Impact of early enteral versus parenteral nutrition on mortality in patients requiring mechanical ventilation and catecholamines: study protocol for a randomized controlled trial (NUTRIREA-2)

BACKGROUND: Nutritional support is crucial to the management of patients receiving invasive mechanical ventilation (IMV) and the most commonly prescribed treatment in intensive care units (ICUs). International guidelines consistently indicate that enteral nutrition (EN) should be preferred over parenteral nutrition (PN) whenever possible and started as early as possible. However, no adequately designed study has evaluated whether a specific nutritional modality is associated with decreased mortality. The primary goal of this trial is to assess the hypothesis that early first-line EN, as compared to early first-line PN, decreases day 28 all-cause mortality in patients receiving IMV and vasoactive drugs for shock. METHODS/DESIGN: The NUTRIREA-2 study is a multicenter, open-label, parallel-group, randomized controlled trial comparing early PN versus early EN in critically ill patients requiring IMV for an expected duration of at least 48 hours, combined with vasoactive drugs, for shock. Patients will be allocated at random to first-line PN for at least 72 hours or to first-line EN. In both groups, nutritional support will be started within 24 hours after IMV initiation. Calorie targets will be 20 to 25 kcal/kg/day during the first week, then 25 to 30 kcal/kg/day thereafter. Patients receiving PN may be switched to EN after at least 72 hours in the event of shock resolution (no vasoactive drugs for 24 consecutive hours and arterial lactic acid level below 2 mmol/L). On day 7, all patients receiving PN and having no contraindications to EN will be switched to EN. In both groups, supplemental PN may be added to EN after day 7 in patients with persistent intolerance to EN and inadequate calorie intake. We plan to recruit 2,854 patients at 44 participating ICUs. DISCUSSION: The NUTRIREA-2 study is the first large randomized controlled trial designed to assess the hypothesis that early EN improves survival compared to early PN in ICU patients. Enrollment started on 22 March 2013 and is expected to end in November 2015. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01802099 (registered 27 February 2013)

The Resilience of Métis Title: Rejecting Assumptions of Extinguishment for Métis Land Rights

The Crown long has disputed Métis title claims by contending that any previously existing Métis rights, including title, have been extinguished. We argue, however, that Métis rights, including title, remain unextinguished in at least some areas of the Métis homeland. In this chapter, we review the three means by which Aboriginal rights can be extinguished in Canadian law: by surrender, by legislation prior to April 17, 1982, and by constitutional amendment. When applied to the Métis homeland, we conclude that these means have not effectively extinguished all Métis rights and title. This chapter builds on our previous work, in which we argue that historical Métis land use patterns can satisfy the test for Aboriginal title as set out by the Supreme Court of Canada in Tsilhqot’in Nation v. British Columbia. Once the Métis have shown that their occupation of their traditional homeland was sufficient, continuous, and exclusive, the next step is to demonstrate that their title to land has not been extinguished. This chapter takes this next step, and thus further strengthens the argument in support of Métis title

“The lands…belonged to them, once by the Indian title, twice for having defended them…and thrice for having built and lived on them”: The Law and Politics of Métis Title

To predict what is on the horizon of the Métis legal landscape, we can look to jurisprudence on First Nations’ rights, given that Métis rights cases are typically ten to fifteen years behind those of First Nations. With the release of the Supreme Court of Canada’s decision in Tsilhqot’in, the next big issue in Métis law may be Métis title. Scholars have doubted the ability of Métis to establish Aboriginal title in Canada for two reasons: first, Métis were too mobile, and second, Métis were too immobile. This paper critically analyzes these positions and argues that the case for Métis title in Canada is a strong one. As such, governments in Canada would do well to focus on resolving outstanding Métis title claims

The Resilience of Métis Title: Rejecting Assumptions of Extinguishment for Métis Land Rights

The Crown long has disputed Métis title claims by contending that any previously existing Métis rights, including title, have been extinguished. We argue, however, that Métis rights, including title, remain unextinguished in at least some areas of the Métis homeland. In this chapter, we review the three means by which Aboriginal rights can be extinguished in Canadian law: by surrender, by legislation prior to April 17, 1982, and by constitutional amendment. When applied to the Métis homeland, we conclude that these means have not effectively extinguished all Métis rights and title. This chapter builds on our previous work, in which we argue that historical Métis land use patterns can satisfy the test for Aboriginal title as set out by the Supreme Court of Canada in Tsilhqot’in Nation v. British Columbia. Once the Métis have shown that their occupation of their traditional homeland was sufficient, continuous, and exclusive, the next step is to demonstrate that their title to land has not been extinguished. This chapter takes this next step, and thus further strengthens the argument in support of Métis title

The Resilience of Métis Title: Rejecting Assumptions of Extinguishment

For many years, the Crown disputed Métis title claims by contending that any previously existing Métis rights, including title, had been extinguished. We argue, however, that this is not the case in at least some areas of the Métis homeland. In this chapter, we review the three means by which Aboriginal rights can be extinguished in Canadian law: by surrender, by legislation prior to 17 April 1982, and by constitutional amendment. This chapter builds on our previous work, in which we argue that historical Métis land use patterns can satisfy the test for Aboriginal title. The relevant case law here is Tsilhqot\u27in Nation v British Columbia, a Supreme Court of Canada decision from 2014. Once the Métis show that their occupation of their traditional homeland is sufficient, continuous, and exclusive, the next step is to demonstrate that their title to land has not been extinguished. Focusing on Manitoba, we take this step, and thus further strengthen the argument in support of Métis title. We do not endorse the jurisprudence pertaining to, or the existence of, the doctrine of extinguishment. Both have been thoroughly and deftly critiqued elsewhere. Our goal is to supplement this critique by highlighting the historical and legal reasons for questioning the applicability of this doctrine to Métis title claims

The Resilience of Métis Title: Rejecting Assumptions of Extinguishment

For many years, the Crown disputed Métis title claims by contending that any previously existing Métis rights, including title, had been extinguished. We argue, however, that this is not the case in at least some areas of the Métis homeland. In this chapter, we review the three means by which Aboriginal rights can be extinguished in Canadian law: by surrender, by legislation prior to 17 April 1982, and by constitutional amendment. This chapter builds on our previous work, in which we argue that historical Métis land use patterns can satisfy the test for Aboriginal title. The relevant case law here is Tsilhqot\u27in Nation v British Columbia, a Supreme Court of Canada decision from 2014. Once the Métis show that their occupation of their traditional homeland is sufficient, continuous, and exclusive, the next step is to demonstrate that their title to land has not been extinguished. Focusing on Manitoba, we take this step, and thus further strengthen the argument in support of Métis title. We do not endorse the jurisprudence pertaining to, or the existence of, the doctrine of extinguishment. Both have been thoroughly and deftly critiqued elsewhere. Our goal is to supplement this critique by highlighting the historical and legal reasons for questioning the applicability of this doctrine to Métis title claims