Faithful pals and familiar locales: differentiating social and spatial site fidelity during reproduction.

Site fidelity-the tendency to reuse familiar spaces-is expected to improve fitness. Familiarity with the local environment is particularly crucial when resource demands or predation risk are high. Consequently, site fidelity often peaks during reproduction when energetic costs are high and offspring are vulnerable. For many species, the environment they experience is not solely a function of geography but also of the social environment. Social fidelity, the selection for familiar social environments, could constitute an independent or parallel strategy to spatial fidelity when considering behaviour at the spatial-social interface. Using global positioning system locations from caribou across Newfoundland, we tested whether females selected calving sites based on proximity to familiar conspecifics, in addition to geographical (spatial) fidelity. These strategies were synergistic, not alternative, and correlated across the population but more variable within individuals. We also tested whether either form of fidelity affected reproductive success. We failed to detect an effect of spatial or social fidelity on reproductive success in this population. Nevertheless, given the association between social and spatial fidelity and the demonstrated fitness consequences of site fidelity in other systems, familiar conspecifics and the potential benefits these social partners provide may be an underappreciated component driving site fidelity.This article is part of the theme issue 'The spatial-social interface: a theoretical and empirical integration'.

Blending census and paleolimnological data allows for tracking the establishment and growth of a major gannet colony over several centuries.

Seabird colonies with long-term monitoring records, i.e., > 50 years, are rare. The population data for northern gannets (Morus bassanus) in Cape St. Mary's (CSM) Ecological Reserve (Newfoundland and Labrador, Canada) is robust, extending back to 1883 when the colony was presumed established. We inferred the colony's historical population shifts by measuring ornithogenic proxies in a dated sediment record collected from a nearby pond. Our record extended to the early eighteenth century, but the proxy data only began to show significant signs of seabird presence between ca. 1832 and 1910, aligning with the period gannets were first observed at CSM. Through the twentieth century, we observed significant increases in δ15N, P, Zn, Cd, and chlorophyll a, coeval with a shift in the dominant diatom species, indicating rapid colony growth. The proxies were overall highest in ca. 2005, corresponding to the reported historical maximum of the gannet colony in 2009. Our results validate that paleo-reconstructions using ornithogenic proxies can accurately reflect population trends and provide a stronger understanding of the colony's establishment and growth. This study highlights the value of applying paleolimnological methods in seabird population studies to frame the history of a colony's dynamics and inform conservation efforts.

Community pharmacists' roles during the closure stage of the COVID-19 pandemic in Newfoundland and Labrador, Canada: a qualitative case study.

OBJECTIVES: To explore the experiences and perspectives of community pharmacists regarding their roles during the closure stage (ie, March to May 2020) of the COVID-19 pandemic in Newfoundland and Labrador (NL), Canada. DESIGN: This qualitative case study included a document analysis and semistructured interviews with community pharmacists who provided direct patient care during the COVID-19 pandemic. The document analysis was used to develop a chronology that informed the interviews. Themes from qualitative interviews were developed through iterative cycles of data review and analysis using applied thematic analysis. Findings are presented specifically for the time period between March and May 2020, defined as the 'Closure Stage'. SETTING: Community pharmacies in NL, Canada. RESULTS: 12 community pharmacists participated in the interviews. Four themes were developed including (1) pharmacists' leadership in continuity of care, (2) pharmacists as medication stewards, (3) pharmacists as a source of COVID-19 health information and (4) the impact of COVID-19 on pharmacists' mental health and well-being. The first three themes described the key roles played by community pharmacists during the early days of the COVID-19 pandemic, including coordinating care, prescribing for common ailments, delivering medications and supplies, providing information on COVID-19 symptoms and their management, renewing chronic medications and protecting the medication supply. Unclear guidance on scope of practice, limited scope of practice, inadequate staffing and limited support from government bodies were identified as barriers to these roles. Facilitators included access to a delivery service, swift regulatory changes, reimbursement and support from colleagues and other healthcare professionals. The fourth theme is presented independently, emphasising the impact of working within the primary healthcare (PHC) system during the COVID-19 pandemic on pharmacists' mental health and well-being. CONCLUSION: Pharmacists played a critical role in the delivery of PHC services during the closure stage of the COVID-19 pandemic. The findings of this research highlight the essential elements of a strong PHC pandemic preparedness plan that is inclusive of community pharmacists, including improved communication strategies, mental health support and access to resources.

