Perspectives of patients who inject drugs on a needle and syringe program at a large acute care hospital.

BACKGROUND: People who inject drugs in North America often continue to inject while hospitalized, and are at increased risk of premature hospital discharge, unplanned readmission, and death. In-hospital access to sterile injection supplies may reduce some harms associated with ongoing injection drug use. However, access to needle and syringe programs in acute care settings is limited. We explored the implementation of a needle and syringe program integrated into a large urban tertiary hospital in Western Canada. The needle and syringe program was administered by an addiction medicine consult team that offers patients access to specialized clinical care and connection to community services. METHODS: We utilized a focused ethnographic design and semi-structured interviews to elicit experiences and potential improvements from 25 hospitalized people who inject drugs who were offered supplies from the needle and syringe program. RESULTS: Participants were motivated to accept supplies to prevent injection-related harms and access to supplies was facilitated by trust in consult team staff. However, fears of negative repercussions from non-consult team staff, including premature discharge or undesired changes to medication regimes, caused some participants to hesitate or refuse to accept supplies. Participants described modifications to hospital policies regarding inpatient drug use or access to an inpatient supervised consumption service as potential ways to mitigate patients' fears. CONCLUSIONS: Acute care needle and syringe programs may aid hospital providers in reducing harms and improving hospital outcomes for people who inject drugs. However, modifications to hospital policies and settings may be necessary.

Healthcare Providers' Perspectives on a Novel Couple-Based HIV Treatment Intervention: A Qualitative Assessment of the Facilitators, Barriers, and Proposed Improvements to Implementation in Zambézia Province, Mozambique.

Mozambique has one of the world's highest HIV/AIDS burdens. Despite significant investment in HIV care and treatment, pregnant and lactating women's retention in care remains suboptimal. One reason for poor maternal retention is lack of male partner support. We tested an interventional couple-based HIV care and treatment, including joint clinical appointments and couple-based educational and support sessions provided by a health counselor and peer educators, respectively. Healthcare providers delivering care for seroconcordant individuals were interviewed regarding their perspectives on facilitators and barriers to the couple-based intervention implementation. Analysis of interview responses was done using MAXQDA. Results pertaining to providers' perspectives on implementation and intervention characteristics were organized, interpreted, and contextualized using the Consolidated Framework for Implementation Research (CFIR 2.0), while providers' suggestions for improvements were coded and organized apart from CFIR. Providers felt the intervention was largely compatible with the local culture, and offered a significant advantage over standard individual-based care by facilitating patient follow-up and reducing wait times by prioritizing couples for services. They also believed it facilitated HIV treatment access through the provision of couple-based counseling that encouraged supportive behaviors towards retention. However, providers reported insufficient privacy to deliver couple-based care at some health facilities and concerns that women in difficult relationships may struggle to meaningfully participate. They suggested providing sessions in alternate clinic settings and offering a limited number of women-only visits. The facilitators and barriers described here contribute to informing the design and implementation of future couple-based interventions to improve HIV care for seroconcordant expectant couples.

Flawed reports can harm: the case of supervised consumption services in Alberta.

Supervised consumption services have been scaled up within Canada and internationally as an ethical imperative in the context of a public health emergency. A large body of peer-reviewed evidence demonstrates that these services prevent poisoning deaths, reduce infectious disease transmission risk behaviour, and facilitate clients' connections to other health and social services. In 2019, the Alberta government commissioned a review of the socioeconomic impacts of seven supervised consumption services in the province. The report is formatted to appear as an objective, scientifically credible evaluation of these services; however, it is fundamentally methodologically flawed, with a high risk of biases that critically undermine its authors' assessment of the scientific evidence. The report's findings have been used to justify decisions that jeopardize the health and well-being of people who use drugs both in Canada and internationally. Governments must ensure that future assessments of supervised consumption services and other public health measures to address drug poisoning deaths are scientifically sound and methodologically rigorous. Health policy must be based on the best available evidence, protect the right of structurally vulnerable populations to access healthcare, and not be contingent on favourable public opinion or prevailing political ideology.

