Antibiotics Drive Expansion of Rare Pathogens in a Chronic Infection Microbiome Model.

Chronic (long-lasting) infections are globally a major and rising cause of morbidity and mortality. Unlike typical acute infections, chronic infections are ecologically diverse, characterized by the presence of a polymicrobial mix of opportunistic pathogens and human-associated commensals. To address the challenge of chronic infection microbiomes, we focus on a particularly well-characterized disease, cystic fibrosis (CF), where polymicrobial lung infections persist for decades despite frequent exposure to antibiotics. Epidemiological analyses point to conflicting results on the benefits of antibiotic treatment yet are confounded by the dependency of antibiotic exposures on prior pathogen presence, limiting their ability to draw causal inferences on the relationships between antibiotic exposure and pathogen dynamics. To address this limitation, we develop a synthetic infection microbiome model representing CF metacommunity diversity and benchmark on clinical data. We show that in the absence of antibiotics, replicate microbiome structures in a synthetic sputum medium are highly repeatable and dominated by oral commensals. In contrast, challenge with physiologically relevant antibiotic doses leads to substantial community perturbation characterized by multiple alternate pathogen-dominant states and enrichment of drug-resistant species. These results provide evidence that antibiotics can drive the expansion (via competitive release) of previously rare opportunistic pathogens and offer a path toward microbiome-informed conditional treatment strategies. IMPORTANCE We develop and clinically benchmark an experimental model of the cystic fibrosis (CF) lung infection microbiome to investigate the impacts of antibiotic exposures on chronic, polymicrobial infections. We show that a single experimental model defined by metacommunity data can partially recapitulate the diversity of individual microbiome states observed across a population of people with CF. In the absence of antibiotics, we see highly repeatable community structures, dominated by oral microbes. Under clinically relevant antibiotic exposures, we see diverse and frequently pathogen-dominated communities, and a nonevolutionary enrichment of antimicrobial resistance on the community scale, mediated by competitive release. The results highlight the potential importance of nonevolutionary (community-ecological) processes in driving the growing global crisis of increasing antibiotic resistance.

Normalization of impaired emotion inhibition in bipolar disorder mediated by cholinergic neurotransmission in the cingulate cortex.

The muscarinic-cholinergic system is involved in the pathophysiology of bipolar disorder (BD), and contributes to attention and the top-down and bottom-up cognitive and affective mechanisms of emotional processing, functionally altered in BD. Emotion processing can be assessed by the ability to inhibit a response when the content of the image is emotional. Impaired regulatory capacity of cholinergic neurotransmission conferred by reduced M2-autoreceptor availability is hypothesized to play a role in elevated salience of negative emotional distractors in euthymic BD relative to individuals with no history of mood instability. Thirty-three euthymic BD type-I (DSM-V-TR) and 50 psychiatrically-healthy controls underwent functional magnetic resonance imaging (fMRI) and an emotion-inhibition paradigm before and after intravenous cholinergic challenge using the acetylcholinesterase inhibitor, physostigmine (1 mg), or placebo. Mood, accuracy, and reaction time on either recognizing or inhibiting a response associated with an image involving emotion and regional functional activation were examined for effects of cholinergic challenge physostigmine relative to placebo, prioritizing any interaction with the diagnostic group. Analyses revealed that (1) at baseline, impaired behavioral performance was associated with lower activation in the anterior cingulate cortex in BD relative to controls during emotion processing; (2) physostigmine (vs. placebo) affected behavioral performance during the inhibition of negative emotions, without altering mood, and increased activation in the posterior cingulate cortex in BD (vs. controls); (3) In BD, lower accuracy observed during emotion inhibition of negative emotions was remediated by physostigmine and was associated with cingulate cortex overactivation. Our findings implicate abnormal regulation of cholinergic neurotransmission in the cingulate cortices in BD, which may mediate exaggerated emotional salience processing, a core feature of BD.

Orthostatic Hypotension: A Practical Approach.

