Outcomes of an integrated care pathway for concurrent major depressive and alcohol use disorders: a multisite prospective cohort study.

BACKGROUND: In 2013, an Integrated Care Pathway (ICP) for concurrent Major Depressive (MDD) and Alcohol Use (AUD) Disorders was developed at the Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada. The ICP was further implemented at 8 other clinical sites across Ontario (the DA VINCI Project) in 2015-2017. The goal of this study was to systematically describe and analyze the main clinical outcomes of the project. METHODS: Data on a non-randomized cohort of patients receiving ICP-based treatment were collected prospectively at nine clinical sites in a variety of clinical settings. STATISTICAL METHODS: descriptive statistics, t-test, chi-square, ANOVA, generalized linear models. RESULTS: Two hundred forty-six patients were enrolled, 58.8% males, mean age was 45.6 years, 170 patients received treatment at academic health centres (AHC), 49 - at community hospitals (CH) and 27 - in family health teams (FHT). There were no major differences in anamnestic parameters and depression severity between the three settings, but there were differences in baseline drinking patterns between subgroups (F = 4.271, df = 2, p = 0.015). Overall completion rate was 70.7% with no significant variation between settings (χ2 = 3.35, df = 2, p = 0.19). Treatment duration in AHC was the longest, and completion rates were the highest. There was a statistically significant and clinically meaningful reduction in the number of drinking days per week (1.81, t = 8.78, p < 0.001). The cohort overall demonstrated significant and meaningful reduction in severity of cravings (Penn Alcohol Craving Scale: 4.42, t = 8.63, p < 0.001) and depressive symptoms (Quick Inventory of Depressive Symptomatology: 4.25, t = 11.26, p < 0.001). While some of the baseline patient characteristics and treatment parameters varied between the settings, the variation in clinical outcomes was mostly insignificant, though clinical improvement was more pronounced in academic setting and with individual therapy. CONCLUSIONS: The study demonstrated that ICP is a feasible and effective treatment for concurrent AUD and MDD that delivers meaningful clinical improvement in a variety of settings. A randomized controlled study is needed to properly compare the treatment outcomes between ICP model and treatment as usual and to further explore the role of various factors on treatment outcomes.

Integrated care pathway for co-occurring major depressive and alcohol use disorders: Outcomes of the first two years.

BACKGROUND: Major Depressive Disorder (MDD) and Alcohol Use Disorder (AUD) are highly prevalent, comorbid, and have significant impact on morbidity, mortality, and socioeconomic burden in Canada. Combined psycho- and pharmacotherapies for both conditions promise better outcomes than treatment as usual (TAU). At the Centre for Addiction and Mental Health, Toronto, Canada, we developed and implemented an Integrated Care Pathway (ICP) specifically for treatment of concurrent MDD and AUD. The goal of the study is to assess the clinical effectiveness of the ICP approach in comparison to TAU. MATERIALS AND METHODS: Non-randomized design, clinical chart review, Chi-square and t-tests, Cohen's d, Linear Mixed Effects Models, Kaplan-Meier, and log-rank analyses. RESULTS: Eighty-one ICP patients were included, matched to 81 controls by age, sex, severity of depressive symptoms, and patterns of drinking. ICP cohort had a significantly lower dropout rate (18.5% vs 69.1%, p < .001; at 16 weeks of treatment, respectively), both cohorts demonstrated significant reduction in the number of heavy drinking days (ß = .01, p < .001) and standard drinks per week (ß = .15, p < .001) with a significantly higher reduction of both indicators over time in the ICP cohort. Significant reduction in depressive symptoms severity (QIDS: 14.6 vs 10.0, p < .001; BDI: 26.3 vs 16.2, p < .001) was observed in ICP cohort (no data for TAU cohort). CONCLUSIONS: The ICP patients demonstrated improvements on several levels including depressive symptoms, and changes in alcohol drinking patterns. The study demonstrated the overall effectiveness of the ICP and apparent advantage over TAU, which must be corroborated through a randomized clinical trial. (Am J Addict 2017;26:602-609) SCIENTIFIC SIGNIFICANCE: This study is one of the first works showing the outcomes of an ICP developed in the mental health area and for co-occurring disorders. Despite the limitations, the relative advantage of the ICP methodology warrants future research in this area.

Integrated Care Pathways for Schizophrenia: A Scoping Review.

