Propranolol reduces IFN-γ driven PD-L1 immunosuppression and improves anti-tumour immunity in ovarian cancer

The immune system plays an important role in controlling epithelial ovarian cancer (EOC). EOC is considered to be a "cold tumour," a tumour that has not triggered a strong response by the immune system. However, tumour infiltrating lymphocytes (TILs) and the expression of programmed cell death ligand (PD-L1) are used as prognostic indicators in EOC. Immunotherapy such as PD-(L)1 inhibitors have shown limited benefit in EOC. Since the immune system is affected by behavioural stress and the beta-adrenergic signalling pathway, this study aimed to explore the impact of propranolol (PRO), a beta-blocker, on anti-tumour immunity in both in vitro and in vivo EOC models. Noradrenaline (NA), an adrenergic agonist, did not directly regulate PD-L1 expression but PD-L1 was significantly upregulated by IFN-γ in EOC cell lines. IFN-γ also increased PD-L1 on extracellular vesicles (EVs) released by ID8 cells. PRO significantly decreased IFN-γ levels in primary immune cells activated ex vivo and showed increased viability of the CD8⁺ cell population in an EV-immune cell co-incubation. In addition, PRO reverted PD-L1 upregulation and significantly decreased IL-10 levels in an immune-cancer cell co-culture. Chronic behavioural stress increased metastasis in mice while PRO monotherapy and the combo of PRO and PD-(L)1 inhibitor significantly decreased stress-induced metastasis. The combined therapy also reduced tumour weight compared to the cancer control group and induced anti-tumour T-cell responses with significant CD8 expression in tumour tissues. In conclusion, PRO showed a modulation of the cancer immune response by decreasing IFN-γ production and, in turn, IFN-γ-mediated PD-L1 overexpression. The combined therapy of PRO and PD-(L)1 inhibitor decreased metastasis and improved anti-tumour immunity offering a promising new therapy.

Using novel methodology to estimate the prevalence of mental disorders in British Columbia, Canada

PURPOSE

A needs-based model of health systems planning uses a systematic estimate of service needs for a given population. Our objective was to derive annual prevalence estimates of specific mental disorders in the adult population of British Columbia, Canada and use a novel triangulation approach encompassing multiple data sources and stratifying these estimates by age, sex, and severity to inform Ministry partners, who commissioned this work.

METHODS

We performed systematic literature reviews and subsequent meta-analyses to derive an annual prevalence estimate for each mental disorder. We then generated age- and sex-specific estimates by triangulating published epidemiological studies, routinely collected province-wide health administrative data, and nationally representative health survey data sources. The age- and sex-specific estimates were further stratified by severity using the Global Burden of Disease severity distributions and published literature.

RESULTS

Anxiety disorders had the highest annual prevalence estimates (6.93%), followed by depressive disorders (6.42%). All other mental disorders had an annual prevalence of less than 1%. Prevalence estimates were consistently higher in younger age groups. Depressive disorders, anxiety disorders, and eating disorders were higher in women, while estimates for bipolar disorders, schizophrenia, and ADHD were slightly higher in men in younger age groups.

CONCLUSION

We generated robust annual prevalence estimates stratified by age, sex, and severity using a triangulation approach. Variation by age, sex, and severity implies that these factors need to be considered when planning for mental health services. Our approach is replicable and can be used as a model for needs-based planning in other jurisdictions.

Evaluation of opt-in HIV testing in the construction workplace using the socioecological framework

Background

Late diagnosis of HIV remains a challenge and the construction workforce has several risk factors for HIV. In the Test@Work programme, we delivered HIV tests embedded within a general health check to construction workers, with high uptake and acceptability. Here, we report the experiences of construction managers and health professionals involved in Test@Work and explore the suitability of construction worksites as a venue for opt-in HIV testing.

Methods

Qualitative interviews (n = 24) were conducted with construction managers who facilitated events (n = 13), and HIV/health check delivery partners (n = 11) at 21 Test@Work events held on construction sites. Interviews explored experiences of events and views towards workplace HIV testing. Event exit questionnaires (n = 107) completed by delivery partners provided qualitative data identifying facilitators and barriers to effective delivery. Thematic analysis identified themes that were mapped against a socioecological framework (individual, interpersonal, organisational, industry, public health).

Results

Delivery partners reported high engagement of construction workers with workplace HIV testing, peer-to-peer encouragement for uptake, and value for accessibility of onsite testing. HIV professionals valued the opportunity to reach an untested population, many of whom had a poor understanding of their exposure to HIV risk. Managers valued the opportunity to offer workplace health checks to employees but some identified challenges with event planning, or provision of private facilities.

Conclusions

The construction sector is complex with a largely male workforce. Providing worksite HIV testing and education to an untested population who have poor knowledge about HIV risk helped to normalise testing, increase uptake, and reduce HIV stigma. However, there are practical barriers to testing in the construction environment. This has global implications for delivery of HIV testing in construction workplace settings.

Key messages

• Delivering workplace HIV testing as part of a general health check helps to normalise HIV testing and reduce HIV-related stigma.

• Workplace testing is convenient, accessible and reaches populations at risk for HIV, but there are some barriers to implementation of rapid tests on construction sites.

Precision of the GE Lunar Total Body-Less Head Scan for the Measurement of Three-Compartment Body Composition in Athletes

INTRODUCTION

Dual energy X-ray absorptiometry (DXA) is widely used for the assessment of lean mass (LM), fat mass (FM) and bone mineral content (BMC). When observing standardised protocols, DXA has a high level of precision for the assessment of total body composition, including the head region. However, including the head region may have limited relevance in athletes and can be problematic when positioning taller athletes who exceed scan boundaries. This study investigated the precision of a new total-body-less-head (TBLH) DXA scan for three-compartment body composition measurement in athletes, with outcomes compared to the standard total-body DXA scan.

METHODS

Precision errors were calculated from two consecutive scans with re-positioning (Lunar iDXA, GE Healthcare, Madison, WI), in male and female athletes from a range of sports. TBLH precision was determined from repeat scans in 95 athletes (male n = 55; female n = 40; age: 26.0 ± 8.5 y; body mass: 81.2 ± 20.5 kg; stature: 1.77 ± 0.11 m), and standard total-body scan precision was derived from a sub-sample of 58 athletes (male n = 19; female n = 39; age: 27.6 ± 9.9 y; body mass: 69.6 ± 14.8 kg; stature: 1.72 ± 0.94 m). Data from the sub-sample were also used to compare precision error and 3-compartment body composition outcomes between the standard total-body scan and the TBLH scan.

RESULTS

TBLH precision errors [root mean squared-standard deviation, RMS-SD (coefficient of variation, %CV)] were bone mineral content (BMC): 15.6 g (0.5%), lean mass (LM): 254.3 g (0.4%) and fat mass (FM): 199.4 g (1.3%). These outcomes compared favourably to the precision errors derived from the standard total-body scan [BMC: 12.4 g (0.4%), LM: 202.2 g (0.4%), and FM: 160.8 g (1.1%)]. The TBLH scan resulted in lower BMC (-19.5%), LM (-6.6%), and FM (-4.5%) compared to the total-body scan (BMC: 2,308 vs. 2,865 g; LM: 46,954 vs. 50,276 g; FM: 15,183 vs. 15,888 g, all p<0.005). ConclusionThe TBLH scan demonstrates high in-vivo precision comparable to that of the standard total-body scan in a heterogeneous cohort of athletes. Given the impact of head exclusion on total body composition outcomes, TBLH scans should not be used interchangeably with the standard total-body scan.

Evaluating the population-level effects of oxycodone restrictions on prescription opioid utilization in Ontario

PURPOSE

To investigate the impact of restrictions on access to long acting oxycodone on prescription opioid use and opioid-related harms.

METHODS

Administrative health data from Ontario, Canada was used to measure differences in opioids dispensed and ED visits for opioid-related overdose, poisoning or substance use following provincial restrictions on access to publicly insured OxyContin (February 29, 2012) and OxyNeo (February 28, 2013). This study focused on the cohort of provincial drug insurance eligible people (people 65+ and select low-income populations) who were dispensed oxycodone prior to the restrictions. Difference-in-differences models with a propensity score matched comparison group of people who were dispensed non-oxycodone opioids were used to estimate the main effects.

