Spatiotemporal epidemiology of substance-related accidental acute toxicity deaths in Canada from 2016 to 2017.

OBJECTIVES: In Canada, substance-related accidental acute toxicity deaths (AATDs) continue to rise at the national and sub-national levels. However, it is unknown if, where, when, and to what degree AATDs cluster in space, time, and space-time across the country. The objectives of this study were to 1) assess for clusters of AATDs that occurred in Canada during 2016 and 2017 at the national and provincial/territorial (P/T) levels, and 2) examine the substance types detected in AATD cases within each cluster. METHODS: Two years of person-level data on AATDs were abstracted from coroner and medical examiner files using a standardized data collection tool, including the decedent's postal code and municipality information on the places of residence, acute toxicity (AT) event, and death, and the substances detected in the death. Data were combined with Canadian census information to create choropleth maps depicting AATD rates by census division. Spatial scan statistics were used to build Poisson models to identify clusters of high rates (p < 0.05) of AATDs at the national and P/T levels in space, time, and space-time over the study period. AATD cases within clusters were further examined for substance types most present in each cluster. RESULTS: Eight clusters in five regions of Canada at the national level and 24 clusters in 15 regions at the P/T level were identified, highlighting where AATDs occurred at far higher rates than the rest of the country. The risk ratios of identified clusters ranged from 1.28 to 9.62. Substances detected in clusters varied by region and time, however, opioids, stimulants, and alcohol were typically the most commonly detected substances within clusters. CONCLUSION: Our findings are the first in Canada to reveal the geographic disparities in AATDs at national and P/T levels using spatial scan statistics. Rates associated with substance types within each cluster highlight which substance types were most detected in the identified regions. Findings may be used to guide intervention/program planning and provide a picture of the 2016 and 2017 context that can be used for comparisons of the geographic distribution of AATDs and substances with different time periods.

Suicide and drug toxicity mortality in the first year of the COVID-19 pandemic: use of medical examiner data for public health in Nova Scotia. / Mortalité par suicide et par intoxication aux drogues ou aux médicaments dans la première année de la pandémie de COVID-19 : utilisation des données des médecins légistes à des fins de santé publique en Nouvelle-Écosse.

INTRODUCTION: The COVID-19 pandemic and governmental responses have raised concerns about any corresponding rise in suicide and/or drug toxicity mortality due to exacerbations of mental illness, economic issues, changes to drug supply, ability to access harm reduction services, and other factors. METHODS: Data were obtained from the Nova Scotia Medical Examiner Service. Case definitions were developed, and their performance characteristics assessed. Pre-pandemic trends in monthly suicide and drug toxicity deaths were modelled and the observed numbers of deaths in the pandemic year compared to expected numbers. RESULTS: There was a significant reduction in suicide deaths in the first year of the COVID-19 pandemic in Nova Scotia, with about 21 fewer non-drug toxicity suicide deaths than expected in March 2020 to February 2021 (risk ratio = 0.82). No change in drug toxicity mortality was detected. Case definitions were successfully applied to free-text cause of death statements and cases where cause and manner of death remained under investigation. CONCLUSION: Processes for case classification and monitoring can be implemented in collaboration with medical examiners/coroners for timely, ongoing public health surveillance of suicide and drug toxicity mortality. Medical examiners and coroners are the stewards of a wealth of data that could inform the prevention of further deaths; it is time to engage these systems in public health surveillance.

Secular trends in weight, stature, and body mass index in Nova Scotia, Canada.

OBJECTIVES: The present study aims to investigate the secular trends of weight, stature, and BMI values in a Nova Scotian sample from 1946 to 1999, with particular focus on how these trends may relate to nutrition and the evolving obesity epidemic. METHODS: Data were collected from investigative (autopsy) records of 1645 individuals (1287 males, 358 females) of European descent at the Nova Scotia Medical Examiner Service. Secular trends were evaluated by linear regression of weight, stature, and BMI with respect to the year of birth. Further analysis of this sample was based on five time periods (birth cohorts), in order to determine whether dramatic shifts in diet and nutrition affected weight, stature, and BMI. RESULTS: Overall, the results of this study demonstrate positive secular trends in weight, stature, and BMI from 1946 to 1999 in the Nova Scotian sample. Subsequent analysis among different time periods shows a secular increase in the weight of Nova Scotian males from 1946 to 1979, and a subsequent decrease in weight in after 1980. For Nova Scotian females, the results show a secular increase in weight from 1946 to 1989, and a subsequent decrease in weight after 1990. Such secular increases in weight coincide with the global nutrition transition, while recent decreasing median weight values may reflect economic growth and urbanization in Nova Scotia. CONCLUSIONS: Overall, the results of the present study indicate that temporal trends in nutrition may have contributed to positive secular changes in weight, stature, and BMI in Nova Scotia, Canada between 1946 and 1999.

