The association between off- and on-premise alcohol outlet density and 100% alcohol-attributable emergency department visits by neighbourhood-level socioeconomic status in Ontario, Canada.

Alcohol availability is positively associated with alcohol use and harms, but the influence of socioeconomic status (SES) on these associations is not well established. This population-based cross-sectional study examined neighbourhood-level associations between physical alcohol availability (measured as off- and on-premise alcohol outlet density) and 100% alcohol-attributable emergency department (ED) visits by neighbourhood SES in Ontario, Canada from 2017 to 2019 (n = 19,740). A Bayesian spatial modelling approach was used to assess associations and account for spatial autocorrelation, which produced risk ratios (RRs) and 95% credible intervals (95% CrI). Each additional off-premise alcohol outlet in a neighbourhood was associated with a 3% increased risk of alcohol-attributable ED visits in both men (RR = 1.03, 95%CrI: 1.02-1.04) and women (RR = 1.03, 95% CrI: 1.02-1.04). Positive associations were also observed between on-premise alcohol outlet density and alcohol-attributable ED visits, although effect sizes were small. A disproportionately greater association with ED visits was observed with increasing alcohol outlet density in the lowest compared to higher SES neighbourhoods. Reducing physical alcohol availability may be an important policy lever for reducing alcohol harm and alcohol-attributable health inequities.

Associations between noticing public health education campaigns about cannabis and risk perceptions in the northern Canadian territories: a cross-sectional study.

This study investigated whether noticing cannabis education campaigns was associated with increased cannabis risk perceptions in Canada's three territories following non-medical cannabis legalization. Data were from the Cannabis Policy Study in the Territories, including 2452 participants, age ≥16 years residing in Yukon, Northwest Territories and Nunavut. Poisson regression with robust standard errors were used to estimate associations between noticing cannabis education campaigns and moderate to very high risk perceptions of daily cannabis smoking, vaping, edible use and exposure to second-hand cannabis smoke, adjusting for sociodemographic characteristics and cannabis-use frequency. Results were compared with associations with risk perceptions of daily alcohol consumption and cigarette smoking, not included in cannabis education campaigns. Interactions were examined between noticing education campaigns and age group and cannabis-use frequency. Cannabis education campaigns were noticed by 40.4% of respondents, with lower awareness among those with lower education and income. Noticing campaigns was associated with higher risk perceptions of daily cannabis smoking [adjusted risk ratio (RRadj) = 1.09, 95% confidence interval (CI): 1.02-1.16] and vaping (RRadj = 1.09, 95%CI: 1.02-1.16). Significant interactions were not found with age group or cannabis-use frequency. Findings are consistent with modest effects of cannabis education campaigns. Approaches are needed to increase reach of cannabis education campaigns, including among groups with lower education and income.

Variability in public health programming and priorities to address health inequities across public health units in Ontario, Canada.

OBJECTIVE: In 2018, Ontario Public Health Standards were updated to include the foundational Health Equity Standard to guide planning, implementation, and evaluation of public health programs and services. Public health units (PHUs), the regional public health bodies, are now required to address health equity through four requirements: (a) Assessing and Reporting; (b) Modifying and Orienting Public Health Interventions; (c) Engaging in Multi-sectoral Collaboration; and (d) Health Equity Analysis, Policy Development, and Advancing Healthy Public Policies. METHODS: This qualitative descriptive study explored how the 27 participating PHUs (out of 34) serving urban (N = 10), mixed urban-rural (N = 15), and rural (N = 9) populations addressed the Health Equity Standard. Using document analysis, we inductively and deductively coded the content of 68 PHU Annual Service Plan and Budget Submissions from a 3-year period (2018-2020) received from the 27 PHUs. RESULTS: Emergent categories were organized into the four requirements and one additional emergent theme: Organizational Implementation of Health Equity. The approaches of embedding health equity into PHUs' activities varied across groups. Urban PHUs presented more diverse strategies, including working with a larger number of organizations, and participating in academic research projects. We found more process standardization and greater discussion of capacity building in urban and mixed urban-rural PHUs. Rural PHUs strategically addressed the needs of their diverse populations through relationship building with Indigenous communities. CONCLUSION: Findings suggest broad implementation of health equity approaches in public health independent of PHUs' geographic size and population dispersion, though strategies and key challenges differ across units.

