Search

Although testicular cancer is a relatively rare lesion, accounting for only 1.1% of all malignant neoplasms in males in Canada, it is the most common cancer among Canadian men 20–45 years of age. Knowledge of the causes of testicular cancer risk in general, and more specifically, its association with diet, remain limited. Data from 601 cases of testicular cancer and 744 population-based controls collected in 8 of the 10 Canadian provinces between 1994–97 were used to explore the relationship between diet and testicular cancer risk. We systematically examined 17 food groups, 15 nutrients and 4 individual foods based on data collected through a 69-item food-frequency questionnaire. Our results suggest that high dairy product intake, in particular high intake of cheese (odds ratio [OR] = 1.87; 95% confidence interval [CI] 1.22–2.86; p-trend < 0.001), is associated with an elevated risk of testicular cancer in Canadian males. © 2003 Wiley-Liss, Inc. [ABSTRACT FROM AUTHOR]

We conducted a population-based case-control study of 1,447 incident rectal cancer cases and 3,106 population controls aged 20–76 years to assess the effect of recreational physical activity, energy intake and obesity on rectal cancer risk in 7 of 10 Canadian provinces in 1994–97. After adjustment for the effect of various potential confounding factors, total recreational physical activity in the highest quartile was associated with an odds ratio (OR) for rectal cancer risk of 0.88 (95% confidence interval [CI] = 0.64–1.20) in women and 1.15 (95% CI = 0.88–1.49) in men. Women and men in the highest quartile of caloric intake (> = 56,741 and > = 63,143 kJ/week) had ORs of 1.50 (95% CI = 1.00–2.25) and 1.61 (95% CI = 1.13–2.28), respectively. Total dietary fat intake was not associated with a risk of rectal cancer after adjustment for caloric intake. Obesity (BMI > = 30 kg/m2) was associated with an OR of 1.44 (95% CI = 1.06–1.95) for women and 1.78 (95% CI = 1.36–2.34) for men. Men and women with lifetime maximum body mass index (BMI) > = 30 kg/m2 had respective ORs of 1.70 (95% CI = 1.30–2.23) and 1.26 (95% CI = 0.96–1.66). The greatest increase in rectal cancer risk was observed in men and women with simultaneous high energy intake, high BMI and low physical activity. Our study provides evidence that physical inactivity, high energy intake and obesity are associated with the risk of rectal cancer, and there is a probable synergic effect among the 3 risk factors. © 2003 Wiley-Liss, Inc. [ABSTRACT FROM AUTHOR]

Background: We sought to improve the immediate and subsequent care of emergency department (ED) patients with acute atrial fibrillation (AF) and flutter (AFL) by implementing the principles of the Canadian Association of Emergency Physicians AF/AFL Best Practices Checklist., Methods: This cohort study included 3 periods: before (7 months), intervention introduction (1 month), and after (7 months), and was conducted at a major academic centre. We included patients who presented with an episode of acute AF or AFL and used multiple strategies to support ED adoption of the Canadian Association of Emergency Physicians checklist. We developed new cardiology rapid-access follow-up processes. The main outcomes were unsafe and suboptimal treatments in the ED., Results: We included 1108 patient visits, with 559 in the before and 549 in the after period. In a comparison of the periods, there was an increase in use of chemical cardioversion (20.6% vs 25.0%; absolute difference [AD], 4.4%) and in electrical cardioversion (39.2% vs 51.2%; AD, 12.0%). More patients were discharged with sinus rhythm restored (66.9% vs 75.0%; AD, 8.1%). The proportion seen in a follow-up cardiology clinic increased from 24.2% to 39.9% (AD, 15.7%) and the mean time until seen decreased substantially (103.3 vs 49.0 days; AD, -54.3 days). There were very few unsafe cases (0.4% vs 0.7%) and, although there was an increase in suboptimal care (19.5% vs 23.1%), overall patient outcomes were excellent., Conclusions: We successfully improved the care for ED patients with acute AF/AFL and achieved more frequent and more rapid cardiology follow-up. Although cases of unsafe management were uncommon and patient outcomes were excellent, there are opportunities for physicians to improve their care of acute AF/AFL patients., Gov Identifier: NCT05468281., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Existing barriers to care were exacerbated by the development and implementation of necessary public health restrictions during the COVID-19 pandemic. Children with complex care needs and their families represent a small portion of the paediatric population, and yet they require disproportionately high access to services. Little is known about the impact of COVID-19 public health measures on this population. This study will generate evidence to uncover the wider impact of COVID-19 measures on the lives of children with complex care needs and their families in relation to policy and service changes. This multi-site sequential mixed methods study will take place across the Canadian Maritime provinces and use an integrated knowledge translation approach. There are two phases to this study: 1) map COVID-19 public health restrictions and service changes impacting children with complex care needs by conducting an environmental scan of public health restrictions and service changes between March 2020 and March 2022 and interviewing key informants involved in the development or implementation of restrictions and service changes, and 2) explore how children with complex care needs and their families experienced public health restrictions and service changes to understand how their health and well-being were impacted., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Curran et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Poverty and socioeconomic disadvantage are important contributors to drug-related harm, but their precise role in overdose risk remains poorly understood. We sought to examine linkages between socioeconomic marginalization and non-fatal overdose risk in a community deeply affected by the ongoing drug poisoning crisis., Methods: This observational study used data derived from two community-recruited prospective cohorts of people who use drugs (PWUD) in Vancouver, British Columbia, Canada. Generalized linear mixed-effects models were used to assess longitudinal associations between multiple dimensions of socioeconomic disadvantage and self-reported non-fatal overdose., Results: Between 2014 and 2020, 1,493 participants (38.2% women; 59.6% white; 35.7% Indigenous) provided 9,968 interviews. Non-fatal overdose was reported by 32.5% of participants over the study period. In multivariable analyses, non-fatal overdose was independently associated with incarceration (adjusted odds ratios [AOR]: 1.42, 95% confidence interval [CI]: 1.08-1.88, p=0.012), homelessness (AOR: 1.57, 95%CI: 1.27-1.93, p<0.001), increased monthly income (AOR: 1.01, 95%CI: 1.00-1.01, p=0.029), and lower material security (AOR: 0.76, 95%CI: 0.67-0.88, p<0.001). We also observed differing strengths of association between illegal income generation and overdose in men (AOR: 1.84, 95%CI: 1.46-2.32, p<0.001) compared to women (AOR: 1.37, 95%CI: 1.06-1.78, p=0.016)., Conclusion: Non-fatal overdose was positively associated with incarceration, homelessness, higher monthly income, material insecurity, and engagement illegal income generating activities, underscoring the importance of addressing the socioeconomic production of overdose risk. These initiatives may include supportive housing interventions, alternative economic supports, and broader drug policy reform., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: MJM is the Canopy Growth professor of cannabis science at the University of British Columbia, a position established through arm's length gifts to the university from Canopy Growth Corporation, a licensed producer of cannabis, and the Government of British Columbia's Ministry of Mental Health and Addictions., (Copyright © 2023. Published by Elsevier B.V.)

