Healthcare delivery gaps in pain management within the first 3 months after discharge from inpatient noncardiac surgeries: a scoping review.

BACKGROUND: Poor pain control during the postoperative period has negative implications for recovery, and is a critical risk factor for development of persistent postsurgical pain. The aim of this scoping review is to identify gaps in healthcare delivery that patients undergoing inpatient noncardiac surgeries experience in pain management while recovering at home. METHODS: Searches were conducted by a medical librarian in PubMed, MEDLINE, EMBASE, EBSCO CINAHL, Web of Science, and Cochrane Database of Systematic Reviews for articles published between 2016 and 2022. Inclusion criteria were adults (≥18 yr), English language, inpatient noncardiac surgery, and included at least one gap in care for acute and/or persistent pain management after surgery within the first 3 months of recovery at home. Two reviewers independently screened articles for inclusion and extracted data. Quotations from each article related to gaps in care were synthesised using thematic analysis. RESULTS: There were 4794 results from databases and grey literature, of which 38 articles met inclusion criteria. From these, 23 gaps were extracted, encompassing all six domains of healthcare delivery (capacity, organisational structure, finances, patients, care processes and infrastructure, and culture). Identified gaps were synthesised into five overarching themes: education (22 studies), provision of continuity of care (21 studies), individualised management (10 studies), support for specific populations (11 studies), and research and knowledge translation (10 studies). CONCLUSIONS: This scoping review identified health delivery gaps during a critical period in postoperative pain management. These gaps represent potential targets for quality improvement and future research to improve perioperative care and longer-term patient-centred outcomes. SCOPING REVIEW PROTOCOL: Open Science Framework (https://osf.io/cq5m6/).

Characterizing the KRAS G12C mutation in metastatic colorectal cancer: a population-based cohort and assessment of expression differences in The Cancer Genome Atlas.

Introduction: In metastatic colorectal cancer (mCRC), RAS mutations impart inferior survival and resistance to anti-epidermal growth factor receptor (EGFR) antibodies. KRAS G12C inhibitors have been developed and we evaluated how KRAS G12C differs from other RAS mutations. Patients and Methods: This retrospective review evaluated patients in British Columbia, Canada with mCRC and RAS testing performed between 1 January 2016 and 31 December 2018. Sequencing information from The Cancer Genome Analysis (TCGA) was also obtained and analysed. Results: Age at diagnosis, sex, anatomic location and stage at diagnosis did not differ by RAS mutation type. Progression free survival on first chemotherapy for patients with metastatic KRAS G12C tumours was 11 months. Median overall survival did not differ by RAS mutation type but was worse for both KRAS G12C (27 months) and non-G12C alterations (29 months) than wildtype (43 months) (p = 0.01). Within the TCGA, there was no differential gene expression between KRAS G12C and other RAS mutations. However, eight genes with copy number differences between the G12C and non-G12C RAS mutant groups were identified after adjusting for multiple comparisons (FITM2, PDRG1, POFUT1, ERGIC3, EDEM2, PIGU, MANBAL and PXMP4). We also noted that other RAS mutant mCRCs had a higher tumour mutation burden than those with KRAS G12C mutations (median 3.05 vs 2.06 muts/Mb, p = 4.2e-3) and that KRAS G12C/other RAS had differing consensus molecular subtype distribution from wildtype colorectal cancer (CRC) (p < 0.0001) but not each other (p = 0.14). Conclusion: KRAS G12C tumours have similar clinical presentation to other RAS mutant tumours, however, are associated with differential copy number alterations.

Population-based assessment of sentinel lymph node biopsy in the management of cutaneous melanoma.

BACKGROUND: Sentinel lymph node biopsy (SLNB) for melanoma plays a central role in determining prognosis and guiding treatment and surveillance strategies. Despite widely published guidelines for SLNB, variation exists in its use. We aimed to determine the frequency of and predictive factors for SLNB in patients with clinically node-negative melanoma in British Columbia. METHODS: A retrospective review was performed of patients with clinically node-negative melanoma diagnosed between January 2015 and December 2017. Patients included had a Breslow depth greater than 0.75 mm or a Breslow depth less than or equal to 0.75 mm with ulceration, or a mitotic rate greater than or equal to 1/mm2. SLNB was considered to be indicated for clinical stages IB to IIC (American Joint Committee on Cancer's AJCC Cancer Staging Manual, seventh edition). RESULTS: A total of 759 patients were included. SLNB was performed in 54.8% (363/662) of patients when indicated. SLNB was more likely to be performed for tumours with a Breslow depth greater than 1.0 mm or a mitotic rate greater than or equal to 1/mm2. SLNB was less likely to be performed in patients older than 75 years and with a nonextremity tumour location. Compliance with SLNB guidelines decreased distant recurrence but did not significantly affect regional recurrence, nor did it have a significant impact on overall survival among patients aged 75 years and younger. CONCLUSION: SLNB is being underutilized in British Columbia. These results are concerning and highly relevant given the rapidly evolving field of adjuvant systemic therapy for high-risk patients and the increased proportion of patients who should be considered for SLNB on the basis of the eighth edition of the AJCC Cancer Staging Manual and current guidelines. Efforts should be made to increase the use of SLNB in appropriate patients.