RESULTS

In the six months following the delisting of OxyContin, MMEs per person per week for all opioids fell by an average of 7.5% in people dispensed oxycodone relative to the comparison group, and an average of 13.8% in chronic recipients of oxycodone. In the six months following the restrictions on OxyNeo, MMEs per person per week fell by an average of 3.1% in all people dispensed oxycodone, and 25.2% in chronic oxycodone recipients. The decline in oxycodone dispensing amongst chronic oxycodone recipients corresponded with an increase in dispensing of other opioid formulations, particularly hydromorphone and fentanyl. No important differences were observed for ED visits related to opioid poisoning, overdose, or substance use disorder.

CONCLUSIONS

Province-wide restrictions on access to long acting oxycodone had an impact on quantities of all opioids dispensed to chronic recipients of oxycodone, but small impacts on the full population of people dispensed oxycodone; the decline in use was partially offset by increases in use of other publicly-funded opioid formulations. This study suggests that policies limiting access to specific prescription opioids led to overall reductions in publicly-funded prescription opioid use, particularly in chronic oxycodone recipients, without immediate evidence of changes in opioid-related ED visits. This article is protected by copyright. All rights reserved.

The relationship between outpatient service use and emergency department visits among people treated for mental and substance use disorders: analysis of population-based administrative data in British Columbia, Canada

Background

Research findings on the association between outpatient service use and emergency department (ED) visits for mental and substance use disorders (MSUDs) are mixed and may differ by disorder type.

Methods

We used population-based linked administrative data in British Columbia, Canada to examine associations between outpatient primary care and psychiatry service use and ED visits among people ages 15 and older, comparing across people treated for three disorder categories: common mental disorders (MDs) (depressive, anxiety, and/or post-traumatic stress disorders), serious MDs (schizophrenia spectrum and/or bipolar disorders), and substance use disorders (SUDs) in 2016/7. We used hurdle models to examine the association between outpatient service use and odds of any ED visit for MSUDs as well count of ED visits for MSUDs, stratified by cohort in 2017/8.

Results

Having had one or more MSUD-related primary care visit was associated with lower odds of any ED visit among people treated for common MDs and SUDs but not people treated for serious MDs. Continuity of primary care was associated with slightly lower ED use in all cohorts. One or more outpatient psychiatrist visits was associated with lower odds of ED visits among people treated for serious MDs and SUDs, but not among people with common MDs.

Conclusion

Findings highlight the importance of expanded access to outpatient specialist mental health services, particularly for people with serious MDs and SUDs, and collaborative models that can support primary care providers treating people with MSUDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07759-z.

Trends in dispensing of individual prescription opioid formulations, Canada 2005-2020

Background

Canada has experienced a distinctly bifurcated pattern of (strong) opioid utilization post-2000, with multifold increases rendering it one of the world’s highest opioid consumption rates, followed by subsequent substantive declines since 2011/2012. Several interventions to control especially high-risk opioid use have been implemented post-2010 at different levels, yet with their effects assessed mostly for overall opioid utilization. Little knowledge exists for over-time patterns of individual opioid formulations.

Methods

Raw information on community-based prescription opioid dispensing for years 2005–2020 were obtained from a large national database based on a stratified sample of 6500 retail pharmacies across Canada (IQVIA/Compuscript), These data were converted into Defined-Daily-Doses/1000 population/day (DDD/1000/day) for individual (strong and weak) opioid formulations—specifically: fentanyl, hydromorphone, hydrocodone, morphine, oxycodone, codeine—per standard methods. Descriptive data on individual opioid dispensing were computed, and segmented regression (or ‘broken-stick’) analysis was applied to the overtime dispensing towards assessing potentially significant ‘breakpoints’ interrupting linear utilization trends. Akaike information criterion (AIC) values were computed to assess the resulting models’ quality-of-fit.

Results

Five of the six opioid formulations featured a lower dispensing level in 2020 compared with 2005, but mostly with peak values in years between, contributing to the overall inversion pattern. For five of the six opioid formulations, a three-segmented model emerged as the best fit for the dispensing observed; only hydrocodone presented a linear (downward) dispensing trend. Among the five interrupted trend models for individual formulations, four (fentanyl, morphine, oxycodone, codeine but not hydromorphone) indicated their initial breakpoint during 2011–2014 introducing a downward dispensing trend. Inconsistently, morphine also featured a recent breakpoint (2018) towards a dispensing increase.

Conclusions

While all opioids showed marked declines, we found heterogeneous patterns of dispensing for individual opioid formulations. While we cannot estimate direct causal effects, opioid control interventions appear to have had differential impacts on dispensing of individual formulations. The earliest breakpoint occurred towards substantive decreases for oxycodone dispensing in 2011; subsequently, there were increases in dispensing of hydromorphone and fentanyl likely due to substitution effects, followed by across-the-board declines post-2015/2016. Recent ‘safer opioid’ distribution programs to reduce illicit/toxic opioid exposure linked with high levels of poisoning fatalities seem to fuel resurgences in select opioid (e.g., morphine) dispensing.

Estimating the Prevalence of Mental and Substance Use Disorders: A Systematic Approach to Triangulating Available Data to Inform Health Systems Planning

OBJECTIVE

To estimate the prevalence of specific mental and substance use disorders (MSUDs), by age and sex, as a first step toward informing needs-based health systems planning by decision-makers.

METHODS

We developed a conceptual framework and a systematic methodology for combining available data sources to yield prevalence estimates for specific MSUDs. Data sources used included published, peer-reviewed literature from Canada and comparable countries, Canadian population survey data, and health administrative data from British Columbia. Several well-established methodologies including systematic review and meta-analyses of published prevalence estimates, modelling of age- and sex-specific distributions, and the Global Burden of Disease severity distribution model were incorporated in a novel mode of triangulation.

RESULTS

Using this novel approach, we obtained prevalence estimates for 10 MSUDs for British Columbia, Canada, as well as prevalence distributions across age groups, by sex.

CONCLUSION

Obtaining reliable assessments of disorder prevalence and severity is a useful first step toward rationally estimating service need and plan health services. We propose a methodology to leverage existing information to obtain robust estimates in a timely manner and with sufficient granularity to, after adjusting for comorbidity and matching with severity-specific service bundles, inform need-based planning efforts for adult (15 years and older) mental health and substance use services.

Emergency department use for mental and substance use disorders: descriptive analysis of population-based, linked administrative data in British Columbia, Canada

OBJECTIVES

Information on emergency department (ED) visits for mental and substance use disorders (MSUDs) is important for planning services but has not been explored in British Columbia (BC), Canada. We describe all MSUD ED visits for people ages 15 and older in the province of BC in 2017/2018 and document trends in MSUD ED visits between 2007/2008 and 2017/2018 by disorder group.

DESIGN

Population-based linked administrative data comprised of ED records and physician billings capturing all MSUD ED visits in BC.

SETTING

BC is Canada's westernmost province with a population of approximately 5 million. Permanent residents receive first-dollar coverage for all medically necessary services provided by licensed physicians or in hospitals, including ED services.

POPULATION

All people age >15 with MSUD ED visits during the study period.

MEASURES

All claims with a service location in the ED or corresponding to fee items billed only in the ED were examined alongside ED visits reported through a national reporting system. Patient characteristics (sex/gender, age, location of residence, income, treated disorders and comorbidities) and previous outpatient service use for all ED visits by visit diagnosis are also described.

RESULTS

A total of 72 363 people made 134 063 visits to the ED in 2017/2018 for needs related to MSUD. MSUD ED visits have increased since 2010, particularly visits for substance use and anxiety disorders. People with more frequent visits were more likely to be male, on public prescription drug plans for income assistance, prescribed psychiatric medications, and living in lower-income neighbourhoods. They used more community-based primary care and psychiatry services and had lower continuity of primary care.

CONCLUSIONS

MSUD ED visits are substantial and growing in BC. Findings underscore a need to strengthen and target community healthcare services and adequately resource and support EDs to manage growing patient populations.

Patterns, trends and determinants of medical opioid utilization in Canada 2005-2020: characterizing an era of intensive rise and fall

BACKGROUND

Into the 21st century, the conflation of high rates of chronic pain, systemic gaps in treatment availability and access, and the arrival of potent new opioid medications (e.g., slow-release oxycodone) facilitated strong increases in medical opioid dispensing in Canada. These persisted until post-2010 alongside rising opioid-related adverse (e.g., morbidity/mortality) outcomes. We examine patterns, trends and determinants of opioid dispensing in Canada, and specifically its 10 provinces, for the years 2005-2020.