Mortality in Innu communities in Labrador, 1993-2018: a cross-sectional study of causes and location of death.

In Canada, most people prefer to die at home. However, the proportion of deaths that occur in hospital has increased over time. This study examined mortality rates and proportionate mortality in Innu communities in Labrador, and compared patterns to other communities in Labrador and Newfoundland. We conducted a cross-sectional ecological study with mortality data from the vital statistics system. This included information about all deaths in Newfoundland and Labrador from 1993 to 2018. We used descriptive statistics and rates to examine patterns by age, sex, cause and location. During the 2003 to 2018 period the leading cause of death in the Innu communities (excluding external causes) was cancer, followed by circulatory disease and respiratory disease. Between 1993 and 2018, there was a lower percentage of hospital deaths and a higher percentage of at home deaths in Innu communities than in the rest of the province. The majority of deaths among Innu were due to cancer and chronic diseases. We found a higher percentage of at home deaths in Innu communities compared to the rest of the province.

Rural suicide in Newfoundland and Labrador: A qualitative exploration of health care providers' perspectives.

INTRODUCTION: Residents of rural regions may have higher and unique suicide risks. Newfoundland and Labrador (NL) is a Canadian province replete with rural regions. Despite an abundance of rural suicide research, heterogeneity in rural regions may preclude amalgamating findings to inform prevention efforts. Thus, exploring the unique needs of NL is needed. Importantly, health care providers (HCP) may afford unique perspectives on the suicide-related needs or concerns of rural life. We asked HCPs of residents of rural NL their perceived suicide risk factors, concerns, and needs for rural NL. METHOD: Twelve HCPs of rural residents of NL completed virtual semi-structured interviews. Interviews were analysed using reflexive thematic analysis [13,14]. RESULTS: HCPs noted individual, psychological, social, and practical factors linked to rural-suicide risk and subsequent needs. Findings highlight the unique challenges of residing and providing health care in rural NL and inform prevention and intervention efforts.

Plastic ingestion, accumulated heavy metals, and health metrics of four Larus gull species feeding at a coastal landfill in eastern Canada.

The objectives of this research were to assess ingested plastics and accumulated heavy metals in four urban gull species. Additionally, the relationships between ingested plastics and selected demographic and health metrics were assessed. Between 2020-2021 during the non-breeding seasons, 105 gulls (46 American herring gulls (HERG, Larus argentatus smithsonianus), 39 great black-backed gulls (GBBG, Larus marinus), 16 Iceland gulls (Larus glaucoides), 4 glaucous gulls (Larus hyperboreus)) were killed at a landfill in coastal Newfoundland and Labrador, Canada, as part of separate, permitted kill-to-scare operations related to aircraft safety. Birds were necropsied, the upper gastrointestinal tract contents were processed using standard techniques, and livers were analyzed for accumulated As, Cd, Hg, and Pb. The relationships between ingested plastics, demographics, and health metrics were assessed in HERG and GBBG. Across all four species, 85 % of birds had ingested at least one piece of anthropogenic debris, with 79 % ingesting at least one piece of plastic. We detected interspecific differences in plastic ingestion and hepatic trace metals, with increased ingested plastics detected in GBBG compared with HERG. For GBBG, levels of ingested plastic were relatively greater for birds with higher scaled mass index, while HERG with more ingested plastic had higher liver lead concentrations.

Moms in motion: Predicting healthcare utilization patterns among mothers in Newfoundland and Labrador.

