For purposes of liability assessment, Canadian criminal law proceeds on a simplistic conceptualization of addiction. It presumes that the continued use of drugs or alcohol on the part of an addict is ...willed and deliberate, without regard to the potential impact of neurobiological vulnerabilities or concomitant mental disorders that impair volition and self-control. Not surprisingly, as a result, there is no accommodation within the law of criminal responsibility for the clinical realities of accused persons with these conditions. Significantly, in its 2011 decision in R v Bouchard-Lebrun, the Supreme Court of Canada signalled a willingness to vary this approach. It suggested that, if there were a risk of future dangerousness on the part of the accused by reason of addiction, resort might be had to the defence of not-criminally-responsible-by-reason-of-mental-disorder (“NCRMD”), and the accused might then be diverted from the correctional system to the forensic psychiatric system. It is perhaps obvious that a treatment-oriented response in a health care setting would benefit individuals seeking to overcome addiction. Moreover, to the extent that substance use and criminality are linked, public safety surely would be enhanced through the supervision of recovering addicts under the terms of Part XX.1 of the Criminal Code. Care must nonetheless be taken. It would be a matter of serious concern if the defence of NCRMD came to be used – unwittingly perhaps – as an alternative pathway for the preventive detention of addict populations.
Abstract The present study compared two putative pharmacotherapies for alcohol abuse and dependence, dehydroepiandrosterone (DHEA) and pregnanolone, with two Food and Drug Administration ...(FDA)-approved pharmacotherapies, naltrexone and acamprosate. Experiment 1 assessed the effects of different doses of DHEA, pregnanolone, naltrexone, and acamprosate on both ethanol- and food-maintained responding under a multiple fixed-ratio (FR)-10 FR-20 schedule, respectively. Experiment 2 assessed the effects of different mean intervals of food presentation on responding for ethanol under a FR-10 variable-interval (VI) schedule, whereas Experiment 3 assessed the effects of a single dose of each drug under a FR-10 VI-80 schedule. In Experiment 1, all four drugs dose-dependently decreased response rate for both food and ethanol, although differences in the rate-decreasing effects were apparent among the drugs. DHEA and pregnanolone decreased ethanol-maintained responding more potently than food-maintained responding, whereas the reverse was true for naltrexone. Acamprosate decreased responding for both reinforcers with equal potency. In Experiment 2, different mean intervals of food presentation significantly affected the number of food reinforcers obtained per session; however, changes in the number of food reinforcements did not significantly affect responding for ethanol. Under the FR-10 VI-80 schedule in Experiment 3, only naltrexone significantly decreased both the dose of alcohol presented and blood ethanol concentration (BEC). Acamprosate and pregnanolone had no significant effects on any of the dependent measures, whereas DHEA significantly decreased BEC, but did not significantly decrease response rate or the dose presented. In summary, DHEA and pregnanolone decreased ethanol-maintained responding more potently than food-maintained responding under a multiple FR-10 FR-20 schedule, and were more selective for decreasing ethanol self-administration than either naltrexone or acamprosate under that schedule. Experiment 2 showed that ethanol intake was relatively independent of the interval of reinforcement in the food-maintained component, and Experiment 3 showed that naltrexone was the most effective drug at the doses tested when the interval for food reinforcement was low and maintained under a variable-interval schedule.
Many victim service organizations are seeking to realign service delivery around principles of racial equity. Dismantling institutional racism is a complex, intensive, and long-term process. ...Therefore, despite this imperative from the field, our knowledge about how social service organizations can effectively advance anti-oppressive practice is limited. This study examined victim advocate perspectives on the role institutional racism played within their work and the supports needed to undo institutional racism within their organization. Six focus groups were conducted with a meaningful cross section of staff members (n = 53) across the organization. Semi-structured interview guides included questions in four domains: (1) racism within client work, (2) challenges to addressing racism, (3) effective solutions, and (4) helpful organizational supports. Transcripts were thematically analyzed using modified constructivist grounded theory methods. Two overarching themes, Identifying Institutional Racism in the Workplace and Advancing Anti-racist Practice, and six subthemes emerged from the analysis. Advocates identified that naming and becoming comfortable talking about race was essential. Further, they believed it was important to acknowledge the ways in which that racism was implicitly built into helping systems at large. Advocates explored how internalized racial stereotypes influenced interactions between black, indigenous, and people of color (BIPOC) and white advocates and their clients in complex ways. Advocates highlighted organizational efforts that supported ongoing personal reflection, the creation of an accountable community, and staff empowerment within the organization as being critical to advancing anti-racist practice. Some advocates also wanted to see the organization move further in the direction of standing with BIPOC communities, particularly around criminal justice concerns. Findings provide important timely insights into how institutional racism manifests within victim service organizations and what organizational actions encourage anti-oppressive practices and culture.
