A survey of undergraduate medical students' gender awareness and bias: the Newfoundland and Labrador perspective.

Background: Female physicians and patients experience gender bias in healthcare. The purpose of this research is to explore medical students' gender bias toward physicians and patients and whether their bias varies by gender. Methods: We surveyed medical students at Memorial University between November 2020 and April 2021. We recruited participants through Facebook, email, and e-posters. We collected demographic information, including gender and class year. We used the Nijmegen Gender Awareness in Medicine Scale to measure gender sensitivity, gender role ideology toward patients, and gender role ideology toward doctors. We analyzed the data using averages and t-tests. Results: Mean gender sensitivity scores were 4/5 indicating high gender sensitivity. Gender role ideology toward doctors mean scores were 2/5 indicating that students did not hold strong stereotypical views toward doctors. Although male students scored higher than female students (p<.05), mean scores for gender role ideology toward patients were low for both male and female students (x¯ <2), indicating low stereotyping toward patients. Conclusions: We found that students held largely non-biased ideologies surrounding gender in medicine and that female students were even less biased than male students for gender role ideology toward patients.

Contexte: Les femmes médecins ou patientes sont victimes de préjugés sexistes dans les soins de santé. L'objectif de cette recherche est d'explorer les préjugés sexistes des étudiants en médecine à l'égard des médecins et des patients et de déterminer si ces préjugés varient en fonction du sexe. Méthodes: Nous avons procédé à une enquête auprès des étudiants en médecine de l'Université Memorial entre novembre 2020 et avril 2021. Nous avons recruté des participants au moyen de Facebook, du courrier électronique et d'affiches électroniques. Nous avons recueilli des données démographiques, y compris le sexe et l'année dans le programme. Nous avons utilisé l'échelle de sensibilisation au genre en médecine de Nijmegen pour mesurer la sensibilité au genre, l'idéologie du rôle du genre envers les patients et l'idéologie du rôle du genre envers les médecins. Nous avons analysé les données à l'aide de moyennes et de tests t. Résultats: Les scores moyens de sensibilité au genre étaient de 4/5, ce qui indique une grande sensibilité au genre. Les scores moyens de l'idéologie du rôle du genre à l'égard des médecins étaient de 2/5, ce qui indique que les étudiants n'avaient pas d'opinion stéréotypée à l'égard des médecins. Bien que les étudiants aient obtenu des scores plus élevés que les étudiantes (p<0,05), les scores moyens pour l'idéologie du rôle du genre à l'égard des patients étaient faibles tant pour les étudiants que pour les étudiantes (x¯<2), ce qui indique un faible niveau d'opinions stéréotypées à l'égard des patients. Conclusions: Nous avons constaté que les étudiants avaient des idéologies largement non biaisées concernant le genre en médecine et que les étudiantes étaient encore moins biaisées que les étudiants en ce qui concerne l'idéologie du rôle du genre envers les patients.

New Geographic Records for Trichinella nativa and Echinococcus canadensis in Coyotes (Canis latrans) from Insular Newfoundland, Canada.

Coyotes (Canis latrans) rapidly expanded across North America during the 20th century and in 1987 colonized insular Newfoundland, Canada. Their arrival brought the potential for new predator-prey interactions and the potential for transmission of parasites to naïve populations. Trichinella spp. and Echinococcus spp. are zoonotic parasites not previously reported from the island of Newfoundland, Canada. Muscle samples (diaphragm and tongue) from 153 coyotes and feces from 35/153 coyotes were collected. Larvae of Trichinella spp. were recovered by muscle digestion from 6/153 coyotes (3.9%) and identified using multiplex PCR and Sanger sequencing as T. nativa. Fecal samples were screened for DNA of Echinococcus spp. using qPCR, and intestines from positive animals were examined for adult cestodes. No fecal samples were positive for DNA of E. multilocularis, and 2/35 (5.7%) samples were positive for E. canadensis, of which one was successfully genotyped as the G10 cervid strain. Echinococcus canadensis has not previously been reported on the island of Newfoundland, historically the only region of Canada where Echinococcus spp. was not known to occur. No species of Trichinella have previously been reported on the island. Both parasites are zoonotic, and hunters, trappers, dog owners, and the general public should be aware of these new risks for public health.

