BackgroundFactors associated with HCV incidence among young Aboriginal people in Canada are still not well understood. We sought to estimate time to HCV infection and the relative hazard of risk factors associated HCV infection among young Aboriginal people who use injection drugs in two Canadian cities.MethodsThe Cedar Project is a prospective cohort study involving young Aboriginal people in Vancouver and Prince George, British Columbia, who use illicit drugs. Participants’ venous blood samples were drawn and tested for HCV antibodies. Analysis was restricted to participants who use used injection drugs at enrolment or any of follow up visit. Cox proportional hazards regression was used to identify independent predictors of time to HCV seroconversion.ResultsIn total, 45 out of 148 participants seroconverted over the study period. Incidence of HCV infection was 26.3 per 100 person-years (95% Confidence Interval [CI]: 16.3, 46.1) among participants who reported using injection drugs for two years or less, 14.4 per 100 person-years (95% CI: 7.7, 28.9) among participants who had been using injection drugs for between two and five years, and 5.1 per 100 person-years (95% CI: 2.6,10.9) among participants who had been using injection drugs for over five years. Independent associations with HCV seroconversion were involvement in sex work in the last six months (Adjusted Hazard Ratio (AHR): 1.59; 95% CI: 1.05, 2.42) compared to no involvement, having been using injection drugs for less than two years (AHR: 4.14; 95% CI: 1.91, 8.94) and for between two and five years (AHR: 2.12; 95%CI: 0.94, 4.77) compared to over five years, daily cocaine injection in the last six months (AHR: 2.47; 95% CI: 1.51, 4.05) compared to less than daily, and sharing intravenous needles in the last six months (AHR: 2.56; 95% CI: 1.47, 4.49) compared to not sharing.ConclusionsThis study contributes to the limited body of research addressing HCV infection among Aboriginal people in Canada. The HCV incidence rate among Cedar Project participants who were new initiates of injection drug use underscores an urgent need for HCV and injection prevention and safety strategies aimed at supporting young people surviving injection drug use and sex work in both cities. Young people must be afforded the opportunity to provide leadership and input in the development of prevention programming.

Full-time direct patient care occupations have greater risk of injury compared to part-time and casual workers within the health care sector.

P ediatric palliative care can be summarized as "an active and total approach to care focused on the enhancement of quality of life for the children with life-threatening conditions and support for the family".1 A life-threatening condition is a condition with no established cure, or for which available treatment has not succeeded, and survival to full adulthood is unlikely. Children requiring, but not enrolled in, a pediatric palliative care program (PPCP) access usual care often through uncoordinated acute care admissions and some episodes of home care, but potentially with some compromise to continuity of care where critical components for family support are lacking. Complex care plans and fluctuating patient needs necessitate a coordination of care within individualized support systems.Pediatric palliative care is a relatively new and evolving field. It varies from adult palliative care in important ways. From a resource utilization perspective, pediatric palliative care is usually delivered over a longer time frame. 2,3It is unclear how enrolment in a PPCP affects health care utilization and costs compared with usual care. Understanding such outcomes may improve the efficiency of health care services for children with life-threatening conditions and support evidence-based planning and resource allocation for PPCPs. We conducted a systematic review of the published literature where inpatient health care resource utilization and costs were compared between children with life-threatening conditions who accessed a PPCP and those who did not. Background: Pediatric palliative care is a relatively new and evolving field, and the cost of pediatric palliative care programs is unclear. We conducted a systematic review to compare inpatient health care utilization and costs among children with life-threatening conditions who have accessed a pediatric palliative care program and those who have not.

