Pre-Mortem Interventions for the Purpose of Organ Donation: Legal Approaches to Consent.

The administration of Pre-Mortem Interventions (PMIs) to preserve the opportunity to donate, to assess the eligibility to donate, or to optimize the outcomes of donation and transplantation are controversial as they offer no direct medical benefit and include at least the possibility of harm to the still-living patient. In this article, we describe the legal analysis surrounding consent to PMIs, drawing on existing legal commentary and identifying key legal problems. We provide an overview of the approaches in several jurisdictions that have chosen to explicitly address PMIs within codified law. We then provide, as an example, a detailed exploration of how PMIs are likely to be addressed in one jurisdiction where general medical consent law applies because there is no specific legislation addressing PMIs - the province of Ontario in Canada.

No consent for brain death testing.

The overwhelming weight of legal authority in the USA and Canada holds that consent is not required for brain death testing. The situation in England and Wales is similar but different. While clinicians in England and Wales may have a prima facie duty to obtain consent, lack of consent has not barred testing. In three recent cases where consent for brain death testing was formally presented to the court, lack of consent was not determinative, and in one case the court questioned whether the clinicians were even required to seek consent from the parents of a child at all.

Seasonal differences in the timing of flight between the invasive winter moth and native Bruce spanworm promotes reproductive isolation.

The European winter moth, Operophtera brumata L. (Lepidoptera: Geometridae), was accidentally introduced to North America on at least 4 separate occasions, where it has been hybridizing with the native Bruce spanworm, O. bruceata Hulst, at rates up to 10% per year. Both species are known to respond to the same sex pheromones and to produce viable offspring, but whether they differ in the seasonal timing of their mating flights is unknown. Therefore, we collected adult male moths weekly along 2 transects in the northeastern United States and genotyped individuals using polymorphic microsatellite markers as males of these 2 species cannot be differentiated morphologically. Along each transect, we then estimated the cumulative proportions (i.e., the number of individuals out of the total collected) of each species on each calendar day. Our results indicate that there are significant differences between the species regarding their seasonal timing of flight, and these allochronic differences likely are acting to promote reproductive isolation between these 2 species. Lastly, our results suggest that the later flight observed by winter moth compared to Bruce spanworm may be limiting its inland spread in the northeastern United States because of increased exposure to extreme winter events.

Establishment and postrelease recovery of Laricobius nigrinus and Laricobius osakensis (Coleoptera: Derodontidae), released for biological control of Adelges tsugae (Hemiptera: Adelgidae), in the Northeastern United States.

Hemlock woolly adelgid (HWA), Adelges tsugae Annand, is a major forest pest in the eastern United States responsible for killing millions of eastern hemlock, Tsuga canadensis (L.) Carrière and Carolina hemlock, T. caroliniana Engelmann. The US biological control program for HWA has largely invested in the rearing and release of Laricobius nigrinus Fender and more recently L. osakensis Montgomery and Shiyake. Though the establishment of L. nigrinus has been well-documented in the southern, mid-Atlantic, and coastal portions of the northeastern United States, documentation in interior areas of the northeastern United States is limited. Establishment of L. osakensis in the northeastern United States has not yet been documented. Release locations in the northeastern United States were surveyed for L. nigrinus and L. osakensis establishment to examine the relationship between establishment success and winter temperatures, as winter minimum temperatures likely limit the northern range of introduced Laricobius species. Our results suggest that L. nigrinus establishment is limited by winter minimum temperatures and that the probability of establishment declines as absolute minimum temperature declines. We found L. nigrinus established at sites in Maine, New York, and Pennsylvania, but did not recover any L. nigrinus in Massachusetts, New Hampshire, or Vermont. Similarly, we found L. osakensis established at sites in New York and Pennsylvania and recovered individuals in Maine, though further sampling is necessary to confirm presence of the F3 generation. We also report the first field observation of reproduction of silver flies, Leucotaraxis argenticollis (Diptera: Chamaemyiidae), released predator of HWA, in the eastern United States.

