A rapid review of current engagement strategies with people who use drugs in monitoring and reporting on substance use-related harms

BACKGROUND

The Canadian drug supply has significantly increased in toxicity over the past few years, resulting in the worsening of the overdose crisis. A key initiative implemented during this crisis has been data monitoring and reporting of substance use-related harms (SRH). This literature review aims to: (1) identify strategies used for the meaningful engagement of people who use drugs (PWUD) in local, provincial, and national SRH data system planning, reporting, and action and (2) describe data monitoring and reporting strategies and common indicators of SRH within those systems.

METHODS

We searched three academic and five gray literature databases for relevant literature published between 2012 and 2022. Team members who identify as PWUD and a librarian at Public Health Ontario developed search strings collaboratively. Two reviewers screened all search results and applied the eligibility criteria. We used Microsoft Excel for data management.

RESULTS

Twenty-two articles met our eligibility criteria (peer-reviewed n = 10 and gray literature reports n = 12); most used qualitative methods and focused on the Canadian context (n = 20). There were few examples of PWUD engaged as authors of reports on SRH monitoring. Among information systems involving PWUD, we found two main strategies: (1) community-based strategies (e.g., word of mouth, through drug sellers, and through satellite workers) and (2) public health-based data monitoring and communication strategies (e.g., communicating drug quality and alerts to PWUD). Substance use-related mortality, hospitalizations, and emergency department visits were the indicators most commonly used in systems of SRH reporting that engaged PWUD.

CONCLUSION

This review demonstrates limited engagement of PWUD and silos of activity in existing SRH data monitoring and reporting strategies. Future work is needed to better engage PWUD in these processes in an equitable manner. Building SRH monitoring systems in partnership with PWUD may increase the potential impact of these systems to reduce harms in the community.

Cohort study of team-based care among marginalized people who use drugs in Ottawa

OBJECTIVE

To describe team-based care use among a cohort of people who use drugs (PWUD) and to determine factors associated with receipt of team-based care.

DESIGN

A cohort study using survey data collected between March and December 2013. These data were then linked to provincial-level health administrative databases to assess patterns of primary care among PWUD in the 2 years before survey completion.

SETTING

Ottawa, Ont.

PARTICIPANTS

Marginalized PWUD 16 years of age or older.

MAIN OUTCOME MEASURES

Patients were assigned to primary care models based on survey responses and then were categorized as attached to team-based medical homes, attached to non-team-based medical homes, not attached to a medical home, and no primary care. Descriptive statistics and multinomial logistic regression were used to determine associations between PWUD and medical home models.

RESULTS

Of 663 total participants, only 162 (24.4%) received team-based care, which was associated with high school level of education (adjusted odds ratio [AOR] = 2.18; 95% CI 1.13 to 4.20), receipt of disability benefits (AOR = 2.47; 95% CI 1.22 to 5.02), and HIV infection (AOR = 2.88; 95% CI 1.28 to 6.52), and was inversely associated with recent overdose (AOR = 0.49; 95% CI 0.25 to 0.94). In comparison, 125 (18.8%) received non-team-based medical care, which was associated with university or college education (AOR = 2.31; 95% CI 1.04 to 5.15) and mental health comorbidity (AOR = 4.18; 95% CI 2.33 to 7.50), and was inversely associated with being detained in jail in the previous 12 months (AOR = 0.51; 95% CI 0.28 to 0.90).

CONCLUSION

Although team-based, integrated models of care will benefit disadvantaged groups the most, few PWUD receive such care. Policy makers should mitigate barriers to physician care and improve integration across health and social services.

A qualitative examination of substance use service needs among people who use drugs (PWUD) with treatment and service experience in Ontario, Canada

BACKGROUND

People who use drugs (PWUD) often have complex health and social support needs related to substance use, yet face numerous barriers to service access, resulting in unmet treatment needs and a corresponding gap in treatment. While initiatives to scale up substance use services for PWUD in Canada - and Ontario - have been undertaken, these have excluded PWUD' perspectives, and their needs have largely been defined by other actors. As end-users of services, PWUD' perspectives are vital to understanding what services are required, and whether existent services are adequate, appropriate and effective. Thus, the present study aimed to elicit in-depth knowledge from PWUD with lived experience of accessing services to better understand their unmet treatment and service needs, towards closing the service and treatment gap in Ontario.

METHODS

This qualitative study included one-on-one interviews conducted with a cohort of n = 45 adult PWUD with substance use and treatment experience in Ontario, Canada. Participants were recruited from substance use services based on ConnexOntario's directory of all provincial addiction services, as well as by word-of-mouth. Questions focused on participants' experiences and perspectives on substance use services towards understanding their service needs. Data underwent an inductive thematic analysis based on key themes that emerged.

RESULTS

Participants commonly engaged in polysubstance use, and identified a number of unmet substance use service needs including complex factors within the current service system that influenced access to available programs. Specifically, participants suggested the need to address stigmatization and system fragmentation, increase service provision and capacity, and scale up specific services and related supports such as harm reduction, counseling, treatment, and housing.

