Increased Australian outpatient private practice psychiatric care during the COVID-19 pandemic: usage of new MBS-telehealth item and face-to-face psychiatrist office-based services in Quarter 3, 2020.

OBJECTIVE: The Australian federal government introduced new COVID-19 psychiatrist Medicare Benefits Schedule (MBS) telehealth items to assist with providing private specialist care. We investigate private psychiatrists' uptake of video and telephone telehealth, as well as total (telehealth and face-to-face) consultations for Quarter 3 (July-September), 2020. We compare these to the same quarter in 2019. METHOD: MBS-item service data were extracted for COVID-19-psychiatrist video and telephone telehealth item numbers and compared with Quarter 3 (July-September), 2019, of face-to-face consultations for the whole of Australia. RESULTS: The number of psychiatry consultations (telehealth and face-to-face) rose during the first wave of the pandemic in Quarter 3, 2020, by 14% compared to Quarter 3, 2019, with telehealth 43% of this total. Face-to-face consultations in Quarter 3, 2020 were only 64% of the comparative number of Quarter 3, 2019 consultations. Most telehealth involved short telephone consultations of ⩽15-30 min. Video consultations comprised 42% of total telehealth provision: these were for new patient assessments and longer consultations. These figures represent increased face-to-face consultation compared to Quarter 2, 2020, with substantial maintenance of telehealth consultations. CONCLUSIONS: Private psychiatrists continued using the new COVID-19 MBS telehealth items for Quarter 3, 2020 to increase the number of patient care contacts in the context of decreased face-to-face consultations compared to 2019, but increased face-to-face consultations compared to Quarter 2, 2020.

Automated Telephone Follow-up for Smoking Cessation in Smokers With Coronary Heart Disease: A Randomized Controlled Trial.

INTRODUCTION: Smokers with coronary heart disease (CHD) benefit from in-hospital cessation treatment, but relapse is common without ongoing support postdischarge. The purpose of this study was to determine if smoking abstinence would be higher after hospital discharge in smokers who received automated telephone follow-up (ATF) and nurse-counseling, compared with a standard care (SC) control group. METHODS: A total of 440 smokers hospitalized with CHD were randomly assigned to the ATF group (n = 216) or to the SC group (n = 224). Participants in the ATF group received automated phone calls 3, 14, 30, 60, 90, 120, 150, and 180 days after hospital discharge. The ATF system posed questions concerning smoking status, confidence in staying smoke-free, and need for assistance. If flagged by the ATF system, a nurse-counselor provided additional counseling by phone. Self-reported continuous smoking abstinence was assessed 26 and 52 weeks postdischarge using intention-to-treat analysis. The main outcome measure was continuous abstinence for weeks 1-26 postdischarge. RESULTS: Participants in the ATF group achieved higher abstinence rates for weeks 1-26 than those in the SC group (odds ratio [OR] = 1.53, 95% confidence interval [CI] = 1.01 to 2.33). There was no significant difference between groups in abstinence rates for weeks 27-52 (OR = 1.37; 95% CI = 0.89 to 2.09). CONCLUSIONS: ATF-mediated follow-up helped smokers with CHD achieve abstinence during the intervention period. There was a trend toward clinically important improvements for weeks 27-52; but between-group differences for this time point did not achieve statistical significance. CLINICAL TRIAL NUMBER: NCT00449852. IMPLICATIONS: Automated telephone follow-up exerts its effect by reinforcing participants' efforts to be smoke-free and by proactively linking people requiring assistance to individualized support (eg, telephone counseling). This study shows that automated telephone follow-up can assist smokers with CHD in remaining smoke-free; however, the success of automated telephone follow-up is limited to the treatment period and abstinence rates after the treatment period were not statistically different from among those receiving standard care. Extended treatment via automated telephone follow-up may provide a solution to extend cessation assistance beyond hospital discharge.

Potential of a nurse telephone triage line to direct elderly to appropriate health care settings.