METHODS

Raw data on prescription opioid dispensing were obtained from a large national community-based pharmacy database (IQVIA/Compuscript), converted into Defined-Daily-Doses/1,000 population/day for 'strong' and 'weak' opioid categories per standard methods. Dispensing by opioid category and formulations by province/year was assessed descriptively; regression analysis was applied to examine possible segmentation of over-time strong opioid dispensing.

RESULTS

All provinces reported starkly increasing strong opioid dispensing peaking 2011-2016, and subsequent marked declines. About half reported lower strong opioid dispensing in 2020 compared to 2005, with continuous inter-provincial differences of > 100 %; weak opioids also declined post-2011/12. Segmented regression suggests breakpoints for strong opioids in 2011/12 and 2015/16, coinciding with main interventions (e.g., selective opioid delisting, new prescribing guidelines) towards more restrictive opioid utilization control.

CONCLUSIONS

We characterized an era of marked rise and fall, while featuring stark inter-provincial heterogeneity in opioid dispensing in Canada. While little evidence for improvements in pain care outcomes exists, the starkly inverting opioid utilization have been associated with extensive population-level harms (e.g., misuse, morbidity, mortality) over-time. This national case study raises fundamental questions for opioid-related health policy and practice.

Correlations between Changes in Medical Opioid Dispensing and Contributions of Fentanyl to Opioid-Related Overdose Fatalities: Exploratory Analyses from Canada

Canada is experiencing an epidemic of opioid-related mortality, with increasing yet heterogeneous fatality patterns from illicit/synthetic (e.g., fentanyl) opioids. The present study examined whether differential provincial reductions in medical opioid dispensing following restrictive regulations (post-2010) were associated with differential contributions of fentanyl to opioid mortality. Annual provincial opioid dispensing totals in defined daily doses/1000 population/day, and change rates in opioid dispensing for the 10 provinces for (1) 2011-2018 and (2) "peak-year" to 2018 were derived from a pan-Canadian pharmacy-based dispensing panel. Provincial contribution rates of fentanyl to opioid-related mortality (2016-2019) were averaged. Correlation values (Pearson's R) between provincial changes in opioid dispensing and the relative fentanyl contributions to mortality were computed for the two scenarios. The correlation between province-based changes in opioid dispensing (2011-2018) and the relative contribution of fentanyl to total opioid deaths (2016-2019) was -0.70 (t = 2.75; df = 8; p = 0.03); the corresponding correlation for opioid dispensing changes ("peak-year" to 2018) was -0.59 (t = -2.06; df = 8; p = 0.07). Provincial reductions in medical opioid dispensing indicated (near-)significant correlations with fentanyl contribution rates to opioid-related death totals. Differential reductions in pharmaceutical opioid availability may have created supply voids for nonmedical use, substituted with synthetic/toxic (e.g., fentanyl) opioids and leading to accelerated opioid mortality. Implications of these possible unintended adverse consequences warrant consideration for public health policy.

Evaluation of a collaborative pharmacy service initiative for people with intellectual disabilities in residential care homes

Introduction

People with Intellectual Disabilities (ID) often have complex care needs and increased likelihood of premature death.1 The NHS has committed to improving the use of psychotropic medicines in people with ID with the Stopping the Over-Medication of People with Learning Disabilities (STOMP) programme.2 In the Wirral a cross-sector, collaborative service initiative involving community pharmacists and a specialist mental health pharmacist was developed to provide pharmaceutical care reviews for ID care home residents, which included an evaluation of the initiative.

Aim

This study aimed to determine the number and type of pharmacists’ interventions and GP recommendations in this service initiative.

Methods

Pharmacists provided pharmaceutical care reviews for ID care home residents using a framework and where applicable made interventions or recommendations to residents’ GPs or consultant psychiatrist. The framework was devised by the lead Consultant, Mental Health Trust lead pharmacist and Local Pharmaceutical Committee representatives to align with national ID priorities.1 Pharmacists were recruited via expressions of interest and direct recruitment by the mental health trust. Using anonymised, aggregated, Clinical Commissioning Group data, an Oversight Group divided all ID care homes in the locality into two groups: homes with residents with low psychotropic medicines use were primarily assigned to community pharmacists, whilst those with higher psychotropic use were assigned to the specialist mental health pharmacist. Pharmacists contacted care home managers and arranged reviews with all residents, sharing learnings in weekly reviews. Community pharmacists identified residents who would benefit from specialist mental health pharmacist review and referred them. Data collected included patient demographic details, medication history, results of assessments completed and interventions/recommendations. Following institutional ethical approval, this data was downloaded from PharmOutcomes into Microsoft Excel and personally identifiable data removed. The data underwent descriptive statistical analysis in SPSS, including frequency counting interventions by type.

Results

The pharmacists conducted reviews with 160 residents (76 by community pharmacists and 84 by the specialist mental health pharmacist) from November 2019 – May 2020, reflecting all residents in visited care homes. These residents were prescribed 1207 medicines, 74% were prescribed 5 or more medicines (i.e. polypharmacy) and 507 interventions or recommendations were made, averaging 3.3 per resident. Table 1 shows that the highest proportion (30.4%) of these were public health related, whilst changing and stopping medicines accounted for 17.9% and 12.8% respectively. The majority (63%) of interventions made by community pharmacists were public health related, whilst those made by the mental health specialist pharmacist most frequently concerned changing medicines (25%), stopping medicines (18%), and blood monitoring (13%).

Conclusion

The study findings indicate a high level of polypharmacy among the ID residents and a high number of interventions / recommendations were needed to improve care, in line with national priorities.1,2 The small scale of the study is acknowledged, and further research is warranted. However, the findings suggest that this service model may be an effective use of the respective skill sets of the pharmacists involved and suitable for wider adoption, with community pharmacists focusing on holistic care and specialist mental health making specialist medicines interventions.

References

1. University of Bristol Norah Fry Centre for Learning Disability Studies. The Learning Disability Mortality Review (LeDeR) Programme Annual Report 2018. Available at: https://www.hqip.org.uk/wp-content/uploads/2019/05/LeDeR-Annual-Report-Final-21-May-2019.pdf (last accessed 12/10/20).

2. NHS England. Stopping over medication of people with a learning disability, autism or both (STOMP). https://www.england.nhs.uk/learning-disabilities/improving-health/stomp/ (last accessed 12/10/20).

112 Outcomes and Clinical Characteristics of COVID-19 Disease in the Frail, Elderly Population of Tayside

Introduction

With advancing age, frailty, multi-morbidity and need for care, elderly patients are some of the most vulnerable to Covid-19 disease. In NHS Tayside, a dedicated Covid-19 Medicine for the Elderly (MFE) Team was formed to care for patients identified as frail and likely to benefit from comprehensive geriatric assessment.

Methods

All Covid-19 patients meeting frailty criteria1, cared for by the Covid-19 MFE Team were identified. Data on outcomes and clinical characteristics for all (140) patients admitted during the first pandemic wave (March–July 2020) was collected using electronic patient records and analysed.

Results

Patients were predominantly male (58.6%). Ages ranged from 65–99 years, with 43.6% aged ≥85 years. 82.1% had one or more of cough, fever and anosmia on admission fitting Covid-19 case definition 2. Lymphopenia was present in 92.1%. Of note, 26.5% of patients had a normal or unchanged chest x-ray report, with only 10.2% showing bilateral peripheral infiltrates. 28-day mortality was 37.1% with Covid-19 Disease listed as primary cause of death in 90.4%.

Conclusion(s)

Entering further “waves” of infection, it is vital that we understand the clinical presentation and course of Covid-19 disease in elderly patients. Our data highlights that any Covid-19 symptom, even in isolation, should raise suspicion of disease. Chest x-rays should not be used alone as a diagnostic tool. The presence of lymphopenia should raise suspicion of Covid-19 infection. In developing an understanding of how elderly patients with Covid-19 present, we can ensure early identification and initiation of appropriate infection control measures.

