Environmental educators work to create an environmentally literate citizenry that is willing and able to tackle complex environmental problems such as climate change, potable water availability, and biodiversity loss. Environmental education (EE) research is a robust field that links practice and research, but lacks a comprehensive model connecting practices and outcomes. The goal of this grounded theory systematic review (GT-SR) was to create a model that identifies the context, strategies, outcomes, and core category associated with EE for secondary students in the United States (U.S.). Systematic review methods were used to locate and screen relevant, peer-reviewed research indexed in academic databases. The first search term, "environmental education," identified studies about EE. To narrow results to those focused on secondary education (grades 6–12), twelve search terms related to middle school and high school were used. After limiting the search to studies published between 2011 and 2018 and in English, 1,009 unique citation records were identified. A screening process for relevancy and quality excluded 982 records leaving 27 studies in the initial final sample. Theoretical sampling identified an additional 12 studies through a second database search and ancestry searching. Data from the 39 studies were analyzed through initial, focused, and theoretical coding using the constant comparative method. During initial coding, descriptive and In Vivo codes were used to organize the data into meaningful chunks. Focused and theoretical coding were used to further abstraction and identify categories. "Authenticity" emerged as the core category suggesting that, in order to be effective, EE for secondary students in the U.S. must be viewed as authentic in the eyes of the participants. The coding process informed the development of the Implementation of Authentic Environmental Education Programs (IAEEP) model. Although not designed to be applicable to all contexts, the model will aid EE practitioners in developing and implementing EE programs for secondary students in the U.S. and guide researchers as they evaluate EE programs. The development of the model also supports the use of a GT-SR as an appropriate and useful method for identifying, screening, and analyzing existing research to create a theoretical model. / Doctor of Philosophy / Environmental educators work to create an environmentally literate citizenry that is willing and able to tackle complex environmental problems such as climate change, lack of potable water, and loss of biodiversity. Environmental education research is a robust field that links practice and research, but lacks a comprehensive model that connects practices with agreed-upon outcomes. This systematic review used a grounded theory approach to create a grounded theory model that identifies the strategies, context, conditions, core category, and outcomes associated with environmental education for secondary students in the United States. Systematic review methods and theoretical sampling were used to locate and screen relevant, peer-reviewed environmental education research. Data from the primary studies were analyzed using initial, focused, and theoretical coding using the constant comparison method. Integration of data from the systematic review and theoretical sampling informed the development of the Implementation of Authentic Environmental Education Programs (IAEEP) model. This model will aid practitioners in developing and implementing environmental education programs for secondary students and guide researchers as they further evaluate environmental education programs.

In the development of a BMJ Rapid recommendation – an international practice guideline initiative led by the MAGIC Evidence Ecosystem Foundation, and aiming to produce trustworthy, accessible and timely guidance – of plasma exchange and dosage of corticosteroids for patients with ANCA-associated vasculitis (AAV) (Chapter 2) two methodological issues arose. The first issue is related to the rating of the certainty of evidence supporting the recommendations. Reviewers experienced challenges in making an explicit statement about what it was in which they were rating their certainty (i.e., the target of the rating of certainty of evidence). Through iterative discussions and presentations at GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) Working Group meetings, the research team developed new GRADE guidance (Chapter 3 and 4) to help systematic reviewers be aware of the importance of determining the target of their rating of certainty of evidence and provided practical principles to help systematic reviewers specify this target. The second issue arose from the process of moving from evidence to decisions. To help the BMJ Rapid recommendation panel interpret the magnitude of benefit and harm associated with plasma exchange, which required understanding patient values and preferences, the research team created a panel survey for eliciting the panelists’ view regarding patient values and preferences. The research team then applied the panel survey approach in some other guidelines. Based on the experience of developing panel surveys, and through iterative discussions and consensus, the research team developed a framework for using surveys to guide guideline panels in making inferences regarding patient values and preferences (Chapter 5). Using interpretive description, the team conducted a qualitative evaluation regarding the influence of the panel surveys on the panels’ understanding of patient values and preferences, interpretation of magnitude of benefits and harms, and on panels’ decision on guideline recommendations (Chapter 6). The panel surveys proved to help guideline panels explicitly consider and incorporate patient values and preferences in making recommendations. / Thesis / Candidate in Philosophy

