Pilot findings on the real-world performance of xylazine test strips for drug residue testing and the importance of secondary testing methods.

Background: Xylazine is a sedative found increasingly in the illicit fentanyl supply that can cause hypotension, bradycardia, necrosis and death. This pilot examined the real-world performance of BTNX xylazine test strips (XTS) in drug residue samples. Methods: This study was nested within a drug checking service in Rhode Island. We tested unmeasured drug residue dissolved in 5 mL of distilled water using XTS and Liquid Chromatography Quadrupole Time-of-Flight Mass Spectrometry (LC-QTOF-MS). Analyses compared XTS and LC-QTOF-MS results to calculate XTS detection of xylazine in residue. Results: Among 41 residue samples, xylazine was detected in 11% by the XTS and 44 % by the laboratory. The LC-QTOF-MS detected xylazine in 18 samples: 4 major, 9 minor, 5 trace by volume relative to the whole sample. The XTS disagreed with the LC-QTOF-MS by indicating a negative result in 77.8 % (N=14) of the samples but never indicated a positive when the LC-QTOF-MS reported xylazine's absence. The XTS correctly detected xylazine 22 % of the time, however, this increased to 100 % of the time if xylazine was a major active component. Conclusions: In this study, the BTNX XTS often disagreed with LC-QTOF-MS by indicating a negative result, likely due to the dilution levels used and sample composition. The XTS may not be accurate in detecting residual amounts of xylazine, especially if xylazine is not a dominant component of the tested sample. Given the novelty of BTNX's XTS products, we recommend XTS only be used in conjunction with other advanced drug checking modalities for residue testing.

High-dose naloxone formulations are not as essential as we thought.

Naloxone is an effective FDA-approved opioid antagonist for reversing opioid overdoses. Naloxone is available to the public and can be administered through intramuscular (IM), intravenous (IV), and intranasal spray (IN) routes. Our literature review investigates the adequacy of two doses of standard IM or IN naloxone in reversing fentanyl overdoses compared to newer high-dose naloxone formulations. Moreover, our initiative incorporates the experiences of people who use drugs, enabling a more practical and contextually-grounded analysis. The evidence indicates that the vast majority of fentanyl overdoses can be successfully reversed using two standard IM or IN dosages. Exceptions include cases of carfentanil overdose, which necessitates ≥ 3 doses for reversal. Multiple studies documented the risk of precipitated withdrawal using ≥ 2 doses of naloxone, notably including the possibility of recurring overdose symptoms after resuscitation, contingent upon the half-life of the specific opioid involved. We recommend distributing multiple doses of standard IM or IN naloxone to bystanders and educating individuals on the adequacy of two doses in reversing fentanyl overdoses. Individuals should continue administration until the recipient is revived, ensuring appropriate intervals between each dose along with rescue breaths, and calling emergency medical services if the individual is unresponsive after two doses. We do not recommend high-dose naloxone formulations as a substitute for four doses of IM or IN naloxone due to the higher cost, risk of precipitated withdrawal, and limited evidence compared to standard doses. Future research must take into consideration lived and living experience, scientific evidence, conflicts of interest, and the bodily autonomy of people who use drugs.

"Politics Versus Policy": Qualitative Insights on Stigma and Overdose Prevention Center Policymaking in the United States.

BACKGROUND: Federal, state, and municipal governments in the United States have been reluctant to authorize overdose prevention centers (OPCs), which are evidence-based approaches for preventing overdose deaths and blood-borne pathogen transmission. METHODS: From July 2022 to February 2023, we explored how stigma manifests in OPC policymaking by conducting in-depth interviews with 17 advocates, legislators, service providers, and researchers involved with OPC advocacy and policymaking in Rhode Island, California, Pennsylvania, and New York. RESULTS: We found that although jurisdictions differed in their OPC policymaking experiences, stigma manifested throughout the process, from planning to authorization. Participants described OPCs as a tool for destigmatizing overdose and substance use, yet confronted institutionalized stigma and discriminatory attitudes toward people who use drugs (PWUD) and harm reduction from multiple sources (eg, politicians, media, and members of the public). Opposition toward OPCs and harm reduction approaches more broadly intersected with public discourse on crime, homelessness, and public disorder. Employed stigma-mitigation strategies included humanizing PWUD, publicizing the benefits of OPCs to the wider community, and strategically engaging media. CONCLUSION: These findings illustrate the importance of understanding stigma at different stages of the policymaking process to better facilitate authorization and eventual implementation of OPCs in the United States.

