Psychiatry's Expanded Integration into Primary Care.

Integrated behavioral care, and in particular, the collaborative care model, has been working to improve access and treatment for people with mental health disorders. Integrated care allows for adaptable, scalable, and sustainable practice that addresses the mental health needs of the public. During the pandemic several challenges emerged to delivering integrated care. This disruption happened at a systems level, team-based care level, scope of care level, and patient access level. This article looks through the lens of those various levels to identify and some of the lessons learned to help build a more resilient and flexible integrated care program.

Development and Implementation of an Integrated Care Fellowship.

BACKGROUND: Integrated care is a common approach to leverage scarce psychiatric resources to deliver mental health care in primary care settings. OBJECTIVE: Describe a formal clinical fellowship devoted to professional development for the integrated care psychiatrist role. METHODS: The development of a formal year-long clinical fellowship in integrated care is described. The curriculum consists of an Integrated Care Didactic Series, Integrated Care Clinical Skill Experiences, and Integrated Care System-Based Leadership Experiences. Evaluation of impact was assessed with descriptive statistics. RESULTS: We successfully recruited 3 classes of fellows to the Integrated Care Fellowship, with 5 program graduates in the first 3 years. All 5 graduated fellows were hired into integrated care and/or telepsychiatry positions. Integrated Care fellows had a high participation rate in didactics (mean attendance = 80.6%; n = 5). We received a total of 582 didactic evaluations for the 151 didactic sessions. On a scale of 1 (poor) to 6 (fantastic), the mean quality of the interactive learning experience was rated as 5.33 (n = 581) and the mean quality of the talk was 5.35 (n = 582). Rotations were rated with the mean overall teaching quality of 4.98/5 (n = 76 evaluations from 5 fellows). CONCLUSIONS: The Integrated Care clinical fellowship serves as a model for training programs seeking to provide training in clinical and systems-based skills needed for practicing integrated care. Whether such training is undertaken as a standalone fellowship or incorporated into existing consultation-liaison psychiatry programs, such skills are increasingly valuable as integrated care becomes commonplace in practice.

Prebiotic Dietary Fiber and Gut Health: Comparing the in Vitro Fermentations of Beta-Glucan, Inulin and Xylooligosaccharide.

Prebiotic dietary fiber supplements are commonly consumed to help meet fiber recommendations and improve gastrointestinal health by stimulating beneficial bacteria and the production of short-chain fatty acids (SCFAs), molecules beneficial to host health. The objective of this research project was to compare potential prebiotic effects and fermentability of five commonly consumed fibers using an in vitro fermentation system measuring changes in fecal microbiota, total gas production and formation of common SCFAs. Fecal donations were collected from three healthy volunteers. Materials analyzed included: pure beta-glucan, Oatwell (commercially available oat-bran containing 22% oat ß-glucan), xylooligosaccharides (XOS), WholeFiber (dried chicory root containing inulin, pectin, and hemi/celluloses), and pure inulin. Oatwell had the highest production of propionate at 12 h (4.76 µmol/mL) compared to inulin, WholeFiber and XOS samples (p < 0.03). Oatwell's effect was similar to those of the pure beta-glucan samples, both samples promoted the highest mean propionate production at 24 h. XOS resulted in a significant increase in the genus Bifidobacterium after 24 h of fermentation (0 h:0.67 OTUs (operational taxonomic unit); 24 h:5.22 OTUs; p = 0.038). Inulin and WholeFiber increased the beneficial genus Collinsella, consistent with findings in clinical studies. All analyzed compounds were fermentable and promoted the formation of beneficial SCFAs.

Gastrointestinal tolerance of low FODMAP oral nutrition supplements in healthy human subjects: a randomized controlled trial.

BACKGROUND: There has been increasing interest in utilizing a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) for the treatment of irritable bowel syndrome (IBS), a functional gastrointestinal disease. While studies have indicated that this diet can be effective at symptom reduction, it is a restrictive diet and patients may find it challenging to find low FODMAP products to meet their nutrient needs. The primary objective of this study was to assess the gastrointestinal (GI) tolerance of three low FODMAP oral nutrition supplements (ONS) in healthy adults. METHODS: A double-blind randomized controlled crossover study was conducted in 21 healthy adults (19-32 years). Fasted subjects consumed one of four treatments at each visit, with a one week wash out period between visits. Each participant received all treatments. Treatments included three low FODMAP ONS formulas (A, B, and C) as well as a positive control consisting of 5 g fructooligosaccharides (FOS) mixed in lactose-free milk. Breath hydrogen was measured at baseline, 1, 2, 3, and 4 h post treatment consumption. Subjective GI symptom questionnaires were completed at baseline, 0.5, 1, 1.5, 2, 3, 4, 12, 24 and 48 h following treatment consumption. Mean breath hydrogen concentrations and baseline corrected area under the curve for both breath hydrogen and GI symptoms were analyzed and compared between treatments. Significance was determined at P < 0.05. RESULTS: The positive control resulted in higher breath hydrogen response compared to all three of the low FODMAP ONS beverages at 3 and 4 h after consumption. There were no differences in GI symptom response between treatments. CONCLUSIONS: All treatments were well tolerated in healthy participants. The low FODMAP formulas resulted in a lower breath hydrogen response compared to the positive control, and may be better tolerated in individuals with IBS. More research should be conducted to better understand the GI tolerance of low FODMAP ONS in individuals with IBS. TRIAL REGISTRATION: The protocol for this study was registered on ClinicalTrials.gov in January 2016 (Clinical Trials ID: NCT02667184 ).

Compliance with melanoma treatment guidelines in a community teaching hospital: time trends and other variables.

BACKGROUND: Variation in the surgical treatment of melanoma occurs despite efforts to standardize care. This may lead to morbidity, inaccurate staging, and poor outcomes, or it may be cost ineffective. The purpose of our study was to evaluate our institutional compliance with National Comprehensive Cancer Network (NCCN) melanoma treatment guidelines. METHODS: We studied 252 clinically node-negative melanoma patients identified from our cancer registry. Treatment data were confirmed by individual review of pathology and operative reports. RESULTS: Documented margins of excision conformed to NCCN guidelines in 87% of Tis-T1 tumors and 60% of T2-T4 tumors. Lymph node staging was performed in 11% of T1a, 64% of T1b, 74% of T2, 63% of T3, and 47% of T4 patients. Treatment by a surgical oncologist achieved margin and lymph node compliance in 95% and 92% of cases versus other practitioners in 38% and 67%, respectively (P < .0001). Documented compliance with margin guidelines improved from 46% to 73% for the years 1995 to 1999 versus 2000 to 2004 (P < .0001) and for lymph node staging and treatment from 74% to 84% (P = .04). Other factors associated with greater adherence to NCCN guidelines were patient age <80 years, upper extremity tumors, and thinner tumors (all P < .05). CONCLUSIONS: Our data suggest that our compliance with NCCN melanoma treatment guidelines was suboptimal. Treatment directed by a surgical oncologist showed the highest rate of adherence to national standards. Further investigation is needed to determine the effect of this on patient outcomes and how best to provide high-quality care to the greatest number of melanoma patients.