C ulturally appropriate, patient-focused end-of-life care is an essential component of health care. Despite a preference to die at home, most Canadians die in hospitals and many receive end-of-life care in intensive care units (ICUs). 1-3 Multiple factors contribute to this discrepancy, including uncertainty about the imminence of death, challenges in communication between health care teams and patients and families, poor health literacy and lack of access to palliative care resources. 3-7 These factors may be more pronounced among people from minority ethnic groups. Differences in preferences for intervention at the end of life among ethnic groups may also influence care; the research showing a preference for dying at home included mostly white Canadians. 1 People of Chinese and South Asian ethnicity are the most rapidly growing ethnic groups in Canada, yet little is known about their end-of-life care. 8,9 Comparative studies from the United States have focused on black and Hispanic Americans 8-13 and suggest that minority ethnicity is associated with lower family-rated quality of end-of-life care, 14 increased use of life-support technologies, 13 and decreased use of advanced directives or hospice. 6,12,15-17 Qualitative research describing end-of-life care for people of Chinese or South Asian ethnicities in international settings shows some common themes, including reluctance to share terminal diagnoses, emphasis on collective as opposed to individual decision-making, and attenuation of differences with acculturation. 6,18,19 For people of Chinese ethnicity, research highlights the influence of Confucian philosophy and the role of children in decisions regarding elderly parents. 20-23 For people of South Asian ethnicity, research emphasizes notions of karma, ambivalence toward the cultural appropriateness of hospices or sedating analgesic

ObjectivesTo systematically review the literature on the neuropsychological, psychosocial, and functional profiles of patients with unruptured intracranial aneurysms.MethodsThis review was limited to peer-reviewed research articles that reported cognitive, psychosocial, and/or functional profiles of patients with unruptured intracranial aneurysms. Studies were identified through Medline and PsychINFO by searching “(unruptured [intracranial OR cerebral] aneurysm) AND (cogniti* OR neuropsycholog* OR anxiety OR depression OR [quality of life] OR work OR employment OR [activities of daily living] OR [instrumental activities of daily living]).” Only articles that were published since January 1997 were considered. Reference lists of included articles were inspected for additional studies. Only articles in English were included. Case studies were excluded. Twenty-two articles were included in this review.ResultsThe literature demonstrates that although treatment for unruptured intracranial aneurysms allays anxiety, it also results in an observable, though transient decline in cognition and daily functioning. Even before treatment, preliminary evidence hints that these patients are not free of such impairments.ConclusionsThe algorithm that underlies the decision to treat an unruptured intracranial aneurysm ought to add more weight to the neuropsychological, psychosocial, and functional profiles of these patients. The clinical relevance of these patients does not begin and end with their risk of rupture.

Background: Patients with heart failure have palliative care needs that can be effectively addressed by specialist palliative care (SPC). Despite this, SPC utilization by this patient population is low, suggesting barriers to SPC referral. We sought to determine the referral practices of cardiologists to SPC. Methods: Cardiologists across Canada were invited to participate in a survey about their referral practices to SPC. Associations between R ESUM EContexte : Les services de soins palliatifs sp ecialis es (SPS) peuvent r epondre efficacement aux besoins des patients pr esentant une insuffisance cardiaque. Malgr e tout, les patients de cette population n'ont pas beaucoup recours aux SPS, ce qui semble indiquer la pr esence d'obstacles à l'orientation vers les SPS. Nous avons entrepris de d eterminer les pratiques des cardiologues en matière d'orientation des patients vers les SPS.

A n intracranial aneurysm is an outpouching of a weakened portion of a cerebral artery, forming a sac that carries a risk of rupture. The prevalence of unruptured intracranial aneurysm (UIA) in the general population is estimated to be 3.2%. 34 Though studies have reported different rates, 13,36,37 an annual rate of rupture of 0.05%-6% was observed in the International Study of Unruptured Intracranial Aneurysms (ISUIA).12 A more recent large-scale study of the natural history of untreated UIA, the Unruptured Cerebral Aneurysm Study of Japan (UCAS), 21 found an annual rupture rate of 0.95%. The risk of rupture was mediated by aneurysm size and location, the presence or absence of a daughter sac (protrusions on the aneurysm's dome), and history of aneurysmal subarachnoid hemorrhage (aSAH). Additionally, geographic location also appears to play a role, with a higher incidence of aneurysms in Japanese and Finnish populations, and lower in South and Central America. obJective The treatment of an unruptured intracranial aneurysm (UIA) is not free of morbidity and mortality, and the decision is made by weighing the risks of treatment complications against the risk of aneurysm rupture. This metaanalysis quantitatively analyzed the literature on the effects of UIA treatment on cognition. methods MEDLINE, Embase, and PsycInfo were systematically searched for studies that reported on the cognitive status of UIA patients before and after aneurysm treatment. The search was restricted to prospective cohort and casecontrol studies published between January 1, 1998, and January 1, 2013. The analyses focused on the effect of treatment on general cognitive functioning, with an emphasis on 4 specific cognitive domains: executive functions, verbal and visual memory, and visuospatial functions. coNclusioNs The treatment of an UIA does not seem to affect long-term cognitive function. However, definitive conclusions were not possible due to the paucity of studies addressing this issue.