Gender identity and sexual orientation are determinants of health that can contribute to health inequities. In the 2SLGBTQIA+ community, belonging to a sexual and/or gender minority group leads to a higher risk of negative health outcomes such as depression, anxiety, and cancer, as well as maladaptive behaviors leading to poorer health outcomes such as substance abuse and risky sexual behavior. Empirical evidence suggests that inequities in terms of accessibility to health care, quality of care, inclusivity, and satisfaction of care, are pervasive and entrenched in the health care system. A better understanding of the current Canadian health care context for individuals of the 2SLGBTQIA+ community is imperative to inform public policy and develop sensitive public health interventions to make meaningful headway in reducing inequity. Our search strategy was Canadian-centric and aimed at highlighting the current state of 2SLGBTQIA+ health inequities in Canada. Discrimination, patient care and access to care, education and training of health care professionals, and crucial changes at the systemic and infrastructure levels have been identified as main themes in the literature. Furthermore, we describe health care-related disparities in the 2SLGBTQIA+ community, and present available resources and guidelines that can guide healthcare providers in narrowing the gap in inequities. Herein, the lack of training for both clinical and non-clinical staff has been identified as the most critical issue influencing health care systems. Researchers, educators, and practitioners should invest in health care professional training and future research should evaluate the effectiveness of interventions on staff attitudinal changes toward the 2SLGBTQIA+ community and the impact on patient outcomes., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Comeau, Johnson and Bouhamdani.)

While conducting nutrition/health research into weight changes during incarceration and related determinants, it became apparent that the correctional setting in Canada was unique and required study design modifications to ensure study success. Consequently, we made many methodological adjustments during recruitment and data collection because of unforeseen challenges in the correctional context. This paper provides an illustrative example and shares insights on the challenges faced when conducting nutrition/health research in Canadian correctional facilities. Guidance on how to adapt research methods to make them more conducive to this unique environment is provided. This paper also highlights the importance of conducting nutrition/health research in this setting, especially given the lack of this type of research and the need for more evidence-based data to guide health promotion and nutritional interventions in Canadian correctional facilities.

Background: The COVID-19 pandemic and consequent public health response may have undermined key responses to the protracted drug poisoning crisis, including reduced access to opioid agonist therapy (OAT) among people with opioid use disorder. Our study objectives were to estimate the prevalence of and identify factors associated with inability to contact OAT prescribers when in need among people on OAT in a Canadian setting during the dual public health crises., Methods: Survey data were collected from three prospective cohort studies of community-recruited people who use drugs between July and November 2020, in Vancouver, Canada. A multivariable logistic regression analysis was used to identify potential factors associated with inability to contact OAT prescribers among patients who accessed OAT in the past 6 months., Results: Among 448 respondents who reported accessing OAT in the past 6 months, including 231 (54.9%) men, 85 (19.0%) reported having been unable to contact OAT prescribers when needed, whereas 268 (59.8%) reported being able to talk to their prescriber when needed, and 95 (21.2%) reported that they did not want to talk to their medication prescriber in the previous 6 months. Among those who reported inability to contact prescribers, 45 (53.6%) reported that their overall ability to contact prescribers decreased since the start of the pandemic. In multivariable analyses, factors independently associated with inability to talk to OAT prescribers included: chronic pain (Adjusted Odds Ratio [AOR] = 1.82; 95% Confidence Interval [CI] 1.02, 3.27), moderate to severe symptoms of depression or anxiety (AOR = 4.74; 95% CI 2.30, 9.76), inability to access health/social services (AOR = 2.66; 95% CI 1.41, 5.02), and inability to self-isolate or socially distance most or all of the time (AOR = 2.13; 95% CI 1.10, 4.14)., Conclusions: Overall, approximately one fifth of the sample reported inability to contact their OAT prescribers when needed, and those people were more likely to have co-occurring vulnerabilities (i.e., co-morbidities, inability to access health/social services) and higher vulnerability to COVID-19. Interventions are needed to ensure optimal access to OAT and mitigate the deepening health inequities resulting from the COVID-19 pandemic and the escalating drug poisoning crisis., (© 2022. The Author(s).)

