Capacity to Consent to Treatment of Substance Use Disorders at Ontario's Consent and Capacity Board: A Review of Past Reported Decisions.

Capacity to consent to treatment of substance use disorders at Ontario's Consent and Capacity Board: A review of past reported decisions.

An Ontario review of legal cases which have considered patients' ability to consent to substance use treatmentsPlain Language SummaryIn general, prescribers must consider whether informed consent was provided prior to starting a treatment. A patient is presumed to be capable to consent to a proposed treatment but could be incapable with respect to any medical treatment. While incapacity is often considered for psychiatric treatments, it could be relevant to substance use treatment like methadone or suboxone, which are also called "Opioid Agonist Therapies" or OAT. OAT is lifesaving and prevents relapse and overdose when a person has an opioid use disorder. If a patient is found incapable of consenting to a treatment, a Substitute Decisions Maker would become the decision maker. In such cases, the patient has the ability to contest or disagree with the finding, and this results in a tribunal hearing at the Consent and Capacity Board in Ontario (CCB). In certain circumstances, the CCB publishes what are known as its Reasons for Decision (RDs), which explain the tribunal's reasoning in coming to a decision in favour of the physician or the person found incapable. This information is publicly searchable. Our methods involved a search of all available CCB RDs in Ontario for search terms related to substance use treatment, such as "methadone". We found that between June 1, 2003 (the date on reporting of RDs began) and June 27, 2023, only 71 RDs involved substance use search terms, out of a total of 10,463 reported RDs. Only one case involved the CCB upholding a finding of incapacity with respect to methadone treatment. These results imply that there are few cases in which the CCB has considered incapacity with respect to substance use treatment, although it is possible that these cases are reported at a lower frequency than other cases.

Managing substance use in patients receiving therapeutic repetitive transcranial magnetic stimulation: A scoping review.

Repetitive Transcranial Magnetic Stimulation (rTMS) is an invaluable treatment option for neuropsychiatric disorders. Co-occurring recreational and nonmedical substance use can be common in those presenting for rTMS treatment, and it is unknown how it may affect the safety and efficacy of rTMS for the treatment of currently approved neuropsychiatric indications. This scoping review aimed to map the literature on humans receiving rTMS and had a history of any type of substance use. The search identified 274 articles providing information on inclusion/exclusion criteria, withdrawal criteria, safety protocols, type of rTMS and treatment parameters, adverse events and effect on primary outcomes that related to substance use. There are neurophysiological effects of substance use on cortical excitability, although the relevance to clinical rTMS practice is unknown. The current literature supports the safety and feasibility of delivering rTMS to those who have co-occurring neuropsychiatric disorder and substance use. However, specific details on how varying degrees of substance use alters the safety, efficacy, and mechanisms of rTMS remains poorly described.

Repetitive transcranial magnetic stimulation for smoking cessation: Next steps for translation and implementation into clinical practice.

Tobacco smoking is a significant determinant of preventable morbidity and mortality worldwide. It is now possible to modulate the activity of the neurocircuitry associated with nicotine dependence using repetitive Transcranial Magnetic Stimulation (rTMS), a non-invasive neurostimulation approach, which has recently demonstrated efficacy in clinical trials and received regulatory approval in the US and Canada. However there remains a paucity of replication studies and real-world patient effectiveness data as access to this intervention is extremely limited. There are a number of unique challenges related to the delivery of rTMS that need to be addressed prior to widespread adoption and implementation of this treatment modality for smoking cessation. In this paper, we review the accessibility, scientific, technological, economical, and social challenges that remain before this treatment can be translated into clinical practice. By addressing these remaining barriers and scientific challenges with rTMS for smoking cessation and delineating implementation strategies, we can greatly reduce the burden of tobacco-related disease worldwide.

Prognostic Features of Preoperative OCT in Retinal Detachments: A Systematic Review and Meta-analysis.

