Not a General Regulatory Power: A Comment on Reference re Assisted Human Reproduction Act

Reference re Assisted Human Reproduction Act is the Supreme Court of Canada’s most important ruling on the criminal law power in more than a decade. It demonstrates that the Court has become uncomfortable with the federal government’s use of section 91(27) of the Constitution Act, 1867 as Parliament’s general regulatory power. The paper begins with a review of the Assisted Human Reproduction Act, with particular reference to those aspects of the statute at issue in the Reference. Next, the three opinions delivered in the Reference are analyzed and their doctrinal significance identified. Finally, consideration is given to the implications for future federalism cases of the principles flowing from the Reference and how in its wake the regulation of health generally and of assisted reproduction technologies particularly should proceed. The author argues that the federalism principles emerging from the Reference are to be welcomed as they will assist in ensuring that the criminal law power does not become the source of wide-ranging civic regulation

Not a General Regulatory Power: A Comment on Reference re Assisted Human Reproduction Act

Reference re Assisted Human Reproduction Act is the Supreme Court of Canada’s most important ruling on the criminal law power in more than a decade. It demonstrates that the Court has become uncomfortable with the federal government’s use of section 91(27) of the Constitution Act, 1867 as Parliament’s general regulatory power. The paper begins with a review of the Assisted Human Reproduction Act, with particular reference to those aspects of the statute at issue in the Reference. Next, the three opinions delivered in the Reference are analyzed and their doctrinal significance identified. Finally, consideration is given to the implications for future federalism cases of the principles flowing from the Reference and how in its wake the regulation of health generally and of assisted reproduction technologies particularly should proceed. The author argues that the federalism principles emerging from the Reference are to be welcomed as they will assist in ensuring that the criminal law power does not become the source of wide-ranging civic regulation

Improving Delivery of Secondary Prophylaxis for Rheumatic Heart Disease in a High-Burden Setting: Outcome of a Stepped-Wedge, Community, Randomized Trial

BACKGROUND Health system strengthening is needed to improve delivery of secondary prophylaxis against rheumatic heart disease. METHODS AND RESULTS We undertook a stepped-wedge, randomized trial in northern Australia. Five pairs of Indigenous community clinics entered the study at 3-month steps. Study phases comprised a 12 month baseline phase, 3 month transition phase, 12 month intensive phase and a 3- to 12-month maintenance phase. Clinics received a multicomponent intervention supporting activities to improve penicillin delivery, aligned with the chronic care model, with continuous quality-improvement feedback on adherence. The primary outcome was the proportion receiving ≥80% of scheduled penicillin injections. Secondary outcomes included "days at risk" of acute rheumatic fever recurrence related to late penicillin and acute rheumatic fever recurrence rates. Overall, 304 patients requiring prophylaxis were eligible. The proportion receiving ≥80% of scheduled injections during baseline was 141 of 304 (46%)-higher than anticipated. No effect attributable to the study was evident: in the intensive phase, 126 of 304 (41%) received ≥80% of scheduled injections (odds ratio compared with baseline: 0.78; 95% confidence interval, 0.54-1.11). There was modest improvement in the maintenance phase among high-adhering patients (43% received ≥90% of injections versus 30% [baseline] and 28% [intensive], P<0.001). Also, the proportion of days at risk in the whole cohort decreased in the maintenance phase (0.28 versus 0.32 [baseline] and 0.34 [intensive], P=0.001). Acute rheumatic fever recurrence rates did not differ between study sites during the intensive phase and the whole jurisdiction (3.0 versus 3.5 recurrences per 100 patient-years, P=0.65). CONCLUSIONS This strategy did not improve adherence to rheumatic heart disease secondary prophylaxis within the study time frame. Longer term primary care strengthening strategies are needed. CLINICAL TRIAL REGISTRATION URL: www.anzctr.org.au. Unique identifier: ACTRN12613000223730

Qualitative Evaluation of a Complex Intervention to Improve Rheumatic Heart Disease Secondary Prophylaxis

BACKGROUND Rheumatic heart disease is a high-burden condition in Australian Aboriginal communities. We evaluated a stepped-wedge, community, randomized trial at 10 Aboriginal communities from 2013 to 2015. A multifaceted intervention was implemented using quality improvement and chronic care model approaches to improve delivery of penicillin prophylaxis for rheumatic heart disease. The trial did not improve penicillin adherence. This mixed-methods evaluation, designed a priori, aimed to determine the association between methodological approaches and outcomes. METHODS AND RESULTS An evaluation framework was developed to measure the success of project implementation and of the underlying program theory. The program theory posited that penicillin delivery would be improved through activities implemented at clinics that addressed elements of the chronic care model. Qualitative data were derived from interviews with health-center staff, informants, and clients; participant observation; and project officer reports. Quantitative data comprised numbers and types of "action items," which were developed by participating clinic staff with project officers to improve delivery of penicillin injections. Interview data from 121 health-center staff, 22 informants, and 72 clients revealed barriers to achieving the trial's aims, including project-level factors (short trial duration), implementation factors (types of activities implemented), and contextual factors (high staff turnover and the complex sociocultural environment). Insufficient actions were implemented addressing "self-management support" and "community linkage" streams of the chronic care model. Increased momentum was evident in later stages of the study. CONCLUSIONS The program theory underpinning the study was sound. The limited impact made by the study on adherence was attributable to complex implementation challenges.This study was funded by the Australian National Health and Medical Research Council (NHMRC) project grant 1027040 and Center of Research Excellence 1080401 and by the Wesfarmers Center for Vaccines and Infectious Diseases at Telethon Kids Institute. Ralph and Maguire are supported by NHMRC fellowships (1142011 and 1046563, respectively)

