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Oliver MJ, Abra G, Béchade C, Brown EA, Sanchez-Escuredo A, Johnson DW, Guedes AM, Graham J, Fernandes N, Jha V, Kabbali N, Knananjubach T, Kam-Tao Li P, Lundström UH, Salenger P, Lobbedez T. Assisted peritoneal dialysis: Position paper for the ISPD. Perit Dial Int 2024; 44:160-170. [PMID: 38712887 DOI: 10.1177/08968608241246447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024] Open
Affiliation(s)
- Matthew J Oliver
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
| | - Graham Abra
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Clémence Béchade
- Université Caen Normandie - UFR de Médecine, CAEN CEDEX, France
- Néphrologie, CHU CAEN, Avenue de la Côte de Nacre, Normandie Université, CAEN CEDEX, France
- ANTICIPE U1086 INSERM-UCN, Centre François Baclesse, Caen, France
| | - Edwina A Brown
- Imperial College Kidney and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | | | - David W Johnson
- Department of Kidney and Transplant Services, University of Queensland at Princess Alexandra Hospital, Brisbane, QLD, Australia
| | | | | | - Natalia Fernandes
- Department of Nephrology, Juiz de Fora University Hospital, Juiz de Fora, Minas Gerais, Brazil
| | - Vivekanand Jha
- George Institute for Global Health, UNSW, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Manipal Academy of Higher Education, Manipal, India
| | - Nadia Kabbali
- Nephrology Department, Hassan II University Hospital, Fez, Morocco
| | - Talerngsak Knananjubach
- Division of Nephrology, Department of Medicine and Center of Excellence in Kidney Metabolic Disorders, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Philip Kam-Tao Li
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Ulrika Hahn Lundström
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | | | - Thierry Lobbedez
- Université Caen Normandie - UFR de Médecine, CAEN CEDEX, France
- Néphrologie, CHU CAEN, Avenue de la Côte de Nacre, Normandie Université, CAEN CEDEX, France
- ANTICIPE U1086 INSERM-UCN, Centre François Baclesse, Caen, France
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Shankar R, Luo N, Lim YW, Khatri P, Leong L, Teo GYX, Mukhopadhyay A, Choo J, Chua HR, Teng GG, Phua J, Hong WZ. Assessing caregiver burden in advanced kidney disease: protocol for a systematic review of the measurement properties of instruments and tools. BMJ Open 2024; 14:e078767. [PMID: 38413158 PMCID: PMC10900375 DOI: 10.1136/bmjopen-2023-078767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 02/08/2024] [Indexed: 02/29/2024] Open
Abstract
INTRODUCTION Caregiver burden is a significant issue in the care of patients with advanced kidney disease. Its assessment is crucial for evaluating the needs of caregivers and for the development of interventions to support them. Several instruments have been developed to measure caregiver burden in these patients. However, the measurement properties of these instruments have not been systematically reviewed. METHODS AND ANALYSIS This systematic review will include a comprehensive search of databases including PubMed, CINAHL, Embase, Cochrane Library, SCOPUS and Web of Science by using keywords and MeSH terms to identify relevant studies starting from each database inception to 1 January 2024 and covering papers in English. The search strategy will combine relevant keywords and database-specific subject headings related to the following concepts: (1) caregivers, (2) burden, stress, distress, (3) chronic kidney disease, end-stage kidney disease, dialysis. Reference lists of eligible articles will also be hand searched. We will include quantitative and qualitative studies evaluating measurement properties of instruments assessing caregiver burden in caregivers of adult patients (aged ≥18 years). Data will be extracted from the selected studies and analysed using the COnsensus-based Standards for the selection of health Measurement INstruments checklist as the study quality assessment tool. Subsequently, the van der Vleuten utility index will be used to critique and categorise the instruments. A narrative that synthesises the utility of all instruments will be presented along with recommendations for the selection of instruments depending on specific clinical contexts. This systematic review will provide an overview of the measurement properties of available instruments, including discussion on reliability, validity and responsiveness. Results from the review may give rise to the subsequent development of most appropriate instrument that could be applied to the assessment of caregiver burden in advanced kidney disease. ETHICS AND DISSEMINATION Ethics approval is not required as this study will merely synthesise data from published studies. The results will be disseminated through peer-reviewed publications as well as conference presentations. PROSPERO REGISTRATION NUMBER CRD42023433906.