CONCLUSIONS

This study identified PWUD' needs in relation to substance use service provision in Ontario, Canada, and highlighted important areas for policy change and program planning and implementation. Concrete recommendations include the development of a government-funded, low-barrier, comprehensive and integrated service delivery and referral models that include PWUD as collaborators and program facilitators to ensure that services are as accessible, effective, and cohesive as possible. Results from this study can be used to enhance provincial substance use treatment and service provision.

A cross-sectional study of factors associated with unstable housing among marginalized people who use drugs in Ottawa, Canada

Introduction

Housing affects an individual’s physical and mental health, particularly among people who use substances. Understanding the association between individual characteristics and housing status can inform housing policy and help optimize the care of people who use drugs. The objective of this study was to explore the factors associated with unstable housing among people who use drugs in Ottawa.

Methods

This is a cross-sectional analysis of data from 782 participants in the Participatory Research in Ottawa: Understanding Drugs (PROUD) Study. PROUD is a prospective cohort study of people who use drugs in Ottawa. Between March and December 2013, participants were recruited through peer-based recruitment on the streets and in social services settings and completed a peer-administered questionnaire that explored socio-demographic information, drug use patterns, community integration, experiences with police and incarceration, and access to health care and harm reduction services. Eligibility criteria included age of 16 years or older, self-reported illicit drug use within the past 12 months and having lived in Ottawa for at least 3 months. Housing status was determined by self-report. “Stable housing” was defined as residence in a house or apartment and “unstable housing” was defined as all other residence types. Exploratory multivariable logistic regression analyses of the association between characteristics of people who use drugs and their housing status were conducted.

Results

Factors that were associated with unstable housing included: recent incarceration; not having a regular doctor; not having received support from a peer worker; low monthly income; income source other than public disability support payments; and younger age. Gender, language, ethnicity, education level, opioid use and injection drug use were not independently associated with housing status.

Conclusions

People who use drugs face significant barriers to stable housing. These results highlight key areas to address in order to improve housing stability among this community.

Changes in substance supply and use characteristics among people who use drugs (PWUD) during the COVID-19 global pandemic: A national qualitative assessment in Canada

BACKGROUND

People who use drugs (PWUD) may be at an increased risk of experiencing negative effects related to COVID-19. Border and non-essential service closures may have placed PWUD at an increased risk of experiencing unintended consequences regarding drug consumption and supply patterns, as well as related outcomes. However, the extent of these effects upon this population is unknown. The current study examined how COVID-19 has impacted substance use supply and use characteristics among a national cohort of PWUD in Canada.

METHODS

We conducted semi-structured one-on-one telephone-based interviews with 200 adult PWUD across Canada who were currently using a licit or illicit psychoactive substance at least weekly, and/or currently receiving opioid agonist treatment (OAT). Thematic analyses were conducted using qualitative software.

RESULTS

PWUD attributed adverse changes to their substance use frequency, supply, use patterns, and risk behaviors and outcomes to COVID-19. Many participants noted supply disruptions with the majority indicating a decrease in potency and availability, and an increase in the price of substances since COVID-19. Nearly half of participants specified that they had increased their substance use, with some experiencing relapses. In terms of changes to risk level, many participants perceived they were at a greater risk for experiencing an overdose.

CONCLUSION

This study demonstrated the impacts of COVID-19 on PWUD, including a significant disruption substance supply. For many, these changes led to increased use and substitution for toxic and adulterated substances, which ultimately amplified PWUD's risk for experiencing related harms, including overdoses. These findings warrant the need for improved supports and services, as well as accessibility of safe supply programs, take home naloxone kits, and novel approaches to ensure PWUD have the tools necessary to mitigate risk when using substances.

Identifying the impacts of the COVID-19 pandemic on service access for people who use drugs (PWUD): A national qualitative study

INTRODUCTION

Closures and reductions in capacity of select health and social services in response to the COVID-19 pandemic may have placed people who use drugs (PWUD) at a disproportionately increased risk for experiencing harms, and resulted in critical treatment disruptions. We conducted the current national study among a cohort of PWUD to understand how COVID-19 has affected service access, including any significant impacts PWUD may have experienced. Results will contribute to the evidence base for informing future pandemic and public health policy planning for vulnerable populations.

METHODS

The project involved qualitative telephone-based interviews with 196 adult (aged 18+) PWUD from across Canada. Eligibility criteria included daily or weekly use of psychoactive substance(s), and/or current enrollment in opioid agonist treatment (OAT). Data collection took place between May and July 2020. Data underwent thematic analyses, and common themes informed the results.

RESULTS

Most participants experienced detrimental service access issues and treatment disruptions during COVID-19, including reduced access to harm reduction services, OAT, withdrawal management and treatment services, medical professionals (e.g., addictions and mental health counseling), shelters/housing, and food banks. Positive impacts included greater access to OAT take-home 'carries' and prescription deliveries. Decreases in service capacity resulted in increased health issues and risky substance use behaviors among PWUD, such as unaccompanied substance use, sharing/re-use of supplies, and overdose events.

