Development of a Value Assessment Framework for Pediatric Health Technologies Using Multicriteria Decision Analysis: Expanding the Value Lens for Funding Decision Making.

OBJECTIVES: A health technology assessment (HTA) does not systematically account for the circumstances and needs of children and youth. To supplement HTA processes, we aimed to develop a child-tailored value assessment framework using a multicriteria decision analysis approach. METHODS: We constructed a multicriteria-decision-analysis-based model in multiple phases to create the Comprehensive Assessment of Technologies for Child Health (CATCH) framework. Using a modified Delphi process with stakeholders having broad disciplinary and geographic variation (N = 23), we refined previously generated criteria and developed rank-based weights. We established a criterion-pertinent scoring rubric for assessing incremental benefits of new drugs. Three clinicians independently assessed comprehension by pilotscoring 9 drugs. We then validated CATCH for 2 childhood cancer therapies through structured deliberation with an expert panel (N = 10), obtaining individual scores, consensus scores, and verbal feedback. Analyses included descriptive statistics, thematic analysis, exploratory disagreement indices, and sensitivity analysis. RESULTS: The modified Delphi process yielded 10 criteria, based on absolute importance/relevance and agreed importance (median disagreement indices = 0.34): Effectiveness, Child-specific Health-related Quality of Life, Disease Severity, Unmet Need, Therapeutic Safety, Equity, Family Impacts, Life-course Development, Rarity, and Fair Share of Life. Pilot scoring resulted in adjusted criteria definitions and more precise score-scaling guidelines. Validation panelists endorsed the framework's key modifiers of value. Modes of their individual prescores aligned closely with deliberative consensus scores. CONCLUSIONS: We iteratively developed a value assessment framework that captures dimensions of child-specific health and nonhealth gains. CATCH could improve the richness and relevance of HTA decision making for children in Canada and comparable health systems.

Perspectives of Canadian health leaders on the relationship between medical assistance in dying and palliative and end-of-life care services: a qualitative study.

BACKGROUND: Medical assistance in dying (MAiD) was legalized in Canada in 2016, but coordination of MAiD and palliative and end-of-life care (PEOLC) services remains underdeveloped. We sought to understand the perspectives of health leaders across Canada on the relationship between MAiD and PEOLC services and to identify opportunities for improved coordination. METHODS: In this quantitative study, we purposively sampled health leaders across Canada with expertise in MAiD, PEOLC, or both. We conducted semi-structured interviews between April 2021 and January 2022. Interview transcripts were coded independently by 2 researchers and reconciled to identify key themes using content analysis. We applied the PATH framework for Integrated Health Services to guide data collection and analysis. RESULTS: We conducted 36 interviews. Participants expressed diverse views about the optimal relationship between MAiD and PEOLC, and the desirability of integration, separation, or coordination of these services. We identified 11 themes to improve the relationship between the services across 4 PATH levels: client-centred services (e.g., educate public); health operations (e.g., cultivate compassionate and proactive leadership); health systems (e.g., conduct broad and inclusive consultation and planning); and intersectoral initiatives (e.g., provide standard practice guidelines across health care systems). INTERPRETATION: Health leaders recognized that cooperation between MAiD and PEOLC services is required for appropriate referrals, care coordination, and patient care. They identified the need for public and provider education, standardized practice guidelines, relationship-building, and leadership. Our findings have implications for MAiD and PEOLC policy development and clinical practice in Canada and other jurisdictions.

A Critical Period for Development of Cerebellar-Mediated Autism-Relevant Social Behavior.

