BACKGROUND:Hepatitis A virus (HAV) infection is infrequently diagnosed in Canada, and little data are available regarding its epidemiology. Transmitted fecal-orally, HAV is an ideal candidate for wastewater-based surveillance (WBS). We set out to characterize HAV using WBS in a low-prevalence setting. METHODS:This observational study was conducted in the province of Alberta, Canada. Weekly composite wastewater samples were collected from eight municipalities (populations 7909-1,306,784), and eight neighbourhoods within Calgary, the largest city. HAV genomic material was quantified using RT-qPCR targeted on VP1 and sequenced at the VP1/2A junction. HAV case data from Alberta's Public Health Laboratory and population demographics from census data were correlated with wastewater HAV burden. RESULTS:Between July and December 2023, low levels of HAV were detected in wastewater from 50% of the municipalities and 50% of urban neighbourhoods (with 15.4% and 8.3% of samples testing positive, respectively). Wastewater HAV levels correlated with clinical HAV prevalence in larger communities. For genotyped clinical cases, wastewater with a matching VP1/2A sequence within a two-week period was observed for 8/9 episodes (median 6.42 days). Wastewater-measured HAV associated with population size, population density, and immigration from HAV endemic areas. CONCLUSION:HAV was detectable in wastewater of both municipalities and neighbourhoods within a low prevalence setting. Wastewater HAV was associated with population metrics and socioeconomic factors, including immigration. WBS data correlated strongly with clinical disease revealing a minimal burden of undiagnosed infections. This demonstrates the feasibility of HAV WBS and its potential as a public health tool in non-endemic settings.

BACKGROUND:While cancer risk is elevated in inflammatory bowel disease (IBD), results are less clear for cervical cancer. Screening has made cervical cancer relatively preventable, but geography impacts access, possibly increasing rates of cancer in rural and remote areas. We investigated (1) odds of cervical cancer, (2) cervical cancer screening participation, and (3) impact of geography (eg, rurality) and immunosuppression on the odds of cervical cancer and cervical cancer screening participation in the IBD population in Alberta, Canada. METHODS:A population-based cohort using administrative healthcare databases (fiscal year 2003/04-2021/22) was used to identify females with IBD (n = 22 245), age- and sex-matched 10 to 1 to control subjects (n = 161 070). The average annual percent change of screening rates and incidence of cervical cancer was calculated through Poisson regression. The odds of cervical cancer were calculated with conditional logistic regression. The role of geography and immunosuppression were assessed in each analysis. RESULTS:Individuals with IBD had lower odds of cervical cancer (odds ratio, 0.75; 95% confidence interval [CI], 0.68 to 0.83), but immunosuppressed individuals were at greater risk (odds ratio, 1.79; 95% CI, 1.48 to 2.15). Cases and controls had similar screening rates, but immunosuppressed individuals were screened more (incidence rate ratio, 1.05; 95% CI, 1.03 to 1.07). Screening declined among individuals with IBD (average annual percentage change, -5.15; 95% CI, -5.30 to -4.99), but incidence rates of cervical cancer remained stable (average annual percentage change, -1.95%; 95% CI, -4.25 to 0.41). While urban and metropolitan individuals with IBD were screened more, we observed no geographic variation in risk of cervical cancer. CONCLUSIONS:Similarities in screening between cases and controls suggest that lifestyle factors (eg, human papillomavirus vaccination, sexual history) may underpin the reduced odds of cervical cancer, rather than screening frequency. Efforts should be made to increase screening in immunosuppressed individuals.

