Opioid Coprescription Through Risk Mitigation Guidance and Opioid Agonist Treatment Receipt.

Importance: At the onset of the COVID-19 pandemic, the government of British Columbia, Canada, released clinical guidance to support physicians and nurse practitioners in prescribing pharmaceutical alternatives to the toxic drug supply. These alternatives included opioids and other medications under the risk mitigation guidance (RMG), a limited form of prescribed safer supply, designed to reduce the risk of SARS-CoV-2 infection and harms associated with illicit drug use. Many clinicians chose to coprescribe opioid medications under RMG alongside opioid agonist treatment (OAT). Objective: To examine whether prescription of hydromorphone tablets or sustained-release oral morphine (opioid RMG) and OAT coprescription compared with OAT alone is associated with subsequent OAT receipt. Design, Setting, and Participants: This population-based, retrospective cohort study was conducted from March 27, 2020, to August 31, 2021, included individuals from 10 linked health administrative databases from British Columbia, Canada. Individuals who were receiving OAT at opioid RMG initiation and individuals who were receiving OAT and eligible but unexposed to opioid RMG were propensity score matched at opioid RMG initiation on sociodemographic and clinical variables. Data were analyzed between January 2023 and February 2024. Exposure: Opioid RMG receipt (≥4 days, 1-3 days, or 0 days of opioid RMG dispensed) in a given week. Main Outcome and Measures: The main outcome was OAT receipt, defined as at least 1 dispensed dose of OAT in the subsequent week. A marginal structural modeling approach was used to control for potential time-varying confounding. Results: A total of 4636 individuals (2955 [64%] male; median age, 38 [31-47] years after matching) were receiving OAT at the time of first opioid RMG dispensation (2281 receiving ongoing OAT and 2352 initiating RMG and OAT concurrently). Opioid RMG receipt of 1 to 3 days in a given week increased the probability of OAT receipt by 27% in the subsequent week (adjusted risk ratio, 1.27; 95% CI, 1.25-1.30), whereas receipt of opioid RMG for 4 days or more resulted in a 46% increase in the probability of OAT receipt in the subsequent week (adjusted risk ratio, 1.46; 95% CI, 1.43-1.49) compared with those not receiving opioid RMG. The biological gradient was robust to different exposure classifications, and the association was stronger among those initiating opioid RMG and OAT concurrently. Conclusions and Relevance: This cohort study, which acknowledged the intermittent use of both medications, demonstrated that individuals who were coprescribed opioid RMG had higher adjusted probability of continued OAT receipt or reengagement compared with those not receiving opioid RMG.

Low-dose naltrexone for post-COVID fatigue syndrome: a study protocol for a double-blind, randomised trial in British Columbia.

INTRODUCTION: A significant proportion of individuals suffering from post COVID-19 condition (PCC, also known as long COVID) can present with persistent, disabling fatigue similar to myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and post-viral fatigue syndromes. There remains no clear pharmacological therapy for patients with this subtype of PCC, which can be referred to as post-COVID fatigue syndrome (PCFS). A low dose of the opioid antagonist naltrexone (ie, low-dose naltrexone (LDN)) has emerged as an off-label treatment for treating fatigue and other symptoms in PCC. However, only small, non-controlled studies have assessed LDN in PCC, so randomised trials are urgently required. METHODS AND ANALYSIS: A prospective, randomised, double-blind, parallel arm, placebo-controlled phase II trial will be performed to assess the efficacy of LDN for improving fatigue in PCFS. The trial will be decentralised and open to eligible individuals throughout the Canadian province of British Columbia (BC). Participants will be recruited through the province-wide Post-COVID-19 Interdisciplinary Clinical Care Network (PC-ICCN) and research volunteer platform (REACH BC). Eligible participants will be 19-69 years old, have had a confirmed or physician-suspected SARS-CoV-2 infection at least 3 months prior and meet clinical criteria for PCFS adapted from the Institute of Medicine ME/CFS criteria. Individuals who are taking opioid medications, have a history of ME/CFS prior to COVID-19 or history of significant liver disease will be excluded. Participants will be randomised to an LDN intervention arm (n=80) or placebo arm (n=80). Participants in each arm will be prescribed identical capsules starting at 1 mg daily and follow a prespecified schedule for up-titration to 4.5 mg daily or the maximum tolerated dose. The trial will be conducted over 16 weeks, with assessments at baseline, 6, 12 and 16 weeks. The primary outcome will be fatigue severity at 16 weeks evaluated by the Fatigue Severity Scale. Secondary outcomes will include pain Visual Analogue Scale score, overall symptom severity as measured by the Patient Phenotyping Questionnaire Short Form, 7-day step count and health-related quality of life measured by the EuroQol 5-Dimension questionnaire. ETHICS AND DISSEMINATION: The trial has been authorised by Health Canada and approved by The University of British Columbia/Children's and Women's Health Centre of British Columbia Research Ethics Board. On completion, findings will be disseminated to patients, caregivers and clinicians through engagement activities within existing PCC and ME/CFS networks. Results will be published in academic journals and presented at conferences. TRIAL REGISTRATION NUMBER: NCT05430152.