Orthostatic hypotension is defined as a decrease in blood pressure of 20 mm Hg or more systolic or 10 mm Hg or more diastolic within three minutes of standing from the supine position or on assuming a head-up position of at least 60 degrees during tilt table testing. Symptoms are due to inadequate physiologic compensation and organ hypoperfusion and include headache, lightheadedness, shoulder and neck pain (coat hanger syndrome), visual disturbances, dyspnea, and chest pain. Prevalence of orthostatic hypotension in the community setting is 20% in older adults and 5% in middle-aged adults. Risk factors such as diabetes mellitus increase the prevalence of orthostatic hypotension in all age groups. Orthostatic hypotension is associated with a significant increase in cardiovascular risk and falls, and up to a 50% increase in relative risk of all-cause mortality. Diagnosis is confirmed by performing a bedside simplified Schellong test, which consists of blood pressure and heart rate measurements after five minutes in the supine position and three minutes after moving to a standing position. If the patient is unable to stand safely or the clinical suspicion for orthostatic hypotension is high despite normal findings on the bedside test, head-up tilt table testing is recommended. Orthostatic hypotension is classified as neurogenic or nonneurogenic, depending on etiology and heart rate response. Treatment goals for orthostatic hypotension are reducing symptoms and improving quality of life. Initial treatment focuses on the underlying cause and adjusting potentially causative medications. Nonpharmacologic strategies include dietary modifications, compression garments, physical maneuvers, and avoiding environments that exacerbate symptoms. First-line medications include midodrine and droxidopa. Although fludrocortisone improves symptoms, it has concerning long-term effects.

Causes and Consequences of COVID-19-Associated Bacterial Infections.

The COVID-19 literature highlights that bacterial infections are more common in fatal cases than recovered cases. If bacterial infections drive mortality in COVID-19, this has clear implications for patient management. However, it is possible that the enrichment of bacterial infections in COVID-19 fatalities is simply a by-product of late-stage pathology, leading to different advice for patient management. To address this question, we review current knowledge on bacterial infections in COVID-19, assess information from past viral respiratory pandemics, and simulate alternate causal models of interactions between virus, bacteria, and mortality in COVID-19. From these models, we conclude that currently available data are not sufficient to discriminate between these alternate causal pathways, and we highlight what data are required to determine the relative contribution of bacterial infection to COVID-19 morbidity and mortality. We further summarize the potential long-term consequences of SARS-CoV-2 infection.

The Athletes' Relationships with Training scale (ART): A self-report measure of unhealthy training behaviors associated with eating disorders.

OBJECTIVE: Several studies indicate that eating-disorder (ED) psychopathology is elevated in athletes compared to non-athletes. The assessment of excessive exercise among athletes is a challenge because, compared to non-athletes, athletes are required to train at higher intensities and for longer periods of time. However, individuals participating in competitive sports are still susceptible to unhealthy physical-activity patterns. Most ED assessments were developed and normed in non-athlete samples and, therefore, do not capture the nuances of athletes' training experiences. The purpose of the current study was to develop and validate a clinically useful, self-report measure of unhealthy training behaviors and beliefs in athletes, the Athletes' Relationships with Training Scale (ART). METHOD: The initial item pool was administered to N = 267 women collegiate athletes who were participating in an ED prevention program study and N = 65 women athletes who were in ED treatment. RESULTS: Factor analyses indicated the ART had a four-factor structure. Factorial and construct validity of the ART were demonstrated. ART scores significantly predicted health care utilization and differed between athletes with an ED versus athletes without an ED. For athletes in ED treatment, ART scores significantly decreased from treatment admission to discharge. DISCUSSION: The ART showed evidence of strong psychometric properties and clinical utility. The ART could be helpful for clinicians and athletic trainers to help gauge whether athletes are engaging in unhealthy training practices that may warrant clinical attention and for tracking clinical outcomes in athletes with EDs who are receiving treatment.

Establishing clinical meaning and defining important differences for Patient-Reported Outcomes Measurement Information System (PROMIS®) measures in juvenile idiopathic arthritis using standard setting with patients, parents, and providers.

BACKGROUND: Patient-Reported Outcomes Measurement Information System (PROMIS) measures are used increasingly in clinical care. However, for juvenile idiopathic arthritis (JIA), scores lack a framework for interpretation of clinical severity, and minimally important differences (MID) have not been established, which are necessary to evaluate the importance of change. METHODS: We identified clinical severity thresholds for pediatric PROMIS measures of mobility, upper extremity function (UE), fatigue, and pain interference working with adolescents with JIA, parents of JIA patients, and clinicians, using a standard setting methodology modified from educational testing. Item parameters were used to develop clinical vignettes across a range of symptom severity. Vignettes were ordered by severity, and panelists identified adjacent vignettes considered to represent upper and lower boundaries separating category cut-points (i.e., from none/mild problems to moderate/severe). To define MIDs, panelists reviewed a full score report for the vignettes and indicated which items would need to change and by how much to represent "just enough improvement to make a difference." RESULTS: For fatigue and UE, cut-points among panels were within 0.5 SD of each other. For mobility and pain interference, cut-scores among panels were more divergent, with parents setting the lowest cut-scores for increasing severity. The size of MIDs varied by stakeholders (parents estimated largest, followed by patients, then clinicians). MIDs also varied by severity classification of the symptom. CONCLUSIONS: We estimated clinically relevant severity cut-points and MIDs for PROMIS measures for JIA from the perspectives of multiple stakeholders and found notable differences in perspectives.

