Background:Increasing incidence rates of colorectal cancer (CRC) diagnosed before age 50 have been reported in Canada and other Western countries. Several organizations have lowered their recommended starting age for CRC screening. We aimed to analyze CRC rates in Canada and model the impacts of lowering the age to start faecal immunochemical test (FIT)-based screening in Canada. Methods:We evaluated the differences in absolute and relative incidence rates between age groups over time using the Canadian Cancer Registry data. Additionally, we used the OncoSim-Colorectal microsimulation model to examine starting FIT screening at 45 years of age over a lifetime time horizon. We estimated changes in CRC cases, deaths, potential years of life gained, and costs. Results:Absolute CRC incidence increased among groups below 50 years of age, with recent birth cohorts experiencing the greatest relative increases. Microsimulation results suggest that screening at 45 would result in fewer CRC cases (15 070) and CRC deaths (6100) in Canada between 2025 and 2071. For every additional 100 colonoscopies, 3.5 fewer CRC cases and 1.4 fewer CRC deaths are expected. Modelling suggests this may lead to an overall cost savings of $233 million CAD over the lifespan of eligible cohorts. Conclusion:Our results indicate that as CRC incidence in younger age groups has continued to increase, lowering the age to start FIT screening to 45 would result in overall population benefit through reduced CRC incidence and mortality. However, given resource considerations, provincial decision makers must evaluate changes in their programs to ensure proper implementation.

Abstract Background Endoscopic retrograde cholangiopancreatography (ERCP) is a ubiquitous and high-risk procedure with variable performance across providers and centres. In this review, we aimed to summarize the evidence related to ERCP practice in 4 domains: indications and alternatives, quality indicators, training and credentialing, and facility standards. Methods We searched MEDLINE, Embase, Cochrane databases, and the grey literature (2000-2026) for ERCP quality standards published by professional societies or health agencies. Records were included if they included recommendations related to the 4 above-mentioned domains. Recommendations were described qualitatively. For quality indicators, we described benchmarks for performance, strength of recommendations, and quality of evidence when available. Results Fifty-seven reports were included from 4 continents. Eighteen unique indications were identified. Seventeen procedural quality indicators were identified. Priority indicators included appropriate indication (benchmark >90% of cases), cannulation success rate (≥85%-90%), management of common bile duct stones <1 cm (≥75%-90%) stent placement below the bifurcation (≥80%-95%), post-ERCP pancreatitis rate (≤6%-10%), and unplanned hospital visit within 30 days of ERCP (<15%). Training recommendations suggested minimum volumes of 100-300 supervised procedures and highlighted a shift towards competency-based assessment tools like The EUS and ERCP Skills Assessment Tool or Direct Observation of Procedural Skills. Facility standards focused on radiation safety, duodenoscope reprocessing/infection control, and mandatory photodocumentation. Conclusion There was substantial alignment among societies on several core ERCP quality metrics, yet variability remains in training and credentialing and facility standards. Significant gaps exist regarding maintenance of competence and ERCP assistant training. This evidence can support health authorities seeking to develop and implement ERCP quality improvement initiatives.

OBJECTIVES:Skin ulcers are a critical indicator of quality of care in nursing homes that influence residents' physical, psychological, and social health. The objective of this study is to understand the influence of developing skin ulcers on deterioration in social engagement in nursing home residents. DESIGN:Observational retrospective cohort study with 1-year follow-up. SETTING AND PARTICIPANTS:Nursing home residents aged ≥50 years were followed quarterly (2008/2009-2009/2010), the latest years in which the Minimum Data Set 2.0 measured social engagement. METHODS:Cumulative incidence ratios (CIRs) and 95% CIs quantified the association between skin ulcer development and deterioration in residents' social engagement levels. RESULTS:About 1.25% first developed new skin ulcers at the annual follow-up assessment; 1.22% developed skin ulcers at a quarterly assessment that persisted at the annual assessment, and 4.53% developed skin ulcers at a quarterly assessment that were resolved by annual assessment. Compared with residents who remained ulcer-free, those with new skin ulcer at annual assessment and persistent skin ulcers were at increased risk of experiencing a reduction in social engagement (CIR, 1.26; 95% CI, 1.11-1.44; CIR, 1.32; 95% CI, 1.16-1.50, respectively). Those with resolved skin ulcers were also at increased risk of social engagement deterioration (CIR, 1.12; 95% CI, 1.04-1.21) than those who remained ulcer-free. CONCLUSION AND IMPLICATIONS:Residents who develop skin ulcers are at a higher risk of deteriorating social engagement. Nursing home staff should strive not only to prevent and treat skin ulcers, but also to support social engagement for those with skin ulcers.

