Perceptions of mental health providers of the barriers and facilitators of using and engaging youth in digital mental-health-enabled measurement based care

Objectives

Increased rates of mental health disorders and substance use among youth and young adults have increased globally, furthering the strain on an already burdened mental health system. Digital solutions have been proposed as a potential option for the provision of timely mental health services for youth, with little research exploring mental health professional views about using such innovative tools. In Alberta, Canada, we are evaluating the implementation and integration of a digital mental health (dMH) platform into existing service pathways. Within this paper we seek to explore mental health professionals' perceptions of the barriers and facilitators that may influence their utilization of digital MH-enabled measurement-based care (MBC) with the youth who access their services.

Methods

A qualitative, descriptive methodology was used to inductively generate themes from focus groups conducted with mental health professionals from specialized mental health services and primary care networks in Alberta.

Results

As mental health professionals considered the barriers and facilitators of using dMH with youth, they referenced individual and family barriers and facilitators to consider. Providers highlighted perceived barriers, including: first, cultural stigma, family apprehension about mental health care, and parental access to dMH and MBC as deterrents to providers adopting digital platforms in routine care; second, perceptions of increased responsibility and liability for youth in crisis; third, perception that some psychiatric and neurodevelopmental disorders in youth are not amenable to dMH; fourth, professionals contemplated youth readiness to engage with dMH-enabled MBC. Participants also highlighted pertinent facilitators to dMH use, noting: first, the suitability of dMH for youth with mild mental health concerns; second, youth motivated to report their changes in mental health symptoms; and lastly, youth proficiency and preference for dMH options.

Conclusions

By identifying professionals' perceptions of barriers and facilitators for youth users, we may better understand how to address misconceptions about who is eligible and appropriate for dMH through training and education.

Post-operative atrial fibrillation: not just a transient phenomenon

Funding Acknowledgements

Type of funding sources: None.

Background

A high proportion of patients undergoing cardiac surgery develop atrial fibrillation (AF) in the immediate post-operative period. To assess whether this translates into long-term AF, studies have used incidence of stroke as a surrogate marker, however the rhythm has not been directly measured. Our study retrospectively reviewed device checks of patients with permanent cardiac devices who underwent cardiac surgery in order to directly measure AF up to 18 months post cardiac surgery.

Purpose

To assess whether the development AF in the immediate post-operative period relates to the prevalence of longer-term AF after cardiac surgery.

Methods

Patients who had undergone a coronary artery bypass graft (CABG) or valve surgery between January 2011 and March 2020 and who had a pre-existing device or a device inserted within 1 year after surgery were identified. Patients were excluded if they had a congenital cardiac condition or a diagnosis of AF pre-operatively. Patients were categorised as having AF in the immediate post-operative period if AF was coded in the electronic ICU observation chart, mentioned on the discharge summary, or found in a device check <6 weeks post-surgery. Device checks were analysed up to 18 months post-surgery and AF was confirmed if lasting >6 minutes and documented on atrial electrogram (EGM). Comorbidities and operation details were gathered from institutional surgical database and medical notes.

Results

359 patients at our institution met initial criteria. 94 had device checks available and were used for final analysis. Mean follow up duration was 377 days. In total 41 (44%) patients developed AF in the immediate post-operative period. Patients developing post-op AF were older (69 vs. 64 years old, p=0.01) and had a different spread in operation type (CABG only 27% vs. 28%, valve only 51% vs. 68%, combined CABG & valve 22% vs. 4%, p=0.02) but there was no difference in other relevant characteristics (see Table 1). In total, 24 (26%) patients developed longer term AF, with significantly higher proportion in those who developed immediate post-operative AF (see Figure 1). Immediate post-operative AF and hypertension demonstrated a significant association with longer-term AF on univariate regression analysis using a significance value of 0.1. On multivariate analysis only immediate post-operative AF remained significant (odds ratio 3.75 (95% confidence interval 1.38-10.22), p=0.01).

Conclusion

Developing AF in the post-operative period appears to be an independent predictor of developing clinically significant AF up to 18 months after surgery. This is an important finding in identifying patients who may be at higher risk of thromboembolic events. Further research is required to determine the optimal approach, in particular consideration of anticoagulation in this patient group.

The effect of cardiac surgery type on incidence of post-operative atrial fibrillation amongst patients with post-procedural conduction disease

Funding Acknowledgements

Type of funding sources: None.

Background

Approximately 1% of cardiac operations result in post-operative heart block (PoHB). Post -operative atrial fibrillation (PoAF) has been quoted as occurring in 40-50% of combined coronary artery bypass graft (CABG) and valvular procedures, 25% of CABG only and 30% of valve only procedures. The co-existence of PoAF in patients with PoHB, and the link to operation type is less well documented.

Purpose

To investigate characteristics predisposing patients post cardiac surgery for PoHB and PoAF.

