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Salmonella in raw cocoa beans (n = 870) from main sourcing areas over nine months was analyzed. It was detected in 71 (ca. 8.2%) samples, with a contamination level of 0.3–46 MPN/g except for one sample (4.1 × 104 CFU/g). Using prevalence and concentration data as input, the impact of thermal treatment in cocoa processing on the risk estimate of acquiring salmonellosis by a random Belgian chocolate consumer was calculated by a quantitative microbiological risk assessment (QMRA) approach. A modular process risk model from raw cocoa beans to cocoa liquor up to a hypothetical final product (70–90% dark chocolate tablet) was set up to understand changes in Salmonella concentrations following the production process. Different thermal treatments during bean or nib steam, nib roasting, or liquor sterilization (achieving a 0–6 log reduction of Salmonella) were simulated. Based on the generic FAO/WHO Salmonella dose–response model and the chocolate consumption data in Belgium, salmonellosis risk per serving and cases per year at population level were estimated. When a 5 log reduction of Salmonella was achieved, the estimated mean risk per serving was 3.35 × 10−8 (95% CI: 3.27 × 10−10–1.59 × 10−7), and estimated salmonellosis cases per year (11.7 million population) was 88 (95% CI:

Seismic activities pose significant challenges to societies globally. Therefore, it is crucial to understand their occurrence, patterns, and impacts. By studying seismic activities, including earthquakes, researchers can investigate their occurrence, distribution, and characteristics which can provide effective management and risk reduction strategies. The southern part of Ghana is prone to earthquakes and this study aims to shed more light into the nature of seismic events in the area and country at large. A systematic review was conducted using the PRISMA technique across three electronic databases (SCOPUS, Dimensions and Google Scholar) to identify relevant studies published between 2000 and 2023. Extraction of data and quality assessment were performed in order to ensure reliability and validity of included studies. Results identified only 17 papers from published records to meet the inclusion criteria. Despite the grave threat earthquakes pose to vital infrastructure and human life in Ghana, research in this area remains remarkably deficient. Our findings underscore the urgent need for further study given the catastrophic potential of seismic disasters in the region. Moreover, upon scrutinizing the methodologies deployed in extant literature concerning seismic activity in Ghana, a recurring constraint that emerged was the scarce availability of data. In essence, this study offers an indispensable panorama of earthquake research in Ghana, bridging the existing knowledge chasm on seismic phenomena in the region. The insights gleaned from this review promise to fortify our comprehension of Ghana's seismic activities, thereby bolstering the country's capabilities for more effective preparedness and response strategies.

Introduction: Colorectal cancer is a leading cause of cancer death in the U.S. Until 2021, the U.S. Preventive Services Task Force recommended colorectal cancer screening for all adults aged 50–75 years. Using a nationally representative sample, we explored the associations between having colorectal cancer screening and key sociodemographic and health-related factors among U.S. adults aged 50–75 years. Methods: We analyzed self-reported data from the National Cancer Institute's Health Information National Trends Survey 5 (Cycle 4) collected from February to June 2020. A multivariable weighted logistic regression model was conducted using all of the factors that were univariably significant with p0.05 were removed one at a time until the remaining factors were all significant collectively with p

Integrated and systematic studies on heat-related illness risk from urban heatwaves are lacking. The effects and predictions of risk reduction policies for heat-related illness risk should not be limited to a particular area of study but should be calculated in a feedback process considering the budget. In this study, we performed dynamic modeling and policy simulation aimed at reducing the risk of heat-related illnesses caused by urban heatwaves in Seoul, Korea. A causal map of the urban heatwave system was created using data from 2010 to 2021, and simulations were performed up to 2040. In analyzing the effect of reducing the incidence of patients with heat-related illnesses compared to the budget invested, the number of patients with heat-related illnesses to be reduced in support policies for the vulnerable group, high-efficiency air conditioners, heatwave shelters, green areas, and eco-friendly cars would be reduced by 0.44, 0.09, 0.0046, 0.0045, and 0.0005 people/billion won in 2035, respectively. The number of heat-related illnesses decreased by 78.0% when policy simulation, which produced the maximum effect with the lowest budget, was performed. The current urban heatwave system in Seoul would not reduce the incidence of patients with heat-related illnesses in the future but, rather, would increase it. Urban heatwave policies did not contribute considerably to the reduction of patients with heat-related illnesses because the intensity of heatwaves owing to climate change outweighed the impact of heatwave policies. We suggest additional budget increases in the order of higher return on investment (ROI).

The increasing availability of open-source and high-quality satellite data has facilitated market developments in the index insurance sector. So far, research and industry spheres have used administrative boundaries of units to estimate regional index values for insurance design. In areas with heterogeneous land use or land cover, however, these indices do not provide sufficient accuracy. This study analyzes potential accuracy gains from land-use classification that allow to design indices specifically for croplands and wheatlands. The validity of this approach is tested along conventional satellite-based products, including the Normalized Difference Vegetation Index (NDVI) and Land Surface Temperature (LST), as well as indices that are not yet widely used in crop insurance industry, like the Enhanced Vegetation Index (EVI), Green Chlorophyll Index (GCI) and Leaf Area Index (LAI). The study covers 2060 yield observations from 152 districts across Central Asia and Mongolia with irrigated, mixed and rainfed wheat farming systems. The results show that the majority of these indices are suitable for detecting wheat yield variations in rainfed and mixed agricultural lands, although they remain ambiguous in irrigated lands. Land-use classification and designing indices based on croplands and wheatlands noticeably increases the relationship between indices and wheat yields in rainfed and mixed lands. Notably, the LAI and GCI out-perform other well-known indices. Overall, freely available satellite data could serve as a good source for establishing index insurance products in Central Asia and Mongolia. Nevertheless, a careful assessment and selection of index and land use classification remains essential.