Background: Settings throughout Canada and the USA continue to experience crises of overdose death due to the toxic unregulated drug supply. Injecting drugs alone limits the potential for intervention and has accounted for a significant proportion of overdose deaths, yet the practice remains understudied. We sought to examine the practice of injecting alone among people who inject drugs (PWID) in Vancouver, Canada., Methods: Data were derived from two prospective cohorts of people who use drugs between June 2016 and November 2018. This analysis was restricted to participants who, in the previous 6 months, reported any injection drug use. Rates of injecting alone were categorized as always, usually, sometimes, or occasionally. We fit a multivariable generalized linear mixed model to identify factors associated with injecting drugs alone., Results: Among 1070 PWID who contributed 3307 observations, 931 (87%) reported injecting alone at least once during the study period. In total, there were 729 (22%) reports of always injecting alone, 722 (21.8%) usually, 471 (14.2%) sometimes, 513 (15.5%) occasionally, and 872 (26.4%) never. In a multivariable model, factors positively associated with injecting drugs alone included male sex (adjusted odds ratio [AOR] 1.69; 95% confidence interval [CI] 1.20-2.37), residence in the Downtown Eastside neighbourhood (AOR 1.43; 95% CI 1.08-1.91), binge drug use (AOR 1.36; 95% CI 1.08-1.72), and experiencing physical or sexual violence or both (AOR 1.43; 95% CI 1.00-2.03). Protective factors included Indigenous ancestry (AOR 0.71; 95% CI 0.52-0.98) and being in a relationship (AOR 0.30; 95% CI 0.23-0.39)., Conclusion: We observed that injecting alone, a key risk for overdose mortality, was common among PWID in Vancouver. Our findings underline the need for additional overdose prevention measures that are gender-specific, culturally appropriate, violence- and trauma-informed, and available to those who inject alone., (© 2022. The Author(s).)

The food served in Canadian penitentiaries was scrutinized following food service reform where Correctional Service Canada (CSC) created a standardized menu to feed incarcerated male individuals. Food in prison is a complex issue because penitentiaries are responsible for providing adequate nutrition to the prison population, who are vulnerable to poor health outcomes but are often seen as undeserving. This study aimed to analyse the national menu served in Canadian penitentiaries, in order to compare them with Dietary Reference Intakes (DRIs) for male adults and the internal nutritional assessment reported by CSC. The goal was to verify if the menu served was adequate and to validate CSC's nutritional assessment. The diet analysis software Nutrific R was used to analyse the 4-week cycle menu. Both analyses were within range for DRIs for most nutrients. However, some nutrients were not within target. The sodium content (3404.2 mg) was higher than the Tolerable Upper Intake Levels (UL) of 2300 mg, the ω-6 (linolenic acid) content (10.8 g) was below the AI of 14 g, and the vitamin D content (16.2 μg) was below the target of 20 μg for individuals older than 70 years. When these outliers were analysed in-depth, the menu offering was consistent with the eating habits of non-incarcerated individuals. Based on this nutritional analysis and interpretation of the results in light of the complex nature of prison food, this study concludes that CSC meets its obligation to provide a nutritionally adequate menu offering to the general population during incarceration., Competing Interests: Claire Johnson currently works as a researcher for Correctional Service Canada. The data and their interpretation are fully represented in the paper, and no censorship has occurred.

Background: The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported., Objective: To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia., Design: Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505)., Setting: 46 U.S. and Canadian hospitals., Participants: Patients aged 50 years or older undergoing hip fracture surgery., Intervention: Spinal or general anesthesia., Measurements: Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care., Results: A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups., Limitation: Missing outcome data and multiple outcomes assessed., Conclusion: Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia., Primary Funding Source: Patient-Centered Outcomes Research Institute .

Purpose: The Canadian Cardiovascular Society (CCS) guidelines for patients undergoing non-cardiac surgery address the lack of standardized management for patients at risk of perioperative cardiovascular complications. Our interdisciplinary group evaluated the implementation of these guidelines., Methods: We used an interrupted time series design to evaluate the effect of implementation of the CCS guidelines, using routinely collected hospital data. The study population consisted of elective, non-cardiac surgery patients who were: i) inpatients following surgery and ii) age ≥ 65 or age 45-64 yr with a Revised Cardiac Risk Index ≥ 1. Outcomes included adherence to troponin I (TnI) monitoring (primary) and adherence to appropriate consultant care for patients with elevated TnI (secondary). Exploratory outcomes included cost measures and clinical outcomes such as length of stay., Results: We included 1,421 patients (706 pre- and 715 post-implementation). We observed a 67% absolute increase (95% confidence interval, 55 to 80; P < 0.001) in adherence to TnI testing following the implementation of the guidelines. In patients who had elevated TnI following guideline implementation (n = 64), the majority (85%) received appropriate follow-up care in the form of a general medicine or cardiology consult, all received at least one electrocardiogram, and half received at least one advanced cardiac test (e.g., cardiac perfusion scan, or percutaneous intervention)., Conclusions: Our study showed the ability to implement and adhere to the CCS guidelines. Large-scale multicentre evaluations of CCS guideline implementation are needed to gain a better understanding of potential effects on clinically relevant outcomes., (© 2021. Canadian Anesthesiologists' Society.)

Adolescence represents a critical transition phase during which individuals acquire eating behaviours that can track into adulthood. This study aims to characterise trends in eating behaviours throughout adolescence by investigating the presence of sub-groups of individuals presenting distinct trajectories of vegetable and fruit, sugary beverage, breakfast and fast-food consumption. Data from 744 MATCH study Canadian participants followed from 11 to 18 Years old (2013-2019) were included in the analyses. Participants reported how often they ate breakfast and consumed vegetables and fruits, sugary beverages and fast foods. Trajectories of eating behaviours over seven years were identified using group-based multi-trajectory modelling. For girls, three different groups were identified, namely 'stable food intake with a decline in daily breakfast consumption' (39.9%), 'moderate food intake and worsening in overall eating behaviours' (38.0%) and 'stable high food intake' (22.1%). For boys, five different groups were identified, namely 'low food intake with stable daily breakfast consumption' (27.3%), 'breakfast-skippers and increasing fast food intake' (27.1%), 'low food intake with a decline in daily breakfast consumption' (23.9%), 'high food intake with worsening of eating behaviours' (13.3%) and 'average food intake with consistently high breakfast consumption' (8.4%). Eating behaviours evolve through various distinct trajectories and sub-group-specific strategies may be required to promote healthy eating behaviours among adolescents.