Physiologic oxygen responses to smoking opioids: an observational study using continuous pulse oximetry at overdose prevention services in British Columbia, Canada.

BACKGROUND: In British Columbia, Canada, smoking is the most common modality of drug use among people who die of opioid toxicity. We aimed to assess oxygen saturation (SpO2) while people smoked opioids during a pilot study that introduced continuous pulse oximetry at overdose prevention services (OPS) sites. METHODS: This was an observational cohort study, using a participatory design. We implemented our monitoring protocol from March to August 2021 at four OPS. We included adults (≥ 18 years) presenting to smoke opioids. A sensor taped to participants' fingers transmitted real-time SpO2 readings to a remote monitor viewed by OPS staff. Peer researchers collected baseline data and observed the timing of participants' inhalations. We analyzed SpO2 on a per-event basis. In mixed-effects logistic regression models, drop in minimum SpO2 ≤ 90% in the current minute was our main outcome variable. Inhalation in that same minute was our main predictor. We also examined inhalation in the previous minute, cumulative inhalations, inhalation rate, demographics, co-morbidities, and substance use variables. RESULTS: We recorded 599 smoking events; 72.8% (436/599) had analyzable SpO2 data. Participants' mean age was 38.6 years (SD 11.3 years) and 73.1% were male. SpO2 was highly variable within and between individuals. Drop in SpO2 ≤ 90% was not significantly associated with inhalation in that same minute (OR: 1.2 [0.8-1.78], p = 0.261) or inhalation rate (OR 0.47 [0.20-1.10], p = 0.082). There was an association of SpO2 drop with six cumulative inhalations (OR 3.38 [1.04-11.03], p = 0.043); this was not maintained ≥ 7 inhalations. Demographics, co-morbidities, and drug use variables were non-contributory. CONCLUSIONS: Continuous pulse oximetry SpO2 monitoring is a safe adjunct to monitoring people who smoke opioids at OPS. Our data reflect challenges of real-world monitoring, indicating that greater supports are needed for frontline responders at OPS. Inconsistent association between inhalations and SpO2 suggests that complex factors (e.g., inhalation depth/duration, opioid tolerance, drug use setting) contribute to hypoxemia and overdose risk while people smoke opioids.

The impact of the COVID-19 pandemic on HIV treatment gap lengths and viremia among people living with HIV British Columbia, Canada, during the COVID-19 pandemic: Are we ready for the next pandemic?

The SARS-CoV-2 (COVID-19) pandemic has impacted the care of people living with HIV (PLWH). This study aims to characterize the impact of the pandemic on the length of HIV treatment gap lengths and viral loads among people living with HIV (PLWH) in British Columbia (BC), Canada, with a focus on Downtown Eastside (DTES), which is one of the most impoverished neighbourhoods in Canada. We analyzed data from the HIV/AIDS Drug Treatment Program from January 2019 to February 2022. The study had three phases: Pre-COVID, Early-COVID, and Late-COVID. We compared results for individuals residing in DTES, those not residing in DTES, and those with no fixed address. Treatment gap lengths and viral loads were analyzed using a zero-inflated negative binomial model and a two-part model, respectively, adjusting for demographic factors. Among the 8982 individuals, 93% were non-DTES residents, 6% were DTES residents, and 1% had no fixed address during each phase. DTES residents were more likely to be female, with Indigenous Ancestry, and have a history of injection drug use. Initially, the mean number of viral load measurements decreased for all PLWH during the Early-COVID, then remained constant. Treatment gap lengths increased for all three groups during Early-COVID. However, by Late-COVID, those with no fixed address approached pre-COVID levels, while the other two groups did not reach Early-COVID levels. Viral loads improved across each phase from Pre- to Early- to Late-COVID among people residing and not residing in DTES, while those with no fixed address experienced consistently worsening levels. Despite pandemic disruptions, both DTES and non-DTES areas enhanced HIV control, whereas individuals with no fixed address encountered challenges. This study offers insights into healthcare system preparedness for delivering HIV care during future pandemics, emphasizing community-driven interventions with a particular consideration of housing stability.

