Linking Primary Care to Community-Based Mental Health Resources via Family Navigation and Phone-Based Care Coordination.

Family navigation (FN) and phone-based care coordination may improve linkages from primary care to community-based mental health referrals, but research on their differential impact is limited. This mixed-methods study compared FN and phone-based care coordination in connecting families to mental health services from primary care. Families of children (56.3% male, mean age = 10.4 years, 85.4% Black) were sequentially assigned to either receive FN through a family-run organization or phone-based coordination via the child psychiatry access program (CPAP). Caregiver-reported children's mental health improved in both groups and both groups were satisfied with services. More families in the CPAP group had appointments made or completed (87%) than families in the FN group (71%) though the difference was not statistically significant. Future research with a larger sample that matches family needs and preferences (e.g., level and type of support) with navigation services would be beneficial.

A Multisystem Approach to Improving Autism Care.

Children with autism face significant barriers to accessing evaluations and intervention services often because of confusing referral processes, lack of centralized coordination across organizations serving children with autism, insurance coverage gaps, multiyear waitlists for diagnostic services, and limited provider knowledge about autism. Racism and systemic inequities exist and persist in autism care across the United States. This article reviews targeted initiatives implemented by a multidisciplinary team to advocate for, and address barriers faced, by autistic children and their families in Washington, DC. We describe initiatives across multiple levels of the health care system including: 1. infrastructure-building initiatives (eg, coalition-building, policy, and advocacy); 2. enabling services (eg, population- and community-level supports that increase provider capacity to serve children's and families' needs); and 3. direct services (eg, innovative, gap-filling programs that directly serve children and families). We review outcomes and describe lessons learned.

Isradipine therapy in Cacna1dIle772Met/+ mice ameliorates primary aldosteronism and neurologic abnormalities.

Somatic gain-of-function mutations in the L-type calcium channel CaV1.3 (CACNA1D gene) cause adrenal aldosterone-producing adenomas and micronodules. De novo germline mutations are found in a syndrome of primary aldosteronism, seizures, and neurologic abnormalities (PASNA) as well as in autism spectrum disorder. Using CRISPR/Cas9, we here generated mice with a Cacna1d gain-of-function mutation found in both adenomas and PASNA syndrome (Cacna1dIle772Met/+). These mice show reduced body weight and increased mortality from weaning to approximately 100 days of age. Male mice do not breed, likely due to neuromotor impairment, and the offspring of female mice die perinatally, likely due to lack of maternal care. Mice generated by in vitro fertilization showed elevated intracellular calcium in the aldosterone-producing zona glomerulosa, an elevated aldosterone/renin ratio, and persistently elevated serum aldosterone on a high-salt diet as signs of primary aldosteronism. Anesthesia with ketamine and xylazine induced tonic-clonic seizures. Neurologic abnormalities included hyperlocomotion, impaired performance in the rotarod test, impaired nest building, and slight changes in social behavior. Intracellular calcium in the zona glomerulosa, aldosterone levels, and rotarod performance responded to treatment with the calcium channel blocker isradipine, with implications for the therapy of patients with aldosterone-producing lesions and with PASNA syndrome.

DC Mental Health Access in Pediatrics: Evaluating a Child Psychiatry Access Program in Washington, DC.

INTRODUCTION: Child psychiatry access programs (CPAPs) provide primary care providers (PCPs) with assistance in mental health diagnosis, management, and resource navigation. METHOD: Data collected from DC Mental Health Access in Pediatrics (MAP) included PCPs and patient demographics, clinical encounter information, and provider satisfaction. RESULTS: DC MAP consult volume increased 349.3% over the first 5 years. Services requested included care coordination (85.8%), psychiatric consultation (21.4%), and psychology/social work consultation (9.9%). Of psychiatry-involved consultations, PCPs managed patient medication care with DC MAP support 50.5% of the time. Most (94.1%) PCPs said they would recommend colleagues use DC MAP, and 29.6% reported diverting patients from the emergency departments using DC MAP. DISCUSSION: DC MAP grew quickly, highlighting program impact and need. Demand for care coordination required flexible staffing and highlighted the need for coordination in pediatrics. Child psychiatry access programs offer an innovative way to enhance PCP management of their patients' mental health needs.

Mental Health Screening in Pediatric Primary Care: Factors Associated With Screening Completion and Elevated Scores.