Description of spatiotemporal patterns of infectious salmon anemia virus (ISAV) detections in marine Atlantic Salmon farms in Newfoundland and Labrador.

OBJECTIVE: The objectives of this study were to describe spatiotemporal patterns of infectious salmon anemia virus (ISAV) detections in marine salmonid production sites in the province of Newfoundland and Labrador in Canada. METHODS: Infectious salmon anemia virus surveillance data between 2012 and 2020 from the province of Newfoundland and Labrador were used. Data comprised a total of 94 sampling events from 20 Atlantic Salmon Salmo salar production sites in which ISAV was detected. Using linear regression models, factors influencing time to detection (days from stocking to first ISAV detection) and time to depopulation (days from first detection to production site depopulation) were investigated. RESULT: Based on 28 unique cases, site-level annual incidence risk of ISAV detection ranged from 3% to 29%. The proportion of ISAV detection by PCR in fish samples ranged from 2% to 45% annually. Overall, ISAV variants from the European clade were more common than variants from the North American clade. The type of ISAV clade, detections of ISAV in nearest production sites based on seaway distances, and year of infectious salmon anemia cases were not associated with time to first ISAV detection. Time to depopulation for sites infected with the ISAV-HPRΔ variant was not associated with ISAV North American or European clades. CONCLUSION: Our results contribute to the further understanding of the changing dynamics of infectious salmon anemia detections in Newfoundland and Labrador since its first detection in 2012 and will likely assist in the design of improved disease surveillance and control programs in the province.

A Population Description of Young Women with Breast Cancer in Newfoundland and Labrador.

It has been well established in the literature that young women tend to carry more aggressive subtypes of breast cancer than their older-aged counterparts. The objective of this study was to describe the characteristics and outcomes of young women with breast cancer. In this retrospective analysis, data were collected for women under the age of 40 years who were diagnosed with breast cancer between 2008 and 2018 in the province of Newfoundland and Labrador. Specifically, data were collected on demographics, staging, pathological characteristics, treatment, and survival outcomes for young women with this disease. Results demonstrate that most of these women were diagnosed between the age of 35 and 39 years (91.2%). Most women presented with early-stage disease (stage I and II-66.4%), while 24% were stage III and 9.6% presented with stage IV metastatic disease. The prevalence of hormone-receptor-positive disease represented 41.9% of the cohort, with triple-negative and HER2+ measuring 27.7% and 30.4%, respectively. Five-year disease-free survival was 80.5% and overall survival was 82.7%. These findings provoke discussion regarding the intersecting roles of genetics, environment, and lifestyle in a region with some of the highest rates of malignancy in the country.

Characteristics of Interval Colorectal Cancer: A Canadian Retrospective Population-Level Analysis from Newfoundland and Labrador.

Interval colorectal cancers (I-CRCs) arise during the interval time period between scheduled colonoscopies. Predicting which patients are at risk of I-CRCs remains an elusive undertaking, but evidence would suggest that most I-CRCs arise from lesions missed on index endoscopy. The procedural factors that lead to missed lesions are numerous and lack consensus in the literature. In Canada, the province of Newfoundland and Labrador has the highest incidence of CRCs. In this study our aim was to examine I-CRCs (3-60 months after last colonoscopy) in NL through a population-level analysis covering 67% of the province from 2001-2018. We estimated the I-CRC rate to be up to 9.3%. Median age of I-CRC diagnosis was 67.1 years with an interval time of 2.9 years. About 57% of these tumors occurred proximal to the splenic flexure, with 53% presenting as local disease. No temporal differences were observed in interval time or tumor distribution. On univariate and multivariable logistical regression, risk of right-sided I-CRC did not correlate to the index colonoscopy indication, bowel preparation quality, size of largest polyp removed, colonoscopy completion rate, or stage at presentation. Improvements in synoptic reporting utilization and national registries are needed to identity risk factors and reduce I-CRC frequency.

Real World Studies of Psoriasis and Mental Illness in Newfoundland and Labrador.