Most inmates gain excessive bodyweight during incarceration in Canadian federal penitentiaries. It is currently unknown if the weight gain is related to participants' higher prevalence of mental illness and/or psychotropic medication use. This study examined how weight change (kg) and body mass index (BMI) change (kg/m 2 ) of 1,420 participants were associated with mental health status and psychotropic medication use. Participants who took psychotropic medications did not gain more weight during incarceration compared to their counterparts who were not taking psychotropic medications (6.5 kg vs. 6.0 kg, p  = 0.87, respectively). However, participants taking psychotropic medications were more likely to be overweight or obese, which means they already had higher BMI at the beginning of their incarceration as opposed to gaining more weight during incarceration. Weight gain of participants observed during incarceration in Canadian federal penitentiaries was not related to the higher prevalence of mental illness or psychotropic medication use.

Competing Interests: Competing interests: Sean Wharton reports receiving honoraria and travel expenses and has participated in academic advisory boards for Novo Nordisk, Bausch Health, Eli Lilly and Janssen. Sean Wharton is also the medical director of a medical clinic specializing in weight management and diabetes. David Lau reports receiving grants and research support from AstraZeneca, Novo Nordisk and the Canadian Institutes of Health Research (CIHR); speaker bureau fees from AstraZeneca, Bausch Health, Boehringer Ingelheim, Diabetes Canada, Eli Lilly, Merck and Novo Nordisk; and consulting fees from Amgen, AstraZeneca, Bausch Health, Boehringer Ingelheim, Gilead, HLS Therapeutics, Janssen, Eli Lilly and Novo Nordisk. Michael Vallis is a member of advisory boards for Novo Nordisk, Bausch Health and LifeScan. Michael Vallis has also received consulting fees from Bausch Health, LifeScan, Novo Nordisk and Sanofi, and speaking fees from Novo Nordisk, Sanofi, Bausch Health, Abbott and AbbVie. Arya Sharma reports receiving speaker’s bureau and consulting fees from Novo Nordisk, Bausch Pharmaceuticals and Astra-Zeneca. Laurent Biertho reports receiving grants from Johnson and Johnson and Medtronic, and is a member of advisory boards for Novo Nordisk and Bausch Health, outside the submitted work. Denise Campbell-Scherer has no personal financial relationships, but reports receiving research funding from the following sources in the past 3 years: Novo Nordisk Alberta Diabetes Fund (NOVAD), a peer-reviewed grant that is a partnership between the University Hospital Foundation, Novo Nordisk and Alberta Innovates joint funders; Alberta Innovates Health Solutions (Cancer Prevention Research Opportunity and Collaborative Research and Innovation Opportunities competitions), CIHR (Strategy for Patient-Oriented Research and Knowledge-to-Action competitions); Northern Alberta Family Medicine Fund; and the Alberta Cancer Prevention and Legacy Fund. She also reports receiving knowledge transfer funding from the following sources in the past 3 years: an unrestricted education grant from Obesity Canada, funded by Novo Nordisk Global; a Worldwide University Network Meeting Grant; an Agency for Healthcare Research and Quality R13 grant for a Healthcare Effectiveness and Outcomes Research; and a Physician Learning Program grant from Alberta Health and the Alberta Medical Association. Angela Alberga reports receiving the following grants: the Santé Award from Fonds de Recherche du Quebec, the Mitacs Accelerate Grant, and the Concordia University Start-up Team Grant, outside the submitted work. Jennifer Brown reports receiving nonfinancial support from Novo Nordisk, and personal fees from Bausch Health, Dietitians of Canada, Obesity Canada and the Canadian Association of Bariatric Physicians & Surgeons. Yoni Freedhoff is the co-owner of the Bariatric Medical Institute and Constant Health, which provide weight management services; Constant Health has received a grant from Novo Nordisk. Yoni Freedhoff is also the author of The Diet Fix: Why Diets Fail and How to Make Yours Work published by Crown Publishing Group, and receives royalties for the book. In addition, he is the sole author of the Weighty Matters blog and a column for Medscape and many other op-eds and articles in which he has publicly expressed opinions about the treatment, management and prevention of obesity. Yoni Freedhoff also regularly speaks on topics related to obesity and receives honoraria and travel costs and expenses for same. Michel Gagner reports receiving speaker honoraria from Ethicon, WL Gore and Medtronic; consulting fees from Novo Nordisk, Bausch Health and Lexington Medical; and holds stock options with Lexington Medical. Margaret Hahn reports receiving consulting fees from Alkermes. Marie-France Langlois reports receiving personal fees from Novo Nordisk, Valeant, Merck Canada, Sanofi, Eli Lilly and Boehringer Ingelheim; a grant from Merck Canada; and other fees from AstraZeneca and from TIMI (Thrombolysis in Myocardial Infarction) Study Group for diabetes clinical research as a principal investigator, all outside the submitted work. David Macklin reports receiving personal fees from Novo Nordisk and Bausch Health, outside the submitted work. Priya Manjoo reports receiving personal fees from Novo Nordisk, Bausch Health and Sanofi; and grants from Boehringer Ingelheim, Sanofi and AstraZeneca, outside the submitted work. Marie-Philippe Morin reports receiving speaker honoraria from Novo Nordisk, Bausch Health, Eli Lilly, Boehringer Ingelheim, Nestlé Health Science, Janssen and AstraZeneca; research subvention from Novo Nordisk and Sanofi; and consultation honoraria from Novo Nordisk, Bausch Health, Eli Lilly, Boehringer Ingelheim, Janssen and AstraZeneca. Sue Pedersen reports receiving personal fees from Novo Nordisk, Bausch Health, Janssen, Eli Lilly, Merck, AstraZeneca, Boehringer Ingelheim, Sanofi, Pfizer; grants from Eli Lilly, AstraZeneca, Boehringer Ingelheim and Sanofi; and nonfinancial support from Novo Nordisk, Bausch Health, Janssen, Eli Lilly, AstraZeneca, Boehringer Ingelheim and Sanofi, outside the submitted work. Megha Poddar reports receiving honoraria for continuing medical education (CME) from Novo Nordisk, Bausch Health, Boehringer Ingelheim, Eli Lilly, Jenssen, Merck, the Canadian Collaborative Research Network and the Antibody Network; education grants from Novo Nordisk and Bausch Health; fees for mentorship from Novo Nordisk; fees for membership of advisory boards from Novo Nordisk and Bausch Health; and a quality improvement project grant from Boehringer Ingelheim. Paul Poirier reports receiving fees for consulting and continuing medical education from AstraZeneca, Boehringer Ingelheim, Janssen, Eli Lilly, Novo Nordisk, Valeant and Bausch Health, outside the submitted work. Judy Shiau reports receiving personal fees from Novo Nordisk and Bausch Health, outside the submitted work. Diana Sherifali reports receiving consulting fees for advice regarding chronic disease and diabetes management from Merck, and a grant from Obesity Canada to support the literature review process, during the conduct of the study. John Sievenpiper reports receiving grants from CIHR, the Nutrition Trialists Fund at the University of Toronto, the International Nut and Dried Fruit Council Foundation, the Tate & Lyle Nutritional Research Fund at the University of Toronto, the American Society for Nutrition, the Glycemic Control and Cardiovascular Disease in Type 2 Diabetes Fund at the University of Toronto, the National Dried Fruit Trade Association, PSI Graham Farquharson Knowledge Translation Fellowship, the Diabetes Canada Clinician Scientist award, the Banting & Best Diabetes Centre Sun Life Financial New Investigator Award, the Canada Foundation for Innovation, and the Ministry of Research and Innovation’s Ontario Research Fund. Dr. Sievenpiper has received personal fees from Perkins Coie LLP, Tate & Lyle, Dairy Farmers of Canada, PepsiCo, Food-Minds LLC, European Fruit Juice Association, International Sweeteners Association, Nestlé Health Science, Canadian Society for Endocrinology and Metabolism, GI Foundation, Pulse Canada, Wirtschaftliche Vereinigung Zucker e.V., Abbott, Biofortis, the European Food Safety Authority, the Physicians Committee for Responsible Medicine, the Soy Nutrition Institute and the Comité Européen des Fabricants de Sucre. Dr. Sievenpiper has received nonfinancial support from Tate & Lyle, PepsiCo, FoodMinds LLC, European Fruit Juice Association, International Sweeteners Association, Nestlé Health Science, Wirtschaftliche Vereinigung Zucker e.V., Abbott, Biofortis, the European Food Safety Authority and the Physicians Committee for Responsible Medicine, Kellogg Canada, American Peanut Council, Barilla, Unilever, Unico Primo, Loblaw Companies, WhiteWave Foods, Quaker, California Walnut Commission, Almond Board of California, outside the submitted work. Dr. Sievenpiper is a member of the International Carbohydrate Quality Consortium and the Clinical Practice Guidelines Expert Committees of Diabetes Canada, European Association for the Study of Diabetes, Canadian Cardiovascular Society, and Obesity Canada, and holds appointments as an Executive Board Member of the Diabetes and Nutrition Study Group of the European Association for the Study of Diabetes, and as Director of the Toronto 3D Knowledge Synthesis and Clinical Trials Foundation. He is also an unpaid scientific adviser for the Program in Food Safety, Nutrition and Regulatory Affairs and the Carbohydrates Committee of the International Life Science Institute North America. He has a spousal relationship with an employee of Anheuser-Busch InBev. Sanjeev Sockalingam reports receiving honoraria from Bausch Health Canada within the last 36 months. Valerie Taylor reports receiving speaker fees from Sunovion. Shahebina Walji reports receiving consulting or advisory board fees from Novo Nordisk, Bausch Health and Takeda and speaker’s bureau fees from Novo Nordisk and Bausch Health. Shahebina Walji also reports selling Optifast Meal replacements through a weight management centre Optifast is a product produced and sold by Nestlé. No other competing interests were declared.

