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BMC Medical Ethics
How do parents experience being asked to enter a child in a randomised controlled trial?
Valerie Shilling1 &
Bridget Young1
BMC Medical Ethics volume 10, Article number: 1 (2009) Cite this article
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As the number of randomised controlled trials of medicines for children increases, it becomes progressively more important to understand the experiences of parents who are asked to enrol their child in a trial. This paper presents a narrative review of research evidence on parents' experiences of trial recruitment focussing on qualitative research, which allows them to articulate their views in their own words.
Parents want to do their best for their children, and socially and legally their role is to care for and protect them yet the complexities of the medical and research context can challenge their fulfilment of this role. Parents are simultaneously responsible for their child and cherish this role yet they are dependent on others when their child becomes sick. They are keen to exercise responsibility for deciding to enter a child in a trial yet can be fearful of making the 'wrong' decision. They make judgements about the threat of the child's condition as well as the risks of the trial yet their interpretations often differ from those of medical and research experts. Individual parents will experience these and other complexities to a greater or lesser degree depending on their personal experiences and values, the medical situation of their child and the nature of the trial. Interactions at the time of trial recruitment offer scope for negotiating these complexities if practitioners have the flexibility to tailor discussions to the needs and situation of individual parents. In this way, parents may be helped to retain a sense that they have acted as good parents to their child whatever decision they make.
Discussing randomised controlled trials and gaining and providing informed consent is challenging. The unique position of parents in giving proxy consent for their child adds to this challenge. Recognition of the complexities parents face in making decisions about trials suggests lines for future research on the conduct of trials, and ultimately, may help improve the experience of trial recruitment for all parties.
When parents are asked to consider enrolling their child in a paediatric clinical trial their primary responsibility is the best interests of their child. This role is very different to an adult deciding about their own participation in a trial, whose role involves exercising individual autonomy [1]. Grappling with complex, medical information is always part of trial decision making but when this is on behalf of a vulnerable and dependent child, rather than to serve one's own rights and interests, the decision will likely feel more serious and possibly overwhelming. Despite this fundamental difference between trials in adult and paediatric medicine, relatively little is known about how the particular role of parents influences the communication about a trial. Insight into this is important if we are to improve families' experiences of trial recruitment, as well as optimise enrolment procedures and suggest appropriate directions for future research.
In this paper we will argue that when parents are approached about a trial for their child, the decision is influenced by particular considerations and requires special management. We will discuss evidence on the complex experience of parents when considering trial entry for their child, what trials mean to them and what contextual factors impact on their experience of decision making. We have drawn primarily on studies which have a qualitative design, though we have included a wider body of evidence where it offered useful insights. Studies using qualitative methodology were specifically targeted because they access participants' accounts in their own words, allowing more scope to explore their meanings and experiences and making fewer assumptions about what is important to them [2].
This discussion does not aim to make specific recommendations for how to discuss randomised clinical trials with parents, rather its intention is to increase awareness of how parents make sense of trials and suggest directions for future research to improve the experience of recruitment to trials from the perspective of all parties involved.
Vulnerability, responsibility and regret
For parents the diagnosis of serious illness in a child can be a shattering experience [3]. When consent is sought soon after diagnosis, parents will be making decisions when they are distressed and vulnerable [4–6], whilst simultaneously trying to comfort their sick child. Being approached about a trial confronts parents with a volume and complexity of information well beyond their everyday experience and they can never be certain about what is the 'right' decision. However, whilst they may be vulnerable, protecting their child is fundamental to the parental role and this will shape how they think about trials. Parents in one study felt personally and directly accountable for their child's outcome on a trial and thought that giving consent for a child would be much more difficult than deciding to take part in a trial themselves [7]. Survey evidence confirms that the responsibility to act in the best interests of one's child is keenly felt, with one third of parents in one study reporting that while they might accept certain research risks for themselves they were much less certain about accepting the same risks for their baby [8].
The sense of responsibility that accompanies parents' decision making about trials may paradoxically render them more vulnerable, especially to the anticipation of regret [9]. Mothers whose children were enrolled into a bone marrow transplant trial dreaded the possibility that they might have to live with the knowledge that they had made the 'wrong' decision and this was intensified when things did not go well for the child [10]. Mothers of children with leukaemia [11] felt highly dependent on clinicians and experienced considerable unease in making decisions about trials with little grasp of the disease. People are motivated to avoid regret by making decisions that minimise its likelihood [12] and the more important the outcome, the greater the anticipation of regret particularly if the outcome is irreversible [13]. In view of the roles and responsibilities of parenthood, the anticipation of regret about potentially 'failing to protect' one's child may be a major influence on parents' decisions about trials. Canvin and colleagues speculate that the sense of responsibility surrounding the trial decisions of parents of children with epilepsy was eased by the voluntary and reversible nature of the decision [14]. However, when things do go wrong, people experience more regret for acts of commission (doing) than for acts of omission (not doing) [15], and think more about harm caused by direct action than about indirect harm [9]. Therefore, parents may hesitate to vaccinate their child even under conditions where the likelihood of a fatal side effect is only a fraction of the death rate from the disease [16], presumably because anticipated regret looms larger for the act of vaccination. As yet no research has looked at whether parents respond in the same way to trial participation – rationalising that not participating minimises the chance of regret and is the 'safest' option.
Understandings of events can, of course, be retrospectively shaped and reconstructed to manage regret. Parents who consented their child to enter the ECMO trial [17] constructed randomisation as offering protection from responsibility should the child have a poor outcome. This protection could be extended to doctors, who in the eyes of some parents could not be held responsible when there was uncertainty as to the best treatment. Some families constructed their views about which is the 'best' arm of the trial based around which arm they were allocated to – for example, some who were allocated to conventional treatment focussed on the likelihood that this avoided the risks associated with the treatment arm and need for transfer to another unit [17].
Recognising this difficult situation for parents, the incompatibility of wanting to do what is best for the child but not knowing what the best course of action is, may be critical in understanding how parents respond to clinical trials. What may seem to the trialist as a misunderstanding of trial rationale may be the parent constructing the situation in a way which is acceptable to their need to protect their child.
The parental role and the function of consent
Decisions about trial entry may be a source of intense emotional strain for parents but being offered options about their child's treatment and research participation is likely to serve important psychological functions, particularly at times when there is little else parents can do instrumentally for the child. Parents of children hospitalised for spinal surgery described the "loss of parental role" and the accompanying helplessness and frustration they experienced as being of a similar magnitude as their distress about the potential of poor surgical outcome and watching their child in pain [18]. The process of consent itself could function as a symbolic acknowledgement of their role when there is little else parents can do.
When asked their views on Zelen randomisation (single consent method), parents whose baby was involved in a conventionally randomised trial were evenly divided on its acceptability [19]. With this method, randomisation takes place prior to discussion with the family. If the child is allocated to the conventional treatment arm, they are not informed about the trial. Only if the child is allocated to the experimental arm is consent sought. In offering 'protection' from the difficulties of trial decision making, the knowledge that there are treatments which they cannot access, and from the knowledge that treatment is determined by chance, this approach might be considered 'kinder' to those families allocated to the conventional treatment arm. However, Zelen randomisation was viewed negatively by some parents because they perceived it as preventing the sense that they were operating in the best interests of their child. As difficult as the decision on trial entry was for parents, they felt it was theirs to make [19]. Similarly, parents who participated in a survey investigating different types of consent to hypothetical neonatal resuscitation trials were more comfortable with prospective consent than with consent which was deferred, waived or required the parent to 'opt-out'. They wanted to be informed about the trial and make the decision themselves [20]. Other surveys provide further evidence that parents value their role in decisions about trial entry – over 90% say they do not want the doctor or nurse to decide on their behalf [21, 22, 8]. Parents upheld these views even when they realised that the quality of their consent was limited or experienced the informed consent process as an additional burden [23], indicating that consent could indeed serve important symbolic functions. Research on trials which involve deferred or waived consent [24] could further inform ideas about the social function of consent and processes of regret, both of which might be configured rather differently depending on whether consent is conventional, waived or deferred.