Effect of predicted travel time to trauma care on mortality in major trauma patients in Nova Scotia

Background: Trauma is a leading contributor to the burden of disease in Canada, accounting for more than 15 000 deaths annually. Although caring for injured patients at designated trauma centres (TCs) is consistently associated with survival benefits, it is unclear how travel time to definitive care influences outcomes. Using a population-based sample of trauma patients, we studied the association between predicted travel time (PTT) to TCs and mortality for patients assigned to ground transport. Methods: Victims of penetrating trauma or motor vehicle collisions (MVCs) in Nova Scotia between 2005 and 2014 were identified from a provincial trauma registry. We conducted cost distance analyses to quantify PTT for each injury location to the nearest TC. Adjusted associations between TC access and injury-related mortality were then estimated using logistic regression. Results: Greater than 30 minutes of PTT to a TC was associated with a 66% increased risk of death for MVC victims (p = 0.045). This association was lost when scene deaths were excluded from the analysis. Sustaining a penetrating trauma greater than 30 minutes from a TC was associated with a 3.4-fold increase in risk of death. Following the exclusion of scene deaths, this association remained and approached significance (odds ratio 3.48, 95% confidence interval 0.98­14.5, p = 0.053). Conclusion: Predicted travel times greater than 30 minutes were associated with worse outcomes for victims of MVCs and penetrating injuries. Improving communication across the trauma system and reducing prehospital times may help optimize outcomes for rural trauma patients.

Contexte: Les traumatismes contribuent pour une bonne part au fardeau de la maladie au Canada; on leur attribue plus de 15 000 décès annuellement. Même si les soins prodigués aux patients victimes de traumatismes dans les centres de traumatologie désignés (CTD) sont toujours associés à des gains au plan de la survie, on ignore quelle est l'influence du temps de transfert vers le CTD sur l'issue. À partir d'un échantillon de patients polytraumatisés basé dans la population, nous avons analysé le lien entre le temps de transfert prévu (TTP) vers le CTD et la mortalité des patients transportés par voie terrestre. Méthodes: On a identifié les victimes de traumatismes pénétrants ou d'accidents de la route en Nouvelle-Écosse entre 2005 et 2014 à partir d'un registre provincial de traumatologie. Nous avons analysé la distance de coût pour quantifier le TTP à partir de chaque scène vers le CTD le plus proche. Les liens ajustés entre l'accès au CTD et la mortalité liée au traumatisme ont ensuite été estimés par régression logistique. Résultats: Un délai de TTP de plus de 30 minutes pour arriver au CTD a été associé à un accroissement de 66 % du risque de décès chez les patients polytraumatisés (p = 0,045). Ce lien s'annulait si on excluait de l'analyse les décès survenus sur la scène de l'accident. Subir un traumatisme ouvert à plus de 30 minutes de distance d'un CTD a été associé à une augmentation par un facteur de 3,4 du risque de décès. Une fois les décès sur la scène de l'accident exclus, ce lien a persisté et s'est rapproché du seuil de signification (rapport des cotes 3,48, intervalle de confiance de 95 % 0,98­14,5, p = 0,053). Conclusion: Des temps de transfert prévus supérieurs à 30 minutes ont été associés une issue plus défavorable pour les victimes d'accidents de la route et de traumatismes pénétrants. L'amélioration de la communication entre les divers éléments du système de traumatologie et la réduction du temps préhospitalier pourrait optimiser l'issue pour les patients victimes de traumatismes en région rurale.

At-a-glance - Concurrent monitoring of opioid prescribing practices and opioid-related deaths: the context in Nova Scotia, Canada. / Aperçu - Surveillance simultanée des pratiques de prescription d'opioïdes et des décès liés à l'usage d'opioïdes : le contexte en Nouvelle-Écosse (Canada).

Timely public health surveillance is required to understand trends in opioid use and harms. Here, opioid dispensing data from the Nova Scotia Prescription Monitoring Program are presented alongside fatality data from the Nova Scotia Medical Examiner Service. Concurrent monitoring of trends in these data sources is essential to detect population-level effects (whether intended or unintended) of interventions related to opioid prescribing.