The Post-Secondary Student Stressors Index: Proof of concept and implications for use.

Objective This study demonstrates the utility of the Post-Secondary Student Stressors Index (PSSI), an instrument designed to identify and evaluate the sources of student stress. The PSSI is comprised of 46 stressors, rated by severity and frequency, across five domains: academics, learning environment, campus culture, interpersonal, and personal. Participants: Pilot testing of the tool was conducted among n = 535 post-secondary students enrolled at an Ontario university. Methods: Mean severity and frequency ratings were calculated for each stressor on the instrument. Results were plotted, and stratified by sex. T-tests for differences in means across sexes were calculated for each stressor. Results: Female students in this sample consistently rated nearly all stressors on the instrument as more severe than their male counterparts. Females also reported higher frequency ratings on average, indicating that they worried about stressors more often than did males. Domain-specific stressors are discussed. Conclusions: The PSSI can provide post-secondary institutions with the ability to improve the targeting of their mental health promotion and mental illness prevention efforts.

Postsecondary Mental Health Policy in Canada: A Scoping Review of the Grey Literature: Politique de santé mentale post-secondaire au Canada: un examen de la portée de la littérature grise.

OBJECTIVE: Concerns surrounding the mental health and well-being of Canadian postsecondary students have increased in recent years, with data suggesting increases in the prevalence of self-reported stress and psychological distress. Strategies to address postsecondary mental health have emerged at the national, provincial, and institutional levels. While reviews of the academic literature on the subject have been conducted, a detailed review of the grey literature has not. The objective of this study was to map the current state of grey literature related to current or recommended action supporting postsecondary mental health and well-being in Canada, with a focus on policy documents and guiding frameworks. METHODS: We conducted a review following Arksey and O'Malley's 5-step framework for scoping reviews, as well as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Our search was restricted to documents with a primary focus on postsecondary mental health, a national or provincial scope, and publication date between 2000 and 2019. RESULTS: While a national policy or guiding framework applicable to all postsecondary institutions across Canada does not yet exist, recommendations for policy at both the national and provincial levels were well aligned, emphasizing the need for a comprehensive approach to addressing mental health services through the use of a whole-campus approach that encompasses both upstream and downstream services. CONCLUSION: Postsecondary sector stakeholders should consider how existing policy documents and guiding frameworks can be used to inform evidence-based, institutionally specific action on postsecondary mental health. More work is required to align the fragmented action occurring across Canada and incentivize postsecondary institutions to create a sustainable, effective strategy to address the increasingly complex and unique mental health needs of their students, staff, and faculty.

Taking a closer look at gender-transformative health promotion programming as a vehicle for addressing gender-based inequities in health and care.

Gender-transformative health promotion addresses the reciprocal transactions between the socio-cultural contexts that shape gender-based values and the gender-normative behaviors and health experiences of individuals. A scoping review was conducted to (a) highlight how, when and under what circumstances gender-transformative health promotion is applied in practice, and (b) critically assess the operationalization of gender-transformative health promotion principles in practice to develop a clearer understanding of potential barriers (both conceptual and practical) that may detract from the broader employment of gender-transformative health promotion as a mainstream programming approach. Specific recommendations, based on the findings of this review, are made in an effort to further the operationalization of gender-transformative health promotion as a mainstream health promotion approach, globally.

Psychometric assessment of the Post- Secondary Student Stressors Index (PSSI).

