Unregulated drugs place a significant burden on individuals and the healthcare system, yet relatively little is known about the mix of substances implicated in the current polydrug crisis and their clinical effects. The current study aims to describe the toxicology and clinical outcomes of unregulated drug poisoning. We conducted a cross-sectional study at a tertiary hospital in Vancouver, British Columbia. Eligible patients were those presenting to the emergency department (ED) with suspected unregulated drug overdose and residual blood samples available for analysis. Chart review was performed to extract relevant clinical data, and liquid chromatography-tandem quadruple mass spectrometry was applied to blood samples to detect a broad panel of substances beyond routine ED toxicology screens. From 148 eligible patients, we randomly selected 69 for toxicology testing (mean age 43years; 74% male). Amphetamines (94%), fentanyl or analogues (67%), and unregulated benzodiazepines (64%) were most prevalent. Polysubstance exposure was nearly universal, with 91% positive for three or more drug classes, 83% for four or more, and nearly half (49%) for six or more concurrently. Clinical interventions were frequent, with naloxone administered to 59% of patients, 25% requiring-assisted ventilation (including two who required intubation). Twenty-eight percent of patients were admitted to hospital, with 4% admitted to intensive care. Complications included loss of consciousness (55%), hypoxia (22%), seizures (9%), severe agitation (6%) and rhabdomyolysis (3%). Unregulated drug poisoning in Vancouver, British Columbia was characterized by polysubstance exposure and frequent complications. Detailed toxicological analysis revealed high rates of unregulated benzodiazepines and stimulant co-detection with opioids, underscoring risks beyond opioid toxicity alone. Clinicians should be aware that unregulated drug poisoning involves multiple substances and may therefore have atypical presentations and/or incomplete response to standard therapy.

Abstract Background Endoscopic retrograde cholangiopancreatography (ERCP) is a complex endoscopic intervention used to manage pancreaticobiliary disorders. Sedation is essential for procedural success, ranging from endoscopist-controlled conscious sedation (CS) to anesthesiologist-administered deep sedation or general anesthesia (GA). While anesthesia use in ERCP is increasing across North America, data comparing sedation strategies in Canadian practice remain limited. Prior studies suggest potential benefits of anesthesia-assisted sedation in reducing procedural failure but raise concerns about cost, resource use, and unclear impact on patient-centered outcomes. Aims To compare patient characteristics, procedural outcomes, and sedation-related complications between ERCPs performed with endoscopist-controlled CS and those with anesthesia-assisted sedation at a large Canadian tertiary care center. Methods This retrospective cohort study included ERCPs performed at St. Paul’s Hospital in Vancouver between August 2023 and July 2025. Patient demographics, sedation modality, procedural characteristics, and clinical outcomes were extracted through chart review. The primary outcome was sedation-related adverse events. Secondary outcomes included length of procedure, recovery time, post-procedural admission, and need for early repeat ERCP. Results A total of 938 ERCPs were analyzed, with 809 under endoscopist and 129 under anesthesia-assisted sedation. Desaturation and hypotension were more common with anesthesia (desaturation 11% vs. 2%, p < 0.005; hypotension 19% vs. 3%, p < 0.0001). Overall sedation-related complication rates were low and comparable between groups (1% in both). The anesthesia group had longer procedures (mean 40 vs. 27 minutes, p < 0.0001), and more frequent use of advanced interventions including Spyglass (15% vs. 1%). Repeat ERCP within 8 weeks was more frequent in the anesthesia group (33% vs. 15%), with most patients receiving the same sedation type for repeat intervention. Conclusions Anesthesia-assisted ERCP was associated with longer procedures, more therapeutic interventions, and higher rates of intra-procedural hypotension and desaturation, without an increase in overall complication rates. Notably, repeat ERCP within 8 weeks was more frequent in the anesthesia group, likely reflecting higher procedural complexity and planned staged interventions. These findings support the selective use of anesthesia for challenging ERCPs while highlighting the safety and efficiency of endoscopist-controlled sedation for most cases. Funding Agencies None