Fetal alcohol spectrum disorder diagnostic clinic capacity in Canadian Provinces and territories.

This study investigated the diagnostic capacity for Fetal Alcohol Spectrum Disorder (FASD) in multidisciplinary clinics across several provincial and one territorial jurisdictions of Canada: Alberta, British Columbia, Manitoba, Ontario and Northwest Territories. The data were collected directly from clinics capable of providing diagnoses of FASD and examined annual capacity for the assessment and diagnosis of FASD per year from 2015 to 2019. In total, 58 FASD diagnostic clinics were identified and 33 clinics participated in this survey. The study identified inadequate FASD diagnostic capacity in all participating jurisdictions. Based on the findings and the current population sizes, it is estimated that 98% of individuals with FASD are undiagnosed or misdiagnosed in Canada. Wait times for FASD diagnosis ranged from 1 month to 4.5 years across participating jurisdictions. The annual FASD diagnostic capacity in the select provinces and territories require at least a 67-fold increase per year.

Quality improvement collaborative approach to COVID-19 pandemic preparedness in long-term care homes: a mixed-methods implementation study.

BACKGROUND: The devastating impact of the COVID-19 pandemic on long-term care (LTC) homes underscores the importance of effective pandemic preparedness and response. This mixed-methods, implementation science study investigated how a virtual-based quality improvement (QI) collaborative approach can improve uptake of pandemic-related promising practices and shared learning across six LTC homes in British Columbia, Canada in 2021 during the COVID-19 pandemic health emergency. METHODS: QI teams consisting of residents, family/informal caregivers, care providers and leadership in LTC homes are supported by QI facilitation and shared learning through virtual communication platforms. QI projects address gaps in outbreak preparation, prevention and response; planning for care; staffing; and family presence. Thematically analysed semi-structured qualitative interviews and a validated questionnaire on organisational readiness investigated participants' perceptions of challenges, success factors and benefits of participating in the virtual QI collaborative approach. RESULTS: Nine themes were identified through interview analysis, including two related to challenges (ie, making time for QI and hands tied by external forces), four regarding factors for successes (ie, team buy-in, working together as a team, bringing together diverse perspectives and facilitators keep us on track) and three on the benefits of the QI collaborative approach (ie, seeing improvements, staff empowerment and appetite for change). Continuous QI facilitation and coaching for QI teams was feasible and sustainable virtually via video conferencing (Zoom). The QI team members showed limited engagement on the virtual communication platform (Slack), which was predominantly used by the implementation science team and QI facilitators to coordinate the study and QI projects, respectively. CONCLUSIONS: The virtual-based QI collaborative approach to pandemic preparedness supported LTC homes to rapidly and successfully form multidisciplinary QI teams, learn about QI methods and conduct timely QI projects to implement promising practice for improved COVID-19 pandemic response.

What is the ideal time to begin tapering opioid agonist treatment? A protocol for a retrospective population-based comparative effectiveness study in British Columbia, Canada.

INTRODUCTION: Opioid agonist treatment (OAT) tapering involves a gradual reduction in daily medication dose to ultimately reach a state of opioid abstinence. Due to the high risk of relapse and overdose after tapering, this practice is not recommended by clinical guidelines, however, clients may still request to taper off medication. The ideal time to initiate an OAT taper is not known. However, ethically, taper plans should acknowledge clients' preferences and autonomy but apply principles of shared informed decision-making regarding safety and efficacy. Linked population-level data capturing real-world tapering practices provide a valuable opportunity to improve existing evidence on when to contemplate starting an OAT taper. Our objective is to determine the comparative effectiveness of alternative times from OAT initiation at which a taper can be initiated, with a primary outcome of taper completion, as observed in clinical practice in British Columbia (BC), Canada. METHODS AND ANALYSIS: We propose a population-level retrospective observational study with a linkage of eight provincial health administrative databases in BC, Canada (01 January 2010 to 17 March 2020). Our primary outcomes include taper completion and all-cause mortality during treatment. We propose a 'per-protocol' target trial to compare different durations to taper initiation on the likelihood of taper completion. A range of sensitivity analyses will be used to assess the heterogeneity and robustness of the results including assessment of effectiveness and safety. ETHICS AND DISSEMINATION: The protocol, cohort creation and analysis plan have been classified and approved as a quality improvement initiative by Providence Health Care Research Ethics Board and the Simon Fraser University Office of Research Ethics. Results will be disseminated to local advocacy groups and decision-makers, national and international clinical guideline developers, presented at international conferences and published in peer-reviewed journals electronically and in print.