BACKGROUND: Previous research has linked excessive stress among post-secondary students to poor academic performance and poor mental health. Despite attempts to ameliorate mental health challenges at post-secondary institutions, there exists a gap in the evaluation of the specific sources of stress for students within the post-secondary setting. METHODS: The goal of this study was to develop a new instrument to better assess the sources of post-secondary student stress. Over the course of two years, the Post-Secondary Student Stressors Index (PSSI) was created in collaboration with post-secondary students as co-developers and subject matter experts. In this study, we used a combination of individual cognitive interviews (n = 11), an online consensus survey modeled after a traditional Delphi method (n = 65), and an online pre- (n = 535) and post-test (n = 350) survey to psychometrically evaluate the PSSI using samples of students from Ontario, Canada. We collected four types of evidence for validity, including: content evidence, response processes evidence, internal structure evidence, and relations to other variables. The test-retest reliability of the instrument was also evaluated. RESULTS: The PSSI demonstrated strong psychometric properties. Content validation and response processes evidence was derived from active student involvement throughout the development and refinement of the tool. Exploratory factor analysis suggested that the structure of the PSSI reflects the internal structure of an index, rather than a scale, as expected. Test-retest reliability of the instrument was comparable to existing, established instruments. Finally, the PSSI demonstrated good relationships with like measures of stress, distress, and resilience, in the hypothesized directions. CONCLUSIONS: The PSSI is a 46-item inventory that will allow post-secondary institutions to pinpoint the most severe and frequently occurring stressors on their campus. This knowledge will facilitate appropriate targeting of priority areas, and help institutions to better align their mental health promotion and mental illness prevention programming with the needs of their campus.

Opening minds in Canada: targeting change.

OBJECTIVE: To summarize the ongoing activities of the Opening Minds (OM) Anti-Stigma Initiative of the Mental Health Commission of Canada regarding the 4 groups targeted (youth, health care providers, media, and workplaces), highlight some of the key methodological challenges, and review lessons learned. METHOD: The approach used by OM is rooted in community development philosophy, with clearly defined target groups, contact-based education as the central organizing element across interventions, and a strong evaluative component so that best practices can be identified, replicated, and disseminated. Contact-based education occurs when people who have experienced a mental illness share their personal story of recovery and hope. RESULTS: Results have been generally positive. Contact-based education has the capacity to reduce prejudicial attitudes and improve social acceptance of people with a mental illness across various target groups and sectors. Variations in program outcomes have contributed to our understanding of active ingredients. CONCLUSIONS: Contact-based education has become a cornerstone of the OM approach to stigma reduction. A story of hope and recovery told by someone who has experienced a mental illness is powerful and engaging, and a critical ingredient in the fight against stigma. Building partnerships with existing community programs and promoting systematic evaluation using standardized approaches and instruments have contributed to our understanding of best practices in the field of anti-stigma programming. The next challenge will be to scale these up so that they may have a national impact.

Stigma in Canada: results from a rapid response survey.

OBJECTIVE: Our paper presents findings from the first population survey of stigma in Canada using a new measure of stigma. Empirical objectives are to provide a descriptive profile of Canadian's expectations that people will devalue and discriminate against someone with depression, and to explore the relation between experiences of being stigmatized in the year prior to the survey among people having been treated for a mental illness with a selected number of sociodemographic and mental health-related variables. METHOD: Data were collected by Statistics Canada using a rapid response format on a representative sample of Canadians (n = 10 389) during May and June of 2010. Public expectations of stigma and personal experiences of stigma in the subgroup receiving treatment for a mental illness were measured. RESULTS: Over one-half of the sample endorsed 1 or more of the devaluation discrimination items, indicating that they believed Canadians would stigmatize someone with depression. The item most frequently endorsed concerned employers not considering an application from someone who has had depression. Over one-third of people who had received treatment in the year prior to the survey reported discrimination in 1 or more life domains. Experiences of discrimination were strongly associated with perceptions that Canadians would devalue someone with depression, younger age (12 to 15 years), and self-reported poor general mental health. CONCLUSIONS: The Mental Health Experiences Module reflects an important partnership between 2 national organizations that will help Canada fulfill its monitoring obligations under the United Nations Convention on the Rights of Persons with Disabilities and provide a legacy to researchers and policy-makers who are interested in monitoring changes in stigma over time.

Opening minds in Canada: background and rationale.