RéSUMé: OBJECTIF: En 2018, les Normes de santé publique de l'Ontario ont été révisées pour inclure, à la base, la norme sur l'Équité en santé, qui guide la planification, la mise en œuvre et l'évaluation des programmes et des services de santé publique. Les bureaux de santé publique (BSP), qui sont les organismes de santé publique régionaux, sont maintenant tenus d'aborder l'équité en santé selon quatre exigences : a) Évaluer et produire des rapports; b) Modifier et orienter les interventions en santé publique; c) Favoriser une collaboration multisectorielle; et d) L'analyse de l'équité en santé, l'élaboration de politiques et la promotion de politiques publiques qui réduisent les iniquités en santé. MéTHODE: Notre étude qualitative descriptive a exploré comment les 27 BSP participants (sur 34) servant des populations urbaines (N = 10), mi-urbaines mi-rurales (N = 15) et rurales (N = 9) ont abordé la norme sur l'Équité en santé. Au moyen d'une analyse documentaire, nous avons inductivement et déductivement codé le contenu de 68 plans de services annuels et projets de budget des 27 BSP participants sur une période de trois ans (2018‒2020). RéSULTATS: Les catégories émergentes ont été triées selon les quatre exigences et un thème supplémentaire : la mise en œuvre de l'équité en santé à l'échelle organisationnelle. Les façons d'intégrer l'équité en santé dans les activités des BSP variaient d'un groupe à l'autre. Les BSP urbains ont présenté des stratégies plus diverses, dont la collaboration avec un plus grand nombre d'organismes et la participation à des projets de recherche universitaires. Nous avons observé une plus grande standardisation des processus et davantage de mentions du renforcement des capacités chez les BSP urbains et mi-urbains mi-ruraux. Les BSP ruraux abordaient stratégiquement les besoins de leurs populations diverses en tissant des liens avec les communautés autochtones. CONCLUSION: Selon ces constats, il y a une mise en œuvre généralisée des approches d'équité en santé dans le système de santé publique, sans égard à l'étendue géographique ou à la dispersion de la population des BSP, mais il existe des différences dans les stratégies employées et dans les difficultés rencontrées par chaque bureau.

Prevalence of cannabis use and the frequency, types, and sources of cannabis products used in northern remote territories of the Canadian legal cannabis market.

OBJECTIVE: The Cannabis Policy Study in the Territories (CPST) is an annual repeat cross-sectional study aiming to evaluate the impacts of cannabis legalization in the Canadian territories (Yukon, Northwest Territories, and Nunavut), where there is a paucity of data on cannabis use. This current study's objective was to describe the 2022 CPST, including methods, population prevalence estimates of cannabis use, and legal cannabis sources and perceptions in the territories. METHODS: The 2022 CPST includes 2462 respondents (aged 16 +) residing in the territories who either use or do not use cannabis. Respondents were recruited through mail-push-to-web invitations sent via licensed mailing lists, sampling from a near census of households in the territories. Population-weighted indicators of cannabis use are described. RESULTS: Past 12-month cannabis use was self-reported by 46.1%, and 21.8% self-reported daily/almost daily use. The most commonly used product types among past 12-month consumers were dried flower (73.4%), edibles (59.0%), and vape oils (35.7%). On average, 74.8% of cannabis products used in the past 12 months were from legal sources, though legal sourcing varied by product type (54.4‒92.2%). Cannabis consumers reported favourable perceptions of legal compared to illegal cannabis products regarding quality, convenience, and safety, but a lesser extent for price. CONCLUSION: Cannabis use is highly prevalent in the territories, particularly daily/almost daily use, and legal market penetration is high despite region remoteness. Following cannabis legalization, monitoring cannabis use prevalence and patterns in remote regions is important for informing the development of harm reduction and prevention initiatives that consider the unique needs of these regions.