Successful establishment, spread, and impact of the introduced parasitoid Spathius galinae (Hymenoptera: Braconidae) on emerald ash borer (Coleoptera: Buprestidae) populations in postinvasion forests in Michigan.

Spathius galinae is a larval parasitoid native to the Russian Far East that was approved for release in the United States in 2015 for biological control of the emerald ash borer (EAB), Agrilus planipennis, an invasive beetle from Asia responsible for widespread mortality of ash trees (Fraxinus spp.) in North America. From 2015 to 2017, 1,340-1,445 females of S. galinae along with males were released into each release plot, paired with a nonrelease control plot (1-12.5 km apart), at 6 postinvasion forested sites containing abundant pole-sized ash trees in Michigan. By 2018, S. galinae had spread to all but one control plot. Based on the first year that S. galinae was found in trees in each control plot and the distances of those trees to the parasitoid release point within each site, we estimated that S. galinae spread at 3.7 (±1.9) km per year after its initial releases in 2015. The proportion of sampled trees with S. galinae broods, brood densities within sampled trees, and parasitism of EAB larvae increased sharply in both control and release plots after the last field releases in 2017, with the highest parasitism rates (42.8-60.3%) in 2020. Life table analysis showed that S. galinae alone reduced EAB's net population growth rate by 35-55% across sites from 2018 to 2020. These results demonstrate that S. galinae has established an increasing population in Michigan and now plays a significant role in reducing EAB populations in the area.

A brain-based definition of death and criteria for its determination after arrest of circulation or neurologic function in Canada: a 2023 clinical practice guideline.

This 2023 Clinical Practice Guideline provides the biomedical definition of death based on permanent cessation of brain function that applies to all persons, as well as recommendations for death determination by circulatory criteria for potential organ donors and death determination by neurologic criteria for all mechanically ventilated patients regardless of organ donation potential. This Guideline is endorsed by the Canadian Critical Care Society, the Canadian Medical Association, the Canadian Association of Critical Care Nurses, Canadian Anesthesiologists' Society, the Canadian Neurological Sciences Federation (representing the Canadian Neurological Society, Canadian Neurosurgical Society, Canadian Society of Clinical Neurophysiologists, Canadian Association of Child Neurology, Canadian Society of Neuroradiology, and Canadian Stroke Consortium), Canadian Blood Services, the Canadian Donation and Transplantation Research Program, the Canadian Association of Emergency Physicians, the Nurse Practitioners Association of Canada, and the Canadian Cardiovascular Critical Care Society.

RéSUMé: Ces Lignes directrices de pratique clinique 2023 Lignes directrices de pratique clinique dicale du décès basée sur l'arrêt permanent de la fonction cérébrale qui s'applique à toute personne, ainsi que des recommandations pour la détermination du décès par des critères circulatoires pour des donneurs d'organes potentiels et des recommandations pour la détermination du décès par des critères neurologiques pour tous les patients sous ventilation mécanique, indépendamment de leur potentiel de donneur d'organes. Les présentes Lignes directrices sont approuvées par la Société canadienne de soins intensifs, l'Association médicale canadienne, l'Association canadienne des infirmiers/infirmières en soins intensifs, la Société canadienne des anesthésiologistes, la Fédération des sciences neurologiques du Canada (représentant la Société canadienne de neurologie, la Société canadienne de neurochirurgie, la Société canadienne de neurophysiologie clinique, l'Association canadienne de neurologie pédiatrique, la Société canadienne de neuroradiologie et le Consortium neurovasculaire canadien), la Société canadienne du sang, le Programme de recherche en don et transplantation du Canada, l'Association canadienne des médecins d'urgence, l'Association des infirmières et infirmiers praticiens du Canada, et la Société canadienne de soins intensifs cardiovasculaires (CANCARE) et la Société canadienne de pédiatrie.