Background and Aims: Multiple developments of squamous dysplasia and squamous cell carcinoma (SCC) in the upper aerodigestive tract have been explained by field cancerization phenomenon and were associated with alcohol and cigarette use. Second primary SCC development after curative treatment impairs patients’ quality of life and survival; however, how these consumption and cessation affect field cancerization is still unknown. Methods: This is a multicenter cohort study including 331 patients with superficial esophageal SCC (ESCC) treated endoscopically and pooled data from 1022 healthy subjects for comparison. Physiological condition in the background esophageal mucosa was classified into 3 groups based on the number of Lugol-voiding lesions (LVLs) per endoscopic view: grade A, 0; grade B, 1–9; or grade C, ≥10 LVLs. Lifestyle surveys were conducted using a self-administered questionnaire. Patients were counseled on the need for alcohol and smoking cessation by physicians and were endoscopically surveyed every 6 months. Results: LVL grades were positively associated with alcohol drinking intensity, flushing reactions, smoking, and high-temperature food and were negatively associated with eating green and yellow vegetables and fruit. Second primary ESCC and head/neck SCC were significantly more prevalent in the grade C LVL (cumulative 5-y incidences 47.1%, 95% confidence interval [CI] = 38.0–57.2 and 13.3%, 95% CI = 8.1–21.5, respectively). Alcohol and smoking cessation significantly reduced the development of second primary ESCC (adjusted hazard ratios 0.47, 95% = CI 0.26–0.85 and 0.49, 95% CI = 0.26–0.91, respectively). Conclusion: Alcohol drinking, smoking, flushing reaction, and high-temperature food were closely associated with field cancerization, and cessation of alcohol and smoking significantly reduced the risk of development of second primary cancer. UMIN Clinical Trials Registry ID:UMIN000001676.

Cardiovascular risk was evaluated in patients admitted to rural inpatient psychiatric services over a one-year period in a sparsely populated region of the United Kingdom. Care records were analysed for risk factor recording, and cardiovascular risk estimated using the QRISK3 calculator, which estimates 10-year risk of myocardial infarction or stroke. Of eligible patients, risk factor recording as part of routine care was completed in 86% of possible QRISK3 inputs, enabling QIRSK3 estimation in all eligible patients. QRISK3 for this group was significantly raised relative to an age, sex and ethnicity-matched population, and high risk of cardiovascular disease (QRISK3 score >10%) was detected in 28% of patients. The results demonstrate that there is significant unmet need in rural patients for cardiovascular risk reduction that could be identified as part of routine care. An opportunity exists to integrate mental and physical healthcare by routinely assessing cardiovascular risk in rural psychiatric inpatients. Resources and training are needed to produce this risk information and act on it.

Understanding the determinants of farmers’ disaster adaptation is significant for risk reduction. This study explores farmers’ willingness and influencing factors to adopt various agricultural and non-agricultural adaptation measures to mitigate irrigation-induced landslides on the Loess Plateau, northern China. Multivariate probit models are applied to address the joint decision-making of multiple choices considering their inter-correlations, using data from 397 farmer survey questionnaires. The results reveal that farmers’ characteristics, landslide experience, social factors, landslide perception, and the present adaptation situation play important but different roles in their adaptation decisions regarding various measures (drip irrigation, drought-tolerant crops, income diversification, and migration). Heterogeneity among farmers is considered: Government support, social network, and perception of landslide causation are essential in affecting all of the farmers’ adaptation decisions, while the impacts of the annual income, gender, land scale, and risk perception on non-agriculture farmers and full-time or part-time farmers are opposite. Notably, current adaptation hinders farmers’ future actions. The probability of adopting a specific measure is estimated to be higher than that of joint adoption. Barriers to adaptation are also addressed, and policy implications are discussed. This study provides a theoretical and practical reference for mitigating landslide risks that are caused by artificial triggers.

Weather and climate-related events have already altered human mobility patterns and led to displacement. While the evidence base is low due to data gaps and scarcity, climate change is expected to reinforce disaster-related displacement. Here we systematically analyze how components of internal displacement data are related to disaster outcomes in Somalia, Afghanistan, the Marshall Islands and Bangladesh using a data inventory tool. We contribute the first programmatic approach to evaluate the evidence of extreme weather impacts on internal displacement in four distinct case studies. We find that the data evidence differs considerably from the disaster displacement process recorded qualitatively in reports. We provide a straightforward, bottom-up application guide that ultimately improves the understanding of changing disaster displacement risks for researchers and practitioners alike. We thereby show nuances in data availability and granularity for potential causal statements between climate change and internal displacement. We conclude that the implementation of data-focused climate policy and action could address obstacles to averting and minimizing disaster displacement.

Background: In 2012, the German Lipoprotein Apheresis Registry (GLAR) was launched. Real-world data on lipoprotein apheresis (LA) treatment are now available for a time period of 11 years. All patients received the maximally tolerated lipid-lowering therapy, which included statins, ezetimibe, bempedoic acid, and either proprotein convertase subtilisin/kexin type 9 (PCSK9) antibodies or antisense therapy., Methods and Results: During the time period from 2012 to 2022, 92 German apheresis centers collected retrospective and prospective observational data of a total of 2,301 patients undergoing regular lipoprotein apheresis (LA) treatment of hypercholesterolemia or/and Lp(a)-hyperlipoproteinemia suffering from progressive atherosclerotic cardiovascular disease (ASCVD), with complete data sets of 1.125 patients, who were the subject of this analysis. More than 61,500 LA sessions are documented in the database. In 2022, all patients treated with LA demonstrated a significant immediate median reduction rate of LDL-C (68.8 %) and Lp(a) (72.9 %). Patient data were analyzed for the incidence rate of major coronary events (MACE) 1 and 2 years before the beginning of LA treatment (y-2 and y-1) and prospectively up to eleven years on LA treatment (y+1 to y+11). During the first two years of LA treatment (y+1 and y+2), a MACE reduction of 73 % was observed and continued to be low during y+3 to y+11, when all LA patients were analyzed. LA patients with only increased Lp(a) levels (Lp(a) ≥ 60 mg/dl (≥120 nmol/l) and an LDL-C < 100 mg/dl (<2.6 mmol/l)) had a higher MACE reduction (85 %; n = 443) in the first two years of LA treatment compared to LA patients with only increased LDL-C-levels (LDL-C ≥ 100 mg/dl (≥2.6 mmol/l); Lp(a) < 60 mg/dl (<120 nmol/l)) (53 %; n = 171). Adverse events of LA remained low (about 5 %) over the eleven years and mainly represented puncture problems (1.0 %). No side effects resulted in termination of LA therapy., Conclusions: The current analysis of GLAR data indicates that regular LA leads to very low incidence rates of cardiovascular events in patients with high LDL-C and/or high Lp(a) levels, progressive ASCVD, and maximally tolerated lipid-lowering medication, including proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition. Additionally, LA was safe with a low rate of adverse effects over an 11-year period. The number of enrolled patients and the duration of observation establish GLAR as the largest LA registry worldwide., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Triple-negative breast cancer (TNBC) is an aggressive subtype of breast cancer that disproportionately affects younger females, non-Hispanic Black women, Hispanic women, and women with the BRCA1 gene mutation. Hereditary genetic testing is particularly important in this population to assess preventative and treatment strategies, however access to genetic testing is variable. A qualitative review was performed to evaluate barriers to genetic testing for patients with TNBC. Mutations common in breast cancer are reviewed along with updated guidelines on management strategies, including the ability to include PARP inhibitors as a treatment strategy. Barriers to genetic testing are multifactorial, with non-Hispanic Black women being tested less often than other groups. The disparity is even further represented by the limited number of non-Hispanic Black patients with TNBC who receive risk-reducing surgery or targeted systemic therapy. Eliminating barriers to genetic testing can allow us to support guideline-directed care for patients with TNBC at higher risk for genetic mutations., Competing Interests: Disclosure The authors have stated that they have no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The effects of the crossing Planetary Boundaries and Global Catastrophic Risk (GCR) events on Disaster Risk Reduction (DRR) efforts, international development targets, and any future international development target iterations are not well understood. However, the crossing of Planetary Boundaries, and GCR events could have significant and adverse effects on the global development gains, capability building, resilience, and adaptability that has been achieved as a result of decades of international development work.A background to the Sustainable Development Goals (SDGs) and the Sendai Framework, GCR, and Planetary Boundaries is first presented. This is followed by an analysis of the possible futures that the world could take considering the aforementioned items. The scenario analysis develops and explores futures for humanity and the Earth for different levels of GCR, and different extents to which the Planetary Boundaries may or may not have been passed. Through this, distinct scenarios are developed: Earth Under Uncertainty, Global Collapse, Stable Earth, and Earth Under Threat. The implementation and success of international targets is inhibited to varying degrees across these possible futures. Furthermore, it is evident that without direct action, the first and last aforementioned scenarios are on a pathway towards that of the Global Collapse scenario.Reactive and preventive policy suggestions are formulated from the scenario analysis, with a recommendation that both types should be developed, adopted, and implemented. Prioritisation should be to preventive policy as there is a lower resource cost. To ensure DRR continues and can be further developed, the Planetary Boundaries, and GCR considerations, should be integrated into both the international development goals and accompanying frameworks that follow on post-2030 from the SDGs, and Sendai Framework.