The uncanny characteristic of cancer has made the disease more complicated over the years, demanding the medical field to seek innovative treatment strategies continuously. The Chimeric Antigen ...Receptor bearing T-cell (CAR T) has emerged as the new paradigm of cancer immunotherapy to tackle cancer's resistance mechanisms in some hematologic malignancies that have relapsed or are unresponsive to treatments. The infusion of CAR T initially began in the inpatient settings and is now evolving into the outpatient units, after gaining remarkable outcomes. The purpose of this project was to develop an educational program for ambulatory nurses to ensure the success of providing this treatment in the outpatient center. A literature review was conducted, and studies show that an infrastructure must be in place because of the complex care requirements and significant neurotoxicities and side effects of CAR T treatments. In January 2019, the ATC leadership team built a robust outpatient educational program to deliver apRejina proved standard and phase i GAR T treatments and embedded them into existing workflow processes in a unit that also provides care for stem cell patients. Solidifying the nursing education was crucial for this project, and competencies included completing GAR T modules, hands-on training and check-off on the inpatient lymphoma/myeloma unit, and in-service by research investigators. Thorough assessment, early detection of the toxicities, and documentation in the electronic medical record (EMR) using the standardized assessment tools are integral to prompt and safe care for these patients. Concurrent with the training, an extensive collaboration with the medical teams, apheresis department, research investigators cell lab, research lab, pharmacy, and scheduling team was completed. Twenty-one nurses achieved CAR T competency, and in March of 2019, the ATG began to provide care for CAR T patients by administering lymphodepleting chemotherapy and doing post GAR T assessments. The CAR T infusions began in December 2019 and has successfully infused seventy GAR T cells. Fifty eight of those were phase 1, three were T-cell for COVID-19 patients, and nine were standard GAR T up to date. Although CAR T therapies may be complex and have varying information and monitoring parameters, these advances are changing the current and future cancer care environment, leading to significant improvements in patient care and outcomes.
Adverse drug events (ADEs) during hospitalization are common. Insulin-related events, specifically, are frequent and preventable. At a tertiary children's hospital, we sought to reduce ...insulin-related ADEs by decreasing the median event rate of hyper- and hypoglycemia over a 12-month period.
Using Lean 6 σ methodology, we instituted a house-wide process change from a single-order ordering process to a pro re nata (PRN) standing order process. The standardized process included parameters for administration and intervention, enabling physician and nursing providers to practice at top of licensure. Automated technology during dose calculation promoted patient safety during dual verification processes. Control charts tracked rates of insulin-related ADEs, defined as hyperglycemia (glucose level >250 mg/dL) or hypoglycemia (glucose level <65 mg/dL). Events were standardized according to use rates of insulin on each nursing unit. The rates of appropriately timed insulin doses (within 30 minutes of a blood sugar check) were assessed.
Baseline median house-wide frequencies of hyperglycemic and hypoglycemic episodes were 55 and 6.9 events (per 100 rapid-acting insulin days), respectively. The median time to insulin administration was 32 minutes. The implementation of the PRN process reduced the median frequencies of hyperglycemic and hypoglycemic episodes to 45 and 3.8 events, respectively. The median time to insulin administration decreased to 18 minutes.
A PRN ordering process and education decreased insulin-associated ADEs and the time to insulin dosing compared with single-entry processes. Engaging bedside providers was instrumental in reducing insulin-related ADEs. Strategies that decrease the time from patient assessment to drug administration should be studied for other high-risk drugs.
Pediatric data on inpatient home insulin pumps are absent in the literature. Understanding safety of home insulin pumps, managed by patients or caregivers, during times of illness will help diabetes ...technology securely move into pediatric hospitals.
To examine whether insulin can be safely and accurately delivered to hospitalized children through home insulin pumps when managed by patients or caregivers.
This single-center, retrospective, observational cohort study included children with insulin-dependent diabetes admitted to a tertiary children's hospital from January 1, 2016, to December 31, 2021. In all these patients, diabetes was the primary or secondary diagnosis on admission.
Insulin delivery via home insulin pump, hospital insulin pump, or subcutaneous injection.
Hyperglycemia (glucose, >250 mg/dL) and hypoglycemia (glucose, <45 mg/dL) rates (quantified as the proportion of total insulin-days), glucose variability, and diabetic ketoacidosis (DKA) recurrences were compared for hospital pumps (manual mode), home pumps (manual mode), and subcutaneous injections using bivariate tests.