AIM: To explore the potential of a nurse health triage telephone line to advise and guide elderly users' decisions regarding the appropriate health care setting and self-care. BACKGROUND: Ageing is a concern in many countries and poses challenges to health care services. Triage and advice lines can play an important role for the (re)organisation of health care delivery. Discussion has been focused on the capacity of these lines to reduce inappropriate demand for acute and emergency departments. METHODS: Cross-sectional descriptive analysis. RESULTS: Nurses directed elders to a health care service both by downgrading their initial intentions (concurring to the most common objective) and by upgrading them (e.g., directing elders that intended to stay at home to acute and emergency care). The intention to comply with the nurse's disposition was high. CONCLUSIONS: The line helped to improve the appropriateness of acute and emergency care demand and to reduce the overall demand for care by elders. There is nonetheless space for improvement given the underuse of the line by elders. IMPLICATIONS FOR NURSING MANAGEMENT: Health telephone-based triage and advice should be promoted to increase the match between the needs of elderly patients and health resources, thus improving health equity.

Is telephone health coaching a useful population health strategy for supporting older people with multimorbidity? An evaluation of reach, effectiveness and cost-effectiveness using a 'trial within a cohort'.

BACKGROUND: Innovative ways of delivering care are needed to improve outcomes for older people with multimorbidity. Health coaching involves 'a regular series of phone calls between patient and health professional to provide support and encouragement to promote healthy behaviours'. This intervention is promising, but evidence is insufficient to support a wider role in multimorbidity care. We evaluated health coaching in older people with multimorbidity. METHODS: We used the innovative 'Trials within Cohorts' design. A cohort was recruited, and a trial was conducted using a 'patient-centred' consent model. A randomly selected group within the cohort were offered the intervention and were analysed as the intervention group whether they accepted the offer or not. The intervention sought to improve the skills of patients with multimorbidity to deal with a range of long-term conditions, through health coaching, social prescribing and low-intensity support for low mood. RESULTS: We recruited 4377 older people, and 1306 met the eligibility criteria (two or more long-term conditions and moderate 'patient activation'). We selected 504 for health coaching, and 41% consented. More than 80% of consenters received the defined 'dose' of 4+ sessions. In an intention-to-treat analysis, those selected for health coaching did not improve on any outcome (patient activation, quality of life, depression or self-care) compared to usual care. We examined health care utilisation using hospital administrative and self-report data. Patients selected for health coaching demonstrated lower levels of emergency care use, but an increase in the use of planned services and higher overall costs, as well as a quality-adjusted life year (QALY) gain. The incremental cost per QALY was £8049, with a 70-79% probability of being cost-effective at conventional levels of willingness to pay. CONCLUSIONS: Health coaching did not lead to significant benefits on the primary measures of patient-reported outcome. This is likely related to relatively low levels of uptake amongst those selected for the intervention. Demonstrating effectiveness in this design is challenging, as it estimates the effect of being selected for treatment, regardless of whether treatment is adopted. We argue that the treatment effect estimated is appropriate for health coaching, a proactive model relevant to many patients in the community, not just those seeking care. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number ( ISRCTN12286422 ).

SymptomCare@Home: Developing an Integrated Symptom Monitoring and Management System for Outpatients Receiving Chemotherapy.

SymptomCare@Home, an integrated symptom monitoring and management system, was designed as part of randomized clinical trials to help patients with cancer who receive chemotherapy in ambulatory clinics and often experience significant symptoms at home. An iterative design process was informed by chronic disease management theory and features of assessment and clinical decision support systems used in other diseases. Key stakeholders participated in the design process: nurse scientists, clinical experts, bioinformatics experts, and computer programmers. Especially important was input from end users, patients, and nurse practitioners participating in a series of studies testing the system. The system includes both a patient and clinician interface and fully integrates two electronic subsystems: a telephone computer-linked interactive voice response system and a Web-based Decision Support-Symptom Management System. Key features include (1) daily symptom monitoring, (2) self-management coaching, (3) alerting, and (4) nurse practitioner follow-up. The nurse practitioner is distinctively positioned to provide assessment, education, support, and pharmacologic and nonpharmacologic interventions to intensify management of poorly controlled symptoms at home. SymptomCare@Home is a model for providing telehealth. The system facilitates using evidence-based guidelines as part of a comprehensive symptom management approach. The design process and system features can be applied to other diseases and conditions.

Exploration of an automated approach for receiving patient feedback after outpatient acute care visits.

