Study What You Do: Developing a Psychotherapy Tracking Database in a Large-Scale Integrated Behavioral Health Service.

PURPOSE: Many individuals with behavioral health challenges receive services in primary care, and integrated behavioral health (IBH) programs can help increase access to evidence-based interventions. IBH programs can benefit substantially from integrating standardized tracking databases that allow for the implementation of measurement-based care to evaluate patient-, clinician-, and practice-level outcomes. We describe the development and integration of Mayo Clinic's pediatric and adult primary care psychotherapy tracking database. METHODS: IBH practice leaders directed the development of a large psychotherapy tracking database that continuously populates from Mayo Clinic's electronic health record system. The database captures numerous patient variables including demographics, behavioral health and substance use issues, psychotherapy principles used, and self-reported symptoms. We retrieved current data for patients empaneled in Mayo Clinic's pediatric and adult primary care psychotherapy programs from June 2014 to June 2022. RESULTS: The tracking database contained data for 16,923 adult patients and 6,298 pediatric patients. The mean age of adult patients was 43.2 years (SD 18.3), 88.1% were non-Latine White, and 66.7% identified as female. The mean age of pediatric patients was 11.6 years (SD 4.2), 82.5% were non-Latine White, and 56.9% identified as female. We provide examples of practical applications of the database across clinical, educational, research, and administrative domains. CONCLUSIONS: The development and integration of a psychotherapy tracking database supports clinician communication, examination of patient outcomes, practice quality improvement efforts, and clinically relevant research. Our description of Mayo Clinic's IBH database may serve as a model for other IBH practices.

Neutral Mechanical Alignment Alters the Native Distal Femoral Joint Line: A Virtual Three-Dimensional Planning Total Knee Arthroplasty Study.

BACKGROUND: Alternative alignment concepts have garnered great interest in an effort to improve patient satisfaction following primary total knee arthroplasty (TKA). The purpose of this study is to determine variation or deviation from an individual's native joint line in primary TKA using neutral mechanical versus a restricted kinematic technique. METHODS: An institutional review board-approved prospective cohort study was performed evaluating the effect of neutral mechanical alignment (nMA) versus a restricted kinematic alignment (rKA) on the native joint line in 100 consecutive patients undergoing primary TKA. Using preoperative computed tomography and intraoperative 3-dimensional software, 2 virtual preoperative plans were created: nMA and rKA. Templated bone resections were recorded. Change in joint line was calculated using known implant planar thickness and planned bone resection. RESULTS: nMA yielded significantly greater deviation from the patient's native joint line along the lateral compartment of the knee (lateral distal femoral condyle, lateral posterior femoral condyle, lateral tibial resection). With nMA, the lateral distal femoral joint line was distalized by a mean 4.3 versus 2.6 mm using rKA technique (P < .001). In rKA, >60% of knees had <3 mm of deviation from the native lateral posterior femoral offset, whereas in nMA, >95% of knees had ≥3 mm change in the lateral posterior femoral condylar offset. CONCLUSION: nMA-TKA resulted in statistically larger joint line deviations compared to rKA-TKA, most notably along the lateral distal femoral condyle joint line. Further analysis is needed to determine the clinical consequences of joint line deviation from the native anatomy using nMA as the target for primary TKA.

The Relationship of Mentorship to Career Outcomes in Academic Psychiatry and Psychology: a Needs Assessment.