Rationale for revisions to the definition of death and criteria for its determination in Canada.

Clarity regarding the biomedical definition of death and the criteria for its determination is critical to inform practices in clinical care, medical research, law, and organ donation. While best practices for death determination by neurologic criteria and circulatory criteria were previously outlined in Canadian medical guidelines, several issues have arisen to force their reappraisal. Ongoing scientific discovery, corresponding changes in medical practice, and legal and ethical challenges compel a comprehensive update. Accordingly, the A Brain-Based Definition of Death and Criteria for its Determination After Arrest of Neurologic or Circulatory Function in Canada project was undertaken to a develop a unified brain-based definition of death, and to establish criteria for its determination after devastating brain injury and/or circulatory arrest. Specifically, the project had three objectives: (1) to clarify that death is defined in terms of brain functions; (2) to clarify how a brain-based definition of death is articulated; and (3) to clarify the criteria for determining if the brain-based definition is met. The updated death determination guideline therefore defines death as the permanent cessation of brain function and describes corresponding circulatory and neurologic criteria to ascertain the permanent cessation of brain function. This article explores the challenges that prompted revisions to the biomedical definition of death and the criteria for its determination and outlines the rationales underpinning the project's three objectives. By clarifying that all death is defined in terms of brain function, the project seeks to align guidelines with contemporary medicolegal understandings of the biological basis of death.

RéSUMé: Il est essentiel que la définition biomédicale du décès et les critères de sa détermination soient précis afin d'éclairer les pratiques en matière de soins cliniques, de recherche médicale, de droit et de don d'organes. Alors que les meilleures pratiques pour la détermination du décès par des critères neurologiques et circulatoires ont déjà été décrites dans les lignes directrices médicales canadiennes, plusieurs problèmes ont été soulevés, lesquels ont motivé leur réévaluation. Les découvertes scientifiques en cours, les changements correspondants dans la pratique médicale et les défis juridiques et éthiques imposent une mise à jour complète. Par conséquent, le projet d'Élaboration d'une définition uniformisée de la mort cérébrale et de critères fondés sur des données probantes pour sa détermination au Canada a été entrepris dans le but d'élaborer une définition uniformisée de la mort cérébrale et d'établir des critères pour sa détermination après une lésion cérébrale dévastatrice et/ou un arrêt circulatoire. Plus précisément, le projet avait trois objectifs : (1) clarifier que le décès est défini en termes de fonctions cérébrales; (2) clarifier la façon dont une définition cérébrale du décès est articulée; et (3) clarifier les critères permettant de déterminer si la définition de mort cérébrale est respectée. Les lignes directrices mises à jour sur la détermination du décès définissent donc le décès comme l'arrêt permanent de la fonction cérébrale et décrivent les critères circulatoires et neurologiques correspondants pour établir l'arrêt permanent de la fonction cérébrale. Cet article explore les défis qui ont motivé la révision de la définition biomédicale du décès et des critères de sa détermination et décrit les raisons d'être qui sous-tendent les trois objectifs du projet. En précisant que tout décès est défini en termes de fonction cérébrale, le projet cherche à aligner les lignes directrices sur les compréhensions médicolégales contemporaines des fondements biologiques de la mort.

Death determination by neurologic criteria-what do families understand?

