A randomized trial of glutamine and antioxidants in critically ill patients.

BACKGROUND: Critically ill patients have considerable oxidative stress. Glutamine and antioxidant supplementation may offer therapeutic benefit, although current data are conflicting. METHODS: In this blinded 2-by-2 factorial trial, we randomly assigned 1223 critically ill adults in 40 intensive care units (ICUs) in Canada, the United States, and Europe who had multiorgan failure and were receiving mechanical ventilation to receive supplements of glutamine, antioxidants, both, or placebo. Supplements were started within 24 hours after admission to the ICU and were provided both intravenously and enterally. The primary outcome was 28-day mortality. Because of the interim-analysis plan, a P value of less than 0.044 at the final analysis was considered to indicate statistical significance. RESULTS: There was a trend toward increased mortality at 28 days among patients who received glutamine as compared with those who did not receive glutamine (32.4% vs. 27.2%; adjusted odds ratio, 1.28; 95% confidence interval [CI], 1.00 to 1.64; P=0.05). In-hospital mortality and mortality at 6 months were significantly higher among those who received glutamine than among those who did not. Glutamine had no effect on rates of organ failure or infectious complications. Antioxidants had no effect on 28-day mortality (30.8%, vs. 28.8% with no antioxidants; adjusted odds ratio, 1.09; 95% CI, 0.86 to 1.40; P=0.48) or any other secondary end point. There were no differences among the groups with respect to serious adverse events (P=0.83). CONCLUSIONS: Early provision of glutamine or antioxidants did not improve clinical outcomes, and glutamine was associated with an increase in mortality among critically ill patients with multiorgan failure. (Funded by the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00133978.).

Global surveillance of cancer survival 1995-2009 : analysis of individual data for 25 676 887 patients from 279 population-based registries in 67 countries (CONCORD-2)

BACKGROUND: Worldwide data for cancer survival are scarce. We aimed to initiate worldwide surveillance of cancer survival by central analysis of population-based registry data, as a metric of the effectiveness of health systems, and to inform global policy on cancer control. METHODS: Individual tumour records were submitted by 279 population-based cancer registries in 67 countries for 25·7 million adults (age 15-99 years) and 75 000 children (age 0-14 years) diagnosed with cancer during 1995-2009 and followed up to Dec 31, 2009, or later. We looked at cancers of the stomach, colon, rectum, liver, lung, breast (women), cervix, ovary, and prostate in adults, and adult and childhood leukaemia. Standardised quality control procedures were applied; errors were corrected by the registry concerned. We estimated 5-year net survival, adjusted for background mortality in every country or region by age (single year), sex, and calendar year, and by race or ethnic origin in some countries. Estimates were age-standardised with the International Cancer Survival Standard weights. FINDINGS: 5-year survival from colon, rectal, and breast cancers has increased steadily in most developed countries. For patients diagnosed during 2005-09, survival for colon and rectal cancer reached 60% or more in 22 countries around the world; for breast cancer, 5-year survival rose to 85% or higher in 17 countries worldwide. Liver and lung cancer remain lethal in all nations: for both cancers, 5-year survival is below 20% everywhere in Europe, in the range 15-19% in North America, and as low as 7-9% in Mongolia and Thailand. Striking rises in 5-year survival from prostate cancer have occurred in many countries: survival rose by 10-20% between 1995-99 and 2005-09 in 22 countries in South America, Asia, and Europe, but survival still varies widely around the world, from less than 60% in Bulgaria and Thailand to 95% or more in Brazil, Puerto Rico, and the USA. For cervical cancer, national estimates of 5-year survival range from less than 50% to more than 70%; regional variations are much wider, and improvements between 1995-99 and 2005-09 have generally been slight. For women diagnosed with ovarian cancer in 2005-09, 5-year survival was 40% or higher only in Ecuador, the USA, and 17 countries in Asia and Europe. 5-year survival for stomach cancer in 2005-09 was high (54-58%) in Japan and South Korea, compared with less than 40% in other countries. By contrast, 5-year survival from adult leukaemia in Japan and South Korea (18-23%) is lower than in most other countries. 5-year survival from childhood acute lymphoblastic leukaemia is less than 60% in several countries, but as high as 90% in Canada and four European countries, which suggests major deficiencies in the management of a largely curable disease. INTERPRETATION: International comparison of survival trends reveals very wide differences that are likely to be attributable to differences in access to early diagnosis and optimum treatment. Continuous worldwide surveillance of cancer survival should become an indispensable source of information for cancer patients and researchers and a stimulus for politicians to improve health policy and health-care systems. FUNDING: Canadian Partnership Against Cancer (Toronto, Canada), Cancer Focus Northern Ireland (Belfast, UK), Cancer Institute New South Wales (Sydney, Australia), Cancer Research UK (London, UK), Centers for Disease Control and Prevention (Atlanta, GA, USA), Swiss Re (London, UK), Swiss Cancer Research foundation (Bern, Switzerland), Swiss Cancer League (Bern, Switzerland), and University of Kentucky (Lexington, KY, USA).