OBJECTIVE: Faculty development is designed to facilitate career advancement of junior faculty but there is limited empirical evidence on how to design an effective program. METHODS: As a first step in the design of an effective program, a needs assessment was conducted. Participants were faculty members of an academic psychiatry department. Participants completed a quantitative and qualitative survey assessing their experience with mentors, academic self-efficacy, career burnout and satisfaction, academic productivity, and perceived barriers to scholarship. RESULTS: Eighty percent (N = 104) of eligible faculty members completed the study survey (54% female; 81% White, 10% underrepresented in medicine). Less than half of the respondents (44%) reported having a current mentor. Number of mentors (r = .33; p < .01), mentorship meetings (r = .35; p < .01), and mentorship quality (r = .33; p < .01) were significantly correlated to a standardized measure of academic self-efficacy. Self-efficacy was significantly associated with academic productivity (r = .44; p < .001) and career satisfaction (r = .29; p < .05). The top barriers to scholarship productivity were time and lack of access to resources. Faculty members without a mentor endorsed more barriers to scholarship (p < .001) than those with a mentor. Themes that emerged from the qualitative data suggest that mentorship supports career advancement through coaching and professional development, invitations to collaborate and resource share, networking, and active teaching. CONCLUSION: Based on the relationship of mentoring to career outcomes, a robust faculty development program needs a formal academic mentorship program to improve career satisfaction and academic productivity.

Optimization and Scale Up of Spray Dried CPZEN-45 Aerosol Powders for Inhaled Tuberculosis Treatment.

PURPOSE: Tuberculosis (TB) remains one of the most serious diseases caused by a single organism. Multiple (MDR) and extensively (XDR) drug resistant disease poses a threat to global health and requires new drugs and/or innovative approaches to treatment. A number of drugs have been proposed as inhaled therapy for TB, frequently prepared by spray drying. CPZEN-45 is a novel anti-tubercular drug that has poor oral bioavailability but has shown promise when administered via inhalation. METHODS: Excipient-free CPZEN-45 HCl has been spray dried into a powder with physicochemical characteristics, aerodynamic particle size distribution, and delivered dose suitable for consideration as an inhaled product. RESULTS: The mass median aerodynamic diameter (MMAD) and geometric standard deviation (GSD) of the powder delivered using a RS01 inhaler were 2.62 ± 0.04 µm and 1.76 ± 0.09, respectively. Additionally, the powder was physically and chemically stable after storage at ambient conditions for >1.5 years with particle size similar to freshly manufactured product. Overages in spray dried powder were recycled the powder and resprayed into drug product likewise resulting in negligible change in quality thus allowing for further preclinical characterization as necessary. CPZEN-45 was scaled up using pilot-scale manufacturing equipment where the density of the powder was increased to facilitate larger delivered doses without affecting the aerodynamic performance properties. CONCLUSION: The spray dried powders were suitable for pharmacokinetics, efficacy and preclinical toxicology studies. The final method of manufacture may be used directly for CGMP particle manufacture to support IND and Phase I clinical trials and beyond.

Vasopressor Therapy in the Intensive Care Unit.

After fluid administration for vasodilatory shock, vasopressors are commonly infused. Causes of vasodilatory shock include septic shock, post-cardiovascular surgery, post-acute myocardial infarction, postsurgery, other causes of an intense systemic inflammatory response, and drug -associated anaphylaxis. Therapeutic vasopressors are hormones that activate receptors-adrenergic: α1, α2, ß1, ß2; angiotensin II: AG1, AG2; vasopressin: AVPR1a, AVPR1B, AVPR2; dopamine: DA1, DA2. Vasopressor choice and dose vary widely because of patient and physician practice heterogeneity. Vasopressor adverse effects are excessive vasoconstriction causing organ ischemia/infarction, hyperglycemia, hyperlactatemia, tachycardia, and tachyarrhythmias. To date, no randomized controlled trial (RCT) of vasopressors has shown a decreased 28-day mortality rate. There is a need for evidence regarding alternative vasopressors as first-line vasopressors. We emphasize that vasopressors should be administered simultaneously with fluid replacement to prevent and decrease duration of hypotension in shock with vasodilation. Norepinephrine is the first-choice vasopressor in septic and vasodilatory shock. Interventions that decrease norepinephrine dose (vasopressin, angiotensin II) have not decreased 28-day mortality significantly. In patients not responsive to norepinephrine, vasopressin or epinephrine may be added. Angiotensin II may be useful for rapid resuscitation of profoundly hypotensive patients. Inotropic agent(s) (e.g., dobutamine) may be needed if vasopressors decrease ventricular contractility. Dopamine has fallen to almost no-use recommendation because of adverse effects; angiotensin II is available clinically; there are potent vasopressors with scant literature (e.g., methylene blue); and the novel V1a agonist selepressin missed on its pivotal RCT primary outcome. In pediatric septic shock, vasopressors, epinephrine, and norepinephrine are recommended equally because there is no clear evidence that supports the use of one vasoactive agent. Dopamine is recommended when epinephrine or norepinephrine is not available. New strategies include perhaps patients will be started on several vasopressors with complementary mechanisms of action, patients may be selected for particular vasopressors according to predictive biomarkers, and novel vasopressors may emerge with fewer adverse effects.