BACKGROUND: To improve and learn from patient outcomes, particularly under new care models such as Accountable Care Organizations and Patient-Centered Medical Homes, requires establishing systems for follow-up and feedback. OBJECTIVE: To provide post-visit feedback to physicians on patient outcomes following acute care visits. DESIGN: A three-phase cross-sectional study [live follow-up call three weeks after acute care visits (baseline), one week post-visit live call, and one week post-visit interactive voice response system (IVRS) call] with three patient cohorts was conducted. A family medicine clinic and an HIV clinic participated in all three phases, and a cerebral palsy clinic participated in the first two phases. Patients answered questions about symptom improvement, medication problems, and interactions with the healthcare system. PATIENTS: A total of 616 patients were included: 142 from Phase 1, 352 from Phase 2 and 122 from Phase 3. MAIN MEASURES: Primary outcomes included: problem resolution, provider satisfaction with the system, and comparison of IVRS with live calls made by research staff. KEY RESULTS: During both live follow-up phases, at least 96% of patients who were reached completed the call compared to only 48% for the IVRS phase. At baseline, 98 of 113 (88%) patients reported improvement, as well as 167 of 196 (85%) in the live one-week follow-up. In the one-week IVRS phase, 25 of 39 (64%) reported improvement. In all phases, the majority of patients in both the improved and unimproved groups had not contacted their provider or another provider. While 63% of providers stated they wanted to receive patient feedback, they varied in the extent to which they used the feedback reports. CONCLUSIONS: Many patients who do not improve as expected do not take action to further address unresolved problems. Systematic follow-up/feedback mechanisms can potentially identify and connect such patients to needed care.

Alcohol, moods and male-female differences: daily interactive voice response over 6 months.

AIMS: The goal of this study was to better understand the predictive relationship in both directions between negative (anger, sadness) and positive (happiness) moods and alcohol consumption using daily process data among heavy drinkers. METHODS: Longitudinal daily reports of moods, alcohol use and other covariates such as level of stress were assessed over 180 days using interactive voice response telephone technology. Participants were heavy drinkers (majority meeting criteria for alcohol dependence at baseline) recruited through their primary care provider. The sample included 246 (166 men, 80 women) mostly Caucasian adults. Longitudinal statistical models were used to explore the varying associations between number of alcoholic drinks and mood scores the next day and vice versa with gender as a moderator. RESULTS: Increased alcohol use significantly predicted decreased happiness the next day (P < 0.005), more strongly for females than males. Increased anger predicted higher average alcohol use the next day for males only (P < 0.005). CONCLUSION: This daily process study challenges the notion that alcohol use enhances positive mood for both males and females. Our findings also suggest a strong association between anger and alcohol use that is specific to males. Thus, discussions about the effects of drinking on one's feeling of happiness may be beneficial for males and females as well as anger interventions may be especially beneficial for heavy-drinking males.

Exploring the usability of a videophone mock-up for persons with dementia and their significant others.

BACKGROUND: Persons with dementia might have considerable difficulties in using an ordinary telephone. Being able to use the telephone can be very important in order to maintain their social network, getting stimulation and for reaching help when needed. Therefore, persons with dementia might need an easy-to-use videophone to prevent social isolation and to feel safe and independent. This study reports the evaluation of the usability of a touch-screen videophone mock-up for persons with dementia and their significant others. METHODS: Four persons with dementia and their significant others tested the videophone mock-up at a living laboratory. In order to gain knowledge of the participants' with dementia ability to use their own computers and telephones, interviews and observations were conducted. RESULTS: Overall, the participants had a very positive attitude towards the videophone. The participants with dementia perceived that it was useful, enjoyable and easy to use, although they initially had difficulties in understanding how to handle some functions, thus indicating that the design needs to be further developed to be more intuitive. CONCLUSIONS: The findings suggest that the videophone has the potential to enable telephone calls without assistance and add quality in communication.

'The right direction'. Primary-care docs see promise in CMS' proposed pay for non face-to-face work.

The CMS has proposed paying physicians for managing patients apart from face-to-face office visits. Among the details under consideration are requiring practices to use an electronic health-record system that supports access to care, care coordination, care management and communications. "It's a step in the right direction. The devil will be in the details and, if the burden of documentation is so high, people may choose not to spend their time doing it," says Dr. Matt Handley, physician and medical director for quality at the Group Health Cooperative.

Practice Patterns and Patient Outcomes After Widespread Adoption of Remote Heart Failure Care.