Completion and Publication Rates of Randomized Controlled Trials in Surgery: An Empirical Study.

OBJECTIVE: To investigate the prevalence of discontinuation and nonpublication of surgical versus medical randomized controlled trials (RCTs) and to explore risk factors for discontinuation and nonpublication of surgical RCTs. BACKGROUND: Trial discontinuation has significant scientific, ethical, and economic implications. To date, the prevalence of discontinuation of surgical RCTs is unknown. METHODS: All RCT protocols approved between 2000 and 2003 by 6 ethics committees in Canada, Germany, and Switzerland were screened. Baseline characteristics were collected and, if published, full reports retrieved. Risk factors for early discontinuation for slow recruitment and nonpublication were explored using multivariable logistic regression analyses. RESULTS: In total, 863 RCT protocols involving adult patients were identified, 127 in surgery (15%) and 736 in medicine (85%). Surgical trials were discontinued for any reason more often than medical trials [43% vs 27%, risk difference 16% (95% confidence interval [CI]: 5%-26%); P = 0.001] and more often discontinued for slow recruitment [18% vs 11%, risk difference 8% (95% CI: 0.1%-16%); P = 0.020]. The percentage of trials not published as full journal article was similar in surgical and medical trials (44% vs 40%, risk difference 4% (95% CI: -5% to 14%); P = 0.373). Discontinuation of surgical trials was a strong risk factor for nonpublication (odds ratio = 4.18, 95% CI: 1.45-12.06; P = 0.008). CONCLUSIONS: Discontinuation and nonpublication rates were substantial in surgical RCTs and trial discontinuation was strongly associated with nonpublication. These findings need to be taken into account when interpreting surgical literature. Surgical trialists should consider feasibility studies before embarking on full-scale trials.

In For a Penny, In For a Pound: The Management and Preservation of E-Theses in EPrints

Presentation at Open Repositories 2014, Helsinki, Finland, June 9-13, 2014

The multicultural moment : the history of the idea and politics of multiculturalism in Sweden in comparative, transnational and biographical context, 1964–1975

The emergence of the idea of multiculturalism in Swedish public discourse and social science in the latter half of the 1960s and introduction of official multiculturalism in 1975 constituted a major intellectual and political shift in the post-war history of Sweden. The ambition of the 1975 immigrant and minority policy to enable the preservation of ethno-cultural minorities and to create a positive attitude towards the new multicultural society among the majority population was also incorporated into Swedish cultural, educational and media policies. The rejection of assimilationism and the new commitment to ethno-cultural diversity, the multicultural moment, has earned Sweden a place on the list of the early adopters of official multiculturalism, together with Canada and Australia. This compilation thesis examines the origins and early post-war history of the idea of multiculturalism as well as the interplay between idea and politics in the shift from a public ideal of homogeneity to an ideal of multiculturalism in Sweden. It does so from a range of conceptual, comparative, transnational, and biographical perspectives. The thesis consists of an introduction (Part I) and four previously published studies (Part II). The primary research result of the thesis concerns the agency involved in the break-through and formal establishment of the idea of multiculturalism in Sweden. Actors such as ethnic activists, experts and officials were instrumental in the introduction and establishment of multiculturalism in Sweden, as they also had been in Canada and in Australia. These actors have, however, not previously been recognized and analysed as significant idea-makers and political agents in the case of Sweden. The intertwined connections between activists, social scientists, linguists, and officials facilitated the transfer of the idea of multiculturalism from a publically contested idea to public policy via the way of The Swedish Trade Union Confederation, academia and the Royal Commission of Immigration. The thesis furthermore shows that the political success of the idea of multiculturalism, such as it was within the limits of the universalist social democratic welfare state, was dependent on whom the claims-makers were, the status and positions they held, and the way the idea of multiculturalism was conceptualised and used. It was also dependent on the migratory context of labour immigration in the 1960s and 1970s and on whose behalf the advocates of multiculturalism made their claims. The majority of the labour immigrants were Finnish citizens from the former eastern half of the kingdom of Sweden who were net contributors to the Swedish welfare state. This facilitated the recognition of their ethno-cultural difference, and, following the logic of universalism, the ethno-cultural difference of other minority groups in Sweden. The historical significance of the multicultural moment is still evident in the contemporary immigration and integration policies of Sweden. The affirmation of diversity continues to set Sweden apart from the rest of Europe, now more so than in the 1970s, even though the migratory context has changed radically in the last 40 years.

A critical examination of the involvement of Canadian high-performance athletes in the development of anti-doping policy

The use of certain perfonnance enhancing substances and methods has been defined as a major ethical breach by parties involved in the governance of highperfonnance sport. As a result, elite athletes worldwide are subject to rules and regulations set out in international and national anti-doping policies. Existing literature on the development of policies such as the World Anti-Doping Code and The Canadian antiDoping Program suggests a sport system in which athletes are rarely meaningfully involved in policy development (Houlihan, 2004a). Additionally, it is suggested that this lack of involvement is reflective of a similar lack of involvement in other areas of governance concerning athletes' lives. The purpose ofthis thesis is to examine the history and current state of athletes' involvement in the anti-doping policy process in Canada's high-perfonnance sport system. It includes discussion and analysis of recently conducted interviews with those involved in the policy process as well as an analysis of relevant documents, including anti-doping policies. The findings demonstrate that Canadian athletes have not been significantly involved in the creation of recently developed antidoping policies and that a re-evaluation of current policies is necessary to more fully recognize the reality of athletes' lives in Canada's high-perfonnance sport system and their rights within that system.

The battle over deficits : the struggle to maintain Canada's social welfare state : a thesis /

Abstract This thesis seeks to answer a number of questions concerning the deficit and debt in Canada. It focuses pri.arily on the federal level of government but with SOBe discussion of provincial governaent policy as well. In ~997, Canada's federal debt caae close ro six hundred billion dollars - $594 billion or 74.4 % of Gross Do.estic Product (GDP) to be exact. The purpose of this theses is threefold: To find out why Canada accu.ulated such a debt, to discover if there is a so-called debt crisis; and to discover if it is possible to preserve Canada's national welfare state given the financial restraints that have been adopted by both federal and provincial governments. Politicians are torn between economist' two contrasting views regarding deficits: Neo-Keynesian and neo-conservative. The neoKeynesian school focuses al1llOst exclusively on the short term stability of the economy and tends to dismiss concerns regarding the level of debt. Neo conservatives focus almost exclusively on the perceived costs of growth in the national debt and are willing to forego any stabilization benefits to ensure that the debt is controlled. These polar view do have one thing in coa.on; both confix-. that deficits influence govermaent policies. Both of these econoBic theories will have far-reaching influences on the federal gover1lJlJent's decision-making process. These economic theories will be discussed throughout this thesis.