This study aimed to examine predictors of complete and elevated youth mental health screens. Parents of 4- to 11-year-old children completed the Strengths and Difficulties Questionnaire (SDQ) during a routine, universal mental health screening initiative in primary care. Bivariate logistic regressions were run to examine associations between independent (visit age, sex, race/ethnicity, language, insurance, and guardian) and dependent variables (screening completion and elevated SDQ score). Parents of younger and Spanish-speaking (vs English-speaking) children were less likely to have a complete SDQ screen. Among those with complete SDQ screens, older children, male children, those with public or no insurance, and those who had a mother (vs father) complete the screener were more likely to have an elevated score. Understanding patterns of screening completion rates and predictors of elevated screens provides valuable information to improve resource mapping and planning. Findings can inform mental health screening implementation and optimization within primary care.

Factors Associated With Psychiatric Readmission of Youths in a Racially Diverse and Urban Hospital Setting.

OBJECTIVE: This study examined predictors of readmission to a psychiatric inpatient unit of an urban children's hospital within 1 year of discharge among a racially diverse sample of youths. METHODS: The authors retrospectively analyzed 2 years of electronic health record data of inpatient psychiatric unit admissions (N=1,604). Multivariate logistic regression and random-effects multinomial logistic regression were used for analyses. RESULTS: The estimated odds ratios for any readmission within 1 year of discharge were significantly higher for Black youths, youths insured by Medicaid, and youths with a length of stay longer than 7 days. Factors remained strongly predictive when examining multiple readmissions versus no readmissions. CONCLUSIONS: Black youths, youths insured by Medicaid, and youths with longer stays were more likely than other youths to be readmitted. Findings suggest the need for interventions such as care coordination to target predictors of readmission and the need to examine inequities in the health care system.

Perinatal Mental Health Task Force: Integrating Care Across a Pediatric Hospital Setting.

Perinatal mood and anxiety disorders (PMADs) are the most common complication of childbirth, with suicide a leading cause of postpartum deaths. PMADs are associated with poor maternal, infant, and family outcomes. Identification and early intervention are imperative for successful treatment. This case study describes the implementation and outcomes of a multidisciplinary Perinatal Mental Health Task Force ("Task Force") at one urban academic children's hospital that was created to promote systems change and health care policy solutions for improved identification and treatment of PMADs. Using the social ecological model as a framework, the Task Force addressed care at the individual, interpersonal, organizational, community, and policy levels. The Task Force applied lessons learned from division-specific screening initiatives to create best practices and make hospital-wide recommendations. This foundational work enabled us to build community bridges and break down internal barriers to shift our pediatric hospital toward prioritizing perinatal mental health. As a result, screening expanded to multiple hospital locations and became a hospital corporate goal, the Perinatal Mental Health Screening Tool Kit was created and disseminated within the community, Task Force members testified in governmental hearings and joined national organizations to inform policy, and Task Force and community collaborations resulted in significant grant funding. Lessons learned have been disseminated nationally. Moving forward, we aim to expand our program and partnerships to ensure that caregivers of infants receive appropriate mental health support to strengthen family well-being. The Task Force can serve as a model for advocates looking to expand and integrate PMAD care.

A CRISPR-Cas9-engineered mouse model for GPI-anchor deficiency mirrors human phenotypes and exhibits hippocampal synaptic dysfunctions.

Pathogenic germline mutations in PIGV lead to glycosylphosphatidylinositol biosynthesis deficiency (GPIBD). Individuals with pathogenic biallelic mutations in genes of the glycosylphosphatidylinositol (GPI)-anchor pathway exhibit cognitive impairments, motor delay, and often epilepsy. Thus far, the pathophysiology underlying the disease remains unclear, and suitable rodent models that mirror all symptoms observed in human patients have not been available. Therefore, we used CRISPR-Cas9 to introduce the most prevalent hypomorphic missense mutation in European patients, Pigv:c.1022C > A (p.A341E), at a site that is conserved in mice. Mirroring the human pathology, mutant Pigv341E mice exhibited deficits in motor coordination, cognitive impairments, and alterations in sociability and sleep patterns, as well as increased seizure susceptibility. Furthermore, immunohistochemistry revealed reduced synaptophysin immunoreactivity in Pigv341E mice, and electrophysiology recordings showed decreased hippocampal synaptic transmission that could underlie impaired memory formation. In single-cell RNA sequencing, Pigv341E-hippocampal cells exhibited changes in gene expression, most prominently in a subtype of microglia and subicular neurons. A significant reduction in Abl1 transcript levels in several cell clusters suggested a link to the signaling pathway of GPI-anchored ephrins. We also observed elevated levels of Hdc transcripts, which might affect histamine metabolism with consequences for circadian rhythm. This mouse model will not only open the doors to further investigation into the pathophysiology of GPIBD, but will also deepen our understanding of the role of GPI-anchor-related pathways in brain development.