Bioethicists and others have pointed out that informed consent did not develop to safeguard autonomy, rather its primary purpose is to preserve well-being [25, 26]. Allmark and Spedding suggest that parental consent for clinical trials is important as a social recognition of the role of parents, but offers little additional protection for children to that provided by appropriate research ethics, safety monitoring and governance procedures. From this position the quality of parental consent might be less critical, and their decision making difficulties could be eased by knowing about ethics [23] and other research safety and governance procedures. Of course, this assumes parents can be confident in the protection offered by research governance and monitoring but a recent review suggests that safety monitoring in paediatric trials may have been inadequate in some cases and highlights the need for monitoring of all paediatric trials [27]. At the same time as wanting the option to decide, parents value doctors' advice about trials [28] and some look to share responsibility for their decisions with practitioners. In one neonatal study three-quarters of parents believed their doctors would not ask to do research if it might put babies in real danger [8] and half indicated that they trusted their doctor and if he or she suggested their baby should enter a trial, they would agree. Though they have authority for their child, parents lack expertise in matters related to the child's illness, and as a consequence, are likely to rely heavily upon the expertise of medical practitioners.
The role of parents in trial decision making is therefore complex – they can be simultaneously responsible for their child and dependent on practitioners. The challenge for trialists in discussing paediatric trials with parents is to balance the tensions this brings, so supporting parents' decision making appropriately and guarding against the possibility of regret [7]. Research on how this might be achieved is much needed. The potential for emotional conflict is apparent in the accounts of parents of babies receiving treatment on NICU [29], who were united in wanting to be considered the primary decision-maker for their baby, but were much less consistent in wishing to be actively involved in decisions which they viewed as serious. The authors suggest that asking parents to do so could carry high 'psychological costs'.
Threat, hope and certainty
The seriousness of the child's condition and the urgency surrounding trial entry will be important influences on how parents experience recruitment to trials, their sense of vulnerability, and the success of communication [23]. In turn, these will have consequences for whether parents retain a sense that they have operated in their child's best interests [30]. Parents considering oncology and neonatal trials report particularly high levels of distress during trial discussions and a sense that this impairs their ability to ask questions or seek additional information [31] occasionally leading them to later doubt their decisions [32]. In these situations the thoughts and emotions of parents are dominated by the fact that they have a very sick child [33] or worse, the fear that their child might die [34]. By contrast, parents of children with less serious chronic illnesses report more comfort in making decisions about trial entry [32] and in judging what is in the best interests of the child because they have experience of the disease. It follows that parents' priorities will vary with the seriousness of their child's illness. For example, parents of children participating in research on mild to moderate asthma rated "learn more about disease" as the primary motivation (from 14 choices) [35]. In chronic childhood illness, the day to day management of the condition, the child's quality of life and the simple practicalities of trial participation may gain importance. This is in marked contrast to parents of children whose lives were in the balance, some of whom struggled even to understand or recall that research participation was voluntary [10].
Parents' worries and misperceptions provide further insights into what trials mean to them and point to specific sources of difficulty in communication. The worry that their child might be randomized to the less effective treatment [31] and the responsibility that they would feel if the child later deteriorated are particularly common [1]. On finding that their child has been allocated to the standard treatment arm, parents sometimes report a sense of disappointment or missed opportunity, as if the child has been deprived of a known beneficial treatment or has 'failed' the selection process. Some mothers felt resentment that they had been asked to go through the trauma of deciding about trial entry for 'nothing' [11]. Others viewed randomisation as a way of allocating limited resources and expressed guilt that their child had been allocated the experimental arm while others had only received conventional treatment [17, 36]. Founded on a difficulty in accepting that there is uncertainty about the effectiveness of trial treatments or an assumption that the experimental treatment will necessarily be superior, these responses remind us that in the face of intense threat and uncertainty, parents look for hope and certainty. In such circumstances it is not surprising they find the uncertainty that is intrinsic to trials challenging both cognitively and emotionally, or that they are liable to construct trial treatments as the answer to their child's needs.
The generally high rates of recruitment to trials in neonatology [37] and childhood cancer [38] suggests the level of threat and parents' consequent needs for hope could be important influences on how they view trials. Parents of chronically and terminally ill children stated that they were prepared to take greater risks in treatment in the hope of a cure [7]. Similarly, parents' decisions about Phase 1 cancer trials, which can bring side-effects and offer little chance of long term medical benefit, may turn upon a fear of 'giving-up' on their child and the need to 'leave no stone unturned'[39, 40]. High recruitment rates may also be testament to the importance that is deservedly placed on research in neonatology and childhood cancer by both parents and trial staff [41, 42]. But they could also be a sign of parents' reluctance to decline a trial where it involves saying "no" to the clinical team on whom their child's care depends. By contrast parents of healthy children considering participation in vaccine research believed that children should only take part in research where the medical benefits outweigh any potential risk [43]. Work comparing what researchers say and intend when they discuss trials with parents, and what parents interpret from these discussions will yield further insights into the challenges for both parties [44] and how they co-construct their views of trials and their respective roles.
In deciding about hypothetical research scenarios, parents and children were more likely to respond intuitively and emotionally to research information than to systematically attempt to consider and weight all the available information. The result was that the 'information' participants used to underpin their decisions was often very different to the information that the researchers intended them to use [45]. Participants' emotional responses to information were shaped by their particular life experiences. Similarly, Chantler and colleagues report that parents who received the same information about a vaccine study varied widely in their perceptions of the risks of the trial, with some seeing it as potentially dangerous while others viewed it as safe with no negative effects. Parents from a professional background in science or ongoing experience of medical care were less likely to cite anxiety and unfamiliarity as a reason for declining the trial, and in the view of the authors, were more open to research and better able to judge the trial's importance and value [43].
If the same information can mean different things to different people, clinicians' assessment of risk will also be influenced by their professional experience, and trial risks as seen by parents may be very different to those perceived by trial staff. Moreover, relative risk, a concept familiar to clinicians accustomed to the uncertainty that is intrinsic to medical practice, could seem very different to parents for whom even improbable risks may be intolerable [46]. Parents and investigators agreed that the risks associated with participation in clinical anaesthesia or surgery research was the most important information to disclose, but parents were more convinced than the investigators of the importance of disclosing the benefits of the research [47]. One interpretation is that risks resonate more deeply with parents and they therefore need to balance these with positive information. Similarly, clinicians viewed the CANDA trial as a low risk, routine trial of broadly equivalent interventions [48] but many parents consenting to the trial viewed it as offering an otherwise unavailable option which might save their baby's life. To the clinician research can be considered low risk when it involves no greater risk than conventional treatment. To the parent everything is high risk because they have a sick child.