A qualitative study on perceptions and experiences of overdose among people who smoke drugs in Vancouver, British Columbia.

BACKGROUND: Smoking unregulated drugs has increased substantially in British Columbia. Intersecting with the ongoing overdose crisis, drug smoking-related overdose fatalities have correspondingly surged. However, little is known about the experiences of overdose among people who smoke drugs accessing the toxic drug supply. This study explores perceptions and experiences of overdose among people who smoke drugs. METHODS: We conducted interviews with 31 people who smoke drugs. Interviews covered a range of topics including overdose experience. Thematic analysis was used to identify themes related to participant perceptions and experiences of smoking-related overdose. RESULTS: Some participants perceived smoking drugs to pose lower overdose risk relative to injecting drugs. Participants reported smoking-related overdose experiences, including from underestimating the potency of drugs, the cross-contamination of stimulants with opioids, and responding to smoking-related overdose events. CONCLUSIONS: Findings highlight the impact the unpredictable, unregulated, and toxic drug supply is having on people who smoke drugs, both among people who use opioids, and among those who primarily use stimulants. Efforts to address smoking-related overdose could benefit from expanding supervised smoking sites, working with people who use drugs to disseminate accurate knowledge around smoking-related overdose risk, and offering a smokable alternative to the unpredictable drug supply.

Snow viruses and their implications on red snow algal blooms.

Algal blooms can give snowmelt a red color, reducing snow albedo and creating a runaway effect that accelerates snow melting. The occurrence of red snow is predicted to grow in polar and subpolar regions with increasing global temperatures. We hypothesize that these algal blooms affect virus-bacteria interactions in snow, with potential effects on snowmelt dynamics. A genomic analysis of double-stranded DNA virus communities in red and white snow from the Whistler region of British Columbia, Canada, identified 792 putative viruses infecting bacteria. The most abundant putative snow viruses displayed low genomic similarity with known viruses. We recovered the complete circular genomes of nine putative viruses, two of which were classified as temperate. Putative snow viruses encoded genes involved in energy metabolisms, such as NAD+ synthesis and salvage pathways. In model phages, these genes facilitate increased viral particle production and lysis rates. The frequency of temperate phages was positively correlated with microbial abundance in the snow samples. These results suggest the increased frequency of temperate virus-bacteria interactions as microbial densities increase during snowmelt. We propose that this virus-bacteria dynamic may facilitate the red snow algae growth stimulated by bacteria.IMPORTANCEMicrobial communities in red snow algal blooms contribute to intensifying snowmelt rates. The role of viruses in snow during this environmental shift, however, has yet to be elucidated. Here, we characterize novel viruses extracted from snow viral metagenomes and define the functional capacities of snow viruses in both white and red snow. These results are contextualized using the composition and functions observed in the bacterial communities from the same snow samples. Together, these data demonstrate the energy metabolism performed by viruses and bacteria in a snow algal bloom, as well as expand the overall knowledge of viral genomes in extreme environments.

Characteristics and Consequences of Falls in People Who Use Wheelchairs in Long-Term Care Settings.