PURPOSE: Currently, there is little empirical data on family understanding about brain death and death determination. The purpose of this study was to describe family members' (FMs') understanding of brain death and the process of determining death in the context of organ donation in Canadian intensive care units (ICUs). METHODS: We conducted a qualitative study using semistructured, in-depth interviews with FMs who were asked to make an organ donation decision on behalf of adult or pediatric patients with death determination by neurologic criteria (DNC) in Canadian ICUs. RESULTS: From interviews with 179 FMs, six main themes emerged: 1) state of mind, 2) communication, 3) DNC may be counterintuitive, 4) preparation for the DNC clinical assessment, 5) DNC clinical assessment, and 6) time of death. Recommendations on how clinicians can help FMs to understand and accept DNC through communication at key moments were described including preparing FMs for death determination, allowing FMs to be present, and explaining the legal time of death, combined with multimodal strategies. For many FMs, understanding of DNC unfolded over time, facilitated with repeated encounters and explanation, rather than during a single meeting. CONCLUSION: Family members' understanding of brain death and death determination represented a journey that they reported in sequential meeting with health care providers, most notably physicians. Modifiable factors to improve communication and bereavement outcomes during DNC include attention to the state of mind of the family, pacing and repeating discussions according to families' expressed understanding, and preparing and inviting families to be present for the clinical determination including apnea testing. We have provided family-generated recommendations that are pragmatic and can be easily implemented.

RéSUMé: OBJECTIF: À l'heure actuelle, il y a peu de données empiriques sur la compréhension des familles de la mort cérébrale et de la détermination du décès. Le but de cette étude était de décrire la compréhension des membres de la famille de la mort cérébrale et du processus de détermination du décès dans le contexte du don d'organes dans les unités de soins intensifs (USI) canadiennes. MéTHODE: Nous avons mené une étude qualitative à l'aide d'entrevues semi-structurées et approfondies avec des membres de la famille à qui on a demandé de prendre une décision de don d'organes au nom de patients adultes ou pédiatriques dont le décès avait été déterminé selon des critères neurologiques (DCN) dans les unités de soins intensifs canadiennes. RéSULTATS: Sur la base d'entrevues avec 179 membres de la famille, six thèmes principaux ont émergé : 1) l'état d'esprit, 2) la communication, 3) le DCN peut être contre-intuitif, 4) la préparation à l'évaluation clinique pour un DCN, 5) l'évaluation clinique pour un DCN et 6) le moment du décès. Des recommandations sur la façon dont les cliniciens peuvent aider les membres de la famille à comprendre et à accepter un DCN par la communication à des moments clés ont été décrites, y compris la préparation des membres de la famille à la détermination du décès, l'autorisation de la présence des membres de la famille et l'explication de l'heure légale du décès, combinées à des stratégies multimodales. Pour de nombreux membres de la famille, la compréhension du DCN s'est développée au fil du temps et a été facilitée par des rencontres et des explications répétées plutôt qu'au cours d'une seule rencontre. CONCLUSION: La compréhension qu'ont les membres de la famille de la mort cérébrale et de la détermination du décès représente un parcours qu'ils ont décrit lors de rencontres successives avec des acteurs de soins de santé, et particulièrement avec des médecins. Les facteurs modifiables pour améliorer la communication et les issues du deuil pendant un DCN comprennent l'attention portée à l'état d'esprit de la famille, le rythme et la répétition des discussions en fonction de la compréhension exprimée par les familles, ainsi que la préparation et l'invitation des familles à être présentes pour la détermination clinique, y compris pendant le test d'apnée. Nous avons fourni des recommandations familiales qui sont pragmatiques et peuvent être facilement mises en œuvre.

Consent for determination of death by neurologic criteria in Canada: an analysis of legal and ethical authorities, and consensus-based working group recommendations.