Increasing flood risk due to rapid urbanization and climate change calls for improved integration between flood risk management and spatial planning processes to enhance the resilience of cities, including in Egypt. Although much work has been conducted on flood impact in Egypt, the gap in integrating flood risk assessment with spatial planning practices has not been discussed in academia. In practice, flood risk assessment is not mandatory for local-level spatial planning projects in Egypt, resulting in increased flood risk. This study examines the causes of this gap and proposes possible solutions that increase flood resiliency. A mixed-method approach was utilized based on a questionnaire survey with local stakeholders in academic and professional categories. The results reveal reasons for the gap, including issues related to the realization of the role of spatial planning in flood risk reduction, lack of coordination between the authorities responsible for developing the flood hazard maps and the spatial planning authority, availability and accessibility of the required data, and subjectivity of conducted flood analyses. Four key recommendations pertain to building an operational framework for integrating flood risk assessment in spatial planning, improving stakeholder awareness and collaboration, strengthening risk communication, and improving both quality and access to data. These measures will help to overcome the identified difficulties and enhance the integration between spatial planning and flood risk assessment, effectively increasing their flood resilience.

BACKGROUND: The incidence of placenta accreta spectrum is increasing in parallel with the growing number of cesarean deliveries performed. A shorter interpregnancy interval following cesarean delivery may prevent adequate scar healing, which could impact the risk of placenta accreta spectrum. OBJECTIVE: We aimed to investigate the association between short interpregnancy intervals and placenta accreta spectrum. STUDY DESIGN: We conducted a retrospective cohort study of patients at risk for placenta accreta spectrum at a tertiary academic center between 2002 and 2020. Our cohort was defined as pregnant individuals at risk for placenta accreta spectrum meeting the following criteria: placenta previa with previous cesarean delivery and/or uterine surgery, anterior low-lying placenta with previous cesarean delivery and/or uterine surgery, ≥3 previous cesarean deliveries, or any previous cesarean delivery with sonographic findings suspicious for placenta accreta spectrum. The primary outcome was surgically or histopathologically confirmed placenta accreta spectrum. Short interpregnancy interval was defined as