BACKGROUND: Psoriasis is a chronic, immune-mediated inflammatory disease with an implied connection to psychiatric disorders. OBJECTIVE: This study aims to illustrate an association between psoriasis and psychiatric disorders using real world data gathered from the Newfoundland and Labrador population. METHODS: Data on 15,100 patients with psoriasis and 75,500 controls (1:5) was collected from the Newfoundland and Labrador Centre for Health Information's Electronic Health Records. The cases and controls were matched for age, sex, and geography. Indicators for psychiatric disorders include diagnosis of mental illnesses from physician's visits and hospitalization records (all coded for mental health using ICD-9 and ICD-10 codes). RESULTS: 9,991 (66.2%) cases were identified to have at least one visit with a diagnostic code for mental illness compared to 42,276 (56.0%), P < .0001 in the control group. The percentage of people coded for anxiety was 36.50% compared to 28.95%, P < .0001; depression was 37.04% compared to 30.19%, P < .0001; and adjustment disorder was 6.89% versus 5.48%, P < .0001, among those with and without psoriasis, respectively. The greatest risk for anxiety [OR 1.4 (1.20, 1.67)] and depression [OR 1.65 (1.36, 2.00)] among psoriasis patients was between the 0 to 20 age group. Women with psoriasis are more likely to have anxiety [OR 1.08 (1.03, 1.13)], depression [OR 1.04 (1.01, 1.09)] and adjustment disorder [OR 1.07 (0.98, 1.17)] compared to female controls. CONCLUSION: Our result shows that patients with psoriasis have an increased prevalence of mental illness. Using real world data to carry out further investigations will better elucidate this association and provide an increased understanding of the association between psoriasis and mental disorders.

Distribution and diversity of dog parvoviruses in wild, free-roaming and domestic canids of Newfoundland and Labrador, Canada.

Some parvoviruses of carnivorans can infect multiple host species. Since many canine parvoviruses were only discovered recently, their host-range is still unexplored. We examined the host distribution and diversity of five dog parvoviruses in four canine populations from Newfoundland and Labrador, Canada, and investigated the potential for these viruses to cross the species barriers. Canine bocavirus 2 (CBoV-2) and the minute virus of canines were detected in stool from free-roaming dogs from Labrador (5/48 [10.4%] and 3/48 [6.3%], respectively) and two different CBoV-2 variants were identified. Canine bufavirus was identified in stool from free-roaming dogs (1/48, 2.1%) and foxes (3/80, 3.8%) from Labrador, but two different variants were observed in the two host species. The variant found in foxes was highly divergent from previously identified strains. Two cachavirus 1 variants, genetically similar to those circulating in other Canadian wildlife, were found in spleens from Newfoundland coyotes (3/87, 3.5%). Canine parvovirus type 2 (CPV-2) was found in stool from free-roaming dogs from Labrador (2/48, 4.2%) and in spleens from Newfoundland coyotes (3/87, 3.5%). Comparing CPV-2 sequences from these hosts to those retrieved from local symptomatic domestic dogs revealed the presence of a highly heterogeneous viral population as detected strains belonged to five different clades. The close relationship between CPV-2a strains from a dog and a coyote suggests the occurrence of viral transfer between wild and domestic canids. The identification of highly related strains with a similar molecular signature characteristic of older CPV-2 strains in free-roaming and domestic dogs suggests a probable common ancestry and that older CPV-2 strains, which have not been identified in dogs since the 1990s, persist in this part of Canada. Follow-up studies should evaluate samples from a larger number of animals and host species to extensively investigate the possible occurrence of cross-species transmission for recently discovered parvoviruses.

Hangings in Newfoundland and Labrador: A 40-year retrospective analysis of medical examiner data.

A comprehensive review of medical examiner data was undertaken of all hanging deaths in the Canadian Maritime province of Newfoundland and Labrador from 1982 to 2021. A total of 811 cases were identified representing suicidal, accidental, and undetermined manners of death. Variables examined included age; sex; seasonality; ligature type; location; time since death; prior attempts/suicidal ideation; presence/absence of a suicide note; and presence/absence of alcohol and drugs. Data subsets were generated, and additional analysis was conducted for hangings involving females; suicidal hangings occurring in the region of Labrador; and those who hanged themselves outdoors. Results indicate that females are choosing to kill themselves by hanging in rapidly increasing numbers. Outdoor suicides by hanging were more common in Newfoundland and Labrador (22.1%) than previously reported in Alberta (11.5%), Texas (5%), and Turkey (12-13%). Unique trends in seasonality were revealed, as were repeated incidents of suicidal clusters. The age distribution was skewed strongly toward youths (10 to 22 years of age), particularly in Labrador. Although Labrador represents only 5% of the total provincial population, it produced 20.1% of the total suicidal hangings in the study. The suicide rate in Canada has decreased by 24% over the past 40 years, yet the rates of suicidal hangings nationally and in Newfoundland and Labrador have increased during the same time period. With a better understanding of the circumstances under which people commit suicide by hanging within the province, it may be possible to target at-risk groups to prevent future cases.

