Gender and Racialization Status of Medical Eponym Namesakes: Cross-sectional Study.

BACKGROUND: Many medical eponyms were established when women and racialized individuals were excluded from medicine. The objective of this study was to determine the gender and racialization status of individuals whose names are incorporated in medical eponyms. METHODS: This study is a cross-sectional analysis of gender and racialization of medical eponym namesakes. The main outcome measures were the study of gender and racialization of medical eponym namesakes found in Whonamedit, Mosby's Medical Dictionary, and the International Classification of Diseases (version 10). The gender and whether the individual was a racialized person were determined using pictures and other available information. RESULTS: We identified 3484 unique eponyms. White men represented the majority of medical eponym namesakes (2190 of 2327, 94.1%) followed by white women (85 of 2327, 3.7%), racialized men (49 of 2327, 2.1%), and racialized women (3 of 2327, 0.1%). In the ICD-10 sub-analysis, white men represented the majority of medical eponym namesakes (476 of 514, 92.6%) followed by white women (22 of 514, 4.3%), racialized men (14 of 514, 2.7%), and racialized women (2 of 514, 0.4%). CONCLUSION: Most medical eponyms represent men and white individuals, highlighting the underrepresentation of women and racialized individuals. This indicates a need to re-examine the ongoing use of medical eponyms which may entrench sexism and racism in medicine and contribute to an environment that makes some feel unwelcome or undervalued.

Shared health governance, mutual collective accountability, and transparency in COVAX: A qualitative study triangulating data from document sampling and key informant interviews.

Background: To facilitate global COVID-19 vaccine equity, the World Health Organization, the Coalition for Epidemic Preparedness Innovations, the Global Alliance for Vaccines and Immunizations, and the United Nations Children's Fund supported the COVID-19 Vaccine Global Access (COVAX) partnership. COVAX's goals may have best been pursued through shared health governance - a theory of global health governance based on six premises, in which global health actors collaborate to achieve a shared goal. Shared health governance employs a framework for accountability termed "mutual collective accountability", in which actors hold each other accountable for achieving their goal, thus relying on transparency with one another. Methods: We conducted a multi-method qualitative study triangulating document analysis and key informant interviews to address the question: To what extent did COVAX employ shared health governance, mutual collective accountability, and transparency? We thus aimed to explore the governance structures and accountability and transparency mechanisms in COVAX and determine whether these constituted shared health governance and mutual collective accountability. Results: We identified 117 documents and interviewed 20 key informants. Our findings suggest that COVAX's co-convening organisations were governed by their individual formal governance mechanisms, while each was formally accountable to its own leadership team, resulting in challenges when activities and decisions involved collaboration between organisations. Furthermore, COVAX's governance lacked transparency, as there was little public information about their decision-making processes and operations, including information about the algorithm with which they make vaccine allocation decision, possibly contributing to its inability to achieve its goals. Conclusions: The COVAX partnership only achieved four of the six premises of shared health governance. Since actors involved in COVAX did not hold one another accountable for their role in the partnership, it did not employ mutual collective accountability, while also lacking in transparency. Although these results do not entirely explain COVAX's shortcomings, they contribute to evidence about the roles of good governance, transparency, and accountability in large global health initiatives and underscore failures of the current global governance system.

The Cost of Providing Comprehensive HIV Services to Key Populations: An Analysis of the LINKAGES Program in Kenya and Malawi.

INTRODUCTION: Timely data on HIV service costs are critical for estimating resource needs and allocating funding, but few data exist on the cost of HIV services for key populations (KPs) at higher risk of HIV infection in low- and middle-income countries. We aimed to estimate the total and per contact annual cost of providing comprehensive HIV services to KPs to inform planning and budgeting decisions. METHODS: We collected cost data from the Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) program in Kenya and Malawi serving female and male sex workers, men who have sex with men, and transgender women. Data were collected prospectively for fiscal year (FY) 2019 and retrospectively for start-up activities conducted in FY2015 and FY2016. Data to estimate economic costs from the provider's perspective were collected from LINKAGES headquarters, country offices, implementing partners (IPs), and drop-in centers (DICs). We used top-down and bottom-up cost estimation approaches. RESULTS: Total economic costs for FY2019 were US$6,175,960 in Kenya and US$4,261,207 in Malawi. The proportion of costs incurred in IPs and DICs was 66% in Kenya and 42% in Malawi. The costliest program areas were clinical services, management, peer outreach, and monitoring and data use. Mean cost per contact was US$127 in Kenya and US$279 in Malawi, with a mean cost per contact in DICs and IPs of US$63 in Kenya and US$104 in Malawi. CONCLUSION: Actions undertaken above the service level in headquarters and country offices along with those conducted below the service level in communities, comprised important proportions of KP HIV service costs. The costs of pre-service population mapping and size estimation activities were not negligible. Costing studies that focus on the service level alone are likely to underestimate the costs of delivering HIV services to KPs.