CONCLUSIONS

Reductions in the accessibility of critical services PWUD rely on during COVID-19 has increased existent substance use and health issues among PWUD, while decreasing their ability to mitigate risks related to substance use. Thus, the expansion of the depth and breadth of support options is crucial. Services must remain open and flexible to the unique needs of PWUD during COVID-19, while novel and effective adaptations and interventions should remain available and accessible post-COVID-19.

Compact, portable, laser induced fluorescence diagnostic for laboratory plasma sources

As diagnostic groups are increasingly called upon to participate in experimental campaigns at remote facilities, there is a need to develop portable versions of plasma diagnostic systems. One such diagnostic is laser induced fluorescence (LIF). Here, we describe a portable LIF apparatus that eliminates the need for an optical table, beam splitters, and an optical chopper. All of the light exiting the laser system is coupled through optical fibers to the experiment and housekeeping diagnostics. The collected light is coupled through an optical fiber as well. A key feature is modulation of the tapered amplifier current instead of physical modulation of the laser output. Using this portable LIF system, measurements of ion temperature, ion flow, and relative metastable ion density are reported for two different remote experiments.

Symposium review: Linking activity-sensor data and physiology to improve dairy cow fertility

Several studies have demonstrated that the intensity of estrous expression is associated with ovulation, ovarian and uterine function, and fertility, and is dependent on social hierarchy and the housing system used. Data from recent studies involving spontaneous and induced estrus have shown that a greater relative increase and longer estrus (captured by different automated activity monitors; AAM) are both associated with improved pregnancy per artificial insemination (AI; around 10 to 14% increase) and decreased pregnancy losses. Intensity and duration of estrus were surprisingly weakly associated with preovulatory follicle diameter and concentrations of plasma estradiol at estrus, whereas ovulation failure was associated with low estrus intensity. Studies have also shown that the display of estrous behavior near AI was associated with the modification of expression of genes related to the immune system, adhesion molecules, and prostaglandin synthesis in the endometrium. Transcripts in leukocytes and in the conceptus tissue associated with maternal recognition of pregnancy as well as conceptus elongation were all associated with differences in the intensity of estrous expression. Most recently, studies from the United States and Canada have demonstrated that reproductive programs emphasizing detection of estrus using AAM can be successful and comparable to intensive timed AI protocol-based programs that incorporate GnRH and PGF_2α treatments. Further, one study concluded that the administration of GnRH at AI for spontaneous estrus events greatly improved pregnancy per AI, but only for cows with reduced intensity of estrous expression, showing the potential to use AAM data as a tool in targeted reproductive programs. Quantitative information from estrus events could be used to improve estrus detection and develop decision-making strategies at the farm level. Future studies in this field should aim to better understand ovarian, conceptus, and endometrial mechanisms associated with either the expression or the intensity of estrus, and to refine the identification of phenotypes related to estrus (relative increase, absolute increase, baseline levels, duration, and repeatability within cow) to improve data usage, estrus detection, and possibly genetic selection.

Engagement in primary health care among marginalized people who use drugs in Ottawa, Canada

BACKGROUND

There may be less primary health care engagement among people who use drugs (PWUD) than among the general population, even though the former have greater comorbidity and more frequent use of emergency department care. We investigated factors associated with primary care engagement among PWUD.

METHODS

The Participatory Research in Ottawa: Understanding Drugs (PROUD) cohort study meaningfully engaged and trained people with lived experience to recruit and survey marginalized PWUD between March-December 2013. We linked this survey data to provincial-level administrative databases held at ICES. We categorized engagement in primary care over the 2 years prior to survey completion as: not engaged (< 3 outpatient visits to the same family physician) versus engaged in care (3+ visits to the same family physician). We used multivariable logistic regression to determine factors associated with engagement in primary care.

RESULTS

Characteristics of 663 participants included a median age of 43 years, 76% men, and 67% living in the two lowest income quintile neighborhoods. Despite high comorbidity and a median of 4 (interquartile range 0-10) primary care visits in the year prior to survey completion, only 372 (56.1%) were engaged in primary care. Engagement was most strongly associated with the following factors: receiving provincial benefits, including disability payments (adjusted odds ratio [AOR] 4.14 (95% confidence interval [CI] 2.30 to 7.43)) or income assistance (AOR 3.69 (95% CI 2.00 to 6.81)), having ever taken methadone (AOR 3.82 (95% CI 2.28 to 6.41)), mental health comorbidity (AOR 3.43 (95% CI 2.19 to 5.38)), and having stable housing (AOR 2.09 (95% CI 1.29 to 3.38)).

CONCLUSIONS

Despite high comorbidity, engagement in primary care among PWUD was low. Our findings suggest that social care (housing, disability, and income support) and mental health care are associated with improved primary care continuity; integration of these care systems with primary care and opioid substitution therapy may lessen the significant morbidity and acute care use among PWUD.