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Affiliation(s)
- Ravi Shankar
- Medical Affairs - Research, Innovation and Enterprise, Alexandra Hospital, National University Health System, Singapore
| | - Nan Luo
- Saw Swee Hock School of Public Health, National University Singapore, Singapore
| | - Yee Wei Lim
- Medical Affairs - Research, Innovation and Enterprise, Alexandra Hospital, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Priyanka Khatri
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Nephrology, Department of Medicine, National University Hospital, National University Health System, Singapore
- Chronic Programme, Alexandra Hospital, National University Health System, Singapore
- Fast Programme, Alexandra Hospital, National University Health System, Singapore
| | - Leanne Leong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Nephrology, Department of Medicine, National University Hospital, National University Health System, Singapore
- Chronic Programme, Alexandra Hospital, National University Health System, Singapore
- Fast Programme, Alexandra Hospital, National University Health System, Singapore
| | - Geraldine Yu-Xuan Teo
- Chronic Programme, Alexandra Hospital, National University Health System, Singapore
- Fast Programme, Alexandra Hospital, National University Health System, Singapore
| | - Amartya Mukhopadhyay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Chronic Programme, Alexandra Hospital, National University Health System, Singapore
- Fast Programme, Alexandra Hospital, National University Health System, Singapore
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Jason Choo
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Horng Ruey Chua
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Nephrology, Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Gim-Gee Teng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Chronic Programme, Alexandra Hospital, National University Health System, Singapore
- Fast Programme, Alexandra Hospital, National University Health System, Singapore
- Division of Rheumatology, Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Jason Phua
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Chronic Programme, Alexandra Hospital, National University Health System, Singapore
- Fast Programme, Alexandra Hospital, National University Health System, Singapore
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Wei Zhen Hong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Nephrology, Department of Medicine, National University Hospital, National University Health System, Singapore
- Chronic Programme, Alexandra Hospital, National University Health System, Singapore
- Fast Programme, Alexandra Hospital, National University Health System, Singapore
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Alaryni AA, Alrowaie F, Alghamdi A, Alabdullah R, Alnutaifi RA, Alajlan R, Alnutaifi RA, Aldakheelallah A, Alshabanat A, Bin Shulhub AS, Moazin OM, Qutob R, Alsolami E, Hakami OA. Assessment of Burden in Caregivers of Patients Undergoing Hemodialysis and Peritoneal Dialysis: A Cross-Sectional Study in Riyadh, Saudi Arabia. Cureus 2024; 16:e52513. [PMID: 38371074 PMCID: PMC10874250 DOI: 10.7759/cureus.52513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2024] [Indexed: 02/20/2024] Open
Abstract
A caregiver attends to the needs or concerns of someone limited by disease, injury, or disability to enhance the patient's quality of life, which can be assessed in three areas: social, physical, and psychological. This cross-sectional study assessed the extent of burden experienced by the caregivers of patients undergoing hemodialysis (HD) and peritoneal dialysis (PD) therapy in King Fahad Medical City in Riyadh, Saudi Arabia. The Zarit Burden Interview Arabic Abridged version (ZBI-A) was used to assess the level of burden experienced by caregivers. The data was collected and examined by professionals using the SPSS version 23. Based on the data of 50 participants, a mean ZBI-12 score of 12.22 ± 7.2 was reported. According to the ZBI scale, "No to mild burden," "Mild to moderate burden," and "High burden" were reported as 46% (n = 23), 38% (n = 19), and 16% (n = 8) of participants, respectively. The internal consistency of the ZBI-12 scale, assessed using Cronbach's alpha, was 0.664, indicating a satisfactory level of internal consistency. It was determined that caregivers of individuals undergoing PD and HD encounter different degrees of burden, with a significant proportion of caregivers experiencing a substantial burden.