The contrast between parents' and clinicians' and trialists' views warrants further investigation but it is unlikely that parents always approach decisions about trials in the way imagined by some – a rational and mechanistic process of weighing up all of the available information before reaching a decision [45, 49]. Associated with a 'rational choice' model of trial decision-making is the assumption that communication is a mechanistic and technical matter of assembling and transmitting the 'correct' information but successful communication about trials or any other topic is more than a technical matter [50]. It is a dynamic, social and emotional process in which the parties interact to construct meaning. Their interaction will be shaped by the particular context and nature of the trial, the hopes, fears, expectations and obligations the parties bring to the trial discussions, and those that continually emerge during the course of discussions and in their later reflections.
Individual and group differences in trial perceptions and information preferences
Even in life threatening situations, not all parents will experience trials as adding "stress to an already stressful situation" [22]. Wide individual differences in parents' responses to being approached about trials have been reported with 20% reporting that the trial reduced their anxiety, 56% felt it made no difference and 24% reporting that the trial increased their anxiety [51]. Associations between anxiety and the decisions parents make about trials have also been observed. Parents who decline trials report higher anxiety, rate the risks of the trial as higher [52] and are more likely to fear randomisation [53], but one study found consenting parents were more anxious than those who declined [54]. Rather than being straightforward the relationship between anxiety and trial decisions may be mediated or moderated by factors such as trust in medical research [55] and the parent-practitioner relationship [56].
Parents also vary in their preferences for trial information [57], some wanting more information whilst others feel overwhelmed by information and want less [58]. Miller and colleagues reported a trend for more information to be associated with greater parental anxiety and less control [59], which may be exacerbated by detailed information on the toxic effects of treatment or mortality rates. Of course, the anxiety experienced by parents will itself impact on their experience and interpretation of the trial information and discussion [60]. In one study of parents of children considering an oncology trial, those with higher levels of anxiety were more likely to report that the risks associated with trial entry were not clearly explained [61]. Getting the level of information right is an important challenge – one study of parents' attitudes to their child's enrolment in a trial of antiretroviral therapy reported a significant relationship between perceiving that information was lacking and unwillingness to enrol in future trials [62]. Similarly Tait and colleagues report that parents who were more satisfied with the clarity and quantity of trial information were more positive about the trial than parents who were dissatisfied with the information [63]. Researchers have suggested a 'goodness of fit' approach between the person and the amount of information given [64].
Discussions about trial participation may have lasting effects for those who decline trials as well as those who accept. Non participants report inaccurate [65] or even harmful misconceptions [48] after being approached about research. Those conducting trials need to understand the processes that underpin these difficulties if they are to be ameliorated. Concern that those who decline or drop out may come to regret their decision [65] might be extended to consider how individuals approached about trials may differ in their tendency to trust others. Evidence suggests that a substantial minority of people find it difficult to trust other people [66] and are less likely to perceive relationships with health professionals as supportive [67]. Such people may be especially at risk of harmful misconceptions if trialists cannot vary their approach according to individual needs. Indeed, the assumption that 'good' communication is synonymous with providing information that is ever more specific or systematic runs counter to the requirement, in complex discussions about trials, to select and tailor according to individual need [59]. There is, of course, a baseline level of information necessary for informed consent [25]. Beyond this, trialists and ethicists could consider how far communication about trials can be configured around the needs and preferences of individual parents [68] as well as the social norms of the setting [25].
Of the few studies that have considered group differences in trial recruitment, most have focussed on families of children with leukaemia. How parents from different socio-demographic backgrounds experience trials has not been explored, though researchers have investigated group differences in rates of trial participation and researcher-defined understanding of trials. Miller and colleagues [59] report that low socio-economic status (SES) and membership of a minority ethnic group (in this case largely Hispanic) was associated with lower understanding of key components of informed consent. A related study reported no differences in likelihood to enrol a child in a trial between English speaking majority parents, English speaking minority parents and non-English speaking minority parents [69]. Parents in the non-English speaking group asked fewer questions than parents in the other groups. The authors link this to Latino cultural norms such as 'respeto' and 'fatalismo' which discourage questions and interactivity and encourage the idea that God will decide the fate of the child [70]. Emphasising the diversity that also exists within different ethnic groups [70] the authors point out that such traditional values are far from uniform within Hispanic groups and tend to be less common in immigrant groups with high SES.
Beyond oncology, research on group differences is limited. Harth and Thong reported that, among other characteristics, parents who put their child forward for an asthma trial were less educated and from less advantaged backgrounds than parents who declined [71] while a study of factors influencing consent to a neonatal trial found no such differences [28]. Tait and colleagues [72] report that greater understanding of 11 key elements of consent (to clinical anaesthesia or surgery trials) was positively associated with parents' educational level but not ethnicity and that understanding was higher in consenters than non-consenters.
Of course, a parent can only understand and recall information if it has been provided in the first place. Miller and colleagues [59] report that practitioners provided less information to ethnic minority parents and parents with low SES and were less likely to ask their opinion or encourage questions. Simon and colleagues [69] also found that non English speaking minority groups were given less information and clarification of features such as randomisation and right to withdraw than either the English speaking majority or minority groups.
Noting how the content of trial discussions and researcher-defined quality of the consent were linked to parental ethnicity or clinician attitude towards parental ethnicity, Simon and Kodish [70] emphasise the danger of making assumptions based on ethnicity or socio-economic factors, which may contribute to the omission of important information for families. However, reports that lower SES is related to less information giving by practitioners, but also to lower anxiety and a greater sense of control among parents [59] point to competing interpretations of group variations. They could represent clinicians' attempts to empower parents by tailoring communication to their needs and avoiding overwhelming them with information.
While it is often reported that parents from minority groups or disadvantaged backgrounds are less likely to understand trials (e.g. [73–75]), little research has investigated how parents from different social and ethnic groups experience being asked to consider a trial for their child. Research of this sort could inform efforts to meet the needs of families from different backgrounds when they are approached about trials.
Although qualitative research on the attitudes, understanding and concerns about medical research has been conducted amongst adults in developing countries (e.g. [76]), the authors are not aware of any qualitative studies that report the experience of being asked to consider a randomised controlled trial for a child, from the perspective of parents in developing countries. Important questions surround the recruitment of children to trials in developing countries and researchers conducting such trials undoubtedly face particular challenges in managing recruitment in societies which are more family and community orientated and less individualistic than developed countries [76]. This represents another important gap in the literature.
Faith and trust in medical care
Good relationships and communication between parents and their clinician offer parents a sense of understanding, safety and trust [59] which in turn may influence decisions about trial entry [77]. Parents considering a cardiac trial expressed a preference for the trial to be explained to them by their cardiologist or surgeon rather than the principal investigator or the research coordinator suggesting that the clinical relationship provides some comfort for families when considering trials [78]. By contrast, lack of confidence in the doctor has been associated with increased difficulty in decision making about trial entry [1]. The relationship with the clinician and its impact on the decision making process may be different across trials. Whilst oncology and neonatology tend to see good rates of trial participation, trial discussions in these settings often take place within hours or days of the family's first meeting with the clinical team suggesting that trust is not necessarily dependent on the longevity of a relationship. Indeed, community-based trials where families will likely have long-standing relationships with their doctors tend to see much lower rates of participation [37]. Evidence that doctors who have long-standing relationships with families fear that an approach about research might damage the relationship [79] and might therefore be inclined to present trials less favourably, throws some light on these findings though more research is needed comparing trials conducted in different clinical settings to better interpret these patterns.