RéSUMé: OBJECTIF: L'Étude sur les politiques relatives au cannabis dans les territoires (Cannabis Policy Study in the Territories ‒ CPST) est une étude transversale annuelle qui a pour but d'évaluer les répercussions de la légalisation du cannabis dans les territoires canadiens (Yukon, Territoires du Nord-Ouest et Nunavut), où il existe peu de données sur la consommation de cannabis. L'objectif de la présente étude était de décrire l'étude CPST de 2022, y compris la méthodologie, les estimations de la prévalence de la consommation de cannabis au sein de la population, ainsi que les sources et les perceptions du cannabis vendu légalement dans les territoires. MéTHODES: L'étude CPST menée en 2022 a consisté à interroger 2 462 personnes âgées de 16 ans et plus qui résident dans les territoires. Les répondants incluent des personnes qui consomment du cannabis et d'autres qui n'en consomment pas. Les répondants ont été recrutés au moyen d'invitations envoyées par la poste à partir de listes d'envoi autorisées. Les échantillons ont été effectués à partir d'un quasi-recensement des ménages qui résident dans les territoires. Les indicateurs pondérés en population de la consommation de cannabis sont décrits. RéSULTATS: Au cours des 12 derniers mois, le pourcentage d'autodéclarations de consommation de cannabis était de 46,1 %, et 21,8 % des répondants ont déclaré consommer quotidiennement ou presque. Les produits les plus couramment utilisés par les consommateurs au cours des 12 derniers mois étaient les fleurs séchées (73,4 %), les produits comestibles (59,0 %) et les huiles de vapotage (35,7 %). En moyenne, 74,8 % des produits de cannabis consommés au cours des 12 derniers mois provenaient de sources légales, bien que l'approvisionnement légal varie selon le type de produit (de 54,4 % à 92,2 %). Les consommateurs de cannabis ont déclaré percevoir favorablement les produits de cannabis vendus légalement comparativement aux produits vendus illégalement en ce qui a trait à la qualité, à la commodité et à la sécurité, mais dans une moindre mesure en matière de prix. CONCLUSION: La consommation de cannabis est très répandue dans les territoires, en particulier la consommation quotidienne ou presque quotidienne. De plus, la pénétration du marché des produits vendus légalement est élevée malgré l'éloignement des régions. À la suite de la légalisation du cannabis, la surveillance de la prévalence et des tendances de consommation du cannabis dans les régions éloignées fournit des renseignements importants pour l'élaboration d'initiatives de réduction des méfaits et de prévention qui tiennent compte des besoins uniques de ces régions.

The association between alcohol retail access and health care visits attributable to alcohol for individuals with and without a history of alcohol-related health-care use.

BACKGROUND AND AIMS: Alcohol retail access is associated with alcohol use and related harms. This study measured whether this association differs for people with and without heavy and disordered patterns of alcohol use. DESIGN: The study used a repeated cross-sectional analysis of health administrative databases. SETTING, PARTICIPANTS/CASES: All residents of Ontario, Canada aged 10-105 years with universal health coverage (n = 10 677 604 in 2013) were included in the analysis. MEASUREMENTS: Quarterly rates of emergency department (ED) and outpatient visits attributable to alcohol in 464 geographic regions between 2013 and 2019 were measured. Quarterly off-premises alcohol retail access scores were calculated (average drive to the closest seven stores) for each geographic region. Mixed-effect linear regression models adjusted for area-level socio-demographic covariates were used to examine associations between deciles of alcohol retail access and health-care visits attributable to alcohol. Stratified analyses were run for individuals with and without prior alcohol-attributable health-care use in the past 2 years. FINDINGS: We included 437 707 ED visits and 505 271 outpatient visits attributable to alcohol. After adjustment, rates of ED visits were 39% higher [rate ratio (RR) = 1.39, 95% confidence interval (CI) = 1.20-1.61] and rates of outpatient visits were 49% higher (RR = 1.49, 95% CI = 1.26-1.75) in the highest versus lowest decile of alcohol access. There was a positive association between alcohol access and outpatient visits attributable to alcohol for individuals without prior health-care attributable to alcohol (RR = 1.65, 95% CI = 1.39-1.95 for the highest to lowest decile of alcohol access) but not for individuals with prior health-care attributable to alcohol (RR = 1.08, 95% CI = 0.90-1.30). There was a positive association between alcohol access and ED visits attributable to alcohol for individuals with and without prior health-care for alcohol for ED visits. CONCLUSION: In Ontario, Canada, greater alcohol retail access appears to be associated with higher rates of emergency department (ED) and outpatient health-care visits attributable to alcohol. Individuals without prior health-care for alcohol may be more susceptible to greater alcohol retail access for outpatient but not ED visits attributable to alcohol.