Abstract Background Eosinophilic esophagitis (EoE) is a chronic, immune-mediated inflammatory disease characterized by eosinophil-predominant inflammation causing esophageal dysfunction. Dupilumab, an anti–IL-4/13 monoclonal antibody, is the first biologic approved for EoE. Since Health Canada approval in 2023, real-world data remain limited. Aims To evaluate clinical, endoscopic, and histologic outcomes in EoE patients treated with dupilumab. Methods A multicenter retrospective review was conducted at four tertiary hospitals in Montreal and Vancouver. Included are biopsy-proven EoE adult and pediatric patients with ≥1 follow-up endoscopy ≥12 weeks after starting dupilumab. Primary outcomes are changes in Eosinophilic Esophagitis Endoscopic Reference Score (EREFS), Index of Severity for Eosinophilic Esophagitis (I-SEE), and peak eosinophil count per high-power field (eos/HPF) on pathology. Secondary outcomes include symptom improvement and post-treatment dilation. Results Of the 49 patients on dupilumab, 36 met inclusion criteria (5 pediatric, 31 adult). Mean pre-treatment EREFS was 2.9±1.9, with a mean 70.1±31.4 eos/HPF on histology. After a mean treatment duration of 44.7±25.7 weeks, EREFS and eos/HPF improved to 1.1±1.1 and 4.5±9.0, respectively. We observed improvements in EREFS, I-SEE score, and eos/HPF post-dupilumab treatment (p < 0.001, Fig. 1). Subjective clinical improvement occurred in 97.2% of patients. During treatment, 37.1% and 90.1% discontinued PPI and inhaled steroids, respectively. Three patients stopped dupilumab for lack of efficacy, pregnancy, and initiation of a new biologic for vasculitis. Four patients had mild injection site reactions, and only three required post-treatment esophageal dilations. Conclusions Our real-world data show dupilumab is a safe, highly effective therapy for EoE across pediatric and adult populations, improving endoscopic, clinical, and histologic disease activity. Funding Agencies None

Environmental Impacts of Kidney Replacement Therapies: A Comparative Lifecycle Assessment.

ObjectiveDespite Eosinophilic Esophagitis (EoE) being a chronic condition, many studies focus on the short-term. This study characterizes patients, treatment effectiveness and outcomes in a pre-biologic era.MethodsThis cohort study (2012–2022) at British Columbia (BC) Children's Hospital in Vancouver, Canada analyzed data from the EoE Registry which was hosted on Research Electronic Data Capture (REDCap) for participating patients <18 years with biopsy-proven diagnosis (≥15 eosinophils/hpf) including demographics, symptoms, allergic history, medications, endoscopy and histology.Results247 patients (71.2% White, 16.7% South Asian, 78.1% male, median age 9 years) were followed over a median 3-year follow up. 85.2% had at least one atopic condition and 17.4% reported Cow's Milk Protein Allergy in infancy. 19.0% lacked follow up endoscopy and in clinic follow-up, 18.2% were on no therapy. At last endoscopy of those on treatment (n = 200), 39.0% used swallowed topical corticosteroids (50.0% remission), 23.0% proton pump inhibitors (29.0% remission), and 39.0% elimination diets (34.0% remission). Over half on medications had imperfect adherence. Overall, 39.0% achieved remission (<15 eosinophils/hpf), (mean peak eosinophils decreased from 55 to 27/hpf, strictures from 7.5% to 2.7%).ConclusionsThis Canadian study reveals remission rates lower than short term studies, but a reduction in strictures in follow-up. Real-life challenges, such as not returning for follow up endoscopy (∼20%), despite no direct care costs, challenges with adherence with ∼20% not taking any therapy and over half not taking medications as prescribed contribute towards remission rates below 50% regardless of treatment. Better patient engagement, addressing barriers to treatment and follow up and exploring novel therapies are needed.