Clinician Satisfaction with Rapid Adoption and Implementation of Telehealth Services During the COVID-19 Pandemic.

Background: To examine clinician perspectives on the acceptability, appropriateness/suitability, and feasibility of video telehealth as a way to deliver mental health services during the COVID-19 pandemic. Materials and Methods: Mental health clinicians were surveyed with 27 Likert questions, using previously validated measures, on satisfaction and implementation experience with video telehealth visits between March and June 2020. Results: A total of 112 of 193 clinicians completed the survey (58.0%), including psychiatrists, psychologists, trainees (i.e., residents and fellows), advanced practice providers, and licensed mental health counselors. Clinicians reported high levels of acceptability, feasibility, and appropriateness of video telehealth; they also reported high levels of satisfaction with video telehealth visits. Seventy-nine and a half (79.5%) reported that their patients seemed highly satisfied with video telehealth visits, and 107 (95.5%) of clinicians responded that they would like video telehealth visits to represent at least 25% of their practice in the future. Discussion: Mental health clinicians showed positive attitudes toward the implementation of video telehealth visits, high levels of satisfaction with this care, and indicated strong interest in continuing this modality as a significant portion of clinical practice. Conclusions: This study demonstrates the ability of mental health clinicians to embrace new technology to expand access to care during the COVID-19 pandemic. Results indicate that telemental health is likely to be an integral part of clinic practice in the future.

Low-dose whole thorax radiation therapy for COVID-19 pneumonia: inpatient onboarding process for a randomized controlled trial.

BACKGROUND: The mortality of the SARS-CoV-2 virus (COVID-19) has been associated with a pulmonary inflammatory response resulting in hypoxemia and rapid clinical decline. PREVENT is an ongoing prospective multicenter Phase II randomized controlled trial where patients hospitalized with COVID-19 pneumonia are randomized to low dose radiation therapy (RT) versus control (clinicaltrials.gov, NCT04466683). We describe the inpatient onboarding process of the center contributing the largest number of patients to this trial. MATERIALS AND METHODS: COVID-19 hospital admissions were attained by the clinical research manager and radiation oncologist daily. Text message contact was made with infectious disease, critical care, and nursing staff with reciprocal discussion of the trial protocol and approval for virtual consulting of the patient. Witnessed informed consent was obtained first by telephone and later in person. Simulation and treatment (performed without a computer plan) was performed on a linear accelerator with one personal protective equipment-protected therapist moving in and out of the treatment room, and a second therapist manning the console. Following on-site dose calculation by physics, the radiation oncologist approved the fields prior to treatment delivery. RESULTS: Between August 28, 2020 and October 6, 2020, the first 10 enrolled patients on this multicenter trial were randomized and treated at our institution; no team member (research staff, radiation oncology) contracted COVID-19 while employing this protocol. CONCLUSION: This represents the first published protocol to address efficient and safe recruitment of COVID-19 patients for a radiation oncology trial, serving as a model for conducting recruitment of COVID-19 patients for clinical trials.

The Role of the Patient-Centered Medical Home in Treating Depression.