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Affiliation(s)
- Abdullah A Alaryni
- Internal Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | | | - Abdullah Alghamdi
- Internal Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Razan Alabdullah
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Raneem A Alnutaifi
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Renad Alajlan
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Raed A Alnutaifi
- College of Medicine, King Saud University Medical City, Riyadh, SAU
| | | | - Alanoud Alshabanat
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | | | - Othillah M Moazin
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Rayan Qutob
- Internal Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Enad Alsolami
- Internal Medicine, University of Jeddah, Jeddah, SAU
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Liu Q, Zhang L, Xiang X, Mao X, Lin Y, Li J, Cui W. The influence of social alienation on maintenance hemodialysis patients' coping styles: chain mediating effects of family resilience and caregiver burden. Front Psychiatry 2023; 14:1105334. [PMID: 37457762 PMCID: PMC10342202 DOI: 10.3389/fpsyt.2023.1105334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Objective Research on the possible impact of social alienation, family resilience, and caregiver burden on the coping styles of Chinese patients on maintenance hemodialysis (MHD) is scarce. We explore the influence of social alienation, family resilience, and caregiver burden on the coping styles of MHD patients, both directly and indirectly. Methods We invited 173 MHD patients and their primary caregivers for a cross-sectional study; the study using convenience sampling method at the hemodialysis center of the First People's Hospital of Foshan. The Chinese version of the generalized social of alienation scale, the Chinese version of the simplified coping style questionnaire, and a sociodemographic questionnaire were completed by the MHD patients, while their primary caregivers had filled out the Chinese family resilience assessment scale, the Chinese version of the Zarit caregiver burden interview, and provided socio-demographic information. SPSS macro program PROCESS v3.3 Model 6 were used for analyses of chain-mediated effects. Results In the mediating effects model, the direct influence of social alienation upon coping styles was significant (95% CI -0.050, -0.014), and social alienation indirectly impacted coping style by family resilience in a significant way (95% CI -0.012, -0.001) or caregiver burden (95% CI -0.013, -0.001). In addition, social alienation significantly impacted coping style by both family resilience and caregiver burden (95% CI -0.008, -0.001). Conclusion Social alienation can exert both a direct and indirect influence on coping styles through the mediating factors of family resilience and caregiver burden. Clinicians can take interventions to strengthen family resilience and reduce caregiver burden, which may be useful in improving socially isolated behaviors and coping skills in MHD patients.
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Affiliation(s)
- Qiaoling Liu
- School of Nursing, College of Medicine, Shantou University, Shantou, China
| | - Li Zhang
- Department of Office, First People’s Hospital of Foshan, Foshan, China
| | - Xia Xiang
- Department of Nursing, First People’s Hospital of Foshan, Foshan, China
| | - Xiaoying Mao
- Department of Office, First People’s Hospital of Foshan, Foshan, China
| | - Ying Lin
- School of Nursing, College of Medicine, Shantou University, Shantou, China
| | - Jingfeng Li
- Hemodialysis Center, First People‘s Hospital of Foshan, Foshan, China
| | - Wen Cui
- College of Nursing, Zunyi Medical University, Zhuhai, China
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Abstract
Haemodialysis (HD) is the commonest form of kidney replacement therapy in the world, accounting for approximately 69% of all kidney replacement therapy and 89% of all dialysis. Over the last six decades since the inception of HD, dialysis technology and patient access to the therapy have advanced considerably, particularly in high-income countries. However, HD availability, accessibility, cost and outcomes vary widely across the world and, overall, the rates of impaired quality of life, morbidity and mortality are high. Cardiovascular disease affects more than two-thirds of people receiving HD, is the major cause of morbidity and accounts for almost 50% of mortality. In addition, patients on HD have high symptom loads and are often under considerable financial strain. Despite the many advances in HD technology and delivery systems that have been achieved since the treatment was first developed, poor outcomes among