Background Although taxes that raise retail tobacco prices and industry-initiated price increases have been shown to decrease tobacco consumption, the scarcity of studies in Latin America and the Caribbean using household- or individual-level data in existing reviews limits their policy relevance. Objective To conduct a systematic review and meta-analysis to assess the association between prices and taxes and the use of tobacco products in Latin America and the Caribbean. Methods We searched six electronic bibliographic databases, two online search engines, two working paper repositories, and hand-searched seven journals. We included all quantitative studies that used any measures of individual or household tobacco use as an outcome, written in English, Portuguese or Spanish. We used random-effects meta-analyses to pool results across studies. Results We found consistent evidence that in Latin American countries, higher cigarette prices were associated with lower cigarette smoking participation, consumption and initiation and that effect sizes were large enough to be policy meaningful. Pooled own-price elasticities indicate that higher prices were associated with a less than proportional decrease in tobacco use (pooled own-price elasticities, participation: –0.14 [95%CI –0.22, –0.06]; consumption: –0.54 [95%CI –0.75, –0.34]; total: -0.75 [95%CI -1.14, -0.36]). We found no consistent evidence that socioeconomic status, age, sex, rurality, or geographic regions affected price responsiveness. Conclusions Our review confirms that taxes that raise tobacco prices can effectively lower tobacco use. Moreover, raising tobacco prices through increased taxes is anticipated to boost tax revenue due to the inelastic nature of the demand for tobacco.

Context: Organizational leadership is essential for adequate and stable financing, strong governance across jurisdictions and sectors, and a competent public health workforce for effective and resilient public health systems. While there have been some efforts to characterize leadership competencies at the individual level, more focus is needed to understand effective governance of public health organizations and systems through the lens of leadership competencies at the organizational level. Objective: To identify organizational level leadership competencies for effective and equitable public health governance. Design: This scoping review included published academic literature from Scopus, Web of Science, Medline, and ProQuest and grey literature from Google Scholar, Canadian Government websites, Trove, FedSys, and Open Grey, published between 2004 and 2023. The search strategy focused on the concepts of governance, leadership, and pub-lic health organizations. An inductive-deductive approach informed the analysis using reflexive thematic analysis and a framework outlining the six functions of public health governance. Results: A total of 35 records were included for analysis; 22 academic and 13 grey literature records. This review identified 9 themes describing organizational leadership competencies for public health governance: 1) Systems thinking 2) Public policy development, implementation and evaluation, 3) Partnership and collaboration, 4) Equity and justice 5) Organizational learning, 6) Oversight, 7) Resource stewardship, 8) Legal authority, 9) Organizational ethics. Conclusions: This scoping review contributes to our understanding of the leadership competencies needed to enact and sustain effective governance at an organizational level. These identified themes and associated competencies can facilitate the creation of organizational culture and values that align with effective governance tenets in public health. Additional research is needed to further apply and contextualize these competencies in different countries and public health settings.

Objective: This scoping review investigates the potential of 6G technology in healthcare, particularly in smart city settings, focusing on its enhanced data capabilities, AI's role in healthcare optimization, infrastructure support, interoperability, quality standards, and privacy and security concerns. Patients and methods: The scoping review followed the Arksey and O'Malley framework, with Levac et al.'s methodological advancements. The review team searched academic databases like PubMed/Medline, SCOPUS, Embase, Web of Sciences, and IEEE Xplore. They also explored grey literature sources like Google Scholar, OpenGrey, and Web of Science Conference Proceedings. A search strategy was developed, and 145 studies were selected from an initial pool of 9835 records from 2010 to 2025. The review categorized 145 studies into three phases, focusing on deploying 6G technology in healthcare, the infrastructure required, and ethical considerations related to the technology's ethical implications. Result: Phase one focused on advancements like real-time imaging, performing medical procedures remotely, using predictive tools to analyze data, and providing care tailored to individual patients. Phase two examined how the next generation of wireless technology (6G) could interact with communication systems, including techniques to handle large amounts of data (massive MIMO) and using extremely high-frequency signals (terahertz communications) to transfer information faster. Phase three explored ethical concerns about applying 6G technology, such as systems that make decisions based on user intentions (intent-driven management) and organizing information around data-based designs (data-driven architecture). The review highlights how 6G technology could revolutionize patient care and medical services by enabling faster data transfers, reducing delays, increasing system capacity, and incorporating artificial intelligence. Conclusion: The scoping review shows the capability of the transformative potential of 6G technology, particularly in healthcare and urban development, emphasizing its enhanced data transfer speeds, reduced latency, and increased capacity that can significantly improve patient care through better remote monitoring, security, and telemedicine services. It stresses the vital role of policymakers in guiding the development of 6G infrastructure, ensuring effective spectrum allocation, and implementing robust security measures while addressing health and electromagnetic exposure concerns. Policymakers are urged to adopt security-by-design principles, adhere to international standards, and foster collaboration among academia, industry, and government to drive innovation and ensure the responsible deployment of 6G technology. By stimulating research and establishing clear performance metrics, they can facilitate continuous improvement and adaptation, ultimately benefiting society as a whole. The review concludes that strategic policy formulation is essential for maximizing the advantages of 6G technology, leading to more intelligent, productive, and sustainable societal frameworks.