Informal caregiving is growing in demand and is far from a uniform experience. Some caregivers report burdensome effects, while others attest to a wide range of benefits associated with their role. In the context of informal caregivers of persons affected by chronic neurological conditions (CNCs), psychological resilience is increasingly being explored as a protective factor that may account for variability in the caregiver experience; however, multiple sclerosis (MS) caregivers are noticeably absent from this body of work. To synthesize current evidence concerning resilience conceptualizations, assessments, and health correlates within this population, this thesis included a systematic review of resilience in CNC informal caregivers in which MS caregivers were unrepresented. Following this review, a qualitative study was conducted in informal MS caregivers to ascertain MS caregivers’ conceptualizations and unique lived experiences of resilience. Twenty-four semi-structured interviews of Canadian MS informal caregivers were conducted. Informed by the socioecological model of resilience in caring relationships, transcripts were analyzed using flexible thematic analysis. In support of the conceptual ambiguity of resilience, caregivers did not concur on a single resilience conceptualization. Emergent themes contributed to the creation of a cyclical model of resilience that incorporates adversity in the form of continuous loss and obstructed health-related self-care, individual and community resources, and multilevel adaptive pathways. We use our model to prompt future research directions and inform the development of effective resilience-enhancing interventions for MS caregivers.

The broad purpose of this dissertation is to enhance the quality of managerial decisions through evidence-based management. Specifically, it raises three key questions: What is evidence? What are the attributes of knowledge that can facilitate informed decision making? How can such knowledge be generated? To answer these questions this thesis proposes a theory of evidence, suggesting that the strength of evidence is contingent upon its methodological fit, contextuality, transparency, replicability, and consensus. A model of evidence-based decision making is offered that explores how managers’ judgment, experience, and personal values along with the values of other stakeholders, contextual factors, and ethical constraints, may affect the decision process. Moreover, this thesis argues that in order to foster evidence-based management practice we need knowledge that is rigorous, relevant and actionable. To this end, a theory of actionability is proposed, and an empirical study is conducted to determine the attributes of actionable management knowledge. Based on the study, an actionability index is suggested. Evidence that is actionable requires sustainable collaborative effort to produce, curate and communicate. To accomplish that a theory of evidence-based collaboration is proposed. This theory conceives the collaboration as an independent organization that oversees the process of bringing rigour, relevance, and actionability together, and provides an interactive platform for producers, arbiters and users of management knowledge to communicate and collaborate. A template, guided by the theory of collaboration, is designed to produce systematic reviews that are useful for management practice. / Dissertation / Doctor of Philosophy (PhD)