This article addresses the following question: should physicians obtain consent from the patient (through an advance directive) or their surrogate decision-maker to perform the assessments, evaluations, or tests necessary to determine whether death has occurred according to neurologic criteria? While legal bodies have not yet provided a definitive answer, significant legal and ethical authority holds that clinicians are not required to obtain family consent before making a death determination by neurologic criteria. There is a near consensus among available professional guidelines, statutes, and court decisions. Moreover, prevailing practice does not require consent to test for brain death. While arguments for requiring consent have some validity, proponents cannot surmount weightier considerations against imposing a consent requirement. Nevertheless, even though clinicians and hospitals may not be legally required to obtain consent, they should still notify families about their intent to determine death by neurologic criteria and offer temporary reasonable accommodations when feasible. This article was developed with the legal/ethics working group of the project, A Brain-Based Definition of Death and Criteria for its Determination After Arrest of Circulation or Neurologic Function in Canada developed in collaboration with the Canadian Critical Care Society, Canadian Blood Services, and the Canadian Medical Association. The article is meant to provide support and context for this project and is not intended to specifically advise physicians on legal risk, which in any event is likely jurisdiction dependent because of provincial or territorial variation in the laws. The article first reviews and analyzes ethical and legal authorities. It then offers consensus-based recommendations regarding consent for determination of death by neurologic criteria in Canada.

RéSUMé: Cet article répond à la question suivante : les médecins doivent-ils obtenir le consentement du patient (au moyen d'une directive médicale anticipée) ou de son mandataire spécial pour réaliser les examens, évaluations ou tests nécessaires pour déterminer si le décès est survenu selon des critères neurologiques? Bien que les organes juridiques n'aient pas encore fourni de réponse définitive, selon la jurisprudence et l'éthique, les cliniciens ne sont pas tenus d'obtenir le consentement de la famille avant de procéder à une détermination de décès selon des critères neurologiques. Il y a un quasi-consensus dans les lignes directrices professionnelles, les lois et les décisions judiciaires disponibles. De plus, la pratique courante n'exige pas le consentement pour procéder aux examens permettant de déterminer une mort cérébrale. Bien que les arguments en faveur de l'exigence d'un consentement aient une certaine validité, leurs défenseurs ne peuvent pas surmonter des considérations plus importantes contre l'imposition d'une exigence de consentement. Néanmoins, même si les cliniciens et les hôpitaux ne sont peut-être pas légalement tenus d'obtenir le consentement, ils devraient tout de même aviser les familles de leur intention de déterminer le décès selon des critères neurologiques et offrir des aménagements raisonnables temporaires lorsque cela est possible. Cet article a été mis au point en collaboration avec le groupe de travail sur les questions légales et éthiques du projet de Définition uniformisée de la mort cérébrale et de critères fondés sur des données probantes pour sa détermination au Canada et développé avec la Société canadienne de soins intensifs, la Société canadienne du sang et l'Association médicale canadienne. Cet article vise à étayer et fournir un contexte au projet et ne vise pas à conseiller spécifiquement les médecins sur le risque juridique qui, de toute façon, varie probablement en raison des différences légales provinciales et territoriales. L'article commence par passer en revue et analyser la jurisprudence et les considérations éthiques. Il propose ensuite des recommandations consensuelles concernant le consentement pour la détermination du décès selon des critères neurologiques au Canada.

Future directions in psychiatric neurosurgery: Proceedings of the 2022 American Society for Stereotactic and Functional Neurosurgery meeting on surgical neuromodulation for psychiatric disorders.

OBJECTIVE: Despite advances in the treatment of psychiatric diseases, currently available therapies do not provide sufficient and durable relief for as many as 30-40% of patients. Neuromodulation, including deep brain stimulation (DBS), has emerged as a potential therapy for persistent disabling disease, however it has not yet gained widespread adoption. In 2016, the American Society for Stereotactic and Functional Neurosurgery (ASSFN) convened a meeting with leaders in the field to discuss a roadmap for the path forward. A follow-up meeting in 2022 aimed to review the current state of the field and to identify critical barriers and milestones for progress. DESIGN: The ASSFN convened a meeting on June 3, 2022 in Atlanta, Georgia and included leaders from the fields of neurology, neurosurgery, and psychiatry along with colleagues from industry, government, ethics, and law. The goal was to review the current state of the field, assess for advances or setbacks in the interim six years, and suggest a future path forward. The participants focused on five areas of interest: interdisciplinary engagement, regulatory pathways and trial design, disease biomarkers, ethics of psychiatric surgery, and resource allocation/prioritization. The proceedings are summarized here. CONCLUSION: The field of surgical psychiatry has made significant progress since our last expert meeting. Although weakness and threats to the development of novel surgical therapies exist, the identified strengths and opportunities promise to move the field through methodically rigorous and biologically-based approaches. The experts agree that ethics, law, patient engagement, and multidisciplinary teams will be critical to any potential growth in this area.