Abstract Over the past two decades, private equity investment in health care has increased substantially. Proponents argue that private equity can optimize and improve health services, while critics warn that the business model of these firms is not aligned with the social values of care delivery and has harmful consequences for health systems and patients. It remains unclear to what extent - and how - subnational, national and supranational governments have attempted to regulate this activity. The purpose of this study therefore was to identify examples of implemented and proposed policy options for regulating private equity activity within health care, with the goal of elucidating the policy options available to regulators. We conducted a narrative review to identify proposed or implemented policy instruments in selected high-income countries, grouping them by type using a conceptual framework based on the works of Milton Friedman and Avedis Donabedian. Our search identified several examples of proposed or implemented policy options for addressing private equity activity in the countries under review. Most of these intervention examples fall into the category of disclosure, while only one focused on regulation of outcomes. Our study suggests that while some countries have started to develop policy interventions to directly address the role of private equity in health care, other countries do not specifically regulate private equity activity.

Individuals born with Trisomy 21 may be more susceptible to experiencing nutrition-related conditions and diseases throughout their lifespan. Seven studies conducted outside of Canada that investigated the impact of nutrition interventions in individuals of different ages (mostly children and youth) born with Trisomy 21 reported mixed results. Furthermore, Canadian clinical nutrition practice guidelines for the provision of care to individuals born with Trisomy 21 tend to be general in nature and may be based on a body of evidence that was not representative of this population. There is a need for well-designed inclusive nutrition research studies to determine the nutritional needs of individuals born with Trisomy 21 and to better understand how to provide person-centred nutrition and healthcare services that achieve nutrition and health equity for these individuals and improve their overall nutritional status and health.

Background: Enhanced recovery after cesarean delivery protocols include evidence-based interventions designed to improve patient experience, pregnancy, and neonatal outcomes while reducing healthcare-related costs. This is the first update of the Enhanced Recovery After Surgery Society guidelines for antenatal and preoperative care before cesarean delivery after the original publication in 2018. Methods: Interventions were selected based on expert consensus using the Delphi method. An updated literature search was conducted in September 2024 using the Embase, PubMed, MEDLINE, EBSCO CINAHL (Cumulative Index of Nursing and Allied Health Literature), Scopus, and Web of Science databases. Targeted searches were performed by a medical librarian to identify relevant articles published since the 2018 Enhanced Recovery After Surgery Society guidelines publication, which evaluated each antenatal and preoperative enhanced recovery after cesarean delivery intervention, focusing on randomized clinical trials and large observational studies (≥800 patients) to maximize search feasibility and relevance. Following a review of the evidence, a consensus was reached regarding the quality of evidence and the strength of recommendation for each proposed intervention according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Results: The 6 recommended enhanced recovery after cesarean delivery interventions are (1) antenatal pathway patient education for scheduled caesarean delivery (evidence low to very low, recommendation strong); (2) multidisciplinary medical and surgical staff education regarding enhanced recovery after cesarean delivery support, intervention implementation, and measurement (evidence low, recommendation strong); (3) optimization of the medical care for pregnant patients with comorbid conditions, such as anemia, obesity, hypertension, prepregnancy and gestational diabetes, smoking (tobacco, cannabis, vaping), congenital heart disease, epilepsy, autoimmune disease, and asthma (evidence moderate, recommendation strong); (4) abdominal skin preparation with chlorhexidine gluconate impregnated cloth (evening before scheduled cesarean delivery) (evidence moderate; recommendation weak); (5) the duration of preoperative fasting based on the content intake (evidence low, recommendation weak); (6) the use of a preoperative, nonparticulate carbohydrate drink (evidence low-moderate, recommendation strong). Conclusion: The first 3 recommendations are for use in the antenatal period (10-38 weeks of gestation), which allow for the optimization of patient comorbidities, whereas the remaining 3 recommendations are for preoperative interventions (skin preparation, preoperative fasting directives, and preoperative carbohydrate supplementation). Educational tools for cesarean delivery with well-designed shared decision-making focus on comorbidity management should be developed. These management tasks are viewed as routine care; however, the measurable success and impact have clinical variance. The enhanced recovery after cesarean delivery goal for patients who are undergoing a scheduled caesarean delivery is to maximize the quality of the pregnant patient's recovery and the fetal-neonatal outcome.