OBJECTIVE: To summarize the background and rationale of the approach taken by the Mental Health Commission of Canada's Opening Minds (OM) Anti-Stigma Initiative. METHOD: The approach taken by OM incorporates a grassroots, community development philosophy, has clearly defined target groups, uses contact-based education as the central organizing element across interventions, and has a strong evaluative component, so that best practices can be identified, replicated, and disseminated. Contact-based education occurs when people who have experienced a mental illness share their personal story of recovery and hope. RESULTS: OM has acted as a catalyst to develop partnerships between community groups who are undertaking anti-stigma work and an interdisciplinary team of academic researchers in 5 universities who are evaluating the results of these programs. CONCLUSIONS: Building partnerships with existing community programs and promoting systematic evaluation using standardized approaches and instruments have contributed to our understanding of best practices in the field of anti-stigma programming.

From sin to science: fighting the stigmatization of mental illnesses.

Our paper provides an overview of current stigma discourse, the origins and nature of the stigma associated with mental illnesses, stigmatization by health providers, and approaches to stigma reduction. This is a narrative review focusing on seminal works from the social and psychological literature, with selected qualitative and quantitative studies and international policy documents to highlight key points. Stigma discourse has increasingly moved toward a human rights model that views stigma as a form of social oppression resulting from a complex sociopolitical process that exploits and entrenches the power imbalance between people who stigmatize and those who are stigmatized. People who have a mental illness have identified mental health and health providers as key contributors to the stigmatization process and worthy targets of antistigma interventions. Six approaches to stigma reduction are described: education, protest, contact-based education, legislative reform, advocacy, and stigma self-management. Stigma denigrates the value of people who have a mental illness and the social and professional support systems designed to support them. It creates inequities in funding and service delivery that undermine recovery and full social participation. Mental health professionals have often been identified as part of the problem, but they can redress this situation by becoming important partners in antistigma work.

United Nations convention on the rights of persons with disabilities: a roadmap for change.

PURPOSE OF REVIEW: This study considers the United Nations Convention on the Rights of Persons with Disabilities as a tool for promoting the full social inclusion of people with a mental or intellectual disability. RECENT FINDINGS: The United Nations Convention has ushered in a new era of discourse that moves beyond a consideration of individual impairments, to focus on the social and environmental barriers that prevent full and effective social participation of people with disabilities. It provides an important social justice framework to guide and integrate disability policy within and across countries. In order to realize its potential, the mental health community must now actively develop a new disability discourse - one that moves beyond the traditional focus on negative protections, such as against forced confinement or coercive treatment, to one that examines the services and supports that are needed to allow people who have a mental illness to become fully functioning members of society. To meet the monitoring requirements of the Convention, the mental health community must actively seek population data to assess the nature of prejudice and discrimination experienced by people with a mental illness. An approach used by Statistics Canada is provided as one such example. SUMMARY: The United Nations Convention is an important roadmap for change, which can be used to shift current mental health discourse from a discussion emphasizing the protection of negative rights, such as from involuntary detention or coerced treatment, to one emphasizing social rights and civic participation.

High school mental health survey: assessment of a mental health screen.

OBJECTIVE: To estimate the size of the population in need of psychiatric diagnostic assessment, based on the 12-month period prevalence of child and adolescent psychiatric disorders in one local high school, and to evaluate the validity of the Diagnostic Interview Schedule for Children Predictive Scales 8 (DPS-8) screen against the National Institute of Mental Health-Diagnostic Interview Schedule for Children-IV (NIMH-DISC-IV) for any diagnosis. METHOD: This 2-stage cross-sectional study included high school students aged 13 to 19 years. In the first stage, we administered the DPS-8 screen. In the second stage, we used the NIMH-DISC-IV. Prevalence and validity were estimated using the Bayesian formula owing to the unequal subsample fractions in the second stage. RESULTS: A total of 222 students participated in the first stage Screen. Of these, 153 completed the second stage NIMH-DISC-IV. In this sample, the prevalence for anxiety disorders was 17%, behaviour disorders was 11%, and depressive disorders was 1%. The overall prevalence of any one of these disorders was 29%. The sensitivity of the DPS-8 screen was 53.4%, specificity was 87.6%, the positive predictive value was 63.8%, and th negative predictive value was 82%. The overall accuracy of the screen was 77%. CONCLUSION: This study highlights some of the difficulties in conducting psychiatric research in a high school population. Despite the difficulties, the DPS-8 screen, if used judiciously by school counsellors, may be helpful in identifying students needing further comprehensive psychiatric assessment.

Employment equity and mental disability.