Importance: Streptococcus pneumoniae is the most commonly identified cause of bacterial pneumonia, and invasive pneumococcal disease (IPD) has a high case fatality rate. The wintertime coseasonality of influenza and IPD in temperate countries has suggested that pathogen-pathogen interaction or environmental conditions may contribute to IPD risk., Objectives: To evaluate the short-term associations of influenza activity and environmental exposures with IPD risk in temperate countries and to examine the generalizability of such associations across multiple jurisdictions., Design, Setting, and Participants: This case-crossover analysis of 19 566 individuals with IPD from 1998 to 2011 combined individual-level outcomes of IPD and population-level exposures. Participants lived in 12 jurisdictions in Canada (the province of Alberta and cities of Toronto, Vancouver, and Halifax), Australia (Perth, Sydney, Adelaide, Brisbane, and Melbourne), and the United States (Baltimore, Providence, and Philadelphia). Data were analyzed in 2019., Exposures: Influenza activity, mean temperature, absolute humidity, and UV radiation at delays of 1 to 3 weeks before case occurrence in each jurisdiction., Main Outcomes and Measures: Matched odds ratios (ORs) for IPD associated with changes in exposure variables, estimated using multivariable conditional logistic regression models. Heterogeneity in effects across jurisdictions were evaluated using random-effects meta-analytic models., Results: This study included 19 566 patients: 9629 from Australia (mean [SD] age, 42.8 [30.8] years; 5280 [54.8%] men), 8522 from Canada (only case date reported), and 1415 from the United States (only case date reported). In adjusted models, increased influenza activity was associated with increases in IPD risk 2 weeks later (adjusted OR [aOR] per SD increase, 1.07; 95% CI, 1.01-1.13). Increased humidity was associated with decreased IPD risk 1 week later (aOR per 1 g/m3, 0.98; 95% CI, 0.96-1.00). Other associations were heterogeneous; metaregression suggested that combinations of environmental factors might represent unique local risk signatures. For example, the heterogeneity in effects of UV radiation and humidity at a 2-week lag was partially explained by variation in temperature (UV index: coefficient, 0.0261; 95% CI, 0.0078 to 0.0444; absolute humidity: coefficient, -0.0077; 95% CI, -0.0125 to -0.0030)., Conclusions and Relevance: In this study, influenza was associated with increased IPD risk in temperate countries. This association was not explained by coseasonality or case characteristics and appears generalizable. Absolute humidity was associated with decreased IPD risk in the same jurisdictions. The generalizable nature of these associations has important implications for influenza control and advances the understanding of the seasonality of this important disease.