Salmonella in raw cocoa beans (n = 870) from main sourcing areas over nine months was analyzed. It was detected in 71 (ca. 8.2%) samples, with a contamination level of 0.3-46 MPN/g except for one sample (4.1 × 10 4 CFU/g). Using prevalence and concentration data as input, the impact of thermal treatment in cocoa processing on the risk estimate of acquiring salmonellosis by a random Belgian chocolate consumer was calculated by a quantitative microbiological risk assessment (QMRA) approach. A modular process risk model from raw cocoa beans to cocoa liquor up to a hypothetical final product (70-90% dark chocolate tablet) was set up to understand changes in Salmonella concentrations following the production process. Different thermal treatments during bean or nib steam, nib roasting, or liquor sterilization (achieving a 0-6 log reduction of Salmonella) were simulated. Based on the generic FAO/WHO Salmonella dose-response model and the chocolate consumption data in Belgium, salmonellosis risk per serving and cases per year at population level were estimated. When a 5 log reduction of Salmonella was achieved, the estimated mean risk per serving was 3.35 × 10 -8 (95% CI: 3.27 × 10 -10 -1.59 × 10 -7 ), and estimated salmonellosis cases per year (11.7 million population) was 88 (95% CI: <1-418). The estimated mean risk per serving was 3.35 × 10 -9 (95% CI: 3.27 × 10 -11 -1.59 × 10 -8 ), and the estimated salmonellosis cases per year was 9 (95% CI: <1-42), for a 6 log reduction. The current QMRA model solely considered Salmonella reduction in a single-step thermal treatment in the cocoa process. Inactivation obtained during other process steps (e.g. grinding) might occur but was not considered. As the purpose was to use QMRA as a tool to evaluate the log reduction in the cocoa processing, no postcontamination from the processing environment and ingredients was included. A minimum of 5 log reduction of Salmonella in the single-step thermal treatment of cocoa process was considered to be adequate., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To explore UK-based clinicians' knowledge of long-term cardiovascular disease (CVD) risks after pre-eclampsia and capture current risk management practice., Study Design: A voluntary online survey was designed to explore clinicians' perception and management of CVD risks after pre-eclampsia. Distribution occurred May-July 2022 via social media and email. The survey assessed awareness of pre-eclampsia's association with future CVD, knowledge of published guidelines on CVD risk management after pre-eclampsia, and current practice of risk-reduction counselling. Results were analysed descriptively., Main Outcome Measure: Clinician knowledge of postpartum cardiovascular risk and management following pre-eclampsia., Results: Of 240 respondents, 72 were midwives, 46 obstetricians, 8 cardiologists, and 114 general practitioners (GPs). Most clinicians knew that pre-eclampsia increases the risk of chronic hypertension (89 %) and stroke (75 %). Awareness was worse for heart failure (47 %) and peripheral vascular disease (55 %). Obstetricians provide CVD risk-reduction counselling to women with pre-eclampsia most frequently: 43 % always counsel and 27 % often counsel. Most other clinicians never counsel patients (midwives: 76 %, cardiologists: 75 %, GPs: 62 %). Most clinicians (84 %) were not aware of CVD risk management guidance after pre-eclampsia and 75 % of cardiologists and GPs never consider pre-eclampsia when assessing cardiovascular risk. Almost all clinicians (91 %) wished for greater education on the topic., Conclusions: This study presents the first assessment of cardiovascular risk awareness after pre-eclampsia amongst UK-based clinicians. Although most knew pre-eclampsia increases CVD risk, patient counselling was limited. Targeted educational initiatives are needed to improve the knowledge-to-practice gap and reduce CVD prevalence after pre-eclampsia., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Introduction: Over one-third of US adolescents engage in health risk and problem behaviors. Additionally, significant percentages of problem-free youth aren't flourishing. Left unaddressed, the lifetime mental/physical health and financial burdens may be substantial. Social-Emotional Learning (SEL) and Positive Youth Development (PYD) programs have proliferated to address the drivers of adaptive versus risk behaviors. Research suggests SEL/PYD program outcomes can be improved by adding techniques that physiologically induce calmness, yet few studies exist., Methods: This randomized controlled trial of 79 urban eighth-graders examined a standardized bio-psycho-social program, SKY Schools, which incorporates a physiologically calming component: controlled yogic breathing., Results: Repeated-measures ANOVAs demonstrated that compared to controls, SKY graduates exhibited significant improvements in emotion regulation, planning and concentration, and distractibility. After 3 months, significant improvements were evidenced in emotion regulation, planning and concentration, identity formation, and aggressive normative beliefs., Conclusion: SEL/PYD programs may benefit by incorporating biologically-calming techniques to enhance well-being and prevent risk/problem behaviors., (© 2024 The Authors. Journal of Adolescence published by Wiley Periodicals LLC on behalf of Foundation for Professionals in Services to Adolescents.)

A novel bat-origin coronavirus emerged in Wuhan, China in December 2019 and continues to spread across China and the world. At the time of writing, a massive global response has been implemented to control the disease as it spreads from person to person. Yet the high-risk human-wildlife interactions and interfaces that led to the emergence of SARS-CoV and of 2019-nCoV continue to exist in emerging disease hotspots globally. To prevent the next epidemic and pandemic related to these interfaces, we call for research and investment in three areas: 1) surveillance among wildlife to identify the high-risk pathogens they carry; 2) surveillance among people who have contact with wildlife to identify early spillover events; and 3) improvement of market biosecurity regarding the wildlife trade. As the emergence of a novel virus anywhere can impact the furthest reaches of our connected world, international collaboration among scientists is essential to address these risks and prevent the next pandemic.

Managed retreat has become a compelling policy imperative as climate change exacerbates socio-natural hazard risks and imminent harm looms for exposed communities. Retreats may be initiated over different times and scales using various instruments by actors, from the state to the private sector and civil society. However, in the absence of a coherent strategic vision, guiding frameworks, and capacity to manage retreats, at-risk communities, their elected representatives, policy makers, and planners are compelled to embark on retreat governance experiments. Consequently, retreat is perceived as a ‘high regrets’ policy imperative with potentially adverse impacts for community wellbeing, as well as political and professional risks. To help translate managed retreat rhetoric into reality, this paper presents a governance framework that acknowledges the multiplicity of ‘managed retreats.’ Using examples from Aotearoa-New Zealand, we identify and delineate retreat modalities and clarify terminology, converging our framework with the international mobility literature to harness the valuable lessons from decades of human mobility practice.

We quantify the potential reduction of risk in practice that is possible by constructing a portfolio of contracts covering weather risks, relative to a portfolio of lower-frequency natural catastrophe risks. First, we illustrate a protection seller’s analysis and reservation price for individual weather risk contracts during a winter period of underwriting. The objective is to earn a requisite return on capital on behalf of the protection seller’s investors while meeting the risk management objectives of the buyer. We use Monte Carlo simulation to compare portfolios of these contracts and observe how optimizing the portfolio can reduce risk and the potential combined cost of the weather risk transfer contracts. Although both weather and natural catastrophe portfolios can be diversified by peril geography and type, we note that additional diversification can be achieved in weather portfolios along the dimension of peril direction due to buyers’ interests in taking opposite sides of weather indices. This is evidenced by our calculation of negatively correlated payouts of weather contracts, something that is harder to achieve for payouts of natural catastrophe contracts. We show that risk reduction of a portfolio of weather risk transfer contracts could potentially exceed that of a portfolio of diversified lower-frequency natural catastrophe contracts. This could enhance the risk-adjusted financial performance of protection sellers. These findings imply that protection buyers, including the most vulnerable organizations and people, could experience lower risk premiums, making weather risk transfer more affordable.