PURPOSE OF REVIEW: This review discusses the role of the patient-centered medical home (PCMH) in treating depression, focusing on findings from primary care-based studies and their implications for the PCMH. RECENT FINDINGS: Pharmacotherapy, psychotherapy, and collaborative care are evidence-based treatments for depression that can be delivered in primary care and extended to diverse populations. Recent research aligns with the core components of the PCMH model. The core components of the PCMH are critical elements of depression treatment. Comprehensive care within the PCMH addresses medical and behavioral health concerns, including depression. Psychiatric and psychological care must be flexibly delivered so services remain accessible yet patient-centered. To ensure the quality and safety of treatment, depression symptoms must be consistently monitored. Coordination within and occasionally outside of the PCMH is needed to ensure patients receive the appropriate level of care. More research is needed to empirically evaluate depression treatment within the PCMH.

Sustainable care coordination: a qualitative study of primary care provider, administrator, and insurer perspectives.

BACKGROUND: Care coordination has been a common tool for practices seeking to manage complex patients, yet there remains confusion about the most effective and sustainable model. Research exists on opinions of providers of care coordination but there is limited information on perspectives of those in the insurance industry about key elements. We sought to gather opinions from primary care providers and administrators in Minnesota who were involved in a CMS (Center for Medicare and Medicaid Services) transformational grant implementing COMPASS (Care Of Mental, Physical And Substance-use Syndromes), an evidence-based model of care coordination for depressed patients comorbid with diabetes and/or cardiovascular disease. We then sought to compare these views with those of private insurance representatives in Minnesota. METHODS: We used qualitative methods to conducted forty-two key informant interviews with primary care providers (n = 15); administrators (n = 15); and insurers (n = 12). We analyzed the recorded and transcribed data, once de-identified, using a frameworks analysis approach. RESULTS: We identified six primary themes: 1) a defined scope, rationale, and key partnerships for building comprehensive care coordination programs, 2) effective information exchange, 3) a trained and available workforce, 4) the need for a business model and a financially justifiable program, 5) a need for evaluation and ongoing improvement of care coordination, and 6) the importance of patient and family engagement. Overall consensus across stakeholder groups was high including a call for payment reform to support a valued service. Despite their role in paying for care, insurance representatives did not stress reduced utilization as more important than other outcomes. CONCLUSIONS: Primary care providers and administrators from different organizations and backgrounds, all with experience in COMPASS, in large part agreed with insurance representatives on the main elements of a sustainable model and the need for health reform to sustain this service.

Supervised, Vigorous Intensity Exercise Intervention for Depressed Female Smokers: A Pilot Study.

INTRODUCTION: Few studies have evaluated exercise interventions for smokers with depression or other psychiatric comorbidities. This pilot study evaluated the potential role of supervised vigorous exercise as a smoking cessation intervention for depressed females. METHODS: Thirty adult women with moderate-severe depressive symptoms were enrolled and randomly assigned to 12 weeks of thrice weekly, in person sessions of vigorous intensity supervised exercise at a YMCA setting (EX; n = 15) or health education (HE; n = 15). All participants received behavioral smoking cessation counseling and nicotine patch therapy. Assessments were done in person at baseline, at the end of 12 weeks of treatment, and at 6 months post-target quit date. Primary end points were exercise adherence (proportion of 36 sessions attended) and biochemically confirmed 7-day point prevalence abstinence at Week 12. Biomarkers of inflammation were explored for differences between treatment groups and between women who smoked and those abstinent at Week 12. RESULTS: Treatment adherence was high for both groups (72% for EX and 66% for HE; p = .55). The Week 12 smoking abstinence rate was higher for EX than HE (11/15 [73%] vs. 5/15 [33%]; p = .028), but no significant differences emerged at 6-month follow-up. Interleukin-6 levels increased more for those smoking than women abstinent at Week 12 (p = .040). CONCLUSIONS: Vigorous intensity supervised exercise is feasible and enhances short-term smoking cessation among depressed female smokers. Innovative and cost-effective strategies to bolster long-term exercise adherence and smoking cessation need evaluation in this population. Inflammatory biomarkers could be examined in future research as mediators of treatment efficacy. IMPLICATIONS: This preliminary study found that vigorous intensity supervised exercise is feasible and enhances short-term smoking cessation among depressed female smokers. This research addressed an important gap in the field. Despite decades of research examining exercise interventions for smoking cessation, few studies were done among depressed smokers or those with comorbid psychiatric disorders. A novel finding was increases in levels of a pro-inflammatory biomarker observed among women who smoked at the end of the intervention compared to those who did not.