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ObjectivesPatients with chronic respiratory disease have significant palliative care needs, but low utilisation of specialist palliative care (SPC) services. Decreased access to SPC results in unmet palliative care needs among this patient population. We sought to determine the referral practices to SPC among respirologists in Canada.MethodsRespirologists across Canada were invited to participate in a survey about their referral practices to SPC. Associations between referral practices and demographic, professional and attitudinal factors were analysed using regression analyses.ResultsThe response rate was 64.7% (438/677). Fifty-nine per cent of respondents believed that their patients have negative perceptions of palliative care and 39% were more likely to refer to SPC earlier if it was renamed supportive care. While only 2.7% never referred to SPC, referral was late in 52.6% of referring physicians. Lower frequency of referral was associated with equating palliative care to end-of-life care (p<0.001), male sex of respirologist (p=0.019), not knowing referral criteria of SPC services (p=0.015) and agreement that SPC services prioritise patients with cancer (p=0.025); higher referral frequency was associated with satisfaction with SPC services (p=0.001). Late referral was associated with equating palliative care to end-of-life care (p<0.001) and agreement that SPC services prioritise patients with cancer (p=0.013).ConclusionsPossible barriers to respirologists’ timely SPC referral include misperceptions about palliative care, lack of awareness of referral criteria and the belief that SPC services prioritise patients with cancer. Future studies should confirm these barriers and evaluate the effectiveness of strategies to overcome them.

Background It is important to understand clinical features of bacteremic urinary tract infection (bUTI), because bUTI is a serious infection that requires prompt diagnosis and antibiotic therapy. Escherichia coli is the most common and important uropathogen. The objective of our study was to characterize the clinical presentation of E coli bUTI. Methods Retrospective cohort study of consecutive adult patients admitted for community acquired E. coli bacteremia from January 1, 2015 to December 31, 2016 was conducted at 4 acute care academic and community hospitals in Toronto, Ontario, Canada. Logistic regression models were developed to identify E coli bUTI cases without urinary symptoms. Results Of 462 patients with E. coli bacteremia, 284 (61.5%) patients had a urinary source. Of these 284 patients, 161 (56.7%) had urinary symptoms. In a multivariable model, bUTI without urinary symptoms were associated with older age (age < 65 years as reference, age 65–74 years had OR of 2.13 95% CI 0.99–4.59 p = 0.0523; age 75–84 years had OR of 1.80 95% CI 0.91–3.57 p = 0.0914; age > =85 years had OR of 2.95 95% CI 1.44–6.18 p = 0.0036) and delirium (OR of 2.12 95% CI 1.13–4.03 p = 0.0207). Sepsis by SIRS criteria was present in 274 (96.5%) of all bUTI cases and 119 (96.8%) of bUTI cases without urinary symptoms. Conclusion The majority of patients with E. coli bacteremia had a urinary source. A significant proportion of bUTI cases had no urinary symptoms elicited on history. Elderly and delirious patients were more likely to have bUTI without urinary symptoms. In elderly and delirious patients with sepsis by SIRS criteria but without a clear infectious source, clinicians should suspect, investigate, and treat for bUTI.

Pseudomonas stutzeri is infrequently isolated from clinical specimens, and if isolated, more likely represents colonization or contamination rather than infection. Despite this, there are dozens of case reports which describe clinically significant P. stutzeri infections at variable sites. A 69-year-old man had a P. stutzeri infection of a prosthetic vascular graft infection, which he received in Panama City. He was successfully treated with a single antipseudomonal agent for 6 weeks and the removal of the infected vascular graft. A 70-year-old man had a P. stutzeri infection of a prosthetic joint, which was successfully treated with a single anti-pseudomonal agent for 6 weeks. There is only one other documented case of a prosthetic vascular graft infection secondary to P. stutzeri. There are 5 documented cases of P. stutzeri prosthetic joint infections. The previous cases were treated with antibiotics and variably, source control with the removal of prosthetic material. Most cases of P. stutzeri infection are due to exposure in health care settings. Immunocompromised states such as HIV or hematological and solid tumor malignancies are risk factors for P. stutzeri infection. Infections caused by P. stutzeri are far less frequent and less fatal than those caused by P. aeruginosa. The etiology of a P. stutzeri infection could be exposure to soil and water, but also contaminated material in the health care setting or an immunocompromised state. Iatrogenic infections that are secondary to health care tourism are a potential cause of fever in the returned traveler.