Promoting healthy school food environments and nutrition in Canada: a systematic review of interventions, policies, and programs.

CONTEXT: The school food environment is a critical interface for child and adolescent nutrition, and there is a need to understand existing literature on Canadian school food environments to identify equity gaps and opportunities, and empower decision-makers to plan for future action. OBJECTIVE: Literature on Canadian school food and nutrition interventions, policies, programs, and their effects on diets and nutritional status are synthesized and appraised in this systematic review. DATA SOURCES: A search strategy was developed for each database used (Medline, Embase, PsycINFO, ERIC, Cochrane Collaboration, Canadian Electronic Library, BiblioMap), with a combination of free text and controlled vocabulary, for articles published from 1990 to 2021. Unpublished data and grey literature were also searched. DATA EXTRACTION: Quantitative and qualitative studies with an observational or intervention study design, reviews, or program evaluations conducted in Canadian schools with participants aged 5-19.9 years were included. Key study characteristics and risk of bias were extracted independently by 2 investigators using a standardized tool. DATA ANALYSIS: A total of 298 articles were included (n = 192 peer reviewed and 106 from the grey literature), which were mostly conducted in Ontario (n = 52), British Columbia (n = 43), and Nova Scotia (n = 28). Twenty-four interventions, 5 nonevaluated programs, and 1 policy involved Indigenous populations. Overall, 86 articles measured and reported on effectiveness outcomes, including dietary intake; anthropometry; knowledge, attitudes, and practices; and physical activity. The literature remains largely heterogenous and primarily focused on nutrition education programs that use subjective assessments to infer changes in nutrition. A key facilitator to implementation and sustainability was community engagement, whereas key barriers were staff capacity, access to resources and funding, and consistent leadership. CONCLUSIONS: This review provides insight into Canadian school food and nutrition interventions, programs, and policies and uncovers important evidence gaps that require careful examination for future evaluations. Governments must create supportive environments that optimize nutrition for children and adolescents through equitable policies and programs. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no. CRD42022303255.

Pivoting school health and nutrition programmes during COVID-19 in low- and middle-income countries: A scoping review.

Background: Preventive and promotive interventions delivered by schools can support a healthy lifestyle, positive development, and well-being in children and adolescents. The coronavirus disease 2019 (COVID-19) pandemic presented unique challenges to school health and nutrition programmes due to closures and mobility restrictions. Methods: We conducted a scoping review to examine how school health and nutrition programmes pivoted during the COVID-19 pandemic, and to provide summative guidance to stakeholders in strategic immediate and long-term response efforts. We searched MEDLINE, Embase, PsycINFO, and grey literature sources for primary (observational, intervention, and programme evaluations) and secondary (reviews, best practices, and recommendations) studies conducted in low- and middle-income countries from January 2020 to June 2023. Programmes that originated in schools, which included children and adolescents (5-19.9 years) were eligible. Results: We included 23 studies in this review. They varied in their adaptation strategy and key programmatic focus, including access to school meals (n = 8), health services, such as immunisations, eye health, and water, sanitation, and hygiene-related activities (n = 4), physical activity curriculum and exercise training (n = 3), mental health counselling and curriculum (n = 3), or were multi-component in nature (n = 5). While school meals, physical activity, and mental health programmes were adapted by out-of-school administration (either in the community, households, or virtually), all health services were suspended indefinitely. Importantly, there was an overwhelming lack of quantitative data regarding modified programme coverage, utilisation, and the impact on children and adolescent health and nutrition. Conclusions: We found limited evidence of successful adaptation of school health and nutrition programme implementation during the pandemic, especially from Asia and Africa. While the adoption of the World Health Organization health-promoting school global standards and indicators is necessary at the national and school level, future research must prioritise the development of a school-based comprehensive monitoring and evaluation framework to track key indicators related to both health and nutrition of school-aged children and adolescents.

Simple steps towards improving safety in obstetric airway management: A quality improvement project.