Hepatitis C Testing, Status and Treatment among Marginalized People Who Use Drugs in an Inner City Setting: An Observational Cohort Study

BACKGROUND

Chronic hepatitis C virus (HCV) infection is common among people who inject drugs (PWID) and is associated with morbidity and premature death. Although HCV can be cured, treatment may be inaccessible. We studied HCV testing, status and treatment among marginalized people who use drugs in Ottawa, Canada, a setting with universal insurance coverage for physician services.

METHODS

We analyzed data from the Participatory Research in Ottawa: Understanding Drugs study, a cross-sectional, peer-administered survey of people who use drugs from 2012 to 2013. We linked responses to population-based health administrative databases and used multivariable Poisson regression to identify factors independently associated with self-reported HCV testing, self-reported positive HCV status, and database-determined engagement in HCV treatment.

RESULTS

Among 663 participants, 562 (84.8%) reported testing for HCV and 258 (45.9%) reported HCV-positive status. In multivariable analysis, HCV-positive status was associated with female gender (RR 1.27; 95%CI 1.04 to 1.55), advancing age (RR 1.03/year; 95%CI 1.02 to 1.04), receiving disability payments (RR 1.42; 95%CI 1.06 to 1.91), injecting drugs (RR 5.11; 95%CI 2.64 to 9.91), ever injecting with a used needle (RR 1.30; 95%CI 1.12 to 1.52), and ever having taken methadone (RR 1.26; 95%CI 1.05 to 1.52). Of HCV positive participants, 196 (76%) were engaged in primary care but only 23 (8.9%) had received HCV therapy. Conclusions/Importance: Although HCV testing and positive status rates are high among PWID in our study, few have received HCV treatment. Innovative initiatives to increase access to HCV treatment for PWID are urgently needed.

96 Association between metabolic diseases and fertility of high-yielding dairy cows in a transition management facility using survival analysis and machine-learning models

This study aimed to evaluate the association between individual and multiple metabolic diseases (MD and MD+) diagnosed during the transition period (±3 wk relative to calving) and the probability of pregnancy until 210 days in milk (DIM) in Holstein-Friesian dairy cows. Disease and reproductive data from a dairy herd with 1946 calvings (n=542 primiparous and n=1404 multiparous cows) were analysed using a 1-year cohort. The recorded MD were milk fever, ketosis, displaced abomasum, retained placenta, metritis, twinning, and clinical mastitis. The association between the 210-DIM pregnancy risk and the MD was evaluated as MD cows (uncomplicated cases) v. MD+ cows (complicated cases) v. healthy cows (3 groups of cows). Univariable survival models were used to analyse the association of MD and MD+ with pregnancy until 210 DIM, accounting for parity. Univariable Cox proportional hazard models were used to quantify the relative risk of pregnancy per day. A hierarchically ordered decision tree and a random forest model were built to explore the importance of MD and parity on the pregnancy risk within the first 210 DIM. Parity affected the 210-DIM pregnancy risk (P&lt;0.001); therefore, all further analyses were stratified by parity. The incidence of MD and MD+ for primiparous and multiparous cows were 29 (n=159) and 9% (n=48), and 23 (n=317) and 11% (n=160), respectively. The overall 210-DIM pregnancy risk was 77% (n=415) for primiparous cows and 62% (n=879) for multiparous cows. Among healthy cows (no MD) the 210-DIM pregnancy risk was 80% (n=269) for primiparous cows and 82% (n=537) for multiparous cows. Conversely, the 210-DIM pregnancy risk for cows with MD or MD+ were 73 (n=116) and 63% (n=30) for primiparous and 48 (n=152) and 46% (n=74) for multiparous cows, respectively. Using the healthy cows as the reference, the 210-DIM hazard ratios for conception were 0.8 for MD [95% confidence interval (CI)=0.6-1.0; P=0.05] and 0.5 for MD+ (95% CI=0.4-0.8; P=0.005) for primiparous cows and 0.5 for MD (95% CI=0.4-0.6; P&lt;0.001) and 0.4 for MD+ (95% CI=0.3-0.6; P&lt;0.001) for multiparous cows. Parity had profound effect on the 210-DIM pregnancy risk. The hazard ratio for conception was reduced when a MD was complicated with another MD (MD+) in both primiparous and multiparous cows. Both the decision tree and random forest analysis also indicated that parity was the most influential variable reducing fertility among cows, followed by (in order of magnitude of effect) milk fever, displaced abomasum, ketosis, and clinical mastitis. Including multiple disease interactions into multivariable Cox proportional hazard models are highly likely to violate the proportional hazards assumption due to complex disease interactions. Machine-learning models represent a valid alternative to accommodate large datasets in the presence of missing values and intricate dependencies among explanatory variables.