RéSUMé: Les services de consommation supervisée ont été établis au Canada et à l'étranger en tant qu'impératif éthique dans le contexte d'une urgence de santé publique. Un grand nombre d'études rigoureuses démontrent que ces services préviennent les décès par empoisonnement, réduisent les comportements à risque de transmission de maladies infectieuses, et facilitent les liens avec d'autres services sociaux et de santé. En 2019, le gouvernement de l'Alberta a commandé un examen des impacts socioéconomiques de sept services de consommation supervisée dans la province. La présentation du rapport donne l'impression que l'évaluation de ces services est objective et scientifiquement crédible; cependant, il présente des faiblesses importantes au plan méthodologique, notamment en raison de la présence de biais qui compromet l'évaluation des preuves scientifiques. Ses conclusions ont été utilisées pour justifier des décisions qui mettent en péril la santé et le bien-être des personnes qui consomment des drogues, tant au Canada qu'à l'étranger. Les gouvernements doivent s'assurer que les futures évaluations des services de consommation supervisée et d'autres mesures de santé publique pour lutter contre les décès par empoisonnement dû aux drogues sont scientifiquement fondées. Les politiques en matière de santé doivent être basées sur les meilleures données disponibles, protéger les droits des populations structurellement vulnérables à accéder aux soins de santé, et ne pas dépendre de l'opinion publique ou d'une idéologie politique dominante.

Real-World Effectiveness of 8-Week Glecaprevir/Pibrentasvir in Treatment-Naïve, Compensated Cirrhotic HCV Patients.

INTRODUCTION: The EXPEDITION-8 clinical trial has demonstrated that treatment-naïve patients with compensated cirrhosis (TN/CC) of HCV genotypes 1-6 can achieve a 98% intent-to-treat sustained virologic response rate 12 weeks post-treatment with an 8-week glecaprevir/pibrentasvir (G/P) regimen. Further real-world evidence is needed to support the effectiveness of 8-week G/P in a clinical practice setting and to consolidate these treatment recommendations. The aim of this study is to contribute real-world evidence for the effectiveness of an 8-week G/P treatment in TN/CC patients with HCV genotypes 1-6. METHODS: Retrospective real-world data from 494 TN/CC patients with HCV genotypes 1-6 were collected between August 2017 to December 2020 from the Symphony Health Solutions administrative claims database. Demographic and clinical characteristics were collected at baseline. Patients were required to have a follow-up HCV ribonucleic acid level at least 8 weeks or more after the end of treatment. The percentage of patients achieving a sustained virologic response (SVR) is reported. RESULTS: The majority of patients were male (58%) and Caucasian (40%), with a mean age of 58 years; 74%, 12%, 12%, and 1% of patients were HCV genotype 1, 2, 3, and 4-6 infected, respectively. SVR was achieved in 95.5% of all patients. Across patient subgroups, SVR was achieved in 95.6% of patients with HCV genotype 3 and in 93% of HCV patients with a recent diagnosis of illicit drug use or abuse (within 6 months prior to G/P initiation). CONCLUSION: Early real-world evidence indicates high effectiveness of the 8-week G/P regimen in TN/CC patients of HCV genotypes 1-6 from a large US claims database.

Tensor image registration library: Deformable registration of stand-alone histology images to whole-brain post-mortem MRI data.

BACKGROUND: Accurate registration between microscopy and MRI data is necessary for validating imaging biomarkers against neuropathology, and to disentangle complex signal dependencies in microstructural MRI. Existing registration methods often rely on serial histological sampling or significant manual input, providing limited scope to work with a large number of stand-alone histology sections. Here we present a customisable pipeline to assist the registration of stand-alone histology sections to whole-brain MRI data. METHODS: Our pipeline registers stained histology sections to whole-brain post-mortem MRI in 4 stages, with the help of two photographic intermediaries: a block face image (to undistort histology sections) and coronal brain slab photographs (to insert them into MRI space). Each registration stage is implemented as a configurable stand-alone Python script using our novel platform, Tensor Image Registration Library (TIRL), which provides flexibility for wider adaptation. We report our experience of registering 87 PLP-stained histology sections from 14 subjects and perform various experiments to assess the accuracy and robustness of each stage of the pipeline. RESULTS: All 87 histology sections were successfully registered to MRI. Histology-to-block registration (Stage 1) achieved 0.2-0.4 mm accuracy, better than commonly used existing methods. Block-to-slice matching (Stage 2) showed great robustness in automatically identifying and inserting small tissue blocks into whole brain slices with 0.2 mm accuracy. Simulations demonstrated sub-voxel level accuracy (0.13 mm) of the slice-to-volume registration (Stage 3) algorithm, which was observed in over 200 actual brain slice registrations, compensating 3D slice deformations up to 6.5 mm. Stage 4 combined the previous stages and generated refined pixelwise aligned multi-modal histology-MRI stacks. CONCLUSIONS: Our open-source pipeline provides robust automation tools for registering stand-alone histology sections to MRI data with sub-voxel level precision, and the underlying framework makes it readily adaptable to a diverse range of microscopy-MRI studies.

