Culturally appropriate consent processes for community-driven indigenous child health research: a scoping review.

BACKGROUND: Current requirements for ethical research in Canada, specifically the standard of active or signed parental consent, can leave Indigenous children and youth with inequitable access to research opportunities or health screening. Our objective was to examine the literature to identify culturally safe research consent processes that respect the rights of Indigenous children, the rights and responsibilities of parents or caregivers, and community protocols. METHODS: We followed PRISMA guidelines and Arksey and O'Malley's approach for charting and synthesizing evidence. We searched MEDLINE, PsycINFO, ERIC, CINAHL, Google Scholar, Web of Science, Informit Indigenous Collection, Bibliography of Native North Americans, and Sociological Abstracts. We included peer-reviewed primary and theoretical research articles written in English from January 1, 2000, to March 31, 2022, examining Indigenous approaches for obtaining informed consent from parents, families, children, or youth. Eligible records were uploaded to Covidence for title and abstract screening. We appraised the findings using a Two-Eyed Seeing approach. These findings were inductively coded using NVivo 12 and analyzed thematically. RESULTS: We identified 2,984 records and 11 eligible studies were included after screening. Three key recommendations emerged: addressing tensions in the ethics of consent, embracing wise practices, and using relational approaches to consent. Tensions in consent concerned Research Ethics Board consent requirements that fall short of protecting Indigenous children and communities when culturally incongruent. Wise practices included allowing parents and children to consent together, land-based consenting, and involving communities in decision-making. Using relational approaches to consent embodied community engagement and relationship building while acknowledging consent for Indigenous children cannot be obtained in isolation from family and community. CONCLUSIONS: Very few studies discussed obtaining child consent in Indigenous communities. While Indigenous communities are not a monolith, the literature identified a need for community-driven, decolonized consent processes prioritizing Indigenous values and protocols. Further research is needed to examine nuances of Indigenized consent processes and determine how to operationalize them, enabling culturally appropriate, equitable access to research and services for all Indigenous children.

The role of low-carbohydrate diets in the intensive care unit.

Low-carbohydrate, high-fat (LCHF) nutrition therapy is characterized by carbohydrates comprising <26% of the daily caloric intake and a higher proportion of fat. LCHF therapies reduce exogenous glucose load, improve glycemic control, decrease inflammation, and improve clinical outcomes such as respiratory function. Given the altered metabolism in critically ill patients, LCHF nutrition therapy may be especially beneficial as it enables the conservation of protein and glucose for metabolic roles beyond energy use. In critical illness, LCHF diets have the potential to reduce hyperglycemia, improve ventilation, decrease hospital length of stay and reduce hospital costs. The purpose of this commentary piece is to describe LCHF nutrition therapy, summarize its impact on health outcomes, and discuss its role in the intensive care unit (ICU). Additional research on the effects of LCHF nutrition therapy on critically ill patients is warranted, including a focus on COVID-19.

Geographic clustering of cannabis stores in Canadian cities: A spatial analysis of the legal cannabis market 4 years post-legalisation.

INTRODUCTION: Following the legalisation of non-medical cannabis in 2018, the number of cannabis stores in Canada has rapidly expanded with limited regulation on their geographic placement. This study characterised the clustering of cannabis stores in Canadian cities and evaluated the association of clustering with provincial policy and sociodemographic variables. METHODS: Cross-sectional spatial analysis of cannabis store density in dissemination areas ('neighbourhoods', n = 39,226) in Canadian cities in September 2022. Cannabis store density was defined as the count of stores within 1000 m of a neighbourhood centre. Clusters of high-density cannabis retail were identified using Local Indicators of Spatial Autocorrelation. Associations between provincial policy (privatised vs. public market), sociodemographic variables and cannabis store density were evaluated using multivariable regression. RESULTS: Clusters of high-density cannabis retail were identified in 86% of Canadian cities, and neighbourhoods in clusters had a median of 5 stores within 1000 m. Toronto, Canada's most populous city, had the most extreme clustering where neighbourhoods in clusters had a median of 10 stores (and a maximum of 25 stores) within 1000 m. Neighbourhoods in private versus public retail markets had a significantly higher neighbourhood-level density of cannabis stores (adjusted rate ratio [aRR] 63.37, 95% confidence interval [CI] 25.66-156.33). Lower neighbourhood income quintile was also associated with a higher neighbourhood-level density of cannabis stores (Q5 vs. Q1, aRR 1.28, 95% CI 1.17-1.40). DISCUSSION AND CONCLUSIONS: Since cannabis was legalised, clusters of high-density cannabis retail have emerged in most Canadian cities and were more likely to form lower income neighbourhoods and in private retail markets.