Social media can be an important source of clinical neuroscience information for healthcare users (e.g., patients, healthcare providers, the general public). This systematic review synthesized evidence on the effectiveness of social media strategies in translating knowledge and disseminating clinical neuroscience information to healthcare users. A systematic review of six electronic databases up to July 29, 2024 was conducted. Original, peer-reviewed articles examining the effectiveness of YouTube, Facebook, LinkedIn, Twitter, social media messaging apps, or a combination of these platforms in translating clinical neuroscience information to healthcare users (e.g., patients, healthcare providers, caregivers, and the general public) were eligible for inclusion. Several proxies (e.g., change in uptake of research, change in awareness, change in knowledge, change in understanding, behaviour change, and/or change in social media metrics) were considered as outcomes of knowledge translation (KT) effectiveness. Two independent reviewers screened articles and assessed risk of bias. The protocol was registered on PROSPERO (ID: CRD42021269034). A total of six studies were included in this review. The included studies used YouTube, Facebook, Twitter, or a combination of social media platforms aimed at healthcare users. Most social media strategies used to disseminate clinical neuroscience information in the included studies (N = 5/6) resulted in improved indicators of KT. However, due to the high risk of bias among the included studies, these results must be interpreted with caution. Disseminating clinical neuroscience information via Facebook, Twitter, YouTube, or a combination of these platforms may achieve the goals of KT. However, there is currently a gap in the literature about clinical neuroscience KT via social media, both in the quantity of studies and quality of evidence. Future research should aim to minimize the risk of bias by controlling for important confounding factors and use objective measures of KT to complement subjective measures.

International migration is contributing to changes in the sociocultural and the economic landscapes of many cities in the world. As part of the changes in cities, we are witnessing an increased use of community gardens as spaces for wellbeing restoration, for social connection, and for addressing the challenge of food insecurity, particularly cultural food insecurity. Cultural food security is one major under-recognized issue, yet is pivotal to address given its role in positively supporting immigrants' settlement and health. However, there is lack of comprehensive evidence of how neighborhoods are changing to accommodate these initiatives and meet the cultural food needs of diverse communities. Our scoping review explored evidence from existing literature on how neighborhoods are changing to accommodate community gardens (CG) as a novel means to address cultural food insecurity among immigrant communities and support place-making and resettlement. Our literature search identified several areas of transformations including the different kinds of community gardens that have emerged, the associated physical, social, cultural, environmental, economic, and policy changes that have been reported in other countries in the Global North. The review also identified multifold benefits of CG in this regard, including benefits to health and wellbeing - the physical (i.e. nutrition and physical activity), mental (e.g., a place for healing for immigrants fleeing war-torn countries, domestic violence, trauma; fostering a connection to the land in new environments via place-making), and social (e.g., fostering community connections and cultural knowledge exchange). Despite the known benefits of community gardens to immigrants' health and wellbeing, there remains a lack of comprehensive evidence in Canada on how neighborhoods are changing to accommodate these initiatives and meet the cultural food needs of diverse communities. Such studies will serve as sources of evidence for novel ideas to address the cultural food needs and food insecurity of immigrant communities, which is becoming a growing public health concern.

Objectives: The charge of the newly formed Society of Critical Care Medicine Sustainability Task Force is to describe actionable items supporting environmental stewardship for ICUs, to discuss barriers associated with sustainability initiatives and outline opportunities for future impact. Data sources: Ovid Medline, EBSCOhost CINAHL, Elsevier Embase, and Scopus databases were searched through to March 2024 for studies reporting on environmental sustainability and critical care. Study selection: Systematic reviews, narrative reviews, quality improvement projects, randomized clinical trials, and observational studies were prioritized for review. Bibliographies from retrieved articles were scanned for articles that may have been missed. Data extraction: Data regarding environmental sustainability initiatives that aimed to quantify, manage, or mitigate pollution and/or carbon emissions with a focus on ICUs, barriers to change, and opportunities for development were qualitatively assessed. Data synthesis: ICUs are resource-intensive and as such, methods to attenuate carbon emissions and waste can play a substantial role in mitigating the sizable burden of healthcare-related pollution and greenhouse gas emissions. Several initiatives and strategies exist for clinicians and providers to engage in environmental stewardship, with specific attention to avoiding low-value care while maintaining or improving patient safety and high-quality care. Increased focus on sustainability can be met with resistance to change, including institutional, financial, and behavioral barriers. Collaboration and innovative thinking create valuable opportunities for clinicians, patients, families, and policymakers to advocate for patient and planetary health. Conclusions: Within the healthcare system, ICUs are well positioned to lead sustainability action, policy, and practice. Critical care teams have the capability and the moral responsibility to mitigate the negative impact of critical care medicine upon our environment and become change agents promoting sustainable healthcare for the benefit of human health.