Diabetes Technology Meeting 2023.

Diabetes Technology Society hosted its annual Diabetes Technology Meeting from November 1 to November 4, 2023. Meeting topics included digital health; metrics of glycemia; the integration of glucose and insulin data into the electronic health record; technologies for insulin pumps, blood glucose monitors, and continuous glucose monitors; diabetes drugs and analytes; skin physiology; regulation of diabetes devices and drugs; and data science, artificial intelligence, and machine learning. A live demonstration of a personalized carbohydrate dispenser for people with diabetes was presented.

Socio-economic inequities in emergency department visits for wholly alcohol-attributable acute and chronic harms in Canada, 2003-2017.

INTRODUCTION: Individuals with low socio-economic position (SEP) experience disproportionate alcohol-attributable harm. Limited research has investigated whether these inequities are driven by alcohol-attributable conditions that are acute or chronic. The study aimed to estimate the sex-specific associations between SEP and incident wholly alcohol-attributable emergency department (ED) visits for acute and chronic harms, respectively. METHODS: A cohort study was conducted using the Canadian Community Health Survey (2003-2008) linked to the National Ambulatory Care Reporting System (2002-2017) in Alberta and Ontario. SEP was measured using educational attainment. Acute and chronic ED visits were captured in the National Ambulatory Care Reporting System follow-up data. Hazard models were fit to estimate the association between SEP and acute and chronic wholly alcohol-attributable ED visits. RESULTS: The analytical sample included 88,865 respondents. In men and women, individuals with lower SEP had increased hazard of acute ED visits (women hazard ratio [HR] 1.75, 95% confidence interval [CI] 1.07-2.87; men HR 3.47, 95% CI 2.29-5.25) and chronic ED visits (women HR 2.24, 95% CI 1.04-4.80; men HR 5.02, 95% CI 2.88-8.75). Acute and chronic wholly alcohol-attributable ED visit rates were higher in men than women. DISCUSSION AND CONCLUSIONS: The findings indicated lower SEP was associated with greater harms for both acute and chronic wholly alcohol-attributable ED visits when compared to their higher SEP counterparts. We conclude that gradients in SEP are associated with acute and chronic harms. These results highlight a need for equitable interventions that reduce the absolute burden of inequities in both acute and chronic wholly alcohol-attributable ED visits.

The Impacts of Selling Alcohol in Grocery Stores in Ontario, Canada: A Before-After Study.

OBJECTIVE: From 2015 to 2019, the Government of Ontario expanded privatized sales of alcohol, licensing 450 grocery stores to sell beer, cider, and wine. The impacts of a nearby grocery store gaining an alcohol license on adults' alcohol use in Ontario are examined, including whether impacts differed by gender. METHOD: Data from 2015-2019 Canadian Community Health Survey participants in Ontario (age ≥ 20 years), living within 1,000 m and 1,500 m of grocery stores that gained a license to sell alcohol and propensity-matched controls were included (1,000 m n = 14,052, 1,500 m n = 30,486). Alcohol use outcomes included past-7-day number of standard drinks consumed, near-daily drinking (≥4 days/week), and heavy drinking (5+ drinks in men/4+ in women, at least once/month). Gender-specific difference-in-differences (DiD) analyses compared changes in alcohol use before and after intervention in intervention and control populations. RESULTS: Decreases in past-7-day drinks, near-daily drinking, and heavy drinking were observed after intervention in both intervention and control populations. At the 1,000 m level, adjusted DiD analyses showed past-7-day drinking in women (risk ratio = 1.21, 95% CI [0.88, 1.60]) and heavy drinking in men (odds ratio = 1.38, 95% CI [0.92, 2.08]) had effect sizes above 1, a relative increase over controls, although confidence intervals crossed 1. Findings did not indicate significant differences in alcohol use in intervention relative to controls for other alcohol use measures and at 1,500 m. CONCLUSIONS: Findings suggest no association between a partial alcohol deregulation initiative in Ontario and alcohol use from 2015 to 2019. It is important to monitor the impacts on alcohol use over time as further alcohol deregulation plans in Ontario and other jurisdictions are considered.

Real-world patient characteristics, treatment patterns, and clinical outcomes associated with tucatinib therapy in HER2-positive metastatic breast cancer.