Others suggest that timing is crucial and discussing research may seem irrelevant and even insensitive in the immediate aftermath of diagnosis of life-threatening illness, unless handled in a way that allows families to feel the overall care and wellbeing of the child is the clinician's main aim [80]. But this raises yet another tension for trialists to negotiate – the therapeutic misconception. Thought to be at the centre of one of the most resilient misunderstandings about research, the therapeutic misconception describes the belief that the purpose of a clinical trial is to benefit the individual patient rather than gather data to develop scientific knowledge (National Bioethics Advisory Commission referenced in [81]). It can be a considerable struggle for patients and families to separate discussions about treatment options and management from those about trial participation [82, 4, 10], particularly when faced with serious illness. Adult patients with advanced cancer interpreted their doctor's offer to participate in a Phase 1 trial as meaning that the trial was the right thing for them [83]. However, the therapeutic misconception may itself be a mislabelling of the situation: a parent's hope that a child may receive a treatment that is later shown to be better than the standard treatment is not fundamentally misinformed, as this is itself the purpose of the trial [23]. The other features of trials such as follow-up visits and extra time spent discussing the child's condition are often perceived by parents as direct benefits of participation (e.g. [84–87]). Given the complexities of trial communication when a child's life is threatened, the therapeutic misconception does not necessarily reflect a straightforward failure of the researcher to adequately explain the research methodology or of the parent to understand it. Indeed, it may be harmful for parents to abandon the therapeutic misconception altogether, as doing so could be tantamount to losing hope and trust in medical practitioners. As Snowdon and colleagues suggest, where care and research become completely disconnected in people's minds, the result may be an "injurious misconception" whereby simply being approached about a trial triggers a disproportionate sense of risk and threat [48].
Putting others first?
Altruism is frequently cited by researchers and parents as a motivation for consenting to paediatric trials, but the weight of the obligation to protect one's child means it is unlikely that it is an overwhelming consideration when parents are deliberating whether to enter their child in a trial. Regardless of whether they declined or accepted, the primary concern for parents considering an anaesthesiology trial was the child's safety [88]. Similarly, while parents believe that clinical research with children is important, they do not necessarily wish to involve their own children in that research [7] and their primary objective is to protect their child from harm [8]. When considering hypothetical, non-beneficial research, Reynolds and Nelson report that parents and children would quickly evaluate the procedural risks of a study and reject or provisionally accept on that basis before considering reasons for participation such as altruism [45]. Hence, fathers of children with cancer were far more likely to reinforce altruism as a reason for research participation when the research was non-invasive but where the research involved the child physically, altruism was not seen as a sufficient reason for taking part [5]. Parents of children in Phase 1 cancer trials where the benefits to others most clearly outweigh the individual gains, spoke of 'carrying on the fight' and 'not being ready to let go', while others clung to the hope of a miracle cure or buying enough time for some other treatment to become available [89]. Understandably, participating in such a trial was seen by parents as a way to do everything they could for their child.
Nevertheless, around two thirds of discussions between parents and practitioners about childhood cancer trials contained some mention of altruism, though it was usually raised by clinicians rather than families [90]. There was no evidence that the mention of altruism affected trial recruitment rates suggesting that it was not coercive, but a number of other studies report altruism to be a motivating factor for parents considering trial entry [28, 91, 92]. In some cases this could be an artefact of the study design: where people are asked retrospectively to indicate a rationale for their actions they can endorse motivations which construct these in a socially desirable light whilst free of other demands. Though it is questionable how far altruism motivates parents to include their children in trials, they may use it functionally as a way of justifying their decision after it has been made. This might be particularly likely where a child has a poor outcome or if a child dies. For bereaved parents, altruism may be a way of finding some small comfort that their child might live on through the lives of those who benefited from the trial [90], and in this way a trial might give some kind of meaning to a loss that otherwise seems unjust and meaningless [89]. It can also be a way of making sense of a complex situation. Entering a child into a trial confers no guaranteed benefit whilst introducing an element of uncertainty into the child's treatment. In reflecting on such a difficult decision parents might look for some positive anchor with which to justify what in some respects is a counterintuitive step. It may be that the promise of benefit to a "future generation" provides such an anchor [90]. It is difficult to uncover these nuances in how families make sense of trials in studies that use questionnaires. The same criticism applies to qualitative research which treats participants' accounts as faithful descriptions of their experiences, rather than as constructions which need to be interpreted in the light of the social context and functions they serve [93, 94].
Sharing responsibility with the child
We have argued that responsibility rather than autonomy is central to understanding the situation of parents when they are approached about trials in paediatrics. However, parents face a new set of issues when their child is old enough to have an opinion on whether they wish to participate in a trial, when the need to protect one's child might come into conflict with the child's wishes. The available evidence indicates that parents negotiate this by allowing the young person to have "their say" in the decision, whilst retaining responsibility for the final decision themselves [95]. Under certain circumstances parents may encourage or persuade children to take part in research: parents of children who had asthma, diabetes, epilepsy or no chronic condition who were considering hypothetical trials [96] and mothers of children with diabetes considering entry to a real trial [84] were prepared to persuade their child to enter a study if they believed that the benefits of participation outweighed the child's fears. Particularly where the child has a life-threatening illness some parents will exclude the child from the decisions about research altogether in order to protect them from distressing information, while other parents will include the child in discussions but make the final decision themselves [97]. This contrasts with studies of hypothetical trials where parents tend to report that the decision-making process was a collaboration with their child. It is likely that the degree of collaboration is related to the threat to the child [7, 96, 98] and to the cognitive capacity of the child [96]. Considered alongside a study examining willingness to participate in hypothetical asthma trials which suggested that adolescents were significantly more willing than parents to enrol in above-minimal risk research [99], this raises further complexities for paediatric trialists. The parents' move from active participant to passive observer in trial decisions as their child grows older is an important area for future research [7].
• In contrast to the autonomy that typifies the situation of adults when they are themselves approached to participate in trials, when parents are asked to consider entering a child in a trial their decision might best be characterised as one that embodies an obligation of responsibility.
• Some parents will see trials as a threat to their child or fear regretting their decision, whilst others see trials as offering hope of better treatments for their child. Almost all parents cherish their role in protecting children and want to secure the best outcome for them, but many are aware of complexities of the medical and research context and how this constrains their fulfilment of this role.
• The conduct of trials with children may benefit from a better understanding of the special situation of parents and their particular need for support that allows them to retain a sense that they have safeguarded their child's interests.
• Research is needed on how this may be realised in practice whilst observing medico-legal requirements. Thinking of consent as a social recognition of the parental role and aiming for 'best possible consent' may open up opportunities to develop approaches to trial communication which incorporate the flexibility for parents to construct what is for them a meaningful understanding of the research, as well as a meaningful exercise of parental responsibility.
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The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6939/10/1/prepub
We would like to thank Professor Paula Williamson for her comments on an earlier version of the manuscript and the reviewers for their helpful suggestions.
The preparation of this paper was supported by a project funded by the NIHR Health Technology Assessment programme (project number 05/516/08). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Department of Health.
Division of Clinical Psychology, School of Population, Community and Behavioural Sciences, Whelan Building, Quadrangle, University of Liverpool, Brownlow Hill, Liverpool, L69 3GB, UK
Valerie Shilling & Bridget Young
Valerie Shilling
Bridget Young
Correspondence to Valerie Shilling.
VS and BY contributed equally to the preparation of this manuscript.
Valerie Shilling and Bridget Young contributed equally to this work.
Shilling, V., Young, B. How do parents experience being asked to enter a child in a randomised controlled trial?. BMC Med Ethics 10, 1 (2009). https://doi.org/10.1186/1472-6939-10-1
DOI: https://doi.org/10.1186/1472-6939-10-1
Parental Role
Trial Participation
Trial Decision
Trial Entry
Trial Recruitment
Submission enquiries: bmcmedicalethics@biomedcentral.com