Enrichment of core competencies to maximize health system impact: An analysis of an embedded research training program.

Introduction: The Health System Impact (HSI) Fellowship is an embedded research training program that aims to prepare doctoral trainees and postdoctoral fellows for stronger career readiness and greater impact as emerging leaders within and beyond the academy, including in learning health systems (LHS). The program supports fellows to develop 10 leadership and research competencies that comprise the Enriched Core Competency Framework in Health Services and Policy Research through a combination of experiential learning, mentorship, and professional development training. This study tracks competency development of HSI fellows over time and examines fellows' perspectives on which program design elements support their competency development. Methods: A competency assessment tool developed for the program was independently completed by 95 postdoctoral and 36 doctoral fellows (self-assessments) and their respective 203 dyad (academic and health system) supervisors in the 2017 to 2019 program cohorts, who independently rated the strength of fellows' 10 competencies at baseline and several points thereafter. Competency strength ratings were analyzed to understand change over time and differences in ratings across groups (between fellows' sex, supervisor type, and supervisor vs. fellow). Program design element ratings were examined to understand perspectives on their contribution toward fellows' competency development. Results: Fellows' competency strength significantly improved in all 10 domains over time, based on independent assessments by the fellows and their dyad supervisors. Supervisors tended to rate the fellows' competency strength higher than the fellows did. Differences in competency ratings between male and female fellows (self-assessments) and between academic and health system supervisors were either negligble or not significant. Fellows identified all nine program design elements as enriching their competency development. Conclusion: The HSI Fellowship provides an opportunity for fellows to develop the full suite of enriched core competencies and to prepare a cadre of emerging leaders with the skills and experience to contribute to the advancement of LHS.

"Make yourself un-NIMBY-able": stakeholder perspectives on strategies to mobilize public and political support for overdose prevention centers in the United States of America.

BACKGROUND: Overdose prevention centers (OPCs), also known as supervised injection facilities and safe consumption sites, are evidenced-based interventions for preventing overdose deaths and drug-related morbidities. The pathways to legalizing OPCs in the USA have confronted multiple social, political, and legal obstacles. We conducted a multi-site, qualitative study to explore heterogeneities in these pathways in four jurisdictions, as well as to understand stakeholder perspectives on valuable strategies for galvanizing political and public support for OPCs. METHODS: From July 2022 to February 2023, we conducted 17 semi-structured, in-depth interviews with OPC policymakers, service providers, advocates, and researchers from California, New York City, Philadelphia, and Rhode Island, where efforts have been undertaken to authorize OPCs. Using inductive thematic analysis, we identified and compared contextually relevant, salient approaches for increasing support for OPCs. RESULTS: Participants described several strategies clustering around five distinct domains: (1) embedding OPC advocacy into broader overdose prevention coalitions to shape policy dialogs; (2) building rapport with a plurality of powerbrokers (e.g., lawmakers, health departments, law enforcement) who could amplify the impact of OPC advocacy; (3) emphasizing specific benefits of OPCs to different audiences in different contexts; (4) leveraging relationships with frontline workers (e.g., emergency medicine and substance use treatment providers) to challenge OPC opposition, including 'NIMBY-ism,' and misinformation; and (5) prioritizing transparency in OPC decision-making to foster public trust. CONCLUSION: While tailored to the specific socio-political context of each locality, multiple OPC advocacy strategies have been deployed to cultivate support for OPCs in the USA. Advocacy strategies that are multi-pronged, leverage partnerships with stakeholders at multiple levels, and tailor communications to different audiences and settings could yield the greatest impact in increasing support for, and diffusing opposition to, future OPC implementation.

Supervised Inhalation Sites: Preventing Overdose and Reducing Health Inequities among People Who Use Drugs.

Policy and research on the implementation of services for people who inhale drugs lag behind similar efforts for people who inject drugs, limiting access to adequate harm reduction resources for people who inhale drugs. This commentary considers why supervised inhalation sites (SIS) are needed, highlights operational characteristics of four existing services, and advocates for future SIS research. Our hope is to encourage the expansion of SIS worldwide for overdose prevention and reduction of health inequities. Given the limited literature regarding SIS, more extensive study of these programs is warranted to incorporate inhalation into the implementation of supervised consumption sites to provide fair opportunities for all people who use drugs to do so safely without fear of stigma and overdose.