Background: Tucatinib is an oral human epidermal growth factor receptor 2 (HER2)-directed therapy approved in combination with trastuzumab and capecitabine for use in patients with previously treated HER2+ metastatic breast cancer (MBC) with/without brain metastases (BM). To inform clinical decision-making, it is important to understand tucatinib use in real-world clinical practice. We describe patient characteristics, treatment patterns, and clinical outcomes for tucatinib treatment in the real-world setting. Methods: This retrospective cohort study included patients diagnosed with HER2+ MBC (January 2017-December 2022) who received tucatinib treatment in a nationwide, de-identified electronic health record-derived metastatic breast cancer database. Patient demographics and clinical characteristics were described at baseline (prior to tucatinib initiation). Key outcomes included real-world time to treatment discontinuation (rwTTD), time to next treatment (rwTTNT), and overall survival (rwOS). Results: Of 3,449 patients with HER2+ MBC, 216 received tucatinib treatment (n=153 with BM; n=63 without BM) and met inclusion criteria. Median (range) age of patients was 56 (28-84) years, 57.9% were White, and 68.5% had Eastern Cooperative Oncology Group performance status ≤1. Median (IQR) follow-up from start of tucatinib treatment was 12 (6-18) months. Among all patients who received tucatinib treatment, median (95% CI) rwTTD was 6.5 (5.4-8.8) months with 39.8% and 21.4% remaining on treatment at 12 and 24 months, respectively. Median (95% CI) rwTTNT was 8.7 (6.8-10.7) months. Patients who received the approved tucatinib triplet combination after ≥1 HER2-directed regimen in the metastatic setting had a similar median (95% CI) rwTTD (any line: 8.1 [5.7-9.5] months; second-line (2L) and third-line (3L): 9.4 [6.3-14.1] months) and rwTTNT (any line: 8.8 [7.1-11.8] months; 2L and 3L: 9.8 [6.8-14.1] months) to the overall population. Overall, median (95% CI) rwOS was 26.6 (20.2-not reached [NR]) months, with similar findings for patients who received the tucatinib triplet (26.1 [18.8-NR] months) and was NR in the subgroup limited to the 2L/3L population. Conclusion: Tucatinib treatment in the real-world setting was associated with a similar median rwTTD, rwTTNT, and rwOS as in the pivotal HER2CLIMB trial, with particular effectiveness in patients in the 2L/3L setting. These results highlight the importance of earlier use of tucatinib in HER2+ MBC.

Is higher school neighbourhood Walk Score associated with greater child pedestrian safety near schools?

Walk Score is a common index used to estimate how suitable the built environment is for walking. Although Walk Score has been extensively validated as a measure of walkability and walking, there are limited studies examining whether commonly used constructs of walkability are associated with traffic safety in children. This study examined the association between Walk Score and child pedestrian injury controlling for observed walking exposure in school zones in Calgary, Toronto and Montreal, Canada. Results indicate that a higher Walk Score was associated with more child pedestrian injuries in all three cities, even after controlling for walking exposure. School travel planning should consider established individual pedestrian collision risk and individual factors rather than assuming a highly walkable environment is also a safe pedestrian environment.

A Scoping Review of the Use of Machine Learning in Health Economics and Outcomes Research: Part 1-Data From Wearable Devices.

OBJECTIVES: With the emerging use of machine learning (ML) techniques, there has been particular interest in using wearable data for health economics and outcomes research (HEOR). We aimed to understand the emerging patterns of how ML has been applied to wearable data in HEOR. METHODS: We identified studies published in PubMed between January 2016 and March 2021. Studies that included at least 1 HEOR-related Medical Subject Headings term, applied an ML, and used wearable data were eligible for inclusion. Two reviewers abstracted information including ML application types and data on which ML was applied and analyzed them using descriptive analyses. RESULTS: A total of 148 studies were identified from PubMed, among which 32 studies met the inclusion criteria. There has been an increase over time in the number of ML studies using wearable data. ML has been more frequently used for monitoring events in real time (78%) than to predict future events (22%). There has been a wide range of outcomes examined, ranging from general physical or mental health (24%) to more disease-specific outcomes (eg, disease incidence [19%] and progression [13%]) and treatment-related outcomes (eg, treatment adherence [9%] and outcomes [9%]). Data for ML models were more often derived from wearable devices with specific medical purposes (60%) than those without (40%). CONCLUSION: There has been a wide range of applications of ML to wearable data. Both medical and nonmedical wearable devices have been used as a data source, showing the potential for providing rich data for ML studies in HEOR.

