Sex differences in suicide mortality in Newfoundland and Labrador: An observational study with medical examiner data from 1997 to 2016.

Background: Globally, the suicide rate is two times higher for males than for females. Previous studies in Newfoundland and Labrador did not examine age-specific rates by sex. The objectives of this study were to determine suicide rates by sex and age group and to compare the demographic and clinical characteristics of males and females who died by suicide. Data and methods: This observational study analyzed a routinely collected dataset based on all medical examiner-determined suicide deaths among people aged 10 years and older in Newfoundland and Labrador, Canada, between 1997 and 2016. Age-standardized and age-specific suicide rates and rate ratios were calculated based on the number of deaths during the period, and descriptive statistics were used to compare demographic and clinical characteristics between males and females. Results: The age-standardized suicide rate was 4.6 times higher among males than females and was higher for males in most age groups. Rates were highest in the young adult age groups for males (20 to 24 years) and females (35 to 39 years). Males who died by suicide were more likely to be from a rural community and to have died by firearm; females were more likely to die by self-poisoning and to have had a mental illness or substance use history. Interpretation: The results are broadly consistent with previous research, though this is the first study to report age-specific suicide rates among females across the life course in Newfoundland and Labrador. The results underscore the need to design public health and clinical interventions that account for sex differences in suicide risks.

Rural-Urban Differences in Suicide Mortality: An Observational Study in Newfoundland and Labrador, Canada: Différences de la Mortalité Par Suicide en Milieu Rural-Urbain: Une Étude Observationnelle à Terre-Neuve et Labrador, Canada.

BACKGROUND: Suicide rates are higher in rural compared to urban areas. Although this pattern appears to be driven by higher rates among men, there is limited evidence about the characteristics of rural people who die by suicide in Canada. The objective of this study was to examine the demographics, manner of death, and social and clinical antecedents of people who died by suicide in rural areas compared to urban areas. METHODS: We conducted an observational study of all suicide deaths that occurred among Newfoundland and Labrador residents between 1997 and 2016 using a linked data set derived from a comprehensive review of provincial medical examiner records. We used t tests and χ2 to assess associations between rural/urban status and variables related to demographics, circumstances, and manner of death, as well as social and medical history. Logistic regression was utilized to assess the independent contribution of any variable found to be significant in univariate analysis. RESULTS: Rural people who died by suicide accounted for 54.8% of all deaths over a 20-year period. Overall, 81.6% of people who died were male. Compared to urban, rural people who died by suicide were younger, more likely to use firearms or hanging, and had a higher mean blood alcohol content at the time of death (27.69 vs. 22.95 mmol/L). Rural people were also less likely to have had a known history of a prior suicide attempt, psychiatric disorder, alcohol or substance abuse, or chronic pain. DISCUSSION: The demographic and clinical differences between rural and urban people who died by suicide underscore the need for suicide prevention approaches that account for place-based differences. A key challenge for suicide prevention in rural communities is to ensure that interventions are developed and implemented in a manner that fits local contexts.

Suicide in Newfoundland and Labrador, Canada: a time trend analysis from 1981 to 2018.

BACKGROUND: The suicide rate in Canada decreased by 24% during the past four decades. However, rates vary between provinces and territories, and not all jurisdictions experienced the same changes. This study examined suicide rates over time in the province of Newfoundland and Labrador. METHODS: We used cross-sectional surveillance data from the Canadian Vital Statistics Death Database to examine suicide rates in Newfoundland and Labrador from 1981 to 2018. We calculated annual age-standardized suicide mortality rates and used joinpoint regression to estimate the average annual percent change (AAPC) in suicide rates overall and by sex, age group, and means of suicide. RESULTS: From 1981 to 2018, 1759 deaths by suicide were recorded among people in Newfoundland and Labrador. The age-standardized suicide mortality rate increased more than threefold over the study period, from 4.6 to 15.4 deaths per 100,000. The suicide rate was higher among males than females, and accounted for 83.1% of suicide deaths (n = 1462); the male-to-female ratio of suicide deaths was 4.9 to 1. The average annual percent change in suicide rates was higher among females than males (6.3% versus 2.0%). Age-specific suicide rates increased significantly for all age groups, except seniors (aged 65 or older); the largest increase was among youth aged 10 to 24 years old (AAPC 3.5; 95% CI, 1.6 to 5.5). The predominant means of suicide was hanging/strangulation/suffocation, which accounted for 43.8% of all deaths by suicide. CONCLUSIONS: The suicide rate in Newfoundland and Labrador increased steadily between 1981 and 2018, which was in contrast to the national rate decline. The disparity between the provincial and national suicide rates and the variations by sex and age underscore the need for a public health approach to prevention that accounts for geographic and demographic differences in the epidemiology of suicide.

