Perceptions of Educational Needs in an Era of Shifting Mental Health Care to Primary Care: Exploratory Pilot Study

BACKGROUND

There is an unmet need for mental health care in Canada. Primary care providers such as general practitioners and family physicians are the essential part of mental health care services; however, mental health is often underestimated and underprioritized by family physicians. It is currently not known what is required to increase care providers' willingness, comfort, and skills to adequately provide care to patients who present with mental health issues.

OBJECTIVE

The aim of this study was to understand the need of caregivers (family members overseeing care of an individual with a mental health diagnosis) and family physicians regarding the care and medical management of individuals with mental health conditions.

METHODS

A needs assessment was designed to understand the educational needs of caregivers and family physicians regarding the provision of mental health care, specifically to seek advice on the format and delivery mode for an educational curriculum to be accessed by both stakeholder groups. Exploratory qualitative interviews were conducted, and data were collected and analyzed iteratively until thematic saturation was achieved.

RESULTS

Caregivers of individuals with mental health conditions (n=24) and family physicians (n=10) were interviewed. Both the caregivers and the family physicians expressed dissatisfaction with the status quo regarding the provision of mental health care at the family physician's office. They stated that there was a need for more educational materials as well as additional support. The caregivers expressed a general lack of confidence in family physicians to manage their son's or daughter's mental health condition, while family physicians sought more networking opportunities to improve and facilitate the provision of mental health care.

CONCLUSIONS

Robust qualitative studies are necessary to identify the educational and medical management needs of caregivers and family physicians. Understanding each other's perspectives is an essential first step to collaboratively designing, implementing, and subsequently evaluating community-based mental health care. Fortunately, there are initiatives underway to address these need areas (eg, websites such as the eMentalHealth, as well as the mentorship and collaborative care network), and information from this study can help inform the gaps in those existing initiatives.

Evaluation of eMentalHealth.ca, a Canadian Mental Health Website Portal: Mixed Methods Assessment

BACKGROUND

Many Canadians have mental health needs, and it can be challenging not knowing where to go for mental health information, services, and support. The website eMentalHealth.ca was created to facilitate and assist Canadians to (1) learn about mental health, (2) screen for common mental health issues, and (3) find mental health services and support.

OBJECTIVE

The aim of this study was to use multiple methods to learn about visitors of eMentalHealth.ca, their perceptions, and their satisfaction with the website.

METHODS

Website analytics (Google Analytics) provided information about the number of unique visits to the website and how the site was used. Web-based self-administered surveys were used to gather additional information on users' characteristics and to assess their perception of the website and satisfaction with the website.

RESULTS

Web analytic results showed that from January 1 to December 31, 2017, there were 651,107 users, with 1.97 million page views. Users were more often female than male, and the majority of users were aged 35 years and older. Most users were located in Canada (612,806/651,107, 94.12%), and the most common city of origin of users was Toronto (101,473/651,107, 15.58%), followed by Ottawa (76,692/651,107, 11.78%), and Montreal (26,621/651,107, 4.09%). Web-based surveys were completed by a total of 370 respondents from June to December 2017. Overall, the majority of users were satisfied with the website (93.0%, 320 out of 344 responses). Positive feedback was related to the content of the website as a helpful resource, and negative feedback was related to technical difficulties as well as the design of the main page. This analysis will be used to help the team with ongoing improvements to the website, for example, improving technical issues and homepage usability.

CONCLUSIONS

Most visitors reported satisfaction with their use of eMentalHealth.ca to learn about mental health as well as where to find help. Mental health websites such as eMentalHealth.ca are a low-cost way to increase public awareness about mental health.

Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process

Until recently, the belief that adequate pain management was not achievable while patients remained on buprenorphine was the impetus for the perioperative discontinuation of buprenorphine. We aimed to use an expert consensus Delphi-based survey technique to 1) specify the need for perioperative guidelines in this context and 2) offer a set of recommendations for the perioperative management of these patients. The major recommendation of this practice advisory is to continue buprenorphine therapy in the perioperative period. It is rarely appropriate to reduce the buprenorphine dose irrespective of indication or formulation. If analgesia is inadequate after optimisation of adjunct analgesic therapies, we recommend initiating a full mu agonist while continuing buprenorphine at some dose. The panel believes that before operation, physicians must distinguish between buprenorphine use for chronic pain (weaning/conversion from long-term high-dose opioids) and opioid use disorder (OUD) as the primary indication for buprenorphine therapy. Patients should ideally be discharged on buprenorphine, although not necessarily at their preoperative dose. Depending on analgesic requirements, they may be discharged on a full mu agonist. Overall, long-term buprenorphine treatment retention and harm reduction must be considered during the perioperative period when OUD is a primary diagnosis. The authors recognise that inter-patient variability will require some individualisation of clinical practice advisories. Clinical practice advisories are largely based on lower classes of evidence (level 4, level 5). Further research is required in order to implement meaningful changes in practitioner behaviour for this patient group.

Exhaust ventilation in attached garages improves residential indoor air quality

Previous research has shown that indoor benzene levels in homes with attached garages are higher than homes without attached garages. Exhaust ventilation in attached garages is one possible intervention to reduce these concentrations. To evaluate the effectiveness of this intervention, a randomized crossover study was conducted in 33 Ottawa homes in winter 2014. VOCs including benzene, toluene, ethylbenzene, and xylenes, nitrogen dioxide, carbon monoxide, and air exchange rates were measured over four 48-hour periods when a garage exhaust fan was turned on or off. A blower door test conducted in each garage was used to determine the required exhaust fan flow rate to provide a depressurization of 5 Pa in each garage relative to the home. When corrected for ambient concentrations, the fan decreased geometric mean indoor benzene concentrations from 1.04 to 0.40 μg/m³ , or by 62% (P<.05). The garage exhaust fan also significantly reduced outdoor-corrected geometric mean indoor concentrations of other pollutants, including toluene (53%), ethylbenzene (47%), m,p-xylene (45%), o-xylene (43%), and carbon monoxide (23%) (P<.05) while having no impact on the home air exchange rate. This study provides evidence that mechanical exhaust ventilation in attached garages can reduce indoor concentrations of pollutants originating from within attached garages.

An assessment of the relationship between the World Health Organization HIV drug resistance early warning indicators and HIV drug resistance acquisition

OBJECTIVES

The World Health Organization (WHO)'s HIV drug resistance (HIVDR) early warning indicators (EWIs) measure antiretroviral therapy (ART)-site factors associated with HIVDR prevention, without HIVDR laboratory testing. We assessed the relationship between EWIs and HIVDR acquisition using data from British Columbia, Canada.

METHODS

Eligible patients were ART-naïve, were ≥ 19 years old, had initiated ART between 1 January 2000 and 31 December 2012, had ≥ 15 months of follow-up, and were without transmitted HIVDR. Patients were followed for acquired HIVDR until 31 March 2014, the last contact date, or death. We built logistic regression models to assess the associations and predictive ability of individual indicators and of the EWI Score (the number of indicators for which a patient did not meet the criteria) on HIVDR acquisition (to any class of HIVDR, lamivudine (3TC)/emtricitabine (FTC), nonnucleoside reverse transcriptase inhibitors (NNRTIs), nucleoside reverse transcriptase inhibitors (NRTIs) or protease inhibitors (PIs)]).

RESULTS

All explored EWIs were associated with at least one class of HIVDR, with the exception of 'ART prescribing practices'. We observed a dose-response relationship between acquiring HIVDR to any antiretroviral class and an increasing EWI score in our predictive logistic regression model. The area under the curve was 0.848 (excellent discrimination). The adjusted odds ratios for acquiring any class of HIVDR for an EWI score of 1, 2 and ≥ 3 versus 0 were 2.30 [95% confidence Interval (CI) 1.21-4.38], 3.35 (95% CI: 1.86-6.03) and 7.26 (95% CI: 4.18-12.61), respectively.

CONCLUSIONS

Several EWIs were associated with and predictive of HIVDR, supporting the WHO EWIs as a component of the HIVDR prevention method in settings where HIVDR testing is not routinely or widely available.

Can changing the timing of outdoor air intake reduce indoor concentrations of traffic-related pollutants in schools?