The cerebellum has been increasingly implicated in autism spectrum disorder (ASD) with many ASD-linked genes impacting both cerebellar function and development. However, the precise timing and critical periods of when abnormal cerebellar neurodevelopment contributes to ASD-relevant behaviors remains poorly understood. In this study, we identify a critical period for the development of ASD-relevant behaviors in a cerebellar male mouse model of tuberous sclerosis complex (TSC), by using the mechanistic target of rapamycin (mTOR) inhibitor, rapamycin, to pharmacologically inhibit dysregulated downstream signaling. We find independent critical periods during which abnormal ASD-relevant behaviors develop for the two core ASD diagnostic criteria, social impairments and behavioral flexibility, and delineate an anatomic, physiological, and behavioral framework. These findings not only further our understanding of the genetic mechanisms underlying the timing of ASD-relevant behaviors but also have the capacity to inform potential therapies to optimize treatment interventions.SIGNIFICANCE STATEMENT No targeted treatments currently exist for autism spectrum disorder (ASD). This complex developmental disorder has established links to genetic and circuit aberrations, yet the precise timing and coordination of these underlying mechanisms that contribute to the spectrum of physiological and behavioral abnormalities remains unclear. Cerebellar pathology is consistently seen in ASD individuals; therefore, we sought to identify the specific windows for cerebellar involvement in the development of ASD-relevant behaviors. Using pharmacologic treatment paradigms, we outline distinct critical periods of developmental vulnerability for ASD-relevant social and inflexible behaviors. From this study, we posit a refined window of time during which ASD symptoms develop that will inform therapeutic timing.

The case against futility.

ABSTRACT: "Futility" is a common concept and terminology used in healthcare. This article uses a 2021 case to explore the concept and use of "futility" by considering its critiques. This article also discusses alternative ways to more clearly communicate concerns about medically harmful or inappropriate and non-beneficial uses of life-sustaining treatments.

A framework for critical care triage during a major surge in critical illness.

During the COVID-19 pandemic, many jurisdictions experienced surges in demand for critical care that strained or overwhelmed their healthcare system's ability to respond. A major surge necessitates a deviation from usual practices, including difficult decisions about how to allocate critical care resources. We present a framework to guide these decisions in the hope of saving the most lives as ethically as possible, while concurrently respecting, protecting, and fulfilling legal and human rights obligations. It was developed in Ontario in 2020-2021 through an iterative consultation process with diverse participants, but was adopted in other jurisdictions with some modifications. The framework features three levels of triage depending on the degree of the surge, and a system for prioritizing patients based on their short-term mortality risk following the onset of critical illness. It also includes processes aimed at promoting consistency and fairness across a region where many hospitals are expected to apply the same framework. No triage framework should ever be considered "final," and there is a need for further research to examine ethical issues related to critical care triage and to increase the extent and quality of evidence to inform critical care triage.

RéSUMé: Pendant la pandémie de COVID-19, de nombreuses régions ont connu une augmentation de la demande de soins intensifs qui a mis à rude épreuve ou dépassé la capacité de réponse du système de santé existant. Lors de toute augmentation importante de cette demande, un écart par rapport aux pratiques habituelles est nécessaire, y compris la prise de décisions difficiles sur la façon d'allouer les ressources en soins intensifs. Nous présentons un algorithme pour guider ces décisions dans l'espoir de sauver le plus de vies possibles et ce, de la manière la plus éthique possible, tout en respectant, en protégeant et en remplissant les obligations légales et en matière de droits de l'homme. Cet algorithme a été élaboré en Ontario en 2020-2021 dans le cadre d'un processus de consultation itératif avec divers participants, mais a été adopté dans d'autres juridictions avec quelques modifications. L'algorithme comprend trois niveaux de triage en fonction du degré d'augmentation de la demande, ainsi qu'un système permettant de prioriser les patients en fonction de leur risque de mortalité à court terme après l'apparition d'une maladie grave. Il comporte également des processus visant à promouvoir l'uniformité et l'équité dans une région où de nombreux hôpitaux vont appliquer le même algorithme. Aucun algorithme de triage ne devrait jamais être considéré comme « définitif ¼, et il est nécessaire d'approfondir les recherches pour examiner les questions éthiques liées au triage aux soins intensifs et accroître l'étendue et la qualité des données probantes afin d'éclairer le triage aux soins intensifs.

Implementation of a nurse-led overdose prevention site in a hospital setting: lessons learned from St. Paul's Hospital, Vancouver, Canada.