TOPIC: To evaluate the prognostic association between preoperative features seen on OCT imaging and postoperative visual acuity (VA) outcomes in rhegmatogenous retinal detachments (RRDs). CLINICAL RELEVANCE: Currently, there is limited literature on the prognostic value of preoperative RRD OCT features. METHODS: A literature search was conducted on Ovid MEDLINE, Ovid Embase, and Cochrane CENTRAL from inception to September 15, 2022. A meta-analysis was performed using a random-effects model. Quality of studies and evidence were assessed using the Joanna Briggs Institute tools and the Grading of Recommendations, Assessment, Development and Evaluation framework, respectively. RESULTS: A total of 1671 eyes of 1670 patients from 29 observational studies were included. Of these, 89% of eyes had a macula-off RRD at presentation. The mean average duration of detachment was 15 ± 10 days. Most eyes (62%) underwent pars plana vitrectomy. Six preoperative OCT features were analyzed: height of retinal detachment (HRD) at the fovea, central macular thickness (CMT), disruption of the ellipsoid zone (EZ) and/or external limiting membrane (ELM), intraretinal cystic cavities (ICCs), outer retinal corrugations (ORCs), and macular detachment. A greater HRD was weakly associated with postoperative VA (Pearson correlation r = 0.35; 95% confidence interval [CI], 0.20-0.48; P < 0.01), and there was no change in this association throughout the postoperative follow-up period. The CMT was not associated with postoperative VA. Eyes with disruption of the EZ and/or ELM had a postoperative VA worse by 0.35 logarithm of the minimum angle of resolution (logMAR) (95% CI, 0.15-0.54; P < 0.01) or 3 Snellen lines. Eyes with ICCs had a postoperative VA worse by 0.14 logMAR (95% CI, 0.01-0.26; P < 0.01) or 2 Snellen lines. Eyes with ORCs did not have a significantly different postoperative VA than eyes without ORCs. Eyes with macular detachment had a postoperative VA worse by 0.15 logMAR (95% CI, -0.31 to 0.00; P = 0.02) or 2 Snellen lines. Overall, the quality of studies ranged from moderate to good (73%-100%). All associations had a low quality of evidence, with CMT being of very low quality. CONCLUSION: Despite the low quality of evidence, a greater HRD, disruption of the EZ and/or ELM, presence of ICCs, and macular detachment were associated with a poor postoperative VA. We propose a standardized nomenclature for consistency and accuracy in reporting preoperative RRD OCT features for future studies. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Early Mental Health Foundations: A Scoping Review of Reflective Functioning in Caregiver-Child Dyads.

International public health strategies indicate a need for equitable resources for wellness in younger children and their caregivers. Reflective functioning, a proxy for emotional regulation abilities, is a key area in this domain. As an emerging area, reflective functioning has not been mapped comprehensively and requires systematic investigation. This review examines "what qualitative and quantitative evidence is there for the value of reflective functioning assessment and intervention studies in caregiver-child dyads?" This scoping review focused on data published to September 2021, focusing on caregivers of children ≤36 months of age (including Medline, PsycINFO, CINAHL, ERIC, Scopus, Web of Science, and Embase). Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines were followed. From 5162 initial articles, 608 papers were screened for full text yielding a final 181 papers. Only 69 studies included multiple ethnicities. Seven of the 69 studies included at least 1 Indigenous person. No studies were conducted in low- to middle-income countries, and no studies reported data on gender identity. This review comprises a novel and comprehensive mapping of the reflective functioning literature in terms of both assessment and intervention studies. The present mapping of the reflective functioning literature indicates the importance of health disparities in caregiver-child dyads (these include gaps and needs for future research). In relation to gaps, studies of adverse childhood experience, consideration of equity, diversity, and inclusion, and global mental health are underrepresented. Future research is needed to provide information on the relevance of gender identity and low- to middle-income countries in relation to the impact on reflective functioning in this context.

Developing, Implementing, and Evaluating an Artificial Intelligence-Guided Mental Health Resource Navigation Chatbot for Health Care Workers and Their Families During and Following the COVID-19 Pandemic: Protocol for a Cross-sectional Study.

BACKGROUND: Approximately 1 in 3 Canadians will experience an addiction or mental health challenge at some point in their lifetime. Unfortunately, there are multiple barriers to accessing mental health care, including system fragmentation, episodic care, long wait times, and insufficient support for health system navigation. In addition, stigma may further reduce an individual's likelihood of seeking support. Digital technologies present new and exciting opportunities to bridge significant gaps in mental health care service provision, reduce barriers pertaining to stigma, and improve health outcomes for patients and mental health system integration and efficiency. Chatbots (ie, software systems that use artificial intelligence to carry out conversations with people) may be explored to support those in need of information or access to services and present the opportunity to address gaps in traditional, fragmented, or episodic mental health system structures on demand with personalized attention. The recent COVID-19 pandemic has exacerbated even further the need for mental health support among Canadians and called attention to the inefficiencies of our system. As health care workers and their families are at an even greater risk of mental illness and psychological distress during the COVID-19 pandemic, this technology will be first piloted with the goal of supporting this vulnerable group. OBJECTIVE: This pilot study seeks to evaluate the effectiveness of the Mental Health Intelligent Information Resource Assistant in supporting health care workers and their families in the Canadian provinces of Alberta and Nova Scotia with the provision of appropriate information on mental health issues, services, and programs based on personalized needs. METHODS: The effectiveness of the technology will be assessed via voluntary follow-up surveys and an analysis of client interactions and engagement with the chatbot. Client satisfaction with the chatbot will also be assessed. RESULTS: This project was initiated on April 1, 2021. Ethics approval was granted on August 12, 2021, by the University of Alberta Health Research Board (PRO00109148) and on April 21, 2022, by the Nova Scotia Health Authority Research Ethics Board (1027474). Data collection is anticipated to take place from May 2, 2022, to May 2, 2023. Publication of preliminary results will be sought in spring or summer 2022, with a more comprehensive evaluation completed by spring 2023 following the collection of a larger data set. CONCLUSIONS: Our findings can be incorporated into public policy and planning around mental health system navigation by Canadian mental health care providers-from large public health authorities to small community-based, not-for-profit organizations. This may serve to support the development of an additional touch point, or point of entry, for individuals to access the appropriate services or care when they need them, wherever they are. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/33717.