Exploring the contextual risk factors and characteristics of individuals who died from the acute toxic effects of opioids and other illegal substances: listening to the coroner and medical examiner voice. / Exploration des facteurs de risque contextuels et des caractéristiques des personnes décédées des effets toxiques aigus d'opioïdes et d'autres substances illégales : prise en compte de l'avis des coroners et des médecins légistes.

INTRODUCTION: Substance-related acute toxicity deaths continue to be a serious public health concern in Canada. This study explored coroner and medical examiner (C/ME)perspectives of contextual risk factors and characteristics associated with deaths from acute toxic effects of opioids and other illegal substances in Canada. METHODS: In-depth interviews were conducted with 36 C/MEs in eight provinces and territories between December 2017 and February 2018. Interview audio recordings were transcribed and coded for key themes using thematic analysis. RESULTS: Four themes described the perspectives of C/MEs: (1) Who is experiencing a substance-related acute toxicity death?; (2) Who is present at the time of death?; (3) Why are people experiencing an acute toxicity death?; (4) What are the social contextual factors contributing to deaths? Deaths crossed demographic and socioeconomic groups and included people who used substances on occasion, chronically, or for the first time. Using alone presents risk, while using in the presence of others can also contribute to risk if others are unable or unprepared to respond. People who died from a substance-related acute toxicity often had one or more contextual risk factors: contaminated substances, history of substance use, history of chronic pain and decreased tolerance. Social contextual factors contributing to deaths included diagnosed or undiagnosed mental illness, stigma, lack of support and lack of follow-up from health care. CONCLUSION: Findings revealed contextual factors and characteristics associated with substance-related acute toxicity deaths that contribute to a better understanding of the circumstances surrounding these deaths across Canada and that can inform targeted prevention and intervention efforts.

At-a-glance - The impact of poisoning-related mortality on life expectancy at birth in Canada, 2000 to 2016. / Aperçu - Incidence de la mortalité par intoxication sur l'espérance de vie à la naissance au Canada (2000-2016).

Increases in opioid-related mortality have contributed to declines in life expectancy at birth in the United States and British Columbia. Canadian national mortality data from 2000 to 2016 were analyzed to determine the contribution of poisoning-related mortality to changes in life expectancy at birth by age group and sex. From 2000 to 2016, life expectancy at birth increased by almost three years; however, mortality due to unintentional poisonings, including those involving opioids, curbed this increase by 0.16 years. Although a national decrease in life expectancy at birth has not been observed in Canada during this period, current trends suggest that the national opioid overdose crisis will continue to attenuate gains to life expectancy.

RÉSUMÉ: L'augmentation de la mortalité liée aux opioïdes a contribué à des baisses de l'espérance de vie à la naissance aux États-Unis et en Colombie-Britannique. Nous avons analysé les données nationales sur la mortalité au Canada entre 2000 et 2016 afin de déterminer dans quelle mesure les décès liés aux intoxications avaient influencé l'espérance de vie à la naissance selon le groupe d'âge et le sexe. Entre 2000 et 2016, l'espérance de vie à la naissance a augmenté de presque trois ans, mais la mortalité attribuable aux intoxications accidentelles, dont celles par opioïdes, a réduit cette hausse de 0,16 an. Même si l'espérance de vie à la naissance n'a pas globalement diminué au Canada pendant cette période, les tendances actuelles laissent présager que la crise nationale des surdoses d'opioïdes va continuer à amoindrir les gains relatifs à l'espérance de vie.

The opioid crisis in Canada: a national perspective. / La crise des opioïdes au Canada : une perspective nationale.