References

1. Healthcare Improvement Scotland. Think Frailty. 2014. http://www.healthcareimprovementscotland.org/his/idoc.ashx?docid=8abd8530-48f3-4152-bbfb-d0918b870ec9&version=-1

2. Scottish Government. Update to Coronavirus Symptoms 2020. https://www.gov.scot/news/update-to-coronavirus-symptoms

Comparison of Crude Population-Level Indicators of Opioid Use and Related Harm in New Zealand and Ontario (Canada)

North America and select other Commonwealth jurisdictions have been experiencing unprecedented opioid epidemics characterized by excessive and persistently high levels of opioid misuse, morbidity and mortality, and related disease burden. Recent discussions have considered whether New Zealand might undergo or needs to expect a similar ‘opioid crisis’. Towards further informing these considerations, we examine and compare essential, publicly available indicators of opioid utilization and harms (mortality) from New Zealand and the Canadian province of Ontario, due to the fact that both operate public health care systems in similar socio-cultural settings. We find that the two jurisdictions have featured vastly different population levels of opioid exposure, opioid consumption patterns (e.g., high-dose/long-term/high-risk prescribing) known as key predictors of adverse outcomes, and levels of opioid mortality as evidenced by concrete epidemiological indicators and data. Specifically for opioid-related death rates, these were already approximately threefold higher in Ontario compared to New Zealand based on most recent comparison data (e.g., 2012); these differentials have likely further grown more recently given major and distinct changes in population-level opioid exposure and risks, and subsequent opioid-related deaths since then in Ontario. Based on the present data and related evidence, New Zealand does not seem to need to anticipate an opioid mortality epidemic similar to that experienced in North America; however, it would be of interest to establish more comprehensive and timely surveillance of key system-level indicators of opioid use and harms as are standard in North America. As such, this inter-jurisdictional comparison makes for a case study in starkly contrasting scenarios of opioid use and harms, the drivers behind which deserve further systematic examination.

Prescription opioid dispensing in Canada: an update on recent developments to 2018

Canada has been home to comparatively extreme developments in prescription opioid (PO) availability and related harms (e.g. morbidity, mortality) post-2000. Following persistent pan-Canadian increases in PO use, select control measures were implemented and PO dispensing levels—while only inconsistently by province—inverted, and began to plateau or decrease post-2012. We examined annual PO dispensing levels in Canada up until 2018, based on representative prescription sample data from community-based retail pharmacies. Annual prescription-based dispensing data were converted into defined daily doses/1000 population/day by province, and mainly categorized into ‘weak’ and ‘strong’ opioids. All provinces indicated decreasing trends in strong PO levels in most recent years, yet with inter-provincial differences of up to one magnitude in 2018; in about half the provinces, dispensing fell to below-2005 levels. British Columbia had the largest decline in strong PO dispensing from its peak rate (− 48.5%) in 2011. Weak opioid dispensing trends remained more inconsistent and bifurcated across Canada. The distinct effects of individual—including many provincially initiated and governed—PO control measures urgently need to be evaluated. In the meantime, recent reductions in general PO availability across Canada appear to have contributed to shortages in opioid supply for existent, sizable (including non-medical) user populations and may have contributed to recent marked increases in illicit opioid use and harms (including rising deaths).

Latent-transforming growth factor beta-binding protein-2 (LTBP-2) is required for longevity but not for development of zonular fibers

Latent-transforming growth factor beta-binding protein 2 (LTBP-2) is a major component of arterial and lung tissue and of the ciliary zonule, the system of extracellular fibers that centers and suspends the lens in the eye. LTBP-2 has been implicated previously in the development of extracellular microfibrils, although its exact role remains unclear. Here, we analyzed the three-dimensional structure of the ciliary zonule in wild type mice and used a knockout model to test the contribution of LTBP-2 to zonule structure and mechanical properties. In wild types, zonular fibers had diameters of 0.5-1.0 micrometers, with an outer layer of fibrillin-1-rich microfibrils and a core of fibrillin-2-rich microfibrils. LTBP-2 was present in both layers. The absence of LTBP-2 did not affect the number of fibers, their diameters, nor their coaxial organization. However, by two months of age, LTBP-2-depleted fibers began to rupture, and by six months, a fully penetrant ectopia lentis phenotype was present, as confirmed by in vivo imaging. To determine whether the seemingly normal fibers of young mice were compromised mechanically, we compared zonule stress/strain relationships of wild type and LTBP-2-deficient mice and developed a quasi-linear viscoelastic engineering model to analyze the resulting data. In the absence of LTBP-2, the ultimate tensile strength of the zonule was reduced by about 50%, and the viscoelastic behavior of the fibers was altered significantly. We developed a harmonic oscillator model to calculate the forces generated during saccadic eye movement. Model simulations suggested that mutant fibers are prone to failure during rapid rotation of the eyeball. Together, these data indicate that LTBP-2 is necessary for the strength and longevity of zonular fibers, but not necessarily for their formation.

Enrichment and preserved functionality of multipotential stromal cells in bone marrow concentrate processed by vertical centrifugation

The concentration of bone marrow (BM) aspirate (BMA) is increasingly valued for bone and cartilage repair, particularly with the rarity and donor-variability of BM-multipotential stromal cells (BM-MSCs). The present study aimed to assess BM-MSC yield following BM concentration using a fast and compact-sized vertical centrifugation system. BMA concentrate (BMAC) was separated in a 1 min process and collected easily after an automatic discarding of plasma and red blood cells. A significant increase in CD45low CD271high cells per BMAC volume (measured using flow-cytometry) was noted (4-fold, p = 0.0001). Additionally, the vertical centrifugation system helped to enrich colony numbers (assessed by CFU-F assays) in BMAC comparably with conventional centrifugation systems, BioCUE™ and SmartPReP-2® (4.3-fold, 4.6-fold and 3-fold, respectively). Next, a functional assessment of BM-MSCs processed by vertical centrifugation was performed, and MSC viability and proliferation were not affected. Also, these BM-MSCs showed similar alkaline phosphatase and calcium levels to those of BMA-MSCs when osteogenically induced. Furthermore, glycosaminoglycans and Nile red levels in addition to the gene expression assays confirmed that there was no significant change in chondrogenic or adipogenic abilities between BMA-MSCs and BMAC-MSCs. The expression levels of selected angiogenic and immunomodulatory mediators were also similar between the two groups. Collectively, the vertical centrifugation system helped to enrich BM-MSCs effectively, while maintaining cell viability and functions. Thus, such a vertical centrifugation system for BM concentration can be valuable for various regenerative therapies.

Methanol photo-reforming with water on pure titania for hydrogen production

The behaviour of titania for the photo-reforming of methanol with water at ambient temperature has been examined. It is shown that the reactivity is very poor, compared with metal-loaded catalysts at low methanol levels in solution, but the rate becomes much higher at high methanol levels, such that the difference from metal-loaded samples is much less. The optimum yield is with approximately a 1 : 1 methanol/water solution. The reaction also proceeds well in the gas phase. During all such catalysis, the titania becomes blue, due to light absorption increasing across the range 400-800 nm. However, this does not result in visible range activity for the photo-reforming and is due to the reduction of the material in the presence of light and the formation of anion vacancies and Ti³⁺ centres. These anion vacancies are only very slowly re-oxidized in air on P25 titania, taking days to recover the original whiteness of the oxide. The performance of anatase, rutile and the mixed phase is compared. This article is part of a discussion meeting issue 'Science to enable the circular economy'.

Examining correlations between opioid dispensing and opioid-related hospitalizations in Canada, 2007-2016

BACKGROUND

High levels of opioid-related mortality, as well as morbidity, contribute to the excessive opioid-related disease burden in North America, induced by high availability of opioids. While correlations between opioid dispensing levels and mortality outcomes are well-established, fewer evidence exists on correlations with morbidity (e.g., hospitalizations).

METHODS

We examined possible overtime correlations between medical opioid dispensing and opioid-related hospitalizations in Canada, by province, 2007-2016. For dispensing, we examined annual volumes of medical opioid dispensing derived from a representative, stratified sample of retail pharmacies across Canada. Raw dispensing information for 'strong opioids' was converted into Defined Daily Doses per 1000 population per day (DDD/1000/day). Opioid-related hospitalization rates referred to opioid poisoning-related admissions by province, for fiscal years 2007-08 to 2016-17, drawn from the national Hospital Morbidity Database. We assessed possible correlations between opioid dispensing and hospitalizations by province using the Pearson product moment correlation; correlation values (r) and confidence intervals were reported.

RESULTS

Significant correlations for overtime correlations between population-levels of opioid dispensing and opioid-related hospitalizations were observed for three provinces: Quebec (r = 0.87, CI: 0.49-0.97; p = 0.002); New Brunswick (r = 0.85;CI: 0.43-0.97; p = 0.004) and Nova Scotia (r = 0.78; CI:0.25-0.95; p = 0.012), with an additional province, Saskatchewan, (r = 0.073; CI:-0.07-0.91;p = 0.073) featuring borderline significance.