Introduction: Cardiac complications after major noncardiac surgery are common and associated with high morbidity and mortality. How preoperative use of beta-blockers may impact perioperative cardiac complications remains unclear., Methods: In a multicentre prospective cohort study, preoperative beta-blocker use was ascertained in consecutive patients at elevated cardiovascular risk undergoing major noncardiac surgery. Cardiac complications were prospectively monitored and centrally adjudicated by two independent experts. The primary endpoint was perioperative myocardial infarction or injury attributable to a cardiac cause (cardiac PMI) within the first three postoperative days. The secondary endpoints were major adverse cardiac events (MACE), defined as a composite of myocardial infarction, acute heart failure, life-threatening arrhythmia, and cardiovascular death and all-cause death after 365 days. We used inverse probability of treatment weighting to account for differences between patients receiving beta-blockers and those who did not., Results: A total of 3839/10 272 (37.4%) patients (mean age 74 yr; 44.8% female) received beta-blockers before surgery. Patients on beta-blockers were older, and more likely to be male with established cardiorespiratory and chronic kidney disease. Cardiac PMI occurred in 1077 patients, with a weighted odds ratio of 1.03 (95% confidence interval [CI] 0.94-1.12, P=0.55) for patients on beta-blockers. Within 365 days of surgery, 971/10 272 (9.5%) MACE had occurred, with a weighted hazard ratio of 0.99 (95% CI 0.83-1.18, P=0.90) for patients on beta-blockers., Conclusion: Preoperative use of beta-blockers was not associated with decreased cardiac complications including cardiac perioperative myocardial infarction or injury and major adverse cardiac event. Additionally, preoperative use of beta-blockers was not associated with increased all-cause death within 30 and 365 days., Clinical Trial Registration: NCT02573532., (Copyright © 2024 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: The North American overdose crisis has continued at unprecedented rates with more than 100,000 overdose deaths occurring in the United States (US) in 2022. Overdose deaths have increasingly been polysubstance-involved, with novel substances (e.g., xylazine) complicating overdose risk and health outcomes. Understanding the effects of-and responses to-a changing drug supply among people who use drugs is critical to modifying harm reduction strategies to be more responsive to people's needs., Methods: This qualitative study draws on data collected from May to December 2022 in Rhode Island. Data include in-depth interviews with 50 people who use drugs and observational fieldwork in spaces frequented by participants (e.g., encampments, drop-in centers). Qualitative data were analyzed thematically drawing on concepts of situated rationality., Results: Participants described significant changes in the drug supply, with many attributing these transitions to COVID-19. Most participants characterized the local supply as "synthetic" with textures, color, and taste evolving. Notably, participants emphasized adverse outcomes related to available supplies, including during use (e.g., intense burning sensations) and post-consumption (e.g., heavy sedation, ongoing withdrawal, necrosis). Given the complex supply, participants highlighted the increased risk of overdose and shared how they altered their use practices to manage evolving health risks., Conclusion: Our results underscore how people who use drugs characterized the local drug supply, including perceived changes to supply contents. Implementing and scaling up harm reduction interventions that reduce risk and reinforce the agency of people who use drugs are urgently needed to effectively address the overdose crisis., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: A substantial proportion of patients with stage III colorectal cancer (CRC) are older than 70 years. Optimal adjuvant chemotherapy (AC) for older patients (OP) continues to be debated, with subgroup analyses of randomized trials not demonstrating a survival benefit from the addition of oxaliplatin to a fluoropyrimidine backbone., Patients and Methods: We analyzed the multisite Australian ACCORD registry, which prospectively collects patient, tumor and treatment data along with long term clinical follow-up. We compared OP (≥70) with stage III CRC to younger patients ([YP] <70), including the proportion recommended AC and any reasons for not prescribing AC. AC administration, regimen choice, completion rates, and survival outcomes were also examined., Results: One thousand five hundred twelve patients enrolled in the ACCORD registry from 2005 to 2018 were included. Median follow-up was 57.0 months. Compared to the 827 YP, the 685 OP were less likely to be offered AC (71.5% vs. 96.5%, P < .0001) and when offered, were more likely to decline treatment (15.1% vs. 2.8%, P < .0001). Ultimately, 60.0% of OP and 93.7% of YP received AC (P < .0001). OP were less likely to receive oxaliplatin (27.5% vs. 84.7%, P < .0001) and to complete AC (75.9% vs. 85.7%, P < .0001). The probability of remaining recurrence-free was significantly higher in OP who received AC compared to those not treated (HR 0.73, P = .04) but not significantly improved with the addition of oxaliplatin (HR 0.75, P = .18)., Conclusion: OP were less likely than YP to receive AC. Receipt of AC reduced recurrences in OP, supporting its use, although no significant benefit was observed from the addition of oxaliplatin., Competing Interests: Disclosure Oliver Piercey: OP has received travel expenses from MSD and an educational speaker fee from BMS; Valerie Heong: VH has received consulting fees or honoraria from AstraZeneca, Novartis, MSD, DKSH and receives grant funding from an NTF HIP grant and an LKC-NHG grant; Jeanne Tie: JT has received consulting fees or honoraria from Haystack Oncology, Seres Therapeutics, Amgen, Servier, Beigene, Novartis, Astra Zeneca, Merck Serono, MSD, Pierre Fabre, BMS, Daichii Sankyo, Illumina, Takeda and Gilead. All other authors report no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Autoimmunity is a multifaceted disorder influenced by both genetic and environmental factors, and metal exposure has been implicated as a potential catalyst, especially in autoimmune diseases affecting the central nervous system. Notably, metals like mercury, lead, and aluminum exhibit well-established neurotoxic effects, yet the precise mechanisms by which they elicit autoimmune responses in susceptible individuals remain unclear. Recent studies propose that metal-induced autoimmunity may arise from direct toxic effects on immune cells and tissues, coupled with indirect impacts on the gut microbiome and the blood-brain barrier. These effects can activate self-reactive T cells, prompting the production of autoantibodies, inflammatory responses, and tissue damage. Diagnosing metal-induced autoimmunity proves challenging due to nonspecific symptoms and a lack of reliable biomarkers. Treatment typically involves chelation therapy to eliminate excess metals and immunomodulatory agents to suppress autoimmune responses. Prevention strategies include lifestyle adjustments to reduce metal exposure and avoiding occupational and environmental risks. Prognosis is generally favorable with proper treatment; however, untreated cases may lead to autoimmune disorder progression and irreversible organ damage, particularly in the brain. Future research aims to identify genetic and environmental risk factors, enhance diagnostic precision, and explore novel treatment approaches for improved prevention and management of this intricate and debilitating disease., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Photosensitization was developed as a risk-reduction strategy against the contamination by environmental mold spores during the bread cooling phase. Two food-grade photosensitizers -chlorophyllin (CHL) and riboflavin (RBF), were used to evaluate the effect of visible (blue) LED illumination against three common bread spoilage molds. Aided by CHL, 405 nm LEDs inactivated Rhizopus stolonifer and Penicillium expansum by 77.4 ± 3.3% and 52.1 ± 7.3% respectively in 30 min on dichloran rose bengal chloramphenicol agar. These reductions were much higher than the corresponding reductions observed with food-grade RBF and 445 nm LEDs - 22.8 ± 3.2% and 45.5 ± 5.9%, indicating that CHL-based photosensitization was more effective as an intervention than RBF-based photosensitization. When the three molds were illuminated on bread after spraying CHL and spot-inoculation, their populations were reduced by 51-58%. CHL-based photosensitization was observed to retain the texture and moisture of the bread samples, but had a statistically significant impact on their colour. The results of this study suggest that CHL-based photosensitization can be developed as a risk reduction method to prevent the spoilage of bread., Competing Interests: Declaration of competing interest The authors declare that they have no conflicting interests in the submission of this manuscript., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