A Model to Improve Care and Enhance the Physician-Patient Relationship for Hospitalized Patients With Opioid Use Disorder.

PROBLEM: Opioid-related morbidity and mortality continues to accelerate, with increasing acute care events for opioid-related causes. Most patients do not receive evidence-based treatment for opioid use disorder (OUD) during acute hospitalizations despite this being an invaluable moment to initiate substance use treatment. Inpatient addiction consult services can bridge this gap and improve patient engagement and outcomes, but varying models and approaches are needed to match institutional resources. APPROACH: To improve care for hospitalized patients with OUD, a work group was formed at the University of Chicago Medical Center in October 2019. An OUD consult service, run by generalists, was created as part of a series of process improvement interventions. Important collaborations with pharmacy, informatics, nursing, physicians, and community partners have occurred over the last 3 years. OUTCOMES: The OUD consult service completes 40-60 new inpatient consults monthly. Between August 2019 and February 2022, the service completed 867 consults from across the institution. Most consult patients were started on medications for opioid use disorder (MOUD), and many received MOUD and naloxone at discharge. Patients who were treated by our consult service experienced lower 30-day and 90-day readmission rates compared with patients who did not receive a consult. Length of stay for patients receiving a consult was not increased. NEXT STEPS: Adaptable models of hospital-based addiction care are needed to improve care for hospitalized patients with OUD. Continued work to reach a higher percentage of hospitalized patients with OUD and to improve linkage to care with community collaborators are important steps to strengthen the care received by individuals with OUD in all clinical departments.

Access to legal cannabis market in Canada over the four years following non-medical cannabis legalisation.

INTRODUCTION: An increasing number of countries are inthe process of legalising non-medical cannabis. We described how the legal market has changed over the first 4 years following legalisation in Canada. METHODS: We collected longitudinal data on operating status and location of all legal cannabis stores in Canada for the first 4 years following legalisation. We examined per capita stores and sales, store closures, and the drive time between stores and each neighbourhood in Canada. We compared measures between public and private retail systems. RESULTS: Four years after legalisation, there were 3305 cannabis stores open in Canada (10.6 stores per 100,000 individuals aged 15+ years). Canadians spent $11.85CAD a month on cannabis per individual aged 15+ years, and 59% of neighbourhoods were within a 5-minute drive of a cannabis store. Over 4 years, per capita stores and per capita sales increased each year by an average of 122.3% and 91.7%, respectively, with larger increases in private versus public systems (4.01 times greater for per capita stores and 2.46 times greater for per capita sales). The annual increase in per capita stores and sales during the first 3 years was 6.0 and 15.5 times greater, respectively, than the increase in the fourth year following legalisation. Over 4 years, 7% of retail store locations permanently closed. DISCUSSION AND CONCLUSION: The legal cannabis market in Canada expanded enormously over the first 4 years following legalisation, with considerable variation in access between jurisdictions. The rapid retail expansion has implications for evaluation of health impacts of non-medical legalisation.

Low dose IV buprenorphine inductions for patients with opioid use disorder and concurrent pain: a retrospective case series.

BACKGROUND: Hospitalizations are a vital opportunity for the initiation of life-saving opioid agonist therapy (OAT) for patients with opioid use disorder. A novel approach to OAT initiation is the use of IV buprenorphine for low dose induction, which allows patients to immediately start buprenorphine at any point in a hospitalization without stopping full agonist opioids or experiencing significant withdrawal. METHODS: This is a retrospective case series of 33 patients with opioid use disorder concurrently treated with full agonist opioids for pain who voluntarily underwent low dose induction at a tertiary academic medical center. Low dose induction is the process of initiating very low doses of buprenorphine at fixed intervals with gradual dose increases in patients who recently received or are simultaneously treated with full opioid agonists. Our study reports one primary outcome: successful completion of the low dose induction (i.e. transitioned from low dose IV buprenorphine to sublingual buprenorphine-naloxone) and three secondary outcomes: discharge from the hospital with buprenorphine-naloxone prescription, self-reported pain scores, and nursing-assessed clinical opiate withdrawal scale (COWS) scores over a 6-day period, using descriptive statistics. COWS and pain scores were obtained from day 0 (prior to starting the low dose induction) to day 5 to assess the effect on withdrawal symptoms and pain control. RESULTS: Thirty patients completed the low dose induction (30/33, 90.9%). Thirty patients (30/33, 90.9%) were discharged with a buprenorphine prescription. Pain and COWS scores remained stable over the course of the study period. Mean COWS scores for all patients were 2.6 (SD 2.8) on day 0 and 1.6 (SD 2.6) on day 5. Mean pain scores for all patients were 4.4 (SD 2.1) on day 0 and 3.5 on day 5 (SD 2.1). CONCLUSIONS: This study found that an IV buprenorphine low dose induction protocol was well-tolerated by a group of 33 hospitalized patients with opioid use disorder with co-occurring pain requiring full agonist opioid therapy. COWS and pain scores improved for the majority of patients. This is the first case series to report mean daily COWS and pain scores over an extended period throughout a low dose induction process.

