IntroductionLes troubles concomitants, définis ici comme la cooccurrence de troubles de santé mentale (TSM) et de troubles liés à l’usage de substances (TUS), posent des problèmes de traitement et de santé publique. Cette étude se penche sur la prévalence et les caractéristiques associées aux TSM uniquement, aux TUS uniquement et aux troubles concomitants chez les Canadiens de 15 ans et plus pendant la pandémie de COVID-19. MéthodologieNous avons analysé les données de l’Enquête sur la santé mentale et l’accès aux soins (ESMAS) de 2022, une enquête transversale menée auprès des Canadiens de 15 ans et plus vivant dans les 10 provinces (n = 9 861). Les TSM et les TUS ont été évalués à l’aide de l’Entrevue composite diagnostique internationale de l’OMS. Les répondants ont été classés en quatre groupes : aucun trouble, TSM uniquement, TUS uniquement et troubles concomitants. Une régression logistique multinomiale a permis de déterminer les caractéristiques sociodémographiques, sanitaires et liées à la pandémie associées à ces catégories de troubles, en utilisant les poids de l’enquête et des méthodes bootstrap. RésultatsParmi les répondants, 1,6 % présentaient des troubles concomitants, 12,2 % des TSM uniquement et 1,6 % des TUS uniquement. Les jeunes adultes, en particulier ceux de 20 à 24 ans, et les personnes issues de la communauté 2ELGBTQI+ présentaient un risque élevé de troubles concomitants. Les autres corrélats étaient un faible niveau de scolarité, une résidence en milieu rural, un faible sentiment d’appartenance et des déficiences fonctionnelles. Les facteurs de stress liés à la pandémie (solitude, difficultés financières et difficultés d’accès aux soins) ont été fortement associés aux troubles concomitants. ConclusionCette étude met en évidence la prévalence et les principaux corrélats des TSM, des TUS et des troubles concomitants chez les adultes canadiens pendant la pandémie de COVID-19. Les populations vulnérables sont les jeunes, les minorités sexuelles et de genre ainsi que les personnes confrontées à l’isolement social ou à des besoins en matière de soins non satisfaits. Ces résultats soulignent l’importance d’assurer des services de santé mentale et de consommation de substances intégrés et accessibles dans le cadre du rétablissement post-pandémique du Canada.

Pain is prevalent among people with HIV (PWH), and many PWH who experience pain also use substances (illicit drug and/or unhealthy alcohol use). While cocaine use and cocaine and alcohol co-use are prevalent in this population, their effects on pain in PWH are unknown. This study aims to investigate the association of cocaine use and co-use of cocaine and alcohol with pain interference among PWH. We completed a secondary analysis of the Boston Alcohol Research Collaboration on HIV/AIDS (ARCH) study, a longitudinal cohort of PWH with a history of substance use. The outcome was pain interference (Brief Pain Inventory). Exposures were recent cocaine use (Addiction Severity Index) and recent unhealthy alcohol use (Timeline Follow Back). Generalized Estimating Equation (GEE) ordinal logistic regression models were employed, adjusted for demographic factors, illicit/non-medical opioid use and cannabis use. Among 251 participants, 22.3

People with serious mental illness and/or substance use disorders are at high risk of chronic physical diseases like diabetes and hypertension and related acute complications but may face barriers to chronic disease management (including medication management and laboratory testing). We describe patterns of service use and chronic disease management among people with diabetes and/or hypertension treated for comorbid serious mental illness and/or substance use disorders. We used linked British Columbia administrative health data from April 1, 2020 to March 31, 2022 to conduct a retrospective cohort study among adults with diabetes and/or hypertension and used standardized differences to compare how health service use and chronic disease management varied for those treated for comorbid serious mental illness and/or substance use disorders. People treated for comorbid serious mental illness and/or substance use disorder had high service use (more primary care visits, ED visits, and hospitalizations) but received less recommended lab testing and medication management for diabetes or hypertension. These findings show people treated for serious mental illness and/or substance use disorders receive inequitable chronic disease management, despite frequent primary care use. Reshaping care to address underlying barriers will be crucial to improving chronic disease management in this population.