"I have such a hard time hitting myself, I thought it'd be easier": perspectives of hospitalized patients on injecting drugs into vascular access devices.

BACKGROUND: Hospital patients who use drugs may require prolonged parenteral antimicrobial therapy administered through a vascular access device (VAD). Clinicians' concerns that patients may inject drugs into these devices are well documented. However, the perspectives of patients on VAD injecting are not well described, hindering the development of informed clinical guidance. This study was conducted to elicit inpatient perspectives on the practice of injecting drugs into VADs and to propose strategies to reduce associated harms. METHODS: Researchers conducted a focused ethnography and completed semi-structured interviews with 25 inpatients at a large tertiary hospital in Western Canada that experiences a high rate of drug-related presentations annually. RESULTS: A few participants reported injecting into their VAD at least once, and nearly all had heard of the practice. The primary reason for injecting into a VAD was easier venous access since many participants had experienced significant vein damage from injection drug use. Several participants recognized the risks associated with injecting into VADs, and either refrained from the practice or took steps to maintain their devices while using them to inject drugs. Others were uncertain how the devices functioned and were unaware of potential harms. CONCLUSIONS: VADs are important for facilitating completion of parenteral antimicrobial therapy and for other medically necessary care. Prematurely discharging patients who inject into their VAD from hospital, or discontinuing or modifying therapy, results in inequitable access to health care for a structurally vulnerable patient population. Our findings demonstrate a need for healthcare provider education and non-stigmatizing clinical interventions to reduce potential harms associated with VAD injecting. Those interventions could include providing access to specialized pain and withdrawal management, opioid agonist treatment, and harm reduction services, including safer drug use education to reduce or prevent complications from injecting drugs into VADs.

Impact of health system engagement on the health and well-being of people who use drugs: a realist review protocol.

BACKGROUND: Although community-level benefits of health system engagement (i.e., health service planning, delivery, and quality improvement, engaged research and evaluation, and collaborative advocacy) are well established, individual-level impacts on the health and well-being of community members are less explored, in particular for people who use or have used illegal drugs (PWUD). Capacity building, personal growth, reduced/safer drug use, and other positive outcomes may or may not be experienced by PWUD involved in engagement activities. Indeed, PWUD may also encounter stigma and harm when interacting with healthcare and academic structures. Our objective is to uncover why, how, and under what circumstances positive and negative health outcomes occur during health system engagement by PWUD. METHODS: We propose a realist review approach due to its explanatory lens. Through preliminary exploration of literature, lived experience input, and consideration of formal theories, an explanatory model was drafted. The model describes contexts, mechanisms, and health outcomes (e.g., mental health, stable/safer drug use) involved in health system engagement. The explanatory model will be tested against the literature and iteratively refined against formal theories. A participatory lens will also be used, wherein PWUD with lived experience of health system engagement will contribute throughout all stages of the review. DISCUSSION: We believe this is the first realist review to explore the contextual factors and underlying mechanisms of health outcomes for PWUD who participate in health system engagement. A thorough understanding of the relevant literature and theoretical underpinnings of this process will offer insights and recommendations to improve the engagement processes of PWUD.

Deep water cuspate stromatolites of the Cryogenian Trezona Formation.

Stromatolites and microbialites contain a rich repository of environmental and biological information. Despite extensive research, questions remain regarding the biological, chemical, and physical processes that control stromatolite macro, meso, and microstructure. We report unusual deep water cuspate stromatolites from the Cryogenian Trezona Formation, South Australia, from a mixed siliciclastic-carbonate open marine ramp setting. Cuspate stromatolite horizons develop near the base of decameter-scale transgression-regression cycles and typically overlie decimeter-scale irregular erosion surfaces. The cuspate structure within the stromatolites form near vertical, stacked cusp structures in cross section. In plan view, the cusps form cm-scale sharp parallel ridges oriented perpendicular to the regional downslope direction and perpendicular to the elongation direction of stromatolites. Stromatolites colonized topographic highs of irregular erosion surfaces (often hardgrounds) and grew in carbonate supersaturated, iron-rich marine waters in low turbidity sediment-starved settings. Cuspate stromatolites are interpreted as forming in deep water environments during maximum transgression as condensed intervals. Their microbial metabolism may require low light and low oxygen. A deep water origin for the Trezona Formation cuspate stromatolites and other Precambrian cuspate stromatolites suggests a link between the cuspate morphology and physical/chemical (carbonate supersaturated, low light, and low oxygen) conditions of Precambrian deep water marine settings.