Objective: To apply an intersectional lens to explore how the interconnected social identities of women across global settings impact access experiences for gender-based violence (GBV) supports. Design: A scoping review. Data sources: We systematically searched seven databases to identify studies published in English from the database inception to January 2023. Inclusion criteria: We included peer-reviewed studies with a primary objective of examining the access experiences of populations who self-identify as women (aged 15 years or older) who have experienced GBV, have intersecting identities (ie, racialisation, poverty, etc) that can further contribute to marginalisation and utilised or sought support services. Methods: Two reviewers independently completed title/abstract, full-text screening and data charting. Integrating intersectionality theory and the McIntyre access framework, we analysed support service access and utilisation across social identities, axes of marginalisation and geographic contexts. Results: 210 papers (195 distinct studies) met the inclusion criteria. Most studies (60%) were published since 2015 and used qualitative methods (63%). Findings reflected intersectional differences in women's experiences of accessing GBV services across contexts and lived experiences. Common findings indicate that seeking GBV support was motivated and enabled by informal supports and positive prior experiences in accessing services. However, findings highlight that structural and systemic constraints in existing support systems (in all study settings) impact access to necessary support services and their alignment with women's needs. Few studies examined health and non-health outcomes associated with unhindered access to care. Conclusions: Women's experiences with GBV support systems in different geopolitical contexts highlight barriers across axes of racialisation, poverty, multidimensional violence and other systemic factors, which are often eclipsed in generic one-size-fits-all models of support. This research can inform transformational policy development and tailored interventions to improve outcomes for all women who experience GBV and thus advance gender equality and equity goals.

Objectives: Primary care attachment represents an inclusive, equitable and cost-effective way of enhancing health outcomes globally. However, the growing shortage of family physicians threatens to disrupt patient-provider relationships. Understanding the consequences of these disruptions is essential for guiding future research and policy. The objectives of this study were to map the existing evidence on the impacts of changes in primary care attachment, identify research gaps and recommend areas for further investigation. Design: Scoping review following Joanna Briggs Institute (JBI) guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist. Two researchers conducted all stages of screening, and study quality was assessed using JBI critical appraisal tools. Key themes included causes of attachment change, direction of change and outcomes aligned with the quintuple aim framework. Both qualitative and quantitative findings were synthesised narratively. Eligibility criteria: Peer-reviewed, English-language articles published between 1999 and 2024 on primary care attachment changes. Information sources: PubMed, Scopus and Web of Science. Results: Of 2045 studies screened, 31 met inclusion criteria, with 60% published after 2020. Most studies originated from high-income countries, particularly the USA (35%) and Canada (29%). Attachment losses and transfers were the most frequently studied, while attachment and unattachment durations were less explored. These changes in attachment were consistently shown to impact patients, providers, clinics and the healthcare system, influencing all aims of the quintuple aim framework, including clinical outcomes, healthcare utilisation, costs, equity and patient experience. Commonly assessed outcomes included clinical impact (68%), health equity (48%), patient experience (32%) and costs (23%), with no study assessing provider experience. Conclusions: This scoping review maps the published literature on changes in primary care attachment and introduces clarifying terminology. Key research gaps include geographical diversity (lack of studies from low- and middle-income countries), attachment gain (limited research on strategies to reconnect unattached patients), attachment duration (insufficient evidence on long-term health outcomes), economic implications (underexplored costs of physician turnover and disruption), provider experiences (lack of studies on how changes in primary care attachment impact provider burnout, job satisfaction and workload) and patient health outcomes (focus on healthcare utilisation rather than direct health outcomes). These findings underscore the need for further research and offer valuable insights for future studies and policy development.

Objective: To estimate the relative efficacy of individual and combinations of prehabilitation components (exercise, nutrition, cognitive, and psychosocial) on critical outcomes of postoperative complications, length of stay, health related quality of life, and physical recovery for adults who have received surgery. Design: Systematic review with network and component network meta-analyses of randomised controlled trials. Data sources: Medline, Embase, PsycINFO, CINAHL, Cochrane Library, and Web of Science were initially searched 1 March 2022, and updated on 25 October 2023. Certainty in findings were assessed using the Confidence in Network Meta-Analysis (CINeMA) approach. Main outcome measures: To compare treatments and to compare individual components informed by partnership with patients, clinicians, researchers, and health system leaders using an integrated knowledge translation framework. Eligible studies were any randomised controlled trial including adults preparing for major surgery who were allocated to prehabilitation interventions or usual care, and where critical outcomes were reported. Results: 186 unique randomised controlled trials with 15 684 participants were included. When comparing treatments using random-effects network meta-analysis, isolated exercise (odds ratio 0.50 (95% confidence interval (CI) 0.39 to 0.64); very low certainty of evidence), isolated nutritional (0.62 (0.50 to 0.77); very low certainty of evidence), and combined exercise, nutrition, plus psychosocial (0.64 (0.45 to 0.92); very low certainty of evidence) prehabilitation were most likely to reduce complications compared with usual care. Combined exercise and psychosocial (-2.44 days (95% CI -3.85 to -1.04); very low certainty of evidence), combined exercise and nutrition (-1.22 days (-2.54 to 0.10); moderate certainty of evidence), isolated exercise (-0.93 days (-1.27 to -0.58); very low certainty of evidence), and isolated nutritional prehabilitation (-0.99 days (-1.49 to -0.48); very low certainty of evidence) were most likely to decrease length of stay. Combined exercise, nutrition, plus psychosocial prehabilitation was most likely to improve health related quality of life (mean difference on Short Form-36 physical component scale 3.48 (95% CI 0.82 to 6.14); very low certainty of evidence) and physical recovery (mean difference in meters on the six min walk test 43.43 (95% CI 5.96 to 80.91); very low certainty of evidence).When comparing individual components using component network meta-analysis, exercise and nutrition were the individual components most likely to improve all critical outcomes. The certainty of evidence for all comparisons across all outcomes was generally low to very low due to trial level risk of bias and imprecision; however, results for exercise and nutritional prehabilitation were robust with exclusion of high risk of bias trials. Conclusions: Consistent and potentially meaningful effect estimates suggest that exercise prehabilitation, nutritional prehabilitation, and multicomponent interventions including exercise may benefit adults preparing for surgery and could be considered in clinical care. However, multicentre trials that are appropriately powered for high priority outcomes and that have a low risk of bias are required to have greater certainty in prehabilitation's efficacy. Registration: International prospective registry of systematic reviews CRD42023353710.