text:
var acquit = require('acquit');

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# Mooring\n\n
[![Build Status](https://travis-ci.org/appersonlabs/Mooring.svg?branch=master)](https://travis-ci.org/appersonlabs/Mooring.svg)
[![Coverage Status](https://coveralls.io/repos/appersonlabs/mooring/badge.svg?branch=master&service=github)](https://coveralls.io/github/appersonlabs/mooring?branch=master)
[![bitHound Overalll Score](https://www.bithound.io/github/appersonlabs/Mooring/badges/score.svg)](https://www.bithound.io/github/appersonlabs/Mooring)

Born from a desire to have an API / hooks system that:\n
- Has a small API surfice
- Is easy to understand
- Has a data flow that is immutable
- Lets pre hooks manipulate the data going into a hooked method
- Lets post hooks manipulate the data coming out from a hooked method
- Not have the hooks stored on the prototype but rather in a seperate object

Credit to the [kareem](https://github.com/vkarpov15/kareem) & [grappling-hook](https://github.com/keystonejs/grappling-hook)
projects for their insight and the inspiration they provided (also some code ;).)\n\n

# API Spec\n\n
`

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redpajama_set_name: RedPajamaGithub


The Czech highest constitutional officials agreed at a meeting on Wednesday that it would be worthwhile to hold a comprehensive and open discussion devoted to the economic and political effectiveness of the anti-Russian sanctions within the European Council.
PRAGUE (UrduPoint News / Sputnik - 12th September, 2018) The Czech highest constitutional officials agreed at a meeting on Wednesday that it would be worthwhile to hold a comprehensive and open discussion devoted to the economic and political effectiveness of the anti-Russian sanctions within the European Council.
Earlier on Wednesday, Czech President Milos Zeman, Speaker of the country's lower house Radek Vondracek, Prime Minister Andrej Babis and Foreign Minister Jan Hamacek held a meeting devoted to the issues relating to the county's foreign policy.
"Concerning the sanction regime of the EU against the Russian Federation, the officials stated that the reasons, which led to the introduction of the sanctions, persist ... The officials also agreed that a complex and open discussion on this topic at the level of the European Council would be useful, including the assessment of the economic and political effectiveness of the sanctions in connection with the procedure of their extension," the joint statement, adopted following the meeting, read.
The situation with the US-China trade wars, the exit of the United Kingdom from the European Union and the Czech Republic's upcoming presidency in the Visegrad Group were among other issues discussed at the meeting.
The relations between Moscow and Western states deteriorated over situation in Ukraine and Crimea's rejoining Russia. The West imposed sanctions against Russia over its alleged interference in the Ukrainian conflict. In turn, Moscow responded by imposing a trade embargo against the EU countries. Since then the Russian authorities have repeatedly stated that the use of sanctions against the country is counterproductive.