OBJECTIVES: In May 2018, St. Paul's Hospital (SPH) in Vancouver (Canada) opened an outdoor peer-led overdose prevention site (OPS) operated in partnership with Vancouver Coastal Health and RainCity Housing. At the end of 2020, the partnered OPS moved to a new location, which created a gap in service for SPH inpatients and outpatients. To address this gap, which was magnified by the COVID-19 pandemic, SPH opened a nurse-led OPS in February 2021. This paper describes the steps leading to the implementation of the nurse-led OPS, its impact, and lessons learned. METHODS: Four steps paved the way for the opening of the OPS: (1) identifying the problem, (2) seeking ethics guidance, (3) adapting policies and practices, and (4) supporting and training staff. RESULTS: The OPS is open between 10:00 and 20:00 and staffed by two nurses per shift. It is accessible to all patients including inpatients, patients in the Emergency Department, and patients attending outpatient services. Between February 1, 2021 and October 23, 2021, the OPS recorded 1612 visits for the purpose of injection, for an average weekly visit number of 42. A total of 46 overdoses were recorded in that 9-month period. Thirty-seven (80%) required administration of naloxone and 12 (26%) required a code blue response. CONCLUSIONS: Due to the unique nature of our OPS, we learned many important lessons in the process leading to the opening of the site and the months that followed. We conclude the paper with lessons learned grouped into six main categories, namely engagement, communication, access, staff education and support, data collection, and safety.

The Unspeakable Nature of Death & Dying During Childhood: A Silenced Phenomenon in Pediatric Care.

In pediatric settings, the concept of hope is frequently positioned as a fundamental aspect of care and at odds with the possibility and proximity of death. This arguably fosters silence about death and dying in childhood despite evidence indicating the benefits of open communication at the end of life. In this paper, we describe the unspeakable nature of death and dying in childhood, including its conceptual and clinical causes and dimensions, its persistence, and the associated challenges for children and youth facing critical illnesses, their families, and society. We explore how the tension between hope and death can be reframed and apply our analysis to the context of medical assistance in dying for mature minors in Canada. Considering the lack of related literature, this paper offers initial reflections to form a framework for the unspeakable nature of death and dying in childhood and to advance the crucial need for research.

Artificial intelligence for good health: a scoping review of the ethics literature.

BACKGROUND: Artificial intelligence (AI) has been described as the "fourth industrial revolution" with transformative and global implications, including in healthcare, public health, and global health. AI approaches hold promise for improving health systems worldwide, as well as individual and population health outcomes. While AI may have potential for advancing health equity within and between countries, we must consider the ethical implications of its deployment in order to mitigate its potential harms, particularly for the most vulnerable. This scoping review addresses the following question: What ethical issues have been identified in relation to AI in the field of health, including from a global health perspective? METHODS: Eight electronic databases were searched for peer reviewed and grey literature published before April 2018 using the concepts of health, ethics, and AI, and their related terms. Records were independently screened by two reviewers and were included if they reported on AI in relation to health and ethics and were written in the English language. Data was charted on a piloted data charting form, and a descriptive and thematic analysis was performed. RESULTS: Upon reviewing 12,722 articles, 103 met the predetermined inclusion criteria. The literature was primarily focused on the ethics of AI in health care, particularly on carer robots, diagnostics, and precision medicine, but was largely silent on ethics of AI in public and population health. The literature highlighted a number of common ethical concerns related to privacy, trust, accountability and responsibility, and bias. Largely missing from the literature was the ethics of AI in global health, particularly in the context of low- and middle-income countries (LMICs). CONCLUSIONS: The ethical issues surrounding AI in the field of health are both vast and complex. While AI holds the potential to improve health and health systems, our analysis suggests that its introduction should be approached with cautious optimism. The dearth of literature on the ethics of AI within LMICs, as well as in public health, also points to a critical need for further research into the ethical implications of AI within both global and public health, to ensure that its development and implementation is ethical for everyone, everywhere.

Early experience with medical assistance in dying in Ontario, Canada: a cohort study.

