Advocating for Policy Change: Examples Emerging From a Medical-Legal Partnership in Primary Care.

Medical-legal partnerships bring legal services directly into clinical settings. Policy advocacy is often opportunistic and varies across partnerships. Our objective was to study policy advocacy that emerged from a medical-legal partnership in Toronto over a four-year period. This study consisted of a document review and thematic analysis, triangulated with data from interviews with legal team members and health providers. We defined policy advocacy as actions associated with attempts to change policy or legislation. The medical-legal partnership engaged in seven distinct cases of policy advocacy: disability support form requirements, changing workplace review, challenging barriers to citizenship, housing, publicly funded medication program (pharma care), safe injection sites, and the need for increased social assistance. Actions taken included presentations at conferences and submissions of briefs to government. We found that a medical-legal partnership resulted in policy advocacy with issues arising from both the health and the legal team with impacts likely greater than if each group had acted alone.

Eviction filings during bans on enforcement throughout the COVID-19 pandemic: an interrupted time series analysis.

OBJECTIVE: Bans on evictions were implemented to reduce the spread of COVID-19 and to protect vulnerable populations during a public health crisis. Our objective was to examine how three bans on eviction enforcement impacted eviction filings from March 2020 through January 2022 in Ontario, Canada. METHODS: Data were derived from eviction application records kept by the Ontario Landlord and Tenant Board. We used segmented regression analysis to model changes in the average weekly filing rates for evictions due to non-payment of rent (L1 filings) and reasons other than non-payment of rent (L2 filings). RESULTS: The average number of weekly L1 and L2 applications dropped by 67.5 (95% CI: 55.2, 79.9) and 31.7 (95% CI: 26.7, 36.6) filings per 100,000 rental dwellings, respectively, following the first ban on eviction enforcement (p < 0.0001). Notably, they did not fall to zero. Level changes during the second and third bans were insubstantial and slope changes for L2 applications varied throughout the study period. The L1 filing rate appeared to increase towards the end of the study period (slope change: 1.3; 95% CI: 0.1, 2.6; p = 0.0387). CONCLUSION: Our findings suggest that while the first ban on eviction enforcement appeared to substantially reduce filing rates, subsequent bans were less effective and none of them eliminated eviction filings altogether. Enacting upstream policies that tackle the root causes of displacement would better equip jurisdictions during future public health emergencies.

RéSUMé: OBJECTIF: Les ordonnances d'expulsion résidentielles ont été suspendues pour réduire la propagation de la COVID-19 et pour protéger les populations vulnérables pendant une crise de santé publique. Notre objectif était d'examiner l'impact de trois interdictions d'exécution d'ordonnance d'éviction sur les requêtes d'expulsion de mars 2020 à janvier 2022 en Ontario, au Canada. MéTHODES: Les données ont été tirées des dossiers de requêtes d'expulsion conservés par la Commission de la location immobilière de l'Ontario. Nous avons utilisé une analyse de régression segmenté pour modéliser les changements dans les taux hebdomadaires moyens de requêtes d'expulsion pour non-paiement du loyer (requêtes L1) et pour des raisons autres que le non-paiement du loyer (requêtes L2). RéSULTATS: Le nombre moyen de demandes hebdomadaires de dépôts de requêtes L1 et L2 a chuté de 67,5 % (IC à 95% : 55,2, 79,9) et de 31,7 % (IC à 95% : 26,7, 36,6) pour 100 000 logements locatifs, respectivement, suite à la première interdiction d'exécution des expulsions. Il est à noter qu'elles ne sont pas tombées à zéro. Les changements du taux de requêtes au cours de la deuxième et la troisième interdictions n'étaient pas substantiels et les changements de pente pour les applications L2 ont varié tout au long de la période d'étude. Le taux de dépôt de L1 a semblé augmenter vers la fin de la période d'étude (changement de pente : 1,3; IC à 95% : 0,1, 2,6; p = 0,0387). CONCLUSION: Nos résultats suggèrent qu'alors que la première interdiction d'exécution des expulsions a semblé réduire considérablement les taux de dépôt d'expulsion, les interdictions ultérieures ont été moins efficaces et aucune d'entre elles n'a complètement éliminé les dépôts d'expulsion. L'adoption de politiques en amont qui s'attaquent plutôt aux causes profondes des expulsions permettrait de mieux équiper les juridictions lors de futures urgences de santé publique.