BACKGROUND:Most guidelines recommend use of sterile water in single-use plastic bottles for irrigation in colonoscopy, a recommendation extrapolated from case reports of infection linked to endoscopic retrograde cholangiopancreatography. Our objective was to identify evidence exploring the impact of tap versus sterile water in colonoscopy on patient, health care resource, and environmental outcomes. METHODS:We performed a scoping review and included any study examining the effects of irrigation source during colonoscopy. A health information specialist searched Embase, MEDLINE, CINAHL, and Web of Science from inception to March 2024 using Peer Review of Electronic Search Strategies standards. Two reviewers performed screening and data extraction using a standardized form. We conducted a quantitative analysis of patient outcomes. RESULTS:Of 335 identified articles, we included 3. All were prospective studies published between 1996 and 2002. Overall, 137 colonoscopies and 38 flexible sigmoidoscopies were reported. Two studies compared sterile versus tap water, with 7 of 118 (6%) and 35 of 327 (11%) positive water cultures, respectively. There were no clinical adverse events. One study compared tap water at warm versus room temperature and measured patient pain scores (2/10 and 4/10, respectively). Infectious complications were not reported. CONCLUSION:There is limited evidence to support either tap or sterile water in irrigation for colonoscopy, but potable tap water may be a safe choice and is environmentally and economically more beneficial than sterile water. In the context of the climate crisis and increasing economic health care burden, tap water in reusable bottles should be strongly considered for irrigation in colonoscopy. Registration: Open Science Framework Registry, https://osf.io/8dgck.

For Asian American family caregivers, transitioning loved ones with dementia into a U.S. nursing home can be particularly challenging due to cultural expectations and the scarcity of linguistically and culturally appropriate care. This qualitative study, focusing on the largest Asian American community, examined the experiences of Chinese family caregivers navigating this transition, using thematic analysis of twelve semi-structured interviews conducted in Mandarin Chinese or English. Filial piety profoundly influenced caregiving decisions. Caregivers reported significant physical, emotional, and financial burdens, with challenges including limited access to culturally and linguistically appropriate nursing home care, concerns about care quality, and difficulties in family discussions about the transition. The findings underscore the need for greater awareness within the Chinese community about dementia care options and for nursing homes to improve culturally sensitive care. Addressing these gaps could ease the transition process and better support caregivers and their loved ones.

Introduction Asian American caregivers supporting loved ones with dementia experience greater burden and more stress than other racial/ethnic groups, warranting the need for more culturally and linguistically appropriate formal support, such as in nursing homes. Transitioning loved ones into nursing homes with dementia care units is a complex process that can be impacted by a multitude of factors. Employing several established frameworks, including the socioecological model, this qualitative study will focus on the largest Asian American subgroup (people of Chinese descent) and explore the experience of family caregivers as they support the transition of their loved ones with dementia into nursing homes in the USA. Our focus will be on the nuanced influences of the Chinese language and culture and COVID-19-related social isolation and racial discrimination.Methods and analysis Recruitment will take place starting in January 2024. Current or former Chinese caregivers for Chinese loved ones with dementia, able to communicate in Mandarin Chinese or English, and currently residing in the USA will be eligible. Key informants with intimate understanding and experience with this population will also be included. Data will be collected through 2024 using semistructured, in-depth interviews with each participant. Depending on participants’ preferences, interviews will be conducted in either Mandarin Chinese or English and either in person, via Zoom or by phone. Interviews will be transcribed verbatim. Iterative thematic analysis will be employed. A coding structure will be developed based on interview questions and themes and patterns that are revealed through data immersion. Transcripts, prepared in their original language, will be dual-coded by bilingual researchers using NVivo 14. Consensus summaries of themes will be prepared. Relevant direct quotes for each thematic area will be identified (those in Chinese will be translated into English) and cited in reports and manuscripts.Ethics and dissemination The study is approved by the UMass Chan Medical School Institutional Review Board (ID: STUDY00001376). Findings will be published in peer-review journals following the consolidated criteria for reporting qualitative research.