Diagnosis Discordance and Neonatal Transport: A Single-Center Retrospective Chart Review.

INTRODUCTION: In Canada, more than 4,000 critically ill newborns per year require transfer. Transports are initially managed based on information conveyed by referral practitioners. OBJECTIVES: To identify the frequency of diagnostic discordance between the referring facility, transport team, and tertiary care center in our outborn neonatal population and to verify the association between discordance events (DEs), prolonged transport stabilization times, and potential risk factors to further inform and facilitate the development of future outreach education initiatives. STUDY DESIGN: In this retrospective chart review, we identified and categorized DEs for patients transported by our service in a 1-year period. Associations between DE, transport stabilization times, and patient variables were studied using univariate and multivariable approaches. RESULTS: From 233 eligible patients, 10.7% of patients had referral to discharge discordance events. No significant association was identified between stabilization time and DE. Birth weight and presence of a neurologic diagnosis were associated with DE. CONCLUSION: Diagnostic discordance was identified in 1 of every 10 neonates transported and found to be associated with patients with higher birth weight and the presence of neurologic diagnoses. Outreach initiatives will be developed and adapted accordingly, with a focus on this population.

Harmonization of clinical practice guidelines for primary prevention and screening: actionable recommendations and resources for primary care.

BACKGROUND: Clinical practice guidelines (CPGs) synthesize high-quality information to support evidence-based clinical practice. In primary care, numerous CPGs must be integrated to address the needs of patients with multiple risks and conditions. The BETTER program aims to improve prevention and screening for cancer and chronic disease in primary care by synthesizing CPGs into integrated, actionable recommendations. We describe the process used to harmonize high-quality cancer and chronic disease prevention and screening (CCDPS) CPGs to update the BETTER program. METHODS: A review of CPG databases, repositories, and grey literature was conducted to identify international and Canadian (national and provincial) CPGs for CCDPS in adults 40-69 years of age across 19 topic areas: cancers, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, hepatitis C, obesity, osteoporosis, depression, and associated risk factors (i.e., diet, physical activity, alcohol, cannabis, drug, tobacco, and vaping/e-cigarette use). CPGs published in English between 2016 and 2021, applicable to adults, and containing CCDPS recommendations were included. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and a three-step process involving patients, health policy, content experts, primary care providers, and researchers was used to identify and synthesize recommendations. RESULTS: We identified 51 international and Canadian CPGs and 22 guidelines developed by provincial organizations that provided relevant CCDPS recommendations. Clinical recommendations were extracted and reviewed for inclusion using the following criteria: 1) pertinence to primary prevention and screening, 2) relevance to adults ages 40-69, and 3) applicability to diverse primary care settings. Recommendations were synthesized and integrated into the BETTER toolkit alongside resources to support shared decision-making and care paths for the BETTER program. CONCLUSIONS: Comprehensive care requires the ability to address a person's overall health. An approach to identify high-quality clinical guidance to comprehensively address CCDPS is described. The process used to synthesize and harmonize implementable clinical recommendations may be useful to others wanting to integrate evidence across broad content areas to provide comprehensive care. The BETTER toolkit provides resources that clearly and succinctly present a breadth of clinical evidence that providers can use to assist with implementing CCDPS guidance in primary care.

Living and working in rural healthcare during the COVID-19 pandemic: a qualitative study of rural family physicians' lived experiences.

BACKGROUND: The COVID-19 pandemic has been pervasive in its impact on all aspects of Canadian society. Along with its pervasiveness, the disease provided unprecedented complexity to the Canadian healthcare infrastructure, eliciting varying responses from the afflicted healthcare systems in Canada. However, insights into the various parameters and complexities endured by Canadian rural physicians and rural healthcare institutions during the pandemic have been scarce. OBJECTIVE: This paper explores the conditions and complexity of living and working of Rural Family Physicians (RFPs) in rural healthcare in Canada during the pandemic. METHODS: Community-based participatory research was utilized as a collaborative and partnership approach, equitably engaged community members in all aspects of research, ranging from designing the research question to analyzing data. Participants of this study include RFPs with at least one year of experience working in rural Canada. Data were collected through telephone interviews and analyzed according to the six-phase guide for the data's inductive thematic analysis. Data collection halted upon saturation. RESULTS: Five significant compiled categories reflect the lived experiences of Rural Family Physicians. 1- virtual care as a challenge or forward progress; 2- canceling in-person visits and interrupting the routine; 3- shortage of health care providers and supporting staff; 4-ongoing coping process with the pandemic guidelines; 5-COVID-19 combat fatigue. DISCUSSION: The inception of COVID-19 has significantly impacted rural physicians across several interconnected issues. This study illuminates the lesser-known effects of the COVID-19 pandemic, which heavily impacts rural healthcare.