Targeting DNA damage response components induces enhanced STING-dependent type-I IFN response in ATM deficient cancer cells and drives dendritic cell activation.

The concept of exploiting tumor intrinsic deficiencies in DNA damage repair mechanisms by inhibiting compensatory DNA repair pathways is well established. For example, ATM-deficient cells show increased sensitivity to the ATR inhibitor ceralasertib. DNA damage response (DDR)-deficient cells are also more sensitive to DNA damaging agents like the DNA crosslinker pyrrolobenzodiazepine (PBD) SG-3199. However, additional antitumor benefits from targeting the DDR pathways, which could operate through the activation of the innate immune system are less well studied. DNA accumulation in the cytosol acts as an immunogenic danger signal, inducing the expression of type-I interferon (IFN) stimulated genes (ISGs) by the activation of the cGAS-STING pathway. Here, we demonstrate that ATM -/- FaDu tumor cells have higher basal expression of ISGs when compared to WT cells and respond to ceralasertib and PBD SG-3199 by inducing higher levels of ISGs in a cGAS-STING-dependent manner. We show that sensitive tumor cells treated with ceralasertib and PBD SG-3199 activate dendritic cells (DCs) via a type-I IFN-dependent mechanism. However, STING deficiency in tumor cells does not prevent DC activation, suggesting that transactivation of the STING pathway occurs within DCs. Furthermore, depletion of the cytosolic DNA exonuclease TREX1 in tumor cells increases DC activation in response to PBD SG-3199-treated tumor cells, indicating that an increase in tumor-derived cytosolic DNA may further enhance DC activation. In summary, in this study, we show that ceralasertib and PBD SG-3199 treatment not only intrinsically target tumor cells but also extrinsically increase tumor cell immunogenicity by inducing DC activation, which is enhanced in ATM-deficient cells.

Perceived COVID-19 health and job risks faced by digital platform drivers and measures in place to protect them: A qualitative study.

INTRODUCTION: As they deliver food, packages, and people across cities, digital platform drivers (gig workers) are in a key position to become infected with COVID-19 and transmit it to many others. The aim of this study is to identify perceived COVID-19 exposure and job risks faced by workers and document the measures in place to protect their health, and how workers responded to these measures. METHODS: In 2020-2021, in-depth interviews were conducted in Ontario, Canada, with 33 digital platform drivers and managers across nine platforms that delivered food, packages, or people. Interviews focused on perceived COVID-19 risks and mitigation strategies. Audio recordings were transcribed verbatim and uploaded to NVivo software for coding by varied dual pairs of researchers. A Stakeholder Advisory Committee played an instrumental role in the study. RESULTS: As self-employed workers were without the protection of employment and occupational health standards, platform workers absorbed most of the occupational risks related to COVID-19. Despite safety measures (e.g., contactless delivery) and financial support for COVID-19 illnesses introduced by platform companies, perceived COVID-19 risks remained high because of platform-related work pressures, including rating systems. We identify five key COVID-19 related risks faced by the digital platform drivers. CONCLUSION: We situate platform drivers within the broad context of precarious employment and recommend organizational- and government-level interventions to prevent digital platform worker COVID-19 risks and to assist workers ill with COVID-19. Measures to protect the health of platform workers would benefit public health aims by reducing transmission by drivers to families, customers, and consequently, the greater population.

A rapid scoping review of COVID-19 and vulnerable workers: Intersecting occupational and public health issues.