BACKGROUND:Youth vaping is a serious public health concern, being more prevalent than any other tobacco use. To inform cessation interventions, we explored what adolescents perceive as their reasons for quitting and strategies to help them quit.METHOD:Semi-structured interviews were conducted with a convenience sample of 11 adolescents reporting vaping in the past 90 days and recruited from a high school in Massachusetts. Interviews were transcribed and dual-coded. Inductive thematic analysis was employed, and thematic summaries were prepared.RESULTS:Reasons adolescents reported for quitting included cost, experiencing "nic-sick" from nicotine withdrawal or excess intake, negative impacts on mood, concentration, or health, and experiencing symptoms of nicotine dependence. Nearly all tried to quit multiple times. Barriers to quitting included exposure to vaping, access to vape products, stress, and "cool" new products or flavors. Quit strategies included avoiding others vaping, seeking social support to quit, addressing peer pressure to continue vaping, learning successful quit strategies from peers, and using distraction strategies or alternatives to vaping.CONCLUSION:Many adolescents who vape want to quit, and most have tried multiple times. Interventions need to engage adolescents with varying reasons to quit, barriers, and quit strategy preferences.CLINICAL TRIAL REGISTRATION:This study is registered through ClinicalTrials.gov. The trial registration number is NCT05140915. The trial registration date is 11/18/2021.

Background Colorectal cancer guidelines recommend screening colonoscopy every 10 years after a negative procedure. If risk reduction extends past 10 years, the recommended interval could be extended, reducing the burden on the individual and health-care system. We aimed to estimate the duration that patients remain at reduced risk of colorectal cancer incidence and mortality after a complete colonoscopy. Methods We did a population-based cohort study of individuals aged 50-65 years between Jan 1, 1994, to Dec 31, 2017. We excluded individuals with previous exposure to colonoscopy or colorectal surgery, those previously diagnosed with colorectal cancer, or a history of hereditary or other bowel disorders. We followed up participants until Dec 31, 2018, and identified all colonoscopies performed in this time period. We used a 9-level time-varying measure of exposure, capturing time since last complete colonoscopy (no complete colonoscopy, <= 5 years, >5-10 years, >10-15 years, and >15 years) and whether an intervention was performed (biopsy or polypectomy). A Cox proportional hazards regression model adjusting for age, sex, comorbidity, residential income quintile, and immigration status was used to estimate the association between exposure to a complete colonoscopy and colorectal cancer incidence and mortality. Findings 5 298 033 individuals (2 609 060 [492%] female and 2 688 973 [508%] male; no data on ethnicity were available) were included in the cohort, with a median follow-up of 1256 years (IQR 626-2013). 90 532 (17%) individuals were diagnosed with colorectal cancer and 44 088 (08%) died from colorectal cancer. Compared with those who did not have a colonoscopy, the risk of colorectal cancer in those who had a complete negative colonoscopy was reduced at all timepoints, including when the procedure occurred more than 15 years earlier (hazard ratio [HR] 062 [95% CI 051-077] for female individuals and 057 [046-070] for male individuals. A similar finding was observed for colorectal cancer mortality, with lower risk at all timepoints, including when the procedure occurred more than 15 years earlier (HR 064 [95% CI 049-083] for female participants and 065 [050-083] for male participants). Those who had a colonoscopy with intervention had a significantly lower colorectal cancer incidence than those who did not undergo colonoscopy if the procedure occurred within 10 years for females (HR 070 [95% CI 063-077]) and up to 15 years for males (062 [053-072]). Interpretation Compared with those who do not receive colonoscopy, individuals who have a negative colonoscopy result remain at lower risk for colorectal cancer incidence and mortality more than 15 years after the procedure. The current recommendation of repeat screening at 10 years in these individuals should be reassessed.