Virtual Healthcare in Rural and Remote Settings: A Qualitative Study of Canadian Rural Family Physicians' Experiences during the COVID-19 Pandemic.

OBJECTIVE: This paper aims to explore the experiences of rural family physicians using virtual healthcare in their clinical practice during the COVID-19 pandemic in Canada. DESIGN: A community-based participatory approach. SETTING: Rural and remote communities in Canada. PARTICIPANTS: Thirteen rural family physicians with at least one year of clinical experience. RESULTS: The data illustrate significant issues associated with virtual healthcare in rural healthcare. The adoption of virtual healthcare has been expressed to pose a harsh polarity; the benefit conferred to rural family physicians with the opportunity to have flexible working hours and work at home while interacting with family members is starkly contrasted with the struggles of insufficient financial support to facilitate setting up virtual healthcare for rural physicians, unreliable technological infrastructure, and inadequate technological resources, which are all exacerbated by the lack of adequate health literacy in rural communities. Results were compiled into five major categories underpinning the lived experiences of rural family physicians: 1-potential trade-off between convenience and quality of care; 2-work-family boundaries; 3-patient-doctor communication; 4-technology as barrier or enabler; 5-increased call duration. CONCLUSION: The differing trends assessed in the findings illustrate the complications faced in providing virtual healthcare, which resonates with the experiences and views of rural physicians. The findings of this study may guide the development of tailored technologies that adjust for the complexity of administering virtual healthcare in rural communities.

Attribute Analytics Performance Metrics from the MAM Consortium Interlaboratory Study.

The multi-attribute method (MAM) was conceived as a single assay to potentially replace multiple single-attribute assays that have long been used in process development and quality control (QC) for protein therapeutics. MAM is rooted in traditional peptide mapping methods; it leverages mass spectrometry (MS) detection for confident identification and quantitation of many types of protein attributes that may be targeted for monitoring. While MAM has been widely explored across the industry, it has yet to gain a strong foothold within QC laboratories as a replacement method for established orthogonal platforms. Members of the MAM consortium recently undertook an interlaboratory study to evaluate the industry-wide status of MAM. Here we present the results of this study as they pertain to the targeted attribute analytics component of MAM, including investigation into the sources of variability between laboratories and comparison of MAM data to orthogonal methods. These results are made available with an eye toward aiding the community in further optimizing the method to enable its more frequent use in the QC environment.

Rural family physician perspectives on communication with urban specialists: a qualitative study.

OBJECTIVE: Communication is a key competency for medical education and comprehensive patient care. In rural environments, communication between rural family physicians and urban specialists is an essential pathway for clinical decision making. The aim of this study was to explore rural physicians' perspectives on communication with urban specialists during consultations and referrals. SETTING: Newfoundland and Labrador, Canada. PARTICIPANTS: This qualitative study involved semistructured, one-on-one interviews with rural family physicians (n=11) with varied career stages, geographical regions, and community sizes. RESULTS: Four themes specific to communication in rural practice were identified. The themes included: (1) understanding the contexts of rural care; (2) geographical isolation and patient transfer; and (3) respectful discourse; and (4) overcoming communication challenges in referrals and consultations. CONCLUSIONS: Communication between rural family physicians and urban specialists is a critical task in providing care for rural patients. Rural physicians see value in conveying unique aspects of rural clinical practice during communication with urban specialists, including context and the complexities of patient transfers.

New Peak Detection Performance Metrics from the MAM Consortium Interlaboratory Study.

The Multi-Attribute Method (MAM) Consortium was initially formed as a venue to harmonize best practices, share experiences, and generate innovative methodologies to facilitate widespread integration of the MAM platform, which is an emerging ultra-high-performance liquid chromatography-mass spectrometry application. Successful implementation of MAM as a purity-indicating assay requires new peak detection (NPD) of potential process- and/or product-related impurities. The NPD interlaboratory study described herein was carried out by the MAM Consortium to report on the industry-wide performance of NPD using predigested samples of the NISTmAb Reference Material 8671. Results from 28 participating laboratories show that the NPD parameters being utilized across the industry are representative of high-resolution MS performance capabilities. Certain elements of NPD, including common sources of variability in the number of new peaks detected, that are critical to the performance of the purity function of MAM were identified in this study and are reported here as a means to further refine the methodology and accelerate adoption into manufacturer-specific protein therapeutic product life cycles.