Mothers have a significant influence on family dynamics, child development, and access to family services. There is a lack of literature on the typical Canadian maternal experience and its influence on access to services for mothers despite recognizing the importance of mothers. A cross-sectional study was conducted to address this research gap that employed Andersen's Behavioral Model of Health Service Use in conjunction with a feminist lens. A total of 1,082 mothers who resided in Newfoundland and Labrador (NL) participated in a province-wide survey in 2017 and reported on their wellbeing, family life, and healthcare utilization. Stepwise binomial logistic regressions and linear regressions were used to predict initiation and continued service utilization within the preceding 12 months, respectively. Mothers who participated in this survey were older, and were more likely to be in a relationship than those in the Canadian census, while no difference was observed in annual income. Approximately half of mothers accessed services for themselves over the previous 12-months, with the overwhelming majority accessing services for their children. Medical services were the most likely to be utilized, and mental health and behavioural services were the most likely services to be needed, but not available. Sociodemographic (e.g., age, education attainment), familial relationships and role satisfaction, health need, and health practices predicted maternal initiation and continued use of services, with a larger number of variables influencing maternal service initiation as compared to continuous use of services. Sociodemographic (e.g., maternal age, community population), maternal social support, health need, and maternal health practices predicted maternal access of at least one child service while family relationships, health need, and maternal health practices predicted maternal use of a range of child services conditional on initial access. These results can support the provincial health system to better support access to care by acknowledging the interdependent nature of maternal and child health care utilization. They also highlight the importance of equitable healthcare access in rural locations. Results are discussed in terms of their clinical relevance to health policy.

A novel technology for harmonizing and analyzing cancer data. Observations from integrating health connect in Newfoundland and Labrador, Canada.

Objective: This article aims to describe the implementation of a new health information technology system called Health Connect that is harmonizing cancer data in the Canadian province of Newfoundland and Labrador; explain high-level technical details of this technology; provide concrete examples of how this technology is helping to improve cancer care in the province, and to discuss its future expansion and implications. Methods: We give a technical description of the Health Connect architecture, how it integrated numerous data sources into a single, scalable health information system for cancer data and highlight its artificial intelligence and analytics capacity. Results: We illustrated two practical achievements of Health Connect. First, an analytical dashboard that was used to pinpoint variations in colon cancer screening uptake in small defined geographic regions of the province; and second, a natural language processing algorithm that provided AI-assisted decision support in interpreting appropriate follow-up action based on assessments of breast mammography reports. Conclusion: Health Connect is a cutting-edge, health systems solution for harmonizing cancer screening data for practical decision-making. The long term goal is to integrate all cancer care data holdings into Health Connect to build a comprehensive health information system for cancer care in the province.

Progress towards World Health Organization HIV Infection 95-95-95 measures in Newfoundland and Labrador, Canada.

The HIV program in Newfoundland and Labrador (NL) provides care for all persons living with HIV (PLWH) in NL, yet progress toward UNAIDS 95-95-95 goals for diagnosis, linkage to care and viral suppression has not previously been documented. This analysis describes engagement in HIV care and virologic outcomes for the NL cohort in 2016 and 2019 and compares this data to the Canadian HIV Observational Cohort (CANOC). A retrospective review of the NL clinic included adults aged >18 years and descriptive statistics for demographics, risk factors, and clinical variables were assessed and compared using χ2 test or Fisher's Exact test (categorical) or Wilcoxon Sum Rank test (continuous). Engagement in care and virologic outcomes for the NL cohort were consistently high over the 2016 to 2019 period with > 98% on antiretroviral therapy (ART), and > 96% having a suppressed virus load. Engagement in care and virologic outcomes among PLWH in NL is high and compares favorably to a national cohort.

Deep-water first occurrences of Ediacara biota prior to the Shuram carbon isotope excursion in the Wernecke Mountains, Yukon, Canada.