Polymeric nanoparticles are among the most widely used nanocarriers for delivering therapeutic molecules. However, their synthesis processes often generate undesirable impurities that could be toxic and challenging to eliminate. In this study, we compared three purification techniques - centrifugation, dialysis, and tangential flow filtration (TFF) - to evaluate their efficacy in removing residual drug, surfactant, and solvent while preserving the nanoparticles' physicochemical features (hydrodynamic size, zeta potential, polydispersity index). Centrifugation excels in eliminating unencapsulated drug and residual surfactant but significantly affects the nanoparticles' physicochemical properties, such as colloidal stability and size homogeneity. On the other hand, dialysis is a gentler technique effective in removing residual solvent but less so for residual surfactant and unencapsulated drug. TFF emerges as a balanced approach, offering a compromise between the two but none of these techniques achieves satisfactory purification at lab-scale alone. While each technique has its merits, none can meet all requirements independently. The optimal purification strategy often involves a combination of techniques, determined on a case-by-case basis considering factors like purity levels, time, costs, and the preservation of critical properties such as drug loading and colloidal stability. This study underscores the need for a nuanced approach in selecting purification strategies for polymeric nanoparticles in drug delivery applications.

Introduction: Vedolizumab is a gut-selective anti-lymphocyte trafficking biologic indicated for the treatment of adult patients with moderately to severely active ulcerative colitis (UC) and Crohn's disease (CD) in Canada. Objective: The objective of this study was to evaluate the cost effectiveness of treatment sequencing for UC and CD from a public healthcare payer perspective, leveraging new real-world evidence from the literature and the EVOLVE study, a retrospective chart review. Methods: Using separate decision tree/Markov models to assess cost effectiveness for UC and CD, two sequencing approaches were estimated for adult patients (≥ 18 years) diagnosed with UC or CD who were biologic-naïve: vedolizumab as first-line biologic followed by anti-tumor necrosis factor (TNF)-α versus first-line anti-TNFα followed by vedolizumab. Treatment effectiveness (response and remission), surgery rates, dose escalation and regain of response and safety inputs were estimated from EVOLVE, a retrospective chart review of real-world data, and evidence synthesis from the literature, whereas costs and utilities were estimated from health technology assessment reports, clinical trials, and the literature. Biosimilar costs were used for anti-TNFα. Both models simulated a 5-year time horizon and discounted costs and outcomes at 1.5%. Probabilistic base-case analyses (n = 10,000) reported total costs (2023 Canadian dollars) and quality-adjusted life-years (QALYs). Several scenario analyses were conducted to explore robustness of results. Results: In UC, vedolizumab as a first-line biologic followed by anti-TNFα resulted in an incremental gain of 0.09 QALYs (2.46 vs. 2.55) and saved $7179 ($134,028 vs. $126,848), making this a dominant strategy compared with first-line anti-TNFα followed by vedolizumab. In CD, use of vedolizumab as a first-line biologic resulted in an incremental gain of 0.04 QALYs (3.35 vs. 3.39) at an incremental cost of $50,631 ($89,850 vs. $140,381) versus first-line anti-TNFα followed by vedolizumab (incremental cost-effectiveness ratio of $1,265,775 per QALY). Conclusions: Based on this analysis, sequencing vedolizumab as a first-line biologic prior to anti-TNFα in UC and CD provided additional clinical benefit to patients. In UC, vedolizumab as a first-line biologic also saved healthcare system costs compared with anti-TNFα, whereas in CD, vedolizumab provided incremental benefit at an incremental cost, which was not considered cost effective at a threshold of $50,000/QALY.

In response to emerging challenges that intersect humans, animals, and environments, there is growing international exigent need to adopt 'One Health' approaches. While One Health efforts are emerging in British Columbia in Canada, there are still challenges to overcome in the adoption of a One Health approach in policymaking. We conducted a comparative analysis of One Health policies in Asia, specifically, Singapore, Hong Kong, Bangladesh, and Thailand, which have well-established and sophisticated One Health approaches, to determine good practices in the implementation of One Health that could be considered for adoption in British Columbia. We conducted a literature review and scan of public-facing One Health websites, strategic action plans, and health databases, complemented by 13 semi-structured interviews with researchers, educators, service providers, human and animal health experts, and policymakers in our chosen Asian jurisdictions and British Columbia. While there was diversity in the One Health approaches taken by four jurisdictions, three key characteristics were present in policymaking processes in all of them: a national One Health strategic action plan, inter-ministerial coordination, and flexibility in the working relationships of public servants. One Health presents an opportunity for British Columbia to take a novel approach to public health policymaking, the one that is more holistic and effective at addressing shared health challenges.