The World Health Organisation's 2022 'blueprint for dementia research' highlights the need for more research into population-level risk reduction. However, definitions of population-level prevention vary, and application to dementia is challenging because of its multi-factorial aetiology and a maturing prevention evidence base. This paper compares and contrasts key concepts of 'population-level prevention' from the literature, explores related theoretical models and policy frameworks, and applies this to dementia risk reduction. We reach a proposed definition of population-level risk reduction of dementia, which focusses on the need to change societal conditions such that the population is less likely to develop modifiable risk factors known to be associated with dementia, without the need for high-agency behaviour change by individuals. This definition, alongside identified policy frameworks, can inform synthesis of existing evidence and help to co-ordinate the generation of new evidence., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Epidemiological evidence shows that higher levels of physical activity reduce the relative risk of colon cancer by up to 20%. To design optimal physical activity interventions for primary prevention, it is important to understand how the specific characteristics of physical activity (type, intensity, overall volume) influence the magnitude of colon cancer risk reduction. Improving our understanding of the underlying biological mechanisms will also help to manipulate physical activity characteristics to precisely target mechanisms of action and identify populations most likely to benefit. This review synthesizes the best available evidence to explore how the type and dose of physical activity moderate the protective effect of physical activity on colon cancer., Competing Interests: Declaration of competing interest None, (Copyright © 2023 The Author. Published by Elsevier Ltd.. All rights reserved.)

Background: Breast cancer is associated with a multitude of risk factors, such as genetic predisposition and mutations, family history, personal medical history, or previous radiotherapy. A prophylactic mastectomy (PM) may be considered a suitable risk-reducing procedure in some cases. However, there are significant discrepancies between national society recommendations and insurance company requirements for PM., Materials and Methods: The authors conducted a cross-sectional analysis of insurance policies for a PM. One-hundred companies were selected based on the greatest state enrolment and market share. Their policies were identified through a Web-based search and telephone interviews, and their medical necessity criteria were extracted., Results: Preauthorized coverage of PMs was provided by 39% of insurance policies (n = 39) and 5 indications were identified. There was consensus amongst these policies to cover a PM for BRCA1/2 mutations (n = 39, 100%), but was more variable for other genetic mutations (15%-90%). Coverage of PM for the remaining indications varied among insurers: previous radiotherapy (92%), pathological changes in the breast (3%-92%), personal history of cancer (64%) and family history risk factors (39%-51%)., Conclusion: There is a marked level of variability in both the indications and medical necessity criteria for PM insurance policies. The decision to undergo a PM must be carefully considered with a patient's care team and should not be affected by insurance coverage status., Competing Interests: Disclosure The authors have stated that they have no conflicts of interest., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Competing Interests: Disclosure CS has reported non-remunerated activities as Coordinator Gynecological Programme for the European School of Oncology. JB has reported fees for advisory board membership for AstraZeneca and Pfizer; fees paid to her institute for roles as local principal investigator for AstraZeneca, MedSire and Pfizer. SLB has reported fees as an author for UpToDate. She has also reported non-remunerated activities as the chair of the Scientific Network on Female Sexual Health and Cancer (academic organisation). MJC has reported fees as an invited speaker for Roche (industry-sponsored symposium in National Conference). She has also reported non-remunerated activities as a member of the Board of Directors of EUSOMA, faculty member of ESO, project lead/lead investigator for the Breast Research Group of INESC TEC and President of MAMA Help (non-profit association for breast cancer patients in Portugal). She serves as a Specialty Editor for The Breast. NC has reported fees for advisory board membership for AstraZeneca, BIOCAD, Clovis Oncology, Eisai, GlaxoSmithKline (GSK), ImmunoGen, Mersana, Merck Sharp & Dohme (MSD)/Merck, Nuvation Bio, OncXerna, Pfizer, PharmaMar, Pieris and Roche; fees as an invited speaker for AstraZeneca, Clovis Oncology, GSK and MSD/Merck; institutional research grants from AstraZeneca, PharmaMar and Roche. She has also reported non-remunerated activities as member of the ESMO Guidelines Steering Committee and chair of the Scientific Committee of Alleanza contro il Tumore Ovarico (ACTO). GC has reported fees for advisory board membership for AstraZeneca, Bristol Myers Squibb (BMS), Celcuity, Daiichi Sankyo, Ellipsis, Exact Sciences, Lilly, Merck, Pfizer, Roche and Veracyte; fees as an invited speaker for AstraZeneca, Daiichi Sankyo, Novartis, Pfizer and Roche; fees for a writing engagement from Pfizer; institutional research grant from Merck for an investigator-initiated trial; institutional funding for phase I studies from Astellas, AstraZeneca, Blueprint Medicine, BMS, Daiichi Sankyo, Kymab, Novartis, Philogen, Relay Therapeutics, (coordinating principal investigator), Roche and Sanofi. He has also reported non-remunerated activities as an Italian National Health Council as Advisor for Ministry of Health (Consiglio Superiore di Sanità), member of the Scientific Council for the patient advocacy association Europa Donna, advisory role at the Fondazione Beretta cancer research foundation, member of the Board of Directors for Lega Italian Lotta ai Tumori (public national company for cancer prevention) and member of the Advisory Council of EUSOMA. SMD has reported personal honoraria from AstraZeneca, BMS and Clovis; fees paid to her institute as coordinating principal investigator for AstraZeneca. DGE has reported fees for advisory board membership for Recursion, SpringWorks and Syantra; consultancy fees for a writing engagement for AstraZeneca. DF has declared no conflicts of interest. NH has reported fees for advisory board membership for Aptitude Health, AstraZeneca, Daiichi Sankyo, Gilead, Novartis, Pfizer, Roche, Sandoz-Hexal, Sanofi and SeaGen; fees as an invited speaker for Art Tempi, AstraZeneca, Daiichi Sankyo, Exact Sciences, Gilead, Lilly, Medscape, MSD, Novartis, Onkowissen, Pierre Fabre, Roche, Sanofi and SeaGen; institutional funding from AstraZeneca, BMS, Daiichi Sankyo, Lilly, MSD, Novartis, Palleos, Pierre Fabre, Roche, SeaGen, TRIO and WSG; ownership interest in the West German Study Group. She has also reported non-remunerated activities as a member of the AGO Breast Guideline Committee and member of the ESO/ESCO Breast Cancer Educational Programs. She is the Founding Editor of the Breast Care journal. CK has reported fees for advisory board membership for Guerbet; fees as an invited speaker for Bayer and Bracco. BL has reported fees received from the Rising Tide Foundation as a patient reviewer. She has also reported non-remunerated activities as a member of the European Society of Gynaecological Oncology (ESGO) ENGAGe (Past Executive Board Member) and chair of KIU—Danish Patient Organisation for Women with Gynaecological Cancer. ELL has reported employment as the Director of the Medical Genetics Institute of the Shaare Zedek Medical Center. She has also reported non-remunerated activity as the vice president of the Israel National Academy of Science in Medicine (non-profit). ML has reported fees for advisory board membership and speaker fees for AstraZeneca, Exact Sciences, Gilead, Lilly, MSD, Novartis, Roche and SeaGen; fees as an invited speaker for Ipsen, Knight, Libbs, Pfizer, Sandoz, SeaGen and Takeda. JAL has reported fees for advisory board membership for Artios Pharma, AstraZeneca, BMS, Clovis Oncology, Eisai, Ellipses, GSK, ImmunoGen, Merck/MSD, Nuvation, Pfizer and VBL Therapeutics; speaker fees from AstraZeneca, Clovis Oncology, GSK and Neopharm; fees related to an independent data monitoring committee for Regeneron; institutional research grants from AstraZeneca, Clovis Oncology, Eisai, GSK, MSD/Merck and Pfizer. He has also reported non-remunerated activities as vice president of the European Society of Gynaecological Oncology (2019-2021). He serves as an associate editor of Therapeutic Advances in Medical Oncology (Sage Publishing). SL has reported fees paid to her institute for advisory board membership for AbbVie, Amgen, AstraZeneca, BMS, Celgene, DSI, EirGenix, Gilead, GSK, Lilly, Merck, Novartis, Pfizer, Pierre Fabre, Relay Therapeutics, Roche, Sanofi and SeaGen; fees paid to her institute as an invited speaker for AstraZeneca, DSI, Gilead, Novartis, Pfizer and Roche; employment as the Chief Executive officer (CEO) of GBG Forschungs GmbH; licensing fees paid to her institute by VM Scope GmbH; research grants to her institute from AstraZeneca, Celgene, Daiichi Sankyo, Immunomedics/Gilead, Novartis, Pfizer and Roche; institutional funding from AbbVie and Molecular Health; fees paid to her institute as principal investigator (Penelope/Padma) from Pfizer; fees paid to her institute from AstraZeneca (SC Capitello), Daiichi Sankyo (SC Destiny B05), Immunomedics/Gilead (SC ASCENT), Novartis (SC SOLAR1), Pfizer (SC PALOMA3), Roche (SC Inavo and SC Katherine), SeaGen (SC HERCLIMB). She has also reported non-remunerated activities as principal investigator for Aphinity, advisory role to Arbeitsgemeinschaft Gynäkologische Onkologie (AGO) Kommission Mamma (group in Germany responsible for breast cancer guidelines), membership of AGO, Deutsche Krebsgesellschaft (DKG), American Society of Clinical Oncology (ASCO) and ESMO including membership of the ESMO Guidelines Committee and past chair of the ESMO Breast Congress. She has reported institutional patents for which she has no financial interests: EP14153692.0, EP21152186.9, EP15702464.7, EP19808852.8. K-AP has reported non-remunerated activities as advisory board member for AstraZeneca, Scientific Advisory Committee member for Breast Cancer Trials, project lead in Australia for the DECRESENDO and OlympiA studies, member of the Expert Advisory Group on Cancer Clusters for the Victorian Department of Health and Human Services, Strategic Advisory Committee member for Breast Cancer Network Australia, Cancer Genetics Reference Committee Member for New South Wales Cancer Institute; advisory role on the register of experts for breast and hereditary cancer for the Medical Oncology Group of Australia and breast cancer optimal care pathway committee member for Cancer Council Victoria. She is also a leadership fellow of the National Health and Medical Research Council (Australia) and a practitioner fellow of the National Breast Cancer Foundation (Australia). SP-S has reported fees paid to her institute for advisory board membership for AstraZeneca, Eli Lilly, Exact Sciences, Medison, Pfizer and Roche; fees paid to her institute as an invited speaker for AstraZeneca, Eli Lilly, Exact Sciences, Medison, Novartis, Pfizer and Roche; fees paid to her institute for consultancy for Medison; personal and institutional research grant for an request for proposal for independent research put out by Shared Progress in Cancer Care and Pfizer.