Ediacara-type macrofossils appear as early as ~575 Ma in deep-water facies of the Drook Formation of the Avalon Peninsula, Newfoundland, and the Nadaleen Formation of Yukon and Northwest Territories, Canada. Our ability to assess whether a deep-water origination of the Ediacara biota is a genuine reflection of evolutionary succession, an artifact of an incomplete stratigraphic record, or a bathymetrically controlled biotope is limited by a lack of geochronological constraints and detailed shelf-to-slope transects of Ediacaran continental margins. The Ediacaran Rackla Group of the Wernecke Mountains, NW Canada, represents an ideal shelf-to-slope depositional system to understand the spatiotemporal and environmental context of Ediacara-type organisms' stratigraphic occurrence. New sedimentological and paleontological data presented herein from the Wernecke Mountains establish a stratigraphic framework relating shelfal strata in the Goz/Corn Creek area to lower slope deposits in the Nadaleen River area. We report new discoveries of numerous Aspidella hold-fast discs, indicative of frondose Ediacara organisms, from deep-water slope deposits of the Nadaleen Formation stratigraphically below the Shuram carbon isotope excursion (CIE) in the Nadaleen River area. Such fossils are notably absent in coeval shallow-water strata in the Goz/Corn Creek region despite appropriate facies for potential preservation. The presence of pre-Shuram CIE Ediacara-type fossils occurring only in deep-water facies within a basin that has equivalent well-preserved shallow-water facies provides the first stratigraphic paleobiological support for a deep-water origination of the Ediacara biota. In contrast, new occurrences of Ediacara-type fossils (including juvenile fronds, Beltanelliformis, Aspidella, annulated tubes, and multiple ichnotaxa) are found above the Shuram CIE in both deep- and shallow-water deposits of the Blueflower Formation. Given existing age constraints on the Shuram CIE, it appears that Ediacaran organisms may have originated in the deeper ocean and lived there for up to ~15 million years before migrating into shelfal environments in the terminal Ediacaran. This indicates unique ecophysiological constraints likely shaped the initial habitat preference and later environmental expansion of the Ediacara biota.

Impact of extreme coastal events on a brackish lake on the Burin Peninsula, Newfoundland, Canada.

The impacts of extreme coastal events (ECEs), such as marine inundations or extreme wind events, on lake ecosystems vary widely from minimal to catastrophic. Accurately predicting the response of a specific system remains challenging due to a limited understanding of the attributes that drive the resilience of lakes. In an attempt to better understand the possible impacts of ECEs on shallow brackish lakes, we employed a paleolimnological approach to reconstruct the responses of Broad Pond to four ECEs identifiable from clear sedimentary markers and dated to ca. 1740, 1790, 1862, and 1993 CE. We aimed to evaluate the overall impacts of ECEs on Broad Pond and their specific effects on various hydrobiont groups. We reinvestigated a previously studied sediment core covering the last ca. 400 years by examining terrestrial and aquatic pollen, spores and non-pollen palynomorphs, cladocerans, and chironomids. Additionally, available diatom data were reexamined. Overall, Broad Pond exhibited resilient responses to ECEs, as indicated by mostly limited compositional turnovers in our proxy records. Statistically significant relationships between species composition and ECEs were observed only for diatoms. The only prolonged change identified is the spread of previously near-absent chironomids in the aftermath of a slight lake refreshment likely associated with the ca. 1740 CE event. This event was also followed by a short-lived (ca. 15 years) five-fold increase in the abundance of Scenedesmus that could have been triggered by the effects of the ECE on nutrient availability. The impact of the remaining three ECEs was discernible only in the diatom record, consistently showing a decline in two calcifobic and oligotrophic species, Achnanthidium petersenii and Platessa oblongella, also evident for the ca. 1740 CE event. The relatively minor ecosystem alteration induced by ECEs in Broad Pond lacks a single explanation and requires consideration of multiple site- and event-specific factors.

Updated Analysis of Radon Exposure and Lung Cancer Mortality in the Cohort of Newfoundland Fluorspar Miners (1950-2016).