Primary health care engagement among marginalized people who use drugs in Ottawa, Canada

IntroductionEngagement in primary health care may be lower among marginalized people who use drugs (PWUD) compared to the general population, despite having greater mental and physical healthcare needs as evidenced by higher co-morbidity, and more frequent use of emergency department care. Objectives and ApproachWe investigated which socio-structural factors were related to primary care engagement among PWUD using rich survey data from the Participatory Research in Ottawa: Understanding Drugs cohort study; these data were deterministically linked to several robust provincial-level health administrative databases held at the Institute for Clinical Evaluative Sciences. We defined primary care engagement over the 2 years prior to survey completion (March-December 2013) as: not engaged (<3 outpatient visits to the same family physician) versus engaged in care (3+ outpatient visits to the same family physician). Multi-variable logistic regression was used to identify factors associated with primary health care engagement. ResultsAmong 663 participants, characteristics include: mean age of 41.4 years, 75.6% male, 66.7% in the lowest two income quintiles, and 51.1% with 6+ co-morbidities. 372 (56%) were engaged in primary care, with a mean of 15.97 visits per year (SD=20.18). Engagement was significantly associated with the following factors: receiving drug benefits from either the Ontario Disability Support Program (adjusted odds ratio [AOR] 4.48; 95% confidence interval [95%CI] 2.64 to 7.60) or Ontario Works (AOR 3.41; 95%CI 1.96 to 5.91), having ever taken methadone (AOR 3.05; 95%CI 1.92 to 4.87), mental health co-morbidity (AOR 2.93; 95%CI 1.97 to 4.36), engaging in sex work in the last 12 months (AOR 2.05; 95%CI 1.01 to 4.13), and having stable housing (AOR 1.98; 95%CI 1.30 to 3.01). Conclusion/ImplicationsNearly half of PWUD are not engaged in primary care, representing missed opportunities to improve health. Engagement in primary care may reflect both an increased need for health care, such as mental health disability, and increased access to primary care through other health and social services, such as housing support.

A cohort study examining emergency department visits and hospital admissions among people who use drugs in Ottawa, Canada

Background

The health of people who use drugs (PWUD) is characterized by multimorbidity and chronicity of health conditions, necessitating an understanding of their health care utilization. The objective of this study was to evaluate emergency department (ED) visits and hospital admissions among a cohort of PWUD.

Methods

We used a retrospective observational design between 2012 and 2013. The population was a marginalized cohort of PWUD (the PROUD study) for whom survey data was linked (n = 663) to provincial health administrative data housed at the Institute for Clinical Evaluative Sciences. We constructed a 5:1 comparison group matched by age, sex, income quintile, and region. The main outcomes were defined as having two or more ED visits, or one or more hospital admissions, in the year prior to survey completion. We used multivariable logistic regression analyses to identify factors associated with these outcomes.

Results

Compared to the matched cohort, PWUD had higher rates of ED visits (rate ratio [RR] 7.0; 95% confidence interval [95% CI] 6.5–7.6) and hospitalization (RR 7.7; 95% CI 5.9–10.0). After adjustment, factors predicting more ED visits were receiving disability (adjusted odds ratio [AOR] 3.0; 95% CI 1.7–5.5) or income assistance (AOR 2.7; 95% CI 1.5–5.0), injection drug use (AOR 2.1; 95% CI 1.3–3.4), incarceration within 12 months (AOR 1.6; 95% CI 1.1–2.4), mental health comorbidity (AOR 2.1; 95% CI 1.4–3.1), and a suicide attempt within 12 months (AOR 2.1; 95% CI 1.1–3.4). Receiving methadone (AOR 0.5; 95% CI 0.3–0.9) and having a regular family physician (AOR 0.5; 95% CI 0.2–0.9) were associated with lower odds of having more ED visits. Factors associated with more hospital admissions included Aboriginal identity (AOR 2.4; 95% CI 1.4–4.1), receiving disability (AOR 2.4; 95% CI 1.1–5.4), non-injection drug use (opioids and non-opioids) (AOR 2.2; 95% CI 1.1–4.4), comorbid HIV (AOR 2.4; 95% CI 1.2–5.6), mental health comorbidity (AOR 2.4; 95% CI 1.3–4.2), and unstable housing (AOR 1.9; 95% CI 1.0–3.4); there were no protective factors for hospitalization.

Conclusions

Improved post-incarceration support, housing services, and access to integrated primary care services including opioid replacement therapy may be effective interventions to decrease acute care use among PWUD, including targeted approaches for people receiving social assistance or with mental health concerns.

Single-Molecule FRET to Measure Conformational Dynamics of DNA Mismatch Repair Proteins

Single-molecule FRET measurements have a unique sensitivity to protein conformational dynamics. The FRET signals can either be interpreted quantitatively to provide estimates of absolute distance in a molecule configuration or can be qualitatively interpreted as distinct states, from which quantitative kinetic schemes for conformational transitions can be deduced. Here we describe methods utilizing single-molecule FRET to reveal the conformational dynamics of the proteins responsible for DNA mismatch repair. Experimental details about the proteins, DNA substrates, fluorescent labeling, and data analysis are included. The complementarity of single molecule and ensemble kinetic methods is discussed as well.