Objectives: The COVID-19 pandemic has had a disproportionate impact on the health of Indigenous Peoples in Canada, Australia, New Zealand and the USA, as reflected in the growing literature. However, Indigenous Peoples are often homogenised, with key differences often overlooked, failing to capture the complexity of issues and may lead to suboptimal public health policy-making. The objective of this review was to assess the extent to which the heterogeneity of the Indigenous Peoples in Canada, Australia, New Zealand and the USA has been reflected in COVID-19 research. Design: This study took the form of a scoping review. Data sources: Medline, Embase, CINAHL and Web of Science were searched for studies investigating COVID-19 pandemic outcomes among Indigenous Peoples in Canada, Australia, New Zealand and the USA. The search dates included January 2019 to January 2024. Eligibility criteria: All citations yielded by this search were subjected to title and abstract screening, full-text review and data extraction. We included original, peer-reviewed research investigating COVID-19-related outcomes among Indigenous Peoples in Canada, Australia, New Zealand or the USA. Data extraction and synthesis: Data extraction was conducted as an iterative process, reaching consensus between two of the study authors. All included studies were analysed through a combination of quantitative descriptive summary and qualitative thematic analysis. Results: Of the 9795 citations found by the initial search, 428 citations were deemed eligible for inclusion. Of these citations: 72.9% compared Indigenous participants to non-Indigenous participants; 10.0% aggregated Indigenous and non-white participants; and 17.1% provided findings for Indigenous participants exclusively. Conclusions: By overlooking the heterogeneity that exists among Indigenous Peoples in Canada, Australia, New Zealand and the USA, researchers and policy-makers run the risk of masking inequities and the unique needs of groups of Indigenous Peoples. This may lead to inefficient policy recommendations and unintentionally perpetuate health disparities during public health crises.

Background: Many people infected with the Mycobacterium tuberculosis complex (the bacteria that cause tuberculosis [TB]) have an inactive stage of infection known as latent tuberculosis infection (LTBI). A person with LTBI is at risk of developing active TB. Screening for, and treating people with, LTBI is an important part of preventing adverse health outcomes, reducing the risk of reactivation and the further spread of tuberculosis in a community. We conducted a health technology assessment of interferon-gamma release assay (IGRA) for the detection of LTBI, compared to the standard tuberculin skin test (TST) to evaluate the diagnostic accuracy, cost-effectiveness, the budget impact of publicly funding, and health care provider preferences and values. Methods: We performed a systematic literature search of the clinical evidence as an overview of systematic reviews. We reported the findings of the identified reviews, including their quality assessment of the body of evidence. We performed a systematic literature search of the economic evidence and included published Canadian cost-effectiveness studies. We assessed the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We developed a probabilistic decision-tree model to estimate the incremental costs of IGRA strategies versus TST alone over 1 year in eligible population subgroups. IGRA was examined as a single test and in a sequential pathway with tuberculin skin test (TST; the test order depended on the type of population). We considered subpopulations at high risk of LTBI for whom IGRA would be preferred, as indicated by the Canadian TB Standards published in 2022 (hereinafter, the Standards); e.g., people who received a Bacille Calmette-Guérin (BCG) vaccine, such as BCG-vaccinated immigrants and people identified in contact investigations. We also considered people with comorbid conditions or who were undergoing treatments that may cause low immune function and, hence, may test incorrectly negative. We estimated the total 5-year budget impact (in 2024 CAD) for publicly funding IGRA testing in Ontario. To contextualize the potential value of IGRA, we spoke with health care providers about people requiring TB testing for LTBI. We attempted to reach out to people who had experience with IGRA or TST but did not receive any feedback. Results: We included 12 systematic reviews that included over 500 unique primary studies in the clinical evidence overview of reviews and found good evidence aligned with the uses of IGRA outlined in the Standards. This overview of reviews summarizes the existing evidence on diagnostic accuracy and the clinical utility of IGRA for LTBI. Interferon-gamma release assay was found to have good evidence as a rule-in test for LTBI due to consistently high specificity. The reviews reported slightly lower sensitivity among people who have underlying immunosuppression conditions (e.g., people who are HIV positive or have received an organ transplant, or are on cancer treatment or dialysis) compared to a more general population. However, compared to TST (the standard test for TB), IGRA appears to have fewer false-positive results, as signaled by a lower risk difference of developing active TB among those who tested positive on both LTBI tests in head-to-head comparisons. This was particularly notable in immunocompromised populations and was also observed in children and the elderly (e.g., people in nursing homes) and those who have received an anti-tuberculin vaccination known as the BCG vaccine.Additionally, IGRA may be informative for people with immunocompromising conditions who are at risk of a false-negative result from a TST, as it yields indeterminate findings, signaling that further clinical investigation may be needed.We included 5 economic studies from Canada (using a public payer perspective), which found that IGRA, either as a sequential test following TST or as a standalone test, was cost-effective or cost-saving compared with TST alone for LTBI in high-risk populations as identified in the Standards. All reviewed studies were of good quality and 3 studies were directly applicable to the Ontario context (GRADE: High). Therefore, we did not conduct a primary economic evaluation for Ontario.Our reference case budget impact analysis showed that publicly funding IGRA in Ontario in all examined subpopulations over the next 5 years was associated with additional costs ranging from $2.99 million (IGRA alone) to $18.80 million (IGRA in sequential pathways with TST). These overall estimates include potential savings in some subpopulations and additional costs in others. In the population-specific analyses, we estimated cost savings of $1.63 million or higher over 5 years with publicly funded IGRA testing in BCG-vaccinated immigrants or BCG-vaccinated people identified via contact investigations (who are susceptible to a false positive result with the TST alone). These cost-savings resulted from reductions in costs of follow-up evaluation and treatment (due to prevention of reactivated LTBI). We found additional costs of about $6.26 million or higher over 5 years with publicly funded IGRA testing in immunocompromised people due to increased appropriate medical evaluations for those who were previously incorrectly identified as negative. In sensitivity analyses, if we assumed a high chance of reactivation of LTBI into active TB in immunocompromised populations, then IGRA testing resulted in cost savings.Health care providers who we surveyed had positive comments about IGRA, and expressed it as patients' preferred test for LTBI, partly because this test requires only 1 office visit (compared to the multiple visits needed for TST), thus reducing the effect of barriers such as transportation, language, childcare and employment arrangements. Conclusions: Interferon-gamma release assay testing was found to have good diagnostic accuracy and to be cost-effective or cost-saving for LTBI in populations aligned with the recommended uses of the Standards. We estimate that publicly funding IGRA in Ontario for all examined population subgroups would result in additional costs of between $2.99 million and $18.80 million over 5 years, depending on how the test is used. In the population-specific analyses, we estimate a cost savings of $1.63 million or higher with IGRA testing in eligible BCG-vaccinated immigrant populations or BCG-vaccinated people identified via contact investigations. There was a preference for IGRA among health care practitioners, particularly to support people who may have challenges with the available alternative tests (e.g., TST).