Traffic emissions have been associated with a wide range of adverse health effects. Many schools are situated close to major roads, and as children spend much of their day in school, methods to reduce traffic-related air pollutant concentrations in the school environment are warranted. One promising method to reduce pollutant concentrations in schools is to alter the timing of the ventilation so that high ventilation time periods do not correspond to rush hour traffic. Health Canada, in collaboration with the Ottawa-Carleton District School Board, tested the effect of this action by collecting traffic-related air pollution data from four schools in Ottawa, Canada, during October and November 2013. A baseline and intervention period was assessed in each school. There were statistically significant (P < 0.05) reductions in concentrations of most of the pollutants measured at the two late-start (9 AM start) schools, after adjusting for outdoor concentrations and the absolute indoor-outdoor temperature difference. The intervention at the early-start (8 AM start) schools did not have significant reductions in pollutant concentrations. Based on these findings, changing the timing of the ventilation may be a cost-effective mechanism of reducing traffic-related pollutants in late-start schools located near major roads.

A randomized double-blind crossover study of indoor air filtration and acute changes in cardiorespiratory health in a First Nations community

Few studies have examined indoor air quality in First Nations communities and its impact on cardiorespiratory health. To address this need, we conducted a crossover study on a First Nations reserve in Manitoba, Canada, including 37 residents in 20 homes. Each home received an electrostatic air filter and a placebo filter for 1 week in random order, and lung function, blood pressure, and endothelial function measures were collected at the beginning and end of each week. Indoor air pollutants were monitored throughout the study period. Indoor PM2.5 decreased substantially during air filter weeks relative to placebo (mean difference: 37 μg/m(3) , 95% CI: 10, 64) but remained approximately five times greater than outdoor concentrations owing to a high prevalence of indoor smoking. On average, air filter use was associated with a 217-ml (95% CI: 23, 410) increase in forced expiratory volume in 1 s, a 7.9-mm Hg (95% CI: -17, 0.82) decrease in systolic blood pressure, and a 4.5-mm Hg (95% CI: -11, 2.4) decrease in diastolic blood pressure. Consistent inverse associations were also observed between indoor PM2.5 and lung function. In general, our findings suggest that reducing indoor PM2.5 may contribute to improved lung function in First Nations communities.

PRACTICAL IMPLICATIONS

Indoor air quality is known to contribute to adverse cardiorespiratory health, but few studies have examined indoor air quality in First Nations communities. Our findings suggest that indoor PM2.5 may contribute to reduced lung function and that portable air filters may help to alleviate these effects by effectively reducing indoor levels of particulate matter.

Method validation and preliminary qualification of pharmacodynamic biomarkers employed to evaluate the clinical efficacy of an antisense compound (AEG35156) targeted to the X-linked inhibitor of apoptosis protein XIAP

Data are presented on pharmacodynamic (PD) method validation and preliminary clinical qualification of three PD biomarker assays. M65 Elisa, which quantitates different forms of circulating cytokeratin 18 (CK18) as putative surrogate markers of both apoptotic and nonapoptotic tumour cell death, was shown to be highly reproducible: calibration curve linearity r2 = 0.996, mean accuracy > 91% and mean precision < 3%, n = 27. Employing recombinant (r) CK18 and caspase cleaved CK18 (CK18 Asp396 neo-epitope) as external standards, kit to kit reproducibly was < 6% (n = 19). rCK18 was stable in plasma for 4 months at -20 degrees C and -80 degrees C, for 4 weeks at 4 degrees C and had a half-life of 2.3 days at 37 degrees C. Cytokeratin 18 Asp396 NE, the M30 Apoptosense Elisa assay antigen, was stable in plasma for 6 months at -20 degrees C and -80 degrees C, for 3 months at 4 degrees C, while its half-life at 37 degrees C was 3.8 days. Within-day variations in endogenous plasma concentrations of the M30 and M65 antigens were assessed in two predose blood samples collected from a cohort of 15 ovarian cancer patients receiving carboplatin chemotherapy and were shown to be no greater than the variability associated with methods themselves. Between-day fluctuations in circulating levels of the M30 and M65 antigens and in XIAP mRNA levels measured in peripheral blood mononuclear cells by quantitative (q) RT-PCR were evaluated in two predose blood samples collected with a 5- to 7-day gap from 23 patients with advanced cancer enrolled in a phase I trial. The mean variation between the two pretreatment values ranged from 13 to 14 to 25%, respectively, for M65, M30 and qRT-PCR. These data suggest that the M30 and M65 Elisa's and qRT-PCR as PD biomarker assays have favourable performance characteristics for further investigation in clinical trials of anticancer agents which induce tumour apoptosis/necrosis or knockdown of the anti-apoptotic protein XIAP.