OBJECTIVES: The purpose of this study was to understand the characteristics and consequences of falls in individuals using wheelchairs in long-term care settings. DESIGN: Observational analysis of real-world falls in long-term care. SETTING AND PARTICIPANTS: Residents using wheelchairs from 2 long-term care facilities in British Columbia, Canada (n = 32 participants, mean age = 84.7 years, 12 women). METHODS: Two raters used the validated Falls Video Analysis Questionnaire, adapted from the original version, to assess the causal, behavioral, and environmental aspects of falls from wheelchairs. RESULTS: A total of 58 wheelchair fall videos were identified out of 300 total videos that were collected from 2007 to 2014. Wheelchair falls were most often caused by incorrect transfer or shift of body weight (70.7%). Participants most often fell backward with 89.7% striking their pelvis. Individuals using wheelchairs had limited protective response, with only 10.3% demonstrating a step response. Improper brake position contributed to 67.2% of falls. No serious fall-related injuries were reported. CONCLUSIONS AND IMPLICATIONS: The findings highlight the unique nature of falls in older adults who use wheelchairs in long-term care settings. Overall, the results of this study support clinical practice and the critical need for developing specialized fall prevention and fall detection interventions for individuals who use wheelchairs in long-term care.

Trajectories of health-related quality of life following road trauma: Latent growth mixture modeling across a 12-month cohort study.

INTRODUCTION: Health-related quality of life (HRQoL) should be considered when evaluating the burden of road trauma (RT) injuries. This study aimed to identify distinct HRQoL trajectories following minor to severe RT injury and determine characteristics of trajectory membership. METHODS: This prospective inception cohort study recruited 1480 RT survivors from three emergency departments in British Columbia, Canada (July 2018 - March 2020). HRQoL outcome was measured with the Short Form 12 survey (SF-12) and the 5-level version of the EuroQol instrument (EQ-5D-5L) at baseline (pre-injury) and at 2, 4, 6, and 12 months post-injury. Potential predictors of outcome trajectory included sociodemographic, psychological, medical, crash, and injury factors collected at baseline. We used a latent growth mixture model to identify distinct recovery trajectories and multinomial logistic regression to determine predictors of trajectory membership. RESULTS: Three distinct HRQoL trajectories were identified for SF-12 subscales and EQ-5D-5L measures: Low/Moderate-Stable, High-Large decline, and High-Slight decline. Participants in the Low/Moderate-Stable trajectory had persistent low to moderate HRQoL before and after the injury. Those in the High-Large decline trajectory had good pre-injury HRQoL followed by persistently decreased HRQoL afterwards. The High-Slight decline trajectory was characterized by good pre-injury HRQoL and only a slight decline afterwards. Participants in the Low/Moderate-Stable and High-Large decline trajectories were considered at risk of permanently poor HRQoL following RT injury given their low HRQoL over a long period of time. Characteristics that placed participants in the Low/Moderate-Stable trajectory were older age, female gender, poor pre-injury health (medical comorbidity, prescribed medication use, complaints in the injured body area(s)), pre-injury somatic symptoms, pain catastrophizing or psychological distress, injury severity (ISS) and injury pain. Patients with head injury were less likely to be in the Low/Moderate-Stable trajectory. Risk factors for membership in the High-Large decline trajectory included older age (for physical HRQoL), younger age (for mental HRQoL), female gender, living alone, pre-injury psychological distress, ISS, injury pain, no expectations for a fast recovery, as well as head injuries, spine/back injuries or lower extremity injuries. CONCLUSIONS: This study highlighted the heterogeneity of HRQoL trajectories following RT injury and the importance of considering differences between characteristics of survivors. In addition to injury type and severity, outcome is related to demographic factors, pre-injury health and pre-injury psychological factors.

Rabbit intakes and predictors of their length of stay in animal shelters in British Columbia, Canada.

Domestic rabbits (Oryctolagus cuniculus) are the fourth most common species admitted to the British Columbia Society for the Prevention of Cruelty to Animals (BC SPCA) shelter system. However, shelter data analysis has largely focused on cats and dogs and little is known about the population dynamics of rabbits in shelters. We analyzed five years of rabbit records (n = 1567) at the BC SPCA to identify trends in intake and predictors of length of stay (LOS) of rabbits. The majority of rabbits were surrendered by their owners (40.2%), with most rabbits being surrendered for human-related reasons (96.9%). Overall, rabbit intakes decreased over the study period. When analyzing by month of intake, rabbit intakes were found to be the highest in May. Most rabbits in our data were adults (46.7%), non-brachycephalic (66.7%), erect-eared (82.5%), short-furred (76.2%), and subsequently adopted (80.3%). The median LOS of rabbits was 29 days, highlighting the pressing need to improve their time to adoption. A linear model was constructed to identify predictors of LOS of adopted rabbits (n = 1203) and revealed that intake year, intake month, source of intake, age, cephalic type, and breed size significantly predicted time to adoption for rabbits (F(37, 1165) = 7.95, p < 2.2e-16, adjusted R2 = 0.18). These findings help characterize shelter population dynamics for rabbits, shed light on the challenges associated with unwanted rabbits, and offer a foundation for animal shelters to design programs and marketing strategies tailored to reduce LOS of rabbits with particular characteristics. Shelter rabbits represent an understudied population and our study highlights the importance of further research in companion rabbits.