Health equity considerations in guideline development: a rapid scoping review.

BACKGROUND: Systematic guidance for considering health equity in guidelines is lacking. This scoping review aims to synthesize current best practices for integrating health equity into guideline development and the benefits or drawbacks of these practices. METHODS: We searched Ovid MEDLINE ALL and Embase Classic+Embase on the Ovid platform, CINAHL on EBSCO, and Web of Science (Core Collection) from 2010 to 2022. We searched grey literature from 2015 to 2022, using the Canadian Agency for Drugs and Technologies in Health Grey Matters checklist and searches of potentially relevant websites. Articles were screened independently by 1 reviewer. Proposed best practices, advantages and disadvantages, and tools were extracted independently by 1 reviewer and qualitatively synthesized based on the relevant steps of a comprehensive checklist covering the stages of guideline development. RESULTS: We included 26 articles that proposed best practices for incorporating health equity within the guideline development process. These practices were organized under different stages of the development process, including guideline planning, evidence review, guideline development and dissemination. Included studies provided best practices from guideline producers, articles discussing health equity in current guidelines, articles addressing strategies to increase equity in the guideline implementation process, and literature reviews of promising health equity practices. INTERPRETATION: Our scoping review identified best practices to incorporate health equity considerations at each phase of guideline development. Identified practices may be used to inform equity-promoting strategies with the guideline development process; however, guideline producers should carefully consider the advantages and disadvantages of best practices when integrating health equity.

Interventions to address potentially inappropriate prescriptions and over-the-counter medication use among adults 65 years and older in primary care settings: protocol for a systematic review.

PURPOSE: To inform recommendations by the Canadian Task Force on Preventive Health Care on potentially inappropriate prescribing and over-the-counter (OTC) medication use among adults aged 65 years and older in primary care settings. This protocol outlines the planned scope and methods for a systematic review of the benefits and harms and acceptability of interventions to reduce potentially inappropriate prescriptions and OTC medication use. METHODS: De novo systematic reviews will be conducted to synthesize the available evidence on (a) the benefits and harms of interventions to reduce potentially inappropriate prescriptions and OTC medications compared to no intervention, usual care, or non- or minimally active intervention among adults aged 65 years and older and (b) the acceptability of these interventions or attributes among patients. Outcomes of interest for the benefits and harms review are all-cause mortality, hospitalization, non-serious adverse drug reactions, quality of life, emergency department visits, injurious falls, medical visits, and the number of medications (and number of pills). Outcomes for the acceptability review are the preference for and relative importance of different interventions or their attributes. For the benefits and harms review, we will search MEDLINE, Embase, and Cochrane Central Register of Controlled Trials for randomized controlled trials. For the acceptability review, we will search MEDLINE, Embase, PsycInfo, Cochrane Central Register of Controlled Trials, and the NHS Economic Evaluation Database for experimental and observational studies with a comparator. Websites of relevant organizations, other grey literature sources, and reference lists of included studies and reviews will be searched. Title and abstract screening will be completed by two independent reviewers using the liberal accelerated approach. Full-text review, data extraction, risk of bias assessments, and GRADE (Grading of Recommendations Assessment, Development and Evaluation) will be completed independently by two reviewers, with any disagreements resolved by consensus or by consulting with a third reviewer. The GRADE approach will be used to assess the certainty of the evidence for outcomes. DISCUSSION: The results of this systematic review will be used by the Canadian Task Force on Preventive Health Care to inform their recommendation on potentially inappropriate prescribing and OTC medication use among adults aged 65 years and older. SYSTEMATIC REVIEW REGISTRATION: PROSPERO (KQ1: CRD42022302313; KQ2: CRD42022302324); Open Science Framework ( https://osf.io/urj4b/ ).

Cash transfer during the COVID-19 pandemic: a multicentre, randomised controlled trial.