Characteristics and Outcomes of ICU Patients Without COVID-19 Infection-Pandemic Versus Nonpandemic Times: A Population-Based Cohort Study.

Outcomes for critically ill COVID-19 are well described; however, the impact of the pandemic on critically ill patients without COVID-19 infection is less clear. OBJECTIVES: To demonstrate the characteristics and outcomes of non-COVID patients admitted to an ICU during the pandemic, compared with the previous year. DESIGN: A population-based study conducted using linked health administrative data comparing a cohort from March 1, 2020, to June 30, 2020 (pandemic) to a cohort from March 1, 2019, to June 30, 2019 (nonpandemic). SETTING AND PARTICIPANTS: Adult patients (18 yr old) admitted to an ICU in Ontario, Canada, without a diagnosis of COVID-19 during the pandemic and nonpandemic periods. MAIN OUTCOMES AND MEASURES: The primary outcome was all-cause in-hospital mortality. Secondary outcomes included hospital and ICU length of stay, discharge disposition, and receipt of resource intensive procedures (e.g., extracorporeal membrane oxygenation, mechanical ventilation, renal replacement therapy, bronchoscopy, feeding tube insertion, and cardiac device insertion). We identified 32,486 patients in the pandemic cohort and 41,128 in the nonpandemic cohort. Age, sex, and markers of disease severity were similar. Fewer patients in the pandemic cohort were from long-term care facilities and had fewer cardiovascular comorbidities. There was an increase in all-cause in-hospital mortality among the pandemic cohort (13.5% vs 12.5%; p < 0.001) representing a relative increase of 7.9% (adjusted odds ratio, 1.10; 95% CI, 1.05-1.56). Patients in the pandemic cohort admitted with chronic obstructive pulmonary disease exacerbation had an increase in all-cause mortality (17.0% vs 13.2%; p = 0.013), a relative increase of 29%. Mortality among recent immigrants was higher in the pandemic cohort compared with the nonpandemic cohort (13.0% vs 11.4%; p = 0.038), a relative increase of 14%. Length of stay and receipt of intensive procedures were similar. CONCLUSIONS AND RELEVANCE: We found a modest increase in mortality among non-COVID ICU patients during the pandemic compared with a nonpandemic cohort. Future pandemic responses should consider the impact of the pandemic on all patients to preserve quality of care.

Agreement and validity of electronic patient self-triage (eTriage) with nurse triage in two UK emergency departments: a retrospective study.

BACKGROUND: Triage and redirection of patients to alternative care providers is one tool used to overcome the growing issue of crowding in emergency departments (EDs). Electronic patient self-triage (eTriage) may reduce waiting times and required face-to-face contact. There are limited studies into its efficacy, accuracy and validity in an ED setting. OBJECTIVES: The aim of this study was to assess the agreement and validity of eTriage with a reference standard of nurse face-to-face triage. A secondary aim was to assess the ability of both systems to predict high and low acuity outcomes. DESIGN: This was a retrospective study conducted over 8 months in two UK hospitals. Inclusion criteria were all ambulatory patients aged ≥18. All patients completed an eTriage and nurse-led triage using the Manchester Triage System (MTS). MAIN RESULTS: During the study period, 43 788 adult patients attended one of the two ED sites and 26 757 used eTriage. A total of 1424 patient episodes had no recorded MTS and were excluded from the study leaving 25 333 paired triages for the final cohort. Agreement between eTriage and nurse triage was low with a weighted Kappa coefficient of 0.14 (95% CI, 0.14-0.15) with an associated weak positive correlation (rs 0.321). Level of undertriage by eTriage compared with nurse triage was 10.1%, and overtriage was 59.2%. The sensitivity for prediction of high acuity outcomes was 88.5% (95% CI, 77.9-95.3%) for eTriage and 53.8% (95% CI 41.1-66.0%) for nurse MTS. The specificity for predicting low risk patients was 88.5% (95% CI, 87.4-89.5%) for eTriage and 80.6% (95% CI, 79.3-81.8%) for nurse MTS. CONCLUSION: Agreement and correlation of eTriage with the reference standard of nurse MTS was low; patients using eTriage tended to over triage when compared to the triage nurse. eTriage had a higher sensitivity for high acuity presentations and demonstrated similar specificity for low acuity presentations when compared to triage nurse MTS. Further work is necessary to validate eTriage as a potential tool for safe redirection of ED attenders to alternative care providers.