BACKGROUND: Medical assistance in dying (MAiD) was legalized across Canada in June 2016. Some have expressed concern that patient requests for MAiD might be driven by poor access to palliative care and that social and economic vulnerability of patients may influence access to or receipt of MAiD. To examine these concerns, we describe Ontario's early experience with MAiD and compare MAiD decedents with the general population of decedents in Ontario. METHODS: We conducted a retrospective cohort study comparing all MAiD-related deaths with all deaths in Ontario, Canada, between June 7, 2016, and Oct. 31, 2018. Clinical and demographic characteristics were collected for all MAiD decedents and compared with those of all Ontario decedents when possible. We used logistic regression analyses to describe the association of demographic and clinical factors with receipt of MAiD. RESULTS: A total of 2241 patients (50.2% women) were included in the MAiD cohort, and 186 814 in the general Ontario decedent cohort. Recipients of MAiD reported both physical (99.5%) and psychologic suffering (96.4%) before the procedure. In 74.4% of cases, palliative care providers were involved in the patient's care at the time of the MAiD request. The statutory 10-day reflection period was shortened for 26.6% of people. Compared with all Ontario decedents, MAiD recipients were younger (mean 74.4 v. 77.0 yr, standardized difference 0.18);, more likely to be from a higher income quintile (24.9% v. 15.6%, standardized difference across quintiles 0.31); less likely to reside in an institution (6.3% v. 28.0%, standardized difference 0.6); more likely to be married (48.5% v. 40.6%) and less likely to be widowed (25.7% v. 35.8%, standardized difference 0.34); and more likely to have a cancer diagnosis (64.4% v. 27.6%, standardized difference 0.88 for diagnoses comparisons). INTERPRETATION: Recipients of MAiD were younger, had higher income, were substantially less likely to reside in an institution and were more likely to be married than decedents from the general population, suggesting that MAiD is unlikely to be driven by social or economic vulnerability. Given the high prevalence of physical and psychologic suffering, despite involvement of palliative care providers in caring for patients who request MAiD, future studies should aim to improve our understanding and treatment of the specific types of suffering that lead to a MAiD request.

The Facilitator Instrument for Team-Based Learning (FIT).

Construct: We sought to evaluate the quality of Team-Based Learning facilitation in both large and small group settings. Background: Team Based Learning (TBL) is an increasingly popular small group instructional strategy in health science education. TBL facilitation skills are unique and differ from those needed to lecture or facilitate other types of small groups. Measuring facilitation skills and providing feedback to TBL instructors is important, yet to date no valid instrument has been developed and published for this purpose. Approach: We created an 11-item instrument (ratings of each item on a 7-point scale) designed to assess TBL facilitation skills, considering major sources of validity. Twelve experts in TBL facilitation and training developed the content of the FIT. To ensure response processes were valid, we used an immediate retrospective probing technique with 4th year medical students who were not part of the study. The Facilitator Instrument for Team-Based Learning (FIT) was piloted with 2,840 medical students in 7 schools in large (year 1 and 2) and small (year 3) courses. The internal structure of the FIT was analyzed. Results: In total, 1,559 and 1,281 medical students in large and small TBL classes, respectively (response rate 88%) rated 33 TBL facilitators. The composite mean score for the FIT was 6.19 (SD = 1.10). Exploratory factor analysis and Cronbach's alpha indicated that all items loaded on 1 factor, accounting for 77% of the item variance. Cronbach's alpha for the 11 items was 0.97. Analysis of facilitator variables and course context indicated that FIT scores were statistically significantly correlated with type of class (pre-clinical or clinical) and size of class as well as the facilitator enjoyment in using TBL as a method. Gender and the amount that facilitators used TBL each year was weakly correlated, with other factors not correlated (years facilitating TBL, confidence in facilitating TBL, and age). Conclusions: Analysis of FIT scores from 2,840 medical students across multiple institutions and teaching settings suggests the utility of the FIT in determining the quality of TBL facilitation across a range of medical education settings. Future research is needed to further analyze course contexts and facilitator variables that may influence FIT scores with additional facilitators. Additionally, FIT scores should be correlated with additional measures of TBL facilitator quality, such as direct observations, especially if these data are used for summative decision-making purposes.

Do You C What I C: Emergency Department Evaluation and Diagnosis of Pediatric Scurvy in an Autistic Child With a Restricted Diet.

Scurvy in modern times may not be as rare as previously thought. The link between adequate intake of vitamin C and scurvy has been known since ancient times and is recorded in Ebers Papyrus. Recent reports indicate that, with restricted diets, vitamin C deficiency is being seen in infants exclusively fed plant-based formula and children with oral aversion, autism, restricted diets, and cerebral palsy. Additional at-risk groups include the older adults and patients having alcoholism. Often costly, emergency department visits and elaborate diagnostic studies lead to fruitless results when a simple diet history is often overlooked. Here, we report a case of pediatric scurvy in an 11-year-old autistic child with a restricted diet who presented with refusal to walk, fatigue, a purpuric rash, and gingival bleeding. The diagnosis was made based on diet history, physical examination findings, and symptom resolution with vitamin C supplementation. Our case report reaffirms that vitamin C deficiency still occurs and should be considered in children with restrictive diets. Early recognition of this disease by physicians provides early diagnosis, avoids costly diagnostic workup and hospitalization, and expedites effective treatment.