patients receiving HD remain a major public health concern. Understanding the epidemiology of HD outcomes, why they might vary across different populations and how they might be improved is therefore crucial, although this goal is hampered by the considerable heterogeneity in the monitoring and reporting of these outcomes across settings. This Review examines the epidemiology of haemodialysis outcomes — clinical, patient-reported and surrogate outcomes — across world regions and populations, including vulnerable individuals. The authors also discuss the current status of monitoring and reporting of haemodialysis outcomes and potential strategies for improvement. Nearly 4 million people in the world are living on kidney replacement therapy (KRT), and haemodialysis (HD) remains the commonest form of KRT, accounting for approximately 69% of all KRT and 89% of all dialysis. Dialysis technology and patient access to KRT have advanced substantially since the 1960s, particularly in high-income countries. However, HD availability, accessibility, cost and outcomes continue to vary widely across countries, particularly among disadvantaged populations (including Indigenous peoples, women and people at the extremes of age). Cardiovascular disease affects over two-thirds of people receiving HD, is the major cause of morbidity and accounts for almost 50% of mortality; mortality among patients on HD is significantly higher than that of their counterparts in the general population, and treated kidney failure has a higher mortality than many types of cancer. Patients on HD also experience high burdens of symptoms, poor quality of life and financial difficulties. Careful monitoring of the outcomes of patients on HD is essential to develop effective strategies for risk reduction. Outcome measures are highly variable across regions, countries, centres and segments of the population. Establishing kidney registries that collect a variety of clinical and patient-reported outcomes using harmonized definitions is therefore crucial. Evaluation of HD outcomes should include the impact on family and friends, and personal finances, and should examine inequities in disadvantaged populations, who comprise a large proportion of the HD population.
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Murasawa M, Watanabe S, Koitabashi K, Shibagaki Y, Sakurada T. A prospective observational study on caregiver burden of elderly peritoneal dialysis patients. Clin Exp Nephrol 2021; 26:376-377. [PMID: 34855020 DOI: 10.1007/s10157-021-02167-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 11/28/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Masaru Murasawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Shiika Watanabe
- Division of Nephrology, JCHO Tokyo Takanawa Hospital, Tokyo, Japan
| | | | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Tsutomu Sakurada
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan.
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Alshammari B, Noble H, McAneney H, Alshammari F, O’Halloran P. Factors Associated with Burden in Caregivers of Patients with End-Stage Kidney Disease (A Systematic Review). Healthcare (Basel) 2021; 9:healthcare9091212. [PMID: 34574986 PMCID: PMC8468425 DOI: 10.3390/healthcare9091212] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 09/07/2021] [Accepted: 09/07/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Caring for a patient with end-stage kidney disease (ESKD) is highly stressful and can impact negatively on the physical and psychological well-being of caregivers. To accurately assess caregiver burden (CB), health care providers (HCPs) need to identify characteristics associated with an increase in CB. AIM The aim of this review is to explore CB in caregivers of adult patients with ESKD and to identify characteristics associated with any increase in CB. METHOD A comprehensive literature search was completed using five electronic databases. Medline, Embase, CINHAL, PsycINFO, and Scopus. The Joanna Briggs Institute checklist (JBI) was used to quality appraise full text papers included in the review. No time limit for the date of publication of studies was employed, to enable the inclusion of more extensive literature. RESULTS A total of 38 relevant studies from 18 countries were identified and included in the review. A variety of patient and caregiver factors can impact positively or negatively on CB, including socio-demographic factors of patients and caregivers, disease-related factors, situational and relational factors, environmental factors, and psychological factors. CONCLUSION This review provides awareness to HCPs of the important factors associated with CB, when assessing or targeting interventions for caregivers experiencing burden.