This article interrogates the diagnostic category of gestational diabetes mellitus (GDM) as a spectral illness, that is transitory, affectively charged, and shaped by regimes of anticipation and surveillance. Drawing on six months of ethnographic fieldwork in Vancouver hospitals, I trace how GDM is enacted not through embodied symptoms but through numerical thresholds, creating a clinical reality that arrives unannounced and often departs before it is ever felt. Despite its apparent disappearance, GDM leaves behind lingering traces: haunting fears of the return of chronic illness, maternal guilt, residual disordered eating tendencies, and the specter of intergenerational risk. Through a conceptual framework that brings together Derrida's notions of the hauntology, spectres, ghosts, and revenants; Fischer's temporal disjunctions of the "no longer" and the "not yet"; and other theories of 'at-riskness' and surveillance in medicine, I argue that GDM initiates a haunting that reconfigures the experience of pregnancy. It summons past traumas, elicits future-oriented anxieties, and embeds the maternal body within a terrain of ongoing clinical and moral oversight. As a diagnosis with a temporal expiration but lasting affective and embodied consequences, GDM demands new analytic attention to how biomedicine produces and manages uncertainty, anticipation, spectrality, and haunting.

A serious illness conversation elicits a patient's wishes, goals and values in the setting of advancing illness. Patients living with structural vulnerabilities and substance use disorders encounter barriers to these conversations and therefore often experience less than ideal deaths. This study aims to understand the needs and preferences of these patients during serious illness conversations in the acute hospital setting and to inform best practice recommendations for serious illness conversations with this patient population. We performed a qualitative research study using interpretive description methodology at a single tertiary care inner-city hospital in Vancouver, British Columbia, Canada. Data was collected from 16 hospitalized participants living with structural vulnerability, substance use disorder and chronic illness. Semi-structured interviews were recorded, transcribed and analyzed iteratively by our research team using thematic analysis. Participants had unmet basic needs and therefore unique priorities during serious illness conversations. Participants frequently had previous negative healthcare experiences which resulted in them guarding their feelings from healthcare providers. Hope was emphasized as an important component of serious illness conversations. Participants also outlined specific preferences and recommendations for healthcare providers engaging in these conversations. Our findings offer several important considerations for engaging in serious illness conversations with patients living with structural vulnerabilities and substance use disorders that, if implemented, should improve the quality of conversations and care.

Acquired hemophilia a results from a provincial registry highlight the need for improvement of clinical outcomes and bypassing agent use

ABSTRACTIntroductionBiased language in documentation can perpetuate stigma, influence treatment decisions, and impact provider–patient relationships. As any person seeking care at acute care hospitals may face stigma, particularly those with substance use or mental health disorders, unbiased documentation is crucial. We sought to determine the prevalence of stigmatizing and biased language in electronic health records written by clinical pharmacists.MethodsThis study was conducted at two acute care teaching hospitals, St. Paul's and Mount Saint Joseph Hospitals in Vancouver, British Columbia, Canada. A list of stigmatizing and biased terms was compiled through literature review and expert consensus. A retrospective, observational, cross‐sectional study of clinical pharmacist notes was performed using a data‐mining algorithm to identify these terms. A content analysis was conducted to explore the ways this terminology was used and to uncover new themes not previously documented in the literature.ResultsBetween November 16, 2019, and September 30, 2023, of 135 671 clinical pharmacist notes reviewed, 42 192 (31.1%) contained at least one stigmatizing or biased term. Commonly identified terms included: compliance, noncompliance, refuses, denies, and smoker. All themes previously documented in the literature (e.g., leading with race/socioeconomic status, incorrect pronouns, employing quotations to suggest lack of credibility) were observed. Additionally, new themes emerged, including the use of punctuation or formatting to amplify the stigmatizing tone and the role of electronic health records in perpetuating stigma.DiscussionStigmatizing language was found in 31.1% of clinical pharmacist notes. Findings from this study are assisting in the development of a multimodal educational intervention aimed at reducing the prevalence of stigmatizing language in clinical pharmacist documentation.