CONCLUSIONS

The correlations observed further add to evidence on opioid dispensing levels as a systemic driver of population-level harms. Notably, correlations were not identified principally in provinces with reported high contribution levels (> 50%) of illicit opioids to mortality, which are not captured by dispensing data and so may have distorted or concealed potential correlation effects due to contamination.

Understanding young peoples' and family members' views of treatment for first episode psychosis in a randomised controlled trial (MAPS)

BACKGROUND

There is limited evidence to inform treatment decision-making in adolescents experiencing first episode psychosis (FEP). In the MAPS trial (Managing Adolescent first Episode Psychosis: a feasibility Study), adolescents with FEP received either antipsychotic medication (AP), psychological intervention (PI), or both. We investigated treatment views of young people and family members across each treatment arm of MAPS.

METHODS

Thirteen adolescents participating in MAPS and eighteen family members attended in-depth audio-recorded interviews to discuss trial treatments. Interviews were analysed using inductive Thematic Analysis, identifying salient themes across these accounts.

FINDINGS

Family members in particular reported an urgent need for treatment regardless of type. Both AP and PI were broadly viewed as acceptable treatment approaches, but for differing reasons which participants weighed against a range of concerns. AP were often seen to reduce symptoms of psychosis, though participants expressed concerns about side effects. PI were viewed as interactive treatment approaches that helped improve understanding of psychosis and enhanced coping, although some found PI emotionally and cognitively challenging. Combining treatments was seen to maximise benefits, with a perceived interaction whereby AP facilitated engagement with PI.

INTERPRETATION

Acceptability of and engagement with treatments for FEP may differ between individual young people and their family/carers. In order to be able to offer fully informed choices, and determine an optimum treatment approach for young people with FEP, definitive trial evidence should be established to determine wanted and unwanted treatment impacts.

FUNDING

NIHR HTA programme (project number 15/31/04).

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

The opioid mortality epidemic in North America: do we understand the supply side dynamics of this unprecedented crisis?

While there has been extensive attention to the 'demand side' - or use and adverse consequences, including mortality - of the 'opioid crisis' presently unfolding across North America, few considerations have focused on the supply side. This paper examines the supply side dynamics of this unprecedented public health phenomenon. We provide evidence for several interrelated supply-side elements that have contributed to the present public health crisis. We observe that initially, persistently high levels of prescription opioid availability and use exposed large proportions of the North American population to opioids, resulting in correspondingly high levels of medical and non-medical use (e.g., involving diversion). While various intervention measures to control prescription opioid availability and use have been implemented in recent years, leading to eventual reductions in opioid dispensing levels, these occurred late in the crisis's evolution. Moreover, these supply reductions have not been met by corresponding reductions in opioid use or demand levels. These growing discrepancies between opioid demand and prescription-based sources have left major gaps in opioid supplies. In response to such supply gaps, highly potent and toxic illicit opioid products have rapidly proliferated across North America, and become a core driver of the dramatic spikes in opioid overdose fatality levels in recent years. These supply-related interrelations are corroborated by a corresponding increase in illicit opioid-related fatalities, which arose just as medical opioid supplies began to decrease in many jurisdictions. Improved analyses and understanding of the supply-side dynamics of the opioid crisis are urgently needed in order to inform future intervention and policy development. Meanwhile, the high mortality toll related to illicit, highly toxic opioid exposure requires sustained solutions, including supply-oriented measures (e.g., safer opioid distribution for at-risk users) towards improved public health protection.

Is supported self-management for depression effective for adults in community-based settings in Vietnam?: a modified stepped-wedge cluster randomized controlled trial

Background

This study tested the effectiveness of a supported self-management (SSM) intervention to reduce symptoms of depression among adults compared with enhanced treatment as usual in community-based and primary care settings in Vietnam.

Methods

The cluster randomized trial included 376 adults in 32 communes in eight provinces. Eligible participants scored > 7 on the SRQ-20 depression scale. Patients with severe symptoms were excluded and referred to tertiary care. Randomization took place at the commune level. The immediate intervention group included 16 communes with 190 participants and the delayed group included 16 communes with 186 participants. Participants in communes randomized to the immediate intervention group received a two-month course of SSM, consisting of a workbook and supportive coaching. Those in communes randomized to the delayed group received enhanced treatment as usual and, for ethical purposes, received the SSM intervention after 4 months. The primary outcome is the effect of SSM on reduction in depression scores as indicated by a reduced proportion of participants with SRQ-20 scores > 7 at 2 months after commencement of SSM intervention. Blinding was not possible during intervention delivery but outcome assessors were blinded. Analysis was intention-to-treat.

Results

At 2 months, 26.4% of the intervention group and 42.3% of the delayed group had SRQ-20 scores > 7. The adjusted odds ratio of having depression between the intervention and control was 0.42 (p < 0.0001), 95% CI (0.28, 0.63). Receiving the intervention thus reduces the odds of having depression by 58%, compared with receiving the control after 2 months of treatment. No adverse events were reported.

Conclusions

Results suggest that SSM is effective for decreasing depression symptoms among adults in community-based settings in Vietnam.

Trial Registration This trial is registered at ClinicalTrials.gov, number NCT03001063.

Correlations between opioid mortality increases related to illicit/synthetic opioids and reductions of medical opioid dispensing - exploratory analyses from Canada

Background

North America has been experiencing a persistent epidemic of opioid-related overdose mortality, which has increasingly been driven by fatalities from illicit, toxic opioids in most recent years. Patterns of synthetic opioid availability and related mortality are heterogeneous across Canada, and differing explanations exist as to their differentiated proliferation. We examined the perspective that heterogeneous province-based variations in prescription opioid availability, facilitated by various control strategies, post-2010 may have created regionally differential supply gaps for non-medical opioid use substituted by synthetic opioid products with differential impacts on mortality risks and outcomes in Canada.

Methods

We examined annual, prescription opioid dispensing rates and changes in the ten Canadian provinces (for the periods of 1) 2011–2018, 2) ‘peak-year’-to-2018) in Defined Daily Doses/1000 population/day, derived from data from a large representative, stratified sample of community pharmacies projected to a Canada total. Annual, provincial opioid-related mortality rates and changes for years 2016–2018 were calculated from federal data. We computed correlation values (Pearson’s R) between respective province-based change rates for prescription opioid dispensing and opioid-related mortality for the two over-time scenarios.

Results

All but one province featured reductions in prescription opioid dispensing 2011–2018; seven of the ten provinces had increases in opioid mortality 2016–2018. The correlation between changes in opioid dispensing (2011–2018) and in opioid-mortality (2016–2018) was r = 0.63 (df = 8, p-value: 0.05); the correlation was r = 0.57 (df = 8, p-value: 0.09) for changes in opioid dispensing ‘peak year’-to-2018, respectively.

Conclusions

Quasi-significant results indicate that recent increases in opioid-related deaths driven by illicit, synthetic opioids tended to be larger in provinces where reductions in prescription opioid availability have been more extensive. It is a plausible explanation that these reductions created supply gaps for non-medical opioid use increasingly filled by illicit, synthetic opioids differentially contributing to opioid-related deaths, generating un-intended adverse effects for previous interventions. General prevention measures to reduce opioid availability, and targeted prevention for at-risk opioid users exposed to toxic drug supply may be include counteractive effects and require coordinated reconciliation.

Evaluation of the GeneQuence® DNA Hybridization Method in Conjunction with 24-Hour Enrichment Protocols for Detection of Salmonella spp. in Select Foods: Collaborative Study

A multilaboratory study was conducted to compare performance of the GeneQuence® DNA hybridization (DNAH) method incorporating new 24 h enrichment protocols and reference culture procedures for detection of Salmonella spp. in select foods. Six food types (raw ground turkey, raw ground beef, dried whole egg, milk chocolate, walnuts, and dry pet food) were tested by the DNAH method and by the culture methods of either the U.S. Department of Agriculture-Food Safety and Inspection Service (USDA-FSIS) or the U.S. Food and Drug Administration's Bacteriological Analytical Manual (FDA/BAM). Fifteen laboratories participated in the study. Four of the foods tested (raw ground turkey, dried whole egg, milk chocolate, and dry pet food), showed no statistically significant differences in performance between the DNAH method and the reference procedure as determined by Chi square analysis. Sensitivity rates for the DNAH method ranged from 92 to 100. The DNAH method, with the specific enrichment protocol evaluated, was found to be ineffective for detection of Salmonella spp. in walnuts. For raw ground beef, results from one trial showed a statistically significant difference in performance, with more positives obtained by the reference method. However, evidence suggests that the difference in the number of positives was likely due to lack of homogeneity of the test samples rather than to DNAH method performance.