Chronic hepatitis B (CHB) and hepatitis D virus (HDV) coinfection are major causes of cirrhosis and hepatocellular carcinoma. The geographic distribution of CHB and alignment of anti-HDV testing with CHB burden remain poorly defined. We aimed to examine if anti-HDV testing and seropositivity align with areas of highest CHB burden. Adults with CHB (2014-2022) were identified using a validated serologic algorithm in the provincial laboratory database capturing HBV/HDV serology. Cases were geolocated to Aggregate Dissemination Areas (ADAs), linked to Alberta Health Services zones and rural-urban continuum levels. Age- and sex-standardized CHB prevalence was calculated per ADA using the 2016 Canadian Census. Descriptive mapping, global spatial autocorrelation and local hotspot analysis were used to assess spatial clustering. Among 8317 persons with CHB, the provincial age- and sex-standardized prevalence was 1.70 per 1000 population (95% CI, 1.66-1.74). Prevalence ranged from 2.15 per 1000 in metropolitan areas to 0.40 per 1000 in remote regions and was higher in Calgary than Edmonton (2.53 vs. 1.73 per 1000). Overall, 17.5% of CHB patients were tested for anti-HDV, and 4.1% of those tested were anti-HDV positive. CHB prevalence hotspots were concentrated in metropolitan ADAs, whereas hotspots of anti-HDV testing and positivity showed only partial overlap with these high-burden areas. CHB burden in Alberta is geographically clustered, particularly within specific neighbourhoods of metropolitan cities, whereas anti-HDV testing remains infrequent and only partially aligned with high-burden areas. Reflex or systematic anti-HDV testing, paired with geographically informed outreach, may improve case detection.

Emergency medical response is complex. The need to make time-based decisions that can impact people’s health requires careful examination. Network analysis, among other methods, can support that time-based decision making. This study explores network analysis through a multi-modal transportation network model to represent both fixed-wing air and ground Emergency Medical Services (EMS) resources. Methods: The study utilized open and EMS industry data to build a geospatial multi-modal network to model potential patient transfer across Alberta (Canada). Results: Within the study’s service area, ground transportation alone is more effective within 101 Km, at which threshold the addition of aerial transport begins to be more time effective, saving 9.7 min over ground transportation only. Between this distance and 417 Km, results show a mixed-use area where a combination of ground only and aerial travel is recommended based on the event pickup location, aircraft availability, and ambulance station location relative to high-speed roads. Beyond 417 Km, aerial transportation is consistently more efficient. There is a high correlation (R2 = 0.82) between trip length and time difference between using ground only mode and combined air and ground. Lastly, the data showed air travel is 6.6 times more expensive than ground travel, with no modeled transfers identifying air as more time-effective than ground travel. Conclusions: Fixed-wing aircraft travel can have a positive impact on patient transfers; however, fluctuations in flight routes and times may require response agencies to implement time buffers to account for these variabilities. No cost savings were seen using fixed-wing aircraft, and the benefit of their use would be realized with efficient patient transfer times, as well as leaving ground ambulances in localized areas.

Out-of-hospital cardiac arrest (OHCA) incidence rate exhibits considerable geographical variations. In Lombardy, the presence of densely populated areas alongside isolated rural municipalities makes analysing health inequalities important. Given their spatial heterogeneity, an explicitly spatial analytical approach is needed. A retrospective ecological study was conducted at the municipal level using data from the Lombardia CARe registry (2021–2024). The incidence of OHCA was calculated for 924 municipalities. Socio-demographic determinants (population density, ageing index and percentage of taxpayers with an annual income below EUR 10,000) were analysed using geographically weighted regression (GWR). Spatial analyses (Moran’s I, LISA and Getis-Ord Gi*) were also applied to identify clusters and hotspots. During the study period, 22,201 OHCA events occurred (incidence rate: 126 per 100,000 inhabitants). Marked spatial heterogeneity emerged, with hotspots primarily located in mountainous and hilly areas, and cold-spots predominantly found in urban and lowland zones. GWR identified spatially non-uniform associations: incidence was inversely associated with population density in some areas, whereas it was positively associated with the ageing index and proportion of low-income taxpayers in others. The incidence of OHCA in Lombardy exhibits important spatial disparities. A spatial analytical approach can effectively identify vulnerable areas, guiding public health policies towards equity and spatial justice.