Background: Suicide is a worldwide concern, claiming nearly one million lives each year. The causes of suicidal behaviour are unclear, but a variety of biological, psychological, social, and environmental factors are thought to contribute to suicide risk. Many cases of suicidal behaviour cannot be explained by conventional risk proposed by clinical and research observations. Recent research has focused on biomarkers of suicidal behaviour, including brain-derived neurotrophic factor (BDNF). This thesis aims to determine the association between BDNF and suicidal behaviour by reviewing the literature and by analyzing clinical data. An additional aim of this thesis is to explore the associations between social factors and suicidal behaviour, with a particular focus on sex differences within these factors. Methods: We explored the associations between biological and social risk factors and suicidal behaviour in several ways. We conducted a systematic review to summarize and evaluate the literature regarding BDNF levels and suicidal behaviour. The protocol for this systematic review was designed and published a priori. We performed a qualitative review of the literature and a meta-analysis of studies of serum BDNF and attempted suicide. Then, we assessed the association between serum BDNF and attempted suicide using a case-control study design. We analyzed data collected from the Study of Determinants of Suicide Conventional and Emergent Risk (DISCOVER), and age- and sex-matched study of attempted suicide. In a sample of 250 participants (84 cases of attempted suicide, 104 psychiatric controls, and 93 community controls), we used linear regression analysis to determine the association between BDNF level and attempted suicide, adjusting for age, sex, body mass index, current smoking status, and antidepressant use. Finally, using the same dataset, we explored the associations of a number of social factors with attempted suicide. In a sample of 343 participants (146 cases, 104 psychiatric controls, and 93 community controls), we used logistic regression analyses to determine the associations between social risk factors and attempted suicide in men and women separately. These included age, education level, employment status, marital status, religious practice, stressful life events, and childhood abuse. Results: Our systematic review included 14 studies. The meta-analysis of three studies of serum BDNF and attempted suicide showed no significant association. The qualitative review of all studies revealed inconsistent findings regarding associations between BDNF and suicidal behaviour. In our study of serum BDNF and attempted suicide in the DISCOVER dataset, attempted suicide was not significantly associated with BDNF level. In our study of social factors for attempted suicide, some sex differences were found: Completion of post-secondary education and religious practice were found to be significant protective factors against attempted suicide only in women, and unemployment and stressful life events were significant risk factors only in men. Conclusion: This thesis provides important findings about the biological and social risk factors for suicidal behaviour. Understanding the determinants of suicidal behaviour can aid clinicians in identifying and treating vulnerable individuals. / Thesis / Master of Science (MSc)

Background and Objectives: Mesothelin, identified as a tumor-associated biomarker, is more often overexpressed in triple receptor-negative breast cancer (TNBC) than in common luminal breast tumor subtype or normal tissues. The objective of this systematic review is to determine the association between the expressions of mesothelin with survival outcomes in patients with TNBC. Methods We searched the following electronic databases: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, PubMed, and Web of Science with no time or language restriction till May 19, 2016. Any prospective or retrospective longitudinal studies that investigate the prognosis of TNBC with mesothelin baseline measurement were selected. Two reviewers independently assessed every article for inclusion, extracted data, and assessed the methodological quality of every eligible trial. Pooled measures of associations were summarized with meta-analyses. Results and conclusions Among the 592 patients with TNBC included in the four eligible studies, 269 patients (45.4%) demonstrated mesothelin expression. For the primary outcome OS, we found the trend toward decreased survival for patients with mesothelin-positive TNBC than those without mesothelin expression. We also found that for long-term OS, the association was statistically significant (OR = 0.46; 95% CI= 0.30 to 0.73; P< 0.001). For the secondary outcomes, we found that mesothelin expression in patients with TNBC was associated with lower DFS and higher overall mortality than those without mesothelin expression. Despite the limitations of sample size, this present study shows a significant association between mesothelin expressions and survival outcomes in patients with TNBC. Patients with mesothelin-positive TNBC could benefit from mesothelin-targeted immunotherapies recently in the development. / Thesis / Master of Science (MSc) / It is unclear whether mesothelin expression in triple-negative breast cancer (TNBC) is an independent prognostic marker for survival. To the best of our knowledge, no systematic review or meta-analysis has ever been done on this topic. The present systematic review aims to evaluate the role of mesothelin as a prognostic marker for TNBC. The primary objective of this review is to synthesize available evidence on the association between the expression of mesothelin and overall survival (OS) of patients with TNBC. The secondary objectives include determining the relationship between the expression of mesothelin and disease-free survival (DFS), distant metastases, and mortality. Despite some limitations, this study shows a significant association between mesothelin expressions and long-term OS rate as well as DFS rate and mortality rate in patients with TNBC. Mesothelin has a prognostic significance for patients with mesothelin based on our findings. Patients with mesothelin-positive TNBC could benefit from mesothelin-targeted immunotherapies in development.