Few SARS-CoV-2 infections detected in Newfoundland and Labrador in the absence of Public Health Laboratory-based confirmation.

OBJECTIVE: To assess the incidence of COVID-19 infection in the absence of a confirmatory test in persons suspecting they contracted COVID-19 and elucidate reasons for their belief. METHODS: We recruited persons with a confirmed COVID-19 diagnosis and persons who believed they may have contracted COVID-19 between December, 2019 and April, 2021 into a study of immunity against SARS-CoV-2. An intake questionnaire captured their perceived risk factors for exposure and symptoms experienced, including symptom duration and severity. ELISA testing against multiple SARS-CoV-2 antigens was done to detect antibodies against SARS-CoV-2. No participant had received COVID-19 vaccination prior to the time of testing. RESULTS: The vast majority of study subjects without Public Health confirmation of infection had no detectable antibodies against SARS-CoV-2. Suspected infection with SARS-CoV-2 generally involved experiencing symptoms common to many other respiratory infections. Unusually severe or persistent symptoms often supported suspicion of infection with SARS-CoV-2 as did travel or contact with travelers from outside Newfoundland and Labrador. Rare cases in which antibodies against SARS-CoV-2 were detected despite negative results of Public Health testing for SARS-CoV-2 RNA involved persons in close contact with confirmed cases. CONCLUSIONS: Broad public awareness and declaration of pandemic status in March, 2020 contributed to the perceived risk of contracting COVID-19 in Newfoundland and Labrador from late 2019 to April 2021 and raised expectation of its severity. Serological testing is useful to diagnose past infection with SARS-CoV-2 to accurately estimate population exposure rates.

Laying the foundation for Real-world evidence studies: a case study from Newfoundland and Labrador.

The Janssen and Newfoundland and Labrador Health Innovation Partnership (JANL-HIP) was established to carry out Real-World Evidence (RWE) projects to generate evidence about disease pathways, healthcare delivery, the effects of clinical interventions. Doing so will support and influence clinical decision-making in Newfoundland and Labrador (NL). This case study describes the foundational elements necessary for a real-world evidence generation project in NL and may provide learning for the effective execution of real-world studies in other jurisdictions. It uses an ongoing project in psoriatic disease in NL to illustrate the partnership and the benefits of RWE studies. Ultimately, the JANL-HIP RWE project aims to inform decisions that will drive improvements in health outcomes, system delivery, and policy mutually beneficial to health ecosystem stakeholders.

A comparison of household food insecurity rates in Newfoundland and Labrador in 2011-2012 and 2017-2018.

OBJECTIVES: The prevalence of household food insecurity in Newfoundland and Labrador (NL) fell sharply between 2007 and 2011, but it appears to have risen since then. Our objective was to compare the prevalence of food insecurity between 2011-2012 and 2017-2018 in relation to population socio-demographic characteristics. METHODS: Our analytic sample comprised all NL households in the Canadian Community Health Survey (CCHS) cycles 2011-2012 and 2017-2018, n = 6800. We stratified the prevalence of household food insecurity for each cycle by socio-demographic characteristics and applied multivariable logistic regression models to determine food insecurity odds in 2017-2018 compared with 2011-2012 after controlling for socio-demographic covariates. Interactions of covariates with survey cycle were tested and models stratified when warranted. RESULTS: The prevalence of food insecurity rose from 12.0% (95% CI 10.5, 13.6) in 2011-2012 to 14.7% (95% CI 13.1, 16.6) in 2017-2018. After adjusting for household socio-demographic variables, the odds of food insecurity was 1.49 (95% CI 1.27, 1.75) in 2017-2018. The prevalence of food insecurity had increased significantly among unattached individuals, renters, households with low educational attainment, and households with income above the Low Income Measure, with concomitant increases in the contribution of these groups to the total provincial prevalence of food insecurity in 2017-2018 compared with that in 2011-2012. CONCLUSION: The odds of food insecurity among NL households increased significantly from 2011-2012 to 2017-2018. Given the serious negative health implications of household food insecurity, the province should draw on the lessons from its earlier success in food insecurity reduction to reverse the current trend.