Pediatric Malaria: Global and North American Perspectives.

Malaria is a leading cause of death in children less than 5 years of age globally, and a common cause of fever in the returning North American traveler. New tools in the fight against malaria have been developed over the past decades: potent artemisinin derivatives; rapid diagnostic tests; long-lasting insecticidal bed nets; and a new vaccine, RTS,S/AS01. Thwarting these advances, parasite and Anopheles vector resistance are emerging. In the meantime, clinicians will continue to see malaria among febrile travelers from the tropics. Early recognition, diagnosis, and treatment can be lifesaving, but rely on the vigilance of frontline clinicians.

Epidemiology and Clinical Characteristics of Individuals with Hepatitis C Virus Infection in the United States, 2017-2019.

INTRODUCTION: Hepatitis C virus (HCV) is the most common bloodborne chronic infection in the US. Following approval of highly effective, direct-acting antivirals in 2014, the diagnostic and treatment rates for HCV infection in the US have evolved. This study assessed the number of individuals with HCV screening or diagnostic testing and the clinical characteristics and treatment of HCV-infected individuals between 2017 and 2019. METHODS: Individuals screened for HCV antibody and/or tested for HCV ribonucleic acid (RNA) from 2017 to 2019 by two large US laboratory companies were included in this analysis. Clinical characteristics, such as HCV genotype, fibrosis stage, HIV coinfection and demographics, were assessed in HCV RNA-positive individuals. HCV treatment and subsequent achievement of sustained virologic response were imputed using data-driven algorithms based on successive viral load decline and negativity. RESULTS: From 2017 to 2019, the number of individuals tested for HCV antibody increased by 5.7%, from 7,580,303 in 2017 to 8,009,081 in 2019. The percentage of individuals tested who were HCV antibody positive was stable, ranging from 5.0% in 2017 to 4.9% in 2018 and 2019. The number of HCV RNA-positive individuals decreased by 5.0% from 382,500 in 2017 to 363,532 in 2019. Of HCV RNA-positive individuals, the proportions with genotype (GT) 3 and minimal fibrosis increased over time; proportions of individuals aged < 40 years increased, while the proportion aged 50 to 59 years decreased. Treatment rates increased from 23.4% in 2017 to 26.8% in 2019. CONCLUSIONS: The percentage of HCV antibody-positive individuals remained stable from 2017 to 2019. The number of individuals tested HCV RNA positive decreased over the years. Demographics shifted toward a younger population with less fibrosis and higher rates of GT3. More than 70% of diagnosed individuals were not treated during this interval, highlighting a need for unfettered access to treatment.

Research- and health-related youth advisory groups in Canada: An environmental scan with stakeholder interviews.

BACKGROUND: Engaging youth throughout the research process improves research quality and outcomes. Youth advisory groups provide one way for youth to express their opinions on relevant issues. OBJECTIVE: This study aimed to identify research- and health-related youth advisory groups ('groups') in Canada and understand the best practices of these groups. METHODS: Google searches and supplementary methods were used to identify relevant groups in Canada. Group information was extracted from websites or through interviews with key informants. RESULTS: We identified 40 groups. Groups were commonly part of a hospital/healthcare facility, nonprofit/health organization or research group. The majority focused on a specific content area, most commonly, mental health. Over half the groups advised on health services. Members' ages ranged from 9 to 35 years. The number of members ranged from 5 to 130. Interviews (n = 12) identified seven categories relating to group practices: (a) group purpose/objectives, (b) group development, (c) group operations, (d) group structure, (e) adult involvement, (f) membership and recruitment and (g) group access. Challenges and facilitators to the success of groups were described within the following themes: (a) retaining engagement, (b) creating a safe environment and (c) putting youth in positions of influence. Advice and recommendations were provided regarding the development of a new group. CONCLUSION: This study provides a comprehensive overview of research- and health-related youth advisory groups in Canada. This information can be used to identify groups that stakeholders could access as well as inform the development of a new group. PATIENT OR PUBLIC CONTRIBUTION: Youth advisory group representatives were interviewed as part of the study.

"You don't have to squirrel away in a staircase": Patient motivations for attending a novel supervised drug consumption service in acute care.