Validation of pharmacodynamic assays to evaluate the clinical efficacy of an antisense compound (AEG 35156) targeted to the X-linked inhibitor of apoptosis protein XIAP

The inhibitor of apoptosis protein, XIAP, is frequently overexpressed in chemoresistant human tumours. An antisense oligonucleotide (AEG 35156/GEM 640) that targets XIAP has recently entered phase I trials in the UK. Method validation data are presented on three pharmacodynamic assays that will be utilised during this trial. Quantitative RT-PCR was based on a Taqman assay and was confirmed to be specific for XIAP. Assay linearity extended over four orders of magnitude. MDA-MB-231/U6-E1 cells and clone X-G4 stably expressing an RNAi vector against XIAP were chosen as high and low XIAP expression quality controls (QCs). Within-day and between-day coefficients of variation (CVs) in precision for cycle threshold (CT) and delta CT values (employing GAPDH and beta 2 microglobulin as housekeepers) were always less than 10%. A Western blotting technique was validated using a GST–XIAP fusion protein as a standard and HeLa cells and SF268 (human glioblastoma) cells as high and low XIAP expression QCs. Specificity of the final choice of antibody for XIAP was evaluated by analysing a panel of cell lines including clone X-G4. The assay was linear over a 29-fold range of protein concentration and between-day precision was 29% for the low QC and 23% for the high QC when normalised to GAPDH. XIAP protein was also shown to be stable at −80°C for at least 60 days. M30-Apoptosense™ plasma Elisa detects a caspase-cleaved fragment of cytokeratin 18 (CK18), believed to be a surrogate marker for tumour cell apoptosis. Generation of an independent QC was achieved through the treatment of X-G4 cells with staurosporine and collection of media. Measurements on assay precision and kit-to-kit QC were always less than 10%. The M30 antigen (CK18-Asp³⁹⁶) was stable for 3 months at −80°C, while at 37°C it had a half-life of 80–100 h in healthy volunteer plasma. Results from the phase I trial are eagerly awaited.

Elevation of neuronal expression of NAIP reduces ischemic damage in the rat hippocampus

We show here that transient forebrain ischemia selectively elevates levels of neuronal apoptosis inhibitory protein (NAIP) in rat neurons that are resistant to the injurious effects of this treatment. This observation suggests that increasing NAIP levels may confer protection against ischemic cell death. Consistent with this proposal, we demonstrate that two other treatments that increase neuronal NAIP levels, systemic administration of the bacterial alkaloid K252a and intracerebral injection of an adenovirus vector capable of overexpressing NAIP in vivo, reduce ischemic damage in the rat hippocampus. Taken together, these findings suggest that NAIP may play a key role in conferring resistance to ischemic damage and that treatments that elevate neuronal levels of this antiapoptotic protein may have utility in the treatment of stroke.

Chronic alterations in dopaminergic neurotransmission produce a persistent elevation of deltaFosB-like protein(s) in both the rodent and primate striatum

