done. This work requires an intersectional lens. Centering the voices, and taking cues from equity-deserving leaders and scholars will help ensure that EDI pathways, such as those used to cultivate department leaders, are more inclusive, effective, and aligned with intentions., Competing Interests: The authors disclose no conflicts of interest that could impact their conduct or reporting of this study., (© 2023 Cameron, LeBlanc, Mahalik, O’Hearn, Simpson; licensee Synergies Partners.)

Clarity regarding the biomedical definition of death and the criteria for its determination is critical to inform practices in clinical care, medical research, law, and organ donation. While best practices for death determination by neurologic criteria and circulatory criteria were previously outlined in Canadian medical guidelines, several issues have arisen to force their reappraisal. Ongoing scientific discovery, corresponding changes in medical practice, and legal and ethical challenges compel a comprehensive update. Accordingly, the A Brain-Based Definition of Death and Criteria for its Determination After Arrest of Neurologic or Circulatory Function in Canada project was undertaken to a develop a unified brain-based definition of death, and to establish criteria for its determination after devastating brain injury and/or circulatory arrest. Specifically, the project had three objectives: (1) to clarify that death is defined in terms of brain functions; (2) to clarify how a brain-based definition of death is articulated; and (3) to clarify the criteria for determining if the brain-based definition is met. The updated death determination guideline therefore defines death as the permanent cessation of brain function and describes corresponding circulatory and neurologic criteria to ascertain the permanent cessation of brain function. This article explores the challenges that prompted revisions to the biomedical definition of death and the criteria for its determination and outlines the rationales underpinning the project's three objectives. By clarifying that all death is defined in terms of brain function, the project seeks to align guidelines with contemporary medicolegal understandings of the biological basis of death., (© 2023. The Author(s).)

This 2023 Clinical Practice Guideline provides the biomedical definition of death based on permanent cessation of brain function that applies to all persons, as well as recommendations for death determination by circulatory criteria for potential organ donors and death determination by neurologic criteria for all mechanically ventilated patients regardless of organ donation potential. This Guideline is endorsed by the Canadian Critical Care Society, the Canadian Medical Association, the Canadian Association of Critical Care Nurses, Canadian Anesthesiologists' Society, the Canadian Neurological Sciences Federation (representing the Canadian Neurological Society, Canadian Neurosurgical Society, Canadian Society of Clinical Neurophysiologists, Canadian Association of Child Neurology, Canadian Society of Neuroradiology, and Canadian Stroke Consortium), Canadian Blood Services, the Canadian Donation and Transplantation Research Program, the Canadian Association of Emergency Physicians, the Nurse Practitioners Association of Canada, and the Canadian Cardiovascular Critical Care Society., (© 2023. The Author(s).)

Background: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is currently diagnosed using a combination of clinical features, imaging, electrocardiography, and genetic investigations. An abnormal signal-averaged electrocardiogram (SAECG) is defined as a minor diagnostic criterion by the 2010 Task Force Criteria, but doubts remain about the value of this investigation., Objective: We evaluated the utility of the SAECG in diagnosing ARVC using the Canadian Arrhythmogenic Right Ventricular Cardiomyopathy Registry, a population representative registry of probands with ARVC and relatives, less influenced by referral bias., Methods: Probands with ARVC and family members from the Canadian Arrhythmogenic Right Ventricular Cardiomyopathy Registry underwent phenotype review. SAECG parameters were compared individually and in combination between those with varying degrees of ARVC severity and healthy controls (family members of probands with ARVC and unexplained sudden death, free of evidence of cardiac disease)., Results: A total of 196 patients with ARVC and 205 controls were included (mean age 44 ± 15 years; 186 of 401 men [46%]). SAECG abnormalities were seen in 83 of 205 controls (40%), 33 of 68 patients with ARVC and mild disease (51%), and 31 of 42 with severe disease (74%). The SAECG associated strongly with imaging abnormalities (major: odds ratio 3.0, 95% confidence interval 1.3-6.9; minor: odds ratio 3.5, 95% confidence interval 0.7-16.5) but not with other aspects of phenotype. Patients carrying pathogenic variants but with minimal phenotype had similar SAECGs to healthy controls (filtered QRS duration 111.2 ± 11.2 ms vs 111 ± 7.6 ms, P = .93; duration of low amplitude signals < 40 μV 32.3 ± 8.9 ms vs 34.2 ± 7.2 ms, P = .32; root mean square of the terminal 40 ms of the filtered QRS complex 43.1 ± 25.2 ms vs 38.2 ± 20.2 ms, P = .38)., Conclusion: The SAECG appears to be a surrogate marker for structural abnormalities seen on imaging in those with ARVC. Great caution is required in interpreting SAECG findings in those without other corroborating evidence of an ARVC phenotype., (Copyright © 2022 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: For many heart failure patients, a heart transplant is required. Few hospitals in Canada perform heart transplants; thus, patients and caregivers must relocate to access transplant care., Objective: This study explores Canadian patients' and caregivers' experiences of to access transplant care and how patients and caregivers define home. The study's goal is to gain insights from the patient and caregiver experience and identify opportunities to improve the experience for those who relocate to access heart transplants. The research question was: How is the concept of home connected to the heart transplant journey?, Methods: We conducted 18 interviews with advanced heart failure patients and caregivers, to explore patient and caregiver experiences of relocating to access transplant care. Patients and caregivers ranged in ages from 20's to 60's and had left their home of origin to move to a new location where medical care was available. 7 patients were male, 3 were female. All caregivers were female., Results: Patients and caregivers identified three supports during relocation: other patients and caregivers, medical team and family. Patients and caregivers defined home as friends, family, community, warmth, safety, belonging and comfort., Conclusion: During relocation, patients and caregivers were supported by: other patients and caregivers, their medical team and family, and how these people made them feel: safe, warm, comfortable and that they belonged is how they defined home. The supports and definitions of home are connected; thus, a sense of home is inextricably linked to the transplant journey for patients and caregivers., Competing Interests: Declaration of Competing Interest The research team has no conflicts of interest to declare., (Crown Copyright © 2022. Published by Elsevier Inc. All rights reserved.)