BACKGROUND: An unprecedented shift to remote heart failure outpatient care occurred during the coronavirus disease 2019 (COVID-19) pandemic. Given challenges inherent to remote care, we studied whether remote visits (video or telephone) were associated with different patient usage, clinician practice patterns, and outcomes. METHODS: We included all ambulatory cardiology visits for heart failure at a multisite health system from April 1, 2019, to December 31, 2019 (pre-COVID) or April 1, 2020, to December 31, 2020 (COVID era), resulting in 10 591 pre-COVID in-person, 7775 COVID-era in-person, 1009 COVID-era video, and 2322 COVID-era telephone visits. We used multivariable logistic and Cox proportional hazards regressions with propensity weighting and patient clustering to study ordering practices and outcomes. RESULTS: Compared with in-person visits, video visits were used more often by younger (mean 64.7 years [SD 14.5] versus 74.2 [14.1]), male (68.3% versus 61.4%), and privately insured (45.9% versus 28.9%) individuals (P<0.05 for all). Remote visits were more frequently used by non-White patients (35.8% video, 37.0% telephone versus 33.2% in-person). During remote visits, clinicians were less likely to order diagnostic testing (odds ratio, 0.20 [0.18-0.22] video versus in-person, 0.18 [0.17-0.19] telephone versus in-person) or prescribe ß-blockers (0.82 [0.68-0.99], 0.35 [0.26-0.47]), mineralocorticoid receptor antagonists (0.69 [0.50-0.96], 0.48 [0.35-0.66]), or loop diuretics (0.67 [0.53-0.85], 0.45 [0.37-0.55]). During telephone visits, clinicians were less likely to prescribe ACE (angiotensin-converting enzyme) inhibitor/ARB (angiotensin receptor blockers)/ARNIs (angiotensin receptor-neprilysin inhibitors; 0.54 [0.40-0.72]). Telephone visits but not video visits were associated with higher rates of 90-day mortality (1.82 [1.14-2.90]) and nonsignificant trends towards higher rates of 90-day heart failure emergency department visits (1.34 [0.97-1.86]) and hospitalizations (1.36 [0.98-1.89]). CONCLUSIONS: Remote visits for heart failure care were associated with reduced diagnostic testing and guideline-directed medical therapy prescription. Telephone but not video visits were associated with increased 90-day mortality.

Brief telephone intervention increases testing for osteoporosis in patients treated in emergency departments for wrist fractures.

Previous studies show that identification and treatment of osteoporosis in patients with minimal trauma fractures treated as outpatients are poor. Our aim was to test two interventions designed to increase rates of identification and treatment. This prospective, action research study, using explicit medical record review and scripted telephone interview, was conducted at emergency departments (ED) of three hospitals from April 2007 to February 2008. Participants were patients aged over 50 years who were treated as outpatients with a minimal trauma wrist fracture. Data collected included demographic and fracture details, bone density testing and osteoporosis-related medication change. There were two interventions staff education in ED and fracture clinic and information provided to patients by telephone by a research nurse. These interventions were applied to all patients sequentially. The outcome measure of interest was the proportion of patients who underwent bone density testing (DEXA scans) in the follow-up period, analysed by intervention (clinic or phone). One hundred and seventeen patients were studied. Eighty-six per cent were female; median age 64 years. Ten per cent (12/117) of the ED/clinic intervention group had undergone testing at follow up. At follow up after the telephone intervention 55% (65/117) had undergone testing (P < 0.001, chi(2)). Patients undergoing testing were significantly more likely to have an osteoporosis-related medication change (relative risk 6.8, 95% CI 2.8-17.9). A brief telephone intervention and provision of information pack significantly improved testing rates for osteoporosis after minimal trauma wrist fracture. An ED/clinic-based intervention resulted in low rates of testing. Treatment of clinical osteoporosis remains suboptimal.

The Behavioral Risk Factors Surveillance System: past, present, and future.

The Behavioral Risk Factor Surveillance System (BRFSS) is a large state-based telephone survey. BRFSS is designed to monitor the leading risk factors for morbidity and mortality in the United States at the local, state, and national levels. The BRFSS has proven to be a powerful tool for building heath-promotion activities. However, the use of telephone-based, random-digit-dial (RDD) methods in public health surveys and surveillance is at a crossroads. Rapid changes in telecommunication, declines in participation rates, increases in the required level of effort and associated costs are becoming key challenges for BRFSS. To maintain the highest data quality and service to the local and state health departments, BRFSS has adopted an ongoing effort to improve coverage and response to the survey. This article provides an overview of the issues faced by BRFSS and the strategies in place to address them.