PURPOSE OF REVIEW: Recent research on the civil rights issue of employment equity for people with psychiatric disabilities is reviewed. RECENT FINDINGS: Mental disorders, particularly depression, are the most frequent source of occupational disability worldwide and are expected to grow. Employers are increasingly aware of the productivity costs associated with mental disorders and the importance of fostering a mentally healthy workforce. Few firms, however, have explicit policies to include disabled people in their workforce, and many employers continue to express prejudicial views toward people with mental disabilities which would exclude them from competitive work. At the same time, disability legislation has not offered the hoped-for protection for people with mental disorders. Employers have expressed concerns over the costs of making workplace accommodations and have successfully battled for a legal definition of disability that excludes many individuals with mental disorders. CONCLUSION: In the absence of antistigma efforts directed toward the business community, one wonders if the growing awareness of the productivity costs associated with mental disability will foster greater employment equity, or fuel more subtle forms of employment discrimination. Low employment levels among people with disabilities remain a major determinant of the social disparities they face.

Attitudes about schizophrenia from the pilot site of the WPA worldwide campaign against the stigma of schizophrenia.

BACKGROUND: A series of surveys were conducted to assess the attitudes of the public, and other groups, toward those with schizophrenia. The aim of these surveys was to aid in the planning and evaluation of the WPA anti-stigma initiative in Alberta, Canada. METHOD: A questionnaire was devised and administered via telephone to over 1,200 individuals in three Alberta cities, and in paper and pencil format to 40 members of the Schizophrenia Society of Alberta and 67 medical students. RESULTS: In contrast to some earlier findings, "loss of mind" was rated to be more disabling than any other handicapping condition. In general, respondents showed a relatively sophisticated understanding of schizophrenia and a higher level of acceptance than might have been predicted. Nonetheless, this acceptance was not as high for situations where closer personal contact was likely, and fears of dangerousness continue to be associated with schizophrenia. The majority of respondents, however, felt that treatment aided those with schizophrenia, expressed support for progressive programmes for the mentally ill, and stated that they would be willing to pay higher taxes so that programming could be improved. CONCLUSIONS: The results do not support the utility of a broad approach for an anti-stigma campaign, but rather suggest a more specific focus, such as perceived dangerousness.

Association between physical illness and suicide among the elderly.

BACKGROUND: Only a few small studies have explored the association between various physical illnesses and suicide in the elderly and they have produced inconsistent results. Thus, we undertook this larger study to more definitively assess the association between elderly suicide and physical illness. METHODS: This case-control study compared the proportion with physical illnesses among 822 cases who committed suicide with that among 944 controls who died due to motor vehicle accident at age 55 years or over in Alberta, Canada. RESULTS: Compared to the motor vehicle accident deaths, the elderly who committed suicide were more likely to have cancer, ischemic heart disease, chronic pulmonary disease, peptic ulcer, prostatic disorder, depression and other psychiatric illnesses. There was no significant difference in the proportion of cerebrovascular disease and diabetes mellitus between the case and control groups before adjustment of demographic and clinical characteristics. After adjustment of these variables, the elderly with any of the following illnesses were more likely to die by suicide than those without the illness: cancer (adjusted odds ratio [95% confidence interval]: 1.73 [1.16-2.58]), prostatic disorder (excluding prostatic cancer, 1.70 [1.16-2.49]), chronic pulmonary disease among the married (1.86 [1.22-2.83]), depression (6.70 [4.72-9.50]) or other psychiatric illness (2.16 [1.68-2.76]). There was no evidence that ischemic heart disease, cerebrovascular disease, peptic ulcer and diabetes mellitus might be associated with suicide in the elderly. CONCLUSIONS: Cancer, prostatic disorder, chronic pulmonary disease among the married and psychiatric illness appear to be associated with suicide among the elderly.

Acceso a los servicios de salud en el marco del TLC / Access to health services under NAFTA

El objetivo de esta publicación es analizar, desde la perspectiva legal, las posibilidades de acceso a la atención de salud de los individuos de alguno de los países signatarios del TLC que se encuentran temporalmente trabajando o residiendo en otro País Miembro. El libro incluye una comparación entre los sistemas de salud de Canadá, Estados Unidos y México, que se centra en sus principios y objetivos, régimen jurídico, estructura institucional, modalidades de funcionamiento y resultados. El estudio detalla las similitudes y diferencias entre los sistemas de estos tres países, con el propósito de anticipar los posibles efectos, positivos y negativos, que el Tratado pueda tener sobre el acceso a los servicios de salud, y las consiguientes expectativas e inquietudes que genera el libre comercio en torno a ellos.