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We assessed the impact of the coronavirus disease 2019 (COVID-19) epidemic in India on the consumption of antibiotics and hydroxychloroquine (HCQ) in the private sector in 2020 compared to the expected level of use had the epidemic not occurred. We performed interrupted time series (ITS) analyses of sales volumes reported in standard units (i.e., doses), collected at regular monthly intervals from January 2018 to December 2020 and obtained from IQVIA, India. As children are less prone to develop symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, we hypothesized a predominant increase in non-child-appropriate formulation (non-CAF) sales. COVID-19-attributable changes in the level and trend of monthly sales of total antibiotics, azithromycin, and HCQ were estimated, accounting for seasonality and lockdown period where appropriate. A total of 16,290 million doses of antibiotics were sold in India in 2020, which is slightly less than the amount in 2018 and 2019. However, the proportion of non-CAF antibiotics increased from 72.5% (95% CI: 71.8% to 73.1%) in 2019 to 76.8% (95% CI: 76.2% to 77.5%) in 2020. Our ITS analyses estimated that COVID-19 likely contributed to 216.4 million (95% CI: 68.0 to 364.8 million; P = 0.008) excess doses of non-CAF antibiotics and 38.0 million (95% CI: 26.4 to 49.2 million; P < 0.001) excess doses of non-CAF azithromycin (equivalent to a minimum of 6.2 million azithromycin treatment courses) between June and September 2020, i.e., until the peak of the first epidemic wave, after which a negative change in trend was identified. In March 2020, we estimated a COVID-19-attributable change in level of +11.1 million doses (95% CI: 9.2 to 13.0 million; P < 0.001) for HCQ sales, whereas a weak negative change in monthly trend was found for this drug. Study limitations include the lack of coverage of the public healthcare sector, the inability to distinguish antibiotic and HCQ sales in inpatient versus outpatient care, and the suboptimal number of pre- and post-epidemic data points, which could have prevented an accurate adjustment for seasonal trends despite the robustness of our statistical approaches. A significant increase in non-CAF antibiotic sales, and particularly azithromycin, occurred during the peak phase of the first COVID-19 epidemic wave in India, indicating the need for urgent antibiotic stewardship measures.

BackgroundPeriodic external accreditation visits aiming to determine whether trauma centres are fulfilling the criteria for optimal care are part of most trauma systems. However, despite the growing trend towards accreditation of trauma centres, its impact on patient outcomes remains unclear. In addition, a recent systematic review found inconsistent results on the association between accreditation and patient outcomes, mostly due to the lack of robust controls. We aim to address these gaps by assessing the impact of trauma centre accreditation on patient outcomes, specifically in-hospital mortality and complications, using an interrupted time series (ITS) design.MethodsWe included all major trauma admissions to five level I and four level II trauma centres in Quebec, Canada between 2008 and 2017. In order to perform ITS, we first obtained monthly and quarterly estimates of the proportions of in-hospital mortality and complications, respectively, for level I and level II centres. Prognostic scores were used to standardise these proportions to account for changes in patient case mix and segmented regressions with autocorrelated errors were used to estimate changes in levels and trends in both outcomes following accreditation.ResultsThere were 51 035 admissions, including 20 165 for major trauma during the study period. After accounting for changes in patient case mix and secular trend in studied outcomes, we globally did not observe an association between accreditation and patient outcomes. However, associations were heterogeneous across centres. For example, in a level II centre with worsening preaccreditation outcomes, accreditation led to −9.08 (95% CI −13.29 to −4.87) and −9.60 (95% CI −15.77 to −3.43) percentage point reductions in mortality and complications, respectively.ConclusionAccreditation seemed to be beneficial for centres that were experiencing a decrease in performance preceding accreditation.

Background/aimsVulnerable road user collisions are a leading cause of injury and death. Speed is the direct mechanism for pedestrian injury risk. We evaluate the effectiveness of automated speed enforcement (ASE) at reducing vehicle speeds in school zones.MethodsQuasi-experimental trial with speeds measured before, during and after ASE implementation. 50 ASE cameras were used at 250 intervention sites in school zones between July 2020 and December 2022. Outcomes were the proportion of vehicles speeding and the 85th percentile vehicle speed.ResultsProportion of vehicles speeding dropped by 45% (RR: 0.55, 95% CI: 0.49, 0.61) and 85th percentile speed dropped by 10.68 km/hour (95% CI: –11.48, –9.88). Reductions in speed were more pronounced at higher speeding thresholds.ConclusionsA significant reduction in speeding was observed when ASE was implemented in urban school zones.