text:
Valentine's Day 2019: Two great recipes for dinner at home
Jenna Pelletier, Providence Journal
Valentine's Day is one of the few days of the year I intentionally opt out of dining out.
There are good restaurant experiences to be had on Cupid's holiday, of course. But to me, an essential part of a romantic dinner is the ability to linger over it, and that's often challenging on such a popular date night. You know what I'm talking about if you've ever experienced the discomfort of trying to decide what to order for dessert while other couples are side-eying your table from the waiting area.
So I usually cook — something richer and more complicated than I would normally make. I braised lamb shanks one year, and seared and simmered my way through Julia Child's Beef Bourguignon recipe another (worth the effort, but just be sure to start cooking around noon if you expect it to be done by dinnertime).
RELATED: Lobster tails are on sale for Valentine's Day. Great! But how do I cook them?
It's a tradition I've kept up whether solo or coupled. One year, when I was newly single, I labored over a New York Strip steak with mushroom sauce and garlic mashed potatoes for one. Mindfully savoring everything I had made, not wallowing in my newfound aloneness on the day of love, felt like a small victory.
When I do have a significant other, I'll often request that we please "save" the date-night dinner out for later in February, when many restaurants are a little less hectic, and then I'll start researching recipes for an elaborate meal at home.
These are the most romantic restaurants in the country
This year, though, I'm slightly altering my cooking plan, based on advice from Jeanie Roland, chef and co-owner of Ella's Food & Drink, in Westerly, R.I., and author of the new cookbook "Butter Love & Cream."
To my surprise, Roland encouraged me to forgo plans to make a complicated, blow-out dinner for my boyfriend, and take it easy in the kitchen instead. It wasn't the advice I was expecting from a chef who triumphed on the television show "Beat Bobby Flay" and taught superstar Taylor Swift how to make ricotta cheese and clarified butter.
5 unique Valentine's Day gift ideas for your loved ones
But indeed, Roland suggested making a quick dinner by whipping up a few simple appetizers that can be prepared mostly in advance.
"Take some pressure off, so you have time for romance," said Roland, who runs her Westerly restaurant and The Perfect Caper, in Punta Gorda, Florida, with her husband, James Roland. "Besides, who wants to canoodle by the fire after you've just had a big, heavy meal?"
Hmm ... good point. So, what to make?
Two starters from Roland's new cookbook, "Butter Love & Cream," fit the bill: Oysters On the Half Shell with Ella's Mignonette, and Lobster-Crab Cakes. Both feel indulgent and special, but don't take hours to prepare.
For days when a more involved meal is called for, her self-published cookbook also includes more time-consuming recipes, such as fresh Chitarra pasta with Shaved Brussels and Bacon, Slow-Roasted Coffee-Spiced Short Ribs, and Duck Dumplings.
The title, "Butter Love & Cream," references two of Roland's favorite ingredients, used liberally in the classical French cooking she was trained in. The other part relates to the passion needed to sustain years in the business, as Roland has at age 52. Ella's is currently in its seventh year of operation and The Perfect Caper is in its 19th.
"Cooking and being a chef are not things you can do half-way," Roland said. "You have to put love into it. And if you're not in that moment to make something, wait and do it when you are."
In fact, Roland spent years trying to write a cookbook. She finally finished it after foot surgery kept her on the couch for awhile. She started simply, by writing out her favorite recipes longhand on yellow legal pads.
"I've had the name of the cookbook in my head for 20 years, so when I finally got a copy, it was magical," she said. " I just wanted to stop and take it all in."
Not unlike a romantic dinner, at home or in a restaurant.
Oysters on the Half Shell with Ella's Mignonette
½ cup rice wine vinegar
½ cup cilantro, finely chopped
½ cup parsley, finely chopped
3 shallots, finely diced
3 serrano peppers, minced
1 teaspoon fresh ginger, grated
1½ tablespoons lime juice
1 tablespoon brown or natural sugar
1 dozen raw oysters
Thoroughly mix together all ingredients except for the oysters until well blended. Refrigerate until ready to use.
To serve, clean and open oysters, then set on ice. Top with sauce, as desired.
Yields approximately 2 cups.
Lobster-Crab Cakes
1 pound jumbo lump crab meat
1½ tablespoons grated fresh ginger
½ teaspoon fish sauce
2 tablespoons chopped cilantro
3 tablespoons minced green onion
1 tablespoon minced jalapeno
2 teaspoons sesame oil
½ cup panko
1 pound cooked lobster meat, diced
In a large bowl, mix together all ingredients except for the lobster. Once incorporated, gently fold in lobster. Chill mixture in the refrigerator for at least 4 hours before forming cakes. Tightly pack mixture into 12 evenly sized cakes, using an ice cream scoop to form, if desired.
Refrigerate until ready to cook.
When ready to cook, preheat oven to 400 F. Heat a nonstick pan lightly coated with cooking spray to medium-high heat. Cook cakes until golden brown on one side. Then transfer to preheated oven to cook for additional 5 minutes.
Serve with spicy mayonnaise, if desired.
Makes 12 cakes.
Recipes from "Butter Love & Cream" by Jeanie Roland.