Leaf habit affects the distribution of drought sensitivity but not water transport efficiency in the tropics.

Considering the global intensification of aridity in tropical biomes due to climate change, we need to understand what shapes the distribution of drought sensitivity in tropical plants. We conducted a pantropical data synthesis representing 1117 species to test whether xylem-specific hydraulic conductivity (KS ), water potential at leaf turgor loss (ΨTLP ) and water potential at 50% loss of KS (ΨP50 ) varied along climate gradients. The ΨTLP and ΨP50 increased with climatic moisture only for evergreen species, but KS did not. Species with high ΨTLP and ΨP50 values were associated with both dry and wet environments. However, drought-deciduous species showed high ΨTLP and ΨP50 values regardless of water availability, whereas evergreen species only in wet environments. All three traits showed a weak phylogenetic signal and a short half-life. These results suggest strong environmental controls on trait variance, which in turn is modulated by leaf habit along climatic moisture gradients in the tropics.

A Scoping Review of the Use of Machine Learning in Health Economics and Outcomes Research: Part 2-Data From Nonwearables.

OBJECTIVES: Despite the increasing interest in applying machine learning (ML) methods in health economics and outcomes research (HEOR), stakeholders face uncertainties in when and how ML can be used. We reviewed the recent applications of ML in HEOR. METHODS: We searched PubMed for studies published between January 2020 and March 2021 and randomly chose 20% of the identified studies for the sake of manageability. Studies that were in HEOR and applied an ML technique were included. Studies related to wearable devices were excluded. We abstracted information on the ML applications, data types, and ML methods and analyzed it using descriptive statistics. RESULTS: We retrieved 805 articles, of which 161 (20%) were randomly chosen. Ninety-two of the random sample met the eligibility criteria. We found that ML was primarily used for predicting future events (86%) rather than current events (14%). The most common response variables were clinical events or disease incidence (42%) and treatment outcomes (22%). ML was less used to predict economic outcomes such as health resource utilization (16%) or costs (3%). Although electronic medical records (35%) were frequently used for model development, claims data were used less frequently (9%). Tree-based methods (eg, random forests and boosting) were the most commonly used ML methods (31%). CONCLUSIONS: The use of ML techniques in HEOR is growing rapidly, but there remain opportunities to apply them to predict economic outcomes, especially using claims databases, which could inform the development of cost-effectiveness models.

Disability and pedestrian road traffic injury: A scoping review.

Disability and ableism remain a nascent area of inquiry in road traffic injury research. A scoping review of academic literature was conducted to understand the state of knowledge on disability and pedestrian-motor vehicle collisions. Sixty-two eligible articles were identified and included. A significantly higher risk of pedestrian collisions, injuries, and fatalities was consistently found among disabled people. Risk factors included individualized factors such as walking speed and crossing decisions of disabled people. The roles of social/political environments in injury risk were less commonly explored. More research is needed to assess how inaccessible or disabling environments may produce elevated risk of pedestrian injury among disabled populations.

Evolution of a Systematic Approach to Smoking Cessation in Ontario's Regional Cancer Centres.

Smoking cessation after a cancer diagnosis can significantly improve a person's prognosis, treatment efficacy and safety, and quality of life. In 2012, Cancer Care Ontario (now part of Ontario Health) introduced a Framework for Smoking Cessation, to be implemented for new ambulatory cancer patients at the province's 14 Regional Cancer Centres (RCCs). Over time, the program has evolved to become more efficient, use data for robust performance management, and broaden its focus to include new patient populations and additional data collection. In 2017, the framework was revised from a 5As to a 3As brief intervention model, along with an opt-out approach to referrals. The revised model was based on emerging evidence, feedback from stakeholders, and an interim program evaluation. Results showed an initial increase in referrals to cessation services. Two indicators (tobacco use screening and acceptance of a referral) are routinely monitored as part of Ontario Health's system-wide performance management approach, which has been identified as a key driver of change among RCCs. Due to the COVID-19 pandemic, many RCCs reported a decrease in these indicators. RCCs that were able to maintain a high level of smoking cessation activities during the pandemic offer valuable lessons, including the opportunity to swiftly leverage virtual care. Future directions for the program include capturing data on cessation outcomes and expanding the intervention to new populations. A focus on system recovery from COVID-19 will be paramount. Smoking cessation must remain a core element of high-quality cancer care, so that patients achieve the best possible health benefits from their treatments.