According to the World Health Organization (WHO), tobacco use causes over 8 million deaths annually including 1.3 million due to second-hand exposure. Furthermore, data from the Tobacco Atlas show that the tobacco industry continues to target new markets in the WHO African region, one of two regions where absolute numbers of smokers continue to increase. Understanding context contributes to policy formulation and implementation ensuring relevance to a country's political economy. Focusing on the WHO African region, this scoping review (i) maps the extent of academic research examining contextual factors on the WHO Framework Convention on Tobacco Control (WHO FCTC) national-level implementation, and (ii) reports on contextual factors impacting the WHO FCTC implementation. Using a stepwise structured approach, we conducted a search across four academic databases, yielding 10 342 articles and 42 were selected for full data extraction. Leichter's four categories of context (situational, structural, cultural and exogenous) and the stages of heuristic policy model guided data extraction. Study findings indicated that situational contextual factors such as the burden of disease or its impact on health can push governments toward policy formulation. Structural contextual factors included political considerations, economic interests, funding, institutional congruence, strength of policy and institutional capacity as important. Cultural contextual factors included the influence of policy entrepreneurs, current social trends and public opinion. Exogenous contextual factors included the WHO FCTC, tobacco industry influence at the national-level and bi-lateral partnerships. Further understanding contextual factors affecting the WHO FCTC national implementation can strengthen policy formulation and align required support with the WHO FCTC Secretariat and other relevant bodies.

Abstract Effective diabetes management can prevent avoidable diabetes-related hospitalizations. This review examines the impact of financial incentives for diabetes management in primary care settings on diabetes-related hospitalizations, hospitalization costs, and premature mortality. To assess the evidence, we conducted a literature search of studies using five databases: Medline, Embase, Scopus, CINAHL and Web of Science. We examined the results by health insurance system, study quality or diabetes population (newly diagnosed diabetes). We identified 32 articles ranging from fair- to high-quality: 19 articles assessed the relationship between financial incentives for diabetes management and hospitalizations, 8 assessed hospitalization costs, and 15 assessed mortality. Many studies found that financial incentives for diabetes management reduced hospitalizations, while a few found no effects. Similar findings were evident for hospitalization costs and mortality. The results did not differ by the type of health insurance system, but the quality of the studies did matter; most high-quality studies reported reduced hospitalizations and/or mortality. We also found that financial incentives tend to be beneficial for patients with newly diagnosed diabetes. We conclude that well-designed diabetes management incentives can reduce diabetes-related hospitalizations, especially for newly diagnosed diabetes patients.