Primary care clinics serve many patients experiencing latent or evident suicide risk and may benefit from implementing suicide care improvements such as the Zero Suicide model. However, little is known about the readiness of clinics to implement such initiatives. We interviewed a range of clinicians (e.g., medical providers, behavioral health providers, nurses; n = 24) from six integrated primary care clinics to better understand strengths and limitations of the milieu, how suicide risk is currently detected and managed, and which implementation strategies could be employed to improve suicide prevention. We found clinics were extremely busy and resource-constrained but had a strong and longitudinal commitment to patients and families. Suicide risk was detected in a variety of ways and clinicians had limited resources to offer these patients. Clinicians sought to preserve patients’ autonomy and trust while also ensuring their safety. Preferred strategies included dissemination of protocols and tools, training, electronic health record changes, and improved staffing. Our findings suggest that suicide prevention initiatives in primary care should attend to the constraints of the care setting, adapting their approach to ensure they fit with workflow while also centering patient autonomy and rapport.

Background:Canada has one of the highest incidences of colorectal cancer (CRC) worldwide. CRC screening improves CRC outcomes and is cost-effective. This study compares Canadian CRC screening programs using essential elements of an organized screening program outlined by the International Agency for Research on Cancer (IARC). Methods:We collaborated with the Cancer Screening in 5 continents (CanScreen5) program, an initiative of IARC. Standardized data collection forms were sent to representatives of provincial and territorial CRC screening programs. Twenty-five questions were selected to reflect IARC's essential elements of an organized screening program. We performed a qualitative analysis of Canada's CRC screening programs and compared programs within Canada and internationally. Results:CRC screening programs exist in 10 provinces and 2 territories. None of the programs in Canada met all the essential criteria of an organized screening program outlined by IARC. Three programs do not send invitations to participate in screening. Among those that do, 4 programs do not include a stool test kit in the invitations. While all provinces met the essential elements for leadership, governance, finance, and access to essential services, there was more heterogeneity in the domains of service delivery as well as information systems and quality assurance. Conclusions:There is considerable heterogeneity in the design of CRC screening programs in Canada and worldwide. Programs should strive to meet all the essential IARC criteria for organized screening if local resources allow, such as issuing invitations and implementing systems to track and compare outcomes to maximize screening program quality, effectiveness, and impact.

Background and objectives: Using US national nursing home data, this cross-sectional study sought to evaluate 1) the association between lack of social engagement and level of cognitive impairment; and 2) the extent to which this association differs by hearing and visual impairment. Research design and methods: Our sample included 793,846 nursing home residents aged >= 50 years. The Index of Social Engagement was categorized as none/lower (0, 1, 2) or higher levels (3 through 6). Cognitive Performance Scale was grouped as intact/mild (0, 1, 2), moderate (3, 4), or severe (5, 6). Multinomial models provided adjusted odds ratio (aOR) and 95 % confidence intervals (CI) between none/lower social engagement and cognitive impairment. We estimated relative excess risk due to interaction (RERI) to quantify the joint effects of social engagement and sensory impairment types. Results: Overall, 12.6 % had lower social engagement, 30.3 % had hearing impairment, and 40.3 % had visual impairment. Compared to residents with high social engagement, those with lower social engagement were more likely to have moderate/severe cognitive impairment (aOR moderate = 2.21, 95 % CI 2.17 -2.26; aOR severe = 6.49, 95 % CI 6.24 -6.74). The impact of low social engagement on cognitive impairment was more profound among residents with hearing impairment and/or visual impairment (RERI hearing = 3.89, 95 % CI 3.62 -4.17; RERI visual = 25.2, 95 % CI 23.9 -26.6)). Discussion and implications: Residents with lower social engagement had higher levels of cognitive impairment. Residents with sensory impairments are potentially more susceptible to the negative impact of lower levels of social engagement on level of cognitive impairment.