The commercial mining of fluorspar in St. Lawrence Newfoundland began in 1933. Miners who worked underground were exposed to high levels of radon progeny, especially before ventilation was introduced into the mines in 1960. The mean cumulative radon exposure for underground miners in this cohort was 380.9 working level months (WLM). A series of studies of this cohort have characterized the increased risks of lung cancer mortality due to radon. We have extended the follow-up of this cohort an additional 15 years to provide additional insights on the risks of low levels of radon exposure, and the modifying effects of time since exposure, age at first exposure, attained age, duration of exposure, and cigarette smoking. The cohort consisted of 1,735 underground and 315 male surface miners who, combined, accrued 81,650 person-years of follow-up. The mortality experience of the cohort was determined from 1950-2016 through record linkage to Canadian national death data. Individual-level estimates of exposure to radon progeny, in WLMs, were determined for each year of employment. We compared the mortality experience of the underground miners to Newfoundland men using the standardized mortality ratio (SMR). Poisson regression models were fit to estimate excess relative risks (ERR) per 100 WLM. There were 236 lung cancer deaths identified, and of these, 221 occurred among underground workers. The SMR for lung cancer among underground miners compared to Newfoundland men was 2.67 (95% CI: 2.33, 3.04). The ERR per 100 WLM for lung cancer mortality, assuming a 5-year exposure lag, was 0.41 (95% CI: 0.23, 0.59). Attained age and time since exposure were important modifiers to the radon-lung cancer relationship. The joint relationship between smoking and radon on lung cancer risk was sub-additive, however, the smoking data were limited and available for only half of the cohort.

Decadal changes in biomass and distribution of key fisheries species on Newfoundland's Grand Banks.

Canadian fisheries management has embraced the precautionary approach and the incorporation of ecosystem information into decision-making processes. Accurate estimation of fish stock biomass is crucial for ensuring sustainable exploitation of marine resources. Spatio-temporal models can provide improved indices of biomass as they capture spatial and temporal correlations in data and can account for environmental factors influencing biomass distributions. In this study, we developed a spatio-temporal generalized additive model (st-GAM) to investigate the relationships between bottom temperature, depth, and the biomass of three key fished species on The Grand Banks: snow crab (Chionoecetes opilio), yellowtail flounder (Limanda ferruginea), and Atlantic cod (Gadus morhua). Our findings revealed changes in the centre of gravity of Atlantic cod that could be related to a northern shift of the species within the Grand Banks or to a faster recovery of the 2J3KL stock. Atlantic cod also displayed hyperaggregation behaviour with the species showing a continuous distribution over the Grand Banks when biomass is high. These findings suggest a joint stock assessment between the 2J3KL and 3NO stocks would be advisable. However, barriers may need to be addressed to achieve collaboration between the two distinct regulatory bodies (i.e., DFO and NAFO) in charge of managing the stocks. Snow crab and yellowtail flounder centres of gravity have remained relatively constant over time. We also estimated novel indices of biomass, informed by environmental factors. Our study represents a step towards ecosystem-based fisheries management for the highly dynamic Grand Banks.

A survey of undergraduate medical students' gender awareness and bias: the Newfoundland and Labrador perspective.

Background: Female physicians and patients experience gender bias in healthcare. The purpose of this research is to explore medical students' gender bias toward physicians and patients and whether their bias varies by gender. Methods: We surveyed medical students at Memorial University between November 2020 and April 2021. We recruited participants through Facebook, email, and e-posters. We collected demographic information, including gender and class year. We used the Nijmegen Gender Awareness in Medicine Scale to measure gender sensitivity, gender role ideology toward patients, and gender role ideology toward doctors. We analyzed the data using averages and t-tests. Results: Mean gender sensitivity scores were 4/5 indicating high gender sensitivity. Gender role ideology toward doctors mean scores were 2/5 indicating that students did not hold strong stereotypical views toward doctors. Although male students scored higher than female students (p<.05), mean scores for gender role ideology toward patients were low for both male and female students (x¯ <2), indicating low stereotyping toward patients. Conclusions: We found that students held largely non-biased ideologies surrounding gender in medicine and that female students were even less biased than male students for gender role ideology toward patients.