RÉSUMÉ: Une surveillance en santé publique en temps opportun est nécessaire pour comprendre les tendances associées à la consommation d'opioïdes et à ses méfaits connexes. Cet article met en correspondance les données sur la délivrance d'opioïdes recueillies par le Nova Scotia Prescription Monitoring Program et les données sur les décès compilées par le Service de médecin légiste de la Nouvelle-Écosse. La surveillance simultanée des tendances au moyen de ces sources de données est essentielle pour détecter les effets sur la population (qu'ils soient intentionnels ou non) des interventions liées à la prescription d'opioïdes.

Cost-effectiveness of adjunct non-pharmacological interventions for osteoarthritis of the knee.

BACKGROUND: There is limited information on the costs and benefits of alternative adjunct non-pharmacological treatments for knee osteoarthritis and little guidance on which should be prioritised for commissioning within the NHS. This study estimates the costs and benefits of acupuncture, braces, heat treatment, insoles, interferential therapy, laser/light therapy, manual therapy, neuromuscular electrical stimulation, pulsed electrical stimulation, pulsed electromagnetic fields, static magnets and transcutaneous electrical nerve Stimulation (TENS), based on all relevant data, to facilitate a more complete assessment of value. METHODS: Data from 88 randomised controlled trials including 7,507 patients were obtained from a systematic review. The studies reported a wide range of outcomes. These were converted into EQ-5D index values using prediction models, and synthesised using network meta-analysis. Analyses were conducted including firstly all trials and secondly only trials with low risk of selection bias. Resource use was estimated from trials, expert opinion and the literature. A decision analytic model synthesised all evidence to assess interventions over a typical treatment period (constant benefit over eight weeks or linear increase in effect over weeks zero to eight and dissipation over weeks eight to 16). RESULTS: When all trials are considered, TENS is cost-effective at thresholds of £20-30,000 per QALY with an incremental cost-effectiveness ratio of £2,690 per QALY vs. usual care. When trials with a low risk of selection bias are considered, acupuncture is cost-effective with an incremental cost-effectiveness ratio of £13,502 per QALY vs. TENS. The results of the analysis were sensitive to varying the intensity, with which interventions were delivered, and the magnitude and duration of intervention effects on EQ-5D. CONCLUSIONS: Using the £20,000 per QALY NICE threshold results in TENS being cost-effective if all trials are considered. If only higher quality trials are considered, acupuncture is cost-effective at this threshold, and thresholds down to £14,000 per QALY.

Development of a model to quantify the accessibility of a Canadian trauma system.

OBJECTIVES: Trauma systems have been widely implemented across Canada, but access to trauma care remains a challenge for much of the population. This study aims to develop and validate a model to quantify the accessibility of definitive care within one provincial trauma system and identify populations with poor access to trauma care. METHODS: A geographic information system (GIS) was used to generate models of pre-scene and post-scene intervals, respectively. Models were validated using a population-based trauma registry containing data on prehospital time intervals and injury locations for Nova Scotia (NS). Validated models were then applied to describe the population-level accessibility of trauma care for the NS population as well as a cohort of patients injured in motor vehicle collisions (MVCs). RESULTS: Predicted post-scene intervals were found to be highly correlated with documented post-scene intervals (ß 1.05, p<0.001). Using the model, it was found that 88.1% and 42.7% of the population had access to Level III and Level I trauma care within 60 minutes of prehospital time from their residence, respectively. Access for victims of MVCs was lower, with 84.3% and 29.7% of the cohort having access to Level III and Level I trauma care within 60 minutes of the location of injury, respectively. CONCLUSION: GIS models can be used to identify populations with poor access to care and inform service planning in Canada. Although only 43% of the provincial population has access to Level I care within 60 minutes, the majority of the population of NS has access to Level III trauma care.

Metal dust deposition in a shotgun wound associated with barrel modification.