Relational continuity, or the ongoing therapeutic relationship between patient and clinician, has been associated with improved outcomes among people with chronic disease and emphasized in primary care policy. It has not yet been studied how relational continuity shapes recommended chronic disease management and whether this relationship is modified by patient complexity. We used linked administrative health data to conduct a retrospective, population-based cohort study among residents of British Columbia, Canada with diabetes and/or hypertension between April 1, 2020 to March 31, 2023. Modified-Poisson regression models were used to calculate adjusted risk ratios (aRR) between relational continuity and a composite outcome of recommended management (including monitoring and prescribing for diabetes or hypertension) and included interaction terms to examine subgroup-specific associations among those treated for serious mental illness, substance use disorder, or with a higher overall burden of comorbidity. Compared to those with low relational continuity, those with complete relational continuity had slightly more recommended management for both diabetes (20.4

Abstract Background Khat ( Catha edulis) is a widely consumed natural amphetamine-analog used across East Africa and the Arabian Peninsula. Accurate field-feasible measurement of recent khat use is a prerequisite for large-scale epidemiological research; yet no validated alternatives to laboratory reference methods have been identified in the scientific literature. This nested validation study evaluated the diagnostic accuracy of two point-of-care measures, a commercial amphetamine immunoassay and a Timeline Followback (TLFB) Assisted Self-Report (ASR), against high-performance liquid chromatography (HPLC) quantification of urinary norephedrine (NE), while additionally assessing agreement between the two field measures. Methods A prospective, random sub-sample of 119 male participants aged 18-40 years from the Gilgel Gibe Field Research Center (GGFRC) longitudinal cohort, Ethiopia (validation timepoint T2, 2015), was used. Three index-reference comparisons were conducted: (1) amphetamine immunoassay (nal von minden, Drug-Screen AMP test, 300Öng/mL cutoff) vs.ÖHPLC; (2) binary ASR (past-week use) vs.ÖHPLC; and (3) binary ASR vs.Öimmunoassay. Sensitivity (positive percent agreement, PPA), specificity (negative percent agreement, NPA), positive predictive value (PPV), negative predictive value (NPV), overall accuracy (overall percent agreement, OPA), and Cohen’s kappa were calculated with 95% confidence intervals. Pre-specified secondary analyses applied three pharmacokinetically-informed recall windows (0-2, 3-5, and 6-7 days prior to interview) to ASR. Results Against HPLC (77 positive, 42 negative), the immunoassay showed perfect specificity (1.0 [0.916-1.0]) and PPV (1.0 [0.91-1.0]) but low sensitivity (0.52 [0.40-0.64]), NPV (0.53 [0.42-0.65]), overall accuracy (0.69 [0.60-0.77]), and weak kappa (0.43 [0.34-0.52]). Binary ASR showed high sensitivity (0.96 [0.89-0.99]), specificity of 0.60 [0.433-0.74], PPV (0.81 [0.72-0.89]), NPV (0.89 [0.72-0.98]), with overall accuracy 0.83 [0.75-0.89] and moderate kappa (0.60 [0.51,0.69]). Restricting ASR to use within 0-2 days improved specificity to 0.69 [0.52-0.84], PPV to 0.86 [0.77-0.93], overall accuracy to 0.87 [0.79-0.93], and kappa to 0.69 [0.61-0.78] (moderate), while sensitivity (0.96 [0.89-0.99]) and NPV (0.89 [0.72-0.98]) remained stable. Against the immunoassay, ASR achieved high PPA of (1.0 [0.91-1.0]), NPA of 0.35 [0.25-0.47], OPA of 0.57 [0.48-0.66], and minimal kappa (0.27 [0.19-0.35]). Conclusions Time-stratified ASR (0-2 days) is a valid, scalable alternative to biological testing for recent khat use in resource-limited settings. The immunoassay’s 300 ng/mL cutoff functions as a marker of heavy or recent high-dose khat use rather than any-use detection. Its perfect specificity and PPV make it valuable as a confirmatory test for substantial exposure, while its lower sensitivity reflects calibration to amphetamine rather than to khat-derived cathinone metabolite. Registration Not registered.