Confidentiality and the telephone in family practice: a qualitative study of the views of patients, clinicians and administrative staff.

BACKGROUND: Confidentiality is considered a cornerstone of the medical consultation. However, the telephone, previously used mainly to negotiate appointments, has become increasingly employed as a means of consultation and may pose new problems in respect to maintaining confidentiality. OBJECTIVE: As part of a qualitative investigation into the views of patients, doctors, nurses and administrative staff on the use of telephone consulting in general practice, we set out to explore the impact of the use of this medium on perceptions of confidentiality. METHOD: We used focus groups of purposively selected patients, clinicians and administrative staff in urban and rural areas. RESULTS: Fifteen focus groups comprising 91 individuals were convened. Participants concerns centred on overheard conversations, the receptionist role in triage, difficulty of maintaining confidentiality in small close-knit communities, errors in identification, third party conversations and answering machines. Telephone consulting, depending on the circumstances, could pose a risk or offer a solution to maintaining confidentiality. CONCLUSIONS: Many of the concerns that patients and health care staff have around confidentiality breaches both on the telephone and face to face are amenable to careful management. Although rare, identification error or fraud can be a potentially serious problem and further thought needs to be given to the problem of misidentification on the telephone and the use of passwords considered.

Association between social asymmetry and depression in older adults: A phone Call Detail Records analysis.

Analyzing social interactions on a passive and non-invasive way through the use of phone call detail records (CDRs) is now recognized as a promising approach in health monitoring. However, deeper investigations are required to confirm its relevance in social interaction modeling. Particularly, no clear consensus exists in the use of the direction parameter characterizing the directed nature of interactions in CDRs. In the present work, we specifically investigate, in a 26-older-adults population over 12 months, whether and how this parameter could be used in CDRs analysis. We then evaluate its added-value for depression assessment regarding the Geriatric Depression Scale score assessed within our population during the study. The results show the existence of three clusters of phone call activity named (1) proactive, (2) interactive, and (3) reactive. Then, we introduce the notion of asymmetry that synthesizes these activities. We find significant correlations between asymmetry and the depressive state assessed in the older individual. Particularly, (1) reactive users are more depressed than the others, and (2) not depressed older adults tend to be proactive. Taken together, the present findings suggest the phone's potential to be used as a social sensor containing relevant health-related insights when the direction parameter is considered.

Adverse symptoms users attribute to e-cigarettes: Results from a national survey of US adults.

BACKGROUND: Little is known about the prevalence of adverse symptoms electronic cigarette (e-cigarette) users report experiencing. METHODS: Between August 2016 and May 2017, we conducted a nationally representative cross-sectional telephone survey of 4964 US adults age 18 and over. Respondents who reported ever trying e-cigarettes were asked whether they ever experienced six symptoms they thought were caused by e-cigarette use. In weighted analyses, we assessed whether symptoms varied by demographics, e-cigarette use frequency, and cigarette smoking status. RESULTS: Approximately one-fourth of respondents (n = 1,624, 26.8%) reported ever trying e-cigarettes. Most were current (40.3%) or former (30.7%) cigarette smokers, with 29.0% never smokers. Just over half (58.2%) reported at least one symptom and on average 1.6 (SE = 0.1) symptoms. Symptoms included cough (40.0%), dry or irritated mouth or throat (31.0%), dizziness or lightheadedness (27.1%), headache or migraine (21.9%), shortness of breath (18.1%), change in or loss of taste (12.9%), or other (6.2%; most commonly nausea, tight chest, congestion). Among past 30-day e-cigarette users, current and never cigarette smokers were more likely than former smokers to report any symptoms (AOR = 5.25, CI = 2.05-13.46 and AOR = 2.58, CI = 0.85-7.81, respectively). CONCLUSIONS: A majority of e-cigarette users reported at least one symptom, most commonly cough or dry or irritated mouth or throat. Former cigarette smokers who used e-cigarettes in the past 30 days were less likely than current or never smokers to report adverse symptoms of e-cigarette use. Future research should examine frequency of symptoms among different user groups to understand how e-cigarettes may influence public health.