Harnessing the power of community-based participatory research: examining knowledge, action, and consciousness in the PROUD study

Community-based participatory research (CBPR) is an approach to research that recognizes the specific knowledge and abilities that individuals from diverse backgrounds bring to the generation of new knowledge for the purpose of social action aimed at improving public health and health equity. In this article, the authors apply Gaventa and Cornwall's dimensions of participatory research to the analysis of 12 semistructured interviews with members of our Community Advisory Committee for the Participatory Research in Ottawa: Understanding Drugs (PROUD) study. This process-to-outcomes framework may help projects more systematically explore their experiences in relation to common CBPR principles and lead to greater conceptual clarity.

Establishing a community-based participatory research partnership among people who use drugs in Ottawa: the PROUD cohort study

Background

Grounded in a community-based participatory research (CBPR) framework, the PROUD (Participatory Research in Ottawa: Understanding Drugs) Study aims to better understand HIV risk and prevalence among people who use drugs in Ottawa, Ontario. The purpose of this paper is to describe the establishment of the PROUD research partnership.

Methods

PROUD relies on peers’ expertise stemming from their lived experience with drug use to guide all aspects of this CBPR project. A Community Advisory Committee (CAC), comprised of eight people with lived experience, three allies and three ex-officio members, has been meeting since May 2012 to oversee all aspects of the project. Eleven medical students from the University of Ottawa were recruited to work alongside the committee. Training was provided on CBPR; HIV and harm reduction; and administering HIV point-of-care (POC) tests so that the CAC can play a key role in research design, data collection, analysis, and knowledge translation activities.

Results

From March-December 2013, the study enrolled 858 participants who use drugs (defined as anyone who has injected or smoked drugs other than marijuana in the last 12 months) into a prospective cohort study. Participants completed a one-time questionnaire administered by a trained peer or medical student, who then administered an HIV POC test. Recruitment, interviews and testing occurred in both the fixed research site and various community settings across Ottawa. With consent, prospective follow-up will occur through linkages to health care records available through the Institute for Clinical and Evaluation Sciences.

Conclusion

The PROUD Study meaningfully engaged the communities of people who use drugs in Ottawa through the formation of the CAC, the training of peers as community-based researchers, and integrated KTE throughout the research project. This project successfully supported skill development across the team and empowered people with drug use experience to take on leadership roles, ensuring that this research process will promote change at the local level. The CBPR methods developed in this study provide important insights for future research projects with people who use drugs in other settings.

Effect of a monensin controlled release capsule on metabolic parameters in transition dairy cows

A prospective field study involving 251 Holstein cows and heifers from five dairy farms near Guelph, Ontario, Canada, was conducted to measure the effect of monensin delivered in a controlled release capsule 3 wk precalving on metabolic function in dairy cows immediately pre- and postcalving. At 3 wk before expected calving, cows were randomly assigned to receive either a controlled release capsule containing monensin or to serve as negative controls. Cows were blood sampled once per week precalving and once in the week following calving, at the same time of day and the same day of the week. Serum was evaluated for beta-hydroxybutyrate (BHBA), nonesterified fatty acids (NEFA), cholesterol, urea, glucose, calcium, and phosphorus. Monensin-treated cows had significantly decreased NEFA and BHBA and significantly increased concentrations of serum cholesterol and urea in the week immediately precalving. No effect of treatment was observed for calcium, phosphorus, or glucose in the precalving period. After calving, concentrations of phosphorus were lower and BHBA tended to be lower, and cholesterol and urea were higher in monensin-treated cows. There was no effect of treatment on NEFA, glucose, or calcium in the first week postcalving. Monensin treatment administered precalving significantly improved indicators of energy balance in both the immediate precalving and postcalving periods. The findings indicate better energy metabolism in monensin-treated cows as they approach calving. Improvement of energy balance before calving is important for the prevention of energy associated metabolic diseases, such as retained placenta, clinical ketosis, and displaced abomasum, which might occur immediately postcalving.

Prepartum monensin for the reduction of energy associated disease in postpartum dairy cows

A total of 1317 Holstein cows from 45 farms in the Canadian provinces of Quebec, Prince Edward Island (PEI) and Ontario were enrolled in a randomized trial during 1998 and 1999 to further confirm the efficacy of a monensin controlled release capsule in preventing periparturient disease in lactating dairy cows. Cows were randomized on the farms to receive either a monensin controlled release capsule (CRC) 2 to 4 wk before expected calving or to serve as negative controls. Health data were collected for 90 d postcalving and were analyzed with logistic regression accounting for the intraherd correlation with generalized estimating equations. Monensin CRC significantly reduced the incidence of both clinical ketosis and abomasal displacement post-calving. There was a numerical but nonsignificant decrease in the incidence of retained placenta in cows receiving a monensin CRC. A pooled analysis of two separate but similar studies (conducted in 1995 and 1998) demonstrated a strengthened association between monensin CRC administration precalving and reduced periparturient disease. A 40% reduction in both abomasal displacement and clinical ketosis was observed with precalving administration of a monensin CRC. In addition, the larger dataset highlighted a trend for a 25% reduction in the incidence of retained placenta in monensin-treated cows. Improved energy metabolism as a result of monensin treatment is likely the mechanism for the reduction in incidence of all three of these diseases. Thus the term "energy associated disease" was created to assess the combined impact of the precalving monensin treatment on the incidence of retained placenta, displaced abomasum, and clinical ketosis. The monensin controlled release capsule reduced the incidence of energy associated disease by 30%.