WHAT'S KNOWN ON THIS SUBJECT: Palliative care is an increasingly important element of pediatric care for children with noncurable, terminal conditions. Freestanding hospices represent one model of care provision; however, little research on this approach has been conducted. WHAT THIS STUDY ADDS:This report documents the experience of North America' s first freestanding hospice over 15 years to better understand the characteristics of children and families enrolled and to establish baseline information for future studies and program planning. abstract OBJECTIVES: Pediatric palliative care has seen the adoption of several service provision models, yet there is minimal literature describing them. Canuck Place Children' s Hospice (CPCH) is North America' s first freestanding pediatric hospice. This study describes the characteristics of and services delivered to all children on the CPCH program from 1996 to 2010. METHODS:A retrospective review of all patient medical records CPCH was conducted. Analyses examined trends and correlations between 40 selected data points: linear regression modeling was used to assess trends over time; t tests were used to examine significant associations between independent means; and the Kaplan-Meier method was used to measure survival probabilities. RESULTS:The study cohort included 649 children. The majority of diagnoses belonged to cancers (30%), and diseases of the neuromuscular (20%), and central nervous systems (18%). The majority of deaths occurred among the cancer (45%), central nervous system (15%), and metabolic disease groups (14%). By study end date, 24% of children were still alive, 61% died, and 15% transitioned to adult services (more than half of whom were cognitively competent). On average, 1024 days were spent on the CPCH program (median = 301). The majority of inpatient hospice discharges were for respite (82%); only 7% were for end-of-life care. Location of death was shared between CPCH (61%), hospital (22%), and home (16%).CONCLUSIONS: Diagnostic groups largely determine the nature and magnitude of services used, and our involvement with pediatric lifethreatening conditions is increasing. Reviews of pediatric palliative programs can help evaluate the services needed by the population served. Pediatrics 2014;134:e765-e772 Dr Siden conceptualized and designed the study, guided the analysis, and reviewed and revised the manuscript; Ms Chavoshi drafted the initial manuscript, carried out the analysis, and finalized the manuscript; Ms Harvey was responsible for data review and entry and database management; Ms Parker reentered data and reviewed data for accuracy; Ms Miller reviewed and revised the manuscript and provided content pertaining to program description and budget; and all authors approved the final manuscript as submitted.www.pediatrics.org/cgi

Resource utilization was very high for all three age groups, demonstrating the intense need for care by children dying of disease. These findings call for the strengthening of palliative care services in the province.

The foundational principle of palliative care is to provide comfort, ameliorate symptoms, and offer emotional support when death is inevitable. Advance care planning (ACP) elicits patients' goals for the future. One important result of an ACP discussion may be an advance directive (AD), a written order delineating explicit wishes regarding medical interventions. Pediatric palliative care (PPC) is a young field and developed many of its approaches as reflections from adult palliative care. ACP has not been well evaluated in children. 1 Often ADs are thought to be synonymous with a ''do not attempt resuscitation'' (DNAR) order, which in turn has been treated as an indicator for a nonintervention-oriented stance and as a proxy for ACP discussions between families and clinicians. 2 Another barrier identified in the literature is physician reluctance to undertake ACP discussions. Clinicians report feeling ill prepared and inadequately trained to carry out such conversations. 3 Studies involving parents of children with lifethreatening conditions showed that parents are interested in ACP, provided there is emotional support available. 3,4 The literature indicates that ACP discussions likely need to occur more than once over time.

The terminal pediatric population referred to PPCP may systematically differ from those under usual care even before enrollment, presenting with higher inpatient utilization in critical care nearing death. A significant portion of inpatient utilization shifted to the hospice, with implications for resource reallocation and enhancements in PPCP referrals.

Internal data from the sole pediatric hospice in British Columbia were utilized to investigate mortality trends among children dying from life-threatening conditions. Characteristics of the sample (hospice) were compared to that of the population (province) for individuals aged 0 to 18 years from 2002 to 2011. The provincial death rate was 2.30 per 10 000. The sample did not significantly vary with respect to sex and geographic distribution when compared to the population. Infants contributed to a significantly larger proportion of pediatric deaths in the population. Children referred to the hospice were more likely to be diagnosed with cancer and diseases of the nervous system. Only 15% of all pediatric deaths due to disease in the province were cared for by the hospice, calling for the strengthening of interdisciplinary palliative care programs.