Hip fractures are common injuries with devastating consequences, including high rates of morbidity and mortality. The purpose of my thesis was to lay the foundation for further research which can fully explore: i) the epidemiology of morbidity and mortality following hip fracture; ii) risk factors for poor outcomes following hip fracture; iii) causes and pathways to mortality following hip fracture; iv) secondary prevention of morbidity and mortality following hip fracture; and v) potential interventions to improve outcomes following hip fracture. To this end, I will first detail the design, execution, results, and ‘lessons learned’ of a prospective observational pilot cohort study that recruited 100 consecutive patients aged ≥18 years presenting with a hip fracture to the Juravinski Hospital and Cancer Centre of the Hamilton Health Sciences. The primary aim of this pilot study was to assess the feasibility of a larger prospective international cohort study. Second, I will present a systematic review and meta-analysis of a promising intervention that consisted of multi-disciplinary (specifically geriatrician-led) co-management of hip fracture patients. This intervention has previously been shown to reduce mortality and length of stay following hip fracture. The meta-analysis presented will determine the effectiveness of this intervention in reducing the incidence, duration, and severity of delirium—a common condition following hip fracture. / Thesis / Master of Science (MSc)

Background: Cannabis is increasingly used for management of chronic pain; however, the benefits and harms of this therapy remain uncertain. We conducted a systematic review to inform harms associated with inhaled cannabis for chronic pain. Methods: We searched MEDLINE, EMBASE, PsychInfo, and Web of Science for non-randomized studies reporting on harms associated with inhaled cannabis use, from inception to October 6, 2021. We used random-effects models for meta-analyses and assessed the certainty of evidence using the GRADE approach. Results: We identified 29 eligible studies enrolling 174,562 participants that reported 145 adverse events. Moderate certainty evidence suggests inhaled cannabis use is probably associated with dry mouth (prevalence: 56%; 95%CI 49 to 64), thirst (prevalence: 44%; 95% CI 33 to 55), fatigue (prevalence: 38%; 95%CI 31 to 45), nausea (prevalence: 17%; 95%CI 8 to 27), increased appetite (prevalence: 13%; 95%CI 9 to 18), dizziness (prevalence: 10%; 95%CI 6 to 14), diarrhea (prevalence: 9%; 95%CI 3 to 18), confusion (prevalence: 9%; 95%CI 5 to 13), mood changes (prevalence: 8%; 95%CI 4 to 15), hallucinations (prevalence: 7%; 95%CI 4 to 10), amnesia (prevalence: 6%; 95%CI 3 to 11), impaired coordination (prevalence: 5%; 95%CI 4 to 6), and disorientation (prevalence: 3%; 95%CI 1 to 7). Moderate certainty evidence shows that, compared to non-users, inhaling cannabis is probably associated with increased risk of shortness of breath (risk difference [RD]: 7%; 95%CI 4 to 10). Conclusions: Our review found moderate certainty evidence that dry mouth, thirst, and fatigue are probably frequently experienced with inhaled cannabis use. Several other adverse events are also probable associated with inhaled cannabis use but were less common. Rigorously conducted cohort studies are needed to inform harms associated with inhaled medical cannabis for chronic pain. / Thesis / Master of Science (MSc) / Increasing recognition of harms associated with long-term opioid therapy for management of chronic pain has generated enthusiasm for alternatives, including medical cannabis which is often consumed through inhalation. This review assesses the harms associated with the use of inhaled cannabis for management of chronic pain. Among serious adverse events, we found that inhaled cannabis is likely associated with amnesia, disorientation, impaired coordination, hallucinations, confusion, dizziness, chronic wheeze, and shortness of breath. Inhaled cannabis may be associated with palpitations, paranoia, anxiety, and cannabis dependence. The effects of inhaled cannabis on lung cancer, depression, and psychosis were uncertain. Among less serious adverse events, we found that inhaled cannabis is likely associated with thirst, fatigue, increased appetite, nausea, mood changes, diarrhea, and dry mouth. Inhaled cannabis may be associated with red eyes, vomiting, phlegm, asthma, and cough. The effects of inhaled cannabis on euphoria and irritability were uncertain.

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