A phase 1 study of the safety, reactogenicity, and immunogenicity of a Schistosoma mansoni vaccine with or without glucopyranosyl lipid A aqueous formulation (GLA-AF) in healthy adults from a non-endemic area

BACKGROUND

Schistosomiasis caused by Schistosoma mansoni (Sm) is a chronic, debilitating and potentially deadly neglected tropical disease. The licensure of a vaccine to prevent schistosomiasis would represent a major breakthrough in public health.

METHODS

The safety and immunogenicity of a candidate Sm vaccine were assessed in this phase I, double-blind, dose-escalation trial. Seventy-two healthy Sm-naïve 18-50 year olds were randomized to receive 3 doses ∼ 8 weeks apart of saline placebo, or 10 µg, 30 µg, or 100 µg of recombinant Sm-Tetraspanin-2 vaccine formulated on aluminum hydroxide adjuvant (Sm-TSP-2/Al) with or without 5 µg of glucopyranosyl lipid A aqueous formulation (GLA-AF). Clinical and serologic responses were assessed for 1 year after dose 3.

RESULTS

Vaccines were safe and well-tolerated. The most common reactions were injection site tenderness and pain, and headache and fatigue. Tenderness and pain were more frequent in groups receiving vaccine with GLA-AF than placebo (p = 0.0036 and p = 0.0014, respectively). Injection site reactions among those given Sm-TSP-2/Al with GLA-AF lasted 1.22 and 1.33 days longer than those receiving Sm-TSP-2/Al without GLA-AF or placebo (p < 0.001 for both). Dose- and adjuvant-related increases in serum IgG against Sm-TSP-2 were observed. Peak IgG levels occurred 14 days after dose 3. Seroresponse frequencies were low among recipients of Sm-TSP-2/Al without GLA-AF, but higher among subjects receiving 30 µg or 100 µg of Sm-TSP-2/Al with GLA-AF. More seroresponses were observed among those given 30 µg or 100 µg of Sm-TSP-2/Al with GLA-AF compared to placebo (p = 0.023 and p < 0.001, respectively). Seroresponse frequencies were 0%, 30%, 50%, and 89%, respectively, among those given placebo, or 10 µg, 30 µg or 100 µg of Sm-TSP-2/Al with GLA-AF, suggesting a dose-response relationship for Sm-TSP-2/Al with GLA-AF (p = 0.0001).

CONCLUSIONS

Sm-TSP-2/Al with or without GLA-AF was safe and well tolerated in a Sm-naïve population. A vaccine like the one under development may represent our best hope to eliminating this neglected tropical disease.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Tramadol dispensing patterns and trends in Canada, 2007-2016

PURPOSE

Opioid use and associated mortality and morbidity have substantially increased in Canada, which recent interventions have aimed to reduce. Tramadol is an atypical prescription-only (but unscheduled under Canada's narcotics law) opioid analgesic and not subject to controls for other (eg, strong) opioids. Given experiences in different jurisdictions, tramadol may have been increasingly dispensed as a "substitute" drug during a period with increasingly restrictive controls for other (scheduled) opioids.

METHODS

We examined the annual population-level retail dispensing (as a proxy for use) of tramadol and (scheduled) "strong opioids" in Canadian provinces for 2007-2016 based on data from a representative national sample of community pharmacies, covering the majority of episodes of opioid dispensing. Data for both aforementioned formulation categories were converted into defined daily doses (DDD)/1000 population/day and examined descriptively and by segmented regression analyses (to identify significant breakpoints in trends).

RESULTS

Tramadol use strongly increased in all provinces until 2009. After 2009, tramadol dispensing levels either decelerated their increase or plateaued; "strong opioid" dispensing levels, in comparison, increased strongly until 2011 and decelerated or decreased for the remaining period. Tramadol was consistently dispensed at lower levels than "strong opioids."

CONCLUSIONS

Tramadol and "strong opioids" showed similar (bifurcated) use trends, with initial increases and subsequent inflections, yet reductions in dispensing occurred earlier for tramadol than for "strong opioids" (the latter occurring following with recent interventions). Distinct from experiences with differential opioid control regimes elsewhere, there is no evidence that tramadol figured as a "substitution" drug for increasingly restricted "strong opioids" in Canada.

Correlations between population-levels of prescription opioid dispensing and related deaths in Ontario (Canada), 2005-2016

Canada is experiencing an ongoing opioid-related public health crisis, including persistently rising opioid (e.g., poisoning) mortality. Previous research has documented marked correlations between population-levels of opioid dispensing and deaths. We examined possible correlations between annual population-level dispensing of specific opioid formulations and related poisoning deaths in Ontario (Canada), for the period 2005-2016. Annual coroner statistics-based numbers of poisoning deaths associated with six main opioid formulations (codeine, fentanyl, hydromorphone, methadone, morphine, and oxycodone) for Ontario were converted into annual death rates (per 100,000 population). Annual dispensing data for the opioid formulations under study were based on commercial retail-sales data from a representative, stratified sample of community pharmacies (IMSQuintiles/IQVIA CompuScript), converted into Defined Daily Doses (DDD/1,000 population/day). Possible relationships between the annual death and dispensing rates were assessed by Pearson's correlation coefficient analyses. Death rates increased for almost all, while dispensing rates increased for half of the opioid categories. A significant positive correlation between death and dispensing rates was found for hydromorphone (r = 0.97, 95% CI: 0.88-0.99) and oxycodone (r = 0.90, 95% CI: 0.68-0.97) formulations; a significant negative correlation was found for codeine (r = -0.78, 95% CI: -0.93 to -0.37). No significant correlations were detected for fentanyl, methadone, and morphine related deaths. Strong correlations between levels of dispensing and deaths for select opioid formulations were found. For select others, extrinsic factors - e.g., increasing involvement of non-medical opioid products (e.g., fentanyl) in overdose deaths - likely confounded underlying correlation effects. Opioid dispensing levels continue to influence population-level mortality levels, and need to be addressed by prevention strategies.

Multi-province epidemiological research using linked administrative data: a case study from Canada

Background

Canada has a publicly-funded universal healthcare system with information systems managed by 13 different provinces and territories. This context creates inconsistencies in data collection and challenges for research or surveillance conducted at the national or multi-jurisdictional level.

Objective

Using a recent Canadian research project as a case study, we document the strengths and challenges of using administrative health data in a multi-jurisdictional context. We discuss the implications of using different health information systems and the solutions we adopted to deal with variations. Our goal is to contribute to better understanding of these challenges and the development of a more integrated and harmonized approach to conducting multi-jurisdictional research using administrative data.

Context and model

Using data from five separate provincial healthcare data systems, we sought to create and report on a set of provincially-comparable mental health and addiction services performance indicators. In this paper, we document the research process, challenges, and solutions. Finally, we conclude by making recommendations for investment in national infrastructure that could help cut costs, broaden scope, and increase use of administrative health data that exists in Canada.

Conclusions

Canada has an incredible wealth of administrative data that resides in 13 territorial and provincial government systems. Navigating access and improving comparability across these systems has been an ongoing challenge for the past 20 years, but progress is being made. We believe that with some investment, a more harmonized and integrated information network could be developed that supports a broad range of surveillance and research activities with strong policy and program implications.

Multi-province epidemiological research using administrative data in Canada: Challenges and opportunities

IntroductionCanada has a publicly-funded universal health care system with information systems managed by 13 provinces and territories. This context creates inconsistencies in data collection and challenges for epidemiological research conducted at the national or multi-jurisdictional level. Objectives and ApproachUsing a recent five-province research project as a case study (BC, AB, MB, ON, QC), we will discuss the strengths and challenges of using Canadian administrative health data in a multi-jurisdictional context. Our goal is to contribute to a better understanding of these challenges and the development of a more integrated and harmonized approach to conducting multi-jurisdictional research. ResultsMulti-jurisdictional data work is feasible but requires detailed coordination and extensive cooperation from all involved. There were noteable variations across provinces in this multi-province study. For example, time required to access the data varied greatly across the five provinces (from 4 to 9 months), and thus there were sequencing challenges, with some provinces being well into the analysis stage while others were still waiting for data. Access to human resources varied across provinces and in some cases led to delays in data abstraction. Cost of data (or analytic support) also varied across provinces, from $12,000 – $15,000. Critical to the success of the project was a coordinating group with expertise in both administrative health data and cross-provincial project coordination. Conclusion/ImplicationsThis project demonstrated the value of comparable data infrastructure with equitable access policies. Many of the disadvantages to multi-province projects using health care administrative data, such as potential coding errors and inconsistencies, can be managed by developing national standards and protocols, and tools that are shared for data cleaning and validation.