Efficacy of a telephone-based intervention among patients with type-2 diabetes; a randomized controlled trial in pharmacy practice.

Background Pharmacists' interventions to improve outcomes of diabetes management have been promising. However, evidence on using telephone-based interventions in pharmacy practice are limited, particularly in developing countries. Objective To evaluate the efficacy of a telephone-based intervention to improve care and clinical outcomes in type-2 diabetes. Setting A referral community pharmacy and drug information center. Method We conducted a two-armed randomized controlled trial on 100 patients with type-2 diabetes. The intervention consisted of 16 telephone calls in 3 month by a trained pharmacist working in an academic drug information center, while the control group received usual care. Before random allocation, patients attended a live education session delivered by pharmacists to learn the basics of diabetes care and to confirm the eligibility criteria. Assessments were performed at baseline, month-3 (after intervention), and month-9 (follow-up). Main outcome measure Hemoglobin A1c (HbA1c). Results Eighty four patient completed the trial. Baseline variables were comparable between the two groups and the baseline value of hemoglobin A1c was 8.00 ± 1.44 in the study population. HbA1c was significantly improved in both groups at month-3 (6.97 ± 1.41 vs. 7.09 ± 1.78) and remained steady at month-9 (6.96 ± 1.44 vs. 7.26 ± 1.85). Lipid profile showed small improvements in the intervention group but was not significant. The adherence score and self-care score improvement was significantly higher in the intervention group at month-3 and were maintained at month-9. Conclusion Medication adherence and self-care significantly improved in the telephone-based intervention group. However, the improvement of clinical outcomes might have been diluted due to the live diabetes education session.

Ayahuasca Exposure: Descriptive Analysis of Calls to US Poison Control Centers from 2005 to 2015.

BACKGROUND: Ayahuasca is a hallucinogenic plant preparation which usually contains the vine Banisteriopsis caapi and the shrub Psychotria viridis. This tea originates from the Amazon Basin where it is used in religious ceremonies. Because interest in these religious groups spreading as well as awareness of use of ayahuasca for therapeutic and recreational purposes, its use is increasing. Banisteriopsis caapi is rich in ß-carbolines, especially harmine, tetrahydroharmine and harmaline, which have monoamine oxidase inhibiting (MAOI) activity. Psychotria viridis contains the 5HT2A/2C/1A receptor agonist hallucinogen N,N-dimethyltryptamine (DMT). Usual desired effects include hallucination, dissociation, mood alteration and perception change. Undesired findings previously reported are nausea, vomiting, hypertension, and tachycardia. METHODS: All human exposure calls reported to the American Association of Poison Controls Centers' (AAPCC) National Poison Data System (NPDS) between September 1, 2005 and September 1, 2015 were reviewed. Cases were filtered for specific plant derived ayahuasca-related product codes. Abstracted data included the following: case age and gender, exposure reason, exposure route, clinical manifestations, treatments given, medical outcomes and fatality. RESULTS: Five hundred and thirty-eight exposures to ayahuasca botanical products were reported. The majority of the calls to poison control centers came from healthcare facilities (83%). The most common route of exposure was ingestion. Most cases were men (437, 81%, 95% CI 77.7% - 84.3%). The median age was 21 (IQR 18-29). Most exposures were acute. Three hundred thirty-seven (63%) were reported to have a major or moderate clinical effect. The most common clinical manifestations reported were hallucinations (35%), tachycardia (34%), agitation (34%), hypertension (16%), mydriasis (13%) and vomiting (6%). Benzodiazepines were commonly given (30%). There were 28 cases in the series who required endotracheal intubation (5%). Four cases were reported to have had a cardiac arrest and 7 a respiratory arrest. Twelve cases had a seizure. Reports of exposures called to poison centers appeared to increase during this period based on annual estimates. Three fatalities were reported. CONCLUSIONS: Ayahuasca use appears to be rising in the United States based on calls to poison control centers. While most use is reported to be safe and well tolerated, with possible beneficial effects, serious and life threatening adverse manifestations are possible. Most of the exposures reported to poison control centers were young people, more likely to be men and already in a healthcare facility. Further research, which includes comprehensive drug testing, will be needed to better identify the risks and effects of ayahuasca use.