From Fordism to neoconservatism : free trade and Canadian industrial policy in an era of globalism /

Nothing today affects the lives of people in countries throughout the industrialized and developing world as much as international trade. Nowhere is this more true than in Canada. Canada's involvement in international trade has a long history dating back to 1854 when it was a British colony. As a major trading country, Canada has always adopted a proactive industrial policy which has been largely responsible for its relative economic prosperi ty. But, wi th businesses now free to invest and divest under the terms of the CUFTA and the NAFTA, the most fundamental concerns for Canadians, in a borderless world, are what powers will the Canadian government have to shape industrial policy, and to what extent can Canada continue as a viable nationstate if it can no longer control its national economy? These are important concerns because, in world without borders, the adjustment process becomes more volatile and more difficult to manage. The CUFTA and the NAFTA not only create the rules for conducting trade, but they also establish a set of new rules for the Canadian government that will diminish its power. As a member of a new North American trading bloc, Canada will find itself subject to a set of forces requiring analysis beyond participation in a conventional free trade area. Because many of the traditional levers of government will now be subject to external control imposed by these agreements, Canada will not be able to mount certain policies in the future that it has relied on in the past. This reality limits the pro-active role of the Canadian state to use policies and programmes for the country's immediate national development. What this thesis attempts is an examination of the evolution of Canadian industrial policy, in effect, the transi tion from Fordism to Neoconservatism, and an assessment of Canada's future as a nation-state as it tries to find security and improved access in a free trade arrangement. Unless Canada takes steps to neutralize the asymmetry of power between itself and the United States through adjustment programmes, it is the contention of this thesis that its economic future is anything but stable.

An international investigation on the validity of the CSAPPA scale in screening for developmental coordination disorder /

The main objective of the present investigation was to continue the research initiated by Hay and colleagues (2004) in examining the efficacy of the Children's Self-Perceptions of Adequacy in and Predilection for Physical Activity (CSAPPA) scale as a proxy for the short form of the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP-SF) in screening for Developmental Coordination Disorder (DCD) in children. To better appreciate DCD knowledge outside Canada, the measurements of this investigation were expanded in Greece. A translated Greek CSAPP A scale and the BOTMP-SF were administered for the first time in Greek children. A second objective was to investigate the relationship between DCD and various risk factors of coronary artery disease (CAD) in Canadian and Greek children. A sample of 591 (Ms=322; Fs=269) Canadian and 392 (Ms=211; Fs=181) Greek children, aged 9 to 13 years, consented to the BOTMP-SF, CSAPP A Scale, participation in physical activity questionnaire, Leger 20-meter Multistage Shuttle Run test, and body fat using bioelectric impedance. Prevalence of DCD in Canada and Greece was 8% and 19%, respectively. Significant agreement (ping the CSAPPA scale to the BOTMP-SF test in both countries. Canadian children revealed significantly lower percent body fat, CSAPPA scores, and participation in physical activity, as well as higher aerobic fitness levels and BOTMP-SF compared to their Greek peers. Clumsiness was associated with increased percent body fat and low aerobic fitness values. Physical activity was a significant mediator in the clumsiness-aerobic fitness relationship. It is concluded that the CSAPPA scale is an accurate, practical, and inexpensive screening tool for DCD, and that motoric competence is associated with aerobic fitness through physical activity participation.

The implications of being an international medical graduate (IMG) in Canadian society : a qualitative study of foreign-trained physicians' resettlement, sense of identity and health status

This qualitative research study used grounded theory methodology to explore the settlement experiences and changes in professional identity, self esteem and health status of foreign-trained physicians (FTPs) who resettled in Canada and were not able to practice their profession. Seventeen foreign-trained physicians completed a pre-survey and rated their health status, quality of life, self esteem and stress before and after coming to Canada. They also rated changes in their experiences of violence and trauma, inclusion and belonging, and racism and discrimination. Eight FTPs from the survey sample were interviewed in semi-structured qualitative interviews to explore their experiences with the loss of their professional medical identities and attempts to regain them during resettlement. This study found that without their medical license and identity, this group of FTPs could not fully restore their professional, social, and economic status and this affected their self esteem and health status. The core theme of the loss of professional identity and attempts to regain it while being underemployed were connected with the multifaceted challenges of resettlement which created experiences of lowered selfesteem, and increased stress, anxiety and depression. They identified the re-licensing process (cost, time, energy, few residency positions, and low success rate) as the major barrier to a full and successful settlement and re-establishment of their identities. Grounded research was used to develop General Resettlement Process Model and a Physician Re-licensing Model outlining the tasks and steps for the successfiil general resettlement of all newcomers to Canada with additional process steps to be accomplished by foreign-trained physicians. Maslow's Theory of Needs was expanded to include the re-establishment of professional identity for this group to re-establish levels of safety, security, belonging, self-esteem and self-actualization. Foreign-trained physicians had established prior professional medical identities, self-esteem, recognition, social status, purpose and meaning and bring needed human capital and skills to Canada. However, without identifying and addressing the barriers to their full inclusion in Canadian society, the health of this population may deteriorate and the health system of the host country may miss out on their needed contributions.