The effects of enhanced milieu teaching and a voice output communication aid on the requesting of three children with autism.

The purpose of this study was to evaluate the effects of enhanced milieu teaching when combined with a voice output communication aid on the requesting skills of three children with autism. The research design was a multiple probe across participants. All sessions were conducted during 5-min play sessions in the child's classroom. All three children learned to use the voice output communication aid to request items during play. Additionally, all three children increased their total requesting during play.

On the Importance of Gravity in DNAPL Invasion of Saturated Horizontal Fractures.

Invasion percolation (IP) models of dense non-aqueous phase liquid (DNAPL) invasion into saturated horizontal fractures typically neglect viscous and gravity forces, as it is assumed that capillarity dominates in many situations. An IP model simulating DNAPL invasion into saturated horizontal fractures was modified to include gravity as a local effect. The model was optimized using a genetic algorithm, and demonstrated that the inclusion of gravity is important for replicating the architecture of the DNAPL invasion pattern. The optimized gravity-included simulation showed the DNAPL invasion pattern to be significantly more representative of the experimentally observed pattern (80% accuracy) than did the optimized gravity-neglected simulation (70% accuracy). Additional simulations of DNAPL invasion in 360 randomly generated fractures were compared with and without gravity forces. These simulations showed that with increasing fracture roughness, the minimum difference between simulations with and without gravity increases to 35% for a standard deviation of the mid-aperture elevation field (SDz ) of 10 mm. Even for low roughness (SDz = 0.1 mm), the difference was as high as 30%. Furthermore, a scaled Bond Number is defined which includes data regarding DNAPL type, media type and statistical characteristics of the fracture. The value of this scaled Bond Number can be used to determine the conditions under which gravity should be considered when simulating DNAPL invasion in a macroscopically horizontal fracture. Finally, a set of equations defining the minimum and maximum absolute percentage difference between gravity-included and gravity-neglected simulations is presented based on the fracture and DNAPL characteristics.

A phenomenological model for particle retention in single, saturated fractures.

Fractured aquifers are some of the most poorly characterized subsurface environments despite posing one of the highest risks to the protection of potable groundwater. This research was designed to improve the understanding of the factors affecting particle transport through fractures by developing a phenomenological model based on laboratory-scale transport data. The model presented in this research employed data from over 70 particle tracer tests conducted in single, saturated, variable-aperture fractures that were obtained from the natural environment and fractured in the laboratory or cast from epoxy in the laboratory. The particles employed were Escherichia coli RS2-GFP and microspheres. The tracer experiments were conducted in natural (dolomitic limestone and granite) as well as epoxy replicas of the natural fractures. The multiple linear regression analysis revealed that the most important factors influencing particle retention in fractures are the ratio of the ionic strength of solution to collector charge, the ratio of particle to collector charge, and the ratio of advective to diffusive forces as described by the Peclet number. The model was able to reasonably (R(2) = 0.64) predict the fraction of particles retained; however, it is evident that some factors not accounted for in the model also contributed to retention. This research presents a novel approach to understanding particle transport in fractures, and illustrates the relative importance of various factors affecting the transport mechanisms. The utility of this model lies in the increased understanding of particle transport in fractures, which is extremely useful for directing future research.

Mass flux from a non-aqueous phase liquid pool considering spontaneous expansion of a discontinuous gas phase.