This review aims to summarize and synthesize studies reporting on changes in sodium levels in packaged food products, restaurant foods, and hospital or school meals, as a result of salt reduction interventions. Studies were extracted from those published in the Science of Salt Weekly between June 2013 and February 2018. Twenty-four studies were identified: 17 assessed the changes in packaged foods, four in restaurant foods, two in hospital or school meals, and one in both packaged and restaurant foods. Three types of interventions were evaluated as part of the studies: voluntary reductions (including targets), labeling, and interventions in institutional settings. Decreases in sodium were observed in all studies (n = 8) that included the same packaged foods matched at two time points, and in the studies carried out in hospitals and schools. However, there was little to no change in mean sodium levels in restaurant foods. The pooled analysis of change in sodium levels in packaged foods showed a decrease in sodium in unmatched food products (-36 mg/100 g, 95% CI -51 to -20 mg/100 g) and in five food categories-breakfast cereals, breads, processed meats, crisps and snacks, and soups. Twenty-two of the 24 studies were from high-income countries, limiting the applicability of the findings to lower resource settings., (©2019 Wiley Periodicals, Inc.)

Objective: This study aimed to determine how inmates' body weight changed during incarceration in Canadian federal penitentiaries, based on their history of tobacco use. Since tobacco was banned from all Canadian federal penitentiaries in 2008, little is known about the unintended health consequences of this ban, especially on inmates' body weight., Design: Cohort study., Setting: Participants were male and female inmates incarcerated for at least 6 months in Canadian federal penitentiaries. We collected data from 10 institutions in two Canadian regions (Ontario and Atlantic)., Participants: We collected data from 754 inmates who volunteered to participate in the study., Intervention: This study examined weight change in relation to a history of tobacco use. In 2016-2017, anthropometric data were collected and compared with recorded anthropometric data at the beginning of incarceration (mean follow-up of 5.0±8.3 years). Self-reported data on tobacco and substance use were collected. Weight change was compared between inmates with and without a history of tobacco use., Outcomes: The main outcome measures were body weight change (kg), body mass index (BMI) change (kg/m 2 ), annual weight change (kg/year), and BMI and waist circumference (cm) at the time of the interview., Results: During incarceration, ex-smokers gained more than twice the amount of weight compared with non-smokers (7.5 kg weight gain for smokers vs 3.7 kg weight gain for non-smokers). Once adjusted for covariates in a regression analysis, for inmates who gained the most weight (75th and 90th percentiles), non-smokers had, respectively, 1.64 and 2.3 lower BMI points than ex-smokers., Conclusions: During incarceration in Canadian federal penitentiaries, inmates with a history of tobacco use gained significantly more weight than non-smokers. This put them at increased risk of developing obesity-related health problems. This information is important for the prison setting when planning related programmes and regulation., Competing Interests: Competing interests: CJ currently works as Coordinator of the Nutrition Management Program for Correctional Service Canada. The data and their interpretation are fully represented in the paper, and no censorship has occurred., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: North America is in the midst of an opioid overdose epidemic. Although take-home naloxone and other measures have been an effective strategy to reduce overdoses, many events are unwitnessed and mortality remains high amongst those using drugs alone. While wearable devices that can detect and alert others of an overdose are being developed, willingness of people who use drugs to wear such a device has not been described., Methods: Drug using persons enrolled in a community-recruited cohort in Vancouver, Canada, were asked whether or not they would be willing to wear a device against their skin that would alert others in the event of an overdose. Logistic regression was used to identify factors independently associated with willingness to wear such a device., Results: Among the 1061 participants surveyed between December 2017 and May 2018, 576 (54.3%) were willing to wear an overdose detection device. Factors independently associated with willingness included ever having overdosed (adjusted odds ratio [AOR] = 1.39, 95% confidence interval [CI] 1.06-1.83), current methadone treatment (AOR = 1.86, 95% CI 1.45-2.40), female gender AOR = 1.41, 95% CI 1.09-1.84) and a history of chronic pain (AOR = 1.53, 95% CI 1.19-1.96). Whereas homelessness (AOR = 0.67, 95% CI 0.50-0.91) was negatively associated with willingness., Conclusions: A high level of willingness to wear an overdose detection device was observed in this setting and a range of factors associated with overdose were positively associated with willingness. Since some factors, such as homelessness may be a barrier, further research is needed to investigate explanations for unwillingness and to evaluate real world acceptability of a wearable overdose detection devices as this technology becomes available.

The Global Burden of Disease (GBD) 2010 study estimated national salt intake for 187 countries based on data available up to 2010. The purpose of this review was to identify studies that have measured salt intake in a nationally representative population using the 24-hour urine collection method since 2010, with a view to updating evidence on population salt intake globally. Studies published from January 2011 to September 2018 were searched for from MEDLINE, Scopus, and Embase databases using relevant terms. Studies that provided nationally representative estimates of salt intake among the healthy adult population based on the 24-hour urine collection were included. Measured salt intake was extracted and compared with the GBD estimates. Of the 115 identified studies assessed for eligibility, 13 studies were included: Four studies were from Europe, and one each from the United States, Canada, Benin, India, Samoa, Fiji, Barbados, Australia, and New Zealand. Mean daily salt intake ranged from 6.75 g/d in Barbados to 10.66 g/d in Portugal. Measured mean population salt intake in Italy, England, Canada, and Barbados was lower, and in Fiji, Samoa, and Benin was higher, in recent surveys compared to the GBD 2010 estimates. Despite global targets to reduce population salt intake, only 13 countries have published nationally representative salt intake data since the GBD 2010 study. In all countries, salt intake levels remain higher than the World Health Organization's recommendation, highlighting the need for additional global efforts to lower salt intake and monitor salt reduction strategies., (©2019 Wiley Periodicals, Inc.)