VOCs are important precursors of ground-level ozone (O3) and secondary organic aerosol (SOA) formation and have been associated with adverse health outcomes including cardiovascular disease, liver function damage, depression, obesity, type 2 diabetes, and hypertension. Under Canada's National Air Pollution Surveillance (NAPS) program, ambient VOCs has been routinely monitored in major urban centers. As part of the Calgary Spatial and Temporal Exposure Modeling (CSTEM) Study, two-week integrated passive VOC samples were collected across 125 urban and non-urban locations during summer (August 2015) and winter seasons (January-February 2016). The spatial monitoring in a dense network provides understanding of spatial variability of VOC sources and support source-based health analyses. In addition, temporal sampling of 2-week integrated VOC measurements were collected each month at 4 sites within the Calgary city limits. Positive matrix factorization (PMF) identified 9 sources from the spatial dataset: gasoline vehicles, diesel vehicles, conventional oil and gas (O&G), solvent use, dry cleaning, chemical processing plants/pulp and paper industry, background, biogenic, and mixed source. While 6 sources were identified from the temporal data set: vehicle emissions, conventional O&G, solvent use, chemical processing plants/pulp and paper industry, biogenic, and mixed source. These results will assist in developing land-use regression models for source-based exposure assessments and will support analysis of source-specific health impacts in future epidemiological studies.

The misuse and over-prescription of antibiotics have contributed to the growing global threat of antimicrobial resistance (AMR), which undermines the efficacy of many antibiotics, including amoxicillin. AMR poses serious risks, such as increased mortality, prolonged hospital stays, and significant burdens on healthcare systems. In this study, we conducted a spatial analysis of amoxicillin resistance across 28 administrative units (Tehsils) of the Malakand region of Pakistan, a mountainous area in the Himalayan foothills where over 90

Understanding factors associated with antimicrobial resistance (AMR) distribution across populations is a necessary step in planning mitigation measures. While associations between AMR and socioeconomic-status (SES), including employment and education have been increasingly recognized in low- and middle-income settings, connections are less clear in high-income countries where SES remains an important influence on other health outcomes. We explored the relationship between SES and AMR in Calgary, Canada using spatially-resolved wastewater-based surveillance of resistomes detected by metagenomics across eight socio-economically diverse urban neighborhoods. Resistomes were established by shotgun-sequencing of wastewater pellets, and qPCR of targeted-AMR genes. SES status was established using 2021 Canadian census data. Conducting this comparison during the height of COVID-related international travel restrictions (Dec. 2020–Oct. 2021) allowed the hypotheses linking SES and AMR to be assessed with limited confounding. These were compared with sewage metagenomes from 244 cities around the world, linked with Human Development Index (HDI). Wastewater metagenomes from Calgary’s socioeconomically diverse neighborhoods exhibit highly similar resistomes, with no quantitative differences (p > 0.05), low Bray-Curtis dissimilarity, and no significant correlations with SES. By comparison, dissimilarity is observed between globally-sourced resistomes (p < 0.05), underscoring the homogeneity of resistomes in Calgary’s sub-populations. The analysis of globally-sourced resistomes alongside Calgary’s resistome further reveals lower AMR burden in Calgary relative to other cities around the world. This is particularly pronounced for the most clinically-relevant AMR genes (e.g., beta-lactamases, macrolide-lincosamide-streptogramin). This work showcases the effectiveness of inclusive and comprehensive wastewater-based surveillance for exploring the interplay between SES and AMR. Antimicrobial resistance (AMR) occurs when antimicrobial treatments fail to work and microbes continue to grow. This is a result of microbes acquiring AMR genes. Antimicrobial resistance (AMR) is an increasing public health threat. Some studies have suggested an association between AMR and socioeconomic factors. The amount of AMR can be monitored by investigating the presence of specific genes indicative of AMR in wastewater. To explore this within a high-income country with publicly funded health care, we collected wastewater from eight socioeconomically diverse neighborhoods across a large Canadian city. Conducted over eleven months during COVID-19-related travel restrictions, we did not observe an association between socioeconomic status of residents and the amount or types of AMR genes in wastewater. We also compared AMR genes from wastewater from cities across the globe, where we observed the presence of AMR genes significantly differed along established socio-economic parameters. Overall, our findings revealed the relationship between AMR genes and socioeconomic factors is dynamic, and context dependent. Lee et al. investigate whether the wastewater resistome of a large Canadian city associates with socioeconomic status (SES) of resident populations using a granular, neighborhood-based approach. No correlation is seen, in contrast with data from other cities around the world, where AMR genes disproportionately concentrate in cities with lower SES.