This article discusses clinical ethics consultation (CEC), and thereby ethics support services in the Canadian context. Commonalities and differences between the three models of ethics support and CEC shared in this article are identified, set within the broader context of the Canadian healthcare system, accreditation, and professionalization of practicing healthcare ethicists., (Copyright 2022 The Journal of Clinical Ethics. All rights reserved.)

Background: The COVID-19 pandemic has had a significant impact on the health system worldwide. The organ and tissue donation and transplantation (OTDT) system is no exception and has had to face ethical challenges related to the pandemic, such as risks of infection and resource allocation. In this setting, many Canadian transplant programs halted their activities during the first wave of the pandemic., Method: To inform future ethical guidelines related to the COVID-19 pandemic or other public health emergencies of international concern, we conducted a literature review to summarize the ethical issues., Results: This literature review identified three categories of ethical challenges. The first one describes the general ethical issues and challenges reported by OTDT organizations and transplantation programs, such as risks of COVID-19 transmission and infection to transplant recipients and healthcare professionals during the transplant process, risk of patient waitlist mortality or further resource strain where transplant procedures have been delayed or halted, and resource allocation. The second category describes ethical challenges related to informed consent in the context of uncertainty and virtual consent. Finally, the third category describes ethical issues related to organ allocation, such as social considerations in selecting transplant candidates., Conclusion: This literature review highlights the salient ethical issues related to OTDT during the current COVID-19 pandemic. As medical and scientific knowledge about COVID-19 increases, the uncertainties related to this disease will decrease and the associated ethical issues will continue to evolve., (© 2021. The Author(s).)

Controlled donation after circulatory determination of death (DCD), where death is determined after cardiac arrest, has been responsible for the largest quantitative increase in Canadian organ donation and transplants, but not for heart transplants. Innovative international advances in DCD heart transplantation include direct procurement and perfusion (DPP) and normothermic regional perfusion (NRP). After death is determined, DPP involves removal and reanimation of the arrested heart on an ex situ organ perfusion system. Normothermic regional perfusion involves surgically interrupting (ligating the aortic arch vessels) brain blood flow after death determination, followed by restarting the heart and circulation in situ using extracorporeal membrane oxygenation. The objectives of this Canadian consensus building process by a multidisciplinary group of Canadian stakeholders were to review current evidence and international DCD heart experience, comparatively evaluate international protocols with existing Canadian medical, legal, and ethical practices, and to discuss implementation barriers. Review of current evidence and international experience of DCD heart donation (DPP and NRP) determined that DCD heart donation could be used to provide opportunities for more heart transplants in Canada, saving additional lives. Although candid discussion identified a number of potential barriers and challenges for implementing DCD heart donation in Canada, it was determined that DPP implementation is feasible (pending regulatory approval for the use of an ex situ perfusion device in humans) and in alignment with current medical guidelines for DCD. Nevertheless, further work is required to evaluate the consistency of NRP with current Canadian death determination policy and to ensure the absence of brain perfusion during this process.