Objective: Recent research found that inmates experience undesirable and rapid weight gain during incarceration in Canadian federal penitentiaries. However, little is known about what factors and daily movement behaviours (e.g., physical activity, screen time, and sleep) influence weight gain during incarceration. This study examines how these 24-h movement/non-movement behaviours contribute to weight gain during incarceration., Methods: This retrospective cohort study explored how weight change outcomes during incarceration (weight change, body mass index (BMI) change, and yearly weight gain) were influenced by physical activity, screen time, and sleep in a convenience sample of 754 inmates. The outcome measures were taken twice, once from participants' medical chart at admission and again during a face-to-face follow-up interview (conducted in 2016-2017; mean follow-up time of 5.0 ± 8.3 years). Physical activity, screen time, and sleep were self-reported. The statistical analysis was chi-square testing, non-parametric median comparison testing, and regression analysis to control for confounders., Results: Inmates who engaged in at least 60 min of daily physical activities gained less weight (4.5 kg) compared to inmates who reported not exercising (8.3 kg). Different types of exercise (cardiovascular exercises, weight lifting, and team sports) were helpful at limiting weight gain, but playing sports was the most effective. Screen time and sleep were not associated with weight gain outcomes., Conclusion: Among the behaviours examined, physical inactivity was significantly associated with higher weight gain during incarceration. However, even high levels of physical activity (> 60 min/day) were not sufficient to eliminate weight gain during incarceration in Canada.

Background: Chlamydia trachomatis and Neisseria gonorrhoeae are the most commonly reported sexually transmitted infections in Canada. Existing national guidance on screening for these infections was not based on a systematic review, and recommendations as well as implementation considerations (e.g., population groups, testing and case management) should be explicit and reflect the quality of evidence. The aim of this systematic review is to synthesize research on screening for these infections in sexually active individuals within primary care. We will also review evidence on how people weigh the relative importance of the potential outcomes from screening, rated as most important by the Canadian Task Force on Preventive Health Care (CTFPHC) with input from patients and stakeholders., Methods: We have developed a peer-reviewed strategy to comprehensively search MEDLINE, Embase, Cochrane Library, CINAHL, and PsycINFO for English and French literature published 1996 onwards. We will also search trial registries and conference proceedings, and mine references lists. Screening, study selection, risk of bias assessments, and quality of findings across studies (for each outcome) will be independently undertaken by two reviewers with consensus for final decisions. Data extraction will be conducted by one reviewer and checked by another for accuracy and completeness. The CTFPHC and content experts will provide input for decisions on study design (i.e., when and whether to include uncontrolled studies for screening effectiveness) and for interpretation of the findings., Discussion: The results section of the review will include a description of all studies, results of all analyses, including planned subgroup and sensitivity analyses, and evidence profiles and summary of findings tables incorporating assessment based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods to communicate our confidence in the estimates of effect. We will compare our findings to others and discuss limitations of the review and available literature. The findings will be used by the CTFPHC-supplemented by consultations with patients and stakeholders and from other sources on issues of feasibility, acceptability, costs/resources, and equity-to inform recommendations on screening to support primary health care providers in delivering preventive care., Systematic Review Registration: International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42018100733.

Background: Canadian penitentiaries have recently been shown to be obesogenic. However, little is known about the eating habits of inmates who gained weight while living in the prison environment., Methods: This retrospective cohort study examined the reported food intake of inmates during incarceration in federal penitentiaries. During a face to face interview, anthropometric measures (2016-2017) were taken and compared to anthropometric data at the beginning of incarceration (mean follow-up of 5.0 ± 8.3 years). Self-reported data on food intake were collected via a food frequency questionnaire., Results: Inmates who gained the most weight (15.7 kg) during incarceration reported not eating vegetables. They were followed by inmates who gained 14.3 kg and reported not eating fruit. Other inmates who gained a significant amount of weight reported not eating cereal, dairy or legumes. Moreover, inmates' weight gain was also assessed by special diets: inmates following a religious diet (4.5 kg) or a diet of conscience (-0.3 kg) gained less weight than inmates not following a diet (5.8 kg). In comparison to other types of diets, inmates on a medical diet gained the most weight (7.5 kg). Furthermore, inmates who gained significant weight (8.0 kg) also reported not purchasing healthy foods from the commissary store (or "canteen"), whereas inmates who gained less weight (4.8 kg) reported purchasing healthy foods from the commissary store (or "canteen"). The observed weight gain was positively associated with food purchased from the commissary store (or "canteen"), but was not associated with the feeding system of the penitentiary (tray, cafeteria or meal plan)., Discussion: Food intake during incarceration is a modifiable risk factor that could be the target of weight management interventions with inmates. Our findings suggest that inmates who gained the most weight also reported having low intake of foods deemed healthy (vegetables, fruit, cereal, dairy and legumes) from food services and from the commissary store (or "canteen") purchases., Competing Interests: Claire Johnson currently works as Coordinator of the Nutrition Management Program for Correctional Service Canada. The data and their interpretation are fully represented in the paper, and no censorship has occurred. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Purpose: University students may be at risk for food insecurity (FI) due to low income coupled with rising tuition, housing, and food costs. This study aimed to determine the prevalence of FI and potential correlates among students at a small, rural Canadian university., Methods: Health Canada's 10-item household food security survey module (HFSSM) was adapted to assess food security status within the postsecondary student population. An additional 11 items measured food access and demographics. The validated, web-based survey was distributed by email and completed by 218 students (15.6% response rate). Participants were classified as food secure, moderately food insecure, or severely food insecure using the HFSSM Adult scale., Results: An overall FI rate of 37.2% was observed. This included 25.7% moderately food insecure and 11.5% severely food insecure. Students in higher years of study and who lived off campus had higher rates of FI., Conclusions: FI appears to be a significant concern for university students and has potential health and academic implications. Further research is needed to clarify the determinants and extent of FI for postsecondary students and to develop strategies to mitigate the prevalence and effects of food insecurity in these young adults.