Legal considerations for the definition of death in the 2023 Canadian Brain-Based Definition of Death Clinical Practice Guideline.

PURPOSE: The new 2023 Canadian Brain-Based Definition of Death Clinical Practice Guideline provides a new definition of death as well as clear procedures for the determination of death (i.e., when that definition is met). Since physicians must practice in accordance with existing laws, this legal analysis describes the existing legal definitions of death in Canada and considers whether the new Guideline is consistent with those definitions. It also considers how religious freedom and equality in the Canadian Charter of Rights and Freedoms might apply to the diagnosis of brain death. METHOD: We performed a legal analysis in accordance with standard procedures of legal research and analysis-including reviews of statutory law, case law, and secondary legal literature. The draft paper was discussed by the Legal-Ethical Working Subgroup and presented to the larger Guideline project team for comment. RESULTS AND CONCLUSION: There are some differences between the wording of the new Guideline and existing legal definitions. To reduce confusion, these should be addressed through revising the legal definitions. In addition, future challenges to brain death based on the Charter of Rights and Freedoms can be anticipated. Facilities should consider and adopt policies that identify what types of accommodation of religious objection and what limits to accommodation are reasonable and well-justified.

RéSUMé: OBJECTIF: Les nouvelles Lignes directrices canadiennes de pratique clinique pour la détermination du décès cérébral de 2023 fournissent une nouvelle définition du décès ainsi que des procédures claires pour la détermination du décès (c.-à-d. lorsque cette définition est respectée). Étant donné que les médecins doivent exercer conformément aux lois en vigueur, la présente analyse juridique décrit les définitions juridiques existantes du décès au Canada et vise à déterminer si les nouvelles Lignes directrices sont conformes à ces définitions. Cette analyse examine également comment la liberté de religion et l'égalité dans la Charte canadienne des droits et libertés pourraient s'appliquer au diagnostic de mort cérébrale. MéTHODE: Nous avons effectué une analyse juridique conformément aux procédures habituelles de recherche et d'analyse juridiques, y compris l'examen du droit écrit, de la jurisprudence et de la littérature juridique secondaire. L'ébauche du document a été examinée par le sous-groupe de travail juridico-éthique et présentée à l'équipe élargie du projet des Lignes directrices pour commentaires. RéSULTATS ET CONCLUSIONS: Il existe certaines différences entre le libellé des nouvelles Lignes directrices et les définitions juridiques existantes. Pour réduire la confusion, il convient de remédier à ces problèmes en révisant les définitions juridiques. De plus, les défis futurs à la mort cérébrale fondés sur la Charte des droits et libertés peuvent être anticipés. Les établissements devraient envisager et adopter des politiques qui précisent quels types d'accommodement d'objection religieuse et quelles limites d'accommodement sont raisonnables et bien justifiés.

Legislation and Policy Recommendations on Organ and Tissue Donation and Transplantation From an International Consensus Forum.