With the development of GIS, and advancement of transparency and open data policy over the years, maps have become an increasingly important tool for communication and distribution of crime related information between police departments and the general public. However, current crime maps exhibit major shortcomings stemming from the methods that yield them. Among them, the use of traditional spatial units, i.e., points and areal spatial units in crime maps has long stood and appears to be an overlooked problem. Conversely, research on novel spatial units has been going on for years, and traditional point-style and areal-style symbolization have been criticized for a long time, e.g., for privacy concerns in point-style maps and calculating crime statistics using population in corresponding visualization in areal spatial units. Nonetheless, crime maps produced by police departments of some major Canadian cities are yet to adopt any novel spatial unit. This study proposes a novel spatial unit: the street segment, to address some problems of existing crime maps using traditional point and areal spatial units. Our results suggest that using the street segment as spatial unit to present crime statistics mitigates some shortcomings of current crime maps, like overgeneralization and privacy concerns. It provides opportunities like Crime Prevention Through Environmental Design (CPTED) and Route Planning and enhances the practical functionality of crime maps by assisting the general public in daily decision-making.

The Calgary Spatial and Temporal Exposure Modeling (CSTEM) Study collected 2-week long filter samples in two different ways to study the spatial–temporal distribution of source contributions to PM 2.5 across Calgary, Alberta, Canada and its peri-urban region in 2015–2016. The spatial study involved 125 sites in each of two periods: August 2015 and January–February 2016. Alternatively, the temporal study collected samples each month at a subset of 4 sites within the Calgary city limits. The samples were analyzed for their chemical compositions and the data subjected to positive matrix factorization (PMF) for source identification and quantification. Five sources (soil/road dust, traffic, road salt, secondary inorganic aerosol/coal, and refineries) were identified from the spatial data set and four sources (soil/road dust, road salt, secondary inorganic aerosol, traffic/wood burning) from the temporal data set. Results demonstrated that PMF can resolve meaningful source types from a spatial or temporal dataset even when they are limited by longer integrated sampling times. Results from the spatial dataset modelling showed higher spatial heterogeneity in PM 2.5 contributions within the urban area, particularly for the local source types (vehicles, road dust, and refineries), demonstrating a key limitation in applying central site estimates of PM 2.5 source contributions across a large urban and non-urban area. Analysis of the temporal data from the 4 urban sites generally showed similarity in their source contributions, reflecting similar local sources, particularly highways and residential areas. Graphical Abstract

Out-of-hospital cardiac arrest (OHCA) is a leading cause of death worldwide. This study presents a preliminary geospatial analysis of OHCA in some provinces of Lombardy (Italy), over the 2015–2023 period. Geospatial analysis can identify areas at high risk of OHCA, highlighting clusters, referred to as “hot-spots” where the occurrence of OHCA is significantly higher than in neighbouring areas or those areas with an increasing number of OHCA during time. This study represents the first spatial distribution of out-of-hospital cardiac arrest (OHCA) in Italy and particularly in the Lombardy region. Our geospatial analysis highlighted a heterogenous distribution of OHCA through the region. A multiscale approach, using global and local analysis from regional to provincial level, highlighted substantial local differences. These differences may be associated with physical features, such as mountains vs. lowland, socioeconomic aspects, such as urban patterns, population density, and rurality, as well as with environmental factors, such as air pollution. We are aware of the limitations of our study and of the importance to refine the territorial grid depending on the purpose. Our results, albeit preliminary, could provide insights for future research in OHCA spatial analysis.