Pediatric Provider Experiences with Implementation of Routine Mental Health Screening.

OBJECTIVE: Despite the utility of universal screening, most pediatric providers rarely use mental health (MH) screening tools. As such, provider descriptions of their experiences with universal screening are limited. The goal of this study was to describe barriers to, and facilitators of, universal MH screening implementation, the perceived impact of such screening, impressions of a screening-focused quality improvement (QI) Learning Collaborative, and lessons learned. METHOD: We invited primary care clinicians participating in a large-scale QI Learning Collaborative on MH screening (n = 107) to complete postproject interviews. Interviews were transcribed and analyzed using constant comparative qualitative analysis, an inductive, iterative process. RESULTS: Eleven interviews were completed and analyzed. Practice sites included academic health centers, a private practice, and a federally qualified health center. Providers described the positive impact of screening (increased identification of MH concerns) and barriers and facilitators of screening at the practice level (clinic and leadership buy-in and electronic medical record integration), the provider level (provider beliefs about the importance of screening), and the patient level (parent literacy). Challenges of linking families with care after screening included lack of adequate referrals, long wait lists, limited bilingual providers, insurance gaps, and inadequate feedback loops. Access to on-site MH clinicians and participation in the Learning Collaborative were described as beneficial. CONCLUSION: Findings elucidate how universal MH screening can be sustainably integrated into real-world primary care settings and may facilitate the uptake of American Academy of Pediatrics recommendations for best practices in screening for MH concerns.

Abnormal brain structure and behavior in MyD88-deficient mice.

While the original protein Toll in Drosophila melanogaster regulates both host defense and morphogenesis, the role of its ortholog Toll-like receptors (TLRs), the interleukin 1 receptor (IL-1R) family, and the associated signaling pathways in mammalian brain development and structure is poorly understood. Because the adaptor protein myeloid differentiation primary response protein 88 (MyD88) is essential for downstream signaling of most TLRs and IL-1R, we systematically investigated the effect of MyD88 deficiency on murine brain structure during development and on behavior. In neonatal Myd88-/- mice, neocortical thickness was reduced, while density of cortical neurons was increased. In contrast, microglia, astrocyte, oligodendrocyte, and proliferating cell numbers were unchanged in these mice compared to wild-type mice. In adult Myd88-/- mice, neocortical thickness was unaltered, but neuronal density in neocortex and hippocampus was increased. Neuron arborization was less pronounced in adult Myd88-/- mice compared to wild-type animals. In addition, numbers of microglia and proliferating cells were increased in the neocortex and subventricular zone, respectively, with unaltered astrocyte and oligodendrocyte numbers, and myelinization was enhanced in the adult Myd88-/- neocortex. These morphologic changes in the brain of adult Myd88-/- mice were accompanied by specific behavioral traits, such as decreased locomotor activity, increased anxiety-like behavior, but normal day/light activity, satisfactory learning, short- and long-term spatial memory, potential cognitive inflexibility, and increased hanging and locomotor behavior within their home cage. Taken together, MyD88 deficiency results in morphologic and cellular changes in the mouse brain, as well as in altered natural and specific behaviors. Our data indicate a pathophysiological significance of MyD88 for mammalian CNS development, structure, and function.

Human gestational N-methyl-d-aspartate receptor autoantibodies impair neonatal murine brain function.