Contact-range gunshot wounds commonly demonstrate deposition of black soot in and around the wound. Deposition of other visible pigments originating from the firearm has not been specifically described. In the current case, an adult male was found dead adjacent to a shotgun fixed in a vice grip with a modified, shortened barrel. A handheld, powered, metal grinding wheel was nearby. Autopsy revealed an intraoral gunshot wound, including soot deposition in and around the mouth and within the wound track. In addition, there was a peculiar, gray, lustrous film on the lips, gingiva, and anterior teeth. The material was concentrated around the most severe areas of injury in the anterior mouth and easily rubbed off with a cotton swab. It was not visualized in the rest of the mouth and not present in the larynx, or the esophagus. Overall, our opinion is that this unique, gray, lustrous film represents deposition of fine metallic dust that accumulated in the barrel of the shotgun during its modification with the grinding wheel. This type of unique pigment deposition should be recognized by forensic pathologists as possibly being related to the discharge of a firearm with a recently modified barrel or other cause for fine metallic dust accumulation within the barrel. Depending on the circumstances of the case, collection of samples of such metal dust deposits could be indicated for subsequent analysis.

The importance of child and youth death review.

The mandate of a formal child death review (CDR) system is to advance understanding of how and why children die, to improve child health and safety, and to prevent deaths and injuries in the future. Areas in which CDR has provided valuable information and/or intervention include sudden death in infancy, unintentional injuries (the leading cause of death in Canadian children and youth one to 19 years of age), suicide in youth, and deaths due to homicide or child maltreatment. When collected systematically using common definitions, information regarding deaths in children and youth can help with understanding the scope of problems. Information about the context of a death can inform potential prevention or intervention activities. CDR can improve medical and mental health best practices, child welfare policies and procedures, and legislation and education relevant to public health and safety. In the United States, the United Kingdom, Australia and New Zealand, CDR processes are mandated by legislation. In Canada, death review teams have diverse structures and functions, and the CDR system is less well developed. The present statement addresses the need for formal, organized child and youth death review in Canada to help strengthen and systemize injury and death prevention efforts.

Le mandat du système officiel d'examen des décès d'enfants (EDE) vise à faire progresser les connaissances sur les causes et le contexte des décès d'enfants, à améliorer la santé et la sécurité des enfants et à prévenir de futurs décès et blessures. L'EDE a fourni de l'information ou des interventions précieuses dans plusieurs secteurs, dont la mort subite pendant la première enfance, les blessures non intentionnelles (la principale cause de décès chez les enfants et les adolescents canadiens de un à 19 ans), le suicide à l'adolescence et les décès par homicide ou maltraitance d'enfant. Lorsqu'elle est recueillie de manière systématique au moyen de définitions communes, l'information relative aux décès d'enfants et d'adolescents peut contribuer à comprendre la portée des problèmes. L'information sur le contexte du décès peut étayer des activités potentielles de prévention ou d'intervention. L'EDE peut améliorer les pratiques exemplaires en matière de santé physique et mentale, les politiques et démarches relatives à la protection de la jeunesse, de même que les lois et l'éducation en matière de santé et sécurité publiques. Aux États-Unis, au Royaume-Uni, en Australie et en Nouvelle-Zélande, les processus d'EDE sont mandatés par la loi. Au Canada, la structure et les fonctions des équipes d'examen des décès sont variées, et le système d'EDE est moins développé. Le présent document de principes traite de la nécessité d'adopter un examen des décès d'enfants et d'adolescents plus officialisé et organisé au Canada, afin de renforcer et de systématiser les efforts en matière de prévention des blessures et des décès.

Factors associated with not seeking professional help or disclosing intent prior to suicide: a study of medical examiners' records in Nova Scotia.

OBJECTIVE: Individual-level data from clinical settings lack information on people who did not seek professional help prior to suicide. We used records of the Nova Scotia Medical Examiner Service (NSMES) to compare people who had contact with a health professional prior to suicide with those who did not. METHOD: We linked data from the NSMES to routine administrative data of the province. RESULTS: The NSMES recorded 108 suicides in Nova Scotia from January 1, 2006, to December 31, 2006; there were 90 male and 18 female suicide deaths. Mean and median age at death were 44.73 (SD 13.33) and 44 years, respectively. Patients aged 40 to 49 years made up one-third of the cases (n = 35) and this was the decade of life with the highest number of suicides. This was also the group least likely to have suicidal intent recorded in the NSMES files (χ(2) = 3.86, df = 1, P = 0.05). Otherwise, there were no significant differences between people who sought help, or disclosed intent, prior to suicide and people who did not. The samples in all cases were predominately male and single. CONCLUSIONS: People aged 40 to 49 years were the age group with the highest absolute number of suicides, but were the least likely to have suicidal intent recorded in the NSMES files. This finding merits further investigation. Medical examiner or coroner data may provide additional information not obtained elsewhere for the surveillance of suicide.