Glycemic Index, Glycemic Load, Fiber, and Gluten Intake and Risk of Laparoscopically Confirmed Endometriosis in Premenopausal Women.

BACKGROUND: The etiology of endometriosis is not well understood. Limited evidence suggests that dietary factors influence risk, but prospective data related to carbohydrate, fiber, and gluten consumption are scarce. Despite this, recommendations concerning fiber, gluten intake, and endometriosis are pervasive in the lay literature. OBJECTIVES: We aimed to investigate the associations of carbohydrate quality [glycemic index (GI) and glycemic load (GL)], fiber intake (total, legume, vegetable, cruciferous vegetable, fruit, cereal), and gluten intake with incident laparoscopically confirmed endometriosis. METHODS: This was a prospective cohort study using data collected from 81,961 premenopausal women in the Nurses' Health Study II (mean age = 36 y in 1991). Diet was assessed with a validated FFQ every 4 y. Cox proportional hazards models were used to calculate rate ratios (RRs) and 95% CIs. RESULTS: A total of 3810 incident cases of laparoscopically confirmed endometriosis were reported over 24 y of follow-up. Women in the highest quintile of GI had 12% (95% CI: 1.01, 1.23; Ptrend = 0.03) higher risk of endometriosis diagnosis than those in the lowest quintile. Total vegetable and cruciferous vegetable fiber intakes were also associated with higher risk (highest compared with lowest quintile RR: 1.13; 95% CI: 1.02, 1.24; Ptrend = 0.004 and RR: 1.17; 95% CI: 1.06, 1.29; Ptrend = 0.02, respectively). Higher intake of fruit fiber was associated with lower risk of endometriosis but the association was not significant after adjusting for the Alternative Healthy Eating Index. Gluten intake was also associated with lower risk (highest compared with lowest quintile RR: 0.91; 95% CI: 0.80, 1.02; Ptrend = 0.01), but these results were not consistent in direction nor statistical significance across sensitivity analyses. No association was observed for GL or total, legume, or cereal fiber intake. CONCLUSIONS: Our findings suggest that carbohydrate quality and specific types of fiber-total vegetable and cruciferous vegetable fiber-are associated with endometriosis diagnosis in premenopausal women. These results also indicate it is unlikely that gluten intake is a strong factor in the etiology or symptomatology of endometriosis.

Real-world outcomes among patients with HER2+ metastatic breast cancer with brain metastases.

BACKGROUND: Among patients with human epidermal growth factor receptor 2-positive (HER2+) metastatic breast cancer (MBC), incidence of brain metastases (BMs) is relatively high and increasing. Despite the high unmet need for patients with HER2+ MBC and BMs, real-world data on treatment patterns and outcomes for these patients are limited. OBJECTIVE: To compare treatment patterns and overall survival (OS) among patients with HER2+ MBC with and without BMs in the United States. METHODS: This was a real-world retrospective cohort study in which adults diagnosed with HER2+ MBC between January 1, 2016, and May 31, 2019, were identified in the Flatiron Health electronic health records database. The cohort was stratified by presence of BMs at MBC diagnosis (baseline) and before the initiation of each line of therapy (LOT). Key outcomes were OS and systemic therapy/regimen used within each LOT. An adjusted Cox proportional hazards model was used to evaluate the impact of BMs on OS. RESULTS: Of 1,755 included patients, 173 (9.9%) had BMs at baseline. Trastuzumab+ pertuzumab-based regimens were the most common first- (n = 689, 44.3%) and second-line (n = 316, 35.3%) treatments for all patients. Among patients with BMs, trastuzumab emtansine was the most common third-line regimen (n = 18, 23.4%). Lapatinib-based regimens were used more frequently among patients with BMs but were used by less than 20% of patients with BMs within any LOT. Median OS was 22.3 and 37.3 months for patients with and without BMs at baseline, respectively. Patients with BMs had a higher risk of death compared with patients without BMs (HR, 3.2; 95% CI = 2.6-3.8). CONCLUSIONS: BMs are associated with an increased risk of mortality among patients with HER2+ MBC. Further studies are needed to evaluate the extent to which novel systemic therapies for HER2+ MBC address the unmet need among patients with BMs. DISCLOSURES: This study was funded by Seagen Inc. Andres Forero-Torres is an employee of and owns stock in Seagen Inc. Kendra DeBusk is an employee of Seagen Inc. and owns stock in Seagen Inc. and Roche. Andy Surinach and Yutong Liu are employees of Genesis Research, which received funding from Seagen Inc. in connection with this study. At the time of this study, Chimeka Ike was an employee of Seagen Inc. and owns stock in Seagen Inc. At the time of this study, Nicolas Lindegger was an employee of Seagen Inc., Seagen International GmbH, and owns stock in Seagen Inc. and Roche. At the time of this study, Naomi Schwartz was a paid consultant to Seagen Inc.; she currently is an employee of and owns stock in Seagen Inc.