Abstract Rationale: Primary ciliary dyskinesia (PCD) is a life-shortening, genetic disorder affecting 1 in 7500 individuals. PCD inhibits motile cilia activity and impacts the respiratory, auditory, olfactory and reproductive systems. Methods that measure the impact of PCD historically have lacked sensitivity to disease progression and failed to account for changes in a patient's daily physical, respiratory or social functioning. Between 2015 and 2017, quality of life questionnaires (QOL-PCD) for adults (18+), adolescents (13-17) or children with caregiver proxy (6-12) were created to comprehensively assess patient-reported outcomes. In 2023, the BEAT-PCD consensus statement recommended using validated QOL-PCD instruments as a core outcome for clinical trials. Our goal was to evaluate current implementation of the QOL-PCD. Methods: Implementation was assessed using data extracted from completed QOL-PCD requests captured in a REDCap database hosted at BC Children's Hospital in Vancouver, BC. Results: 81% of requests for the QOL-PCD have been successfully fulfilled (47/58). On average, there were 6 QOL-PCD requests per year between 2018 and 2023, however requests increased 136% in 2024. The QOL-PCD is largely accessed for research purposes (74%) rather than clinical monitoring (21%). 62% of completed requests originated from academic institutions. 79% specifically use adult questionnaires, compared to adolescent (66%) and child questionnaires (62%). Approximately 2500 individuals worldwide have/will be assessed using the QOL-PCD, including 1339 adults, 586 teenagers and 594 children. On average, 43 adults, 29 adolescents or 27 children are assessed by each age-specific version request. The QOL-PCD has been distributed most to the USA (10), Germany (5) and Turkey (5), although the QOL has been utilized on every continent. Of 15 available languages, the most common are English (55%) and German (21%). Latin American Spanish is the third most requested language, however there is no validated translated QOL-PCD (Figure 1). Finally, slightly more than half of QOL users (53%) agreed to share anonymous data obtained using the questionnaires, compared to 21% who do not agree. Conclusion: QOL-PCD comprehensively assesses the impact of PCD throughout the lifespan and its use has increased sharply in the past year, likely due to published consensus statements. Questionnaires are largely used for academic research studies, particularly in North America and Europe. Future validated translations of the QOL-PCD, such as Latin American Spanish, may further improve utilization, particularly in the Global South. Outreach to increase access of data captured by QOL users will also facilitate future development of this important tool.

Abstract Rationale: Despite increasing complexity and disease severity of critical illness admissions to the intensive care unit (ICU), more people are surviving critical illness than in previous decades; however, post intensive care mortality remains high. There are currently no prognostic tools that are used to predict long-term outcomes in post-ICU survivors. Functional status, a measure of an individual's physical independence, is used prognostically to inform clinical decision making in diseases with high risk of long-term mortality, such as cardiorespiratory diseases and cancer. Thus, the purpose of this study was to investigate the prognostic significance of ICU functional status to predict long-term mortality in critical illness survivors. Methods: Using a retrospective design, functional status measured daily in patients who were in the ICU at St. Paul's Hospital in Vancouver, B.C. between 2019-2022 were collected. Patients were classified as having a high peak ICU functional status (i.e., standing or walking; n=311) or a low peak functional status (peak mobility of awake but supine; n=328). Patients were excluded if they were admitted to the ICU for &amp;lt;48 hours and if there were multiple admissions for an individual, only the index admission was included. Kaplan Meier estimates were performed to determine the independent association between functional status and survival. A multivariable cox proportional model was used to determine risk of all-cause mortality with adjustment for important covariates such as age, ICU length of stay, disease severity at ICU entry (APACHE II score), length of mechanical ventilation, the use of vasoactive drugs, and the presence of delirium. Results: There was a total of 2584 admissions to the ICU between 2019-2022. Of those, 311 were classified as having a high functional status and 328 as having low functional status. Median follow-up time was 24 months; 244 deaths were reported during this period. High ICU functional status was an independent predictor of overall survival in the Kaplan Meier analysis (p=0.024). Compared with low ICU functional status, the adjusted Hazard Ratio (HR) for all-cause mortality was 0.76 (CI, 0.58-0.9) for the high functional status group. Conclusions: Peak ICU functional status predicts long-term survival probability. Individuals with high ICU functional status experience a significantly lower risk of mortality after ICU discharge.