Laryngectomy clinical pathway: development and review

OBJECTIVE

The goal of the study is to determine if the implementation of a protocol for the preoperative and postoperative care of patients receiving a laryngectomy for cancer of the larynx or hypopharynx (i.e., laryngectomy clinical pathway) reduced length and cost of hospital stay without increasing complication rates.

DESIGN

This study is a comparison of the perioperative course of two groups of laryngectomy patients. Data were collected retrospectively from the records of patients operated on before the implementation of the clinical pathway as the institutional historical control. Comparison was made with data collected prospectively on patients operated on after the implementation of the clinical pathway.

SETTING

The study was performed at a mid-sized teaching hospital associated with two regional cancer centres. All surgeries were performed by one of two otolaryngology-head and neck surgeons and residents under their supervision.

METHODS

The demographic, patient, tumour, treatment, dietary, and complication data were analyzed. Fisher's exact (two-tailed) statistical test was used for parametric data and Wilcoxon scores for nonparametric data.

MAIN OUTCOME MEASURE

The principal outcome measure was the length of postoperative inpatient stay. Secondary outcome measures were readmissions and postoperative complications.

RESULTS

There was a statistically significant decrease of 6.7 days in the mean length of hospitalization in the clinical pathway group even when taking postoperative readmissions into account. There was no concomitant increase in surgical complications. The mean reduction in hospital cost per case was calculated to be $3,420 (Can).

CONCLUSIONS

Application of a clinical pathway for patients receiving laryngectomy is both feasible and effective.

Consistent associations of HLA class I and II and transporter gene products with progression of human immunodeficiency virus type 1 infection in homosexual men

Polymorphic products of genes in the HLA region contributing to variability in the course of human immunodeficiency virus type 1 (HIV-1) infection were identified by screening 375 Caucasian seroconverters who were aggregated from 3 cohorts. AIDS-free time was related to numerous (15) class I alleles, alone or in conjunction with transporter protein variants, to homozygosity at the A or B locus, and to alleles of two class II haplotypes. A prognostic scoring algorithm derived from the 3 cohorts captured multiple HLA contributions to protection or to risk (relative hazard=0.57-60 per unit increase in score, all P<<.001). The impact of HLA was strong and appeared independent of the effects of chemokine receptor/ligand polymorphisms and antiretroviral treatment. The algorithm also predicted divergent rates of CD4+ cell decline in 2 other groups, totaling 227 seropositive persons (P=.06 - <.001). Confirmation of these relationships should encourage investigation of HIV-1 antigen processing and presentation mediated by polymorphisms in the HLA region.

Same-day admission thyroidectomy programme: quality assurance study

OBJECTIVE

This study was conducted to evaluate the effectiveness of a same-day admission thyroidectomy programme.

DESIGN

Prospective patient surveys and a retrospective quality assurance study were conducted.

METHOD

Management of the initial 58 patients having a thyroidectomy at St. Joseph's Hospital, London, Ontario, after May 1992 when a same-day admission thyroidectomy programme was initiated, was evaluated. Early in the process, staff evaluation of the programme was also surveyed.

RESULTS

The average length of stay for these patients was reduced from 4.5 to 3.2 days. No operative delays, cancellations, readmissions, or increased complications resulted from the new protocol. Also, patient and staff acceptance of the new programme was high.

CONCLUSION

Our success with this programme has encouraged us to apply these concepts to more complex surgical patients.

A prospective randomized comparison of the accuracy of computer-assisted versus GUSTO nomogram--directed heparin therapy

Failure to adequately anticoagulate the blood of patients receiving recombinant tissue plasminogen activator (TPA) leads to greater rates of rethrombosis. In a multicentered, randomized trial in 51 patients we compared the ability to achieve and maintain therapeutic anticoagulation by use of computer-assisted heparin therapy or the GUSTO (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) heparin nomogram guidelines in patients with myocardial infarction treated with recombinant TPA. Heparin therapy was initiated with either computer-generated starting doses or GUSTO guideline starting doses. Activated partial thromboplastin times were measured every 6 to 8 hours for the first 24 hours. The therapeutic range used in this trial was 1.5 to 2.5 times the patient's baseline activated partial thromboplastin time (APTT). Ninety-four percent of the APTT ratios in the computer group were equal to or greater than 1.5 in the first 24 hours compared with 78% in the GUSTO group (p < 0.009). No significant difference in bleeding was found (7.7% for GUSTO; 4.2% for computer). Incremental time-dependent changes in heparin dose were found (day 1, 1110 +/- 243 units/hr, APTT ratio = 2.5 +/- 1.4; day 3, 1380 +/- 374 units/hr, APTT ratio, 1.9 +/- 0.4). Computer-assisted heparin therapy TPA results in superior anticoagulation accuracy compared with the GUSTO guidelines. In addition, the pharmacodynamic response to heparin changes in the 2 to 3 days after administration of TPA, leading to greater heparin requirements.