Background: Human milk is thought to reduce infant atopy risk. The biologic mechanism for this protective effect is not fully understood., Objectives: We tested the hypothesis that infant consumption of 4 microRNAs (miR-146b-5p, miR-148b-3p, miR-21-5p, and miR-375-3p) in human milk would be associated with reduced atopy risk., Methods: The Breast Milk Influence of the Microtranscriptome Profile on Atopy in Children over Time (IMPACT) study involved a cohort of mother-infant dyads who planned to breastfeed beyond 4 mo. Infant consumption of the 4 human milk microRNAs (miRNAs) in the first 6 mo was calculated as the product of milk miRNA concentration and the number of human milk feeds, across 3 lactation stages: early milk (0-4 wk), transitional milk (4-16 wk), and mature milk (16-24 wk). The primary outcome was infant atopy in the first year, defined as atopic dermatitis (AD), food allergies, or wheezing. The final analysis included 432 human milk samples and 7824 wk of longitudinal health data from 163 dyads., Results: Seventy-three infants developed atopy. Forty-one were diagnosed with AD (25%), 33 developed food allergy (20%), and 10 had wheezing (6%). Eleven developed >1 condition (7%). Infants who did not develop atopy consumed higher concentrations of miR-375-3p (d = 0.18, P = 0.022, adj P = 0.044) and miR-148b-3p (d = 0.23, P = 0.007, adj P = 0.028). The consumption of miR-375-3p (X2 = 5.7, P = 0.017, OR: 0.92, 95% CI: 0.86, 0.99) was associated with reduced atopy risk. Concentrations of miR-375-3p increased throughout lactation (r = 0.46, F = 132.3, P = 8.4 × 10-34) and were inversely associated with maternal body mass (r = -0.11, t = -2.1, P = 0.032)., Conclusions: This study provides evidence that infant consumption of miR-375-3p may reduce atopy risk., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Aims: Assess the effect of a diabetes program on lifestyle, metabolic, and mental health parameters in relatives of patients with T2D, and correlate changes between relatives and patients., Methods: Relatives were included in a structured program for patients with T2D. They received individualized interventions or were asked to follow lifestyle modifications indicated to their patient with diabetes. Outcomes were change in BMI, fat loss, patients achieving LDL-c and triglycerides goals, exercise, and mental health indicators at three and twelve months., Results: We included 200 relatives. Obesity was present in 42 %, hypertension in 8.5 %, hypercholesterolemia in 29.5 %, and hypertriglyceridemia in 46 % of relatives. Relatives lost - 3.7 kg and - 3.0 kg of body fat at three months and one-year evaluations. At least 60 % achieved normal triglycerides and LDL-c, and 40 % exercised at least 150 min/week. Anxiety symptoms dropped from 37 % to 22 % (p = 0.001), and depressive symptoms from 22 % to 12.9 % (p = 0.01) at three months. Correlations were found between the changes in relatives and patients in weight at three months (r = 0.22, p = 0.001), one year (r = 0.3, p < 0.001), and the number of goals achieved at one year., Conclusion: Relatives of patients with diabetes attending a multidisciplinary program for T2D benefit in metabolic, lifestyle, and mental health indicators., Competing Interests: Conflicts of interest The authors declare no potential conflicts of interest concerning this article's research, authorship, and publication, (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Women at increased risk of breast cancer have options to mitigate that risk. Understanding factors that increase risk and utilizing tools for quantitative estimates are important to be able to adequately counsel and target strategies for patients. On the basis of these estimates, patients may be able to engage in risk reduction interventions and increased screening, including chemoprevention or surgical risk reduction. Multiple organizations have published guidelines supporting risk assessment, genetic assessment, increased screening, and prevention measures for these women., Competing Interests: Declaration of competing interest None., (Copyright © 2021. Published by Elsevier Ltd.)