To estimate the global journey of a generic clonazepam pill to map steps of production, distribution, and disposal. PubMed; Google Scholar; industry and market reports; gray literature; pharmaceutical databases (eg, PharmaCompass); export records; pharmacies in Hamilton, Ont; industry professionals and leaders such as pharmaceutical company vice presidents, professors, a supply chain insurance company, and sustainable procurement consulting companies; and an international not-for-profit company. Data related to clonazepam's standard pharmaceutical production process, life cycle system boundaries, and most probable production locations were included in this review. This study depicts the estimated journey of a clonazepam pill's production and distribution, with the prescription being filled in Vancouver, BC. It begins with the extraction of salts to produce the active pharmaceutical ingredient. The main centres for clonazepam's active pharmaceutical ingredient and excipient salt extraction and production are in India and China. Quality testing and stocking occur elsewhere, such as within the European Union. The product is then shipped back to India for the next manufacturing stages. Excipients are shipped from China to India and are incorporated into formulation and tableting. The product is then sent to global markets for the final stages of pill formation and regional distribution. After shipment through Europe and Asia, the journey continues through several locations within the United States, specifically New Jersey, for the final stages of manufacturing. Once manufacturing is finalized in New Jersey, the pill is shipped to and repackaged in Tennessee for distribution and then sent to Canadian industry clusters, typically within the greater Toronto area in Ontario. Pills are then shipped to pharmacies and hospitals in Vancouver, BC, for consumer use. The total distance travelled in this scenario is approximately 63,162 km, not including the entire process of producing and shipping excipients or local retailer shipments. Health care prescribing practices have tangible environmental impacts and manufacturers should continue to invest in operational streamlining to reduce greenhouse gas emissions.

Transanal endoscopic microsurgery (TEM) is a safe and effective therapy for local excision of rectal lesions, but early postoperative infectious and inflammatory complications are variably defined in the literature. The aim of this study was to describe post-TEM syndrome, a cluster of postoperative symptoms related to a local inflammatory process seen in a subset of patients after TEM. We conducted a retrospective cohort study using prospectively collected observational data of all patients who underwent TEM at St. Paul's Hospital in Vancouver, British Columbia, between 2006 and 2017. During the study period, 795 patients were treated by TEM at the study institution. Of these, 56 patients had postoperative pain or fever and 26 patients were determined to have post-TEM syndrome based on our definition. Sixteen patients presented within the first 2 postoperative days, with all patients presenting within 1 week. All patients who underwent cross-sectional imaging (n = 11) had a combination of inflammatory changes with stranding and free fluid, or with small bubbles of free intraperitoneal, retroperitoneal, or mesorectal air, or with both; they did not have signs of free perforation or abscess at the surgical site. Nearly all patients with post-TEM syndrome (96%) did not progress to further infectious complications. Most patients' (92%) post-TEM symptoms resolved within 1 week of conservative treatment. We provided a description of post-TEM syndrome, the constellation of symptoms arising from a localized inflammatory response in a subset of patients after TEM. This syndrome is uncommon, and nearly all patients recovered with conservative management without a need for more invasive intervention.

ABSTRACTIntroductionStigma is a major driver of harms associated with substance use and can interfere with the provision of high‐quality, effective healthcare for people who use drugs. Our study aimed to explore the relationship between mental health clinicians' comfort in providing substance use care and their attitudes towards substance use.MethodsIn this cross‐sectional study, the Brief Substance Abuse Attitudes Survey was administered among a convenience sample of mental health clinicians [N = 71] working in an acute care setting in Vancouver, Canada. One‐way ANOVA and the Kruskal–Wallis test were used to examine the association between three levels of comfort and five predefined attitude subgroups. STROBE checklist for cross‐sectional studies was used.ResultsLevel of comfort was significantly associated with attitudes towards substance use across three subscales: permissiveness, nonstereotyping and treatment optimism. In pairwise comparisons, the neutral group held significantly less permissive attitudes when compared to the comfortable group. However, the neutral group held more stereotypical views and less optimism about treatment outcomes, when compared to the comfortable and uncomfortable groups, respectively.Discussion and ConclusionsOur findings highlight that mental health clinicians who are undecided or neutral about their comfort in providing substance use care are more likely to have negative views towards people with substance use disorders. Future work should explore, implement and evaluate education and training to reduce substance use disorder‐related stigma among mental health clinicians and other health professionals.

ObjectiveTo identify physician perspectives on factors associated with physician burnout, protective factors against burnout, and to seek potential solutions for this pervasive problem.DesignA qualitative study with semistructured focus group interviews...