BACKGROUND: Acute care hospitals have been described as a high risk environment for people who use drugs (PWUD). Formal and informal bans on drug use can lead patients to conceal their use and consume under unsafe circumstances. Provision of hospital-based supervised consumption services (SCS) could help reduce drug-related harms and improve patient care. However, no peer-reviewed research documents patient experiences with attending SCS in this setting. To address this gap, the present study examines key factors that shape patients' decisions to attend or not attend a novel SCS embedded within a large, urban acute care hospital in Western Canada. METHODS: We adopted a focused ethnographic design and conducted 28 semi-structured interviews with SCS-eligible patients. We examined participant accounts thematically, and Rhodes' "Risk Environment" framework helped guide our analysis. RESULTS: Most participants perceived the SCS as a safer environment that made it possible to reduce drug-related risks and avoid using in unsafe areas of the hospital where they could be caught by staff, security, or police. However, some participants did not trust that the SCS would provide adequate protection from criminalization, which motivated them to avoid the site. Several participants also worried about the potential for unwanted changes to their patient care following SCS use. Physical site and policy limitations, such as eligibility requirements and a lack of infrastructure to support supervised inhalation, were additional reasons for not attending the SCS. CONCLUSION: PWUD in this study attended the hospital-based SCS in an attempt to reduce risks associated with their hospital stay. However, we note a number of access barriers that should be addressed to ensure optimal uptake. Wider provision of SCS in acute care requires both changes to the hospital environment and broader drug policy reform.

Supporting the full participation of people who use drugs in policy fora: Provision of a temporary, conference-based overdose prevention site.

The overdose epidemic in North America remains acute and interventions are needed to mitigate harm and prevent death. People who use/d drugs (PWUD) hold essential knowledge to guide the development of these interventions and conferences are vital fora for hearing their perspectives and building support for new policies and programs. However, little guidance exists on how to best ensure the safety of PWUD during conferences. In October 2018, a low-threshold overdose prevention site (OPS) was implemented at a national drug policy and harm reduction conference in Edmonton, Canada. The OPS provided delegates with a monitored space to consume drugs and access drug consumption supplies. This commentary describes the implementation of the OPS with the aim of providing practical guidance for organizers of future substance use-related conferences, meetings, and other events.

Systematic review of the use of process evaluations in knowledge translation research.

BACKGROUND: Experimental designs for evaluating knowledge translation (KT) interventions can provide strong estimates of effectiveness but offer limited insight into how the intervention worked. Consequently, process evaluations have been used to explore the causal mechanisms at work; however, there are limited standards to guide this work. This study synthesizes current evidence of KT process evaluations to provide future methodological recommendations. METHODS: Peer-reviewed search strategies were developed by a health research librarian. Studies had to be in English, published since 1996, and were not excluded based on design. Studies had to (1) be a process evaluation of a KT intervention study in primary health, (2) be a primary research study, and (3) include a licensed healthcare professional delivering or receiving the intervention. A two-step, two-person hybrid screening approach was used for study inclusion with inter-rater reliability ranging from 94 to 95%. Data on study design, data collection, theoretical influences, and approaches used to evaluate the KT intervention, analysis, and outcomes were extracted by two reviewers. Methodological quality was assessed with the Mixed Methods Appraisal Tool (MMAT). RESULTS: Of the 20,968 articles screened, 226 studies fit our inclusion criteria. The majority of process evaluations used qualitative forms of data collection (43.4%) and individual interviews as the predominant data collection method. 72.1% of studies evaluated barriers and/or facilitators to implementation. 59.7% of process evaluations were stand-alone evaluations. The timing of data collection varied widely with post-intervention data collection being the most frequent (46.0%). Only 38.1% of the studies were informed by theory. Furthermore, 38.9% of studies had MMAT scores of 50 or less indicating poor methodological quality. CONCLUSIONS: There is widespread acceptance that the generalizability of quantitative trials of KT interventions would be significantly enhanced through complementary process evaluations. However, this systematic review found that process evaluations are of mixed quality and lack theoretical guidance. Most process evaluation data collection occurred post-intervention undermining the ability to evaluate the process of implementation. Strong science and methodological guidance is needed to underpin and guide the design and execution of process evaluations in KT science. REGISTRATION: This study is not registered with PROSPERO.

Uptake into a bedside needle and syringe program for acute care inpatients who inject drugs.