Alcohol is a leading cause of preventable morbidity and mortality, with emergency departments (EDs) carrying a substantial burden. We aimed to estimate sex-specific associations between alcohol consumption and (1) the probability of alcohol-attributable ED visits, (2) per-person ED costs, and (3) variation across major condition groups. We analyzed 45,275 past-week drinkers from Ontario using the Canadian Community Health Survey (2000–2006) linked to ED records (2007–2017) and cost estimates. Two-part models estimated the probability and per-person cost of alcohol-attributable ED visits, stratified by sex and condition. Over 1.2 million alcohol-attributable ED visits and 542 million CAD in costs occurred during follow-up. Alcohol consumption was associated with higher ED visit probability and costs overall and among men, and with higher costs among women. Harms extended beyond heavy drinkers and were distributed across the population. These results support continuum-of-risk guidelines and the need for both population-wide and sex-specific prevention strategies.

IntroductionConcurrent disorders, defined here as co-occurring mental health disorders (MHD) and substance use disorders (SUD), pose challenges for treatment and public health. This study examines the prevalence and characteristics associated with MHD only, SUD only, and concurrent disorders among Canadians aged 15 and older during the COVID-19 pandemic. MethodsWe analyzed data from the 2022 Mental Health and Access to Care Survey (MHACS), a cross-sectional survey of Canadians aged 15 and older living in the 10 provinces (n = 9861). MHD and SUD were assessed using the WHO Composite International Diagnostic Interview. Respondents were classified into four groups: no disorder, MHD only, SUD only, and concurrent disorders. Multinomial logistic regression identified sociodemographic, health, and pandemic-related characteristics associated with these disorder categories, using survey weights and bootstrap methods. ResultsAmong respondents, 1.6% had concurrent disorders, 12.2% had a MHD only, and 1.6% had a SUD only. Younger adults, especially those aged 20 to 24, and 2SLGBTQI+ individuals had elevated risk for concurrent disorders. Additional correlates included lower education, rural residence, weak sense of belonging, and functional impairment. Pandemic-related stressors—loneliness, financial hardship, and difficulty accessing care—were strongly associated with concurrent disorders. ConclusionThis study highlights the prevalence and key correlates for MHD, SUD, and concurrent disorders among Canadian adults during the COVID-19 pandemic. Vulnerable populations include younger individuals, sexual and gender minorities, and those facing social isolation or unmet care needs. These findings underscore the importance of ensuring integrated, accessible mental health and substance use services in Canada’s postpandemic recovery.

Adverse childhood experiences (ACEs) have been linked to poorer health and well-being across the lifespan. This study examined the associations of two dimensions of ACEs (threat and deprivation) with 30 chronic conditions (CCs) and their multimorbidity. Further, we assessed whether social support availability (SSA) moderated these associations. This study used data from the Canadian Longitudinal Study on Aging (CLSA). The sample included 38,191 adults aged 45–89 from the CLSA baseline (2011–2015) cohort. Participants self-reported chronic physical health conditions and ACEs. Logistic regression was used to assess associations between ACE dimensions and CC outcomes, including CC domains based on functional and physiological linkages, adjusting for sociodemographic factors. Effect modification by overall SSA was also assessed. Of 38,191 participants, 44

Background: Multi-criteria decision analysis (MCDA) has been used to quantify drug harms in the United Kingdom, the European Union, Australia, and New Zealand. This paper presents the result of an MCDA conducted in Canada, with the aim of informing Canadian drug policy and contributing to public understanding of drugs' relative harms.Methods: A panel composed of 20 experts from six provinces determined 16 drugs to evaluate on 16 dimensions of harm (ten representing harm to people who use the drug; six representing harm to others). At a two-day decision conference, the panel scored each drug on a scale of 0-100 for each harm criterion, then weighted the relative importance of each criterion.Results: This analysis of drug harms in Canada found that alcohol causes the most harm overall, with a cumulative weighted score of 79. It was followed by tobacco (45), nonprescription opioids (33), cocaine (19), methamphetamine (19), and cannabis (15). The finding that alcohol causes the most harm is consistent with the results of previous MCDA drug harm studies.Conclusion: These harm scores express population-level harm rather than individual-level "harmfulness." They reflect not only a drug's pharmacological risk profile but also the current policy context in Canada. The high score for alcohol underscores a failure to adopt policies to address alcohol-related harms, despite the known health harms and the existence of proven policy measures. More broadly, when developing drug policies, governments should consider the harm-both individual and societal-caused by drugs and by the laws and regulations that govern them.