Background: Medication errors may occur during chemotherapy and can have fatal consequences. Healthcare Failure Mode and Effects Analysis (FMEA) is a method used to detect potential risks and prevent them., Objective: Aim of this study was to evaluate the medication process of intravenous tumor therapy in order to guarantee a high standard of patient safety., Methods: The main part of the study was performed at the University Hospital of Bonn, Germany. After assembling a multidisciplinary team, the individual steps of prescription, compounding, transport, and administration of chemotherapy were mapped in a flow diagram. The possible failures were identified and analyzed by calculating the risk priority numbers (RPNs). Finally, corrective actions were developed and after hypothetical implementation re-analyzed to measure their effects on the process. Subsequently, a shortened FMEA based on the catalogue failure modes developed in Bonn was carried out at the University Hospital of Cologne in order to evaluate its transferability to another hospital., Results: A total of 52 potential failure modes was identified in Bonn. Relating to the RPNs the most critically steps in the process were associated with the prescription, namely, incorrect information about individual parameters of the patient; non-standardized chemotherapy protocols; and problems related to supportive therapy. A significant risk reduction for most of the failure modes was assessed by implementing suitable corrective actions. The shortened FMEA in Cologne led to a different ranking of failure modes., Conclusion: The implementation of this analysis has not only identified various safety gaps, but also shows how patient safety during chemotherapy can be enhanced. Moreover, it has sensitized the practitioners to failure modes potentially occurring in their work routine., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Hypertension is possibly the most powerful, modifiable risk factor for the development of heart failure. Chronic hypertension drives cardiac remodeling within the left ventricle resulting in hypertensive heart disease, which ultimately manifests as heart failure. Early detection and appropriate management are necessary to prevent heart failure as well as other cardiovascular diseases. Achieving blood pressure goals in conjunction with using evidence-based treatments can improve clinical outcomes for patients with comorbid hypertension and heart failure., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The COVID-19 pandemic has greatly exacerbated the United States' overdose crisis. However, the overlapping impacts of COVID-19 and the overdose crisis have not been experienced equally, with unstably housed people who use drugs (PWUD) disproportionately impacted. Amid these changes, there is a need to understand how risk is experienced and managed among unstably housed PWUD to address health and social needs more effectively., Methods: This project draws on ethnographic research conducted from June 2020 to April 2021 in Rhode Island. Data include 39 in-depth interviews with unstably housed PWUD and approximately 50 h of ethnographic fieldwork conducted alongside street-based outreach workers., Results: COVID-19 risks were primarily contextualized in relation to participants' prior experiences of overdose events and adverse health outcomes. However, participants had varying levels of risk tolerance that were managed in ways that allowed them to reassert control and agency within the uncertainty of overlapping public health crises. Given participants' level of structural vulnerabilities, COVID-19 risk was managed alongside meeting their basic needs to survive., Conclusions: Findings demonstrate how COVID-related public health measures (e.g., stay-at-home orders, service closures) reinforced participants' structural vulnerabilities in ways that increased their risk of health and social harms. Implementing and scaling up programs that meet the basic needs of individuals, including permanent housing, social supports, and overdose prevention interventions (e.g., supervised consumption sites) is critically needed to address intersecting risks faced by unstably housed PWUD., Competing Interests: Declarations of Interest No conflicts to declare., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Crystal methamphetamine (hereafter crystal) is associated with deleterious health outcomes, such as drug dependence and physical and mental health disorders. While some harms from crystal use can affect all users, there may be additional risks for people who combine the use of drug with sex. Compared with the broader population, gay and bisexual men in Australia report a higher prevalence of methamphetamine use, and crystal is the most commonly injected illicit drug among this population. The Crystal, Pleasures and Sex between Men research project was conducted between 2017 and 2019 and examined gay and bisexual men's crystal use in four capital cities in Australia, with the aim of identifying how to best support men who use crystal for sex. In this article, we examine how risk is understood and prioritised by gay and bisexual men who combine crystal use and sex and identify the range of risk reduction practices that they used. We classified these risks as those associated with the transmission of HIV, HCV and STIs, and those associated with dependence on either crystal or the sex it facilitated. Gay and bisexual men overwhelmingly prioritised the risk of dependence over any other risks associated with crystal-enhanced sex, and this prioritization was reflected in the risk reduction practices they employed. While some of the strategies that gay and bisexual men have adopted may contradict anticipated public health principles, they derive from a carefully considered and shared approaches to the generation of pleasure, the maintenance of a controlled form of feeling "out of control", and the negotiated reduction of risk. The consolidation of these strategies effectively constitutes a "counterpublic health" underpinned by forms of "sex-based sociality", which gives primacy to the priorities and practices of gay and bisexual men in Australia who combine crystal and sex., Competing Interests: Declarations of Interest None., (Copyright © 2021 Elsevier B.V. All rights reserved.)