There is international variability in the determination of death. Death in donation after circulatory death (DCD) can be defined by the permanent cessation of brain circulation. Post-mortem interventions that restore brain perfusion should be prohibited as they invalidate the diagnosis of death. Retrieval teams should develop protocols that ensure the continued absence of brain perfusion during DCD organ recovery. In situ normothermic regional perfusion (NRP) or restarting the heart in the donor's body may interrupt the permanent cessation of brain perfusion because, theoretically, collateral circulations may restore it. We propose refinements to current protocols to monitor and exclude brain reperfusion during in situ NRP. In abdominal NRP, complete occlusion of the descending aorta prevents brain perfusion in most cases. Inserting a cannula in the ascending aorta identifies inadequate occlusion of the descending aorta or any collateral flow and diverts flow away from the brain. In thoracoabdominal NRP opening the aortic arch vessels to atmosphere allows collateral flow to be diverted away from the brain, maintaining the permanence standard for death and respecting the dead donor rule. We propose that these hypotheses are correct when using techniques that simultaneously occlude the descending aorta and open the aortic arch vessels to atmosphere., (© 2020 The Authors. American Journal of Transplantation published by Wiley Periodicals, Inc. on behalf of The American Society of Transplantation and the American Society of Transplant Surgeons.)

Background: Cardiac implantable electrical devices (CIEDs) are subject to advisories and complications that can result in morbidity and mortality for patients; there is currently no system in Canada to track these., Methods: This was a multicenter, prospective cohort study conducted at 5 centers to determine feasibility. Patients with a de novo high-voltage (HV) lead implantation were included and followed for a minimum of 1 year., Results: There were 611 leads enrolled into the registry over 18 months. The mean age was 62.4 ± 12.8 years; 144 (23.6%) women were enrolled. The indication for lead implantation was for primary prevention in 65.5%. There were 497 (82.1%) de novo devices (single chamber: 54.5%, dual chamber: 20.5%, cardiac resynchronization therapy [CRT] 25.0%); the remainder of the procedures was a system revision for either upgrade (8.1%) or lead revision (9.8%). The lead revision rate at 1 year was 3.4%, with the primary reason being lead dislodgements. Mortality rate was 3.8% at 1 year. The rate of any device-related complication was 2.0% at 30 days, with the highest rate in CRT implants (4.9%, P = 0.0105). At 1 year, the complication rate was 4.5%, with no significant difference among device types., Conclusions: This study demonstrates that device surveillance is feasible and highlights (1) the need for CIED surveillance to track device-related complications, (2) the scope of this should be larger, and (3) mandatory participation should be considered. This system could predict CIEDs that may be susceptible to higher than usual rates of failure, mitigating adverse outcomes in patients., (Copyright © 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Identification and appropriate management of patients with atrial fibrillation (AF) is critical to mitigate the consequences of the disease. We sought to assess the frequency and pattern of the emergency department (ED) use by patients who presented with AF and/or atrial flutter (AFL) in a midsized Canadian hospital., Methods: We conducted a retrospective cohort analysis of patients who presented to the ED with AF and/or AFL during the calendar years 2010-2012. Patients were identified using the MUSE (General Electric Healthcare, Bucks, United Kingdom) electrocardiogram database and matched with the National Ambulatory Care Reporting System and Discharge Abstract Database up to and including December 31, 2013, a follow-up period of 12 months. The number of presentations and time between visits was assessed. Admissions were identified and lengths of stay and reason for admission were recorded., Results: We identified 1361 patients who represented a total of 4783 visits to the ED, a mean of 2.8 ± 2.9 visits per patient with 949 (69.7%) who returned for a subsequent ED visit in the subsequent 12 months. Mean time between base and subsequent visits was 136.8 ± 114.2 days. ED visits generated 1462 admissions (63.0% at repeat ED visits); mean length of stay was 9.7 ± 16.0 days. Stroke or transient ischemic attack accounted for 80 return visits and 8 deaths in 77 patients, 74% of whom with subtherapeutic or no anticoagulation medication., Conclusions: Presentation to the ED with AF and/or AFL, either as a primary reason for consultation or as a secondary diagnosis, was associated with a high risk of subsequent re-presentation and hospital admission., (Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: A unique form of lead failure has been described in the Riata (8-F) and Riata ST (7-F) silicone defibrillation lead degradation of the outer insulation, resulting in the externalization of conductor cables., Objective: To assess rates of lead revision due to lead failure in Riata leads affected by the Riata advisory., Methods: Nineteen implantable cardioverter-defibrillator implant and follow-up centers were surveyed., Results: As of March 1, 2012, there were 5043 known affected leads implanted in Canada. Data on 4358 (86.4%) leads were obtained; 65.3% of these were Riata (8-F) and 32.4% were Riata ST (7-F) leads. The median time from implant to last follow-up was 5 years. Electrical abnormalities were reported in 4.6% of the affected leads; 8.0% of these were found to have concomitant radiographic evidence of externalization. The rate of electrical failure was higher in the 8-F (5.2%) vs 7-F (3.3%) leads (P = .007). Oversensing with or without inappropriate shocks was reported in 39.8% of the leads with confirmed failure. Abnormally high or low impedance values (29.9%) and elevated pacing capture thresholds (43.8%) were frequently reported. One death (0.5%) attributed to lead failure was reported. Among the leads that were replaced, 21% were extracted. Two major complications (1.0%) were attributed to extraction of these leads., Conclusions: The overall rate of lead failure in the Riata (8-F) and Riata ST (7-F) leads is higher than previously reported by using passive surveillance data. The impact of recent advisories related to these leads is not yet apparent., (Copyright © 2013 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Potential conflicts between the roles of physicians and researchers have been described at the theoretical level in the bioethics literature (Czoli, et al., 2011). Physicians and researchers are generally in mutually distinct roles, responsible for patients and participants respectively. With increasing emphasis on integration of research into clinical settings, however, the role divide is sometimes unclear. Consequently, physician-researchers must consider and negotiate salient ethical differences between clinical- and research-based obligations (Miller et al, 1998). This paper explores the subjective experiences and perspectives of 30 physician-researchers working in three Canadian paediatric settings. Drawing on qualitative interviews, it identifies ethical challenges and strategies used by physician-researchers in managing dual roles. It considers whether competing obligations could have both positive and adverse consequences for both physician-researchers and patients. Finally, we discuss how empirical work, which explores the perspectives of those engaged in research and clinical practice, can lead the way to understanding and promoting best practice.