Presence of Nonhemolytic Pneumolysin in Serotypes of Streptococcus pneumoniae Associated with Disease Outbreaks

Pneumolysin is an important virulence factor of the human pathogen Streptococcus pneumoniae. Sequence analysis of the ply gene from 121 clinical isolates of S. pneumoniae uncovered a number of alleles. Twenty-two strains were chosen for further analysis, and 14 protein alleles were discovered. Five of these had been reported previously, and the remaining 9 were novel. Cell lysates were used to determine the specific hemolytic activities of the pneumolysin proteins. Six strains showed no hemolytic activity, and the remaining 16 were hemolytic, to varying degrees. We report that the nonhemolytic allele reported previously in serotype 1, sequence type (ST) 306 isolates is also present in a number of pneumococcal isolates of serotype 8 that belong to the ST53 lineage. Serotype 1 and 8 pneumococci are known to be associated with outbreaks of invasive disease. The nonhemolytic pneumolysin allele is therefore associated with the dominant clones of outbreak-associated serotypes of S. pneumonia

Testing peatland testate amoeba transfer functions: Appropriate methods for clustered training-sets

Transfer functions are widely used in palaeoecology to infer past environmental conditions from fossil remains of many groups of organisms. In contrast to traditional training-set design with one observation per site, some training-sets, including those for peatland testate amoeba-hydrology transfer functions, have a clustered structure with many observations from each site. Here we show that this clustered design causes standard performance statistics to be overly optimistic. Model performance when applied to independent data sets is considerably weaker than suggested by statistical cross-validation. We discuss the reasons for these problems and describe leave-one-site-out cross-validation and the cluster bootstrap as appropriate methods for clustered training-sets. Using these methods we show that the performance of most testate amoeba-hydrology transfer functions is worse than previously assumed and reconstructions are more uncertain

Development of a new pan-European testate amoeba transfer function for reconstructing peatland palaeohydrology

In the decade since the first pan-European testate amoeba-based transfer function for peatland palaeohydrological reconstruction was published, a vast amount of additional data collection has been undertaken by the research community. Here, we expand the pan-European dataset from 128 to 1799 samples, spanning 35° of latitude and 55° of longitude. After the development of a new taxonomic scheme to permit compilation of data from a wide range of contributors and the removal of samples with high pH values, we developed ecological transfer functions using a range of model types and a dataset of ∼1300 samples. We rigorously tested the efficacy of these models using both statistical validation and independent test sets with associated instrumental data. Model performance measured by statistical indicators was comparable to other published models. Comparison to test sets showed that taxonomic resolution did not impair model performance and that the new pan-European model can therefore be used as an effective tool for palaeohydrological reconstruction. Our results question the efficacy of relying on statistical validation of transfer functions alone and support a multi-faceted approach to the assessment of new models. We substantiated recent advice that model outputs should be standardised and presented as residual values in order to focus interpretation on secure directional shifts, avoiding potentially inaccurate conclusions relating to specific water-table depths. The extent and diversity of the dataset highlighted that, at the taxonomic resolution applied, a majority of taxa had broad geographic distributions, though some morphotypes appeared to have restricted ranges

Improving the Quality of Dentistry (IQuaD):a cluster factorial randomised controlled trial comparing the effectiveness and cost-benefit of oral hygiene advice and/or periodontal instrumentation with routine care for the prevention and management of periodontal disease in dentate adults attending dental primary care

Acknowledgements The authors wish to thank Mark Forrest and the programming team at CHaRT; Cynthia Fraser, our information specialist, for assistance with referencing; Moira Swan, who was the dental research nurse and part of the OA team in Newcastle upon Tyne; Louise Campbell for secretarial support and data management; our original statistician in the group, Andy Elders; senior IT manager Gladys Macpherson; senior trial administrator at the TCOD Marilyn Laird; Luke Vale for his involvement with the design of the health economic analysis at the inception of the trial; Maria Dimitrova, who assisted the health economists in the collection of unit costs; staff of the Scottish Primary Care Research Network, who assisted with screening eligible patients at dental practices; staff of the North East Commissioning Support Unit who assisted with research payments to dental practices in the north-east; members of the TMC and Periodontal Advisory Group for their ongoing advice and support of the trial; the independent members of the TSC and DMC; and the staff at recruitment sites who facilitated recruitment, treatment and follow-up of trial participants. The Health Services Research Unit and the Health Economics Research Unit is core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorate.Peer reviewedPublisher PD

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy