Nicotine replacement therapy 'gift cards' for hospital inpatients who smoke: a prospective before-and-after controlled pilot evaluation.

INTRODUCTION: A common barrier identified by individuals trying to quit smoking is the cost of cessation pharmacotherapies. The purpose of this evaluation was to: (1) Assess the feasibility of offering nicotine replacement therapy (NRT) 'gift cards' to hospitalised smokers for use posthospitalisation; and, (2) Estimate the effect of providing NRT gift cards on 6-month smoking abstinence. METHODS: A prospective, quasi-experimental, before-and-after controlled cohort design with random sampling was used to compare patients who had received the Ottawa Model for Smoking Cessation (OMSC) intervention ('control') with patients who received the OMSC plus a $C300 Quit Card ('QCI'), which they could use to purchase any brand or form of NRT from any Canadian pharmacy. RESULTS: 750 Quit Cards were distributed to the three participating hospitals of which 707 (94.3%) were distributed to patients. Of the cards received by patients, 532 (75.2%) were used to purchase NRT. A total of 272 participants completed evaluation surveys (148 control; 124 QCI).Point prevalence abstinence rates adjusted for misreporting among survey responders were 15.3% higher in the QCI group, compared with controls (44.4% vs 29.1%; OR 1.95, 1.18-3.21; p=0.009). Satisfaction was high among participants in both groups, and among staff delivering the QCI. QCI participants rated the intervention as high in terms of motivation, ease of use and helpfulness. CONCLUSIONS: The NRT gift card appears to be a feasible and effective smoking cessation tool that removes a primary barrier to the use of evidence-based smoking cessation pharmacotherapies, while motivating both patients and health providers.

Performance Obligations to Improve Delivery of Hospital-Initiated Smoking Cessation Interventions: A Before-and-After Evaluation.

INTRODUCTION: This study evaluated whether introducing performance obligations (a policy intervention) to service agreements between hospitals (n = 15) and their local health authority: (1) improved provision of an evidence-based tobacco cessation intervention (the "Ottawa Model" for Smoking Cessation) and (2) changed the quality of the cessation intervention being delivered. METHODS: Interrupted time series analysis was used to evaluate the change in the proportion of smoker patients provided the Ottawa Model 3 years before and 3 years after introducing the performance obligations. Changes in secondary outcomes related to program quality were described using mean differences, risk differences, and risk ratios, as appropriate. RESULTS: The proportion and number of patients provided the Ottawa Model doubled in the 3-year period following introduction of the new policy-from 3453 patients (33.7%) in the year before to 6840 patients (62.8%) in the final assessment year. This resulted in a signification slope change (+9.2%; 95% confidence interval [CI] 4.5%, 13.9%; p = .01) between the pre- and post-obligation assessment periods, signifying the policy had a positive impact on performance. Quality and effectiveness of the in-hospital intervention remained steady. CONCLUSIONS: Implementation of performance obligations by a healthcare funder increased delivery of an evidence-based smoking cessation intervention across multiple hospitals. Given the known health and economic impacts of smoking cessation interventions, health authorities and hospitals should consider pairing adoption of systematic interventions, like the Ottawa Model, with policy to enhance reach and impact. IMPLICATIONS: • The hospital-based Ottawa Model for Smoking Cessation (OMSC) intervention has been shown to increase smoking abstinence, while reducing mortality and healthcare utilization.• The uptake of systematic, evidence-based interventions, like the OMSC, by hospitals has been relatively low despite the known positive impacts.• The introduction of smoking cessation performance obligations by a healthcare funder resulted in more patients receiving an OMSC intervention while in hospital, with no corresponding change in intervention quality or effectiveness.• Healthcare funders and hospitals should consider pairing the adoption of effective, systematic interventions, like the OMSC, with policy to enhance reach and impact.

Redeployment during the first wave of the COVID-19 pandemic: implications for a clinical research workforce.

BACKGROUND: Health professionals are considered a group vulnerable to developing mental health symptoms during a pandemic, with redeployment being a risk factor. However, previous literature suggests workplace communication can be a protective element. AIMS: An audit aimed to evaluate NHS research staff's experiences of redeployment in order to provide suggestions for future improvements in the process. METHODS: A questionnaire was disseminated to all staff in the clinical research directorate of an NHS trust. Responses were analysed using thematic analysis. FINDINGS: Over half the redeployed staff experienced perceived negative psychological outcomes. The main reported contributor to this was perceived lack of communication. CONCLUSION: Communication needs to be improved in future redeployments. Future research should consider a larger cohort and more input from team members who remained on the pre-COVID-19 studies in order to improve the transition back from redeployment.

Reduced tactile acuity in chronic low back pain is linked with structural neuroplasticity in primary somatosensory cortex and is modulated by acupuncture therapy.

Prior studies have shown that patients suffering from chronic Low Back Pain (cLBP) have impaired somatosensory processing including reduced tactile acuity, i.e. reduced ability to resolve fine spatial details with the perception of touch. The central mechanism(s) underlying reduced tactile acuity are unknown but may include changes in specific brain circuitries (e.g. neuroplasticity in the primary somatosensory cortex, S1). Furthermore, little is known about the linkage between changes in tactile acuity and the amelioration of cLBP by somatically-directed therapeutic interventions, such as acupuncture. In this longitudinal neuroimaging study, we evaluated healthy control adults (HC, N â€‹= â€‹50) and a large sample of cLBP patients (N â€‹= â€‹102) with structural brain imaging (T1-weighted MRI for Voxel-Based Morphometry, VBM; Diffusion Tensor Imaging, DTI) and tactile acuity testing using two-point discrimination threshold (2PDT) over the lower back (site of pain) and finger (control) locations. Patients were evaluated at baseline and following a 4-week course of acupuncture, with patients randomized to either verum acupuncture, two different forms of sham acupuncture (designed with or without somatosensory afference), or no-intervention usual care control. At baseline, cLBP patients demonstrated reduced acuity (greater 2PDT, P â€‹= â€‹0.01) over the low back, but not finger (P â€‹= â€‹0.29) locations compared to HC, suggesting that chronic pain affects tactile acuity specifically at body regions encoding the experience of clinical pain. At baseline, Gray Matter Volume (GMV) was elevated and Fractional Anisotropy (FA) was reduced, respectively, in the S1-back region of cLBP patients compared to controls (P â€‹< â€‹0.05). GMV in cLBP correlated with greater 2PDT-back scores (ρ â€‹= â€‹0.27, P â€‹= â€‹0.02). Following verum acupuncture, tactile acuity over the back was improved (reduced 2PDT) and greater improvements were associated with reduced S1-back GMV (ρ â€‹= â€‹0.52, P â€‹= â€‹0.03) and increased S1-back adjacent white matter FA (ρ â€‹= â€‹-0.56, P â€‹= â€‹0.01). These associations were not seen for non-verum control interventions. Thus, S1 neuroplasticity in cLBP is linked with deficits in tactile acuity and, following acupuncture therapy, may represent early mechanistic changes in somatosensory processing that track with improved tactile acuity.

Randomized Trial of First-Line Behavioral Intervention to Reduce Need for Medication in Children with ADHD.

A study conducted in an analogue summer treatment setting showed that when concurrently receiving behavioral intervention, many children with Attention-Deficit Hyperactivity Disorder (ADHD) did not need medication or maximized responsiveness at very low doses. The present study followed participants in that summer study into the subsequent school year to investigate whether the same pattern would extend to the natural school and home settings. There were 127 unmedicated children with ADHD between the ages of 5 and 13 who were randomly assigned to receive or not receive behavioral consultation (BC) at the start of the school year. Children were evaluated by teachers and parents each week to determine if central nervous system stimulant treatment was needed. Children who received BC were approximately half as likely those who did not (NoBC) to initiate medication use each week at school or home and used lower doses when medicated at school. This produced a 40% reduction in total methylphenidate exposure over the course of the school year. BC and NoBC groups did not significantly differ on end-of-year teacher or parent ratings of behavior, which were positive. Moreover, BC and NoBC groups did not significantly differ in cost of treatment; although children in the BC condition accrued additional costs via the BC, these costs were offset by the associated delay and reduction in medication use. Results add to a growing literature suggesting that the use of low-intensity behavioral intervention as a first-line treatment reduces or eliminates the need for medication in children with ADHD.

A novel "embryo-endometrial" adhesion model can potentially predict "receptive" or "non-receptive" endometrium.

OBJECTIVE: To establish a model of human implantation that responds to hormonal stimuli and can differentiate between endometrium from fertile women and those with idiopathic infertility. DESIGN: A trophoblast stem cell (trophectodermal) line (TSC; derived from human pre-implantation embryo) was used to form trophectodermal spheroids (TS). TS attachment to monolayers of endometrial epithelial cell lines or primary endometrial epithelial cells (pHEECs) was determined. SETTING: Independent Medical Research Institute with close clinical linkages INTERVENTIONS: Spheroid attachment and outgrowth was determined with added hormones (estradiol 17ß (E), E + medroxyprogesterone acetate (MPA) or E + MPA + human chorionic gonadotropin (hCG)). Spheroid attachment to E/MPA treated pHEEC prepared from fertile women or those with idiopathic infertility tested. MAIN OUTCOME MEASURE: Firmly attached spheroids counted after co-culture for 6 h. Outgrowth was determined by quantitation of area covered by spheroid after firm adhesion. RESULTS: Functional adhesion of TS to two endometrial epithelial cell lines, Ishikawa and ECC-1 cells, was hormonally responsive, with adhesion/outgrowth increased by E/MPA (ECC-1; p < 0.01, Ishikawa; p < 0.01) and E/MPA/hCG (ECC-1; p < 0.001, Ishikawa p < 0.01) versus E alone. The same pattern of hormone responsiveness was observed in pHEEC obtained from fertile women (E vs, E/MPA; p < 0.01, E vs. E/MPA/hCG; p < 0.001). TS adhered to 85% of pHEEC obtained from fertile women (11/13) and 11% of pHEEC obtained from women with unexplained infertility (2/18, p < 0.001). CONCLUSION: This new model of "embryo" implantation largely discriminates between endometrial epithelial cells obtained from fertile vs. infertile women based on adhesion; this holds potential as an in vitro "diagnostic" tool of endometrial infertility.

Rural family medicine training site: Proposed framework.

OBJECTIVE: To develop a framework for a successful rural family medicine training program and to assess the potential for a rural family medicine residency training program using the Weyburn and Estevan areas of Saskatchewan as test sites. DESIGN: A mixed-method design was used; however, the focus of this article was on the qualitative data collected. Questions formulated for the semistructured interviews evolved from the literature. SETTING: Rural Saskatchewan. PARTICIPANTS: Community physicians and representatives from the Sun Country Regional Health Authority, the Saskatchewan Ministry of Health, and the University of Saskatchewan. METHODS: The data were documented during the interviews using a laptop computer, and the responses were reviewed with participants at the end of their interviews to ensure accuracy. The qualitative data collected were analyzed using inductive thematic analysis. MAIN FINDINGS: Through the analysis of the data several themes emerged related to implementing a rural family medicine residency training program. Key predictors of success were physical resources, physician champions, physician teachers, educational support, administrative support, and other specialist support. Barriers to the development of a rural family medicine training site were differing priorities, lack of human resources, and lack of physical resources. CONCLUSION: A project of this magnitude requires many people at different levels collaborating to be successful.

Case report: Adult with bipolar disorder and autism treated with ketamine assisted psychotherapy.

Background: Evidence has increased in recent years regarding the potential for ketamine to serve as a novel treatment option for a range of conditions, particularly depression (unipolar and bipolar). However, research regarding ketamine as a potential therapeutic for Autism Spectrum Disorder (ASD) is lacking, despite high overlap with bipolar depression and theoretical foundations for its use. Case presentation: A 29-year-old man with bipolar disorder and Autism Spectrum Disorder, type 2 diabetes, presented with mood swings and suicidal thoughts, and anger outbursts occurring daily. The patient was referred by a psychiatrist due to irritability and outbursts during the previous 5 months. These outbursts were unable to be controlled by the medications prescribed, included yelling and screaming, and the patient was unable to speak with the psychiatrist. The patient underwent ketamine assisted psychotherapy with 6 initial IV infusions of ketamine over a 1 month period followed by 2 booster IV ketamine infusions. Following ketamine treatment, dramatic reductions in outbursts were observed as well as reductions in anxiety, suicidality, and depression scores. Conclusion: This case study adds to the scant literature regarding ketamine treatment for individuals with bipolar disorder and ASD. We did not find ASD to be a contraindication for IV ketamine and ketamine assisted psychotherapy. Reductions in anger outbursts, anxiety, suicidality, and depression suggest ketamine treatment might be tailored to individuals with bipolar disorder and ASD, and additional systematized research is warranted. Although potential mechanisms of action are not clear, these data add to the discussion regarding clinical practice considerations and the potential for ketamine to improve quality of life and associated metrics.

Measuring Active Transportation on National Health Surveys in Canada From 1994 to 2020.

BACKGROUND: Active transportation (AT), described as self-powered modes of travel (eg, walking and cycling), is an important source of health-promoting physical activity. While AT behaviors have been measured on national health surveys in Canada for over 2 decades, historic prevalence has not been previously reported. We aimed to document the measures of AT on Canada's various national health surveys, examine AT over time, and interpret them within the context of evolving methods of assessment. METHODS: We compiled and summarized the questions used to measure AT among Canadians on 4 national health surveys: National Population Health Survey (1994-1998), Canadian Community Health Survey (2000-2020), Canadian Health Measures Survey (2007-2019), and the Health Behaviour in School-aged Children Study (2010-2018). Among youth and adults (12+ y), we summarized over time: (1) the prevalence of AT participation and (2) time spent in AT (in hours per week) among those who report any AT participation. Where possible, we reported separate estimates of walking and cycling and produced an aggregate estimate of total AT. We stratified results by age group and sex. RESULTS: Changes in AT survey questions over time and between surveys limit the interpretation and comparability of temporal trends. Nevertheless, a consistently higher proportion of females report walking, while a higher proportion of males report cycling. Irrespective of mode, males report spending more total time in AT. Participation in AT tends to decrease with age, with youth reporting the highest rates of AT and young adults often spending the most time in AT. CONCLUSIONS: Monitoring trends in AT can help assess patterns of behavior and identify whether promotion strategies are needed or whether population interventions are effective. Our evaluation of AT over time is limited by questions surveyed; however, consistent differences in AT by age and sex are evident over time. Moving forward, ensuring consistency of AT measurement over time is essential to monitoring this important behavior.

Qualitative evaluation of the SHARING Choices trial of primary care advance care planning for adults with and without dementia.

BACKGROUND: Primary care can be an important setting for communication and advance care planning (ACP), including for those with dementia and their families. The study objective was to explore experiences with a pragmatic trial of a communication and ACP intervention, SHARING Choices, in primary care for older adults with and without dementia. METHODS: We conducted qualitative interviews using tailored semi-structured guides with three groups: ACP facilitators who conducted the intervention; clinicians, managers, and administrators from sites randomized to the intervention; and patients and families who met with ACP facilitators. We used thematic analysis to identify and synthesize emergent themes based on key Consolidated Framework for Implementation Research concepts and Proctor's Implementation Outcomes, triangulating the three groups' perspectives. RESULTS: We identified five key themes. For acceptability, perceptions of the intervention were mostly positive, although some components were not generally implemented. For adoption, respondents perceived that ACP facilitators mainly focused on conducting ACP, although facilitators often did not implement the ADRD and family engagement aspects with the ACP. For relational connections, ACP facilitator-practice and clinician communication and engagement were key to how the intervention was implemented. For adaptability, ACP facilitators and health systems adapted how the ACP facilitation component was implemented to local preferences and over time, given the pragmatic nature of the trial. And, for sustainability, ACP facilitators and clinicians/managers/facilitators were positive that the intervention should be continued but noted barriers to its sustainability. Patients and families generally did not recall the intervention. CONCLUSIONS: ACP facilitators and clinicians, managers, and administrators had positive perceptions of the ACP facilitator component of the intervention in this pragmatic trial with adaptation to local preferences. However, engaging those with dementia and families was more challenging in the implementation of this intervention.

Integrating weight bias awareness and mental health promotion into obesity prevention delivery: a public health pilot study.

INTRODUCTION: Promoting healthy weight is a top priority in Canada. Recent federal guidelines call for sustained, multisectoral partnerships that address childhood obesity on multiple levels. Current healthy weight messaging does not fully acknowledge the influence of social determinants of health on weight. METHODS: An interactive workshop was developed and implemented by a team of academic researchers and health promoters from the psychology and public health disciplines to raise awareness about 1) weight bias and its negative effect on health, 2) ways to balance healthy weight messaging to prevent the triggering of weight and shape preoccupation, and 3) the incorporation of mental health promotion into healthy weight messaging. We conducted a full-day workshop with 342 Ontario public health promoters and administered a survey at preintervention, postintervention, and follow-up. RESULTS: Participation in the full-day workshop led to significant decreases in antifat attitudes and the internalization of media stereotypes and to significant increases in self-efficacy to address weight bias. Participants reported that the training heightened their awareness of their own personal weight biases and the need to broaden their scope of healthy weight promotion to include mental health promotion. There was consensus that additional sessions are warranted to help translate knowledge into action. Buy-in and resource support at the organizational level was also seen as pivotal. CONCLUSION: Professional development training in the area of weight bias awareness is associated with decreases in antifat attitudes and the internalization of media stereotypes around thinness. Health promoters' healthy weight messaging was improved by learning to avoid messages that trigger weight and shape preoccupation or unhealthful eating practices among children and youth. Participants also learned ways to integrate mental health promotion and resiliency-building into daily practice.

Trading health for a healthy weight: the uncharted side of healthy weights initiatives.

Healthy eating and weight initiatives have been incorporated into many schools to combat the growing obesity problem. There is little research, however, on the effectiveness of these programs or any inadvertent harmful effects on children's mental health. Our aims were to report on how school-based healthy weights initiatives can trigger the adoption of unhealthy behaviours for some children. This is a case series of four children seen at specialized eating disorder clinics. Each child attributed eating pattern changes to information garnered from school-based healthy eating curricula. Unanticipated consequences of these initiatives are described and alternative approaches are discussed.

Capturing patient experience.

Patient experience is a crucial measure of the quality of patient care in healthcare settings. It encompasses all the patient's interactions with staff and their exposure to equipment, procedures, environment and service structure during one care episode. Capturing patient experience is one way of ensuring that patients' voices are heard and can form the basis of an audit or service improvement project designed to evaluate or enhance the patient-centredness of care. Nurses are increasingly involved in audits and service improvement projects, so it is important that they understand what patient experience is, how it differs from patient satisfaction and what approaches can be used to measure it. This article defines patient experience, describes data collection methods and discusses factors to consider when planning to collect patient experience data, notably the validity, reliability and rigour of the data collection tool.

Evaluation of Peak Inspiratory Flow Rate in Hospitalized Palliative Care Patients with COPD.

Dry powder inhalers are an effective yet costly COPD medication-delivery device. Patients must possess a minimum peak inspiratory flow rate (PIFR) for inhaled medication to be properly deposited into the lungs. Hospitalized palliative-care patients with diminished lung function due to advanced COPD may not possess the minimum PIFR (30 L/min) for adequate drug delivery. This study aims to quantify PIFR values for hospitalized palliative-care patients with advanced COPD to evaluate whether these patients meet the minimum PIFR requirements. Hospitalized patients ≥18 years old with a palliative-care consultation were eligible if they had a diagnosis of advanced COPD (GOLD C or D). Patients were excluded if they lacked decision-making capacity or had a positive COVID-19 test within the previous 90 days. Three PIFR values were recorded utilizing the In-CheckTM device, with the highest of the three PIFR attempts being utilized for statistical analysis. Eighteen patients were enrolled, and the mean of the highest PIFR readings was 72.5 L/min (±29 L/min). Post hoc analysis indicated 99.9% power when comparing the average best PIFR to the minimum PIFR (30 L/min) but only 51.4% power when compared to the optimal PIFR (60 L/min). This study found that palliative-care patients possess the minimum PIFR for DPI drug delivery.

Thalamocortical Mechanisms Underlying Real and Imagined Acupuncture.

Both acupuncture and imagery have shown potential for chronic pain management. However, the mechanisms underlying their analgesic effects remain unclear. This study aims to explore the thalamocortical mechanisms underlying acupuncture and video-guided acupuncture imagery treatment (VGAIT), a combination of acupuncture and guided imagery, using the resting-state functional connectivity (rsFC) of three thalamic subdivisions-the ventral posterolateral thalamus (VPL), mediodorsal thalamus (MD), and motor thalamus subregion (Mthal)-associated with somatosensory, limbic, and motor circuity. Twenty-seven healthy individuals participated in a within-subject randomized crossover design study. Results showed that compared to sham acupuncture, real acupuncture altered the rsFC between the thalamus and default mode network (DMN) (i.e., mPFC, PCC, and precuneus), as well as the prefrontal and somatosensory cortex (SI/SII). Compared to the VGAIT control, VGAIT demonstrated greater rsFC between the thalamus and key nodes within the interoceptive network (i.e., anterior insula, ACC, PFC, and SI/SII), as well as the motor and sensory cortices (i.e., M1, SMA, and temporal/occipital cortices). Furthermore, compared to real acupuncture, VGAIT demonstrated increased rsFC between the thalamus (VPL/MD/Mthal) and task-positive network (TPN). Further correlations between differences in rsFC and changes in the heat or pressure pain threshold were also observed. These findings suggest that both acupuncture- and VGAIT-induced analgesia are associated with thalamocortical networks. Elucidating the underlying mechanism of VGAIT and acupuncture may facilitate their development, particularly VGAIT, which may be used as a potential remote-delivered pain management approach.

Prevalence, Perceptions, and Patterns of Cannabis Use Among Cardiac Inpatients at a Tertiary-Care Hospital: A Cross-Sectional Survey.

Background: Cannabis use may adversely affect cardiovascular health. Patterns of use by cardiac patients are unknown. We evaluated the prevalence, perceptions, and patterns of cannabis use among cardiac inpatients. Methods: A consecutive cross-section of cardiac inpatients, hospitalized between November 2019 and May 2020, were surveyed in-person or via telephone. Descriptive statistics and logistic regression were used to examine the characteristics of cannabis use. Results: The prevalence of past-12-month cannabis use was 13.8% (95% confidence interval [CI]: 11.8%-16.0%). Characteristics independently associated with cannabis use were as follows: age < 64 years (< 44 years, odds ratio [OR] = 3.96 [95% CI: 1.65-9.53]; age 45-64 years, OR = 2.72 [95% CI: 1.65-4.47]); tobacco use in the previous 6 months (OR = 1.91 [95% CI: 1.18-3.07]); having a cannabis smoker in one's primary social group (OR = 4.17 [95% CI: 2.73-6.38]); and a history of a mental health diagnosis (OR = 1.82 [95% CI: 1.19-2.79]). Among those using cannabis, 70.5% reported smoking or vaping it; 47.2% reported daily use. Most did not know the tetrahydrocannabinol (THC; 71.6%) or cannabidiol (CBD; 83.3%) content of their cannabis, or the dose of cannabis in their edibles (66.7%). As defined by Canada's Lower Risk Cannabis Use Guidelines, 96.7% of cannabis users reported ≥ 1 higher-risk use behaviour (mean = 2.3, standard deviation = 1.2). Over 60% of patients expressed no intention to quit or reduce cannabis use in the next 6 months. Conclusions: Cannabis use appears prevalent among cardiac patients. Most users demonstrated higher-risk use behaviours and low intentions to quit. Further work is needed to understand the impacts of cannabis use on the cardiovascular system and to develop guidelines and educational tools relating to lower-risk use, for cardiac patients and providers.

Contexte: L'utilisation du cannabis peut nuire à la santé cardiovasculaire, mais les habitudes d'utilisation des patients atteints de troubles cardiaques ne sont pas connues. Nous avons évalué la prévalence, les perceptions et les habitudes d'utilisation du cannabis chez des patients hospitalisés présentant des troubles cardiaques. Méthodologie: Une analyse transversale a été réalisée en interrogeant en personne ou au téléphone des patients hospitalisés consécutivement entre novembre 2019 et mai 2020 et présentant des troubles cardiaques. Des statistiques descriptives et une régression logistique ont été utilisées pour examiner les caractéristiques liées à l'utilisation du cannabis. Résultats: La prévalence de l'utilisation du cannabis au cours des 12 mois précédents était de 13,8 % (intervalle de confiance [IC] à 95 % : 11,8 % à 16,0 %). Les caractéristiques indépendamment associées à l'utilisation du cannabis étaient les suivantes : âge < 64 ans (< 44 ans, rapport de cotes [RC] = 3,96 [IC à 95 % : 1,65 à 9,53]; âge de 45 à 64 ans, RC = 2,72 [IC à 95 % : 1,65 à 4,47]); tabagisme dans les six mois précédents (RC = 1,91 [IC à 95 % : 1,18 à 3,07]); présence d'un consommateur de cannabis au sein du cercle social principal (RC = 4,17 [IC à 95 % : 2,73 à 6,38]); et diagnostic antérieur lié à la santé mentale (RC = 1,82 [IC à 95 % : 1,19 à 2,79]). Parmi les utilisateurs de cannabis, 70,5 % d'entre eux ont rapporté qu'ils fumaient ou vapotaient et 47,2 % ont déclaré en consommer quotidiennement. La plupart ne connaissaient pas le contenu en tétrahydrocannabinol (THC; 71,6 %) ou en cannabidiol (CBD; 83,3 %) du cannabis consommé, ou la dose contenue dans les aliments à base de cannabis consommés (66,7 %). Au total, 96,7 % des utilisateurs de cannabis ont rapporté ≥ 1 comportement(s) à risque élevé (moyenne = 2,3, écart-type = 1,2) selon les Recommandations canadiennes pour l'usage du cannabis à moindre risque. Par ailleurs, plus de 60 % des patients n'ont exprimé aucune intention d'interrompre ou de diminuer leur consommation de cannabis au cours des six prochains mois. Conclusions: L'utilisation du cannabis semble courante chez les patients qui présentent des troubles cardiaques. La plupart des utilisateurs ont démontré des comportements à risque élevé, et une faible intention de mettre fin à leur consommation. D'autres études sont requises pour caractériser les répercussions de l'utilisation du cannabis sur l'appareil cardiovasculaire et élaborer des lignes directrices et des outils éducatifs à l'intention des patients atteints de troubles cardiaques et des professionnels de la santé en vue de favoriser un usage à moindre risque.

Single and Combined Effects of Multiple Intensities of Behavioral Modification and Methylphenidate for Children with ADHD in the Home Setting.

Behavioral treatment, stimulants, and their combination are the recommended treatments for childhood attention-deficit/hyperactivity disorder (ADHD). The current study utilizes within-subjects manipulations of multiple doses of methylphenidate (placebo, 0.15, 0.30, and 0.60 mg/kg/dose t.i.d.) and intensities of behavioral modification (no, low, and high intensity) in the summer treatment program (STP) and home settings. Outcomes are evaluated in the home setting. Participants were 153 children (ages 5-12) diagnosed with ADHD. In alignment with experimental conditions implemented during the STP day, parents implemented behavioral modification levels in three-week intervals, child medication status varied daily, and the orders were randomized. Parents provided daily reports of child behavior, impairment, and symptoms and self-reported parenting stress and self-efficacy. At the end of the study, parents reported treatment preferences. Stimulant medication led to significant improvements across all outcome variables with higher doses resulting in greater improvement. Behavioral treatment significantly improved child individualized goal attainment, symptoms, and impairment in the home setting and parenting stress and self-efficacy. Effect sizes indicate that behavioral treatment combined with a low-medium dose (0.15 or 0.30 mg/kg/dose) of medication results in equivalent or superior outcomes compared to a higher dose (0.60 mg/kg/dose) of medication alone. This pattern was seen across outcomes. Parents overwhelmingly reported preferring treatment with a behavioral component as a first-choice treatment (99%). Results underscore the need to consider dosing as well as parent preference when utilizing combined treatment approaches. This study provides further evidence that combining behavioral treatment and stimulant medication may reduce the stimulant dose needed for beneficial effects.