Costing analysis of a point-of-care drug checking program in Rhode Island.

BACKGROUND: Drug checking is a harm reduction strategy that provides greater awareness and information about the drug supply to the community. While fentanyl test strips are low-cost and available in most parts of the U.S., community-based organizations are considering using more sophisticated technologies, such as Fourier-transform infrared (FTIR) spectroscopy to test drugs. FTIR can detect multiple substances in a non-destructive manner that can be rapidly communicated to the program client by a trained technician, however implementation costs in community-based settings have not been assessed. METHODS: We conducted a costing analysis of a new pilot drug checking service that employed an FTIR spectrometer, fentanyl test strips and confirmatory testing in Rhode Island from January 2023-May 2023. We used microcosting methods to determine the overall cost during this period and cost per drug checked, reflecting realistic service capacity. RESULTS: Among 101 drug samples that were voluntarily submitted and tested, 53% tested positive for fentanyl, 39% for cocaine, 9% for methamphetamine and 13% for xylazine, a powerful sedative. The total cost during this period was $71,044 and the cost per drug checked was $474, though sensitivity analyses indicated that the cost would rise to $78,058 - $83,058 or $544 - $593 for programs needing to pay for specialized training. CONCLUSIONS: These findings demonstrate feasibility and inform the resources needed to scale-up drug checking services to reduce overdose risk.

A survey of North American drug checking services operating in 2022.

BACKGROUND: Drug overdose deaths have reached record-breaking levels in North America. Drug checking services (DCS) provide localized information on the contents of drugs to individuals and communities. Depending on the design, individuals can submit drug samples for onsite "real-time" testing or offsite testing. The results can shed light on emerging drugs in the community and support ongoing prevention and surveillance efforts. We sought to describe and report aggregate outcomes of DCS operating in North America. METHODS: The North American Drug Checking Survey was launched in 2022 to characterize and monitor DCS operating in the region. Sixteen organizations from the US (n = 9), Canada (n = 5), and Mexico (n = 2) responded to the survey. Each organization reported on their program's operations and provided service delivery outcomes (site- or program-level) in the aggregate. RESULTS: Participating organizations reported testing a total of 49,786 drug samples between 2014 and 2022. DCS were run by community-led organizations (44%), health departments (25%), universities (19%), or clinical/private laboratories (19%). The types of samples tested differed between programs (e.g., solids vs. liquids, drug paraphernalia accepted). While most organizations tested onsite using fentanyl test strips (88%) and Fourier-transform infrared (FTIR) spectroscopy (63%), many sent samples offsite for confirmatory testing (63%), most often with mass spectrometry. Common facilitators of operating a DCS included: interest of clients (69%), interest of service providers (63%), and receiving external technical assistance (63%). Barriers included: the lack of funding (81%) or staff (50%), gaps in technical expertise (38%), as well as laws banning the possession and/or distribution of illicit drug samples, drug paraphernalia, or drug checking equipment (38%). CONCLUSION: DCS are scaling up in North America. Given the evolving and localized nature of illicit drug supplies, supporting the establishment and operations of DCS could enhance the public's understanding of local drug supplies to reduce drug-related harms over time.

Motives for Cannabis Use and Risky Decision Making Influence Cannabis Use Trajectories in Teens.

The current study will examine the interactive effects of motives for cannabis use (i.e., health or recreational) and risky decision making (DM) on cannabis use trajectories among adolescents. Data from 171 adolescents, aged 14-17 at the initial visit (baseline), were prospectively analyzed across five time points approximately six months apart. Latent growth curve modeling and linear regression analyses were used. We found a significant interactive effect of "recreational motives" and risky DM on the rate of cannabis use over time. Specifically, among those less likely to use cannabis for recreational purposes, riskier DM was associated with a faster increase in the rate of use over time relative to those with lower risky DM. Additionally, a significant main effect showed that those with a greater proclivity to use cannabis for health purposes had higher initial levels of use at baseline and faster increases in the rate of use over time. Regardless of risky DM, using cannabis for health purposes is associated with faster increases in cannabis use escalation. Additionally, risky DM does impact the association between recreational motives for use and cannabis use trajectories. Future work should examine these associations with additional motives for cannabis use that have been previously validated within the literature.