Are Smoking Cessation Treatments Associated with Suicidality Risk? An Overview.

Risk of suicidality during smoking cessation treatment is an important, but often overlooked, aspect of nicotine addiction research and treatment. We explore the relationship between smoking cessation interventions and suicidality and explore common treatments, their associated risks, and effectiveness in promoting smoking reduction and abstinence. Although active smokers have been reported to have twofold to threefold increased risk of suicidality when compared to nonsmokers,1-4 research regarding the safest way to stop smoking does not always provide clear guidelines for practitioners wishing to advise their patients regarding smoking cessation strategies. In this article, we review pharmacological and cognitive behavioral therapy (CBT) options that are available for people seeking to quit smoking, focusing on the relationship between the ability of these therapies to reduce smoking behavior and promote abstinence and suicidality risks as assessed by reported suicidality on validated measures, reports of suicidal ideation, behaviors, actual attempts, or completed suicides. Pharmacotherapies such as varenicline, bupropion, and nicotine replacement, and CBTs, including contextual CBT interventions, have been found to help reduce smoking rates and promote and maintain abstinence. Suicidality risks, while present when trying to quit smoking, do not appear to demonstrate a consistent or significant rise associated with use of any particular smoking cessation pharmacotherapy or CBT/contextual CBT intervention reviewed.

Cultural humility and racial microaggressions in counseling.

Racial microaggressions may contribute to poor counseling outcomes in racial/ethnic minority clients. The present study examined the occurrence of racial microaggressions in counseling using a large and diverse sample and explored the association between perceived cultural humility of the counselor and racial microaggressions. Racial/ethnic minority participants (N = 2,212) answered questions about the frequency and impact of racial microaggressions in counseling and the characteristics of their counselor. The majority of clients (81%) reported experiencing at least 1 racial microaggression in counseling. Participants most commonly reported racial microaggressions involving denial or lack of awareness of stereotypes and bias and avoidance of discussing cultural issues. There were few differences in racial microaggression frequency or impact based on client race/ethnicity and counselor race/ethnicity. Racially matched clients viewed racial microaggressions as more impactful than did clients who were not racially matched. Client-perceived cultural humility of the counselor was associated with fewer microaggressions experienced in counseling. We conclude by discussing limitations, areas for future research, and implications for counseling.

Longitudinal evaluation of patient-reported outcomes measurement information systems measures in pediatric chronic pain.

The Patient-Reported Outcomes Measurement Information System (PROMIS) initiative is a comprehensive strategy by the National Institutes of Health to support the development and validation of precise instruments to assess self-reported health domains across healthy and disease-specific populations. Much progress has been made in instrument development, but there remains a gap in the validation of PROMIS measures for pediatric chronic pain. The purpose of this study was to investigate the construct validity and responsiveness to change of 7 PROMIS domains for the assessment of children (ages: 8-18) with chronic pain--Pain Interference, Fatigue, Anxiety, Depression, Mobility, Upper Extremity Function, and Peer Relationships. The PROMIS measures were administered at the initial visit and 2 follow-up visits at an outpatient chronic pain clinic (CPC; N = 82) and at an intensive amplified musculoskeletal pain day-treatment program (N = 63). Aim 1 examined construct validity of PROMIS measures by comparing them with corresponding "legacy" measures administered as part of usual care in the CPC sample. Aim 2 examined sensitivity to change in both CPC and amplified musculoskeletal pain samples. Longitudinal growth models showed that PROMIS' Pain Interference, Anxiety, Depression, Mobility, Upper Extremity, and Peer Relationship measures and legacy instruments generally performed similarly with slightly steeper slopes of improvement in legacy measures. All 7 PROMIS domains showed responsiveness to change. Results offered initial support for the validity of PROMIS measures in pediatric chronic pain. Further validation with larger and more diverse pediatric pain samples and additional legacy measures would broaden the scope of use of PROMIS in clinical research.

Qualitative Evaluation of Pediatric Pain Behavior, Quality, and Intensity Item Candidates and the PROMIS Pain Domain Framework in Children With Chronic Pain.