BACKGROUND: Guidelines from the Obstetric Anaesthetists' Association and Difficult Airway Society state that 'a videolaryngoscope should be immediately available for all obstetric general anaesthetics'. OBJECTIVE: To report the incidence of videolaryngoscopy use, and other airway management safety interventions, in an obstetric population before and after various quality improvement interventions. DESIGN: Prospective data collection was undertaken over 18 months, divided into three separate 6-month periods: June to November 2019; March to August 2021; January to June 2022. These periods relate to evaluation of specific quality improvement interventions. SETTING: The project was carried out in a large tertiary referral obstetric unit. PATIENTS: We identified 401 pregnant women (> 20 weeks' gestation) and postnatal women (up to 48 h post delivery) undergoing an obstetric surgical procedure under general anaesthesia. INTERVENTIONS: To standardise practice, an intubation checklist was introduced in December 2020 and multidisciplinary staff training in August 2021. MAIN OUTCOME MEASURES: Primary outcome measures were use of a Macintosh-style videolaryngoscope and tracheal intubation success. Secondary outcome measures were use of an intubation checklist; low flow nasal oxygen; and ramped patient positioning. RESULTS: Data from 334 tracheal intubations (83.3% of cases) were recorded. Videolaryngoscope use increased from 60% in 2019, to 88% in 2021, to 94% in 2022. Tracheal intubation was successful in all patients, with 94% first pass success overall and only 0.9% requiring three attempts. Use of secondary outcome measures also increased: low flow nasal oxygen from 48% in 2019 to 90% in 2022; ramped positioning from 95% in 2021 to 97% in 2022; and checklist use from 63% in 2021 to 92% in 2022. CONCLUSIONS: We describe the successful adoption of simple safety measures introduced into routine practice. These comprised videolaryngoscopy, ramped positioning and low flow nasal oxygen. Their introduction was supported by the implementation of an intubation checklist and multidisciplinary team training.

Use of whole blood deployment programs for mass casualty incidents: South Texas experience in regional response and preparedness.

INTRODUCTION: Firearm-related deaths have become the leading cause of death in adolescents and children. Since the Sutherland Springs, TX mass casualty incident (MCI), the Southwest Texas Regional Advisory Council for trauma instituted a prehospital whole blood (WB) program and blood deployment program for MCIs. METHODS: The program was adopted statewide by the Texas Emergency Medical Task Force, of which Southwest Texas Regional Advisory Council is the lead for Emergency Medical Task Force 8. The recent active shooter MCI in Uvalde, TX was the first time the MCI blood deployment program had been used. To our knowledge, no other similar programs exist in this or any other country. RESULTS: On May 24, 2022, 19 children and 2 adults were killed at an MCI in Uvalde, TX. The MCI WB deployment protocol was initiated, and South Texas Blood and Tissue Center prepared 15 U of low-titer O-positive whole blood and 10 U of leukoreduced O packed cells. The deployed blood arrived at Uvalde Memorial Hospital within 67 minutes. One of the pediatric patients sustained multiple gunshots to the chest and extremities. The child was hypotensive and received 2 U of leukoreduced O packed cells, one at the initial hospital and another during transport. On arrival, the patient required 2 U of low-titer O-positive whole blood and underwent a successful hemorrhage control operation. The remaining blood was returned to South Texas Blood and Tissue Center for distribution. CONCLUSION: Multiple studies have shown the association of early blood product resuscitation and improved mortality, with WB being the ideal resuscitative product for many. The ongoing efforts in South Texas serve as a model for development of similar programs throughout the country to reduce preventable deaths. This event represents the first ever successful deployment of WB to the site of an MCI related to a school shooting in the modern era. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Strategies for the removal of short-term indwelling urethral catheters in adults.