INTRODUCTION: This review provides a national summary of what is currently known about the Canadian opioid crisis with respect to opioid-related deaths and harms and potential risk factors as of December 2017. METHODS: We reviewed all public-facing opioid-related surveillance or epidemiological reports published by provincial and territorial ministries of health and chief coroners' or medical examiners' offices. In addition, we reviewed publications from federal partners and reports and articles published prior to December 2017. We synthesized the evidence by comparing provincial and territorial opioid-related mortality and morbidity rates with the national rates to look for regional trends. RESULTS: The opioid crisis has affected every region of the country, although some jurisdictions have been impacted more than others. As of 2016, apparent opioid-related deaths and hospitalization rates were highest in the western provinces of British Columbia and Alberta and in both Yukon and the Northwest Territories. Nationally, most apparent opioid-related deaths occurred among males; individuals between 30 and 39 years of age accounted for the greatest proportion. Current evidence suggests regional age and sex differences with respect to health outcomes, especially when synthetic opioids are involved. However, differences between data collection methods and reporting requirements may impact the interpretation and comparability of reported data. CONCLUSION: This report identifies gaps in evidence and areas for further investigation to improve our understanding of the national opioid crisis. The Public Health Agency of Canada will continue to work closely with the provinces, territories and national partners to further refine and standardize national data collection, conduct special studies and expand information-sharing to improve the evidence needed to inform public health action and prevent opioid-related deaths and harms.

INTRODUCTION: Cette recension offre un panorama à l'échelle nationale de ce que l'on savait, en décembre 2017, au sujet de la crise des opioïdes au Canada, en matière de décès et de méfaits liés à la consommation d'opioïdes et en matière de facteurs de risque potentiels. MÉTHODOLOGIE: Nous avons examiné tous les rapports de surveillance et les rapports épidémiologiques sur les opioïdes destinés au public ayant été publiés par les ministères de la Santé des provinces et des territoires et les bureaux des coroners en chef ou des médecins légistes. Nous avons également examiné les publications de nos partenaires fédéraux ainsi que les rapports et les articles sur le sujet publiés jusqu'à décembre 2017. Nous avons synthétisé les données en comparant les taux de mortalité et de morbidité liés à la consommation d'opioïdes dans les provinces et les territoires aux taux observés à l'échelle nationale afin de déceler d'éventuelles tendances à l'échelle régionale. RÉSULTATS: La crise des opioïdes touche toutes les régions du pays, mais certaines sont plus durement atteintes que d'autres. En effet, depuis 2016, les taux de décès et d'hospitalisations apparemment liés à la consommation d'opioïdes sont plus élevés dans les provinces de l'Ouest que sont la Colombie­Britannique et l'Alberta, ainsi qu'au Yukon et dans les Territoires du Nord­Ouest. À l'échelle nationale, la plupart des décès apparemment liés à la consommation d'opioïdes sont survenus chez des hommes et ils ont touché en plus grande proportion les 30 à 39 ans. Les données disponibles laissent penser qu'il existe des différences régionales en matière de résultats de santé en fonction de l'âge et du sexe, en particulier lorsque des opioïdes synthétiques sont en cause. Toutefois, des différences relevant des méthodes de collecte et des exigences relatives à la déclaration des données peuvent jouer sur l'interprétation et la comparabilité des résultats. CONCLUSION: Ce rapport relève des lacunes en ce qui concerne certaines données et certains domaines, auxquelles il faudra remédier en menant des études plus approfondies pour mieux comprendre la crise nationale des opioïdes. L'Agence de la santé publique du Canada va continuer de travailler en étroite collaboration avec les provinces, les territoires et ses partenaires nationaux pour affiner et normaliser les processus de collecte de données à l'échelle nationale, mener des études spécifiques et améliorer l'échange d'information, afin que l'on dispose de meilleures données sur lesquelles se fonder pour élaborer des mesures de santé publique et prévenir les décès et les méfaits liés aux opioïdes.

Optimizing Blood Transfusion Practices Through Bundled Intervention Implementation in Patients With Gynecologic Cancer Undergoing Laparotomy.