RéSUMé: OBJECTIFS: La prévalence de l'insécurité alimentaire des ménages à Terre-Neuve-et-Labrador (T.-N.-L.) a connu une forte baisse entre 2007 et 2011, mais depuis, elle semble avoir augmenté. Nous avons cherché à comparer la prévalence de l'insécurité alimentaire entre 2011-2012 et 2017-2018 en lien avec le profil sociodémographique de la population. MéTHODE: Notre échantillon d'analyse comprenait tous les ménages de T.-N.-L. inclus dans les cycles 2011-2012 et 2017-2018 de l'Enquête sur la santé dans les collectivités canadiennes (ESCC), soit n = 6 800. Nous avons stratifié la prévalence de l'insécurité alimentaire des ménages pour chaque cycle selon le profil sociodémographique et appliqué des modèles de régression logistique multivariée pour déterminer la probabilité d'insécurité alimentaire en 2017-2018 comparativement à 2011-2012 compte tenu des covariables sociodémographiques. Nous avons testé les interactions des covariables avec les cycles de l'enquête et stratifié les modèles au besoin. RéSULTATS: La prévalence de l'insécurité alimentaire a augmenté, passant de 12 % (IC de 95 % 10,5, 13,6) en 2011-2012 à 14,7 % (IC de 95 % 13,1, 16,6) en 2017-2018. Après l'apport d'ajustements pour tenir compte des variables sociodémographiques des ménages, la probabilité d'insécurité alimentaire était de 1,49 (IC de 95 % 1,27, 1,75) en 2017-2018. La prévalence de l'insécurité alimentaire avait augmenté de façon significative chez les personnes seules, les locataires, les ménages ayant un faible niveau d'instruction et les ménages ayant un revenu supérieur à la mesure de faible revenu, avec des augmentations concomitantes de l'apport de ces groupes à la prévalence provinciale totale de l'insécurité alimentaire en 2017-2018 par rapport à 2011-2012. CONCLUSION: La probabilité d'insécurité alimentaire des ménages de T.-N.-L. a augmenté de façon significative entre 2011-2012 et 2017-2018. Étant donné les graves conséquences négatives de l'insécurité alimentaire des ménages pour la santé, la province devrait tirer des leçons de son succès antérieur dans la réduction de l'insécurité alimentaire pour inverser la tendance actuelle.

The Incidence of Cutaneous Malignant Melanoma in Eastern Newfoundland and Labrador, Canada, from 2007 to 2015.

BACKGROUND: The incidence of cutaneous malignant melanoma continues to increase worldwide and in Canada. It is unclear whether the increase in incidence and clinical characteristic trends of cutaneous malignant melanoma are similar in the province of Newfoundland and Labrador. OBJECTIVE: The objective of this study is to examine the incidence and trends of cutaneous malignant melanoma in Eastern Newfoundland and Labrador. METHODS: Patients aged 18 years or older diagnosed with cutaneous malignant melanoma were identified from the Eastern Health Authority's Cancer Registry. The diagnosis was confirmed by a pathologist via histological subtype. Patients were excluded if the diagnosis was unspecified, a nonmelanoma skin cancer or if there was a recurrence in the same lesion location. In total 298 patients diagnosed with cutaneous malignant melanoma from 2007 to 2015 were included in the analysis. RESULTS: The total incidence increased from 4.1 to 15.6 cases/100,000 person-years, which represents a 283.0% increase from 2007 to 2015. The largest increases in incidence were seen in males and patients aged from 60 to 79 years. The most common lesion anatomical locations were the trunk in males and the lower extremity in females. The majority of cases had a Breslow thickness below 1.0 mm. CONCLUSION: The incidence of cutaneous malignant melanoma in Eastern Newfoundland and Labrador is increasing at a faster rate than in any other region in Canada. Health care providers should work to be aware of the clinical trends and risk factors associated with this disease to facilitate early detection and prevent morbidity.

The prevalence and patterns of use of point-of-care ultrasound in Newfoundland and Labrador.