Background: Machine learning tools can expedite systematic review (SR) processes by semi-automating citation screening. Abstrackr semi-automates citation screening by predicting relevant records. We evaluated its performance for four screening projects., Methods: We used a convenience sample of screening projects completed at the Alberta Research Centre for Health Evidence, Edmonton, Canada: three SRs and one descriptive analysis for which we had used SR screening methods. The projects were heterogeneous with respect to search yield (median 9328; range 5243 to 47,385 records; interquartile range (IQR) 15,688 records), topic (Antipsychotics, Bronchiolitis, Diabetes, Child Health SRs), and screening complexity. We uploaded the records to Abstrackr and screened until it made predictions about the relevance of the remaining records. Across three trials for each project, we compared the predictions to human reviewer decisions and calculated the sensitivity, specificity, precision, false negative rate, proportion missed, and workload savings., Results: Abstrackr's sensitivity was > 0.75 for all projects and the mean specificity ranged from 0.69 to 0.90 with the exception of Child Health SRs, for which it was 0.19. The precision (proportion of records correctly predicted as relevant) varied by screening task (median 26.6%; range 14.8 to 64.7%; IQR 29.7%). The median false negative rate (proportion of records incorrectly predicted as irrelevant) was 12.6% (range 3.5 to 21.2%; IQR 12.3%). The workload savings were often large (median 67.2%, range 9.5 to 88.4%; IQR 23.9%). The proportion missed (proportion of records predicted as irrelevant that were included in the final report, out of the total number predicted as irrelevant) was 0.1% for all SRs and 6.4% for the descriptive analysis. This equated to 4.2% (range 0 to 12.2%; IQR 7.8%) of the records in the final reports., Conclusions: Abstrackr's reliability and the workload savings varied by screening task. Workload savings came at the expense of potentially missing relevant records. How this might affect the results and conclusions of SRs needs to be evaluated. Studies evaluating Abstrackr as the second reviewer in a pair would be of interest to determine if concerns for reliability would diminish. Further evaluations of Abstrackr's performance and usability will inform its refinement and practical utility.

Background: Although opioid-agonist therapy with methadone or buprenorphine/naloxone is currently the mainstay of medical treatment for opioid use disorder, these medications often are not well accepted or tolerated by patients. Recently, extended release naltrexone (XR-NTX), an opioid antagonist, has been advanced as an alternative treatment. The willingness of opioid-addicted patients to take XR-NTX has not been well described., Methods: Opioid-using persons enrolled in a community-recruited cohort in Vancouver, Canada, were asked whether or not they would be willing to take XR-NTX. Logistic regression was used to independently identify factors associated with willingness to take the medication., Results: Among the 657 participants surveyed between June 1, 2013, and November 30, 2013, 342 (52.1%) were willing to take XR-NTX. One factor positively associated with willingness was daily heroin injection (adjusted odds ratio [AOR] = 1.53; 95% confidence interval [CI] = 1.02-2.31), whereas Caucasian ethnicity was negatively associated (AOR = 0.59; 95% CI = 0.43-0.82). Satisfaction with agonist therapy (13.4%) and unwillingness to stop opioids being used for pain (26.9%) were the most common reasons for being unwilling to take XR-NTX., Conclusions: A high level of willingness to take XR-NTX was observed in this setting. Interestingly, daily injection heroin use was positively associated with willingness, whereas Caucasian participants were less willing to take XR-NTX. Although explanations for unwillingness were described in this study, further research is needed to investigate real-world acceptability of XR-NTX as an additional option for the treatment of opioid use disorder.

Background: The tocopherol-based oil-in-water emulsion adjuvant system family (AS03) improves antigen sparing with split-virion H5N1 influenza vaccines, representing an important development for pandemic preparedness. In this phase 1/2 randomized, controlled, observer-blinded study in 680 adults, we assessed the immunogenicity and safety of A/Indonesia/5/05 H5N1 (IBCDC-RG2, clade 2.1) prepandemic candidate vaccines produced at 2 separate manufacturing sites., Methods: Two doses, each of which contained 3.75 microg of hemagglutinin antigen, were given 21 days apart either without adjuvant or with an adjuvant system containing 11.86 mg or 5.93 mg of tocopherol (AS03)., Results: The AS03-adjuvanted A/Indonesia/05/2005 (NIBRG-14) vaccines were significantly more immunogenic than nonadjuvanted vaccine in homologous assays. Neutralizing cross-clade immunogenicity against clades 1, 2.2, and 2.3 was demonstrated at day 42 with all vaccines; at 6 months, seroconversion rates were highest for clade 2.2 (60.7%) and for clade 1 (38.3%). Adjuvantation was associated with increased short-term injection-site reactions (pain) in 80% of participants, with such reactions assessed as being of grade 3 severity for 4.0% of doses. No other safety or reactogenicity concerns were identified over 6 months of follow-up., Conclusions: Humoral responses against the adjuvanted 3.75-microg hemagglutinin antigen vaccines from both manufacturing sites fulfilled European and US licensure criteria for immunogenicity for influenza vaccines.

Urban firefighters are at risk for posttraumatic stress disorder (PTSD) due in part to their exposure to duty-related trauma. This study compared duty-related trauma exposures and the prevalences of posttraumatic stress in U.S. and Canadian firefighters. Both samples reported relatively numerous and frequent posttrauma symptoms, and the rates of self-reported PTSD prevalence did not differ significantly. However, analysis of departmental records for respondents' previous year on duty revealed significant differences in both frequencies and categories of traumatic incident exposures. Some of the vulnerability and moderating risk factors associated with PTSD caseness differed between the U.S. and Canadian samples. Potential explanations for the observed differences in risk factors for PTSD in these 2 firefighter samples are considered.