This paper summarizes the existing evidence for integrated care pathways (ICPs) for the treatment of schizophrenia. Scoping review methods following PRISMA guidelines were employed due to the variable nature of the evidence in this area. The review identified 13 papers. Of these papers, 7 focused on describing ICP content and process-related data and 6 examined clinical outcomes. Of the 6 studies providing outcome data, 2 reported improved outcomes associated with ICPs. Conceptually, ICPs hold great promise for improving the quality of schizophrenia care. However, in contrast with other specialty healthcare domains, the schizophrenia ICP evidence base is very limited and has not fulsomely begun to address ICPs for effectiveness.

The genomic landscape of oesophagogastric junctional adenocarcinoma.

The incidence of oesophagogastric junctional (OGJ) adenocarcinoma is rising rapidly in western countries, in contrast to the declining frequency of distal gastric carcinoma. Treatment options for adenocarcinomas involving the oesophagogastric junction are limited and the overall prognosis is extremely poor. To determine the genomic landscape of OGJ adenocarcinoma, exomes of eight tumours and matched germline DNA were subjected to massively parallel DNA sequencing. Microsatellite instability was observed in three tumours which coincided with an elevated number of somatic mutations. In total, 117 genes were identified that had predicted coding alterations in more than one tumour. Potentially actionable coding mutations were identified in 67 of these genes, including those in CR2, HGF , FGFR4, and ESRRB. Twenty-nine genes harbouring somatic coding mutations and copy number changes in the MSS OGJ dataset are also known to be altered with similar predicted functional consequence in other tumour types. Compared with the published mutational profile of gastric cancers, 49% (57/117) of recurrently mutated genes were unique to OGJ tumours. TP53, SYNE1, and ARID1A were amongst the most frequently mutated genes in a larger OGJ cohort. Our study provides an insight into the mutational landscape of OGJ adenocarcinomas and confirms that this is a highly mutated and heterogeneous disease. Furthermore, we have uncovered somatic mutations in therapeutically relevant genes which may represent candidate drug targets.

Topical Diltiazem Ointment For Post- Hemorrhoidectomy Pain.

BACKGROUND: Hemorrhoids are one of the most common anal pathology affecting millions of people around the world. Milligan-Morgan open hemorrhoidectomy is the most effective hemorrhoidectomy method used as gold standard procedure. Post-operative pain is recognized as a distressing complication of hemorrhoidectomy leading to increase hospital stay and psychological stress to both patient and surgeon. This study is designed to determine the efficacy of diltiazem gel in relieving pain after hemorrhoidectomy caused by anal muscle spasm. This will lead to decreased hospital stay and save both patient and surgeon from stress in postoperative period. OBJECTIVE: To compare mean post-operative pain in patients undergoing hemorrhoidectomy with vs. without topical application of diltiazem gel. METHODS: Total 80 patients who were diagnosed with third- and fourth-degree hemorrhoids and undergo hemorrhoidectomy were included in the study. Patients were randomly allocated to two groups using opaque sealed envelope method. Group A and B both have 40 patients in each group. Pain score was measured on visual analogue scale (VAS) by asking the patients to fill a questionnaire or by the help of the doctor. RESULTS: The patient's average age was 39.98±7.98 years. At 24 hours, mean pain score was significantly high in group B than group A [7.23±0.95 vs. 5.38±1.06; p=0.0005]. At 3rd post-operative day, mean pain score was significantly high in group B than group A [5±0.78 vs. 3.08±0.99; p=0.0005]. Seventy percent cases were observed in group B which required rescue analgesia. CONCLUSIONS: It is concluded that application of diltiazem ointment at perianal area with standard treatment considerably decreases pain after haemorrhoidectomy.

Development and Implementation of an Ambulatory Integrated Care Pathway for Major Depressive Disorder and Alcohol Dependence.

Integrated care pathways (ICPs) provide an approach for delivering evidence-based treatment in a hospital setting. This column describes the development and pilot implementation in a clinical setting of an ICP for patients with concurrent major depressive disorder and alcohol dependence at the Centre for Addiction and Mental Health (CAMH), an academic tertiary care hospital, in Toronto, Canada. The ICP methodology includes evidence reviews, knowledge translation, process reengineering, and change management. Pilot results indicate high patient satisfaction, evidence of symptom improvement, and excellent retention.