Symptom Burden and Time from Symptom Onset to Cancer Diagnosis in Patients with Early-Onset Colorectal Cancer: A Multicenter Retrospective Analysis.

Background: The incidence of colorectal cancer (CRC) is decreasing in individuals >50 years due to organised screening but has increased for younger individuals. We characterized symptoms and their timing before diagnosis in young individuals. Methods: We identified all patients diagnosed with CRC between 1990-2017 in British Columbia, Canada. Individuals <50 years (n = 2544, EoCRC) and a matched cohort >50 (n = 2570, LoCRC) underwent chart review to identify CRC related symptoms at diagnosis and determine time from symptom onset to diagnosis. Results: Across all stages of CRC, EoCRC presented with significantly more symptoms than LoCRC (Stage 1 mean ± SD: 1.3 ± 0.9 vs. 0.7 ± 0.9, p = 0.0008; Stage 4: 3.3 ± 1.5 vs. 2.3 ± 1.7, p < 0.0001). Greater symptom burden at diagnosis was associated with worse survival in both EoCRC (p < 0.0001) and LoCRC (p < 0.0001). When controlling for cancer stage, both age (HR 0.87, 95% CI 0.8-1.0, p = 0.008) and increasing symptom number were independently associated with worse survival in multivariate models. Conclusions: Patients with EoCRC present with a greater number of symptoms of longer duration than LoCRC; however, time from patient reported symptom onset was not associated with worse outcomes.

Receipt of COVID-19 emergency funds and engagement in sex work during COVID-19 among people who use drugs: evidence from Vancouver, Canada.

BACKGROUND: During the early period of the COVID-19 pandemic, public health orders disrupted income generation in numerous sectors and many governments provided emergency financial support. Access to government support and changes in engagement in sex work during the early period of the pandemic among people who use drugs (PWUD) are not well described. In the present study, we investigate the prevalence and correlates of engaging in sex work during the COVID-19 pandemic, among PWUD in Vancouver, Canada. METHODS: Data derived from three harmonized cohorts of PWUD. Using multivariable logistic regression, we characterized factors associated with engaging in sex work in the last month between July 17 and November 30, 2020. Reports of changes in frequency of engagement in sex work since the pandemic were also collected. RESULTS: Of the 864 individuals included in this analysis, 55 (6.4%) reported sex work engagement in the last month. Among these participants, 40.7% reported receiving COVID-19 income support in the past month vs. 52.7% of the rest of the sample, though receipt of income support in the past six months was similar between the two groups (72.2% vs. 75.7%, p = 0.624). In multivariable analysis, receipt of financial support in the last month was negatively associated with engagement in sex work in the last month (adjusted odds ratio [AOR] = 0.44 [95% confidence interval [CI]: 0.24-0.81]). Among 69 participants who responded to a question regarding changes in engagement in sex work, 38 (55.1%) reported a decrease, 11 (15.9%) reported an increase, 19 (27.5%) reported no change, and 1 (1.4%) reported cessation. CONCLUSIONS: Findings document that engagement in sex work appears to have declined early in the pandemic. Participants who received income support in the past month were less likely to report recent engagement in sex work. Findings suggest that recent receipt of income support may have contributed to reductions in engagement in sex work. Additional investigation is warranted.

Implementation opportunities and challenges to piloting a community-based drug-checking intervention for sexual and gender minority men in Vancouver, Canada: a qualitative study.