redpajama_set_name: RedPajamaCommonCrawl


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AET Highlights
Conventional Shipping
STS Lightering
Shuttle Tankers
We Trade Globally
AET Chairman Mr Yee Yang Chien featured in Lloyd's 2017 Power List
We are pleased to announce that MISC President/Group CEO and AET Chairman, Mr Yee Yang Chien, is featured in Lloyd's Oil and gas shipping's 2017 Power List, which places him amongst the ten most influential figures in oil and gas shipping worldwide.
This annual list recognises the most impactful leaders in the industry by reviewing global candidates through a two metric criteria – their 'market weight' and 'aura'. 'Market weight' refers to the general influence of the candidate's company in the market, while 'aura' refers to the candidate's soft power to influence the industry by their individual investment decisions, public calls at conferences or other business behaviours.
Congratulations Mr Yee, on a significant acknowledgement. Click here to read the full article.
About Lloyd's List
Lloyd's List is an editorial analysis of corporations in the shipping industry, providing business-critical information for leading decision makers in the global shipping community. Drawing its analytical capabilities from Lloyd's List Intelligence and a global network of reporters with dedicated knowledge of key sectors and geographies, its target market comprises of major pillars of the industry, namely ship-owners, ship brokers, maritime regulators, government shipping, ship builders and energy firms, among others. Lloyd's List is the only information provider that covers all aspects of shipping, from finances and markets, to regulations and seafarers on the ship's bridge.
AET Offshore Celebrates 5-year Safety Milestone
On 21st December, AET Offshore (AETO) and the Global Lightering Team celebrated the remarkable accomplishment of now over five years Lost Time Injury (LTI) free (July 2015 – 2020). The...
AET receives ISO 37001 Anti-Bribery Management System certification
We are pleased to have received the ISO 37001:2016 certification which is the first international Anti-Bribery Management System standard designed to help organisations combat bribery risk in their own operations...
AET is honoured to receive the MPA Singapore International Safety@Sea Award
AET is honoured to be named as one of the award winners of Maritime & Port Authority of Singapore (MPA) International Safety@Sea Award for Outstanding Contribution to Search and Rescue...
AET at a Glance
STS Operations
Copyright © 2020 AET Tanker Holdings Sdn. Bhd.


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The Australian Children's Laureate Foundation relies on the skills, passion and abilities of many individuals in order to achieve its goals and meet its objectives. On this page you can find out more about partners and friends of the ACLF, the ACLF board, and ACLF office staff.
Partners & Friends of the Australian Children's Laureate Initiative
ACLF would like to thank our funding partners, sponsors donors and friends for helping us make the Australian Children's Laureate initiative a reality.
Major funding has gratefully been received from the Federal Government via the Australia Council for the Arts, the Copyright Agency Ltd Cultural Fund, the Australian Publishers Association, and the Australian Association of Independent Schools of Western Australia. Previous support from Bolinda Audio and the Cages Foundation was also vital to ACLF's development.
Other financial support has been received from the Children's Publishing Committee of the Australian Publishers' Association (APA), Australian Society of Authors (ASA), Children's Book Council of Australia and its branches, State Library NSW, State Library Queensland, National Library of Australia, MONA, Book Links Qld Inc, and the Department for Education and Early Childhood Develeopment (SA). Publisher support has been received from: Penguin Random House Australia, Allen & Unwin, and bookseller Mark Rubbo.
In-kind support has also been received from the volunteer ACLF board members, Books Illustrated, the Australian School Libraries Association, Scholastic Australia, the Micador Group, Splitting Image, Penguin Random House Australia, Allen & Unwin, HaperCollins Publishers Australia, the Australian Booksellers Association, and Carclew Youth Arts.
If you would like to support the Australian Children's Laureate Initiative by offering financial, in-kind or volunteer support, please contact ACLF via email on admin@childrenslaureate.org.au
The Laureate Patron: Noni Hazlehurst AM
Alison Lester AM, Noni Hazlehurst AM and Boori Monty Pryor. Photo credit: Andre Castellucci
Meet the ACLF Board
Bruce Ellis, ACLF Chair, Bruce is a Partner at PwC in Melbourne with over 30 years' experience in advising a broad range of clients with a focus on closely held private and family businesses and their owners. He provides independent advice to financially successful individuals, families and business owners. He believes that community and philanthropic organisations play a vital role in binding society together and has been involved in community organisations for 30 years in committee and office bearing roles. His belief in the power of storytelling and reading for his children led to him joining the Board of ACLF in October 2017. Bruce is a Fellow and Accredited Financial Planning Specialist of the Institute of Chartered Accountants in Australia. He holds a Bachelor of Business degree (with distinction) from RMIT.
Dr Robyn Sheahan-Bright, ACLF Deputy-Chair, has operated justified text writing and publishing consultancy services since 1997 and has published widely on children's and YA literature. She's judged several awards including being inaugural chair of the judging panel for the Prime Minister's Literary Awards (Children and YA) in 2010 and 2011. She began her career as a children's librarian, later co-established a small children's publishing imprint, and was also inaugural Executive Director of the Queensland Writers Centre (1991–7), of which she is a life member. She's currently President of IBBY Australia Inc. She was recipient of the 2011 CBCA (Qld) Dame Annabelle Rankin Award, the 2012 CBCA Nan Chauncy Award, and the 2014 QWC Johnno Award.
Ron Gorman, – Deputy Director AISWA, The Literature Centre, Board Member – Fogarty Learning Centre, Edith Cowan University, Convenor – Small Schools Collegiate Group. Ron Gorman is the Deputy Director of AISWA, a position he has held since 2008. Ron was the organisation's Senior Literacy Consultant and Projects Manager from 2000-2008. He is a former classroom teacher who taught in Victorian schools in the early 1980s, at Culunga Aboriginal School in Guildford WA in 1983, and at Lance Holt Primary School in Fremantle from 1984-1991. He was principal of Lance Holt from 1991-1999.
Laurine Croasdale has had a long career in publishing, working as an editor, packager and consultant in both Australia and the UK. She has written scripts for the television show Hi5 and had over 15 fiction and non-fiction books published for children. Her latest book, iHarry, was released by Penguin in 2011. Laurine also presents workshops to schools via video conference with Literature Live! and tutored at the Sydney Writer's Centre and the NSW Writer's Centre.
Kim Kane writes fiction for children and young adults published in Australia and overseas. Before she commenced writing full time, Kim was an intellectual property and commercial lawyer in both private practice and for a listed company. Prior to ACLA, Kim was the Vice Chair of Express Media Inc. She also sat on the board of the Australian Teachers of Media (Vic) (ATOM).
Mandy Vandenelshout is a media lawyer with the Australian Broadcasting Corporation. She assists program makers and journalists with defamation, contempt, contract, intellectual property, privacy and consumer law advice. She has also worked as the in-house lawyer for the ABC's Commercial arm dealing with all kinds of projects involving artists, authors, publishers and actors. She works with a number of community organisations including Primary Ethics. Mandy is also endeavouring to learn the Chinese language!
Bill Hanlon is a CPA accredited accountant and has worked in commercial organisations. He has also spent15 years working in the not-for-profit sector. This includes a volunteer position as a director on the board of a credit union rising to the position of chairperson over a 10 year period. Bill enjoys working as the Treasurer of ACLF, using his financial skills to assist in the important work of the Foundation.
Emily Banyard is a marketing, publicity and digital communications specialist. She started her career as a publicist at Simon & Schuster, Random House and Michael O'Mara Books in the UK. She then worked at arts consultancy FMcM Associates in London where her clients included authors and illustrators, publishing houses, literature festivals, books fairs, prizes, charities and arts organisations. She returned to Australia in 2017 and is currently Marketing and Communications Manager at the Australian Society of Authors.
The ACLA office Team
Lindy Batchelor, ACLF Program Manager, has always been an enthusiastic participant in the world of Australian children's literature. She has worked as a primary teacher; a librarian in schools and public libraries as well Taronga Zoo; author; reviewer; bookseller, and event coordinator for a children's bookshop. Lindy was the founding President of the Northern Sydney sub branch of the Children's Book Council of Australia, and is actively involved in various aspects of the Australian children's book industry, including her voluntary involvement with the NSW Committee of the Australian Children's Laureate Foundation since 2015. She is looking forward to her new role as Program Manager in working to help promote the ACLF's statement that 'reading changes lives'. Lindy works as a volunteer children's guide at the Art Gallery of New South Wales.
lbatchelor@childrenslaureate.org.au
Lee Burgemeestre, ACLF Office Administrator, is a graphic designer and illustrator. She has a Master of Fine Arts and a Diploma of Graphic Design. Early in her career she decided to focus her design expertise on education, health and the arts, as these are close to her heart. As well being a book designer and illustrator, Lee has lectured at Monash University and worked in design studios, theatre, and television post-production. She relishes finding the most artistic and functional approach to each project. Her close association with many people in the Australian children's book industry has made for a particularly delicious creative journey.
admin@childrenslaureate.org.au