OBJECTIVE: To evaluate the effect of a one-time cash transfer of $C1000 in people who are unable to physically distance due to insufficient income. DESIGN: Open-label, multi-centre, randomised superiority trial. SETTING: Seven primary care sites in Ontario, Canada; six urban sites associated with St. Michael's Hospital in Toronto and one in Manitoulin Island. PARTICIPANTS: 392 individuals who reported trouble affording basic necessities due to disruptions related to COVID-19. INTERVENTION: After random allocation, participants either received the cash transfer of $C1000 (n=196) or physical distancing guidelines alone (n=196). MAIN OUTCOME MEASURES: The primary outcome was the maximum number of symptoms consistent with COVID-19 over 14 days. Secondary outcomes were meeting clinical criteria for COVID-19, SARS-CoV-2 presence, number of close contacts, general health and ability to afford basic necessities. RESULTS: The primary outcome of number of symptoms reported by participants did not differ between groups after 2 weeks (cash transfer, mean 1.6 vs 1.9, ratio of means 0.83; 95% CI 0.56 to 1.24). There were no statistically significant effects on secondary outcomes of the meeting COVID-19 clinical criteria (7.9% vs 12.8%; risk difference -0.05; 95% CI -0.11 to 0.01), SARS-CoV-2 presence (0.5% vs 0.6%; risk difference 0.00 95% CI -0.02 to 0.02), mean number of close contacts (3.5 vs 3.7; rate ratio 1.10; 95% CI 0.83 to 1.46), general health very good or excellent (60% vs 63%; risk difference -0.03 95% CI -0.14 to 0.08) and ability to make ends meet (52% vs 51%; risk difference 0.01 95% CI -0.10 to 0.12). CONCLUSIONS: A single cash transfer did not reduce the COVID-19 symptoms or improve the ability to afford necessities. Further studies are needed to determine whether some groups may benefit from financial supports and to determine if a higher level of support is beneficial. TRIAL REGISTRATION NUMBER: NCT04359264.

Improving opioid guideline adherence: evaluation of a multifaceted, theory-informed pilot intervention for family physicians.

OBJECTIVES: Opioid-related deaths continue to increase in North America, an epidemic that was initiated by high rates of opioid prescribing. We designed a multifaceted, theory-informed Opioid Self-Assessment (OSA) package, to increase adherence to the Canadian Opioid Guideline among family physicians. This study aimed to assess changes in Canadian family physicians' knowledge and practices after completing the OSA package. DESIGN: We conducted a mixed-method evaluation using a pre-test and post-test design that involved the collection of both qualitative and quantitative data. SETTING: This research was conducted in the primary care setting in Ontario, Canada. PARTICIPANTS: We recruited a purposive sample of nine family physicians in Ontario who use long-term opioid therapy to treat patients with chronic pain. INTERVENTIONS: The OSA package included four components: an online knowledge test, an online learning programme, a safe medication practice self-assessment questionnaire and chart audit with feedback. OUTCOME MEASURES: Our measures included changes in knowledge, opioid safety practices and physicians' perspectives on the OSA package. RESULTS: We found statistically significant improvements between pre-test and post-test knowledge scores at both baseline and 6-month follow-up. Physicians' scores improved significantly on five of the seven core characteristics of the practice self-assessment questionnaire. On the chart audits, we observed an improvement in patient education between baseline and 6 months. Qualitative interviews showed that participants appreciated embedded resources in the OSA package. The completion of the package stimulated identification of gaps or deficits in practice and served as a useful reminder to discuss risk and safety with patients. Participants described the chart review as helpful in prompting discussions with their patients, identifying deficits and strengths and a 'primary motivator' for project participation. CONCLUSIONS: The OSA package has the potential to improve medication safety practices in primary care related to opioid monitoring and adherence to current opioid guidelines.

Investigating pharmaceutical marketing in Canada using American prosecutions.

BACKGROUND: Pharmaceutical companies are prohibited from marketing medications for off-label uses in both the United States and Canada. In the United States, there have been several recent multi-billion dollar settlements with pharmaceutical companies based, partly, on off-label promotion. Health Canada has not publicized any investigations into, or prosecutions of, pharmaceutical companies for off-label promotion in Canada even though many of the same medications are marketed here. The prohibition on off-label promotion is largely directed at preventing pharmaceutical companies from circumventing the drug licensing process and attendant safety checks. OBJECTIVE: To determine if sanctions for off-label pharmaceutical promotion in one jurisdiction can be used to regulate marketing in another. METHODS: We reviewed and compared the laws and regulatory bodies in Canada and the United States to determine if Canadian regulators could use the findings of American regulators. RESULTS: There were no important differences in the laws and regulatory bodies in Canada and the United States related to off-label promotion. CONCLUSIONS: Canadian regulators can use the findings of American regulators to investigate off-label promotion in Canada. All countries should consider using sanctions in other jurisdictions to direct the deployment of limited regulatory resources.