INTRODUCTION: Point-of-care ultrasound (POCUS) is used for diagnostic and procedural guidance by physicians in Newfoundland and Labrador (NL). POCUS use is largely limited to urban locations and the training is variable amongst physicians. The primary aim of this study was to determine the prevalence of POCUS devices in NL and the secondary aim was to characterise the patterns of POCUS use amongst physicians in NL. METHODS: This is a mixed-methods cross-sectional study. We determined the prevalence of POCUS devices from purchase records and the patterns of POCUS use through theme-based interviews. The interviews were transcribed, coded and analysed using standardised qualitative methods. RESULTS: Ten physicians (3 females, 5 rural) participated in the interviews. The overall prevalence of POCUS devices in NL was 12.5/100,000 population. Participants in urban areas had more access to POCUS training and devices. Participants used POCUS on a daily or weekly basis to rule in or out life-threatening conditions and improve access to specialist care. The benefits of POCUS included expedited investigations, decreased radiation and increased patient satisfaction. The barriers to using POCUS were lack of training, time, devices, image archiving software, difficulty generating and interpreting images and patient body habitus. CONCLUSION: This is the first study to our knowledge to report the prevalence of POCUS devices in Canada. Physicians who practise in rural NL have limited access to POCUS devices and have identified barriers to POCUS training. Connecting physicians in rural areas with POCUS experts through a province-wide POCUS network may address these barriers and improve healthcare access.

Résumé Introduction: L'échographie ciblée est utilisée par les médecins de Terre-Neuve-et-Labrador (T.-N.-L.) pour guider le diagnostic et certaines interventions. L'échographie ciblée est grandement limitée aux régions urbaines et la formation des médecins sur son utilisation est variable. Cette étude visait en premier lieu à déterminer la prévalence des appareils d'échographie ciblée à T.-N.-L. et en deuxième lieu, à caractériser les habitudes d'utilisation de l'échographie ciblée chez les médecins de T.-N.-L. Méthodes: Il s'agit d'une étude transversale à méthodes mixtes. Nous avons déterminé la prévalence des appareils d'échographie ciblée à partir de registres d'achat, et les habitudes d'utilisation de l'échographie ciblée à partir d'entrevues thématiques. Dix médecins (3 de sexe féminin, 5 de régions rurales) ont participé aux entrevues. Les entrevues ont été transcrites, codées et analysées à l'aide de méthodes qualitatives standardisées. Résultats: La prévalence générale des appareils d'échographie ciblée à T.-N.-L. était de 12.5/100 000 populations. Les participants des régions urbaines avaient un meilleur accès à la formation sur l'échographie ciblée et aux appareils. Les participants utilisaient l'échographie ciblée tous les jours ou toutes les semaines pour inclure ou éliminer les affections potentiellement mortelles et améliorer l'accès aux spécialistes. Les bienfaits de l'échographie ciblée étaient l'accélération des examens, la réduction des rayonnements et une meilleure satisfaction des patients. Les obstacles à l'échographie ciblée étaient l'absence de formation, de temps, d'appareils et de logiciel d'archivage des images, la difficulté à générer et à interpréter les images, et les caractéristiques physionomiques du patient. Conclusion: À notre connaissance, il s'agit de la première étude à avoir rapporté la prévalence des appareils d'échographie ciblée au Canada. Les médecins qui pratiquent dans les régions rurales de T.-N.-L. ont un accès limité aux appareils d'échographie ciblée et ont identifié des obstacles à la formation sur l'échographie ciblée. Pour faire tomber ces obstacles et améliorer l'accès aux soins de santé, il serait utile de relier les médecins des régions rurales à des spécialistes d'échographie ciblée dans un réseau provincial d'échographie ciblée. Mots-clés: Échographie, examen ciblé, services de santé ruraux, formation médicale continue, cadre de compétences.

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.

Development of a primary care pandemic plan informed by in-depth policy analysis and interviews with family physicians across Canada during COVID-19: a qualitative case study protocol.