BACKGROUND: This article reports the results of a rapid scoping review of the literature on COVID-19 transmission risk to workers in essential sectors such as retail, health care, manufacturing, and agriculture, and more particularly the experiences of workers in precarious employment and social situations. METHODS: Following scoping review methods, we included 30 studies that varied in terms of methodology and theoretical approaches. The search included peer-reviewed articles and grey literature published between March and September 2020. RESULTS: Based on the studies reviewed, we found that COVID-19 infection and death rates increased not only with age and comorbidities, but also with discrimination and structural inequities based on racism and sexism. Racial and ethnic minority workers, including migrant workers, are concentrated in high-risk occupations and this concentration is correlated to lower socioeconomic conditions. The COVID-19 pandemic appears in the occupational health and safety spotlight as an exacerbator of already existing socioeconomic inequalities and social inequalities in health, especially in light of the intersection of issues related to racism, ethnic minority status, and sexism. CONCLUSIONS: This review provides early evidence about the limitations of institutions' responses to the pandemic, and their capacity to provide a safe and decent working environment for all workers, regardless of their employment status or the social protections they may enjoy under normal circumstances. It is also important to think about these issues in the postpandemic context, when conditions of precariousness and vulnerability persist and possibly worsen.

From Opiophobia to Overprescribing: A Critical Scoping Review of Medical Education Training for Chronic Pain.

BACKGROUND: Chronic pain is a significant health problem strongly associated with a wide range of physical and mental health problems, including addiction. The widespread prevalence of pain and the increasing rate of opioid prescriptions have led to a focus on how physicians are educated about chronic pain. This critical scoping review describes the current literature in this important area, identifying gaps and suggesting avenues for further research starting from patients' standpoint. METHODS: A search of the ERIC, MEDLINE, and Social Sciences Abstracts databases, as well as 10 journals related to medical education, was conducted to identify studies of the training of medical students, residents, and fellows in chronic noncancer pain. RESULTS: The database and hand-searches identified 545 articles; of these, 39 articles met inclusion criteria and underwent full review. Findings were classified into four inter-related themes. We found that managing chronic pain has been described as stressful by trainees, but few studies have investigated implications for their well-being or ability to provide empathetic care. Even fewer studies have investigated how educational strategies impact patient care. We also note that the literature generally focuses on opioids and gives less attention to education in nonpharmacological approaches as well as nonopioid medications. DISCUSSION: The findings highlight significant discrepancies between the prevalence of chronic pain in society and the low priority assigned to educating future physicians about the complexities of pain and the social context of those afflicted. This suggests the need for better pain education as well as attention to the "hidden curriculum."

Failure to cope: the hidden curriculum of emergency department wait times and the implications for clinical training.

PURPOSE: The study explored optimal intraprofessional collaboration between physicians in the emergency department (ED) and those from general internal medicine (GIM). Prior to the study, a policy was initiated that mandated reductions in ED wait times. The researchers examined the impact of these changes on clinical practice and trainee education. METHOD: In 2010-2011, an ethnographic study was undertaken to observe consults between GIM and ED at an urban teaching hospital in Ontario, Canada. Additional ad hoc interviews were conducted with residents, nurses, and faculty from both departments as well as formal one-on-one interviews with 12 physicians. Data were coded and analyzed using concepts of institutional ethnography. RESULTS: Participants perceived that efficiency was more important than education and was in fact the new definition of "good" patient care. The informal label "failure to cope" to describe high-needs patients suggested that in many instances, patients were experienced as a barrier to optimal efficiency. This resulted in tension during consults as well as reduced opportunities for education. CONCLUSIONS: The authors suggest that the emphasis on wait times resulted in more importance being placed on "getting the patient out" of the ED than on providing safe, compassionate, person-centered medical care. Resource constraints were hidden within a discourse that shifted the problem of overcrowding in the ED to patients with complex chronic conditions. The term "failure to cope" became activated when overworked physicians tried to avoid assuming care for high-needs patients, masking institutionally produced stress and possibly altering the way patients are perceived.