Differences in the volume of pharmaceutical advertisements between print general medical journals.

BACKGROUND: Pharmaceutical advertisements have been argued to provide revenue that medical journals require but they are intended to alter prescribing behaviour and they are known to include low quality information. We determined whether a difference exists in the current level of pharmaceutical advertising in print general medical journals, and we estimated the revenue generated from print pharmaceutical advertising. METHODS: Six print general medical journals in Canada, the United States, and the United Kingdom were sampled between 2007 and 2012. The number of advertisements and other journal content in selected issues of the Canadian Medical Association Journal (CMAJ), Canadian Family Physician (CFP), Journal of the American Medical Association (JAMA), New England Journal of Medicine (NEJM), British Medical Journal (BMJ), and Lancet were determined. Revenue gained from pharmaceutical advertising was estimated using each journal's 2013 advertising price list. FINDINGS: The two Canadian journals sampled (CMAJ, CFP) contained five times more advertisements than the two American journals (JAMA, NEJM), and two British journals (BMJ, Lancet) (p<0.0001). The estimated annual revenue from pharmaceutical advertisements ranged from £0.025 million (for Lancet) to £3.8 million (for JAMA). The cost savings due to revenue from pharmaceutical advertising to each individual subscriber ranged from £0.02 (for Lancet) to £3.56 (for CFP) per issue. CONCLUSION: The volume of pharmaceutical advertisements differs between general medical journals, with the two Canadian journals sampled containing the most advertisements. International and temporal variations suggest that there is an opportunity for all general medical journals to reduce the number of pharmaceutical advertisements, explore other sources of revenue, and increase transparency regarding sources of revenue.

Questionable content of an industry-supported medical school lecture series: a case study.

BACKGROUND: Medical schools are grappling with how best to manage industry involvement in medical education. OBJECTIVE: To describe a case study of industry-supported undergraduate medical education related to opioid analgesics. METHOD: Institutional case study. RESULTS: As part of their regular curriculum, Canadian medical students attended pain pharmacotherapy lectures that contained questionable content about the use of opioids for pain management. The lectures were supported by pharmaceutical companies that market opioid analgesics in Canada and the guest lecturer was a member of speakers bureaus of the same companies. These conflicts of interests were not fully disclosed. A reference book that reinforced some of the information in the lectures and that was paid for by a sponsoring company was made available to students. This is the first report of an association between industry sponsorship and the dissemination of potentially dangerous information to medical students. CONCLUSIONS: This case demonstrates the need for better strategies for preventing, identifying and dealing with problematic interactions between the pharmaceutical industry and undergraduate medical education. These might include the avoidance of unnecessary conflicts of interest, more disclosure of conflicts, an open process for dealing with recognised problems and internationally harmonised conflict of interest policies.

How the Illicit Drug Economy Contributes to HIV Risk in St Vincent and the Grenadines.

St Vincent and the Grenadines (SVG) is the largest marijuana producer in the Eastern Caribbean. As the European Union has phased out preferred access for its banana crop, marijuana has become one of the main sources of income and a safety net for many young men, in particular. HIV is a problem for youth in SVG where 60% of the population and 50% of cumulative AIDS cases are among individuals under 30 years of age. To explore the relationship between the economic context and HIV, we used rapid appraisal methods including field observations, interviews, and focus groups with 43 key informants. We found that the marijuana-related economy has contributed to social conditions favoring HIV transmission among young people in several interrelated ways. A lively youth culture exists which includes frequent parties, heavy drinking, sex with multiple partners, and the desire to be seen with the best material goods. Men with access to money are able to attract younger partners for parties and sex. Condoms are infrequently used. We conclude that reducing HIV risk will require structural interventions to reduce discrimination and increase economic opportunity.

Direct assessment of qualia in a blindsight participant.

Experimenters generally infer whether participants have visual experiences based on metacognitive responses. We showed a well-studied blindsight participant, GY, several definitions of the term "qualia" and then questioned him about whether he felt or he experienced qualia in his normal and blind fields. We found, contrary to others who have used different methods for measuring qualia, that GY does not have qualia for stationary stimuli in his blind field. This novel method for directly assessing qualia embraces the idea that experiences should be related by the experiencer, not the experimenter.