To evaluate existing alcohol policies in Canadian provinces and territories (P/Ts) against evidence-based best practice policies aimed at reducing alcohol-related harms and improving population health. Alcohol policies in Canadian P/Ts were evaluated across 11 policy domains. The scoring rubric was formulated based on the latest evidence-based public health criteria. Policy domains were weighted to reflect their relative effectiveness and scope. Data were collected by the research team, reviewed and validated by government contacts, and scored by designated team members. Scores were calculated for each P/T and policy domain. Additionally, a Best Existing Policies (BEP) score was calculated to demonstrate the score that could be achieved by any P/T if they adopted all the best policies currently in place somewhere in Canada. Scored against best practice policy criteria, the average score across all P/Ts was 37

Rationale: Cannabis liberalization has stimulated public and academic interest in whether cannabis impairs driving. As access to cannabis for research purposes has relaxed, the number of studies focused on this topic has grown considerably. However, synthesizing, translating and applying research findings focused on driving under the influence of cannabis (DUIC) is complicated by the absence of a standard definition of "impairment," as well as the absence of a theoretical framework to guide converging evidence. Objectives: In this theoretical essay, we aim to bring attention to, and help resolve, conceptual and operational issues that arise in defining "impairment." We also aim to explain how target constructs within the DUIC literature relate to one another and provide a theoretical account of how driving is affected by cannabis. Results: First, we propose three guiding principles for conceptually and operationally defining impaired driving and related concepts. These include considering the distinctions between drug effects and impaired driving; the distinctions between driving performance and driver behaviour; and, parallels between motor vehicle crashes and other forms of accident. Then, we introduce an adapted theoretical framework, based on prior theories focused on normal driver behaviour, to link research findings and provide an account of how cannabis affects driving. Conclusions: Within the DUIC literature there is an assortment of related, but distinct, concepts pertaining to impaired driving. We suggest terminology, definitions and a theoretical framework so researchers, stakeholders, policy makers and the public can share a common understanding of how cannabis affects driving.

To examine trends in opioid toxicity mortality in Nova Scotia and its health zones from 2009 to 2023, focusing on differences between pharmaceutical and non-pharmaceutical opioid-related deaths. We conducted a population-based study using data on annual opioid toxicity mortality rates from 2009 to 2023, stratified by health zone and opioid type. An interrupted time series (ITS) analysis was applied to assess changes in mortality trends across three pandemic-related periods. Comparisons were made between pharmaceutical and non-pharmaceutical opioid mortality to assess evolving patterns of opioid-related harm. Opioid toxicity mortality in Nova Scotia declined during the peri-pandemic period (2019–2021) but increased significantly post-pandemic, particularly in non-pharmaceutical opioid-related deaths, which steadily rose after 2021. Pharmaceutical opioid-related deaths remained higher than non-pharmaceutical deaths. Health zone analysis revealed geographic variation: the Central Zone experienced stable pharmaceutical mortality with rising non-pharmaceutical deaths post-pandemic; the Eastern Zone saw higher pharmaceutical mortality pre-pandemic, which declined during the peri-pandemic period, while non-pharmaceutical deaths remained low; the Northern Zone had stable pharmaceutical mortality but rising non-pharmaceutical deaths post-pandemic; and the Western Zone exhibited consistently lower mortality rates across both opioid types. This study reveals significant shifts in opioid-related mortality trends in Nova Scotia, with a rise in non-pharmaceutical opioid deaths post-pandemic, while pharmaceutical opioids remain a major contributor. Geographic variations across health zones highlight the need for region-specific public health strategies. Ongoing efforts to reduce both pharmaceutical and illicit opioid misuse through harm reduction and improved prescribing practices are crucial.