Public health emergency preparedness: a framework to promote resilience.

BACKGROUND: Emergencies and disasters impact population health. Despite the importance of upstream readiness, a persistent challenge for public health practitioners is defining what it means to be prepared. There is a knowledge gap in that existing frameworks lack consideration for complexity relevant to health systems and the emergency context. The objective of this study is to describe the essential elements of a resilient public health system and how the elements interact as a complex adaptive system. METHODS: This study used a qualitative design employing the Structured Interview Matrix facilitation technique in six focus groups across Canada. Focus group participants were practitioners from public health and related sectors. Data collection generated qualitative data on the essential elements, and interactions between elements, for a resilient public health system. Data analysis employed qualitative content analysis and the lens of complexity theory to account for the complex nature of public health emergency preparedness (PHEP). The unit of study was the local/regional public health agency. Ethics and values were considered in the development of the framework. RESULTS: A total of 130 participants attended the six focus groups. Urban, urban-rural and rural regions from across Canada participated and focus group size ranged from 15 to 33 across the six sites. Eleven elements emerged from the data; these included one cross-cutting element (Governance and leadership) and 10 distinct but interlinked elements. The essential elements define a conceptual framework for PHEP. The framework was refined to ensure practice and policy relevance for local/regional public health agencies; the framework has ethics and values at its core. CONCLUSIONS: This framework describes the complexity of the system yet moves beyond description to use tenets of complexity to support building resilience. This applied public health framework for local/regional public health agencies is empirically-derived and theoretically-informed and represents a complex adaptive systems approach to upstream readiness for PHEP.

Compassion focused therapy: Exploring the effectiveness with a transdiagnostic group and potential processes of change.

OBJECTIVES: This study aimed to examine the effectiveness of a compassion focused therapy (CFT) group with a transdiagnostic population, as compared to treatment as usual (TAU). A secondary aim was to explore the potential processes of change within the treatment. DESIGN: A non-randomized control trial was used. METHOD: Fifty-eight participants who engaged in group CFT were compared to 29 participants receiving TAU. Group CFT consisted of 14 sessions twice weekly for 5 weeks and once weekly for 4 weeks. Participants completed measures of psychopathology, shame, self-criticism, fears of self-compassion, and social safeness, at pre-treatment, post-treatment, and 2-month follow-up. Potential processes of change were examined using correlations and regression analysis. RESULTS: Significantly greater improvements were found for levels of psychopathology, fears of self-compassion and social safeness for CFT, compared to TAU. Additionally, analyses showed improvements in shame and self-criticism within the CFT group but not the TAU group. All improvements were maintained at 2-month follow-up. Improvements in psychopathology were predicted by changes in self-criticism and fears of self-compassion. CONCLUSION: Compassion focused therapy appears to be an effective group intervention for a range of mental health difficulties. The positive impact of the CFT model with a transdiagnostic group emphasizes the value of addressing underlying psychological process, rather than symptoms alone. PRACTITIONER POINTS: Compassion focused therapy is a multimodal therapy designed to target high levels of shame and self-criticism. Compassion focused therapy has been shown previously to have positive results within a range of diagnostic-specific populations. While there is an emerging research base, limited studies assessing effectiveness with transdiagnostic populations have been published. CFT was shown to have a significant effect in reducing levels of psychopathology, compared to TAU. A number of potential processes of change were identified: Changes in psychopathology were significantly correlated with changes in self-criticism and fears of self-compassion.

Surgical frailty assessment: a missed opportunity.