INTRODUCTION: Given the recurrent risk of respiratory illness-based pandemics, and the important roles family physicians play during public health emergencies, the development of pandemic plans for primary care is imperative. Existing pandemic plans in Canada, however, do not adequately incorporate family physicians' roles and perspectives. This policy and planning oversight has become increasingly evident with the emergence of the novel coronavirus disease, COVID-19, pandemic. This study is designed to inform the development of pandemic plans for primary care through evidence from four provinces in Canada: British Columbia, Newfoundland and Labrador, Nova Scotia, and Ontario. METHODS AND ANALYSIS: We will employ a multiple-case study of regions in four provinces. Each case consists of a mixed methods design which comprises: (1) a chronology of family physician roles in the COVID-19 pandemic response; (2) a provincial policy analysis; and (3) qualitative interviews with family physicians. Relevant policy and guidance documents will be identified through targeted, snowball and general search strategies. Additionally, these policy documents will be analysed to identify gaps and/or emphases in existing policies and policy responses. Interviews will explore family physicians' proposed, actual and potential roles during the pandemic, the facilitators and barriers they have encountered throughout and the influence of gender on their professional roles. Data will be thematically analysed using a content analysis framework, first at the regional level and then through cross-case analyses. ETHICS AND DISSEMINATION: Approval for this study has been granted by the Research Ethics of British Columbia, the Health Research Ethics Board of Newfoundland and Labrador, the Nova Scotia Health Authority Research Ethics Board and the Western University Research Ethics Board. Findings will be disseminated via conferences and peer-reviewed publications. Evidence and lessons learnt will be used to develop tools for government ministries, public health units and family physicians for improved pandemic response plans for primary care.

The Association of Upper Body Obesity with Insulin Resistance in the Newfoundland Population.

Body-fat distribution is a primary risk factor for insulin resistance and cardiovascular disease. Visceral fat explains only a portion of this risk. The link between upper-body fat and insulin resistance is uncertain. Furthermore, upper-body fat is not clearly defined. Dual-energy X-ray absorptiometry (DXA) can accurately quantify body fat. In this study, we explored the relationship between non-visceral upper-body adiposity and insulin resistance and other markers of metabolic syndrome. Fat proportions in the upper body, leg, and visceral regions were quantified by using DXA in 2547 adult Newfoundlanders aged 19 and older. Adjusting for remaining fat regions, we performed partial correlation analysis for each body region and insulin resistance defined by the Homeostatic Model of Assessment (HOMA). Similarly, partial correlation analysis was also performed between each fat region and other markers of metabolic syndrome, including high-density lipoprotein cholesterol (HDL), triglycerides (TG), body mass index (BMI), and blood pressure. Major confounding factors, including age, caloric intake, and physical activity, were statistically controlled by using partial correlation analysis. Interactions between sex, menopausal status, and medication status were also tested. Arm adiposity was correlated with HOMA-IR (R = 0.132, p < 0.001) and HOMA-ß (R = 0.134, p < 0.001). Visceral adiposity was correlated with HOMA-IR (R = 0.230, p < 0.001) and HOMA-ß (R = 0.160, p < 0.001). No significant correlation between non-visceral trunk adiposity and insulin resistance was found. Non-visceral trunk adiposity was negatively correlated with HDL in men (R = -0.110, p < 0.001) and women (R = -0.117, p < 0.001). Non-visceral trunk adiposity was correlated with TG (total: R = 0.079, p < 0.001; men: R = 0.105, p = 0.012; women: R = 0.078, p = 0.001). In menopausal women, leg adiposity was negatively correlated with HOMA-IR (R = -0.196, p < 0.001) and HOMA-ß (R = -0.101, p = 0.012). Upper-body adiposity in the arms is an independent contributor to insulin resistance. Upper-body adiposity in the non-visceral trunk region is an independent contributor to metabolic syndrome. Leg adiposity is protective against metabolic syndrome in women.

Transition from pediatric to adult aftercare for survivors of pediatric cancer in Newfoundland and Labrador: a qualitative study.

BACKGROUND: Childhood cancer survivors (CCSs) face increased risks during the period when they leave pediatric care and transition into adult-focused aftercare. We examined the experiences of CCSs entering adult-focused aftercare to gain a better understanding of current transition practices and barriers to transition, and to identify opportunities for improving care. METHODS: We conducted a qualitative study using in-person and telephone semi-structured interviews. Childhood cancer survivors who recently transitioned out of pediatric care and health care providers (HCPs) who provide care for CCSs in Newfoundland and Labrador were identified using purposive sampling. Participants were interviewed between July 2017 and March 2019. Data were analyzed using both qualitative descriptive and thematic analysis. RESULTS: We conducted interviews with 5 CCSs and 9 HCPs. All CCSs interviewed reported receiving aftercare through their pediatric oncology program; only 2 reported receiving any form of aftercare in the adult setting. The lack of a structured transition process for CCSs in the province emerged as a theme in this study. Interview participants identified several barriers to transition: the added challenges for survivors in rural areas, changes in the availability of services after the transition to adult-focused aftercare, challenges associated with navigating the adult system, and a lack of education on transitioning into adult aftercare. INTERPRETATION: We found that there was little preparation for the transition of CCSs into adult care, and their aftercare was disrupted. Programs serving CCSs have opportunities to improve care by standardizing and better supporting these transitions, for example through the development of context-appropriate educational resources.