OBJECTIVE: Maternal autoantibodies are a risk factor for impaired brain development in offspring. Antibodies (ABs) against the NR1 (GluN1) subunit of the N-methyl-d-aspartate receptor (NMDAR) are among the most frequently diagnosed anti-neuronal surface ABs, yet little is known about effects on fetal development during pregnancy. METHODS: We established a murine model of in utero exposure to human recombinant NR1 and isotype-matched nonreactive control ABs. Pregnant C57BL/6J mice were intraperitoneally injected on embryonic days 13 and 17 each with 240µg of human monoclonal ABs. Offspring were investigated for acute and chronic effects on NMDAR function, brain development, and behavior. RESULTS: Transferred NR1 ABs enriched in the fetus and bound to synaptic structures in the fetal brain. Density of NMDAR was considerably reduced (up to -49.2%) and electrophysiological properties were altered, reflected by decreased amplitudes of spontaneous excitatory postsynaptic currents in young neonates (-34.4%). NR1 AB-treated animals displayed increased early postnatal mortality (+27.2%), impaired neurodevelopmental reflexes, altered blood pH, and reduced bodyweight. During adolescence and adulthood, animals showed hyperactivity (+27.8% median activity over 14 days), lower anxiety, and impaired sensorimotor gating. NR1 ABs caused long-lasting neuropathological effects also in aged mice (10 months), such as reduced volumes of cerebellum, midbrain, and brainstem. INTERPRETATION: The data collectively support a model in which asymptomatic mothers can harbor low-level pathogenic human NR1 ABs that are diaplacentally transferred, causing neurotoxic effects on neonatal development. Thus, AB-mediated network changes may represent a potentially treatable neurodevelopmental congenital brain disorder contributing to lifelong neuropsychiatric morbidity in affected children. ANN NEUROL 2019;86:656-670.

Increasing Mental Health Engagement From Primary Care: The Potential Role of Family Navigation.

Early engagement in mental health intervention is critical, yet the vast majority of children who are experiencing mental health concerns are not receiving needed services. Pediatric primary care clinics have been recognized as an ideal setting in which to identify and address mental health problems early, although engagement in mental health services within primary care and in community-based settings remains low. Navigators, or individuals with experience in navigating the mental health system, have been highlighted as promising partners in efforts to improve engagement in mental health services. Navigation has a growing body of research support among adults and in targeting medical concerns, but there has been limited research on integrating family navigators into pediatric primary care settings to address mental health concerns. Despite this gap in the evidence base, we believe there is significant promise for the use of this model in addressing children's mental health needs. In this report, we discuss factors contributing to high levels of unmet mental health needs and low levels of engagement in mental health services, the role that navigators can play in increasing engagement in mental health care, and implications and recommendations related to integrating mental health-focused family navigators into pediatric primary care settings.

Mesenchymal stem cell­derived extracellular vesicles promote the in vitro proliferation and migration of breast cancer cells through the activation of the ERK pathway.

Mesenchymal stem cells (MSCs) have been demonstrated to be involved in tumor progression and the modulation of the tumor microenvironment, partly through their secretome. Extracellular vesicles (EVs) are membranous nanovesicles secreted by multiple types of cells and have been demonstrated to mediate intercellular communication in both physiological and pathological conditions. However, numerous questions still remain regarding the underlying mechanisms and functional consequences of these interactions. The purpose of this study was to investigate the effects of human umbilical cord mesenchymal stem cell­derived EVs (hUC­MSC­EVs) on the proliferation, migration and invasion of human breast cancer cells. We successfully generated and identified hUC­MSCs and hUC­MSC­EVs which were used in this study. The results revealed that treatment of the MDA­MB­231 and MCF­7 human breast cancer cells with medium containing hUC­MSC­EVs significantly enhanced the proliferation, migration and invasion of the cells in vitro. Treatment of the cells with medium containing hUC­MSC­EVs also reduced E­cadherin expression and increased N­cadherin expression, thus promoting the epithelial­mesenchymal transition (EMT) of the breast cancer cells. Treatment of the breast cancer cells with extracellular signal­regulated kinase (ERK) inhibitor prior to the interaction with hUC­MSC­EVs significantly reversed the enhanced proliferation, migration and invasion, as well as the EMT of the breast cancer cells induced by the hUC­MSC­EVs. On the whole, these data indicate that hUC­MSC­EVs promote the invasive and migratory potential of breast cancer cells through the induction of EMT via the ERK pathway, leading to malignant tumor progression and metastasis. Taken together, the findings of this study suggest that targeting pathways to reverse EMT may lead to the development of novel therapeutic approaches with which to combat breast cancer.

Nesfatin-130-59 Injected Intracerebroventricularly Increases Anxiety, Depression-Like Behavior, and Anhedonia in Normal Weight Rats.