Using an antibody that recognizes the products of all known members of the fos family of immediate early genes, it was demonstrated that destruction of the nigrostriatal pathway by 6-hydroxydopamine (6-OHDA) lesions of the medial forebrain bundle produces a prolonged (>3 months) elevation of Fos-like immunoreactivity in the striatum. Using retrograde tract tracing techniques, we have previously shown that this increase in Fos-like immunoreactivity is located predominantly in striatal neurons that project to the globus pallidus. In the present study, Western blots were performed on nuclear extracts from the intact and denervated striatum of 6-OHDA-lesioned rats to determine the nature of Fos-immunoreactive protein(s) responsible for this increase. Approximately 6 weeks after the 6-OHDA lesion, expression of two Fos-related antigens with apparent molecular masses of 43 and 45 kDa was enhanced in the denervated striatum. Chronic haloperidol administration also selectively elevated expression of these Fos-related antigens, suggesting that their induction after dopaminergic denervation is mediated by reduced activation of D2-like dopamine receptors. Western blot immunostaining using an antibody which recognizes the N-terminus of FosB indicated that the 43 and 45 kDa Fos-related antigens induced by dopaminergic denervation and chronic haloperidol administration may be related to a truncated form of FosB known as deltaFosB. Consistent with this proposal, retrograde tracing experiments confirmed that deltaFosB-like immunoreactivity in the deafferented striatum was located predominantly in striatopallidal neurons. Gel shift experiments demonstrated that elevated AP-1 binding activity in denervated striata contained FosB-like protein(s), suggesting that enhanced deltaFosB levels may mediate some of the effects of prolonged dopamine depletion on AP-1-regulated genes in striatopallidal neurons. In contrast, chronic administration of the D1-like receptor agonist CY 208243 to 6-OHDA-lesioned rats dramatically enhanced deltaFosB-like immunoreactivity in striatal neurons projecting to the substantia nigra. Western blot immunostaining revealed that deltaFosB and, to a lesser extent, FosB are elevated by chronic D1-like agonist administration. Both the quantitative reverse transcriptase-polymerase chain reaction and the ribonuclease protection assay demonstrated that deltafosB mRNA levels were substantially enhanced in the denervated striatum by chronic D1-like agonist administration. Lastly, we examined the effects of chronic administration ofD1-like and D2-like dopamine receptor agonists on striatal deltaFosB expression in the 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) primate model of Parkinson's disease. In monkeys rendered Parkinsonian by MPTP, there was a modest increase in deltaFosB-like protein(s), while the development of dyskinesia produced by chronic D1-like agonist administration was accompanied by large increases in DeltaFosB-like protein(s). In contrast, administration of the long-acting D2-like agonist cabergoline, which alleviated Parkinsonian symptoms without producing dyskinesia reduced deltaFosB levels to near normal. Taken together, these results demonstrate that chronic alterations in dopaminergic neurotransmission produce a persistent elevation of deltaFosB-like protein(s) in both the rodent and primate striatum.

C-fos mediates antipsychotic-induced neurotensin gene expression in the rodent striatum

The ubiquitous inducibility of the immediate-early gene c-fos in the central nervous system has led to the search for downstream genes which are regulated by its product, Fos. Recent evidence suggests that c-fos induction by a single injection of the classical antipsychotic haloperidol may contribute to the subsequent increase in neurotensin gene expression in the rodent striatum. Consistent with this proposal, in the present study haloperidol-induced Fos-like immunoreactivity and neurotensin/neuromedin N messenger RNA were found to be expressed by the same population of striatal neurons. Moreover, inhibition of haloperidol-induced c-fos expression by intrastriatal injection of antisense phosphorothioate oligodeoxynucleotides complimentary either to bases 109-126 or 127-144 of c-fos attenuated the subsequent increase in neurotensin/neuromedin N messenger RNA. However, injection of a sense phosphorothioate oligodeoxynucleotide corresponding to bases 127-144 of c-fos did not reduce haloperidol-induced c-fos or neurotensin/neuromedin N expression. Furthermore, constitutive expression of Jun-like immunoreactivity in the striatum was not reduced by either the sense or antisense phosphorothioate oligodeoxynucleotides. Similarly, the sense and antisense phosphorothioate oligodeoxynucleotide failed to reduce proenkephalin messenger RNA, which is located in the same striatal neurons that express haloperidol-induced neurotensin/neuromedin N messenger RNA, which is located in the same striatal neurons that express haloperidol-induced neurotensin/neuromedin N messenger RNA. Lastly, haloperidol-induced increases in nerve growth factor I-A-, JunB- and FosB-like immunoreactivity and fosB messenger RNA were not decreased by intrastriatal injection of either the sense or antisense phosphorothioate oligodeoxynucleotides. These results indicate that the antisense phosphorothioate oligodeoxynucleotides attenuated haloperidol-induced neurotensin/neuromedin N expression by selectively reducing c-fos expression and emphasize the potential importance of immediate-early gene induction in the mechanism of action of this antipsychotic drug.