INTRODUCTION:To describe opioid prescribing patterns for opioid-naive patients who filled prescriptions after surgical or emergency care. METHODS:We conducted a population-based, cross-sectional study of opioid-naive adults who filled opioid prescriptions within 14 days of receiving surgical or emergency care in Nova Scotia, Canada. Using linked administrative databases, we estimated the prevalence of opioid prescriptions with >7 days' supply, ≥90 morphine milligram equivalents (MME)/day or long-acting opioids. We assessed the association of care setting and specialty with these outcomes. RESULTS:Among 124,515 patients, 36,716 (29.5%) were opioid-naive. The median opioid supply duration was 3 days (IQR 2-5), the median dose was 50 MME/day (IQR 30-75). Prescriptions for >7 days, ≥90 MME/day or involving long-acting opioids were filled by 10.9%, 20.2% and 0.7% of the patients, respectively. Hydromorphone (50%) and codeine (26.4%) were the most filled opioids. The emergency care setting had double the odds of filling >7 days' supply (OR 2.13, 95% CI 1.99-2.28), and 69% lower chance of filling ≥90 MME/day (OR 0.31, 95% CI 0.29-0.33) than surgical care. In the surgical care setting, there was significant variation across medical specialties. Otolaryngology was associated with a higher chance of prescribing >7 days' opioid supply than general surgery (OR 4.89, 95% CI 3.86-6.20). Orthopaedic surgery had a higher likelihood of ≥90 MME/day prescriptions (OR 2.92, 95% CI 2.58-3.30) than general surgery. DISCUSSION AND CONCLUSIONS:Opioid prescribing patterns vary significantly by setting and specialty in Nova Scotia, Canada. Our results emphasise the need for tailored guidelines that consider clinical context and specialty to enhance patient safety and reduce opioid misuse risk.

BACKGROUND:During the coronavirus disease 2019 (COVID-19) pandemic, Health Canada issued a temporary exemption for the Controlled Drugs and Substances Act (CDSA). Very little is known about pharmacists prescribing opioids under the CDSA temporary exemption. OBJECTIVE:This study aimed to evaluate the impact of CDSA subsection 56(1) temporary exemption on prescribing of opioids by direct patient care pharmacists during COVID-19 between February 1, 2018, and April 30, 2022. METHODS:Descriptive statistics (sample mean, sample SD, sample proportion) and data visualization tools were used to explore the possible changes owing to CDSA. In the first stage, a linear regression model was fit to the data to detect the changes. Second, the time dependence of the data was checked by examining the autocorrelation plots and testing the dependence of the residuals, and then a suitable time series process was used. RESULTS:The mean overall pharmacist-prescribed opioid weekly claims increased from 0.0 (per-CDSA policy period) to 57.0 (post-CDSA policy period). The time series regression for the mean-level change for the overall prescription data was 36.29 (95% CI 27.14-48.52, P < 0.0001). The time series regression for the mean-level change for the analgesic prescription data and the opioid use disorder prescription data was 28.95 (95% CI 20.88-40.13, P < 0.0001) and 6.74 (95% CI 5.80-7.82, P < 0.0001). CONCLUSIONS:The temporary exemption under the CDSA during the COVID-19 pandemic allowed pharmacists in Nova Scotia to prescribe opioids, ensuring continuity of opioid therapy for adults. Future studies are needed to investigate the reasons behind the low uptake of CDSA exemptions by pharmacists involved in direct patient care.

INTRODUCTION:British Columbia's (BC) three-year drug decriminalization policy-introduced in January 2023 and amended just over a year later in 2024-had multiple goals, including reducing drug use stigma, shifting perceptions of drug use from a criminal to a health issue, and improving health outcomes for people who use drugs. As part of the policy, the BC government was required to implement public education tools to raise awareness and build understanding of the policy. However, little is known about the scope or impact of these public education efforts or how the information environment shaped public perceptions and attitudes toward the policy. To address these gaps, this study examines: 1) how BC's decriminalization policy was communicated and represented across government and media sources, and 2) how exposure to these information sources influenced public support and perceptions of safety. METHODS:This mixed-methods study analyzed 98 government resources, 301 media articles, and a cross-sectional public opinion survey of 1200 BC residents. Content analyses of government resources and media articles examined government resource and media source intent, misinformation, misleading narratives, and perspectives, while the public opinion survey assessed information exposure, policy support, and perceived safety. RESULTS:Approximately one-quarter of all sources were government resources, and among those with publication dates, only 13 % were released prior to the policy's implementation and 9 % contained misinformation, representing a missed opportunity for expectation-setting and public education. In contrast, 34 % of media articles contained misinformation, commonly misrepresenting the policy's intent and linking decriminalization to increased crime, disorder, and public drug use. Survey findings showed no significant associations between specific information sources and outright opposition. However, respondents exposed to multiple information sources were significantly less likely to report a neutral stance compared to support (OR [95 % CI]: 0.31 [0.15-0.65]). Those accessing official/academic sources or multiple sources were also less likely to feel less safe (OR [95 % CI]: 0.22 [0.07-0.71] and 0.43 [0.24-0.78]). CONCLUSION:These findings highlight critical gaps in government communication and the dominance of misrepresentative media framing in shaping public attitudes. Effective drug policy requires not only legislative change but also proactive, coordinated, and sustained public education strategies to counter misinformation, reduce stigma, and build lasting support.