Background While the risk of cancer in inflammatory bowel disease (IBD) is elevated, studies indicate a lower odds of gynecological cancers. Cervical cancer has become relatively preventable as a result of screening programs. However, geographic access impacts screening, possibly resulting in higher rates of cancer in rural areas. Aims To investigate in the IBD population: (1) the odds of cervical neoplasia (squamous intraepithelial neoplasia grade III or cervical cancer) compared to matched controls, (2) screening rates (Pap smears), and (3) impact of urban vs rural residence on these estimates. Methods We conducted a population-based matched cohort study using administrative healthcare databases in Alberta to identify females with IBD (n=22,245), age- and sex-matched 10-to-1 to controls (n=161,070) from fiscal years 2003–2021. The Alberta Cancer Registry provided morphology and diagnosis date for cervical neoplasia. Physician Claims provided Pap smears. Screening rates were defined as Pap smears per person-year (PY), with eligible Pap smears being those received by individuals aged 21–69, as per provincial screening guidelines. The Provincial Registry provided annual geographic data indicating urban vs rural residency. Average annual percentage change (AAPC) in screening and incidence of cervical neoplasia was calculated using Poisson regression. Conditional logistic regression compared cervical neoplasia in cases and controls, reported as odds ratios (ORs) and 95% confidence intervals (CIs), and evaluated rurality as an effect modifier using an interaction term. Two-sample t-tests compared mean Pap smears per PY between urban and rural populations. Results Females with IBD have lower odds of both cervical cancer (OR: 0.65; 95%CI: 0.47, 0.92) and neoplasia (OR: 0.76; 95%CI: 0.68, 0.84) compared to controls, but rural status was not a modifier (p=0.38). Screening rates in those with IBD were not significantly different from controls (p=0.49). Rural individuals with IBD were screened less than their urban counterparts (0.086 vs 0.30 Pap smears per PY, p<0.001), and a similar pattern was observed in controls (0.087 vs 0.29 Pap smears per PY, p<0.001). The proportion of eligible individuals with IBD receiving Pap smears decreased over time (AAPC: −5.15; 95%CI: −5.30, −4.99), while the diagnosis of cervical neoplasia was stable (AAPC: −0.14; 95%CI: −2.03, 1.79). Conclusions Individuals with IBD had lower odds of cervical neoplasia and cancer, regardless of rural vs urban status. Screening was lower for rural individuals in both IBD and non-IBD populations. Although screening rates declined in individuals with IBD, the detection of cervical neoplasia remained stable. Future studies should explore barriers to and timing of screening, especially in rural areas, as well as the reasons for the reduced risk of cervical neoplasia in IBD. Yearly proportion of eligible individuals receiving a Pap smear in the IBD population (top) and yearly rate of cervical neoplasia diagnoses (bottom) in individuals with IBD. Funding Agencies CIHR