Non-pharmacological treatment of depression: a systematic review and evidence map.

BACKGROUND: The comparative effectiveness of non-pharmacological treatments of depression remains unclear. METHODS: We conducted an overview of systematic reviews to identify randomised controlled trials (RCTs) that compared the efficacy and adverse effects of non-pharmacological treatments of depression. We searched multiple electronic databases through February 2016 without language restrictions. Pairs of reviewers determined eligibility, extracted data and assessed risk of bias. Meta-analyses were conducted when appropriate. RESULT: We included 367 RCTs enrolling ∼20 000 patients treated with 11 treatments leading to 17 unique head-to-head comparisons. Cognitive behavioural therapy, naturopathic therapy, biological interventions and physical activity interventions reduced depression severity as measured using standardised scales. However, the relative efficacy among these non-pharmacological interventions was lacking. The effect of these interventions on clinical response and remission was unclear. Adverse events were lower than antidepressants. LIMITATION: The quality of evidence was low to moderate due to inconsistency and unclear or high risk of bias, limiting our confidence in findings. CONCLUSIONS: Non-pharmacological therapies of depression reduce depression symptoms and should be considered along with antidepressant therapy for the treatment of mild-to-severe depression. A shared decision-making approach is needed to choose between non-pharmacological therapies based on values, preferences, clinical and social context.

Drotrecogin alfa (activated) in adults with septic shock.

BACKGROUND: There have been conflicting reports on the efficacy of recombinant human activated protein C, or drotrecogin alfa (activated) (DrotAA), for the treatment of patients with septic shock. METHODS: In this randomized, double-blind, placebo-controlled, multicenter trial, we assigned 1697 patients with infection, systemic inflammation, and shock who were receiving fluids and vasopressors above a threshold dose for 4 hours to receive either DrotAA (at a dose of 24 µg per kilogram of body weight per hour) or placebo for 96 hours. The primary outcome was death from any cause 28 days after randomization. RESULTS: At 28 days, 223 of 846 patients (26.4%) in the DrotAA group and 202 of 834 (24.2%) in the placebo group had died (relative risk in the DrotAA group, 1.09; 95% confidence interval [CI], 0.92 to 1.28; P=0.31). At 90 days, 287 of 842 patients (34.1%) in the DrotAA group and 269 of 822 (32.7%) in the placebo group had died (relative risk, 1.04; 95% CI, 0.90 to 1.19; P=0.56). Among patients with severe protein C deficiency at baseline, 98 of 342 (28.7%) in the DrotAA group had died at 28 days, as compared with 102 of 331 (30.8%) in the placebo group (risk ratio, 0.93; 95% CI, 0.74 to 1.17; P=0.54). Similarly, rates of death at 28 and 90 days were not significantly different in other predefined subgroups, including patients at increased risk for death. Serious bleeding during the treatment period occurred in 10 patients in the DrotAA group and 8 in the placebo group (P=0.81). CONCLUSIONS: DrotAA did not significantly reduce mortality at 28 or 90 days, as compared with placebo, in patients with septic shock. (Funded by Eli Lilly; PROWESS-SHOCK ClinicalTrials.gov number, NCT00604214.).

Treatment outcomes of depression: the pharmacogenomic research network antidepressant medication pharmacogenomic study.

BACKGROUND: The effectiveness of selective serotonin reuptake inhibitors (SSRIs) in patients with major depressive disorder (MDD) is controversial. AIMS: The clinical outcomes of subjects with nonpsychotic MDD were reported and compared with the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study outcomes to provide guidance on the effectiveness of SSRIs. METHODS: Subjects were treated with citalopram/escitalopram for up to 8 weeks. Depression was measured using the Quick Inventory of Depressive Symptomatology-Clinician Rated (QIDS-C16) and the 17-item Hamilton Depression Rating Scale. RESULTS: The group of subjects with at least 1 follow-up visit had a remission (QIDS-C16 ≤ 5) rate of 45.8% as well as a response (50% reduction in QIDS-C16) rate of 64.8%, and 79.9% achieved an improvement of 5 points or higher in QIDS-C16 score. The Pharmacogenomic Research Network Antidepressant Medication Pharmacogenomic Study subjects were more likely to achieve a response than STAR*D study subjects. After adjustment for demographic factors, the response rates were not significantly different. When reporting the adverse effect burden, 60.5% of the subjects reported no impairment, 31.7% reported a minimal-to-mild impairment, and 7.8% reported a moderate-to-severe burden at the 4-week visit. CONCLUSIONS: Patients contemplating initiating an SSRI to treat their MDD can anticipate a high probability of symptom improvement (79.9%) with a low probability that their symptoms will become worse. Patients with lower baseline severity have a higher probability of achieving remission. The Pharmacogenomic Research Network Antidepressant Medication Pharmacogenomic Study replicates many findings of the first phase of the STAR*D study after controlling for the differences between the studies.

Integrated Behavioral Health Implementation and Training in Primary Care: A Practice-Based Research Network Study.

INTRODUCTION: Integrating behavioral health services into primary care has a strong evidence base, but how primary care training programs incorporate integrated behavioral health (IBH) into care delivery and training has not been well described. The goal of this study was to evaluate factors related to successful IBH implementation in family medicine (FM) residency programs and assess perspectives and attitudes on IBH among program leaders. METHODS: FM residency programs, all which are required to provide IBH training, were recruited from the American Academy of Family Physicians National Research Network. After completing eligibility screening that included the Integrated Practice Assessment Tool (IPAT) questionnaire, 14 training programs were included. Selected practices identified 3 staff in key roles to be interviewed: medical director or similar, behavioral health professional (BHP), and chief medical officer or similar. RESULTS: Forty-one individuals from 14 FM training programs were interviewed. IPAT scores ranged from 4 (Close Collaboration Onsite) to 6 (Full Collaboration). Screening, outcome tracking, and treatment differed among and within practices. Use of curricula and trainee experience also varied with little standardization. Most participants described similar approaches to communication and collaboration between primary care clinicians and BHPs and believed that IBH should be standard practice. Participants reported space, staff, and billing support as critical for sustainability. CONCLUSIONS: Delivery and training experiences in IBH varied widely despite recognition of the value and benefits to patients and care delivery processes. Standardizing resources and training and simplifying and assuring reimbursement for services may promote sustainable and high quality IBH implementation.

Emergency department risk model: timely identification of patients for outpatient care coordination.

OBJECTIVE: Major depressive disorder (MDD) is linked to a 61% increased risk of emergency department (ED) visits and frequent ED usage. Collaborative care management (CoCM) models target MDD treatment in primary care, but how best to prioritize patients for CoCM to prevent frequent ED utilization remains unclear. This study aimed to develop and validate a risk identification model to proactively detect patients with MDD in CoCM at high risk of frequent (≥ 3) ED visits. STUDY DESIGN: This retrospective cohort study utilized electronic health records from Mayo Clinic's primary care system to develop and validate a machine learning-based risk identification model. The model predicts the likelihood of frequent ED visits among patients with MDD within a 12-month period. METHODS: Data were collected from Mayo Clinic's primary care system between May 1, 2006, and December 19, 2018. Risk identification models were developed and validated using machine learning classifiers to estimate frequent ED visit risks over 12 months. The Shapley Additive Explanations model identified variables driving frequent ED visits. RESULTS: The patient population had a mean (SD) age of 39.78 (16.66) years, with 30.3% being male and 6.1% experiencing frequent ED visits. The best-performing algorithm (elastic-net logistic regression) achieved an area under the curve of 0.79 (95% CI, 0.74-0.84), a sensitivity of 0.71 (95% CI, 0.57-0.82), and a specificity of 0.76 (95% CI, 0.64-0.85) in the development data set. In the validation data set, the best-performing algorithm (random forest) achieved an area under the curve of 0.79, a sensitivity of 0.83, and a specificity of 0.61. Significant variables included male gender, prior frequent ED visits, high Patient Health Questionnaire-9 score, low education level, unemployment, and use of multiple medications. CONCLUSIONS: The risk identification model has potential for clinical application in triaging primary care patients with MDD in CoCM, aiming to reduce future ED utilization.