Supporting breastfeeding in rural Newfoundland and Labrador communities during COVID-19.

Exclusive breastfeeding for the first 6 months of life has become the global standard of infant feeding for its extensive benefits to maternal and infant health. Public health programs, such as the Baby-Friendly Initiative, have helped increase the national breastfeeding initiation rate to 90%. However, initiation rates in Newfoundland and Labrador (NL) continue to rank the lowest in the country at 70%, with a 6-month exclusivity rate of 16%. This commentary will discuss the influence of geographical location, societal norms, and accessibility to health care services on breastfeeding in rural and remote NL communities. While the SARS-CoV-2 virus itself does not impact the mother's ability to breastfeed, the indirect impacts of COVID-19 on health care services, social isolation, and economic burden challenge breastfeeding initiation and continuation. Priority solutions will draw on capacity building by emphasizing relationships within the community to deliver innovative and appropriate support programs. Continued education with health practitioners and further research into breastfeeding barriers in rural communities is critical moving forward.

RéSUMé: L'allaitement maternel exclusif pendant les six premiers mois de la vie est devenu la norme mondiale de l'alimentation du nourrisson en raison de ses nombreux avantages pour la santé maternelle et infantile. Les programmes de santé publique, tels que le Baby Friendly Initiative, ont contribué à porter le taux national d'initiation à l'allaitement maternel à 90 %. Cependant, le taux d'initiation à Terre-Neuve-et-Labrador, à 70 %, se classe parmi les plus bas du pays, avec un taux d'exclusivité de 6 mois de 16 %. Ce commentaire discutera l'influence de la localisation géographique, des normes sociétales et de l'accessibilité des services de soins de santé sur l'allaitement maternel dans les communautés rurales et éloignées de Terre-Neuve-et-Labrador. Bien que le virus SRAS-CoV-2 lui-même n'empêche pas l'allaitement, les impacts indirects du COVID-19 sur les services de santé, l'isolement social et le fardeau économique compliquent l'initiation et la poursuite de l'allaitement. Les solutions s'appuieront sur le renforcement des capacités en mettant l'accent sur les relations au sein de la communauté pour offrir des programmes de soutien innovants et appropriés. La formation continue des praticiens de la santé et des recherches supplémentaires sur les obstacles à l'allaitement dans les communautés rurales sont essentielles pour aller de l'avant.

Investigation of prevalence of biologic use and discontinuation rates in moderate-to-severe psoriasis patients in Newfoundland and Labrador using real-world data.

Real-world data for psoriasis includes registries, and meta-analyses could help guide biologic therapy choice. The objective was to determine the prevalence and reason for discontinuation of biologic or PD4 inhibitor therapy in patients with moderate-to-severe psoriasis in Newfoundland and Labrador, Canada from 2001 to 2017. A retrospective cohort study was conducted on data collected between 2001 and 2017, to determine the type of biologic therapy or PD4 inhibitor, length of treatment, prevalence of and reason for discontinuation. As multiple patients have been on more than one therapy (ie, an average of 1.8), the 459 patients included in the registry have had a total of 913 exposures to biologic or PD4 inhibitors. The treatment mean time was 37 months (SD 39.95). A total of 180 patients remained on their first biologic of which 75% were male. The average number of biologics per patient was 1.99. The reasons for discontinuation were primary failure (28.5%), adverse events (26.4%), secondary failure (24.3%), patient choice (4.4%), other/unknown in (6.6%), drug withdrawal from market (6.8%), and drug coverage issues (3%). The most common reasons for discontinuation of biologics or PD4 inhibitors include primary failure, adverse events, and secondary failures. Males were more likely to remain on their first biologic.

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.