OBJECTIVE:To estimate effects of a policy introducing universal, no-cost public coverage for prescription contraception on use in British Columbia, Canada. DESIGN:Population based, controlled, interrupted time series analysis. SETTING:10 Canadian provinces. PARTICIPANTS:Prescription medications dispensed to reproductive aged (15-49 years) female residents of British Columbia, Canada, compared with a synthetic control derived from the nine other Canadian provinces and a population based cohort of 859 845 female individuals in British Columbia (age 15-49 years) between 1 April 2021 and 30 June 2024. INTERVENTION:Introduction of a universal contraception coverage policy in April 2023, where the public insurer pays 100% of prescription costs. OUTCOME MEASURES:Number of monthly dispensations for long-acting reversible contraception (LARC) and number of monthly dispensations for all forms of prescription contraception (including LARC), percentage of reproductive aged female residents using LARC and using all forms of prescription contraception, and the proportion of people using prescription contraception who use LARC (LARC market share). Segmented regression models were used to estimate policy effects by comparing the expected outcome values after 15 months of the policy (ie, the counterfactual, derived from trends before the policy and changes in the control) with the observed values, with 95% confidence intervals (CIs) estimated using bootstrapping. RESULTS:In April 2021, 3249 (95% CI 3066 to 3391) LARC prescriptions were dispensed in British Columbia, with a declining slope trend of -17 (-30 to -7) fewer dispensed per month before the policy. Monthly LARC dispensations increased by 1050 (942 to 1487) immediately after British Columbia's policy change and saw a steady increasing trend after the policy introduction. An additional 1273 (963 to 1698) monthly LARC prescriptions were dispensed 15 months after policy implementation compared with the expected volume, representing an estimated 1.49-fold (1.34 to 1.77) increase. Dispensations for all prescription contraception (including LARC) increased by 1981 (356 to 3324) per month, representing a 1.04-fold (1.01 to 1.07) increase. Among the 859 845 female residents aged 15-49 years in the population, 9.1% were using LARC in April 2021. 15 months after the policy, 11 375 (10 273 to 13 013) more individuals were using LARC than expected without the policy, representing an additional 1.3% (1.2% to 1.5%) of the population. The policy led to an additional 1.7% (1.5% to 2.3%) of the population using any prescription contraception. 15 months after the policy, the LARC market share was 1.9% (1.2% to 2.3%) higher than expected. CONCLUSIONS:Universal, no-cost public coverage in British Columbia increased prescription contraception use overall, driven by increased LARC use. As such, cost seems to be an important contributor to contraception use and method selection at the population level.

Introduction: Despite significant global efforts towards eliminating hepatitis C virus (HCV) infection, multiple challenges remain in achieving this goal. In this study, we assessed the impact of geographical variation on HCV diagnosis and treatment rates in Alberta, Canada. Methods: Adults aged >= 20 years with a positive HCV antibody were identified from the provincial administrative sources from the fiscal years 2012 through 2017. To assess the differences across Alberta's rural-urban continuum, high-resolution spatial analyses using global and local spatial autocorrelation were applied to the HCV age- and sex-standardized prevalence rate at the sub-local geographic area level. We compared and tested differences in HCV RNA tests, HCV RNA positivity rates, and HCV treatment status across the different areas. Results: Between 2012 and 2017, we identified 18,768 patients who had tested positive for HCV Ab. Within this cohort, only 63.1% had HCV RNA repetitive. The HCV RNA positivity rate was 42.1%, and 65.3% had received HCV treatment after testing as HCV RNA positive. HCV Ab positive case counts exhibited a spatial distribution consistent with that of the population at risk: 67.5% in metro, 11.1% in urban, 19.7% in rural, and 1.8% in remote areas. The metropolitan area of Edmonton's age-and sex-standardized prevalence of 8.2 (95% CI 8.0-8.4) per 1,000 persons was higher than Calgary's standardized prevalence of 5.0 (95% CI 5.1-5.4) per 1,000 persons (p < 0.001). HCV RNA and HCV treatment rates demonstrated significant spatial variation. Conclusions: HCV prevalence, diagnosis, and treatment exhibit significant spatial variation across rural-urban Alberta. Implementation of geographically oriented screening and treatment interventions would result in a time- and cost-efficient HCV elimination strategy.

Wastewater-based surveillance (WBS) has been established as a powerful tool that can guide health policy at multiple levels of government. However, this approach has not been well assessed at more granular scales, including large work sites such as University campuses. Between August 2021 and April 2022, we explored the occurrence of SARS-CoV-2 RNA in wastewater using qPCR assays from multiple complimentary sewer catchments and residential buildings spanning the University of Calgary's campus and how this compared to levels from the municipal wastewater treatment plant servicing the campus. Real-time contact tracing data was used to evaluate an association between wastewater SARS-CoV-2 burden and clinically confirmed cases and to assess the potential of WBS as a tool for disease monitoring across worksites. Concentrations of wastewater SARS-CoV-2 N1 and N2 RNA varied significantly across six sampling sites - regardless of several normalization strategies - with certain catchments consistently demonstrating values 1-2 orders higher than the others. Relative to clinical cases identified in specific sewersheds, WBS provided one-week leading indicator. Additionally, our comprehensive monitoring strategy enabled an estimation of the total burden of SARS-CoV-2 for the campus per capita, which was significantly lower than the surrounding community (p & LE;0.001). Allele-specific qPCR assays confirmed that variants across campus were representative of the community at large, and at no time did emerging variants first debut on campus. This study demonstrates how WBS can be efficiently applied to locate hotspots of disease activity at a very granular scale, and predict disease burden across large, complex worksites.