Integrated Behavioral Health Adaptations During the COVID-19 Pandemic.

INTRODUCTION: COVID-19 pandemic lockdowns threatened standard components of integrated behavioral health (IBH) such as in-person communication across care teams, screening, and assessment. Restrictions also exacerbated pre-existing challenges to behavioral health (BH) access. METHODS: Semistructured interviews were completed with clinicians from family medicine residency programs on the impact of the pandemic on IBH care delivery along with adaptations employed by care teams to ameliorate disruption. RESULTS: Participants (n = 41) from 14 family medicine residency programs described the rapid shift to virtual care, creating challenges for IBH delivery and increased demand for BH services. With patients and care team members at home, virtual warm handoffs and increased attention to communication were necessary. Screening and measurement were more difficult, and referrals to appropriate services were challenging due to higher demand. Tele-BH facilitated continued access to BH services but was associated with logistic challenges. Participants described adaptations to stay connected with patients and care teams and discussed the need to increase capacity for both in-person and virtual care. DISCUSSION: Most practices modified their workflows to use tele-BH as COVID-19 cases increased. Participants shared key learnings for successful implementation of tele-BH that could be applied in future health care crises. CONCLUSION: Practices adapted readily to challenges posed by pandemic restrictions and their ability to sustain key elements of IBH during the COVID-19 pandemic demonstrates innovation in maintaining access when in-person care is not possible, informing strategies applicable to other scenarios.

Primary care utilization and mental health diagnoses among adult patients requiring interpreters: a retrospective cohort study.

BACKGROUND: Patients requiring interpreters may utilize the health care system differently or more frequently than patients not requiring interpreters; those with mental health issues may be particularly difficult to diagnose. OBJECTIVE: To determine whether adult patients requiring interpreters exhibit different health care utilization patterns and rates of mental health diagnoses than their counterparts. DESIGN: Retrospective cohort study examining patient visits to primary care (PC), express care (EC), or the emergency department (ED) of a large group practice within 1 year. PATIENTS: Adult outpatients (n = 63,525) with at least one visit within the study interval and information regarding interpreter need. MAIN MEASURES: Mean visit counts, counts of mental disorders, and somatic symptom diagnoses between patients requiring interpreters (IS patients) and not requiring interpreters (non-IS patients). KEY RESULTS: IS patients (n = 1,566) had a higher mean number of visits overall (3.10 vs. 2.52), in PC (2.54 vs. 1.95), and in ED (0.53 vs. 0.44) than non-IS patients (all p < 0.01). IS patients had a lower mean number of visits in EC than non-IS patients (0.03 vs. 0.13; p < 0.01). Interpreter need remained a significant predictor of visit count in multivariate analyses including age, sex, insurance, and clinical complexity. A greater proportion of IS patients were high utilizers (10+ visits) than non-IS patients (3.6 % vs. 1.7 %; p < 0.01). IS patients had a lower frequency of mental health diagnoses (13.9 % vs. 16.7 %), but a higher frequency of diagnoses recognized as potential somatic symptoms including diseases of the nervous (29.3 % vs. 24.2 %), digestive (22.6 % vs. 14.5 %), and musculoskeletal systems (43.2 % vs. 34.5 %), and ill-defined conditions (61 % vs. 49.9 %), all p < 0.01. CONCLUSIONS: IS patients visited PC more often than their counterparts and were more often high utilizers of care. Two sources of high utilization, mental health diagnoses and somatic symptoms, differed appreciably between our populations and may be contributing factors.

Patient self-assessment factors predictive of persistent depressive symptoms 6 months after enrollment in collaborative care management.