Legal education in crisis: healing and humanizing Canadian law schools /

Western law schools are suffering from an identity and moral crisis. Many of the legal profession's problems can be traced to the law school environment, where students are taught to reason and practice in ways that are often at odds with their own personalities and values and even with generally accepted psychologically healthy practices. The idealism, ethic of care, and personal moral compasses of many students become eroded and even lost in the present legal education system. Formalism, rationalism, elitism, and big business values have become paramount. In such a moment of historical crisis, there exists the opportunity to create a new legal education story. This paper is a conceptual study of both my own Canadian legal education and the general legal education experience. It examines core problems and critiques of the existing Western legal education organizational and pedagogical paradigm to which Canadian law schools adhere. New approaches with the potential to enrich, humanize, and heal the Canadian law school experience are explored. Ultimately, the paper proposes a legal education system that is more interdisciplinary, theoretically and practically integrated, emotionally intelligent, technologically connected, morally accountable, spiritual, and humane. Specific pedagogical and curricular strategies are suggested, and recommendations for the future are offered. The dehumanizing aspects of the law school experience in Canada have rarely been studied. It is hoped that this thesis will fill a gap in the research and provide some insight into an issue that is of both academic and public importance, since the well-being of law students and lawyers affects the interests of their clients, the general public, and the integrity and future of the entire legal system.

Migrations and gradations : reappraising the health profile of immigrants to Canada

New immigrants to Canada typically have a more favourable health profile than the non-immigrant population. This phenomenon, known as the 'healthy immigrant effect', has been attributed to both the socioeconomic advantage (ie. educational attainment, occupational opportunity) of non-refugee immigrants and existing screening protocols that admit only the healthiest of persons to Canada. It has been suggested that this health advantage diminishes as the time of residence in Canada increases, due in part to the adoption of health-risk behaviours such as alcohol and cigarette use, an increase in excess body weight, and declining rates of physical activity. However, the majority of health research concerning immigrants to Canada has been limited to cross-sectional studies (Dunn & Dyck, 2000; Newbold & Danforth, 2003), which may mask an immigrant-specific cohort effect. Furthermore, the practice of aggregating foreign-bom persons by geographical regions or treating all immigrants as a homogeneous group may also obfuscate intra-immigrant differences in health. Accordingly, this study uses the Canadian National Population Health Surveys (NPHS) and data from the United Nations Development Program (UNDP) to prospectively evaluate factors that predict health status among immigrants to Canada. Each immigrant in the NPHS was linked to the UNDP Human Development Index of their country of birth, which uses a combined measure of health, education, and per capita income of the populace. The six-year change in health function, psychological distress, and self-rated health were considered from a population health perspective (Evans, 1994), using generalized-estimating equations (GEE) to examine the compounding effect of past and recent predictors of health. Demographic

Aging policy: a case study of co-ordination in Canadian governments

ABSTRACT Canada is an aging society. The number of people aged sixty-five and over is rising, while the number of people under twenty is declining. These two concurrent changes in the age structure have produced a sh~ft in the demographic composition of Canada which is commonly referred to as the aging phenomenon. Regardless of whether or not the number of people under twenty continues to decline, the number of elderly in Canada will almost double over the next twenty years. This rapidly growing elderly clientele will doubtless have an impact on Canadian governments. Federal, provincial and municipal governments are presently providing a variety of programs that have a special bearing on the aged and most senior citizens are beneficiaries of one or more of these programs. The ramifications of a rapidly growing elderly clientele are obvious. In order to cope with the impact of a significant increase in the number of elderly persons, the development and implementation of aging policy must be co-ordinated at each level of government and between and among levels of government. If aging policy is not co-ordinated, the results are likely to be: inappropriate policy decisions; duplication and overlap; and, ineffective and irresponsive services. No one benefits from these results. The need for co-ordination is apparent. The purpose of this thesis is to examine existing governmental efforts to co-ordinate policy in the field of aging. These efforts are examined by focusing on interactions directed at co-ordination between and among major actors in aging policy. A framework is used to structure the description and analysis of these interactions. The variables of formalisation and intensity and the concept of power are instrumental in analysing interactions for co-ordination. The underlying intent of this thesis is to discover some of the main gaps in existing governmental efforts to co~ordinate aging policy. Gaps are, in fact, discovered. Several explanations for the existence of gaps in interactions for co-ordination are discussed. A major hypothesis involving a relationship between a bureaucratic form of organisation and interactions for coordination is suggested. Finally, three recommendations for improving co-ordination in aging policy are offered.