OBJECTIVE: To examine blood transfusion practices and develop a standardized bundle of interventions to address the high rate of perioperative red blood cell transfusion among patients with ovarian and endometrial cancer. METHODS: This was a retrospective cohort study. Our primary aim was to determine whether an implemented bundled intervention was associated with a reduction in perioperative red blood cell transfusions among cases of laparotomy for cancer. Secondary aims included comparing perioperative demographic, surgical, complication, and cost data. Interventions included blood transfusion practice standardization using American Society of Anesthesiologists guidelines, an intraoperative hemostasis checklist, standardized intraoperative fluid status communication, and evidence-based use of tranexamic acid. Prospective data from women undergoing laparotomy for ovarian or endometrial cancer from September 28, 2015, to May 31, 2016, defined the study cohort and were compared with historical controls (September 1, 2014, to September 25, 2015). Outcomes were compared in the full unadjusted cohorts and in propensity-matched cohorts. RESULTS: In the intervention and historical cohorts, respectively, 89 and 184 women underwent laparotomy for ovarian cancer (n=74 and 152) or advanced endometrial cancer (n=15 and 32). Tranexamic acid was administered in 54 (60.7%) patients. The perioperative transfusion rate was lower for the intervention group compared with historical controls (18.0% [16/89] vs 41.3% [76/184], P<.001), a 56.4% reduction. This improvement in the intervention group remained significant after propensity matching (16.2% [13/80] vs 36.2% [29/80], P=.004). The hospital readmission rate was also lower for the intervention group compared with historical controls (1.1% [1/89] vs 12.5% [23/184], P=.002); however, this improvement did not attain statistical significance after propensity matching (1.2% [1/80] vs 7.5% [6/80], P=.12). Cost analysis demonstrated that this intervention was cost-neutral during index hospitalization plus 30-day follow-up. CONCLUSION: Application of a standardized bundle of evidence-based interventions was associated with reduced blood use in our gynecologic oncology practice.

Immigrant Arrival and Tuberculosis among Large Immigrant- and Refugee-Receiving Countries, 2005-2009.

Objective. Tuberculosis control in foreign-born populations is a major public health concern for Australia, Canada, New Zealand, United Kingdom, and the United States, large immigrant- and refugee-receiving countries that comprise the Immigration and Refugee Health Working Group (IRHWG). Identifying and comparing immigration and distribution of foreign-born tuberculosis cases are important for developing targeted and collaborative interventions. Methods. Data stratified by year and country of birth from 2005 to 2009 were received from these five countries. Immigration totals, tuberculosis case totals, and multidrug-resistant tuberculosis (MDR TB) case totals from source countries were analyzed and compared to reveal similarities and differences for each member of the group. Results. Between 2005 and 2009, there were a combined 31,785,002 arrivals, 77,905 tuberculosis cases, and 888 MDR TB cases notified at the federal level in the IRHWG countries. India, China, Vietnam, and the Philippines accounted for 41.4% of the total foreign-born tuberculosis cases and 42.7% of the foreign-born MDR tuberculosis cases to IRHWG. Interpretation. Collaborative efforts across a small number of countries have the potential to yield sizeable gains in tuberculosis control for these large immigrant- and refugee-receiving countries.

Low-frequency ultrasound for patients with lower leg ulcers due to chronic venous insufficiency: a report of two cases.