Evaluating the Impact of Brave Technology Co-op's Novel Drug Overdose Detection and Response Devices in North America: a Retrospective Study.

Assess the preliminary impact of Brave Technology Co-op's overdose detection devices that have been implemented in housing, medical, social service facilities, and several private settings in North America. Administrative data was collected by Brave on their Buttons and Sensors during several proof-of-concept projects and full installations in Canada and United States (US) between December 2018 and July 2022. Data analyzed provided insights on the number of overdoses detected and reversed (averted overdose deaths) using Brave Sensors and Buttons, along with other programmatic and session-specific indicators. Implementation of 486 Brave Buttons and 148 Brave Sensors in Canada has detected and prevented 108 overdose deaths (100 using Buttons and 8 using Sensors) whereas implementation of 170 Buttons in the US has averted 2 overdose deaths to date, with the potential to save many more lives. Brave's devices hold promise for increasing rates of overdose detection and preventing overdose deaths.

Peripartum Traumas and Mental Health Outcomes in a Low-Income Sample of NICU Mothers: A Call for Family-Centered, Trauma-Informed Care.

Postpartum depression (PPD), postpartum anxiety (PPA), and post-traumatic stress disorder (PTSD) among birthing people have increased substantially, contributing to adverse maternal/infant dyad outcomes, with a high prevalence in the neonatal intensive care unit (NICU). Despite calls for trauma-informed care in the NICU and high rates of post-traumatic stress, little research has examined the rates of or the relationships between peripartum mood and adverse child experiences (ACEs) in NICU mothers or evaluated which peripartum traumas are most distressing. This study employed structural equation modeling (SEM) to explore whether peripartum-related traumas and NICU-related stressors mediated the associations between ACEs and mental health outcomes in 119 lower-income, racially diverse mothers in a Level IV NICU. Mental health concerns were prevalent and highly comorbid, including 51.3% PPA, 34.5% PPD, 39.5% post-traumatic stress, and 37% with ≥4 ACEs. The majority (53.8%) of mothers endorsed multiple peripartum traumas; NICU admission was the most common trauma (61%), followed by birth (19%), pregnancy (9%), and a medical event in the NICU (9%). Our SEMs had good fit and demonstrated that ACEs predicted peripartum distress. Trauma-informed care efforts should employ transdiagnostic approaches and recognize that women commonly present to the NICU with childhood trauma history and cumulative peripartum traumas.

High-Dose Naloxone Formulations Are Not as Essential as We Thought.

Naloxone is a U.S. Food and Drug Administration (FDA) approved opioid antagonist for reversing opioid overdoses. Naloxone is available to the public, and can be administered through intramuscular (IM), intravenous (IV), and intranasal spray (IN) routes. Our literature review aimed to improve understanding regarding the adequacy of the regularly distributed two doses of low-dose IM or IN naloxone in effectively reversing fentanyl overdoses and whether high-dose naloxone formulations (HDNF) formulations are an optimal solution to this problem. Moreover, our initiative incorporated the perspectives and experiences of people who use drugs (PWUD), enabling a more practical and contextually-grounded analysis. We began by discussing the knowledge and perspectives of Tennessee Harm Reduction, a small peer-led harm reduction organization. A comprehensive literature review was then conducted to gather relevant scholarly works on the subject matter. The evidence indicates that, although higher doses of naloxone have been administered in both clinical and community settings, the vast majority of fentanyl overdoses can be successfully reversed using standard IM dosages with the exception of carfentanil overdoses and other more potent fentanyl analogs, which necessitate three or more doses for effective reversal. Multiple studies documented the risk of precipitated withdrawal using high doses of naloxone. Notably, the possibility of recurring overdose symptoms after resuscitation exists, contingent upon the half-life of the specific opioid. Considering these findings and the current community practice of distributing multiple doses, we recommend providing at least four standard doses of IN or IM naloxone to each potential bystander, and training them to continue administration until the recipient achieves stability, ensuring appropriate intervals between each dose. Based on the evidence, we do not recommend HDNF in the place of providing four doses of standard naloxone due to the higher cost, risk of precipitated withdrawal and limited evidence compared to standard IN and IM. All results must be taken into consideration with the inclusion of the lived experiences, individual requirements, and consent of PWUD as crucial factors. It is imperative to refrain from formulating decisions concerning PWUD in their absence, as their participation and voices should be integral to the decision-making process.