Food for thought. What you eat depends on your sex and eating companions.

In a naturalistic study, we investigated the influence of gender, group size and gender composition of groups of eaters on food selected for lunch and dinner (converted to total calories per meal) of 469 individuals (198 groups) in three large university cafeterias. In dyads, women observed eating with a male companion chose foods of significantly lower caloric value than those observed eating with another woman. Overall, group size was not a significant predictor of calories, but women's calories were negatively predicted by numbers of men in the group, while the numbers of women in the group had a marginally significant positive impact on calorie estimates. Men's calorie totals were not affected by total numbers of men or women. This study supports previous investigations, but is unique in making naturalistic observations.

The effectiveness of a proven chronic disease prevention and screening intervention in diverse and remote primary care settings: an implementation study on the BETTER 2 Program.

BACKGROUND: The Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care (BETTER) randomised control trial (RCT) showed that the BETTER Program improved chronic disease prevention and screening (CDPS) by 32.5% in urban team-based primary care clinics. AIM: To evaluate outcomes from implementation of BETTER in diverse clinical settings. DESIGN & SETTING: An implementation study was undertaken to apply the CDPS intervention from the BETTER trial to diverse settings in BETTER 2. Patients aged 40-65 years were invited to enrol in the study from three clinics in Newfoundland and Labrador, Canada. METHOD: At baseline, eligibility for 27 CDPS actions (for example, cancer, diabetes and hypertension screening, lifestyle) was determined. Patients then met with a trained provider and prioritised goals to address their eligible CDPS actions. Providers received training in behaviour change theory and practice. Descriptive analysis of clinical outcomes and success factors were reported. RESULTS: A total of 154 patients (119 female and 35 male) had a baseline visit; 106 had complete outcome assessments, and the remainder had partial outcome assessments. At baseline, patients were eligible for a mean of 12.3 CDPS actions and achieved a mean of 6.0 (49%, 95% confidence intervals [CI] = 24% to 74%) at 6-month follow-up, including reduced hypertension (86% of eligible patients, 95% CI = 67% to 96%), weight control (51% of eligible patients, 95% CI = 42% to 60%), and smoking cessation (36% of eligible patients, 95% CI = 17% to 59%). Male, highly educated, and lower income individuals achieved a higher proportion of CDPS manoeuvers than their counterparts. CONCLUSION: Clinical outcomes from this implementation study were comparable with those of the prior BETTER RCT, providing support for the BETTER Program as an effective approach to CDPS in more diverse general practice settings.

Do pretty women inspire men to discount the future?

Organisms 'discount the future' when they value imminent goods over future goods. Optimal discounting varies: selection should favour allocations of effort that effectively discount the future relatively steeply in response to cues promising relatively good returns on present efforts. However, research on human discounting has hitherto focused on stable individual differences rather than situational effects. In two experiments, discounting was assessed on the basis of choices between a smaller sum of money tomorrow and a larger sum at a later date, both before and after subjects rated the 'appeal' of 12 photographs. In experiment 1, men and women saw either attractive or unattractive opposite-sex faces; in experiment 2, participants saw more or less appealing cars. As predicted, discounting increased significantly in men who viewed attractive women, but not in men who viewed unattractive women or women who viewed men; viewing cars produced a different pattern of results.

Nominal kinship cues facilitate altruism.

We investigated whether names in common promote altruistic behaviour, predicting that this would be especially so for relatively uncommon names, for surnames (which are better kinship cues than first names), and among women (who, although less willing than men to help strangers, according to prior research, are also the primary "kin keepers"). We solicited help from 2960 email addressees, with the request ostensibly coming from a same-sex person sharing both, either, or neither of the addressee's first and last names. As anticipated, addressees were most likely to respond helpfully when senders shared both their names (12.3%) and least likely when they shared neither (2.0%), and this was especially true for relatively uncommon names. A shared surname was more effective than a shared first name only if it was relatively uncommon. Women were substantially more likely to reply than men. These results indicate that names elicit altruism because they function as salient cues of kinship.

Cues of paternal uncertainty and father to child physical abuse as reported by mothers in Rio de Janeiro, Brazil.