Managed alcohol programs (MAPs) offer safe and regulated doses of alcohol to individuals with high-risk drinking behaviours unresponsive to other treatments. These harm reduction programs aim to reduce alcoholrelated harms and increase access to housing, health, and social services. In our study we aimed to understand the impacts of MAP participation on access to healthcare. Using a mixed methods design, we analyzed data collected in six Canadian cities between 2014 and 2017. Data sources included surveys from MAP participants (n = 188) and locally recruited and matched control participants (n = 198), and semi-structured interviews with MAP participants (n = 56). In the quantitative cross-sectional analysis, MAP participants were more likely to report regular (OR 1.77 [1.02 - 3.07]) and satisfactory (OR 2.02 [1.04 - 3.91]) access to healthcare compared to controls. We identified variable findings in access to healthcare between a subset of MAP (n = 82) and control (n = 116) participants with 12-month longitudinal follow-up data; however, when MAP participants were on the program, they had an increased likelihood of reporting regular (OR 2.16 [1.04 - 4.48]) and satisfactory (OR 3.23 [1.09 - 9.54]) access to healthcare compared to when they were off the program. Themes generated from the qualitative analysis illustrated the services offered within and alongside MAPs, the impacts of the MAP environment on access to healthcare, and the time needed to develop trusting relationships and address complex needs. These findings highlight the importance of long-term supportive care to improve access to healthcare among those experiencing homelessness and alcohol use disorders.

BACKGROUND:The number of young people who use e-cigarettes is rising. It remains unclear whether e-cigarette use impairs lung function. We aimed to compare ventilation distribution between young adults exposed to e-cigarettes and an unexposed group. METHODS:Study participants included otherwise healthy young adults (18-24 years) who self-reported e-cigarette use and unexposed participants who had no history of e-cigarette, tobacco or cannabis exposure. Exposure to e-cigarettes was defined using three measures: 1) ever-exposed, 2) daily use and 3) puff frequency, which includes none (unexposed), minimal (<2 puffs·h-1), moderate (3-4 puffs·h-1) and heavy (≥5 puffs·h-1). Ventilation distribution was measured using the multiple-breath washout test and reported as lung clearance index (LCI). RESULTS:A total of 93 participants were recruited; 38 unexposed and 41 exposed participants had LCI measures. The exposed group consisted predominately of participants who used flavoured e-liquids (94.5%) that contained nicotine (93.5%). The magnitude and direction of the difference in LCI across the exposure definitions was similar. Compared with the unexposed group, in the unadjusted models LCI was higher in those with any e-cigarette use (mean difference 0.15, 95% CI -0.004-0.31), daily users (mean difference 0.10, 95% CI -0.08-0.28) and heavy users (mean difference 0.22, 95% CI 0.03-0.41). CONCLUSION:This preliminary work suggests that LCI may be a useful biomarker to measure the effects of e-cigarette use on ventilation distribution and to track early functional impairment of the small airways.

Cannabis and Alcohol Involvement in Motor Vehicle Crashes: Reflections in the Era of Legalization Mark Asbridge PhD, and Jeff Brubacher MD Affiliation Mark Asbridge is with the Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada. Jeff Brubacher is with the Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada. CopyRightCorrespondence should be sent to Mark Asbridge, Department of Community Health and Epidemiology, Dalhousie University, Centre for Clinical Research, 5790 University Ave, Halifax, Nova Scotia, Canada, B3H 1V7 (e-mail: mark.asbridge@dal.ca). Reprints can be ordered at https://ajph.org by clicking the "Reprints" link. CONTRIBUTORS M. Asbridge and J. Brubacher contributed to the conceptualization, drafting, and revision of the article, and approved the final version. https://doi.org/10.2105/AJPH.2024.307657 Accepted: March 05, 2024 Published Online: April 18, 2024