Early on in the development of Practicing Healthcare Ethicists Exploring Professionalization (PHEEP), the founding members recognized the need to address and meet two important goals: (1) the creation of a dynamic, rigorous process to support the exploratory work, and (2) the establishment of the means--deliberative engagement--to generate and justify the substantive content of professionalization-related products, such as practice standards and position statements. Drawing from social justice and deliberative democracy conceptions and insights (among others), the authors identify and describe the core elements of the "process scaffolding" and "deliberative means" that inform PHEEP's deliberative engagement methodology. The paper demonstrates how these process and substantive features have been meaningfully instantiated in the decision making framework established by PHEEP for its use in the development of professionalization-related products by Canadian practicing healthcare ethicists.

There are several important conceptual issues and questions about the practice of healthcare ethics that can, and should, inform the development of any practice standards. This paper provides a relatively short overview of seven of these issues, with the invitation for further critical reflection and examination of their relevance to and implications for practice standards. The seven issues described include: diversity (from the perspective of training and experience); moral expertise and authority/influence; being an insider or outsider; flexibility and adaptability (for local contexts of practice); the relative weighting of procedural and normative aspects of ethics practice; making mistakes or errors; and conflicts of interest in practice.

Background: It has been observed that replacement of an implantable cardioverter-defibrillator generator in response to a device advisory may be associated with a substantial rate of complications, including death. The risk of lead revision in response to a lead advisory has not been determined previously., Methods and Results: Twenty-five implantable cardioverter-defibrillator implantation and follow-up centers from the Canadian Heart Rhythm Society Device Advisory Committee were surveyed to assess complication rates as a result of lead revisions due to the Sprint Fidelis advisory issued in October 2007. As of June 1, 2009, there had been 310 lead failures found in 6237 Sprint Fidelis leads in Canada (4.97%) over a follow-up of 40 months. There were 469 leads to be revised, 66% for confirmed fracture. Of the patients who underwent revision, 95% had a new lead inserted, whereas 4% had a pace/sense lead added. The lead was removed in 248 cases (53%), by simple traction in 61% and by laser lead extraction in 33%. Complications were encountered in 14.5% of the lead revisions; 7.25% of these were major, whereas 7.25% were minor. There were 2 deaths (0.43%). The overall risk of complications (19.8%) was greater in those who underwent lead removal at the time of revision than in those whose leads were abandoned (8.6%; P=0.0008)., Conclusions: The overall rate of major complications that arose from lead revision due to the Sprint Fidelis advisory was significant. This must be taken into account when lead revision is planned in those patients who have not yet demonstrated an abnormality in lead performance.