BackgroundIt is estimated that more than 270 000 people die yearly in alcohol-related crashes globally. To tackle this burden, government interventions, such as laws which restrict blood alcohol concentration (BAC) levels and increase penalties for drunk drivers, have been implemented. The introduction of private-sector measures, such as ridesharing, is regarded as alternatives to reduce drunk driving and related sequelae. However, it is unclear whether state and private efforts complement each other to reduce this public health challenge.MethodsWe conducted interrupted time-series analyses using weekly alcohol-related traffic fatalities and injuries per 1 000 000 population in three urban conglomerates (Santiago, Valparaíso and Concepción) in Chile for the period 2010–2017. We selected cities in which two state interventions—the ‘zero tolerance law’ (ZTL), which decreased BAC, and the ‘Emilia law’ (EL), which increased penalties for drunk drivers—were implemented to decrease alcohol-related crashes, and where Uber ridesharing was launched.ResultsIn Santiago, the ZTL was associated with a 29.1% decrease (95% CI 1.2 to 70.2), the EL with a 41.0% decrease (95% CI 5.5 to 93.2) and Uber with a non-significant 28.0% decrease (95% CI −6.4 to 78.5) in the level of weekly alcohol-related traffic fatalities and injuries per 1 000 000 population series. In Concepción, the EL was associated with a 28.9% reduction (95% CI 4.3 to 62.7) in the level of the same outcome. In Valparaíso, the ZTL had a −0.01 decrease (95% CI −0.02 to −0.00) in the trend of weekly alcohol-related crashes per 1 000 000 population series.ConclusionIn Chile, concomitant decreases of alcohol-related crashes were observed after two state interventions were implemented but not with the introduction of Uber. Relationships between public policy interventions, ridesharing and motor vehicle alcohol-related crashes differ between cities and over time, which might reflect differences in specific local characteristics.

Background Sexual and gender minority populations experience elevated risks for suicidality. This study aimed to assess prevalence and disparities in non-fatal suicidality and potential protective factors related to social support and health care access among sexual and gender minority youth and adults and their heterosexual and cisgender counterparts in Canada. The second objective was to examine changes in the prevalence of suicidal ideation and protective factors during the COVID-19 pandemic. Methods Pooled data from the 2015, 2016 and 2019 Canadian Community Health Surveys were used to estimate pre-pandemic prevalence of suicidal ideation, plans and attempts, and protective factors. The study also estimated changes in the prevalence of recent suicidal ideation and protective factors in fall 2020, compared with the same period pre-pandemic. Results The prevalence of suicidality was higher among the sexual minority populations compared with the heterosexual population, and the prevalence was highest among the bisexual population, regardless of sex or age group. The pre-pandemic prevalence of recent suicidal ideation was 14.0% for the bisexual population, 5.2% for the gay/lesbian population, and 2.4% for the heterosexual population. The prevalence of lifetime suicide attempts was 16.6%, 8.6%, and 2.8% respectively. More than 40% of sexual minority populations aged 15–44 years had lifetime suicidal ideation; 64.3% and 36.5% of the gender minority population had lifetime suicidal ideation and suicide attempts. Sexual and gender minority populations had a lower prevalence of protective factors related to social support and health care access. The prevalence of recent suicidal ideation among sexual and gender minority populations increased in fall 2020, and they tended to experience longer wait times for immediate care needed. Conclusions Sexual and gender minority populations had a higher prevalence of suicidality and less social support and health care access compared to the heterosexual and cisgender populations. The pandemic was associated with increased suicidal ideation and limited access to care for these groups. Public health interventions that target modifiable protective factors may help decrease suicidality and reduce health disparities. Highlights • This study provides population-based pre-pandemic estimates of the prevalence of non-fatal suicidality (suicidal ideation, plans, and attempts) among sexual and gender minority populations in Canada using pooled data from the 2015, 2016, and 2019 Canadian Community Health Survey. • Sexual and gender minority populations had a higher prevalence of suicidal ideation, plans, and attempts, compared with heterosexual and cisgender populations, regardless of sex or age group. Among sexual minority populations the bisexual population had the highest prevalence of suicidality. • More than 40% of sexual minority populations aged 15 to 44 years had lifetime suicidal ideation; two thirds and one third of the gender minority population had lifetime suicidal ideation and suicide attempts, respectively. • Sexual minority populations had a lower prevalence of social support and health care access; the presence of social support and health care access was related to lower prevalence of recent suicidal ideation. • The onset of the COVID-19 pandemic was associated with increased recent suicidal ideation among the sexual and gender minority populations, especially for males, adolescents, and young adults.

Older adults have become a significant portion of the trauma population. Exploring their specificities is crucial to better meet their specific needs. The primary objective was to evaluate the temporal changes in the incidence, demographic and trauma characteristics, injury pattern, in-hospital admission, complications, and outcome of older trauma patients. A multicenter retrospective cohort study was conducted using the Quebec Trauma Registry. Patients aged ≥16 years admitted to one of the three adult level-I trauma centers between 2003 and 2017 were included. Descriptive analyses and trend-tests were performed to describe temporal changes. A total of 53,324 patients were included, and 24,822 were aged ≥65 years. The median [IQR] age increased from 57[36-77] to 67[46-82] years, and the proportion of older adults rose from 41.8% in 2003 to 54.1% in 2017. Among those, falls remain the main mechanism (84.7%-88.3%), and the proportion of severe thorax (+8.9%), head (+8.7%), and spine (+5%) injuries significantly increased over time. The proportion of severely injured older patients almost doubled (17.6%-32.3%), yet their mortality decreased (-1.0%). Their average annual bed-days consumption also increased (+15,004 and +1,437 in non-intensive care wards and ICU, respectively). Since 2014, older adults have represented the majority of admissions in Level-I trauma centers in Québec. Their bed-days consumption has greatly increased, and their injury pattern and severity have deeply evolved, while we showed a decrease in mortality.