BACKGROUND:We described longitudinal trends in the incidence of episodes of care (EOC) and follow-up care for pediatric concussion in relation to age, sex, rurality of patient residence, point of care, and area-based socioeconomic status (SES) in Alberta, Canada.METHODS:A retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients <18 years of age who received a diagnosis of concussion, other specified injuries of head, unspecified injury of head, or post-concussion syndrome between April 1, 2004 and March 31, 2018. Data were geospatially mapped.RESULTS:Concussion EOCs increased 2.2-fold over the study period, follow-up visits 5.1-fold. Care was increasingly received in physician office (PO) settings. Concussion diagnoses in rural and remote areas occurred in emergency department (ED) settings more often than in metro centres or urban areas (76%/75% vs. 52%/60%). Proportion of concussion diagnoses was positively related to SES and age. Diagnosis and point of care varied geographically.CONCLUSIONS:The shift in care to PO settings, increased incidence of all diagnoses, and the higher use of the ED by some segments of the population all have important implications for appropriate clinical management and the efficient provision of health care for pediatric concussion.IMPACT:This is the first study to use EOC to describe longitudinal trends in incidence and follow-up care for pediatric concussion in relation to age, sex, rurality, point of care, and area-based SES. We report increased incidence of concussion in both emergency and outpatient settings and the proportion of diagnoses was positively related to SES and age. Patients increasingly received care for concussion in PO over time. Geospatial mapping indicated that the incidence of concussion and unspecified injury of head varied geographically and temporally. Results have important implications for appropriate clinical management and efficient provision of health care following pediatric concussion.

Background Attendance at a subspecialty pregnancy clinic for women with inflammatory bowel disease (IBD) improves disease-specific pregnancy knowledge. We examined the impact of attendance at a dedicated IBD-pregnancy clinic on IBD and perinatal outcomes. Methods Using linked administrative databases in Alberta, Canada (2012-2019), we identified 1061 pregnant women with IBD who delivered singleton liveborn infants in-hospital who did (n = 314) and did not attend (n = 747) the clinic. Propensity score weighted multivariable log-binomial and multinomial logistic regression models were used to determine the risk of IBD and perinatal outcomes. Results The median number of clinic visits was 3 (Q1-Q3, 3-5), with 34.7% completing a preconception consultation. A greater proportion of women who attended lived near the clinic, were nulliparous, had a disease flare prior to pregnancy, and were on maintenance IBD medication (P < .05). Women who attended had increased risks of a disease flare during pregnancy (adjusted risk ratio [aRR], 2.02; 95% CI, 1.45-2.82), an IBD-related emergency department visit during pregnancy (aRR, 2.66; 95% CI, 1.92-3.68), and cesarean delivery (aRR, 1.78; 95% CI, 1.23-2.57). Despite this, clinic attendees had a decreased risk of delivering an infant with a low Apgar score at 1 minute (risk ratio [RR], 0.49; 95% CI, 0.32-0.76) and 5 minutes (RR, 0.32; 95% CI, 0.12-0.87). Conclusions Women who attended a dedicated IBD-pregnancy clinic were more likely to have a disease flare prior to pregnancy, reflecting a more severe disease phenotype, but had similar perinatal outcomes and infants with better Apgar scores at birth. Our study suggests the value of these subspecialty clinics in providing enhanced IBD-specific prenatal care.