Low-frequency ultrasound may facilitate debridement and healing of chronic wounds, including lower leg wounds in patients with chronic venous insufficiency (CVI). To evaluate the use of a low-frequency ultrasound (LFU) device with a curette, two patients with CVI and chronic wounds were treated for a period of 2 to 3 weeks. A 63-year-old woman with rheumatoid arthritis and two wounds, one on the right lower leg (250 cm³) and one wound on the left medial leg (0.80 cm³), present for 12 months; and a 77-year-old man with cardiopulmonary issues with seven wounds, three on the left medial calf (1.2 cm³, 11.40 cm³, and 0.72 cm³), one on the left anterior calf (0.30 cm³), two on the right posterior calf (0.90 cm³, 0.30 cm³), and one on the right anterior calf (0.14 cm³), present for 3 months consented to participate in the study. Both patients received low-intensity (50-70 µm), low-frequency (35 kHz) ultrasound at an intensity of 50% through a saline mist in addition to antimicrobial dressing with silver, a multilayer compression bandage system applied at every visit, and pain medication as needed. Both patients received treatments every 1 to 3 weeks that were not timed. Treatment continued until no additional slough or other necrotic tissue could be removed from the wound bed; the female patient received two treatment sessions and the male received three. Average wound volume did not change significantly from the first to last treatment session (t(8)-1.2, P = 0.26). Five wounds (56%) with initial measurements of 0.8 cm³, 0.72 cm³, 0.3 cm³, 0.3 cm³, and 0.14 cm³ reduced in volume by 100%. Mean wound characteristic scores changed significantly (P <0.05) for amount of fibrin, periwound skin, drainage amount, and color. In addition, the number of wounds filled with slough decreased from 89% at the first session to 22% at the final treatment session. The results of this study suggest LFU may have been beneficial for these patients with CVI. Additional studies using larger sample sizes are needed to evaluate the effect of this treatment on a variety of chronic wounds and to compare its effectiveness to other debridement methods.

Late diagnosis and entry to care after diagnosis of human immunodeficiency virus infection: a country comparison.

BACKGROUND: Testing for HIV infection and entry to care are the first steps in the continuum of care that benefit individual health and may reduce onward transmission of HIV. We determined the percentage of people with HIV who were diagnosed late and the percentage linked into care overall and by demographic and risk characteristics by country. METHODS: Data were analyzed from national HIV surveillance systems. Six countries, where available, provided data on two late diagnosis indicators (AIDS diagnosis within 3 months of HIV diagnosis, and AIDS diagnosis within 12 months before HIV diagnosis) and linkage to care (≥ 1 CD4 or viral load test result within 3 months of HIV diagnosis) for people diagnosed with HIV in 2009 or 2010 (most recent year data were available). PRINCIPAL FINDINGS: The percentage of people presenting with late stage disease at HIV diagnosis varied by country, overall with a range from 28.7% (United States) to 8.8% (Canada), and by transmission categories. The percentage of people diagnosed with AIDS who had their initial HIV diagnosis within 12 months before AIDS diagnosis varied little among countries, except the percentages were somewhat lower in Spain and the United States. Overall, the majority of people diagnosed with HIV were linked to HIV care within 3 months of diagnosis (more than 70%), but varied by age and transmission category. CONCLUSIONS: Differences in patterns of late presentation at HIV diagnosis among countries may reflect differences in screening practices by providers, public health agencies, and people with HIV. The percentage of people who received assessments of immune status and viral load within 3 months of diagnosis was generally high.

HIV diagnoses in indigenous peoples: comparison of Australia, Canada and New Zealand.

In industrial countries, a number of factors put indigenous peoples at increased risk of HIV infection. National surveillance data between 1999 and 2008 provided diagnoses for Aboriginal and Torres Strait Islanders (Australia), First Nations, Inuit and Métis (Canada excluding Ontario and Quebec) and Maori (New Zealand). Each country provided similar data for a non-indigenous comparison population. Direct standardisation used the 2001 Canadian Aboriginal male population for comparison of five-year diagnosis rates in 1999-2003 and 2004-2008. Using the general population as denominators, we report diagnosis ratios for presumed heterosexual transmission, men who have sex with men (MSM) and intravenous drug users (IDU). Age standardised HIV diagnosis rates in indigenous peoples in Canada in 2004-2008 (178.1 and 178.4/100 000 for men and women respectively) were higher than in Australia (48.5 and 12.9/100 000) and New Zealand (41.9 and 4.3/100 000). Higher HIV diagnosis rates related to heterosexual contact among Aboriginal peoples, especially women, in Canada confirm a widening epidemic beyond the conventional risk groups. This potential of a generalised epidemic requires urgent attention in Aboriginal communities; available evidence can inform policy and action by all stakeholders. Although less striking in Australia and New Zealand, these findings may be relevant to indigenous peoples in other countries.