Crude estimates of prescription opioid-related misuse and use disorder populations towards informing intervention system need in Canada

BACKGROUND

Numerous interventions aimed at addressing the Canadian 'opioid crisis' have been implemented. However, no empirical estimaes of the number of people with problematic prescription opioid (PO) use exist to inform and guide intervention system needs.

METHODS

The annual numbers of Canadian adults (≥ 15 years) with PO misuse and/or use disorders ('addiction') were estimated by combining data on the prevalence and associated 95% Confidence Intervals (CIs) of PO use in the Canadian population, obtained from national surveys, with PO misuse and use disorders transition probabilities, obtained from high-quality studies in recent meta-analyses. Uncertainty Intervals (UI) were estimated using Monte Carlo simulations.

RESULTS

Population estimates of PO use were highest in 2008, with 5,967,046 (95% CI: 5,635,543-6,326,173) people using POs (representing 21.6% of adults), and lowest in 2015, with 3,941,935 (95% CI: 3,580,842-4,272,937) people using POs (13.1%). Furthermore, PO misuse and use disorders were highest in 2008, with 1,408,223 (95% UI: 878,686-1,951,211; 5.1% of adults) and 525,100 (95% UI 258,288-801,472; 1.9%) people with PO misuse and use disorders respectively. These numbers declined to 930,297 (95% UI: 576,083-1,295,310; 3.1% of adults) and 346,890 (95% UI: 168,310-532,941; 1.2%) people with PO misuse and use disorders, respectively, in 2015.

CONCLUSION

While seemingly declining over-time, the crude population estimates for problematic PO use were high, likely outweighing current intervention capacities. Furthermore, these estimates do not account for the delay of onset and duration of PO misuse and disorders. Thus, more rigorous problem population estimates should be generated to guide interventions.

A Comparison of Mental Health Performance Indicators in Canada

BackgroundThere is growing recognition of the need for consistent and reliable reporting on mental health and addiction (MHA) services in Canada. While there have been improvements in the area of reporting within provinces, comparable measures across provinces are often confined to hospitalization data. The aim of this project was to test the feasibility of creating MHA performance indicators that could be compared across Canadian provinces. MethodsA team of scientists from five provinces collaboratively developed the following six MHA performance indicators for ages 10 and up, using hospital, emergency, physician billing and mortality data (pop. 33.2 million): Access to the same family physician for people with MHA problems First contact for MHA problems was in an emergency department Physician follow-up after hospitalization for MHA problems Rate of suicide attempts among people diagnosed with MHA problems Suicide rates among people diagnosed with MHA problems Mortality of people diagnosed with MHA problems To facilitate meaningful inter-provincial comparisons, consensus definitions and standardized analytic processes were developed. Within age groups, 95% CI’s were calculated to determine if there were significant differences across years within age bands. Results are presented in a comparative format. FindingsWe found similar patterns across provinces but significant variation in the absolute rates, with no province consistently best across all indicators. In general, outcomes were poor among adolescents and young adults compared to older groups. ConclusionsThe results of this pilot indicate the process is feasible and meaningful. Future work could include generating comparisons on a regular basis to track system improvement; development of other measures of importance to stakeholders; and the expansion of the process to other provinces and territories. To our knowledge, this is the first report of provincial teams working collaboratively to generate comparable data on the performance of mental health services in Canada.

Introducing supported self-management for depression to primary care in Vietnam: A feasibility study in preparation for a randomized controlled trial

INTRODUCTION

Although depression is a major contributor to the global burden of disease, services remain scarce in many low- and middle-income countries. In Vietnam, depression services are limited, and the government has recently prioritized primary care and community-based service integration. We conducted a pilot study in 2 districts of Hanoi to test the feasibility of (a) introducing a supported self-management (SSM) intervention for adult depression in primary care in Vietnam, and (b) conducting a randomized controlled trial (RCT) to test the effectiveness of the intervention.

METHOD

We conducted focus groups with providers (n = 16) and community members (n = 32) to assess the appropriateness of an Antidepressant Skills Workbook for use in Vietnam. We trained providers (n = 23) to screen patients using the Self-Reporting Questionnaire-20 (SRQ-20) depression scale and to deliver SSM for a 2-month period. A total of 71 patients were eligible to participate in the study, with depression (SRQ-20) and disability (World Health Organization Disability Assessment Schedule 2.0) scores assessed at baseline and 1 and 2 months.

RESULTS

Study results demonstrate the feasibility of conducting a full RCT in Vietnam and suggest that SSM is an appropriate care model for the Vietnamese context. There was a statistically significant decrease in depression symptoms on the SRQ-20 and in functional disability in all domains for the World Health Organization Disability Assessment Schedule 2.).

CONCLUSION

Feasibility study results suggested that a full RCT was warranted. An unanticipated outcome of the study was the uptake of the model by the Ministry of Labor, Invalids, and Social Affairs in 2 additional provinces. (PsycINFO Database Record

Patterns, Changes, and Trends in Prescription Opioid Dispensing in Canada, 2005-2016

BACKGROUND

Levels of prescription opioid (PO) dispensing have been rising in Canada - also in global comparison - since the mid-2000s, and are co-occurring with extensive PO-related morbidity and mortality. Previous analyses have demonstrated correlations between PO dispensing and related harm levels, yet also distinct heterogeneous interprovincial PO-dispensing patterns, in regards to quantities and individual PO formulations. Several system-level interventions have been implemented recently (since 2012) to address high PO-use levels and related harms in Canada; the effects of these interventions on PO-dispensing levels remain largely unexamined.

OBJECTIVES

Our aim was to examine over-time patterns and trends of levels of PO dispensing quantitatively (in defined daily doses [DDDs]) for 'strong' and 'weak' opioids and qualitatively (by individual PO formulations) by province and Canada total, for the period of 2005-2016.

METHODS

We examined annual PO-dispensing levels, by 'weak' and 'strong' POs (individual PO formulations, but excluding methadone), by province and for Canada total, from 2005-2016. Raw dispensing information for POs were obtained from IMSQuintiles CompuScript [new name: IQVIA], based on monthly retail dispensing data from a representative sample of community pharmacies covering about 80% of all dispensing episodes in Canada. These data were converted into annual dispensing values in DDDs (DDD/1,000 population/day), based on standard methodology, for the PO formulation groups of interest. Patterns and trends of 'strong' and 'weak' POs and individual PO formulations were examined descriptively, aided by segmented regression analyses to identify significant break-points in over-time trends. In addition, changes in 'strong'/'weak' PO dispensing ratios between 2005 and 2016 were examined.

RESULTS

'Weak' PO use remained largely stable across Canada over the study period. For 'strong' PO dispensing, half of the provinces featured consistent increases, while remaining provinces presented initial increases with subsequently reverting downward trends at divergent levels. Dispensing of individual 'strong' PO formulations varied interprovincially; specifically, substantial decreases for oxycodone co-occurred with increases in other 'strong' PO formulations. The dispensing ratios for 'strong'/'weak' POs increased significantly across jurisdictions between 2005 and 2016 (P < .05).

LIMITATIONS

Retail pharmacy-based data do not cover the total - but the large majority - of PO dispensing in Canada. There are limitations to DDD/1,000 population/day as a comparative measurement unit for PO dispensing. The causal contribution of interventions associated with changes in PO dispensing observed cannot be verified with the data available.

CONCLUSIONS

Heterogeneous trends for PO dispensing, driven mostly by variations in 'strong' PO use, continue to be observed provincially across Canada. Recent changes in PO dispensing are likely influenced by recent intervention efforts (e.g., PO de-scheduling, monitoring, guidelines) aiming to reduce PO-related harms, which, however, have shown limited impact on PO-dispensing levels to date.

KEY WORDS

Opioids, prescribing, dispensing, interventions, policy, population, monitoring, Canada.