Contexte: Les femmes médecins ou patientes sont victimes de préjugés sexistes dans les soins de santé. L'objectif de cette recherche est d'explorer les préjugés sexistes des étudiants en médecine à l'égard des médecins et des patients et de déterminer si ces préjugés varient en fonction du sexe. Méthodes: Nous avons procédé à une enquête auprès des étudiants en médecine de l'Université Memorial entre novembre 2020 et avril 2021. Nous avons recruté des participants au moyen de Facebook, du courrier électronique et d'affiches électroniques. Nous avons recueilli des données démographiques, y compris le sexe et l'année dans le programme. Nous avons utilisé l'échelle de sensibilisation au genre en médecine de Nijmegen pour mesurer la sensibilité au genre, l'idéologie du rôle du genre envers les patients et l'idéologie du rôle du genre envers les médecins. Nous avons analysé les données à l'aide de moyennes et de tests t. Résultats: Les scores moyens de sensibilité au genre étaient de 4/5, ce qui indique une grande sensibilité au genre. Les scores moyens de l'idéologie du rôle du genre à l'égard des médecins étaient de 2/5, ce qui indique que les étudiants n'avaient pas d'opinion stéréotypée à l'égard des médecins. Bien que les étudiants aient obtenu des scores plus élevés que les étudiantes (p<0,05), les scores moyens pour l'idéologie du rôle du genre à l'égard des patients étaient faibles tant pour les étudiants que pour les étudiantes (x¯<2), ce qui indique un faible niveau d'opinions stéréotypées à l'égard des patients. Conclusions: Nous avons constaté que les étudiants avaient des idéologies largement non biaisées concernant le genre en médecine et que les étudiantes étaient encore moins biaisées que les étudiants en ce qui concerne l'idéologie du rôle du genre envers les patients.

Co-roosting relationships are consistent across years in a bat maternity group.

Long-lived, group living animals have the potential to form multiyear relationships. In some temperate bat species, maternity groups break apart and rejoin both daily, as females depart to forage and select day roosts to use, and annually, as bats leave for and return from hibernation. Here, we investigated whether bats have persistent social preferences by testing whether relationships between dyads in a focal year could be predicted by previous years. We also hypothesized that experience influences social preferences and predicted that an individual's age would influence its network position, while familiarity with bats of the same cohort would drive persistent social preferences. We quantified roost co-occurrence in little brown myotis (Myotis lucifugus) in Salmonier Nature Park, Newfoundland, Canada both within and among years. We found that roost co-occurrence patterns of previous years still had predictive value even when accounting for potential roost fidelity. However, we found no evidence that cohort familiarity or age explained any of the variation. Overall, we found long-term patterns of association in this temperate bat species that suggest levels of social complexity akin to other large mammal species.

New Geographic Records for Trichinella nativa and Echinococcus canadensis in Coyotes (Canis latrans) from Insular Newfoundland, Canada.

Coyotes (Canis latrans) rapidly expanded across North America during the 20th century and in 1987 colonized insular Newfoundland, Canada. Their arrival brought the potential for new predator-prey interactions and the potential for transmission of parasites to naïve populations. Trichinella spp. and Echinococcus spp. are zoonotic parasites not previously reported from the island of Newfoundland, Canada. Muscle samples (diaphragm and tongue) from 153 coyotes and feces from 35/153 coyotes were collected. Larvae of Trichinella spp. were recovered by muscle digestion from 6/153 coyotes (3.9%) and identified using multiplex PCR and Sanger sequencing as T. nativa. Fecal samples were screened for DNA of Echinococcus spp. using qPCR, and intestines from positive animals were examined for adult cestodes. No fecal samples were positive for DNA of E. multilocularis, and 2/35 (5.7%) samples were positive for E. canadensis, of which one was successfully genotyped as the G10 cervid strain. Echinococcus canadensis has not previously been reported on the island of Newfoundland, historically the only region of Canada where Echinococcus spp. was not known to occur. No species of Trichinella have previously been reported on the island. Both parasites are zoonotic, and hunters, trappers, dog owners, and the general public should be aware of these new risks for public health.

Perceptions of Magnetic Resonance Imaging During Pregnancy: A Newfoundland and Labrador Perspective.