Purpose: CAN-SAVE R is a Canadian multicenter study that compares the effects of a new pacing mode algorithm designed to minimize right ventricular (V) pacing versus DDD mode with a long atrioventricular (AV) delay in a general population of pacemaker (PM) recipients., Study Participants: Patients with permanent atrial fibrillation (AF) or high-degree AV block (AVB) were excluded. We present preliminary data collected in 208 patients (mean age=71 +/- 11 years, 68% men), for the 2-month baseline period during which all PM were programmed in the new pacing mode. The pacing indications were sinus node disease (SND) without AVB in 39%, AVB without SND in 30%, SND and AVB in 16%, and miscellaneous in 15% of patients., Results: The mean percent V pacing in the overall population was 9.5 +/- 23.8% (range=0-100%, median <1%), ranging between 0.5 +/- 1.5% (median=0) in patients without AVB and 18.7 +/- 31.2% in patients (median = 1) with AVB. Adverse events potentially related to the new pacing mode were observed in two patients with AVB., Conclusions: A new pacing mode was effective and safe in a general population of PM recipients without permanent AVB and was associated with an overall <1% median V pacing. CAN-SAVE R will compare the long-term effects of the new pacing mode with DDD with a long AV delay on clinical outcomes and cardiac function.

Background: Implantable cardioverter defibrillator (ICD) generator advisories present management dilemmas for physicians regarding competing risks of ICD failure and replacement-related complications. There is currently a paucity of long-term data concerning the complications associated with advisory ICD replacement., Objective: In a large multicenter advisory ICD generator replacement cohort followed for 12 months, we aimed to assess replacement-related complications by performing a case-control determination of complication risk factors to identify characteristics that could assist with advisory ICD replacement decision making., Methods: Twelve large ICD implanting centers reviewed the 1-year follow-up outcome of advisory ICDs replaced between October 2004 and October 2005. The complication cohort was characterized and compared in a nested case-control analysis with age- and gender-matched controls without complications from the same replacement population., Results: At the 12 participating institutions, 451 of 2635 advisory ICD devices were replaced (17.1%). Over 355 +/- 204 days of follow-up, there were 41 (9.1%) complications; 27 (5.9%) required reoperation and included two deaths. There were 14 minor complications (3.1%). Multivariate analysis demonstrated that the number of previous pocket procedures was associated with an increase in complications and that combined consultant and fellow operators was associated with a decrease in complications compared with a single operator alone., Conclusions: Complications from advisory ICD generator replacement are frequent and include infection and, rarely, death. The risk of replacement is increased in patients with multiple previous pocket procedures.

Background: Defibrillation threshold (DFT) testing has traditionally been a routine part of implantable cardioverter-defibrillator (ICD) implantation, despite a lack of compelling evidence that it predicts or improves outcomes. In the past, when devices were much less reliable, DFT testing seemed prudent; however, modern ICD systems have such a high rate of successful defibrillation that many electrophysiologists now question whether DFT testing is still worthwhile, particularly since DFT testing may now be the highest acute risk component of ICD implantation., Objective: The purpose of this study was to systematically document complications directly attributable to intraoperative DFT testing., Methods: We obtained data on DFT-related complications from all 21 adult ICD implant centers in Canada, covering the period from January 1, 2000, to September 30, 2006., Results: There were a total of 19,067 ICD implants in Canada during the study period. There were three DFT testing-related deaths, five DFT testing-related strokes, and 27 episodes that required prolonged resuscitation. Two patients had significant clinical sequelae after prolonged resuscitation., Conclusions: The risk of severe complications from intraoperative DFT testing appears small, even allowing for the underestimation of its true rate with the current study methodology. These slight but measurable risks must be considered when assessing the risk-benefit ratio of the procedure. Additional data from ongoing prospective ICD registries and/or clinical trials are required.