BACKGROUND: Urinary catheterisation is a common procedure, with approximately 15% to 25% of all people admitted to hospital receiving short-term (14 days or less) indwelling urethral catheterisation at some point during their care. However, the use of urinary catheters is associated with an increased risk of developing urinary tract infection. Catheter-associated urinary tract infection (CAUTI) is one of the most common hospital-acquired infections. It is estimated that around 20% of hospital-acquired bacteraemias arise from the urinary tract and are associated with mortality of around 10%. This is an update of a Cochrane Review first published in 2005 and last published in 2007. OBJECTIVES: To assess the effects of strategies for removing short-term (14 days or less) indwelling catheters in adults. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register, which contains trials identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 17 March 2020), and reference lists of relevant articles. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) and quasi-RCTs that evaluated the effectiveness of practices undertaken for the removal of short-term indwelling urethral catheters in adults for any reason in any setting. DATA COLLECTION AND ANALYSIS: Two review authors performed abstract and full-text screening of all relevant articles. At least two review authors independently performed risk of bias assessment, data abstraction and GRADE assessment. MAIN RESULTS: We included 99 trials involving 12,241 participants. We judged the majority of trials to be at low or unclear risk of selection and detection bias, with a high risk of performance bias. We also deemed most trials to be at low risk of attrition and reporting bias. None of the trials reported on quality of life. The majority of participants across the trials had undergone some form of surgical procedure. Thirteen trials involving 1506 participants compared the removal of short-term indwelling urethral catheters at one time of day (early morning removal group between 6 am to 7 am) versus another (late night removal group between 10 pm to midnight). Catheter removal late at night may slightly reduce the risk of requiring recatheterisation compared with early morning (RR 0.71, 95% CI 0.53 to 0.96; 10 RCTs, 1920 participants; low-certainty evidence). We are uncertain if there is any difference between early morning and late night removal in the risk of developing symptomatic CAUTI (RR 1.00, 95% CI 0.61 to 1.63; 1 RCT, 41 participants; very low-certainty evidence). We are uncertain whether the time of day makes a difference to the risk of dysuria (RR 2.20; 95% CI 0.70 to 6.86; 1 RCT, 170 participants; low-certainty evidence). Sixty-eight trials involving 9247 participants compared shorter versus longer durations of catheterisation. Shorter durations may increase the risk of requiring recatheterisation compared with longer durations (RR 1.81, 95% CI 1.35 to 2.41; 44 trials, 5870 participants; low-certainty evidence), but probably reduce the risk of symptomatic CAUTI (RR 0.52, 95% CI 0.45 to 0.61; 41 RCTs, 5759 participants; moderate-certainty evidence) and may reduce the risk of dysuria (RR 0.42, 95% CI 0.20 to 0.88; 7 RCTs; 1398 participants; low-certainty evidence). Seven trials involving 714 participants compared policies of clamping catheters versus free drainage. There may be little to no difference between clamping and free drainage in terms of the risk of requiring recatheterisation (RR 0.82, 95% CI 0.55 to 1.21; 5 RCTs; 569 participants; low-certainty evidence). We are uncertain if there is any difference in the risk of symptomatic CAUTI (RR 0.99, 95% CI 0.60 to 1.63; 2 RCTs, 267 participants; very low-certainty evidence) or dysuria (RR 0.84, 95% CI 0.46 to 1.54; 1 trial, 79 participants; very low-certainty evidence). Three trials involving 402 participants compared the use of prophylactic alpha blockers versus no intervention or placebo. We are uncertain if prophylactic alpha blockers before catheter removal has any effect on the risk of requiring recatheterisation (RR 1.18, 95% CI 0.58 to 2.42; 2 RCTs, 184 participants; very low-certainty evidence) or risk of symptomatic CAUTI (RR 0.20, 95% CI 0.01 to 4.06; 1 trial, 94 participants; very low-certainty evidence). None of the included trials investigating prophylactic alpha blockers reported the number of participants with dysuria. AUTHORS' CONCLUSIONS: There is some evidence to suggest the removal of indwelling urethral catheters late at night rather than early in the morning may reduce the number of people who require recatheterisation. It appears that catheter removal after shorter compared to longer durations probably reduces the risk of symptomatic CAUTI and may reduce the risk of dysuria. However, it may lead to more people requiring recatheterisation. The other evidence relating to the risk of symptomatic CAUTI and dysuria is too uncertain to allow us to draw any conclusions. Due to the low certainty of the majority of the evidence presented here, the results of further research are likely to change our findings and to have a further impact on clinical practice. This systematic review has highlighted the need for a standardised set of core outcomes, which should be measured and reported by all future trials comparing strategies for the removal of short-term urinary catheters. Future trials should also study the effects of short-term indwelling urethral catheter removal on non-surgical patients.

Paramedic utilization of Vision, Aphasia, Neglect (VAN) stroke severity scale in the prehospital setting predicts emergent large vessel occlusion stroke.

BACKGROUND: Numerous stroke severity scales have been published, but few have been studied with emergency medical services (EMS) in the prehospital setting. We studied the Vision, Aphasia, Neglect (VAN) stroke assessment scale in the prehospital setting for its simplicity to both teach and perform. This prospective prehospital cohort study was designed to validate the use and efficacy of VAN within our stroke systems of care, which includes multiple comprehensive stroke centers (CSCs) and EMS agencies. METHODS: The performances of VAN and the National Institutes of Health Stroke Scale (NIHSS) ≥6 for the presence of both emergent large vessel occlusion (ELVO) alone and ELVO or any intracranial hemorrhage (ICH) combined were reported with positive predictive value, sensitivity, negative predictive value, specificity, and overall accuracy. For subjects with intraparenchymal hemorrhage, volume was calculated based on the ABC/2 formula and the presence of intraventricular hemorrhage was recorded. RESULTS: Both VAN and NIHSS ≥6 were significantly associated with ELVO alone and with ELVO or any ICH combined using χ2 analysis. Overall, hospital NIHSS ≥6 performed better than prehospital VAN based on statistical measures. Of the 34 cases of intraparenchymal hemorrhage, mean±SD hemorrhage volumes were 2.5±4.0 mL for the five VAN-negative cases and 17.5±14.2 mL for the 29 VAN-positive cases. CONCLUSIONS: Our VAN study adds to the published evidence that prehospital EMS scales can be effectively taught and implemented in stroke systems with multiple EMS agencies and CSCs. In addition to ELVO, prehospital scales such as VAN may also serve as an effective ICH bypass tool.