Background: In medicine, x-rays are used to generate images of tissues and structures inside the body. X-rays are emitted by a source device and, after passing through the body, strike a detector, which forms an image of the tissues and structures the x-rays passed through. Dual-energy subtraction (DES) x-ray systems use radiation of different energy spectra (energy levels) and the principle of differential absorption characteristics of bone and soft tissue to produce separate bone and soft tissue x-ray images, in addition to a conventional x-ray image. The aim is to minimize potential issues with anatomical overlap with conventional x-ray that may obscure some findings. Single-exposure, DES flat panel x-ray detectors produce a conventional x-ray image in addition to DES bone and soft tissue x-ray images using a single x-ray exposure. We conducted a health technology assessment of single-exposure, DES digital flat panel x-ray detectors in adults for indications such as pneumonia, pneumothorax, and pulmonary nodules, and for visualizing lines and tubes, compared with conventional x-ray. Our assessment included an evaluation of the diagnostic accuracy, the impact on diagnostic confidence, patient management and clinical outcomes, the budget impact of publicly funding the technology, and the experiences, preferences, and values of health care providers. Methods: We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using the QUADAS-C tool and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic literature search on the economic evidence of single-exposure, DES flat panel x-ray detectors. We did not conduct a primary economic evaluation because of limited evidence on the implications of this technology. We analyzed the budget impact of publicly funding single-exposure, DES flat panel detectors in Ontario hospitals. To contextualize the potential value of single-exposure, DES flat panel x-ray detectors, we spoke with people with expertise in diagnostic imaging, including radiologists and other health care practitioners. Results: The clinical evidence review identified 2 eligible observational studies that assessed the use of single-exposure, DES flat panel x-ray detectors to generate DES bone and soft tissue x-ray images and a conventional x-ray image. The findings of 1 study suggest an improvement in the sensitivity and specificity for the detection of pulmonary nodule calcification with the use of single-exposure, DES soft tissue and conventional x-ray images compared with using a conventional x-ray image alone (results were statistically significant for 2 out of 5 reviewers; GRADE: Low). In one study, x-ray image reviewers reported an improvement in the visibility of the tips of lines and tubes (although these were visualized with the conventional x-ray image alone) in all patients and an improvement in the diagnostic confidence in 16 (57.1%) patients, with no difference in the time to review the images with the use of single-exposure, DES bone and soft tissue x-ray images plus the conventional x-ray image compared with using the conventional x-ray image alone, but the evidence is very uncertain (GRADE: Very low).The economic evidence review identified 1 costing study in the US setting. This analysis suggested adoption of single-exposure, DES x-ray detectors may lead to cost savings. However, this study was deemed not directly applicable to the Ontario setting. The cost-effectiveness of single-exposure, DES flat panel x-ray detectors is therefore unknown. Owing to the limited evidence on the impact of these detectors on short-term outcomes such as diagnostic accuracy and workflow, and long-term costs and health outcomes, we did not conduct a primary economic evaluation. Our budget impact analysis estimated that, for a typical community hospital, purchasing 3 detectors to retrofit existing x-ray machines would lead to an additional cost of $12,137 per institution. However, there is a large degree of uncertainty around the downstream costs and benefits of this technology.We interviewed 20 health care providers who had expertise with x-ray systems. Those who had the opportunity to interpret the x-ray images produced by a single-exposure, DES detector in a clinical setting were supportive of this technology and perceived an increase in confidence with diagnosing patients. Retrofitting existing x-ray systems to be compatible with the single-exposure, DES detector posed a challenge for operators as it was not a seamless process. Those who operated the retrofitted x-ray systems using the single-exposure, DES detector commented on issues related to workflow, including the physical specifications, connectivity, battery life, and maneuverability as barriers to use. Participants who did not have experience using the DES detector technology expressed uncertainty regarding the benefits compared to the alternative options currently in use in Ontario, such as image enhancing software, emerging artificial intelligence technology, and low-dose CT scanning. None of the users had experience with a fully integrated mobile x-ray system (i.e., a mobile x-ray system that did not require retrofitting to be compatible with the single-exposure, DES detector). Conclusions: The use of single-exposure, DES flat panel x-ray detectors may lead to an improvement in the sensitivity and specificity to detect pulmonary nodule calcification compared with conventional x-ray, but the evidence is very uncertain for its effect on the visibility of the tips of lines and tubes, diagnostic confidence, and time to review the x-ray images compared with conventional x-ray. Evidence gaps include lack of evidence for the use of the technology for most populations and outcomes that we sought to evaluate. Due to limited clinical and economic evidence, the cost-effectiveness of single-exposure, DES flat panel x-ray detectors is currently unknown. We estimate that purchasing 3 detectors to retrofit with existing x-ray machines may lead to an additional cost of $12,137 per institution. Users of single-exposure, DES x-ray detectors who viewed and interpreted the images produced spoke positively about their experience with the technology and expressed an increase in confidence when making a diagnosis. Participants who operated the retrofitted single-exposure, DES x-ray detector commented on issues that negatively impacted their workflow. The experiences of providers with a fully integrated system are unknown at this time.