BACKGROUND: Preoperative frailty predicts adverse postoperative outcomes. Despite the advantages of incorporating frailty assessment into surgical settings, there is limited research on surgical healthcare professionals' use of frailty assessment for perioperative care. METHODS: Healthcare professionals caring for patients enrolled at a Canadian teaching hospital were surveyed to assess their perceptions of frailty, as well as attitudes towards and practices for frail patients. The survey contained open-ended and 5-point Likert scale questions. Responses were compared across professions using independent sample t-tests and correlations between survey items were analyzed. RESULTS: Nurses and allied health professionals were more likely than surgeons to think frailty should play a role in planning a patient's care (nurses vs. surgeons p = 0.008, allied health vs. surgeons p = 0.014). Very few respondents (17.5%) reported that they 'always used' a frailty assessment tool. Results from qualitative data analysis identified four main barriers to frailty assessment: institutional, healthcare system, professional knowledge, and patient/family barriers. CONCLUSION: Across all disciplines, the lack of knowledge about frailty issues was a prominent barrier to the use of frailty assessments in practice, despite clinicians' understanding that frailty affects their patients' outcomes. Confidence in frailty assessment tool use through education and addressing barriers to implementation may increase use and improve patient care. Healthcare professionals agree that frailty assessments should play a role in perioperative care. However, few perform them in practice. Lack of knowledge about frailty is a key barrier in the use of frailty assessments and the majority of respondents agreed that they would benefit from further training.

Is current preoperative frailty assessment adequate?

SUMMARY: Preoperative frailty predicts adverse postoperative outcomes. Recommendations for preoperative assessment of elderly patients include performing a frailty assessment. Despite the advantages of incorporating frailty assessment into surgical settings, there is limited research on surgical health care professionals' perception and use of frailty assessment for perioperative care. We surveyed local health care employees to assess their attitudes toward and practices for frail patients. Nurses and allied health professionals were more likely than surgeons to agree frailty should play a role in planning a patient's care. Lack of knowledge about frailty issues was a prominent barrier to the use of frailty assessments in practice, despite clinicians understanding that frailty affects their patients' outcomes. Results of this survey suggest further training in frailty issues and the use of frailty assessment instruments is necessary and could improve the uptake of such tools for perioperative care planning.

Evaluation of a New Thermal Fog Machine for Control of Adult Aedes albopictus in a Large Enclosed Space.

Testing of the PSO BASDKA-AC1200 multifunction ultrafine particle atomization machine, a thermal fog machine, with Aqualuer 20-20(®) (permethrin 20.6%, piperonyl butoxide 20.6%) was conducted against Aedes albopictus. The machine was set at a 40 sec maximum burst interval dispersing 36 ml of chemical with an average droplet volume of 50%. Female adult Ae. albopictus were placed into cylindrical paper cages and adhered to poles at 5, 8, 10, 15, and 25 m from the center point of the machine. Control cages consisted of 1 cage placed at 5, 10, and 25 m. Control and treatment groups were left in the experiment area for 15 min. Initial knockdown after 15 min and 24 h mortality were documented. At 15 min post-treatment, Ae. albopictus displayed less than 50% knockdown. After 24 h, all treatment cages displayed greater than 90% mortality. Further bottle bioassays were conducted to determine the lowest chemical dose possible to achieve a lethal dose of 90%. A 1% dilution (10 ml Aqualuer 20-20 to 1,000 ml of polyether) of Aqualuer showed high mortality in the laboratory. However, after running 3 repetitions of a 1% dilution, there was no significant difference between the mortality of the mosquitoes at any of the distances 24 h post-treatment. This study indicates that the test machine would be an applicable and suitable machine for control of Ae. albopictus in enclosed spaces.

Evaluation of Three Commercial Handheld Ultra-Low-Volume Foggers with Aqualure® 20-20 Against Adult Aedes albopictus.

The Anastasia Mosquito Control District (AMCD) tests all equipment before field use to determine if machines are suitable for the needs of the district. Three handheld ultra-low-volume (ULV) foggers--the American LongRay (ULV) Fogger Model 3600B with rechargeable lithium battery (DC model), American LongRay ULV Fogger Model 3600E with 110V or 220V AC power (AC model), and Boston Fog Battery Motorized Fogger (Boston Fogger)--were compared to determine which fogger would be most suitable for use by AMCD. Mortality of caged Aedes albopictus was analyzed after 24 h to determine the success of a single application. All 3 foggers resulted in 100% mortality after 24 h using the insecticide Aqualuer 20-20 (active ingredients permethrin 20.6% and piperonyl butoxide 20.6%) 1:5 dilution with reverse osmosis water. Based on operator safety, robustness, and operational performance, the American LongRay DC model was found to be the most suitable at administering Aqualuer 20-20 against caged adult Ae. albopictus.