Energy metabolism, intracellular Na+ and contractile function in isolated pig and rat hearts during cardioplegic ischemia and reperfusion: 23Na- and 31P-NMR studies

The purpose of the study was to compare the role of Na ions in the damage caused by cardioplegic ischemia in fast (rat) and slow (pig) hearts. Changes in intracellular Na+ (Na+i), high energy phosphates, and contractile function were assessed during ischemia (36 degrees C) and reperfusion in KCl-arrested perfused hearts using 31P-NMR and shift reagent (DyTTHA3-)-aided 23Na-NMR spectroscopy. In the pig hearts the rates of decrease of phosphocreatine (PCr), ATP and intracellular pH (pHi) were 3-4 times slower than the rates observed in the rat hearts. In the pig hearts PCr was observable (approximately 10%) during first 80 min of the ischemic period (90 min). Comparable decreases in ATP (32.0 +/- 6 vs. 38 +/- 15% of initial) and pHi, (to 6.14 +/- 0.06 vs. 6.10 +/- 0.15) observed after 90 and 20 min ischemia in pig and rat hearts, respectively, were associated with a smaller Na+i increase in the pig hearts (to 175 +/- 31%) than in the rat hearts (to 368 +/- 62%). This Na+ increase in the rat hearts preceded development of ischemic contracture (41 +/- 6 mmHg at 23.6 +/- 0.7 min) while no contracture was observed in pig hearts. Reperfusion of the rat hearts (at 30 min ischemia) was followed by partial recovery of PCr (44 +/- 3%) and Na+i (234 +/- 69%) and poorer recovery of the pressure-rate product (PRP, 9 +/- 4%) and end-diastolic pressure (EDP, 72 +/- 5 mmHg) compared to the pig hearts (PCr, 106 +/- 25%; Na+i, 82 +/- 17%; PRP, 24 +/- 3%; EDP, 4.6 +/- 2.5 mmHg). The loss of function in the pig hearts was reversed by increasing Ca++ in the perfusate from 1 to 2.3 mM and resulted in a rise in both PRP and oxygen consumption rate, V(O2), from 24 +/- 3.3 to 64.5 +/- 5.8% and from 55 +/- 10 to 74 +/- 10% of the control levels, respectively. The PRP/delta V(O2) ratio was halved in the post-ischemic pig hearts and returned to the pre-ischemic level following Ca++ stimulation. It is suggested that the higher stability of Na+ homeostasis to ischemic stress in the pig heart may result from: 1) a lower ratio of the rate of ATP hydrolysis to glycolytic ATP production; 2) differences in the kinetic properties of the Na+ transporters. Reduced Na+ accumulation during ischemia and reperfusion is beneficial for metabolic and functional preservation of cardiomyocytes.

Modulation of lung-associated natural killer activity by resident and activated alveolar macrophages

Alveolar macrophages (AM) freshly obtained by bronchoalveolar lavage suppressed significantly, in a dose-dependent fashion, lung interstitial lymphocytes cytotoxicity against the NK-sensitive target cells, YAC-1. Kinetic experiments revealed that AM-mediated suppression of NK activity was seen following short-term incubation of AM with lymphocytes (4 h) and was unchanged after a 24 h co-culture period. Freshly obtained lung lymphocytes and lymphocytes incubated for 24 h were similarly inhibited by AM. In addition, incubation of AM for 24 h did not abrogate their suppressive effect on lung NK activity. Interestingly, AM-conditioned media, also caused a significant inhibition of lung NK activity. Furthermore, in vitro activation of AM with lipopolysaccharide (LPS, 5 micrograms/ml) and muramyl dipeptide (MDP, 20 micrograms/ml) significantly enhanced the inhibitory effect of AM on lung NK activity. Similarly, in vivo activation of AM locally by intratracheal instillation of attapulgite, an inflammatory agent, resulted in greater AM-mediated down regulation. Taken together, these data indicate that lung NK activity is modulated by locally derived factors and suggest that pharmacologic manipulation of AM may play a determining role in the activation of lung NK activity by biological response modifiers (BRM).