Nesfatin-1 is a well-established anorexigenic peptide. Recent studies indicated an association between nesfatin-1 and anxiety/depression-like behavior. However, it is unclear whether this effect is retained in obesity. The aim was to investigate the effect of nesfatin-130-59-the active core of nesfatin-1-on anxiety and depression-like behavior in normal weight (NW) and diet-induced (DIO) obese rats. Male rats were intracerebroventricularly (ICV) cannulated and received nesfatin-130-59 (0.1, 0.3, or 0.9 nmol/rat) or vehicle 30 min before testing. Nesfatin-130-59 at a dose of 0.3 nmol reduced sucrose consumption in the sucrose preference test in NW rats compared to vehicle (⁻33%, p < 0.05), indicating depression-like/anhedonic behavior. This dose was used for all following experiments. Nesfatin-130-59 also reduced cookie intake during the novelty-induced hypophagia test (-62%, p < 0.05). Moreover, nesfatin-130-59 reduced the number of entries into the center zone in the open field test (-45%, p < 0.01) and the visits of open arms in the elevated zero maze test (-39%, p < 0.01) in NW rats indicating anxiety. Interestingly, DIO rats showed no behavioral alterations after the injection of nesfatin-130-59 (p > 0.05). These results indicate an implication of nesfatin-130-59 in the mediation of anxiety and depression-like behavior/anhedonia under normal weight conditions, while in DIO rats, a desensitization might occur.

Electronic and Steric Tuning of Catalytic H2 Evolution by Cobalt Complexes with Pentadentate Polypyridyl-Amine Ligands.

Structural modifications of molecular cobalt catalysts have provided important insights into the structure-function relationship for the hydrogen evolution reaction. We have shown that replacement of equatorial pyridines with more basic and conjugate isoquinoline groups of a pentadentate ligand results in lower overpotential and higher catalytic activity for electro- and photolytic H2 production in aqueous solutions. To fully understand the electronic and steric effects of the axial group that lies trans to the proposed cobalt hydride intermediate, isoquinoline groups were introduced in two new pentadentate ligands, N, N-bis(2-pyridinylmethyl)[3-(2-pyridinyl)isoquinoline)]-1-methanamine (DPA-1-MPI) and N, N-bis(2-pyridinylmethyl)[1-(2-pyridinyl)-isoquinoline)]-3-methanamine (DPA-3-MPI). Despite a slight structural difference of the introduced isoquinoline group, the resulting cobalt complexes display drastic changes in their electro- and photochemical properties. There are positive shifts of 290 and 260 mV, respectively, for the CoII/CoI and CoIII-H/CoII-H couples from [Co(DPA-1-MPI)(H2O)](PF6)3 to [Co(DPA-3-MPI)(H2O)](PF6)3, with the former being ∼32 times as active as the latter in photocatalytic H2 production. Density functional theory (DFT) calculations show that the protonation of CoI to yield the CoIII-H species is energetically more favorable for [Co(DPA-1-MPI)(H2O)](PF6)3 than that of [Co(DPA-3-MPI)(H2O)](PF6)3. Both experimental results and DFT computations suggest that the presence of a planar conjugate bipyridyl unit or its isoquinoline derivative is a key feature for stabilizing low valent CoI species toward proton binding. The incorporation of an electron-donating group trans to the proposed Co-H species also facilitates proton binding and H-H bond formation, which is proposed to occur by the heterolytic coupling of CoII-H species. The overall catalytic H2 evolution is presented as the modified electron transfer (E)-proton transfer (C)-electron transfer (E)-proton transfer (C) (mod-ECEC) pathway. This study provides important new insight into the electronic and steric factors controlling catalytic H2 production by Co complexes with pentadentate ligands.

Mental Health Screening Quality Improvement Learning Collaborative in Pediatric Primary Care.

BACKGROUND: In the United States, up to 20% of children experience a mental health (MH) disorder in a given year, many of whom remain untreated. Routine screening during annual well visits is 1 strategy providers can use to identify concerns early and facilitate appropriate intervention. However, many barriers exist to the effective implementation of such screening. METHODS: A 15-month quality improvement learning collaborative was designed and implemented to improve screening practices in primary care. Participating practices completed a survey at 3 time points to assess preparedness and ability to promote and support MH issues. Monthly chart reviews were performed to assess the rates of screening at well visits, documentation of screening results, and appropriate coding practices. RESULTS: Ten practices (including 107 providers) were active participants for the duration of the project. Screening rates increased from 1% at baseline to 74% by the end of the project. For the 1 practice for which more comprehensive data were available, these screening rates were sustained over time. Documentation of results and appropriate billing for reimbursement mirrored the improvement seen in screening rates. CONCLUSIONS: The learning collaborative model can improve MH screening practices in pediatric primary care, an important first step toward early identification of children with concerns. More information is needed about the burden placed on practices and providers to implement these changes. Future research will be needed to determine if improved identification leads to improved access to care and outcomes.