There is a shared global commitment to improving baseline donation and transplantation performance metrics in a manner consistent with ethics and local cultural and social factors. The law is one tool that can help improve these metrics. Although legal systems vary across jurisdictions, our objective was to create expert, consensus guidance for law and policymakers on foundational issues underlying organ and tissue donation and transplantation (OTDT) systems around the world. Methods: Using the nominal group technique, a group composed of legal academics, a transplant coordinator/clinician, and a patient partner identified topic areas and recommendations on foundational legal issues. The recommendations were informed by narrative literature reviews conducted by group members based on their areas of expertise, which yielded a range of academic articles, policy documents, and sources of law. Best practices were identified from relevant sources in each subtopic, which formed the basis of the recommendations contained herein. Results: We reached consensus on 12 recommendations grouped into 5 subtopics: (i) legal definitions and legislative scope, (ii) consent requirements for donation' (iii) allocation of organs and tissue' (iv) operation of OTDT systems' and (v) travel for transplant and organ trafficking. We have differentiated between those foundational legal principles for which there is a firm basis of support with those requiring further consideration and resolution. Seven such areas of controversy are identified and discussed alongside relevant recommendations. Conclusions: Our recommendations encompass some principles staunchly enshrined in the OTDT landscape (eg, the dead donor rule), whereas others reflect more recent developments in practice (eg, mandatory referral). Although some principles are widely accepted, there is not always consensus as to how they ought to be implemented. As the OTDT landscape continues to evolve, recommendations must be reconsidered for the law to keep pace with developments in knowledge, technology, and practice.

Neurologic Physiology after Removal of Therapy (NeuPaRT) study: study protocol of a multicentre, prospective, observational, pilot feasibility study of neurophysiology after withdrawal of life-sustaining measures.

INTRODUCTION: In donation after circulatory determination of death, death is declared 5 min after circulatory arrest. This practice assumes, but does not explicitly confirm, permanent loss of brain activity. While this assumption is rooted a strong physiological rationale, paucity of direct human data regarding temporal relationship between cessation of brain activity and circulatory arrest during the dying process threatens public and healthcare provider trust in deceased organ donation. METHODS AND ANALYSIS: In this cohort study, we will prospectively record cerebral and brainstem electrical activity, cerebral blood flow velocity and arterial blood pressure using electroencephalography (EEG), brainstem evoked potentials, transcranial doppler and bedside haemodynamic monitors in adult patients undergoing planned withdrawal of life sustaining measures in the intensive care units at five hospital sites for 18 months. We will use MATLAB to synchronise waveform data and compute the time of cessation of each signal relative to circulatory arrest. Our primary outcome is the feasibility of patient accrual, while secondary outcomes are (a) proportion of patients with complete waveform recordings and data transfer to coordinating site and (b) time difference between cessation of neurophysiological signals and circulatory arrest. We expect to accrue 1 patient/site/month for a total of 90 patients. ETHICS AND DISSEMINATION: We have ethics approval from Clinical Trials Ontario (protocol #3862, version 1.0, date 19 January 2022.) and the relevant Research Ethics Board for each site. We will obtain written informed consent from legal substitute decision makers. We will present study results at research conferences including donor family partner forum and in peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT05306327.

Effects of emamectin benzoate trunk injections on protection of neighboring ash trees against emerald ash borer (Coleoptera: Buprestidae) and on established biological control agents.

The emerald ash borer (EAB), Agrilus planipennis Fairmaire, is the most destructive invasive pest on ash (Fraxinus spp.) in the United States. We determined whether ash trees injected with emamectin benzoate (EB) could protect untreated neighboring ash trees. We also determined whether the selective treatment of ash trees with EB injections had adverse effects on the establishment of introduced larval parasitoids Tetrastichus planipennis Yang and Spathius galinae Belokobylskij & Strazenac. In experiment one, trees were treated with EB and then retreated 3 years later. Five years post initial treatment, we found that 90% of treated ash trees retained healthy crowns, significantly higher than those of untreated control ash trees (16%). For experiment two, trees only received one treatment of EB and after 2 years 100% of treated ash trees retained healthy crowns, significantly higher than those of untreated ash trees (50%). In both experiments, we found that distance from the central EB-treated tree was not a significant predictor for tree health or presence of EAB exit holes. Although distance from the EB-treated trees appeared to have a significant positive relationship with woodpecker feeding signs on neighboring trees, such relationships did not result in significant differences in the proportion of neighboring ash trees retaining healthy crowns between EB treatment and control plots. The introduced EAB parasitoids appeared to have established equally well between treatment and control plots. Findings are discussed in the context of integration of EB trunk injection with biological control for protection of North American ash against EAB.