Early Career Outcomes of Embedded Research Fellows: An Analysis of the Health System Impact Fellowship Program.

BACKGROUND: This descriptive study reports the early career outcomes of postdoctoral fellows who completed a novel embedded fellowship training program, the Canadian Institutes of Health Research (CIHR) Health System Impact (HSI) Fellowship. The program was designed to support impact-oriented career paths of doctoral graduates, build research capacity within health system organizations, and help to advance learning health systems in Canada. METHODS: Employment of fellowship alumni upon completion of the program were tracked using internet searches of publicly accessible online sources and complemented with program survey data. RESULTS: Descriptive analyses show that all 87 eligible alumni included in the study are currently employed (100% of 87), with 92% employed in Canada. Their employment spans several sectors, including in academic (37%), public (29%), healthcare delivery (17%), and private (14%) sectors. Altogether, 32% of alumni held hybrid roles with an affiliation in academia and another sector. The most common position types were senior scientist (42%), professorships (18%), and director, manager or administrator roles (12%). Program reporting data indicate that these employment outcomes are generally consistent with the group's career aspirations reported at the start of the fellowship program, and that the program receives high ratings from fellows in the extent it is believed to support their career preparedness and readiness (4.49 out of 5). CONCLUSION: We find that HSI Fellow alumni are employed mostly in research-related roles in a range of sectors including, but not limited to academia, that they positively perceive the program's success in elevating their career readiness and potential to make an impact - suggesting that the program may help equip fellows with the skills, readiness and networks for a broad array of employment sectors and roles. The findings are a promising signal of the demand for research talent and the growing capacity for learning health systems in Canada.

An exploratory follow-up study of cannabis use and decision-making under various risk conditions within adolescence.

OBJECTIVE: Studies examining the associations between decision-making (DM) and cannabis use (CU) often use cross-sectional, adult samples, and composite scores or single tasks to assess DM. The present study explored differential associations between tasks assessing DM under various risk conditions (i.e., ambiguous vs. explicit; gain vs. loss) and CU frequency, CU-related problems, and CU disorder (CUD) onset across a 2-year period within adolescence. METHOD: Adolescents (n = 401, 90% Hispanic) aged 14-17 at baseline participated in five biannual assessments. CU frequency, CU-related problems, and CUD were assessed using the Drug Use History Questionnaire, Marijuana Problems Scale, and Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, fourth edition, respectively. DM was assessed using the Iowa gambling task (IGT), Game of Dice Task (GDT), and Cups Task. We used latent growth curve modeling to examine bidirectional associations between DM and escalation in CU frequency and CU-related problems, and discrete time survival analyses to determine whether baseline performance across DM tasks predicted CUD onset. RESULTS: Baseline performance on the GDT predicted greater escalation in CU (ß = .200, p = .008) and CU-related problems (ß = .388, p = .035). No other significant associations were found. CONCLUSIONS: DM under explicit risk may be a more salient risk factor for escalating CU and CU-related problems than DM under ambiguous risk. Deficits in executive functioning could partially explain the results. Findings suggest that neurocognitive development should inform prevention and intervention efforts focused on reducing CU. Given the exploratory nature of the present study, replication of findings is needed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Cannabis use and episodic memory performance among adolescents: Moderating effects of depression symptoms and sex.

OBJECTIVE: Cannabis use has been linked to poorer episodic memory. However, little is known about whether depression and sex may interact as potential moderators of this association, particularly among adolescents. The current study addresses this by examining interactions between depression symptoms and sex on the association between cannabis use and episodic memory in a large sample of adolescents. METHOD: Cross-sectional data from 360 adolescents (M age = 17.38, SD = .75) were analyzed at the final assessment wave of a two-year longitudinal study. We used the Drug Use History Questionnaire to assess for lifetime cannabis use, and the Computerized Diagnostic Interview Schedule for Children, Fourth edition to assess the number of depression symptoms in the past year. Subtests from the Wechsler Memory Scale, Fourth Edition and the California Verbal Learning Test, Second Edition were used to assess episodic memory performance. RESULTS: The effect of the three-way interaction among cannabis use, depression symptoms, and sex did not have a significant impact on episodic memory performance. However, follow-up analyses revealed a significant effect of the two-way interaction of cannabis use and depression symptoms on episodic memory, such that associations between cannabis use and episodic memory were only significant at lower and average levels of depression symptoms. CONCLUSIONS: Contrary to our hypotheses, we found that as depression symptoms increased, the negative association between cannabis use and episodic memory diminished. Given the use of a predominantly subsyndromic sample, future studies should attempt to replicate findings among individuals with more severe depression.