The long spine board does not reduce lateral motion during transport--a randomized healthy volunteer crossover trial.

OBJECTIVE: For thirty years, emergency medical services agencies have emphasized limiting spinal motion during transport of the trauma patient to the emergency department. The long spine board (LSB) has been the mainstay of spinal motion restriction practices, despite the paucity of data to support its use. The purpose of this study was to determine reduction in lateral motion afforded by the LSB in comparison to the stretcher mattress alone. METHODS: This was a randomized controlled crossover trial where healthy volunteer subjects were randomly assigned to either LSB or stretcher mattress only. All subjects were fitted with a rigid cervical collar, secured to the assigned device (including foam head blocks), and driven on a closed course with prescribed turns at a low speed (<20 mph). Upon completion, the subjects were then secured to the other device and the course was repeated. Each subject was fitted with 3 graduated-paper disks (head, chest, hip). Lasers were affixed to a scaffold attached to the stretcher bridging over the patient and aimed at the center of the concentric graduations on the disks. During transport, the degree of lateral movement was recorded during each turn. Significance was determined by t test. RESULTS: In both groups, the head demonstrated the least motion with 0.46±0.4-cm mattress and 0.97±0.7-cm LSB (P≤ .0001). The chest and hip had lateral movement with chest 1.22±0.9-cm mattress and 2.22±1.4-cm LSB (P≤ .0001), and the hip 1.20±0.9-cm mattress and 1.88±1.2-cm LSB (P≤ .0001), respectively. In addition, lateral movement had a significant direct correlation with body mass index. CONCLUSION: The stretcher mattress significantly reduced lateral movement during transport.

Urethral (indwelling or intermittent) or suprapubic routes for short-term catheterisation in hospitalised adults.

BACKGROUND: Indwelling urethral catheters are often used for bladder drainage in hospital. Urinary tract infection is the most common hospital-acquired infection, and a common complication of urinary catheterisation. Pain, ease of use and quality of life are important to consider, as well as formal economic analysis. Suprapubic catheterisation can also result in bowel perforation and death. OBJECTIVES: To determine the advantages and disadvantages of alternative routes of short-term bladder catheterisation in adults in terms of infection, adverse events, replacement, duration of use, participant satisfaction and cost effectiveness. For the purpose of this review, we define 'short-term' as intended duration of catheterisation for 14 days or less. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 26 February 2015), CINAHL (searched 27 January 2015) and the reference lists of relevant articles. SELECTION CRITERIA: We included all randomised and quasi-randomised trials comparing different routes of catheterisation for short-term use in hospitalised adults. DATA COLLECTION AND ANALYSIS: At least two review authors extracted data and performed 'Risk of bias' assessment of the included trials. We sought clarification from the trialists if further information was required. MAIN RESULTS: In this systematic review, we included 42 trials.Twenty-five trials compared indwelling urethral and suprapubic catheterisation. There was insufficient evidence for symptomatic urinary tract infection (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.61 to 1.69; 5 trials, 575 participants; very low-quality evidence). Participants with indwelling catheters had more cases of asymptomatic bacteriuria (RR 2.25, 95% CI 1.63 to 3.10; 19 trials, 1894 participants; very low quality evidence) and more participants reported pain (RR 5.62, 95% CI 3.31 to 9.55; 4 trials, 535 participants; low-quality evidence). Duration of catheterisation was shorter in the indwelling urethral catheter group (MD -1.73, 95% CI -2.42 to -1.05; 2 trials, 274 participants).Fourteen trials compared indwelling urethral catheterisation with intermittent catheterisation. Two trials had data for symptomatic UTI which were suitable for meta-analysis. Due to evidence of significant clinical and statistical heterogeneity, we did not pool the results, which were inconclusive and the quality of evidence was very low. The main source of heterogeneity was the reason for hospitalisation as Hakvoort and colleagues recruited participants undergoing urogenital surgery; whereas in the trial conducted by Tang and colleagues elderly women in geriatric rehabilitation ward were recruited. The evidence was also inconclusive for asymptomatic bacteriuria (RR 1.04; 95% CI 0.85 to 1.28; 13 trials, 1333 participants; very low quality evidence). Almost three times as many people developed acute urinary retention with the intermittent catheter (16% with urethral versus 45% with intermittent); RR 0.45, 95% CI 0.22 to 0.91; 4 trials, 384 participants.Three trials compared intermittent catheterisation with suprapubic catheterisation, with only female participants. The evidence was inconclusive for symptomatic urinary tract infection, asymptomatic bacteriuria, pain or cost.None of the trials reported the following critical outcomes: quality of life; ease of use, and cost utility analysis. AUTHORS' CONCLUSIONS: Suprapubic catheters reduced the number of participants with asymptomatic bacteriuria, recatheterisation and pain compared with indwelling urethral. The evidence for symptomatic urinary tract infection was inconclusive.For indwelling versus intermittent urethral catheterisation, the evidence was inconclusive for symptomatic urinary tract infection and asymptomatic bacteriuria. No trials reported pain.The evidence was inconclusive for suprapubic versus intermittent urethral catheterisation. Trials should use a standardised definition for symptomatic urinary tract infection. Further adequately-powered trials comparing all catheters are required, particularly suprapubic and intermittent urethral catheterisation.