UNLABELLED: As initial steps in a broader effort to develop and test pediatric pain behavior and pain quality item banks for the Patient-Reported Outcomes Measurement Information System (PROMIS), we used qualitative interview and item review methods to 1) evaluate the overall conceptual scope and content validity of the PROMIS pain domain framework among children with chronic/recurrent pain conditions, and 2) develop item candidates for further psychometric testing. To elicit the experiential and conceptual scope of pain outcomes across a variety of pediatric recurrent/chronic pain conditions, we conducted 32 semi-structured individual and 2 focus-group interviews with children and adolescents (8-17 years), and 32 individual and 2 focus-group interviews with parents of children with pain. Interviews with pain experts (10) explored the operational limits of pain measurement in children. For item bank development, we identified existing items from measures in the literature, grouped them by concept, removed redundancies, and modified the remaining items to match PROMIS formatting. New items were written as needed and cognitive debriefing was completed with the children and their parents, resulting in 98 pain behavior (47 self, 51 proxy), 54 quality, and 4 intensity items for further testing. Qualitative content analyses suggest that reportable pain outcomes that matter to children with pain are captured within and consistent with the pain domain framework in PROMIS. PERSPECTIVE: PROMIS pediatric pain behavior, quality, and intensity items were developed based on a theoretical framework of pain that was evaluated by multiple stakeholders in the measurement of pediatric pain, including researchers, clinicians, and children with pain and their parents, and the appropriateness of the framework was verified.

Learning how the electron transport chain works: independent and interactive effects of instructional strategies and learners' characteristics.

In order to develop an expert-like mental model of complex systems, causal reasoning is essential. This study examines the differences between forward and backward instructional strategies' in terms of efficiency, students' learning and progression of their mental models of the electronic transport chain in an undergraduate metabolism course (n = 151). Additionally, the participants' cognitive flexibility, prior knowledge, and mental effort in the learning process are also investigated. The data were analyzed using a series of general linear models to compare the strategies. Although the two strategies did not differ significantly in terms of mental model progression and learning outcomes, both groups' mental models progressed significantly. Mental effort and prior knowledge were identified as significant predictors of mental model progression. An interaction between instructional strategy and cognitive flexibility revealed that the backward instruction was more efficient than the conventional (forward) strategy for students with lower cognitive flexibility, whereas the conventional instruction was more efficient for students with higher cognitive flexibility. The results are discussed and suggestions for future research on the possible moderating role of cognitive flexibility in the area of health education are presented.

HGF induces epithelial-to-mesenchymal transition by modulating the mammalian hippo/MST2 and ISG15 pathways.

Epithelial to mesenchymal transition (EMT) is a fundamental cell differentiation/dedifferentiation process which is associated with dramatic morphological changes. Formerly polarized and immobile epithelial cells which form cell junctions and cobblestone-like cell sheets undergo a transition into highly motile, elongated, mesenchymal cells lacking cell-to-cell adhesions. To explore how the proteome is affected during EMT we profiled protein expression and tracked cell biological markers in Madin-Darby kidney epithelial cells undergoing hepatocyte growth factor (HGF) induced EMT. We were able to identify and quantify over 4000 proteins by mass spectrometry. Enrichment analysis of this revealed that expression of proteins associated with the ubiquitination machinery was induced, whereas expression of proteins regulating apoptotic pathways was suppressed. We show that both the mammalian Hippo/MST2 and the ISG15 pathways are regulated at the protein level by ubiquitin ligases. Inhibition of the Hippo pathway by overexpression of either ITCH or A-Raf promotes HGF-induced EMT. Conversely, ISG15 overexpression is sufficient to induce cell scattering and an elongated morphology without external stimuli. Thus, we demonstrate for the first time that the Hippo/MST2 and ISG15 pathways are regulated during growth-factor induced EMT.

Disclosure and self-report of emotional, social, and physical health in children and adolescents with chronic pain--a qualitative study of PROMIS pediatric measures.