Having successfully performed for numerous affairs and audiences throughout the states, our quality Greek bands provide custom music at a variety of events. We include a variety of Greek songs and dance music.
Having provided a variety of songs and dances, our Greek bands perform with exceptional talent. Having successfully performed in numerous affairs, we attribute our success by satisfying our clients and their guests in a professional manner. By doing so, we accomplish our repertoire of old, new, and topical Greek songs and dances. We provide an upbeat song selection, include a balance of Greek and American music, and are professional in stage presence.
We provide a complete entertaining package, providing live Greek and DJ-coordinated American music.
Having played Greek music for over 100 years, we provide a variety of music, including a variety of song solos and instrumental solos.
In addition to our band, we provide traditional ethnic Greek dancers and DJ services.


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Samsung Galaxy M30s - Price, Features and Specifications
Hans News Service | 30 Aug 2019 12:04 PM GMT
Samsung Galaxy M30s will give a fierce competition to Realme, Xiaomi, Oppo and other brand's phones under Rs 20,000 on this prominent feature
Samsung is all set to launch its next big mid-range smartphone Galaxy M30s in India. The Samsung Galaxy M30s will be unveiled in September, and the firm is focusing on offering superior camera, battery life and performance that too for a price lesser than Rs 20,000.
A 6,000mAh battery will power the Galaxy M30s device. This is the first handset from Samsung to have this massive battery. Also, this is the first handset in the country for less than Rs 20,000 to offer a 6,000mAh battery. Samsung will also support fast charging feature. The device will have a USB Type-C port with 3.5mm headphone jack. The handset will sport a triple-lens rear camera with a 48MP primary sensor along with 8MP and 5MP secondary sensors.
When it comes to display, the smartphone will feature a 6.4-inch Full HD+ Super AMOLED Infinity-U display or a U-cut punch-hole screen, for selfies, it will have a 13MP front camera. An octa-core Exynos 9 series processor will power the phone. The Galaxy M30s might run on Exynos 9610.
Samsung Galaxy M30s will be available in two RAM and storage options-- 4GB of RAM/ 64GB storage and 6GB of RAM/ 128GB storage. Both the variants will offer microSD card support. The device runs Android 9.0 Pie OS-based OneUI.


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Modeling small cigar smoke in the lungs
Distinguished professor Tony Wexler is modeling the smoke from small cigars and cigarillos to see where and how it settles in the lungs. Photo from Max Pixel (https://www.maxpixel.net/photo-2313673).
Posted by Noah A Pflueger-Peters
Everyone knows cigarettes are bad for you. Much research has been done and because of that, legislators have put a lot of sales restrictions and taxes on them. This is why companies are developing new products that deliver nicotine such as vapes, small cigars and cigarillos that have sugary flavors to addict a new generation of users.
These newer products have really caught on, especially with young people, who are adopting them faster than they can be researched or regulated.
Mechanical and Aerospace Engineering Distinguished Professor Tony Wexler looks to change this. He and his team recently received a three-year grant from the UC Tobacco-Related Disease Research Program (TRDRP) to study the health effects of small cigars and cigarillos, nicotine products sold in small packs and marketed as cheap alternatives to cigarettes.
"There's a whole bunch of new products out there and the FDA is scrambling trying to figure out how to regulate this stuff," he said.
Wexler, the director of the UC Davis Air Quality Research Center, has spent his career studying particles in the atmosphere and how these particles affect health. In this study, he'll look at how and where particles from these products settle in the lungs to determine the possible health effects. One thing they're going to look for is "hotspots" where the particles build up.
"We're especially interested in hotspots, because presumably it's those places in the lung where you get a lot of particle deposition and where you are therefore more likely to get cancer or have some other respiratory problem from smoking," he explained.
To study this, Wexler will work with researchers who will mathematically model smoke as it travels through the lungs using data from rats. The models will be used to translate the data to humans.
Understanding where these particulates settle in the lungs is key to understanding their short-term and long-term effects on humans.
"One of the goals of this project is to figure out if there are hotspots and if there are, where are they? And do these hotspots correspond to regions where other people observe cancer or emphysema or other kinds of respiratory illness?" he said. "Actually mapping the deposition has never been done before."
If the project is successful, Wexler plans to adapt this research for vapes, heat-not-burn cigarettes and other nicotine products.
Along with directing the Center for Air Quality Research, Wexler has appointments in the Departments of Mechanical and Aerospace Engineering, Civil and Environmental Engineering and the Land, Air and Water Resources.
Read more about Wexler and his research.
Portrait Image
Anthony Wexler
Distinguished Professor
Seongkyu Lee partners with Hyundai to develop low-noise air taxis
Why Drones Are Important in Sustainable Agriculture in the 21st Century
Space Engineering at UC Davis
Math breakthrough speeds supercomputer simulations
A Breath Test for Opioids


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