OBJECTIVES: This study aimed to identify enablers and barriers to participation in MRI for clinical indications and scientific research, and to determine the perceptions of MRI performed during pregnancy. METHODS: We conducted a survey of 156 pregnant people in Newfoundland and Labrador including sociodemographic information, obstetrical history, MRI history, and willingness to participate in an MRI. Categorical variables were analyzed using a Fisher exact test and open-ended questions were analyzed using thematic analysis. RESULTS: In total, 80% of participants reported willingness to receive an MRI while pregnant for clinical indications compared to 24% for research. Only 10% reported prior knowledge about MRI during pregnancy and most participants (94%) wanted additional information from their physician before feeling comfortable with the procedure. Participants who knew someone with complications during pregnancy were more likely to be willing to participate in an MRI for research (uncorrected P < 0.05). Participants' positive perceptions towards MRI during pregnancy for clinical indications were that it was a necessary and useful procedure, while the negative perceptions identified MRI as unsafe. For research MRI, participants' positive perceptions included that it would add to the advancement of knowledge and the negative perceptions were that it was an unnecessary and risky procedure. CONCLUSIONS: Strategies are needed to improve patient knowledge about the benefits and safety of MRI during pregnancy. The present study suggests recruitment for research should incorporate education on safety concerns and relative risk, personal stories about the benefits of MRI in diagnosing pregnancy complications and should highlight the contribution to advancing scientific knowledge.

Changes in Medical Cannabis Use After Recreational Cannabis Legalization in Canada.

Background: As part of its recreational cannabis legalization in October 2018, Canada imposed an excise tax of 10% (or $1 a gram, whichever is higher) on both recreational and medical cannabis. There is little evidence to inform the ongoing debate on whether the legalization had adverse impacts on medical cannabis use. Methods: We used an interrupted time series design and data on medical cannabis shipments (i.e., mail-order deliveries of cannabis from a licensed producer to a patient authorized to obtain medical cannabis) in Canada between quarter 1 of 2014 and quarter 1 of 2020. We examined changes in medical cannabis shipments after Canada's recreational cannabis legalization both across Canada and for each province. As this study used publicly available, province-level aggregate data, ethics approval was not required. Results: Recreational cannabis legalization was associated with significant reductions in medical cannabis use in 7 out of 10 Canadian provinces. Compared with the counterfactual estimated from prelegalization trends, the reduction in quarter 1 of 2020 varied from 500 shipments per 100,000 population (95% CI=312-688 shipments per 100,000 population) or 32% (95% CI=22-43%) in Newfoundland and Labrador to 3,778 shipments per 100,000 population (95% CI=2,972-4,585 shipments per 100,000 population) or 74% (95% CI=68-79%) in Alberta. At the national level, the number of medical cannabis shipments decreased by 823 per 100,000 population (95% CI=725-921 shipments per 100,000 population) or 48% (95% CI=45-52%). Conclusions: Recreational cannabis legalization was associated with reductions in medical cannabis use. Our findings call for policy attention to address possible adverse impacts of recreational cannabis legalization on medical cannabis users.

Sex-based tuberculosis mortality in Newfoundland, 1900-1949: Implications for populations in transition.

OBJECTIVE: During the second epidemiological transition, tuberculosis (TB) is one disease that declined substantially enough to reduce all-cause mortality. Sex-based differences in TB mortality may reveal an important dimension of population health transitions between the urbanizing and rural regions of Newfoundland. MATERIALS AND METHODS: For the island of Newfoundland, yearly age-standardized sex-based TB mortality rates were calculated using individual death records from 1900 to 1949 (n = 30 393). Multiple linear regression models predict the relative rates (RR) of sex-based mortality and the absolute difference between males and females while controlling for time and region (the urbanizing Avalon Peninsula or rural Newfoundland). Multiple linear regression models also predict the median age at death from TB while controlling for time, region, and sex to assess if TB was shifting to an older adult disease compared to those typically afflicted in ages 20-44. RESULTS: Female TB mortality was relatively and absolutely higher than males; additionally, RR and absolute differences between male and female mortality were significantly lower in rural Newfoundland than the Avalon Peninsula. Median age at death for males was significantly higher than females, and differences in median age at death increased over time. DISCUSSION: The historically high prevalence of TB throughout Newfoundland, including domestic, social, and public health responsibilities of women, likely contributed to increased exposure and transmission, leading to higher observed mortality. Sex-based TB outcomes should be considered in the discussion of the progression of the epidemiological transition as dynamic inequalities that do not necessarily fit contemporary generalizations of sex-based TB epidemiology.