Background There are high rates of computed tomography (CT) utilization in the emergency department (ED) for patients with inflammatory bowel disease (IBD), despite guidelines recommending judicious use. We performed a national survey to better understand perceptions and practice patterns of Canadian physicians related to CT imaging in the ED.Methods Our survey was developed by a multistep iterative process with input from key stakeholders between 2021 and 2022. It evaluated Canadian gastroenterologists', surgeons', and emergency physicians' (1) perceived rates of IBD findings detected by CT, (2) likelihood of performing CT for specific presentations and (3) comfort in diagnosing IBD phenotypes/complications without CT.Results A total of 208 physicians responded to our survey: median age 44 years (IQR, 37-50), 63% male, 68% academic, 44% emergency physicians, 39% gastroenterologists, and 17% surgeons. Compared with emergency physicians and surgeons, gastroenterologists more often perceived that CT would detect inflammation alone and less often IBD complications. Based on established rates in the literature, 13 (16%) gastroenterologists, 33 (40%) emergency physicians, and 21 (60%) surgeons overestimated the rates of at least one IBD complication. Although most physicians were more comfortable diagnosing inflammation compared to IBD complications without CT, gastroenterologists were significantly less likely to recommend CT imaging for non-obstructive/penetrating presentations compared with emergency physicians and surgeons with results that varied by IBD subtype.Conclusion This national survey demonstrates differences in physician perceptions and practices regarding CT utilization in the ED and can be used as a framework for educational initiatives regarding appropriate usage of this modality. Many people with intestine problems go to the emergency room and get special pictures called computed tomography scans. These pictures can be helpful, but they cost a lot, use radiation, and impact the environment. We asked different types of doctors why they ordered these scans. Gastroenterologists, who know a lot about intestine issues, often thought the scans would find only inflammation, not other problems. Emergency doctors and surgeons had different ideas. Sixteen percent of gastroenterologists, 40% of emergency doctors, and 60% of surgeons thought these scans found more complications than they really did. Most doctors feel okay diagnosing intestine issues without using these scans. Gastroenterologists are less likely to ask for scans if patients in the emergency room do not have signs of intestine problems. Our survey helps us understand why doctors order these scans. This information will help create programs to teach doctors when it is right to use scans.

BACKGROUND:The prevalence of eating disorders is higher in transgender and non-binary compared to cisgender people. Gender diverse people who seek eating disorder treatment often report struggling to find affirming and inclusive treatment from healthcare clinicians. We sought to understand eating disorder care clinicians' perceptions of facilitators of and barriers to effective eating disorder treatment for transgender and gender diverse patients.METHODS:In 2022, nineteen US-based licensed mental health clinicians who specialized in eating disorder treatment participated in semi-structured interviews. We used inductive thematic analysis to identify themes around perceptions and knowledge of facilitators and barriers to care for transgender and gender diverse patients diagnosed with eating disorders.RESULTS:Two broad themes were identified: (1) factors affecting access to care; and (2) factors affecting care while in treatment. Within the first theme, the following subthemes were found: stigmatization, family support, financial factors, gendered clinics, scarcity of gender-competent care, and religious communities. Within the second theme, prominent subthemes included discrimination and microaggressions, provider lived experience and education, other patients and parents, institutions of higher education, family-centered care, gendered-centered care, and traditional therapeutic techniques.CONCLUSION:Many barriers and facilitators have potential to be improved upon, especially those caused by clinicians' lack of knowledge or attitudes towards gender minority patients in treatment. Future research is needed to identify how provider-driven barriers manifest and how they can be improved upon to better patient care experiences.

ObjectivesTo explore experiences of U.S. (United States) nursing home leadership during the COVID-19 pandemic in their efforts to address resident loneliness and social isolation and to elicit stories about personal and professional impacts on themselves and staff.DesignQualitative inquiry via three optional open-ended questions appended to a national self-administered survey of American nursing home leaders was employed. Textual data was analyzed using an iterative reflexive thematic approach.Setting and participantsA stratified sample frame defined by facility size (beds: 30-99, 100+) and quality ratings (1, 2-4, 5) was employed. Web survey links and paper surveys were sent to 1,676 nursing home directors of nursing between February and May 2022.ResultsOpen text responses were collected from 271 nursing homes. Broad themes included: 1) Addressing needs of residents & families; 2) Challenges; and 3) Personal experiences of nursing home leadership/staff. Respondents described trauma to residents, staff, and leadership. Resident loneliness was addressed using existing and newer technologies and innovative indoor and outdoor activities. Residents experienced fear, illness, loss, and sometimes death. Isolation from family and lack of touch were particularly difficult. Regulations were seen as punitive while ignoring emotional needs of residents. Staffing challenges and pressures to do more with less created additional stress. Leadership and staff made significant sacrifices resulting in physical, social, and emotional consequences. Beneficial outcomes included staff bonding, professional growth, and permanent implementation of new interventions.Conclusions and implicationsNew and creative interventions were successfully implemented to address social isolation and loneliness. Improved Wi-Fi and other nursing home infrastructure upgrades are needed to maintain them. Reimagining often conflicting overlapping federal, state, and local regulations, grounding them in good clinical judgement, and incentivizing performance improvement should be considered. Trauma experienced by staff needs to be addressed to deal with current and future workforce needs.