Overdose Detection Technologies to Reduce Solitary Overdose Deaths: A Literature Review.

Drug overdoses were a leading cause of injury and death in the United States in 2021. Solitary drug use and solitary overdose deaths have remained persistent challenges warranting additional attention throughout the overdose epidemic. The goal of this narrative review is to describe recent global innovations in overdose detection technologies (ODT) enabling rapid responses to overdose events, especially for people who use drugs alone. We found that only a small number of technologies designed to assist in overdose detection and response are currently commercially available, though several are in the early stages of development. Research, development, and scale-up of practical, cost-effective ODTs remains a public health imperative. Equipping places where people live, learn, work, worship, and play with the necessary tools to detect and prevent overdose deaths could complement ongoing overdose prevention efforts.

Childhood adversity and co-occurring post-traumatic stress and externalizing symptoms among a predominantly low-income, African American sample of early adolescents.

Although there is strong evidence supporting the association between childhood adversity and symptomatology during adolescence, the extent to which adolescents present with distinct patterns of co-occurring post-traumatic stress (PTS) and externalizing symptoms remains unclear. Additionally, prior research suggests that experiencing nonviolent, negative life events may be more salient risk factors for developing some forms of psychopathology than exposure to violence. The current study used latent profile analysis to identify subgroups of early adolescents with distinct patterns of PTS, physical aggression, delinquency, and substance use, and examined subgroup differences in exposure to three forms of violent and nonviolent childhood adversity. Participants were a predominantly low-income, African American sample of 2,722 urban middle school students (M age = 12.9, 51% female). We identified four symptom profiles: low symptoms (83%), some externalizing (8%), high PTS (6%), and co-occurring PTS and externalizing symptoms (3%). A higher frequency of witnessing violence was associated with increased odds of membership in subgroups with externalizing symptoms, whereas a higher frequency of nonviolent, negative life events was associated with increased odds of membership in subgroups with PTS symptoms. Interventions aimed to address childhood adversity may be most effective when modules addressing both PTS and externalizing symptoms are incorporated.

What We Have Heard: Next Steps for Long-Term Care Pandemic Preparedness in Canada.

In this concluding article, Healthcare Excellence Canada and the Canadian Institutes of Health Research reflect upon and respond to the lessons learned from the contributing articles in the special issue and summarize key takeaways for the next steps in evidence-informed pandemic preparedness in long-term care in Canada. The implications of their cross-organizational partnership for achieving collective impact now and in the future are also discussed.

Accelerating Health System Transformation through Research to Achieve the Quadruple Aim and Health Equity.

The Canadian Institutes of Health Research - Institute of Health Services and Policy Research's (IHSPR's) Strategic Plan 2021-2026: Accelerate Health Care System Transformation through Research to Achieve the Quadruple Aim and Health Equity for All (CIHR IHSPR 2021) outlines the Institute's key priority areas for investment and activity over the next five years. IHSPR used an evidence-informed strategic planning process that was pan-Canadian in scope and designed to elicit the health services and policy research priorities of decision makers, providers, researchers, patients, communities and the public. This paper outlines IHSPR's four key strategic priorities for supporting and optimizing research in transforming Canada's healthcare delivery systems over the next five years.

How Do We Build the Human Capital for a True Learning Healthcare System?

Our healthcare systems depend on human capital for effectiveness. The Canadian Institutes of Health Research - Institute of Health Services and Policy Research has prioritized building capacity for "solution-oriented research and evidence-informed health care system transformation" (CIHR IHSPR 2021a: 20) as a core strategic direction. In this commentary, we articulate strategies for positioning PhD-trained scientists at the forefront of this transformation, including refreshing a competency framework that outlines the skill set required for maximum impact, exploring opportunities to expand embedded research career pathways and considering new ways to support the evolution of learning health systems. We conclude highlighting the need to modernize how real-world research impact is recognized.