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COVID-19 mitigation strategies have led to widespread school closures around the world. Initially, these were undertaken based on data from influenza outbreaks in which children were highly susceptible and important in community-wide transmission. An argument was made that school closures were necessary to prevent harm to vulnerable adults, especially the elderly. Although data are still accumulating, the recently described complication, pediatric multisystem inflammatory syndrome, is extremely rare and children remain remarkably unaffected by COVID-19. We also do not have evidence that children are epidemiologically important in community-wide viral spread. Previous studies have shown long-term educational, social, and medical harms from school exclusion, with very young children and those from marginalized groups such as immigrants and racialized minorities most affected. The policy and ethical implications of ongoing mandatory school closures, in order to protect others, need urgent reassessment in light of the very limited data of public health benefit. Résumé Les stratégies d'atténuation de la COVID-19 ont mené à des vagues de fermetures d'écoles dans le monde entier. Au départ, ces fermetures ont été décidées d'après les données sur les éclosions grippales, durant lesquelles les enfants sont très susceptibles et jouent un rôle important dans la transmission communautaire. On a fait valoir que les fermetures d'écoles étaient nécessaires pour protéger les adultes vulnérables, surtout les personnes âgées. Les données s'accumulent encore, mais le syndrome inflammatoire multisystémique chez les enfants, une complication décrite récemment, est extrêmement rare, et les enfants demeurent remarquablement peu touchés par la COVID-19. Nous n'avons pas non plus de preuves de leur importance épidémiologique dans la propagation communautaire du virus. Par contre, selon des études antérieures, l'exclusion scolaire cause des préjudices à long terme sur le plan éducatif, social et médical, et les très jeunes enfants et ceux des groupes marginalisés, comme les immigrants et les minorités racisées, en sont les plus touchés. Les conséquences stratégiques et éthiques de la prolongation des fermetures d'écoles obligatoires pour protéger les autres doivent être réévaluées d'urgence, vu les données très limitées sur les avantages que cela représente pour la santé publique.

Background: Following the Supreme Court of Canada's Carter Decision, medical assistance in dying (MAID) became possible with individual court orders in February 2016. Subsequently, on June 17, 2016, legislation was passed that eliminated the need for court orders, essentially making physicians the arbiters of these requests. Canadian health-care facilities now face the challenge of addressing this unprecedented patient health-care need. Aim: To describe the manner in which London Health Sciences Center has approached local and regional requests for MAID, including the administration, ethics, privacy, and clinical process. Design: A health-care systems descriptive study.

BACKGROUND:The majority of patients who die in hospital have a "Do Not Resuscitate" (DNR) order in place at the time of their death, yet we know very little about why some patients request or agree to a DNR order, why others don't, and how they view discussions of resuscitation status. METHODS:We conducted semi-structured interviews of English-speaking medical inpatients who had clearly requested a DNR or full code (FC) order after a discussion with their admitting team, and analyzed the transcripts using a modified grounded-theory approach. RESULTS:We achieved conceptual saturation after conducting 44 interviews (27 DNR, 17 FC) over a 4-month period. Patients in the DNR group were much older than those in the FC group, but they had broadly similar admission diagnoses and comorbidities. DNR patients reported much greater familiarity with the subject and described a more positive experience than FC patients with their resuscitation discussions. Participants typically requested FC or DNR orders based on personal, relational or philosophical considerations, but these considerations manifested differently depending on the participant's preference for resuscitation. Most FC patients stated that would not want a prolonged period of life support, and they would not want resuscitation in the event of a poor quality of life. FC and DNR patients understood resuscitation and DNR orders differently. DNR patients described resuscitation in graphic, concrete terms that emphasized suffering and futility, and DNR orders in terms of comfort or natural processes. FC patients understood resuscitation in an abstract sense as something that restores life, while DNR orders were associated with substandard care or even euthanasia.CONCLUSION: Our study identified important differences and commonalities between the perspectives of DNR and FC patients. We hope that this information can be used to help physicians better understand the needs of their patients when discussing resuscitation.

1 Endotoxin-induced vascular hyporeactivity to phenylephrine (PE) is well described in rodent aorta, but has not been investigated in smaller vessels in vitro. 2 Segments of rat superior mesenteric artery were incubated in culture medium with or without foetal bovine serum (10%) for 6, 20 or 46 h in the presence or absence of bacterial lipopolysaccharide (LPS; 1 ± 100 mg ml 71 ). 3 Contractions to PE were measured with or without nitric oxide synthase (NOS) inhibitors: L-NAME (300 mM), aminoguanidine (AMG; 400 mM) 1400W (10 mM) and GW273629 (10 mM); the guanylyl cyclase inhibitor, ODQ (3 mM); the COX-2 inhibitor, NS-398 (10 mM). Contractile responses to the thromboxane A 2 mimetic, U46619 were also assessed. 4 In the presence of serum, LPS induced hyporeactivity at all time points. In its absence, hyporeactivity only occurred at 6 and 20 h. 5 L-NAME and AMG fully reversed hyporeactivity at 6 h, whereas they were only partially e ective at 20 h and not at all at 46 h. In contrast partial reversal of peak contraction was observed with 1400W (62% at 46 h), GW273629 (57% at 46 h) and ODQ (75% at 46 h). COX-2 inhibition produced no reversal. 6 In contrast to PE, contractions to U46619 were substantially less a ected by LPS. 7 We describe a well-characterized reproducible model of LPS-induced hyporeactivity, which is largely mediated by the NO-cyclic GMP-dependent pathway. Importantly, long-term (2-day) production of NO via iNOS is demonstrated. Moreover, conventional doses of L-NAME and AMG became increasingly ine ective over time. Thus, the choice of inhibitor merits careful consideration in long-term models.

The number of patients on cardiac transplant waitlists exceeds the number of available donor organs. Cardiac donation is currently limited to those declared dead by neurologic criteria in all but three countries. Cardiac donation after circulatory determination of death (cardiac DCDD) can be conducted using direct procurement and perfusion (DPP) or normothermic regional perfusion (NRP). Implementation of cardiac DCDD in many countries has been slowed by ethical debates within the donation and transplantation community. We conducted a national survey to determine the perceptions of healthcare providers regarding cardiac DCDD. Methods We conducted an electronic survey of 398 healthcare providers who are involved in the management of heart donors and/or heart transplant recipients in Canada (226 nurses, 82 critical care physicians, 31 donation specialists, and 59 transplant specialists). Our primary outcomes were their attitudes towards and concerns regarding cardiac DCDD protocols This article is accompanied by an editorial. Please see Can J Anesth 2020; 67: this issue.

Although ongoing inappropriate care appeared to be a rare occurrence, the issue was a concern to at least one caregiver in one-third of cases. Public awareness for end-of-life issues, adequate communication, and up-to-date knowledge and practice in determining the wishes of critically ill patients are potential target areas to improve end-of-life care and reduce inappropriate care in the ICU. A daily, prospective survey of multidisciplinary caregivers, such as the survey used in the present study, is a viable and valuable means of determining the scope and causes of inappropriate care in the ICU.