There were 18 096 insulin-days among 2738 patients aged 0.5 to 25 years (median age, 15.8 years IQR, 12.3-18.3 years). Overall, 990 (5.5%) of insulin-days involved hospital insulin pumps, and 775 (4.3%) involved home pumps. A total of 155 insulin-days (15.7%) involving hospital pumps were hyperglycemic, compared with 209 (27.0%) involving home pumps and 7374 (45.2%) involving injections (P < .001). Moderate hypoglycemia days comprised 31 insulin-days (3.1%) involving hospital pumps compared with 35 (4.5%) involving home pumps and 830 (5.1%) involving injections (P = .02). Severe hypoglycemia did not differ significantly according to insulin delivery method. Two patients using injections (0.01%) developed DKA; no patients using hospital or home pumps developed DKA.
In this cohort study, home insulin pump use was found to be safe in a children's hospital regarding hyperglycemia and hypoglycemia. These data support use of home insulin pumps during pediatric admissions in patients who do not require intensive care and without active DKA.
AIM: To compare the outcomes of a cohort of Crohn’s disease (CD) patients undergoing early surgery (ES) to those undergoing initial medical therapy (IMT).METHODS: We performed a review of a ...prospective database CD patients managed at a single tertiary institution. Inclusion criteria were all patients with ileal or ileocolonic CD between 1995-2014. Patients with incomplete data, isolated colonic or perianal CD were excluded. Primary endpoints included the need for,and time to subsequent surgery. Secondary endpoints included the number and duration of hospital admissions,and medical therapy.RESULTS: Forty-two patients underwent ES and 115 underwent IMT. The operative intervention rate at 5 years in the ES group was 14.2% vs IMT 31.3% (HR = 0.41, 95%CI: 0.23-0.72, p = 0.041). The ES group had fewer hospital admissions per patient median 1 vs 3 (p = 0.012) and fewer patients required anti-TNF therapy than IMT (33.3% vs 57%, p = 0.003). A subgroup analysis of 62 IMT patients who had undergone surgery were compared to ES patients, and showed similar 5 year (from index surgery) re-operation rates 16.1% vs 14.3%. In this subset, a significant difference was still found in median number of hospital admissions favouring ES, 1 vs 2 (p = 0.002).CONCLUSION: Our data supports other recent studies suggesting that patients with ileocolonic CD may have a more benign disease course if undergoing early surgical intervention, with fewer admissions to hospital and a trend to reduced overall operation rates.
Compassion fatigue (CF) is defined as a sudden onset of the inability to experience feelings or compassion for others that is triggered by a nurse’s inability to separate his/her feelings of stress ...and anxiety associated with caring for patients who have suffered from a traumatic event. The practice problem addressed in this doctoral project was the lack of knowledge of emergency department nurses (EDNs) related to CF in the work setting, resulting in a negative impact on a nurse’s ability to provide quality care to patients. The purpose of the project was to present an educational program on how to recognize, prevent, and manage CF. Framed within Stamm’s theoretical model of compassion satisfaction and CF, the project was guided by the steps within the Walden University Manual for Staff Education Project and the practice question addressed whether the literature would support an evidence-based educational program on CF for EDNs. The evaluation/validation for the project included an evaluation of the curriculum by the three content experts (in which learning objectives were deemed met), content validation of the pre-/post-test items by the content experts (all test items were deemed relevant to the learning objectives, with the validity index scale analysis at 1.00), and finally, a paired t test to determine knowledge gained from pre- to post-test that resulted in a significant (p < 0.0001) improvement in knowledge. A potential positive social change resulting from the project is a healthy work environment where EDNs understand and reduce their risks for CF, which may ultimately promote optimal patient care and improved health outcomes.
Human papilloma virus (HPV) is a common virus that can cause genital warts and certain cancers. The HPV vaccine is effective in preventing many HPV-associated diseases, however, vaccination rates ...suggest many remain unprotected. This study examined successful strategies used by physicians to improve HPV vaccination rates. Providers with above average vaccination rates were identified. A representative from each provider participated in an interview to identify strategies used to boost HPV vaccination. Key strategies in ensuring vaccine completion were reminders, education, standing orders, and scheduling future vaccine appointments at time of first dose. Other successful strategies included coupling the HPV vaccine with adolescent vaccines, administering during well-visits, and recommending the vaccine as protection against cancer and genital warts. Findings suggest successful and widely used methods among high performing providers in Louisiana, the majority of which should be easily reproducible with minimal resources to improve HPV vaccination rates.
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