Post colonoscopy colorectal cancer (PCCRC) is a wellwith PCCRCs are more likely to present emergently and to die from their cancers compared with those whose cancers are detected at the initial colonoscopy.2 There are challenges in measuring PCCRCs and reporting them in a timely fashion, which limits the usefulness of PCCRC as an endoscopist quality indicator. Endoscopist adenoma detection rate (ADR) is easier to measure and report in a timely fashion and has been found to be inversely associated with PCCRC.3 However, to date, this association has been limited to ADR for primary screening colonoscopies. Although intended to facilitate comparisons across practices and jurisdictions, measuring ADR on colonoscopies done for a single indication only has proved challenging.4 For this reason, as early as 2016, the UK colonoscopy quality guidance recommended overall ADR (across all indications in people 18 years and older) be used instead.5 However, until now, there was a paucity of data to support this

BACKGROUND:The overall impact of social connectedness on health outcomes in older adults living in nursing homes and assisted living settings is unknown. Given the unclear health impact of social connectedness for older adults in congregate long-term care settings worldwide, a comprehensive systematic review is required to evaluate the overall relationship between social connectedness and health outcomes for them. OBJECTIVES:The purpose of this article was to synthesize the literature regarding the health impact of social connectedness among older adults living in nursing homes or assisted living settings. METHODS:Using PRISMA guidelines, we identified eligible studies from Scopus, MEDLINE, PsycINFO, CINAHL and Cochrane databases (1990-2021). Bias and quality reporting assessment was performed using standardized criteria for cohort, cross sectional and qualitative studies. At each stage, ≥ 2 researchers conducted independent evaluations. RESULTS:Of the 7350 articles identified, 25 cohort (follow-up range: 1 month-11 years; with two also contributing to cross sectional), 86 cross sectional, eight qualitative and two mixed methods were eligible. Despite different instruments used, many residents living in nursing homes and assisted living settings had reduced social engagement. Quantitative evidence supports a link between higher social engagement and health outcomes most studied (e.g. depression, quality of life). Few studies evaluated important health outcomes (e.g. cognitive and functional decline). Most cohort studies showed that lack of social connectedness accelerated time to death. CONCLUSIONS:Social connectedness may be an important modifiable risk factor for adverse health outcomes for older adults living in nursing homes and assisted living facilities. Most studies were cross sectional and focused on quality of life and mental health outcomes. Longitudinal studies suggest that higher social engagement delays time to death. Evidence regarding other health outcomes important to older adults was scant and requires further longitudinal studies.

Studies exploring patient experience with eating disorder specialists have reported poor gender competency among clinicians, as revealed through patient-clinician interactions. Through interviews with eating disorder specialists, the authors sought to (1) clarify how and why current practice and clinical training may not meet the needs of transgender and gender-diverse patients, (2) assess where and how clinicians received education on gender identity, and (3) how changes can be made to meet educational and patient needs. Specialists were recruited, and semi-structured interviews were conducted. Narratives were coded by two independent coders, using thematic analysis. Four key themes emerged from 19 completed interviews: Training and education received, importance of receiving training or education, self-education, and improvements recommended by clinicians. Only ~ 16% ( n = 3) of clinicians reported sufficient training both in graduate school and through their place of employment. Most with sufficient education received it at their clinic/practice. Despite lacking formal training, all clinicians engaged in some form of self-education on gender. These findings support the need for standardized and comprehensive graduate curricula, in-service training, and continuing education requirements. Advocacy is required to encourage accrediting organizations to mandate training on gender among mental health clinicians.