INTRODUCTION AND AIMS: Injection drug use is associated with significant morbidity and mortality worldwide. Needle and syringe programs (NSP) have been shown to reduce negative health outcomes for people who inject drugs. However, NSPs have limited reach in hospitals, and no peer-reviewed research has examined NSP implementation in acute care settings. We describe the implementation of an inpatient NSP offered through an addiction medicine consultation service in a large, urban acute care hospital in Edmonton, Canada, and compared characteristics of inpatients who did versus did not access the NSP. DESIGN AND METHODS: Administrative data were reviewed for all addiction medicine consult service intakes between 11 July 2016 and 14 January 2018. We calculated the proportion of intakes in which patients: (i) were offered syringes; and (ii) accepted syringes. Multivariate analyses were used to examine associations between these outcomes and patient age and sex. RESULTS: Patients reported injecting drugs in 597 (31%) of 1907 intakes during the study period. People who inject drugs were offered syringes in 334 (56%) of these intakes, and accepted syringes in 124 (37%) of them. Female patients were more likely to accept syringes. DISCUSSION AND CONCLUSIONS: In a recently implemented NSP for hospital inpatients, just over half of patients who reported injection drug use were offered syringes, and the rate of patient acceptance was low. Further research is necessary to describe best practice for inpatient NSPs and identify and remove any barriers that prevent some inpatients from either being offered or accepting syringes.

Physical modeling of vortical cross-step flow in the American paddlefish, Polyodon spathula.

Vortical cross-step filtration in suspension-feeding fish has been reported recently as a novel mechanism, distinct from other biological and industrial filtration processes. Although crossflow passing over backward-facing steps generates vortices that can suspend, concentrate, and transport particles, the morphological factors affecting this vortical flow have not been identified previously. In our 3D-printed models of the oral cavity for ram suspension-feeding fish, the angle of the backward-facing step with respect to the model's dorsal midline affected vortex parameters significantly, including rotational, tangential, and axial speed. These vortices were comparable to those quantified downstream of the backward-facing steps that were formed by the branchial arches of preserved American paddlefish in a recirculating flow tank. Our data indicate that vortices in cross-step filtration have the characteristics of forced vortices, as the flow of water inside the oral cavity provides the external torque required to sustain forced vortices. Additionally, we quantified a new variable for ram suspension feeding termed the fluid exit ratio. This is defined as the ratio of the total open pore area for water leaving the oral cavity via spaces between branchial arches that are not blocked by gill rakers, divided by the total area for water entering through the gape during ram suspension feeding. Our experiments demonstrated that the fluid exit ratio in preserved paddlefish was a significant predictor of the flow speeds that were quantified anterior of the rostrum, at the gape, directly dorsal of the first ceratobranchial, and in the forced vortex generated by the first ceratobranchial. Physical modeling of vortical cross-step filtration offers future opportunities to explore the complex interactions between structural features of the oral cavity, vortex parameters, motile particle behavior, and particle morphology that determine the suspension, concentration, and transport of particles within the oral cavity of ram suspension-feeding fish.

Sexual orientation disclosure in health care: a systematic review.

BACKGROUND: Significant health disparities between sexual minority individuals (that is, lesbian, gay, bisexual, or transgender [LGBT]) and heterosexual individuals have been demonstrated. AIM: To understand the barriers and facilitators to sexual orientation (SO) disclosure experienced by LGBT adults in healthcare settings. DESIGN AND SETTING: Mixed methods systematic review, including qualitative, quantitative, and mixed methods papers following PRISMA guidelines. METHOD: Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT) and a qualitative synthesis was performed. Studies were included if their participants were aged ≥18 years who either identified as LGBT, had a same-sex sexual relationship, or were attracted to a member of the same sex. RESULTS: The review included 31 studies representing 2442 participants. Four overarching themes were identified as barriers or facilitators to SO disclosure: the moment of disclosure, the expected outcome of disclosure, the healthcare professional, and the environment or setting of disclosure. The most prominent themes were the perceived relevance of SO to care, the communication skills and language used by healthcare professionals, and the fear of poor treatment or reaction to disclosure. CONCLUSION: The facilitators and barriers to SO disclosure by LGBT individuals are widespread but most were modifiable and could therefore be targeted to improve healthcare professionals' awareness of their patients' SO. Healthcare professionals should be aware of the broad range of factors that influence SO disclosure and the potential disadvantageous effects of non-disclosure on care. The environment in which patients are seen should be welcoming of different SOs as well as ensuring that healthcare professionals' communication skills, both verbal and non-verbal, are accepting and inclusive.