OBJECTIVE: Paternity is uncertain, so if paternal feelings evolved to promote fitness, we might expect them to vary in response to variables indicative of paternity probability. We therefore hypothesized that the risk of lapses of paternal affection, including abusive assaults on children, will be exacerbated by cues of non-paternity. METHODS: Cross-sectional study of 331 Brazilian mothers, interviewed about 1 focal child (age 1-12) residing with her and the putative father. Child physical abuse was assessed using the Conflict Tactic Scales: Parent Child (CTSPC). Two potential cues of (non) paternity were (1) whether the parents co-resided when the child was conceived, and (2) whether third parties allegedly commented on father-child resemblance. Data were analyzed through multiple logistic regressions. RESULTS: Mothers reported child physical abuse by 15.9% (95% CI 4.6-27.1) of fathers who had not cohabited with them at conception, compared to 5.9% (95% CI 3.1-8.7) of those who had. The odds ratio for abuse by fathers who had not cohabited at conception in relation to those who had-adjusted for income, education, age, sex of child, whether child was first born, household size, time father spent with child, and alcohol abuse and drug use by father-was 4.3 (95% CI 1.4-13.8). Mothers reported abuse of 7.0% (95% CI 4.0-10.0) of children who purportedly resembled their fathers, versus 8.7% (95% CI 0.2-17.1) of those who did not. CONCLUSION: According to maternal reports, not having co-resided at conception quadrupled the chance of child physical abuse by currently co-residing Brazilian fathers. The reported prevalence of abuse was unrelated to reported allegations of father-child resemblance.

Homicide and impunity: an ecological analysis at state level in Brazil.

OBJECTIVE: To assess a new impunity index and variables that have been found to predict variation in homicide rates in other geographical levels as predictive of state-level homicide rates in Brazil. METHODS: This was a cross-sectional ecological study. Data from the mortality information system relating to the 27 Brazilian states for the years 1996 to 2005 were analyzed. The outcome variables were taken to be homicide victim rates in 2005, for the entire population and for men aged 20-29 years. Measurements of economic and social development, economic inequality, demographic structure and life expectancy were analyzed as predictors. An 'impunity index', calculated as the total number of homicides between 1996 and 2005 divided by the number of individuals in prison in 2007, was constructed. The data were analyzed by means of simple linear regression and negative binomial regression. RESULTS: In 2005, state-level crude total homicide rates ranged from 11 to 51 per 100,000; for young men, they ranged from 39 to 241. The impunity index ranged from 0.4 to 3.5 and was the most important predictor of this variability. From negative binomial regression, it was estimated that the homicide victim rate among young males increased by 50% for every increase of one point in this ratio. CONCLUSIONS: Classic predictive factors were not associated with homicides in this analysis of state-level variation in Brazil. However, the impunity index indicated that the greater the impunity, the higher the homicide rate.

Risk indicators to identify intimate partner violence in the emergency department.

BACKGROUND: Intimate partner violence against women is prevalent and is associated with poor health outcomes. Understanding indicators of exposure to intimate partner violence can assist health care professionals to identify and respond to abused women. This study was undertaken to determine the strength of association between selected evidence-based risk indicators and exposure to intimate partner violence. METHODS: In this cross-sectional study of 768 English-speaking women aged 18-64 years who presented to 2 emergency departments in Ontario, Canada, participants answered questions about risk indicators and completed the Composite Abuse Scale to determine their exposure to intimate partner violence in the past year. RESULTS: Intimate partner violence was significantly associated with being separated, in a common-law relationship or single (odds ratio [OR] = 2.08, 95% confidence interval [CI] 1.17-3.71); scoring positive for depression (OR = 4.26, 95% CI 2.11-8.60) or somatic symptoms (OR = 4.09, 95% CI 2.18-7.67); having a male partner who was employed less than part time (OR = 5.12, 95% CI 2.46-10.64), or having a partner with an alcohol (OR = 4.36, 95% CI 2.16-8.81) or drug problem (OR = 4.63, 95% CI 1.89-11.38). Each unit increase in the number of indicators corresponded to a four-fold increase in the risk of intimate partner violence (OR = 3.92, 95% CI 3.06-5.02); women with 3 or more indicators had a greater than 50% probability of a positive score on the Composite Abuse Scale. Intimate partner violence was not associated with pregnancy status. CONCLUSION: Specific characteristics of male partners, relationships and women's mental health are significantly related to exposure to intimate partner violence in the past year. Identification of these indicators has implications for the clinical care of women who present to health care settings.

Are juvenile offenders extreme future discounters?

It has been the prevailing view that young offenders are more present oriented than their peers, but this view has little empirical basis other than the actions that have defined these youth as offenders. In the present study, we used a decision task with actual monetary consequences to assess the tendency of young offenders and a control group of high school students to discount the future. The young offenders were not significantly different from the students in discounting the future, even though the young offenders scored significantly higher on a sensation-seeking personality scale, were less likely to have lived with their fathers, and had changed schools more often. Young offenders and control participants were also similar in the extent to which they manifested a clear vision of the future by anticipating which future milestones would occur sooner, in a task pairing milestones with each other and with year markers.