An agenda for 21st century neurodevelopmental medicine: lessons from autism

The future of neurodevelopmental medicine has the potential of situating child neurology at the forefront of a broad-based public health effort to optimize neurodevelopmental outcomes of children born with high-prevalence and diverse genetic, pre- and peri-natal, and environmental burdens compromising early brain development and leading to lifetime disabilities. Building on advancements in developmental social neuroscience and in implementation science, this shift is already occurring in the case of emblematic neurodevelopmental disorders such as autism. Capitalizing on early neuroplasticity and on quantification of trajectories of social-communicative development, new technologies are emerging for high-throughput and cost-effective diagnosis and for community-viable delivery of powerful treatments, in seamless integration across previously fragmented systems of healthcare delivery. These solutions could be deployed in the case of other groups of children at greater risk for autism and communication delays, such as those born extremely premature or with congenital heart disease. The galvanizing concept in this aspirational future is a public health focus on promoting optimal conditions for early brain development, not unlike current campaigns promoting pre-natal care, nutrition or vaccination.

The effectiveness of a Supported Self-management task-shifting intervention for adult depression in Vietnam communities: study protocol for a randomized controlled trial

Background

Depressive disorders are one of the leading causes of disease and disability worldwide. In Vietnam, although epidemiological evidence suggests that depression rates are on par with global averages, services for depression are very limited. In a feasibility study that was implemented from 2013 to 2015, we found that a Supported Self-management (SSM) intervention showed promising results for adults with depression in the community in Vietnam.

This paper describes the Mental Health in Adults and Children: Frugal Innovations (MAC-FI) trial protocol that will assess the effectiveness of the SSM intervention, delivered by primary care and social workers, to community-based populations of adults with depression in eight Vietnamese provinces.

Methods/design

The MAC-FI program will be assessed using a stepped-wedge, randomized controlled trial. Study participants are adults aged 18 years and over in eight provinces of Vietnam. Study participants will be screened at primary care centres and in the community by health and social workers using the Self-reporting Questionnaire-20 (SRQ-20). Patients scoring >7, indicating depression caseness, will be invited to participate in the study in either the SSM intervention group or the enhanced treatment as usual control group. Recruited participants will be further assessed using the World Health Organization’s Disability Assessment Scale (WHODAS 2.0) and the Cut-down, Annoyed, Guilty, Eye-opener (CAGE) Questionnaire for alcohol misuse. Intervention-group participants will receive the SSM intervention, delivered with the support of a social worker or social collaborator, for a period of 2 months. Control- group participants will receive treatment as usual and a leaflet with information about depression. SRQ-20, WHODAS 2.0 and CAGE scores will be taken by blinded outcome assessors at baseline, after 1 month and after 2 months. The primary analysis method will be intention-to-treat.

Discussion

This study has the potential to add to the knowledge base about the effectiveness of a SSM intervention for adult depression that has been validated for the Vietnamese context. This trial will also contribute to the growing body of evidence about the effectiveness of low-cost, task-shifting interventions for use in low-resource settings, where specialist mental health services are often limited.

Trial registration

Retrospectively registered at ClinicalTrials.gov, identifier: NCT03001063. Registered on 20 December 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1924-5) contains supplementary material, which is available to authorized users.

Use of medication and psychological counselling among Canadians with mood and/or anxiety disorders

INTRODUCTION

This study describes the use of prescription medications and psychological counselling in the past 12 months among Canadian adults with a self-reported mood and/or anxiety disorder diagnosis; the sociodemographic and clinical characteristics associated with their use; and reasons for not using them.

METHODS

We used data from the 2014 Survey on Living with Chronic Diseases in Canada-Mood and Anxiety Disorders Component. The study sample (n = 2916) was divided into four treatment subgroups: (1) taking medication only; (2) having received counselling only; (3) both; or (4) neither. We combined the first three subgroups and carried out descriptive and multivariate logistic regression analyses comparing those who are taking medication and/or have received counselling in the past 12 months, versus those doing neither. Estimates were weighted to represent the Canadian adult household population living in the 10 provinces with diagnosed mood and/or anxiety disorders.

RESULTS

The majority (81.8%) of Canadians with a mood and/or an anxiety disorder diagnosis reported they are taking medications and/or have received counselling (47.6% taking medications only; 6.9% received counselling only; and 27.3% taking/having received both). Upon controlling for individual characteristics, taking medications and/or having received counselling was significantly associated with older age; higher household income; living in the Atlantic region or Quebec versus Ontario; and having concurrent disorders or mood disorders only. Symptoms controlled without medication was the most common reason for not taking medications, while preferring to manage on their own and taking medications were among the common reasons for not having received counselling.

CONCLUSION

The majority of Canadian adults with a mood and/or an anxiety disorder diagnosis are taking medications, while few have received counselling. Insights gained regarding the factors associated with these treatments, and reasons for not using them, emphasize the importance of discussing treatment options and perceived barriers with patients to ensure they receive the best treatment according to their needs and preference.

PdZn catalysts for CO2 hydrogenation to methanol using chemical vapour impregnation (CVI)

The formation of PdZn bimetallic alloys on ZnO, TiO₂ and Al₂O₃ supports was investigated, together with the effect of alloy formation on the CO₂ hydrogenation reaction. The chemical vapour impregnation (CVI) method produced PdZn nanoparticles with diameters of 3–6 nm. X-ray photoelectron spectroscopy and X-ray diffraction revealed the changes in the structure of the PdZn alloy that help stabilise formate intermediates during methanol synthesis. PdZn supported on TiO₂ exhibits high methanol productivity of 1730 mmol kg_cat⁻¹ h⁻¹ that is associated with the high dispersion of the supported PdZn alloy.

A Sensorimotor Integation Test Battery for CVA Clients: Preliminary Evidence of Reliability and Validity

A newly developed Sensorimotor Integration Test Battery (SMITE) for assessing sensorimotor integration deficits in cerebral vascular accident (CVA) clients consists of 16 scales adapted from Ranka and Chapparo. Alpha reliabilities obtained from 84 CVA clients ranged from fair (.45) to strong (.95) but averaged .82 for all tests combined. The scales were further examined under four definitions of validity: discriminant validity, construct (factorial) validity, clinical validity, and robustness against biases due to sex or age. The Hooper Test of Visual Organization, Finger Maze, and Finger Identification Tests discriminated among locations of various cerebral vascular insults; clinical validity measures were strongest for the Symbol Digit Modalities Test, Visual Attention Test, Motor Accuracy, and Imitation of Non-Habitual Postures. The test results showed little bias in terms of clients' sex or age. Four major factors were identified among the battery's individual tests: Sensorimotor Integration, Visual Processing, Tactile Discrimination, and a diagnosis factor that includes the three standardized tests of visual/spatial organization. The SMITB clearly extracts more information during its 90-minute administration setting than clinicians and therapists currently use.

Designing an information interface to support sharing of information in cancer care

This paper describes the design, implementation and testing of a functional prototype interface which enables primary healthcare teams to access the information system supporting clinical oncology specialists in South Wales, UK. A lack of information sharing has been recognized for some time as a barrier to improving the primary care of cancer patients. This extension to the existing ISCO information system will allow sharing of information about patient management at all levels of cancer patient support (general practitioners, hospital-based clinicians and palliative care teams). The application was designed to allow general practitioners to gain access to the existing system. This will give all healthcare professionals interested in a cancer patient's care the advantage of accessing detailed multiple providers' electronic casenotes in almost real time, thus improving communication of information within a care team. However, no attempt was made to include the much bigger issue of patients and their families or carers in the scope of the project at this stage, as this is an area requiring separate investigation. The pilot also enables general practitioners to determine the information they require and the information they need to be able to communicate with the cancer specialists.

H2 production by the photocatalytic reforming of cellulose and raw biomass using Ni, Pd, Pt and Au on titania

Here, we report a method for sustainable hydrogen production using sunlight and biomass. It is shown that cellulose can be photoreformed to produce hydrogen, even in solid form, by use of metal-loaded titania photocatalysts. The experiments performed verified that the process is enabled by initial hydrolysis via glucose, which itself is shown to be efficiently converted to produce hydrogen by photocatalysis. Importantly, it is shown that not only precious metals such as Pt, Pd and Au can be used as the metal component, but also much more economic and less environmentally damaging Ni is effective. Even more importantly, we show for the first time, to the best our knowledge, that fescue grass as raw biomass can be effective for hydrogen production without significant pre-treatment. This provides additional benefits for the efficiency of biomass hydrogen production, because fewer processing steps for the raw material are required than in the production of purer forms of cellulose, for example.