Background: Studies have provided strong evidence that personal protective equipment (PPE) effectively reduces the risk of transmitting highly infectious emerging diseases among healthcare providers (HCPs). However, literature examining this phenomenon specifically within the context of the COVID-19 pandemic remains limited. This study explored the behaviours and contributing factors influencing HCPs’ use of PPE, as well as how they established a sense of safety while caring for patients with COVID-19. Methods: We conducted 22 semi-structured interviews with HCPs who provided direct care to patients with COVID-19 in the medical and critical care units of a large urban hospital in Vancouver, British Columbia. An interpretive description approach was used to understand staff narratives and identify key themes. Results: Staff reported high confidence in their PPE practices, citing factors such as emerging evidence and guidance, infection prevention and control (IPAC) protocols, occupational experience, specific PPE workflows, and point-of-care risk assessments. Within the broader context of the COVID-19 pandemic in British Columbia, staff identified several factors that influenced their PPE behaviours: PPE accessibility and availability, staff education, environmental reminders, staffing levels, environmental cleaning, physical space, time constraints, patient acuity and workload, PPE fatigue, the evolution of SARS-CoV-2 variants, vaccination status, occupational culture, and systemic trust. Conclusions: Overall, our findings highlight the importance of a relational approach in supporting HCPs to keep both patients and colleagues safe during the pandemic. By fostering trust and open communication, infection control practitioners (ICPs) can help HCPs navigate the challenges of misinformation and psychological stress. Identifying the factors that shape PPE behaviour enables ICPs to design targeted interventions that address frontline staff needs and promote effective PPE practices. Ultimately, the development of realistic, context-sensitive guidelines — along with addressing the mental and informational challenges faced by HCPs – is crucial to enhancing safety and adherence to infection control practices in future public health emergencies.

BackgroundThe prevalence of physician burnout increased notably during the COVID-19 pandemic, but whether measures of burnout differed based on physician specialty is unknown. The authors sought to determine the prevalence of burnout, worklife conflict, and intention to quit among physicians from different specialties.MethodsThis is a cross-sectional online survey of physicians working at 2 urban hospitals in Vancouver, Canada, from August to October 2021. Responses were categorized by specialty (including surgical and nonsurgical), and data about whether physicians provided frontline patient care during COVID-19 were also included. Physician burnout was measured using the Maslach Burnout Inventory.ResultsThe survey response rate was 42% (209/498). The overall prevalence of burnout was 69%. Burnout was not significantly different by specialty or between frontline COVID-19 specialties compared with other specialties. Physicians in surgical specialties were more likely to report work–life conflict than those in nonsurgical specialties (p = 0.012). Differences in intention to quit among specialties were not statistically significant.ConclusionDuring the COVID-19 pandemic, physician burnout was high across physicians, without significant differences between specialties, highlighting the need to support all physicians.

Individuals with a substance use disorder (SUD) often face barriers to accessing health care, resulting in unmet needs and delayed care. Hospital-based services have the potential to engage individuals with a SUD in ongoing treatment, but there is limited literature characterising this population. The Outcomes for Patients Accessing Addiction Care study was a prospective hospital-based cohort study conducted at St. Paul's Hospital in Vancouver, Canada. Participants were recruited from January 2018 to March 2020. Data were collected through an interviewer-administered questionnaire, including socio-demographic information, substance use history and mental health screening. The cohort included 536 participants, with 31% aged 30-39 years, 63% identifying as White and 74% reporting male sex at birth. Nearly half of the participants were either homeless or living in single room occupancy. Use of substances more than once per week was reported for tobacco/nicotine (86%), marijuana (43%), non-medical use of prescription drugs (29%), illicit stimulants (52%) and illicit opioids (61%). This preliminary report provides a description of a hospital-based cohort of individuals with a SUD accessing addiction care. The findings highlight demographic characteristics, mental health issues, substance use patterns and barriers to accessing services. Understanding these factors can inform the development of patient-centred interventions and improve engagement and retention in addiction care. Further research is needed to explore interventions and program effectiveness in this population.

Librarian involvement in systematic reviews was associated with higher quality of reported search methods: a cross-sectional survey

Patients’ Beliefs About Their Cardiovascular Medications After Acute Coronary Syndrome: A Prospective Observational Study