High-dose ara-C and etoposide in refractory or relapsing acute leukemia

A total of 32 patients (15 men and 17 women) presenting with relapsing or refractory acute leukemia were treated with a 3-h infusion of 3 g/m2 cytosine arabinoside (ara-C) twice daily on days 1-6 and a 1-h infusion of 100 mg/m2 etoposide on days 1-5. In all, 6 subjects had acute lymphocytic leukemia (ALL); 25 had acute myeloid leukemia (AML) of types M1 (n = 6), M2 (n = 10), M4 (n = 5), and M5 (n = 4); and 1 had mixed-type leukemia. The median age was 35 years (ranges, 16-62 years). Of the patients presenting with AML, 11 were primarily refractory and 3 became refractory after their first relapse. Six subjects had an early first relapse following a complete remission (CR) that lasted less than 6 months and five, a second relapse. Another patient underwent a primary relapse after greater than 6 months but had been heavily pretreated. In all, 5 subjects with refractory AML achieved a CR (36%; 95% confidence interval (CI), 10%-62%) as did 7 patients exhibiting relapsing AML (58%; CI, 30%-86%). Three patients who had relapsing or resistant ALL achieved a CR. Side effects consisted of severe hematotoxicity associated with granulocytopenia of less than 500/mm3 that lasted for a mean of 23.6 days and thrombocytopenia of less than 20,000/mm3 whose mean duration was 20.8 days. Marked gastrointestinal toxicity and infections were also prevalent. Cutaneous and ocular toxicity as well as allergic, pulmonary and cerebellar side effects were observed in a few cases. We conclude that the combination of high-dose ara-C and etoposide is a powerful but toxic induction regimen for refractory or relapsed acute leukemia.

Recombinant human interferon (IFN) alpha-2b in chronic myelogenous leukaemia: dose dependency of response and frequency of neutralizing anti-interferon antibodies

Twenty-seven patients with Philadelphia chromosome positive chronic myelogenous leukaemia in the chronic phase were treated with low doses of recombinant interferon (IFN) alpha-2b. Ten patients entered a complete and six a partial haematologic remission with a median duration of 5.8 and 9.1 months respectively. Five minor cytogenetic responses were observed. These results are inferior compared to other studies with higher interferon-doses. Fever was an acute side effect after injection of IFN, limb pains and fatigue occurred protractedly. Haematologic side effects, nonspecific EEG changes, weight loss, and development of pulmonary infiltrates were observed in later periods of the treatment. Eight patients developed neutralizing anti-IFN antibodies after 4.2-20.4 months (median 12.8 months). Anti-IFN antibodies were associated with relapse or refractoriness to IFN treatment: five out of nine patients with rising WBC after initial fall had antibodies, while four did not. Two out of four patients with primary non-response had IFN-antibodies. These results may indicate a serious problem in the long-term treatment of CML with recombinant interferon.

[Standardisation of TRH test for the exact determination of thyroxine treatment (author's transl)]

A TRH test was performed on 50 patients treated on a daily thyroxine dose of 50-200 microgram. Results were compared with a test performed at the earliest three weeks on the same thyroxine dosage, but the latter having been interrupted for 24 hours. In the first case T4 was 8.96 +/- 2.9 microgram/dl, in the second 7.08 +/- 2.0 microgram/dl; T3 in the first case 1.28 +/- 0.3 ng/ml, in the second 1.03 +/- 0.25 ng/ml. This indicates that with both thyroid hormones the levels were higher on the day of administration than 24 hours later. Correspondingly, TRH-stimulated TSH secretion was definitely lower on the day of treatment. delta TSH (TSH after 30 minutes minus TSH zero value) was 16.1 +/- 26.5 on day of treatment, 27.3 +/- 35.6 micro U/ml after pause. Accordingly, to achieve "fine tuning" of T4 treatment, such as for euthyroid goitre, the TRH tests standardised on 200 microgram TRH should be performed after a T4-free 24-hour interval. delta TSH should then not be more regimen, drug-induced hyperthyroidism can be definitely avoided.

[On the question of cortisol administration in adrenocortical insufficiency (author's transl)]

The question whether clinically normal adrenal cortical function can be satisfactorily checked by laboratory studies during substitution treatment with adrenocortical hormones was investigated in 39 patients with adrenal insufficiency. The routine measurement of serum cortisol levels (2 to maximally 7 hours after the morning dose of hydrocortisone or cortisone acetate) revealed marked individual variations which were relatively independent of the morning dosage. Similar extreme variations were found for free urinary corticoids in 24-hour urine. Both values could not be correlated with the clinically individualised and satisfactory long-term substitution dosage and cannot be used, therefore, in the customary manner to assess a normal hormonal state. It appears unlikely that such information can altogether be obtained from plasma levels.