Differential regulation of steroid nuclear receptor coregulator expression between normal and neoplastic prostate epithelial cells.

BACKGROUND: Deregulated androgen receptor (AR) action is critical for prostate cancer (PCa) progression. Aberrant expression of AR-associated coregulators contributes to AR activity in PCa. The mechanisms underlying coregulator expression in PCa are under intense investigation as they may lead to alternative means of targeting AR activity in PCa cells. We have recently shown that over 30% of coregulator expression in the PCa cell line LNCaP is subject to androgen regulation. METHODS: Using multiple PCa cell lines as well as xenograft models, non-malignant prostate epithelial cell lines and androgen-responsive tissues derived from a male Wistar rat model system, we explored the effect of androgen stimulation and androgen deprivation on the expression of the core coactivators SRC1, SRC2, SRC3, CBP, and p300. RESULTS: Androgen stimulation of model systems representing PCa led to a decrease in the expression of SRC1, SRC2, SRC3, CBP, and p300, whereas androgen deprivation induced the expression of these coactivators. In contrast, expression of these coregulators remained largely unaffected following changes in the androgenic milieu in AR-positive models representing non-malignant prostate cells and tissues. CONCLUSIONS: Our data indicate differences in the regulation of coregulator expression between neoplastic and normal prostate cells. These findings emphasize the important potential of targeting the mechanisms regulating coregulator expression for therapeutic intervention in PCa.

Induction of FLIP expression by androgens protects prostate cancer cells from TRAIL-mediated apoptosis.

BACKGROUND: Prostate tumors initially regress in response to androgen-ablation therapy. However, most cancers eventually relapse with an androgen-depletion-independent (ADI) phenotype that is often more aggressive than the original androgen-dependent (AD) tumor. Importantly, most relapsed tumors still rely upon androgen receptor (AR) activity for proliferation and survival. The cellular Fas/FasL-associated death domain protein-like inhibitory protein (FLIP) inhibits activation of procaspase-8 by death receptor-mediated signaling at the cell surface. In the current study, we examined the androgenic regulation of FLIP and its contribution to protecting prostate cancer cells from death receptor-mediated apoptosis. METHODS: FLIP expression in tissues from intact and castrated rats as well as androgen-treated prostate cancer cell lines (LNCaP, C4-2, LNCaP-Rf, and DU-145) was monitored via Real-Time RT-PCR and immunoblot. Induction of apoptosis by TRAIL, the death receptor ligand, was determined via microscopic observation and cell counting of fragmented nuclei following fixation and staining with Hoechst 33285. RESULTS: FLIP mRNA and protein expression was reduced following castration in multiple rat tissues, including dorsolateral prostate and seminal vesicles. Androgenic induction of FLIP mRNA and protein was observed in isogenic AD LNCaP and ADI LNCaP-Rf cells, but not the isogenic ADI C4-2 cell line. Protection from TRAIL-induced apoptosis by androgen was completely blocked when LNCaP-Rf cells were depleted of endogenous FLIP via siRNA transfection. CONCLUSIONS: Androgenic protection from TRAIL-induced apoptosis is predominantly via enhanced transcription of FLIP in prostate cancer cells. Loss of androgen-sensitivity in ADI prostate cancer cells highlights this pathway as a potential target for future therapy of prostate cancer.