In 2005, an unprecedented number of recalls were issued on pacemakers and implantable cardioverter defibrillators. While recalls in the cardiac rhythm device industry are not new, the sheer magnitude of potentially affected patients in 2005 led to a great deal of concern, frustration, and even anger. Physicians have, in many instances, been uncertain when (or if) to recommend device replacement in an environment where the magnitude of the risk and the potential consequences of device failure have not been well defined in a timely way. Doctors and patients are now calling for reform of postmarket analysis and reporting mechanisms. The present article provides a uniquely Canadian perspective on this international issue. Potential solutions include the development of a set of realistic and common expectations, a restoration of confidence in postmarket analysis and reporting mechanisms, increased data transparency, and an increased role for patient and physician groups.

The experience of being listened to for older adults living in long-term care facilities was explored using a qualitative descriptive method outlined in Parse (2001), with the human becoming theory as the theoretical framework. The themes that emerged from this study--Nurturing Contentment, Vital Genuine Connections, and Deference Triumphs Mediocrity--affirmed the experience of being listened to as fundamental to the participants' quality of life. The findings expand nursing theory, provide enhanced understanding of the experience of being listened to, and offer ideas for future research. Through the voices of older adults participating in this study, the authors learn how critical listening is to quality care, and thus to excellence in nursing practice.

In 2004, the Canadian Cardiovascular Society formed an Access to Care Working Group with a mandate to use the best science and information available to establish reasonable triage categories and safe wait times for common cardiovascular services and procedures through a series of commentaries. The present commentary discusses the rationale for access benchmarks for urgent cardiac catheterization and revascularization, including hospital transfer in the setting of non-ST elevation acute coronary syndromes. The literature on standards of care, wait times, wait list management and clinical trials was reviewed. A survey of all cardiac catheterization directors in Canada was performed to develop an inventory of current practices in identifying and triaging patients. The Working Group recommended the following medically acceptable wait times for access to diagnostic catheterization and revascularization in patients presenting with acute coronary syndromes: for diagnostic catheterization and percutaneous coronary intervention, the target should be 24 h to 48 h for high-risk, three to five days for intermediate-risk and five to seven days for low-risk patients; for coronary artery bypass graft surgery, the target should be three to five days for high-risk, two to three weeks for intermediate-risk and six weeks for low-risk patients. All stakeholders must affirm the appropriateness of these standards and work continuously to achieve them. However, some questions remain around what are the best clinical risk markers to delineate the triage categories and the utility of clinical risk scores to assist clinicians in triaging patients for invasive therapies.

The Canadian Cardiovascular Society is the national professional society for cardiovascular specialists and researchers in Canada. In the spring of 2004, the Canadian Cardiovascular Society Council formed an Access to Care Working Group in an effort to use the best science and information to establish reasonable triage categories and safe wait times for access to common cardiovascular services and procedures. The Working Group has elected to publish a series of commentaries to initiate a structured national discussion on this very important issue. Access to treatment with implantable cardioverter defibrillators is the subject of the present commentary. The prevalence pool of potentially eligible patients is discussed, along with access barriers, regional disparities and waiting times. A maximum recommended waiting time is proposed and the framework for a solution-oriented approach is presented.

Providing quality care in a timely manner is a key goal of the healthcare system. Who defines quality care is a pivotal question to be answered in an era of well-informed clients. The Registered Nurses Association of Ontario's (RNAO) Client-Centred Care Best Practice Guideline puts patients where they belong--at the centre of care. This guideline recommends that nurses embrace as foundational to their practice a set of values and beliefs. These include: respect, human dignity and the belief that clients are the experts regarding their own lives. Clients must be provided the opportunity to lead their care as much as they choose. Moreover, the guideline recommends that nurses advocate for their clients' goals within the entire healthcare team. Recommendations regarding the organization of nursing care emphasize continuity and consistency of care and caregiver as paramount to providing timely and responsive client-centred-care. This article presents the rationale for the development of a CCC-BPG and highlights its key recommendations. It also discusses the responsibilities of healthcare practitioners and administrators in working together to ensure that these recommendations are incorporated into every aspect of client care and services.

A study of 200 patients referred to a community neurologist showed that 87.5% of the patients were seen in the office and only 12.5% in hospital. Neurological signs were present in 52% and 28.5% had neurological signs which materially affected the diagnosis. A questionnaire sent to several teaching centers showed that only one center sent students and residents to community neurologists' offices at all and in most centers the resident spent just 10 to 20% of his time seeing out-patients. It was felt that the balance of in-patient/out-patient teaching for students and residents was wrong, and that more emphasis should be placed on the neurological history than on the examination. Proposals are made to involve the community neurologist as well as the academic neurologist in the training of students and residents which would benefit all four groups.