The trauma team leader (TTL) is a “model” of a specifically dedicated team leader in the emergency department (ED), but its benefits are uncertain. The primary objective was to assess the impact of the TTL on 72-hour mortality. Secondary objectives included 24-hour mortality and admission delays from the ED. Major trauma admissions (Injury Severity Score (ISS)≥12) in 3 Canadian Level-1 trauma centres were included from 2003 to 2017. The TTL program was implemented in centre 1 in 2005. An interrupted time series (ITS) analysis was performed. Analyses account for the change in patient case-mix (age, sex, and ISS). The two other centres were used as control in sensitivity analyses Among 20,193 recorded trauma admissions, 71.7% (n=14,479) were males. The mean age was 53.5 ± 22.0 years. The median [IQR] ISS was 22 [16–26]. TTL implementation was not associated with a change in the quarterly trends of 72-hour or 24-hour mortality: adjusted estimates with 95% CI were 0.32 [−0.22;0.86] and −0.07 [−0.56;0.41] percentage-point change. Similar results were found for the proportions of patients admitted within 8 hours of ED arrival (0.36 [−1.47;2.18]). Sensitivity analyses using the two other centres as controls yielded similar results. TTL implementation was not associated with changes in mortality or admission delays from the ED. Future studies should assess the potential impact of TTL programs on other patient-centred outcomes using different quality of care indicators.

Background Injury is second only to cardiovascular disease in terms of acute care costs in North America. One key to improving injury care efficiency is to generate knowledge on the determinants of resource use. Socio-economic status (SES) is a documented risk factor for injury severity and mortality but its impact on length of stay (LOS) for injury admissions is unknown. This study aimed to examine the relationship between SES and LOS following injury. This multicenter retrospective cohort study was based on adults discharged alive from any trauma center (2007–2012; 57 hospitals; 65,486 patients) in a Canadian integrated provincial trauma system. SES was determined using ecological indices of material and social deprivation. Mean differences in LOS adjusted for age, gender, comorbidities, and injury severity were generated using multivariate linear regression. Results Mean LOS was 13.5 days. Patients in the highest quintile of material/social deprivation had a mean LOS 0.5 days (95 % CI 0.1-0.9)/1.4 days (1.1-1.8) longer than those in the lowest quintile. Patients in the highest quintiles of both social and material deprivation had a mean LOS 2.6 days (1.8-3.5) longer than those in the lowest quintiles. Conclusions Results suggest that patients admitted for traumatic injury who suffer from high social and/or material deprivation have longer acute care LOS in a universal-access health care system. The reasons behind observed differences need to be further explored but may indicate that discharge planning should take patient SES into consideration.

Objectives This study aimed to synthesise the available knowledge, identify unexplored areas and discuss general limits of the published evidence. We focused on outcomes commonly hypothesised to be affected by child labour: nutritional status, harmful exposures and injuries. Methods Four electronic databases (EMBASE, MEDLINE, Scopus, ISI Web of Science) were searched in November 2017. All articles published since 1996, without restrictions on language, were considered for inclusion. Results Out of the 1090 abstracts initially identified by the search, 78 articles were selected for inclusion and reviewed. Most of the studies were conducted in Asia and South America, and only a third of them compared working children to a control group of non-working children. Child labour appears to be associated with poor nutritional status, diseases due to harmful exposures, and a higher prevalence of injuries. Conclusions Despite evidence for a negative relation between child work and health, the cross-sectional design of most studies limits the causal interpretation of existing findings. More rigorous observational studies are needed to confirm and better quantify these associations.

IntroductionUnderstanding the impact of non-pharmaceutical COVID-19 interventions (NPIs) on road safety has become increasingly important to uncover the unintended consequences of the pandemic. This study explores how NPIs influenced alcohol-related and speed-related traffic collisions, including fatalities and serious injuries, in five cities of the province of Québec, Canada: Montréal, Québec, Laval, Longueuil and Sherbrooke.MethodsWe performed Poisson interrupted time-series analyses using daily traffic fatality and injury data from 2015 to 2022, to assess the change in rate expressed per 10 000 population. A Québec COVID-19 NPIs Index was applied, incorporating 58 interventions enacted from March 2020 to March 2022 in these cities. We accounted for weather conditions and seasonal patterns and divided the pandemic period into four semesters to better understand changes over time.ResultsThe analysis revealed a nuanced interaction between NPIs and road safety. Alcohol-related injuries decreased during stringent NPIs, particularly in Montréal, Québec city and Longueuil. In contrast, the effects on speed-related incidents were mixed, with Montréal and Laval, showing increases and the other three cities displaying no meaningful changes across the four semesters.ConclusionsThese findings highlight the necessity for ad hoc road safety strategies that address specific patterns of alcohol consumption and speeding risks during future pandemic-related disruptions.