BACKGROUND: In response to the overdose crisis, a collaborative group of two community-based organizations, a health authority and a research institute in Vancouver, Canada, implemented a pilot community-based drug checking (CBDC) intervention for sexual and gender minority (SGM) men. This study identified key factors that influenced the implementation of the CBDC intervention, including opportunities and challenges. METHODS: We conducted semi-structured interviews with seven pertinent parties involved in the CBDC, including policymakers, researchers and representatives from community-based organizations. These interviews were coded and analyzed using domains and constructs of the Consolidated Framework for Implementation Research. RESULTS: While drug-related stigma was identified as a challenge to deliver drug checking services, participants described the context of the overdose crisis as a key facilitator to engage collaboration between relevant organizations (e.g., health authorities, medical health officers, community organizations) to design, resource and implement the CBDC intervention. The implementation of the CBDC intervention was also influenced by SGM-specific needs and resources (e.g., lack of information about the drug supply). The high level of interest of SGM organizations in providing harm reduction services combined with the need to expand drug checking into community spaces represented two key opportunities for the CBDC intervention. Here, SGM organizations were recognized as valued partners that fostered a broader culture of harm reduction. Participants' emphasis that knowing the composition of one's drugs is a "right to know", particularly in the context of a highly contaminated illicit drug market, emerged as a key implementation factor. Lastly, participants emphasized the importance of involving SGM community groups at all stages of the implementation process to ensure that the CBDC intervention is appropriately tailored to SGM men. CONCLUSIONS: The context of the overdose crisis and the involvement of SGM organizations were key facilitators to the implementation of a drug checking intervention in SGM community spaces. This study offers contextualized understandings about how SGM knowledge and experiences can contribute to implement tailored drug checking interventions.

Applying a climate-biodiversity-health framework to support integrated food systems planning and policy.

Food systems impact different aspects of sustainability and human life, such as pollution, health, climate change, biodiversity loss, water shortage, and soil infertility. However, in many places, food systems are neither resilient nor sustainable. Integrated planning approaches can help to overcome fragmented strategies and policies in ways that improve the sustainability and resilience of food systems. This study explores such an approach by applying a climate-biodiversity-health (CBH) nexus to local and regional food systems in the Comox Valley region, British Columbia, Canada. The CBH nexus is used as an analytical lens to identify systems relationships among food systems, climate change, biodiversity and health issues and strategies in the region. The employs a place-based approach entailing semi-structured interviews with provincial, regional, and local stakeholders in order to develop a holistic understanding of planning challenges, strategies and their outcomes through the CBH lens. Outcomes of this work include a system map that can be used as a framework for elucidating how various strategies align or conflict with different CBH imperatives and can be used to support integrated community sustainability planning and policy-making efforts. The framework is developed within the Comox Valley context, but it can be adapted to other communities. This paper details the development of this framework, the interconnections between different components, and how this framework can be adopted in other communities.

Cardiovascular health amongst South Asian populations in British Columbia: A situational and comparative analysis of preventative strategies.

This analysis provides an overview of cardiovascular health among South Asian populations in British Columbia (BC), Canada utilizing peer-reviewed literature, alongside data from public health authorities and relevant jurisdictions. The analysis identified risk factors for cardiovascular disease (CVD) amongst South Asians and discussed preventative public health strategies and interventions to mitigate disease burden. The situational analysis discussed the disproportionate increased risk for CVD in South Asians when compared to other ethnicities in BC, highlighting lifestyle choices, genetic predispositions, socio-economic status (SES), and post-migration-related challenges. The analysis identified a disproportionate increase in heart disease in South Asian males and females when compared to White males and females. A review of evidence from peer-reviewed literature identified previously conducted studies and intervention strategies to address CVD and its risk factors. Common themes across multiple studies included addressing physical inactivity and dietary habits as increased cholesterol, obesity, and DM reported as the most common prevalent CVD risk factors in South Asians. The most significantly studied modifiable risk factors in literature for South Asians included diet and physical inactivity. To identify promising public health interventions, a comparative analysis was conducted identifying multiple public health programs from three different jurisdictions: Ontario, New York, and California to better understand successful preventative strategies to decrease risk factors for CVD. A New York based study implemented preventive health programs at employment sites with high prevalence of South Asians, such as Taxi drivers. Successful interventions included culturally relevant diabetes prevention programs, community outreach and health risk assessments in religious centers, health fairs at employment sites, and culturally competent online behavioural modification programs addressing diet and physical activity. Findings from the analysis suggest successful implementation of programs include those from a cultural lens. These include culturally tailored virtual classes, programs with modified risk assessment tools, preventative health community outreach in religious centers, interventions at workplaces with a high number of South Asians, and behavioural modification programs with nutritionists and health coaches.

Tumor-Infiltrating Lymphocytes in Triple-Negative Breast Cancer.