Trends in treatment patterns and costs of care among patients with advanced stage cervical cancer.

BACKGROUND: Current treatments for recurrent or metastatic cervical cancer (r/mCC) do not offer satisfactory clinical benefits, with most patients progressing beyond first-line (1L) treatment. With new treatments under investigation, understanding current treatment patterns, the impact of newly approved therapies, and total costs of care for r/mCC are important. METHODS: A retrospective analysis of a US commercial insurance claims database to identify adult patients with r/mCC between 2015 and Q1-2020; defining 1L treatment as the first administration of systemic treatment without concomitant chemoradiation or surgery. Patient characteristics, treatment regimens, duration of therapy, and total costs of care were evaluated for each line of therapy. RESULTS: 1323 women initiated 1L treatment for r/mCC (mean age, 56.1 years; mean follow-up, 16.5 months). One-third (n = 438) had evidence of second-line (2L) treatment; of these, 129 (29%) had evidence of third-line (3L) treatment. No regimen represented a majority among 2L+ treatments. The 2018 approval of pembrolizumab led to increased 2L immunotherapy use (0% in 2015, 37% in 2019/Q1-2020). However, only a small proportion of patients stayed on immunotherapy for a prolonged period. Mean per-patient-per-month total costs of care during treatment were $47,387 (1L), $77,661 (2L), and $53,609 (3L), driven primarily by outpatient costs. CONCLUSIONS: No clear standard of care was observed in 2L+. Although immunotherapy is increasingly used in 2L+, only a small subset of patients stayed on immunotherapy for a prolonged period, suggesting a need for more therapeutic options. Better understanding of disease biology and the introduction of new therapies may address these unmet needs.

Child pedestrian and cyclist injuries, and the built and social environment across Canadian cities: the Child Active Transportation Safety and the Environment Study (CHASE).

INTRODUCTION: Traffic injury is a leading and preventable cause of child death and disability, with child pedestrians and cyclists particularly vulnerable. Examining built environment correlates of child pedestrian and cyclist motor vehicle collisions (PCMVC) in different settings is needed to promote an evidence-based approach to road safety. METHODS: We conducted a cross-sectional study across multiple urban/suburban environments in Canada (Calgary, Toronto, Montreal, Laval, Peel Region). All public elementary schools were included (n=1030). We examined the role of land use/social environments, road environments and traffic safety interventions on the rates of child PCMVC within 1000 m of schools. Multivariable negative binomial regression was conducted for all cities and by individual city. In a subset of schools (n=389), we examined associations when controlling for active school transportation (AST). RESULTS: Mean PCMVC rate per school ranged from 0.13 collisions/year in Peel to 0.35 in Montreal. Child PCMVC were correlated with land use, social and road environments and traffic safety interventions. In fully adjusted models, social and land use features remained the most important correlates. New immigrant population had the largest positive association with child PCMVC (incidence rate ratio (IRR): 1.26, 95% CI 1.06 to 1.50), while old housing (pre-1960) density was most protective (IRR: 0.83, 95% CI 0.77 to 0.90). AST was associated with PCMVC, but it had no effect on the relationships between PCMVC and other social/environmental correlates. CONCLUSION: The built environment and social factors influence rates of child PCMVC. Opportunities to reduce child PCMVC exist through modifications to city design and road environments and implementing traffic safety interventions.