First report of multiple Rickettsia sp., Anaplasma sp., and Ehrlichia sp. in the San Miguel Department of El Salvador from zoonotic tick vectors.

Neglected bacterial zoonoses are a group of Neglected Tropical Diseases (NTDs) that are commonly underdiagnosed and underreported due to their undifferentiated febrile illness symptomology. Spotted fever group rickettsioses (SFGR), a subset of tick-borne bacterial zoonoses, belong in this group. There is a dichotomy in the reporting and recognition of these pathogens in Central America: countries with reduced human development scores-like El Salvador-have little to no research or surveillance dedicated to these pathogens and the diseases they cause. This was the third-ever tick survey in El Salvador, highlighting the knowledge gap in this country. A total of 253 ticks were collected from 11 animals at two farm sites and one veterinary office. Standard and quantitative PCR were used to detect presence of SFGR, Ehrlichia, and Anaplasma sp. pathogens in ticks. Ehrlichia sp. were detected in 2.4% of all collected ticks and Anaplasma sp. were detected in 5.5% of all ticks. Rickettsia rickettsii was amplified in 18.2% of ticks, and amplicons similar to R. parkeri, and R. felis were found in 0.8% and 0.4%, of collected ticks, respectively. This is the first report of these pathogenic bacterial species in El Salvador. This study emphasizes the need for further surveillance and research including incorporating additional human seroprevalence and testing to understand the public health burden in this country.

Inequities in organ and tissue donation and transplantation for sexual orientation and gender identity diverse people: A scoping review.

Sexual orientation and gender identity (SOGI)-diverse populations experience discrimination in organ and tissue donation and transplantation (OTDT) systems globally. We assembled a multidisciplinary group of clinical experts as well as SOGI-diverse patient and public partners and conducted a scoping review including citations on the experiences of SOGI-diverse persons in OTDT systems globally to identify and explore the inequities that exist with regards to living and deceased OTDT. Using scoping review methods, we conducted a systematic literature search of relevant electronic databases from 1970 to 2021 including a grey literature search. We identified and screened 2402 references and included 87 unique publications. Two researchers independently coded data in included publications in duplicate. We conducted a best-fit framework synthesis paired with an inductive thematic analysis to identify synthesized benefits, harms, inequities, justification of inequities, recommendations to mitigate inequities, laws and regulations, as well as knowledge and implementation gaps regarding SOGI-diverse identities in OTDT systems. We identified numerous harms and inequities for SOGI-diverse populations in OTDT systems. There were no published benefits of SOGI-diverse identities in OTDT systems. We summarized recommendations for the promotion of equity for SOGI-diverse populations and identified gaps that can serve as targets for action moving forward.

Two Views of Vulnerability in the Evolution of Canada's Medical Assistance in Dying Law.

Canada is six years into a new era of legalized medical assistance in dying (MAiD). The law continues to evolve, following a pattern in which Canadian courts rule that legal restrictions on eligibility for MAiD are unconstitutional and Parliament responds by gradually expanding eligibility for MAiD. The central tension underlying this dialogue between courts and government has focused on two conceptions of how to best promote and protect the interests of people who are vulnerable by virtue of intolerable and irremediable suffering due to an illness, disease, or disability. Do we, as a society, have a duty to protect vulnerable people from seeking certain medical procedures that are contrary to their interests, as those are perceived by others? Or do we have a duty to uphold their rights to autonomy, including the right to make choices within a range that may be constrained by many factors, some of which may be socially unjust? This is a recurrent problem in bioethics and medical law, which we explore through the lens of how Canadian courts and Parliament have grappled with defining eligibility for MAiD.