Importance:The association between hydraulic fracturing and human development is not well understood. Several studies have identified significant associations between unconventional natural gas development and adverse birth outcomes; however, geology and legislation vary between regions.Objective:To examine the overall association between residential proximity to hydraulic fracturing sites and adverse birth outcomes, and investigate whether well density influenced this association.Design, Setting, and Participants:This population-based retrospective cohort study of pregnant individuals in rural Alberta, Canada, took place from 2013 to 2018. Participants included reproductive-aged individuals (18-50 years) who had a pregnancy from January 1, 2013, to December 31, 2018, and lived in rural areas. Individuals were excluded if they lived in an urban setting, were outside of the age range, or were missing data on infant sex, postal code, or area-level socioeconomic status.Exposures:Oil and gas wells that underwent hydraulic fracturing between 2013 to 2018 were identified through the Alberta Energy Regulator (n = 4871). Individuals were considered exposed if their postal delivery point was located within 10 km of 1 or more wells that was hydraulically fractured during 1 year preconception or during pregnancy.Main Outcomes and Measures:Outcomes investigated were spontaneous and indicated preterm birth, small for gestational age, major congenital anomalies, and severe neonatal morbidity or mortality.Results:After exclusions, the sample included 26 193 individuals with 34 873 unique pregnancies, and a mean (SD) parental age of 28.2 (5.2) years. Small for gestational age and major congenital anomalies were significantly higher for individuals who lived within 10 km of at least 1 hydraulically fractured well after adjusting for parental age at delivery, multiple births, fetal sex, obstetric comorbidities, and area-level socioeconomic status. Risk of spontaneous preterm birth and small for gestational age were significantly increased in those with 100 or more wells within 10 km.Conclusions and Relevance:Results suggest that individuals who were exposed to hydraulic fracturing within pregnancy may be at higher risk of several adverse birth outcomes. These results may be relevant to health policy regarding legislation of unconventional oil and gas development in Canada and internationally.

We present a large-scale spatiotemporal analysis of excess mortality (EM) in the first COVID-19 epidemic wave in Lombardy and Veneto. Spatial statistics show that EM is spatially heterogenous in both regions. Global spatiotemporal correlation identifies EM trends that differ across regions during the epi-curve peak, but are uniform in early and late stages. Local spatiotemporal correlation identifies EM hotspots, coldspots, and transition zones. Identifying process dynamics and local features, spatiotemporal correlation can support epidemic surveillance.

Rural Canadians have high health care needs due to high prevalence of osteoarthritis (OA) but lack access to care. Examining realized access to three types of providers (general practitioners (GPs), orthopedic surgeons (Ortho), and physiotherapists (PTs)) simultaneously helps identify gaps in access to needed OA care, inform accessibility assessment, and support health care resource allocation. Travel time from a patient’s postal code to the physician’s postal code was calculated using origin–destination network analysis. We applied descriptive statistics to summarize differences in travel time, hotspot analysis to explore geospatial patterns, and distance decay function to examine the travel pattern of health care utilization by urbanicity. The median travel time in Alberta was 11.6 min (IQR = 4.3–25.7) to GPs, 28.9 (IQR = 14.8–65.0) to Ortho, and 33.7 (IQR = 23.1–47.3) to PTs. We observed significant rural–urban disparities in realized access to GPs (2.9 and IQR = 0.0–92.1 in rural remote areas vs. 12.6 and IQR = 6.4–21.0 in metropolitan areas), Ortho (233.3 and IQR = 171.3–363.7 in rural remote areas vs. 21.3 and IQR = 14.0–29.3 in metropolitan areas), and PTs (62.4 and IQR = 0.0–232.1 in rural remote areas vs. 32.1 and IQR = 25.2–39.9 in metropolitan areas). We identified hotspots of realized access to all three types of providers in rural remote areas, where patients with OA tend to travel longer for health care. This study may provide insight on the choice of catchment size and the distance decay pattern of health care utilization for further studies on spatial accessibility.