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Affiliation(s)
- Bushra Alshammari
- Medical Biology Centre, School of Nursing and Midwifery, Queen’s University Belfast, 97 Lisburn Rd, Belfast BT9 7BL, UK; (H.N.); (P.O.)
- College of Nursing, University of Hail, Hail 2440, Saudi Arabia
- Correspondence: or
| | - Helen Noble
- Medical Biology Centre, School of Nursing and Midwifery, Queen’s University Belfast, 97 Lisburn Rd, Belfast BT9 7BL, UK; (H.N.); (P.O.)
| | - Helen McAneney
- UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems, School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland;
| | - Farhan Alshammari
- Department of Pharmaceutics, College of Pharmacy, University of Hail, Hail 2440, Saudi Arabia;
| | - Peter O’Halloran
- Medical Biology Centre, School of Nursing and Midwifery, Queen’s University Belfast, 97 Lisburn Rd, Belfast BT9 7BL, UK; (H.N.); (P.O.)
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Carboni-Jiménez A, Rice DB, Levis B, Cañedo-Ayala M, Imran M, Chiovitti M, Benedetti A, Thombs BD. Intensity of care and perceived burden among informal caregivers to persons with chronic medical conditions: a systematic review and meta-analysis. Disabil Rehabil 2021; 44:6230-6246. [PMID: 34455877 DOI: 10.1080/09638288.2021.1966675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE Informal caregivers provide ongoing assistance to a loved one with a health condition. No studies have compared caregiving intensity and perception of burden across chronic medical conditions. MATERIALS AND METHODS Databases were searched from inception through 11 September 2020 to identify studies that included the Level of Care Index or the Zarit Burden Inventory (ZBI) among caregivers for people with chronic diseases. Pooled mean ZBI scores and 95% confidence intervals by medical condition were calculated using a random effects model and heterogeneity with I2. RESULTS Ninety-seven included articles reported on 98 unique samples across 21 chronic diseases. No study used the Level of Care Index. Among 12 disease groups with more than one study, heterogeneity was too high (I2 range: 0-99.6%, ≥76.5% in 11 groups) to confidently estimate burden. The percent of studies rated high risk of bias ranged from 0% to 98%, but all external validity items were rated as high-risk in >50% of studies. CONCLUSIONS Findings highlight the need for studies on caregiver burden to improve sampling techniques; better report sampling procedures and caregiver and care recipient characteristics; and develop a standard set of outcomes, including a measure of caregiving intensity. Systematic Review Registration: CRD42017080962IMPLICATIONS FOR REHABILITATIONThe amount of burden reported by caregivers to loved ones is associated with reduced physical and mental health.We found considerable heterogeneity in perceived burden reported by informal caregivers across different studies within disease groups, which is likely related to methodological issues, including sampling techniques.Health care providers who use research on caregiver burden should assess how representative study samples may be and exercise caution in drawing conclusions.
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Affiliation(s)
- Andrea Carboni-Jiménez
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.,Department of Psychiatry, McGill University, Montreal, Canada
| | - Danielle B Rice
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.,Department of Psychology, McGill University, Montreal, Canada
| | - Brooke Levis
- Centre for Prognosis Research, School of Medicine, Keele University, Staffordshire, UK
| | - Mara Cañedo-Ayala
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | - Mahrukh Imran
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | - Matthew Chiovitti
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | - Andrea Benedetti
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada.,Respiratory Epidemiology and Clinical Research Unit, McGill University Health Centre, Montreal, Canada.,Department of Medicine, McGill University, Montreal, Canada
| | - Brett D Thombs
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.,Department of Psychiatry, McGill University, Montreal, Canada.,Department of Psychology, McGill University, Montreal, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada.,Department of Medicine, McGill University, Montreal, Canada.,Department of Educational and Counselling Psychology, McGill University, Montreal, Canada.,Biomedical Ethics Unit, McGill University, Montreal, Canada
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