The partitioning of non-aqueous phase liquid (NAPL) compounds to a discontinuous gas phase results in the repeated spontaneous expansion, snap-off, and vertical mobilization of the gas phase. This mechanism has the potential to significantly affect the mass transfer processes that control the dissolution of NAPL pools by increasing the vertical transport of NAPL mass and increasing the total mass transfer rate from the surface of the pool. The extent to which this mechanism affects mass transfer from a NAPL pool depends on the rate of expansion and the mass of NAPL compound in the gas phase. This study used well-controlled bench-scale experiments under no-flow conditions to quantify for the first time the expansion of a discontinuous gas phase in the presence of NAPL. Air bubbles placed in glass vials containing NAPL increased significantly in volume, from a radius of 1.0 mm to 2.0 mm over 215 days in the presence of tetrachloroethene (PCE), and from a radius of 1.2 mm to 2.3 mm over 22 days in the presence of trans-1,2-dichloroethene (tDCE). A one-dimensional mass transfer model, fit to the experimental data, showed that this expansion could result in a mass flux from the NAPL pool that was similar in magnitude to the mass flux expected for the dissolution of a NAPL pool in a two-fluid (NAPL and water) system. Conditions favouring the significant effect of a discontinuous gas phase on mass transfer were identified as groundwater velocities less than approximately 0.01 m/day, and a gas phase that covers greater than approximately 10% of the pool surface area and is located within approximately 0.01 m of the pool surface. Under these conditions the mass transfer via a discontinuous gas phase is expected to affect, for example, efforts to locate NAPL source zones using aqueous concentration data, and predict the lifetime and risk associated with NAPL source zones in a way that is not currently included in the common conceptual models used to assess NAPL-contaminated sites.

Dissolution of entrapped DNAPLs in variable aperture fractures: experimental data and empirical model.

An appreciation of the dissolution from entrapped nonaqueous phase liquids (NAPLs) in fractures is essential as we attempt to understand and predict the fate of NAPLs present in fractured rock systems. Eight long-term dissolution experiments using 1,1,1-trichloroethane and trichloroethylene were conducted in two laboratory-scale dolomitic limestone variable aperture fractures under various conditions. Between 560 and 2600 fracture volumes of water were passed through the fractures resulting in the removal of 10-60% of the initial mass trapped. The effluent concentration profiles revealed three distinct and characteristic stages of dissolution: an initial pseudosteady stage, a transient stage, and a tailing stage. On average, 8% of the initial volume of NAPL present was removed during the initial pseudosteady stage. Data from the dissolution experiments were used in conjunction with statistical techniques to develop a continuous empirical model describing the initial pseudosteady and transient stages of dissolution. The model was used to successfully replicate effluent concentration data from two separate and independent dissolution experiments. The experimental results provide an indication of the expected dissolution behavior of entrapped NAPLs, while the developed model is a useful tool for characterizing mass transfer rates in variable aperture fractures.

Hemochorial placentation in the primate: expression of vascular endothelial growth factor, angiopoietins, and their receptors throughout pregnancy.

Vascular development and its transformation are necessary for successful hemochorial placentation, and vascular endothelial growth factor (VEGF), angiopoietins, and their receptors may be involved in the molecular regulation of this process. To determine the potential role of these putative regulators in a widely studied primate, the common marmoset, we investigated their mRNA expression and protein location in the placenta throughout pregnancy using in situ hybridization, Northern blot analysis, and immunocytochemistry. VEGF was localized in decidual and cytotrophoblast cells, and its highest expression was found in the maternal decidua. The Flt receptor was exclusively detected in the syncytial trophoblast with increasing expression in placentae from 10 wk to term. Soluble Flt (sFlt) was also detectable by Northern blot analysis. KDR receptor expression was restricted to mesenchymal cells during early placentation and to the fetoplacental vasculature during later placentation. KDR expression increased throughout pregnancy. Angiopoietin-1 (Ang-1) was localized in the syncytial trophoblast, being highly expressed in the second half of gestation. Ang-2 mRNA localized exclusively to maternal endothelial cells, and was highly expressed in 10-wk placentae. The Tie-2 receptor was found in cytotrophoblast cells and in fetal and maternal vessels. High Tie-2 levels were detected in the wall of chorion vessels at 14-wk, 17-wk, and term placentae. These results suggest that the processes of trophoblast invasion, maternal vascular transformation, and fetoplacental vascular differentiation and development are regulated by the specific actions of angiogenic ligand-receptor pairs. Specifically, 1) VEGF/Flt and Ang-1/Tie-2 may promote trophoblast growth, 2) VEGF/KDR and Ang-1/Tie-2 may support fetoplacental vascular development and stabilization, 3) sFlt may balance VEGF actions, and 4) Ang-2/Tie-2 may remodel the maternal vasculature.