SHARING Choices: Lessons Learned from a Primary-Care Focused Advance Care Planning Intervention.

BACKGROUND: Few advance care planning (ACP) interventions have been scaled in primary care. PROBLEM: Best practices for delivering ACP at scale in primary care do not exist and prior efforts have excluded older adults with Alzheimer's Disease and Related Dementias (ADRD). INTERVENTION: SHARING Choices (NCT#04819191) is a multicomponent cluster-randomized pragmatic trial conducted at 55 primary care practices from two care delivery systems in the Mid-Atlantic region of the U.S. We describe the process of implementing SHARING Choices within 19 practices randomized to the intervention, summarize fidelity to planned implementation, and discuss lessons learned. OUTCOMES: Embedding SHARING Choices involved engagement with organizational and clinic-level partners. Of 23,220 candidate patients, 17,931 outreach attempts by phone (77.9%) and the patient portal (22.1%) were made by ACP facilitators and 1215 conversations occurred. Most conversations (94.8%) were less than 45 minutes duration. Just 13.1% of ACP conversations included family. Patients with ADRD comprised a small proportion of patients who engaged in ACP. Implementation adaptations included transitioning to remote modalities, aligning ACP outreach with the Medicare Annual Wellness Visit, accommodating primary care practice flexibility. LESSONS LEARNED: Study findings reinforce the value of adaptable study design; co-designing workflow adaptations with practice staff; adapting implementation processes to fit the unique needs of two health systems; and modifying efforts to meet health system goals and priorities.

Systematic review: conservative treatments for secondary lymphedema.

BACKGROUND: Several conservative (i.e., nonpharmacologic, nonsurgical) treatments exist for secondary lymphedema. The optimal treatment is unknown. We examined the effectiveness of conservative treatments for secondary lymphedema, as well as harms related to these treatments. METHODS: We searched MEDLINE®, EMBASE®, Cochrane Central Register of Controlled Trials®, AMED, and CINAHL from 1990 to January 19, 2010. We obtained English- and non-English-language randomized controlled trials or observational studies (with comparison groups) that reported primary effectiveness data on conservative treatments for secondary lymphedema. For English-language studies, we extracted data in tabular form and summarized the tables descriptively. For non-English-language studies, we summarized the results descriptively and discussed similarities with the English-language studies. RESULTS: Thirty-six English-language and eight non-English-language studies were included in the review. Most of these studies involved upper-limb lymphedema secondary to breast cancer. Despite lymphedema's chronicity, lengths of follow-up in most studies were under 6 months. Many trial reports contained inadequate descriptions of randomization, blinding, and methods to assess harms. Most observational studies did not control for confounding. Many studies showed that active treatments reduced the size of lymphatic limbs, although extensive between-study heterogeneity in areas such as treatment comparisons and protocols, and outcome measures, prevented us from assessing whether any one treatment was superior. This heterogeneity also precluded us from statistically pooling results. Harms were rare (< 1% incidence) and mostly minor (e.g., headache, arm pain). CONCLUSIONS: The literature contains no evidence to suggest the most effective treatment for secondary lymphedema. Harms are few and unlikely to cause major clinical problems.

50 practical medication tips at end of life.

Patients with a life-limiting illness frequently experience pain and other symptoms. It is important to pay close attention when medication therapy is used to manage these symptoms. Occasionally, practitioners need to be creative in selecting, dosing, administering, and discontinuing medications at the end of life because of the patient's changing health care needs. This article offers practical end-of-life medication tips including, but not limited to, medication administration; guidance on how to increase and decrease doses; medication selection for difficult-to-treat patients; alternative dosage formulations; routes of medication administration; debridement medication regimens; and appropriate drug therapy selection.