Importance: The association of tumor-infiltrating lymphocyte (TIL) abundance in breast cancer tissue with cancer recurrence and death in patients with early-stage triple-negative breast cancer (TNBC) who are not treated with adjuvant or neoadjuvant chemotherapy is unclear. Objective: To study the association of TIL abundance in breast cancer tissue with survival among patients with early-stage TNBC who were treated with locoregional therapy but no chemotherapy. Design, Setting, and Participants: Retrospective pooled analysis of individual patient-level data from 13 participating centers in North America (Rochester, Minnesota; Vancouver, British Columbia, Canada), Europe (Paris, Lyon, and Villejuif, France; Amsterdam and Rotterdam, the Netherlands; Milan, Padova, and Genova, Italy; Gothenburg, Sweden), and Asia (Tokyo, Japan; Seoul, Korea), including 1966 participants diagnosed with TNBC between 1979 and 2017 (with follow-up until September 27, 2021) who received treatment with surgery with or without radiotherapy but no adjuvant or neoadjuvant chemotherapy. Exposure: TIL abundance in breast tissue from resected primary tumors. Main Outcomes and Measures: The primary outcome was invasive disease-free survival [iDFS]. Secondary outcomes were recurrence-free survival [RFS], survival free of distant recurrence [distant RFS, DRFS], and overall survival. Associations were assessed using a multivariable Cox model stratified by participating center. Results: This study included 1966 patients with TNBC (median age, 56 years [IQR, 39-71]; 55% had stage I TNBC). The median TIL level was 15% (IQR, 5%-40%). Four-hundred seventeen (21%) had a TIL level of 50% or more (median age, 41 years [IQR, 36-63]), and 1300 (66%) had a TIL level of less than 30% (median age, 59 years [IQR, 41-72]). Five-year DRFS for stage I TNBC was 94% (95% CI, 91%-96%) for patients with a TIL level of 50% or more, compared with 78% (95% CI, 75%-80%) for those with a TIL level of less than 30%; 5-year overall survival was 95% (95% CI, 92%-97%) for patients with a TIL level of 50% or more, compared with 82% (95% CI, 79%-84%) for those with a TIL level of less than 30%. At a median follow-up of 18 years, and after adjusting for age, tumor size, nodal status, histological grade, and receipt of radiotherapy, each 10% higher TIL increment was associated independently with improved iDFS (hazard ratio [HR], 0.92 [0.89-0.94]), RFS (HR, 0.90 [0.87-0.92]), DRFS (HR, 0.87 [0.84-0.90]), and overall survival (0.88 [0.85-0.91]) (likelihood ratio test, P < 10e-6). Conclusions and Relevance: In patients with early-stage TNBC who did not undergo adjuvant or neoadjuvant chemotherapy, breast cancer tissue with a higher abundance of TIL levels was associated with significantly better survival. These results suggest that breast tissue TIL abundance is a prognostic factor for patients with early-stage TNBC.

"Death Is a Possibility for Those without Shelter": A Thematic Analysis of News Coverage on Homelessness and the 2021 Heat Dome in Canada.

Among the most vulnerable to the health-harming effects of heat are people experiencing homelessness. However, during the 2021 Heat Dome, the deadliest extreme heat event (EHE) recorded in Canada to date, people experiencing homelessness represented the smallest proportion of decedents (n = 3, 0.5%)-despite the impacted region (British Columbia) having some of the highest rates of homelessness in the country. Thus, we sought to explore the 2021 Heat Dome as a media-based case study to identify potential actions or targeted strategies that were initiated by community support agencies, individuals and groups, and communicated in the news during this EHE that may have aided in the protection of this group or helped minimize the mortality impacts. Using media articles collated for a more extensive investigation into the effects of the 2021 Heat Dome (n = 2909), we identified a subset which included content on people experiencing homelessness in Canada (n = 274, 9%). These articles were thematically analysed using NVivo. Three main themes were identified: (i) public warnings issued during the 2021 Heat Dome directly addressed people experiencing homelessness, (ii) community support services explicitly targeting this population were activated during the heat event, and (iii) challenges and barriers faced by people experiencing homelessness during extreme heat were communicated. These findings suggest that mass-media messaging and dedicated on-the-ground initiatives led by various organizations explicitly initiated to support individuals experiencing homelessness during the 2021 Heat Dome may have assisted in limiting the harmful impacts of the heat on this community.