OBJECTIVES: To examine the content validity of the Patient-Reported Outcomes Measurement Information System pediatric measures, including the pain interference scale, among children and adolescents (aged 8-18 years) who experience chronic pain. To describe children's understandings of the health domain constructs and elucidate verbal and conceptual aspects of self-reported pain-related functioning, which shape disclosure and reporting. METHODS: 34 children and youth with diagnoses of juvenile idiopathic arthritis or noninflammatory chronic pain completed semistructured and cognitive interviews exploring the meaning, experience, and expression of up to 4 of the Patient-Reported Outcomes Measurement Information System pediatric domains: anger, anxiety, depressive symptoms, fatigue, pain interference, and peer relationships. Team-based thematic and content analyses were conducted. RESULTS: Clear verbal and social-cognitive differences were observed in representations and accounts of the domain-experiences across age-groups, but we noted little, if any, evidence of problems with content validity. CONCLUSIONS: Findings suggest the importance of a rigorous developmental approach for understanding the verbal and cognitive dimensions of pediatric self-reports and patient-reported outcomes.

Are older patients comfortable discussing sexual health with nurses?

BACKGROUND: Sexual health is an important component of quality of life, yet practitioners do not routinely query older adults about their sexual health concerns. PURPOSE: The aims of this study were to ascertain whether older adults (a) have unanswered questions about their sexual health; (b) are asked about their sexual health, disease, and medications that could affect their sexual health and their knowledge of STDs and HIV/AIDS; (c) would welcome a care provider initiating the conversation about their sexual health; (d) would be comfortable with discussing their sexual health with a nurse; and (e) identify some barriers to discussing sexual health for the older adult. METHOD: This was a quantitative cross-sectional study that used a 24-item investigator-developed survey which was distributed to residents of retirement communities and participants in fitness classes in the Puget Sound, Washington, region. RESULTS: A total of 101 surveys were completed. The participants' average age was 81 years (range = 62-96 years); 70.3% were women (n = 71) and 25.7% were men (n = 26). When asked what sexual health meant, participants said it encompassed physical pleasure with one's partner or oneself and psychological and physiological health; 47.1% (n = 41) want to be asked about their sexual health at their healthcare visit, and 86% (n = 78) reported that they were comfortable discussing sexual health and were not embarrassed or offended. Male respondents preferred discussing with a physician rather than a nurse (52.2%, p = .01, n = 12), whereas female respondents indicated that they were willing to talk with either a physician or a nurse (56.9%, p = .01, n = 37). IMPLICATIONS: The results of this study have the potential to inform treatment approaches, improve outcomes, and enhance communication with older adults regarding issues of sexual health that impact quality of life.

Collaboration between psychiatrists and clergy in recognizing and treating serious mental illness.

OBJECTIVE: A surprisingly high number of Americans seek clergy support for treatment of mental illness. However, little is known about how the clergy prepare for fulfilling this need or their beliefs regarding mental illness. This study examined the ability to recognize and treat mental illness among Hawaii's Protestant clergy. METHODS: Ninety-eight clergy members responded to the survey. RESULTS: Most (71%) reported feeling inadequately trained to recognize mental illness. The most common cause of mental illness that clergy members cited was medical (37%), yet when asked to comment on two case vignettes, many reported that they would provide counseling instead of referral. When referrals were made, 41% considered shared religious beliefs between parishioner and provider important, and 15% considered shared beliefs essential. CONCLUSIONS: These findings highlight the need for collaboration between mental health professionals and the clergy. Knowledge of a patient's belief system may help improve crisis interventions and treatment planning for religious patients.

Pharmacists and Natural Health Products: A systematic analysis of professional responsibilities in Canada

Natural health products such as herbs, vitamins and homeopathic medicines are widely available in Canadian pharmacies. Purpose: to conduct a systematic analysis of Canadian pharmacy policies and guidelines to explore pharmacists’ professional responsibilities with respect to natural health products. Methods: Legislation, codes of ethics, standards of practice and guidance documents that apply to the practice of pharmacy in each Canadian jurisdiction were systematically collected and examined to identify if, and how, these instruments establish professional duties in regard to natural health products. Results: The majority of Canadian jurisdictions now include some explicit reference to natural health products in standards of practice policy or guideline documents. Often natural health products are simply assumed to be included in the over-the-counter (OTC) product category and thus professional responsibilities for OTCs are relevant for natural health products. A minority of provinces have specific policies on natural health products, herbals or homeopathy. In addition, the National Association of Pharmacy Regulatory Authorities’ Model Standards of Practice specifically refers to natural health products. Most policy documents indicate that pharmacists should inquire about natural health product use when counselling patients and, when asked, should provide accurate information regarding the efficacy, toxicity, side effects or interactions of natural health products. Public messaging also indicates that pharmacists are knowledgeable professionals who can provide evidence-based information about natural health products. Conclusions: Explicit policies or guidelines regarding pharmacists’ professional responsibilities with respect to natural health products currently exist in the majority of Canadian jurisdictions (AU)