BACKGROUND: Collaborative care management (CCM) is effective for improving depression outcomes. However, a subset of patients will still have symptoms after 6 months. This study sought to determine whether routinely obtained baseline clinical, demographic, and self-assessment variables would predict which patients endorse persistent depressive symptoms (PDS) after 6 months. By estimating the relative risk associated with the patient variables, we aimed to outline the combinations of factors predictive of PDS after CCM enrollment. METHODS: We retrospectively reviewed 1,110 adult primary care patients with the diagnosis of major depressive disorder enrolled in a CCM program and evaluated those with PDS (defined as patient health questionnaire-9score ≥10) 6 months after enrollment. RESULTS: At baseline, an increased depression severity, worsening symptoms of generalized anxiety, an abnormal screening on the mood disorder questionnaire (MDQ) and the diagnosis of recurrent episode of depression were independent predictors of PDS. A patient with severe, recurrent depression, an abnormal MDQ screen, and severe anxiety at baseline had a predicted 42.1% probability of PDS at 6 months. In contrast, a patient with a moderate, first episode of depression, normal MDQ screen, and no anxiety symptoms had a low probability of PDS at 6.6%. CONCLUSIONS: This study identified several patient self-assessment scores and clinical diagnosis that markedly predicted the probability of PDS 6 months after diagnosis and enrollment into CCM. Knowledge of these high-risk attributes should alert the clinician to monitor select patients more closely and consider altering therapy appropriately.

Antidepressant Medication Use Among Patients with Depression: Comparison between Usual Care and Collaborative Care Using Care Managers.

Depression poses a significant economic and health burden, yet it remains underdiagnosed and inadequately treated. The STAR*D trial funded by the National Institute of Mental Health showed that more than one antidepressant medication is often necessary to achieve disease remission among patients seen in both psychiatric and primary care settings. The collaborative care model (CCM), using care managers, has been shown to be effective in numerous studies in achieving sustained outcomes in depression management compared to usual care. This model was adopted in a statewide depression treatment improvement initiative among primary care clinics in Minnesota, which was launched in March 2008. In this study, records of patients who were enrolled in CCM from March 2008 until March 2009 were reviewed and compared to those under usual care. Patients who were followed under the CCM had a significantly greater number of antidepressant medication utilizations when compared to those under usual care. After 6 months, mean PHQ-9 score of patients under CCM was statistically lower than those in usual care. There was no significant difference in both mean PHQ-9 scores at 6 months and antidepressant utilization between the 2 groups among patients aged 65 years and older.

Engineering neuroglobin nitrite reductase activity based on myoglobin models.

Neuroglobin is a hemoprotein expressed in several nervous system cell lineages with yet unknown physiological functions. Neuroglobin presents a very similar structure to that of the related globins hemoglobin and myoglobin, but shows an hexacoordinate heme as compared to the pentacoordinated heme of myoglobin and hemoglobin. While several reactions of neuroglobin have been characterized in vitro, the relative importance of most of those reactions in vivo is yet undefined. Neuroglobin, like other heme proteins, can reduce nitrite to nitric oxide, providing a possible route to generate nitric oxide in vivo in low oxygen conditions. The reaction kinetics are highly dependent on the nature of the distal residue, and replacement of the distal histidine His64(E7) can increase the reaction rate constants by several orders of magnitude. However, mutation of other distal pocket positions such as Phe28(B10) or Val68(E11) has more limited impact on the rates. Computational analysis using myoglobin as template, guided by the structure of dedicated nitrite reductases like cytochrome cd1 nitrite reductase, has pointed out that combined mutations of the residues B10 and CD1 could increase the nitrite reductase activity of myoglobin, by mimicking the environment of the distal heme pocket in cytochrome cd1 nitrite reductase. As neuroglobin shows high sequence and structural homology with myoglobin, we hypothesized that such mutations (F28H and F42Y in neuroglobin) could also modify the nitrite reductase activity of neuroglobin. Here we study the effect of these mutations. Unfortunately, we do not observe in any case an increase in the nitrite reduction rates. Our results provide some further indications of nitrite reductase regulation in neuroglobin and highlight the minor but critical differences between the structure of penta- and hexacoordinate globins.