Education, sport and myth in the community of Glengarry, Ontario : the athletic career of Roderick R. McLennan. 260 St. Catharines, Ont. : Faculty of Education, Brock University ;

This study examined how the athletic career of Roderick R. McLennan contributed to the popularization and subsequent development of Caledonian games in Ontario during the latter nineteenth century. Initially, the development of Caledonian games during the 1800s was examined to provide a contextual framework for McLennan's career. This investigation revealed that the games emerged from rural athletic events at pioneer working bees in the first quarter of the nineteenth century to regional sporting events by the mid-1800s, and finally into annual federated Caledonian games in 1870. Noteworthy primary source material for this chapter included the John MacGillivray Papers at the National Archives of Canada, the Scottish American Journal (NY) and the files retained by the Glengarry Sport Hall of Fame in Maxville, Ontario. Following the investigation of Caledonian games, McLennan's early athletic career was studied. Analysis of the Roderick and Farquhar McLennan Papers at the Archives of Ontario and the newspapers from the period revealed that McLennan rose to popularity in 1865 through a "Championship of the World" hammer throwing match in Cornwall and two "Starring Tours". The next chapter examined the height of McLennan's career through an investigation of the Roderick McLennan versus Donald Dinnie rivalry of the early .. n 1870s. It was detennined that the rivalry between McLennan and Dinnie, the champion athlete of Highland games in Scotland, was a popular attraction and had an impact on the Toronto and Montreal games of 1870 and the Toronto games of 1872. Finally, the athletic records established by McLennan during the 1860s and 1870s were investigated. These records were examined through the context of a media controversy over McLennan's feats that developed in the early 1880s between two newspapers. This controversy erupted between the Toronto Mail and the Spirit of the Times. Caledonian games in Canada have only been briefly examined and a thorough examination of prominent Canadian figures in this context has yet to be undertaken. This study unearths a prominent Canadian athlete of Scottish decent and details his involvement in the Caledonian games of nineteenth century Ontario.

Ethics in government and business

Canadians appear to hold the activities of those in government and in big business in low esteem. Media reports of several high-profile political and corporate instances of unethical conduct have reinforced the public's concern for the status of ethical conduct and honesty in government and in big business. The response by public and private sector managers to unethical conduct by employees is largely in the form of 'ethical rules' which both sectors agree provide a measure of certainty as to the ethical conduct expected from employees. Since research on ethics in the public and private sectors is limited and since ethics is a topic of increasing concern to both sectors, this thesis provides data that could assist managers in dealing with the issue of ethical conduct within their respective organizations. The purpose of this thesis is to compare the state of ethical conduct within public and private sector organizations in Canada. This is accomplished through a description and analysis of the approaches taken by the public and private sectors as well as the four professions of law, engineering, accountancy and medicine. Ethical conduct within the public sector focuses on the ethical behaviour of public servants rather than elected officials. The underlying intent of this thesis is to discover if contemporary ethical problems are similar in the public and iv private sectors with respect to the four ethical areas of conflict of interest, political activity, problem public comment and confidentiality. The comparative data on both public and private sector ethics are assessed and similarities and differences are identified. One major finding emerges from this study. Codes of ethics in both the public and private sectors are perceived by management to play an important role in the prevention of unethical conduct. A procedure for developing a code of ethics is presented along with recommendations as to the administration of a code of ethics. Finally, recommendations are made as to the role of education in ethics.