Los productos sanitarios naturales, tales como las plantas medicinales las vitaminas y los medicamentos homeopáticos están ampliamente disponibles en las farmacias canadienses. Objetivo: Realizar un análisis sistemático de las políticas y guías farmacéuticas canadienses para explorar las responsabilidades profesionales de los farmacéuticos con respecto a los productos sanitarios naturales. Métodos: Se recopilaron y analizaron sistemáticamente los códigos de ética, los estándares de práctica y las guías que son de aplicación al ejercicio de la farmacia en cada jurisdicción canadiense para identificar si, y como, establecían deberes profesionales en relación a los productos sanitarios naturales. Resultados: La mayoría de las jurisdicciones canadienses actualmente incluyen alguna referencia explícita a los productos sanitarios naturales en los estándares de práctica, políticas o guías. A menudo se asume que los productos sanitarios naturales están incluidos en la categoría de productos over-the-counter (OTC) así que las responsabilidades profesionales para los ORC son de aplicación para los productos sanitarios naturales. Una minoría de provincias tiene políticas específicas sobre productos sanitarios naturales, plantas medicinales u homeopatía. Además, los estándares de práctica de la Asociación Nacional de Autoridades Regulatorias de la Farmacia se refieren a los productos sanitarios naturales. La mayoría de las políticas indican que los farmacéuticos deberían preguntar sobre el uso de los productos sanitarios naturales cuando aconsejan a los pacientes y, cuando se les pregunte, deberían proporcionar información precisa sobre eficacia, toxicidad, efectos adversos o interacciones de los productos sanitarios naturales. La publicidad también indica que los farmacéuticos son profesionales expertos que pueden proporcionar información basada en la evidencia sobre los productos sanitarios naturales. Conclusiones: Actualmente existen en la mayoría de las jurisdicciones canadienses políticas explícitas o guías sobre la responsabilidad profesional de los farmacéuticos con respecto a los productos sanitarios naturales (AU)

Pharmacists and Natural Health Products: A systematic analysis of professional responsibilities in Canada.

PURPOSE: Natural health products (natural health products) such as herbs, vitamins and homeopathic medicines are widely available in Canadian pharmacies. The purpose of this paper was to conduct a systematic analysis of Canadian pharmacy policies and guidelines to explore pharmacists' professional responsibilities with respect to natural health products. METHODS: Legislation, codes of ethics, standards of practice and guidance documents that apply to the practice of pharmacy in each Canadian jurisdiction were systematically collected and examined to identify if, and how, these instruments establish professional duties in regard to natural health products. RESULTS: The majority of Canadian jurisdictions now include some explicit reference to natural health products in standards of practice policy or guideline documents. Often natural health products are simply assumed to be included in the over-the-counter (OTC) product category and thus professional responsibilities for OTCs are relevant for natural health products. A minority of provinces have specific policies on natural health products, herbals or homeopathy. In addition, the National Association of Pharmacy Regulatory Authorities' Model Standards of Practice specifically refers to natural health products. Most policy documents indicate that pharmacists should inquire about natural health product use when counselling patients and, when asked, should provide accurate information regarding the efficacy, toxicity, side effects or interactions of natural health products. Public messaging also indicates that pharmacists are knowledgeable professionals who can provide evidence-based information about natural health products. CONCLUSIONS: Explicit policies or guidelines regarding pharmacists' professional responsibilities with respect to natural health products currently exist in the majority of Canadian jurisdictions.

A survey of occupational therapists in Canada about their knowledge and use of the ICF.

BACKGROUND: The current impact of the International Classification of Functioning, Disability and Health (ICF) on the field of occupational therapy within Canada is unknown. PURPOSE: To survey occupational therapists in Canada about their knowledge, use of and suggestions for education about the ICF. METHOD: Mixed methods design included (i) an online survey, with data analyzed using quantitative methods; and (ii) semi-structured interviews with a purposeful sample of 10 therapists, using content analysis. RESULTS: The online survey was completed by 587 occupational therapists (17.6% return). Four hundred and ten respondents (70.0%) indicated some ICF knowledge, and 121 of those individuals (29.5%) reported using it in practice. Interview participants suggested resources, perceived meaning and investment factors impact ICF knowledge. Suggested uses include frameworks and interprofessional collaboration, while ideas for education involve meaningful and accessible formats. PRACTICE IMPLICATIONS: The ICF may be useful to occupational therapists in different settings if it fulfills a meaningful purpose and fits with practice models.