Methods

We screened patients who had undergone CABG, aortic or mitral valve replacements (AVR and MVR respectively) or mitral valve repairs at Bristol Royal Infirmary between 1/1/2010 and 1/4/2020. We created a merged surgical and electrophysiological database identifying patients with permanent pacemakers inserted within 30 days of cardiac surgery for PoHB to create our final database. By reviewing electronic notes we identified patients in this cohort who developed PoAF prior to discharge. We excluded patients with congenital heart defects or known prior atrial fibrillation. We then analysed the incidence of both PoHB and PoAF for different operation subtypes.

Results

Of the 10779 operations, 6625 (61%) were CABG-Only, 4124 (38%) were Valve-Only and 1219 (11%) were combined CABG&Valve. In total 85 (0.8%) patients developed PoHB. There was a higher proportion of female patients in the PoHB group but no other demographic differences (See Table 1). In terms of operation type, the PoHB group contained a significantly higher proportion of patients who had undergone AVR (78% vs. 28%, p<0.001). There was also a significant association with operations performed on cardiopulmonary bypass and with longer cross clamp time however this did not remain statistically significant on multivariate analysis. Valve surgery was associated with a higher proportion of patients developing PoHB than CABG, with AVR relating to the highest PoHB rates (AVR 2.0%, MVR 0.9%, CABG 0.2%, p<0.0001). Both mechanical and bioprosthetic AVR were associated with a higher proportion of patients developing PoHB than MVR.

In our cohort 34/85 (41%) patients with POHB developed post-operative AF. After univariate analysis of the patient and operation factors listed in Table 1, only age and body mass index were predictors of development of PoAF after multivariate analysis (age: odds ratio 1.81 (1.02-1.36), p=0.024, BMI: odds ratio 1.09 (1.02-1.17), p=0.01), with no association to surgical parameters.

Conclusion

PoHB occurs commonly following both CABG and valve procedures, with higher incidence in the setting of valve surgery, with our data showing a 2 fold higher chance of PoHB in patients undergoing aortic versus mitral valve replacements. In contrast, there is no clear relationship between type of surgery and development of postoperative atrial fibrillation in this cohort but larger studies are warranted.

Thiel-embalmed porcine placenta: A valid and reusable microsurgical practice model

BACKGROUND

Simulation models are increasingly important for skill acquisition during microsurgery training. Prosthetics, living and non-living biological models have been proposed in the literature in the optics of recreating real-life scenarios in a controlled environment. This study aims to validate and prove the reusability of a novel non-living biological model: the porcine placenta.

METHODS

A prospective comparative study was carried out to assess face and content validities of the proposed model, as well as the reusability and quality of the Thiel-embalming method. Participants were asked answer a questionnaire for each anastomosis they performed on porcine placental vessels of ≤2mm (small) and 2-4mm (large). Scores were classified according to different subgroups, either small or large vessels and first or second sessions. Reliability analysis of the questionnaire was carried out using Cronbach's α, to ensure an α>0.7. Median scores for each question were analyzed using boxplots and compared amongst each subgroup using a non-parametric independent Mann-Whitney U test.

RESULTS

With nine participants, the Cronbach's α for each category of question was 0.867, 0.778, 0.720 and 0.593. Statistical differences were found between responses of small and large vessels on 5/10 questions, where large vessels reported higher validity. No statistical differences were found between scores of the first and second sessions.

CONCLUSION

By evaluating face and content validity, the Thiel-embalmed porcine placenta has proven its suitability as a microsurgery model, especially for vessels of larger caliber. Qualities that distinguish this model is its reliable reusability, its low cost-effectiveness, and its ethical acceptability.

Child abuse and all-cause mortality in the Canadian population

Background

A history of child abuse is common and is associated with the later occurrence of risky health behaviors, mental disorders, and chronic conditions, strongly suggesting that child abuse may be associated with elevated mortality. However, most of the literature on child abuse has studied psychosocial/behavioral or medical outcomes and have not addressed mortality directly.

Methods

Data from the 2012 Canadian Community Health Survey, linked to the Canadian Vital Statistics Database, were used in the analysis. The CCHS-2012 interview (n = 19,830) retrospectively assessed childhood physical abuse, sexual abuse, and witnessing intimate partner violence before the age of 16. Each type of abuse was analyzed separately using Cox proportional hazards models for all-cause mortality. Hazard ratios (HR) and associated 95% confidence intervals (CI) were estimated with and without adjustment for covariates.

Results

An effect on mortality was observed among men for witnessing interpersonal violence (age-adjusted HR 2.47, 95% CI 1.48-4.12), and severe physical abuse (age-adjusted HR 2.3, 95% CI 1.21-4.36). In each case, the association was not significant for women; the age-adjusted HRs being 0.93 (95% CI: 0.51-1.70) and 0.59 (95%CI: 0.64-2.60) respectively. The association was seen only among those reporting frequent abuse ( > =10 times) and weakened (became not significant) with adjustment for covariates that may mediate the association such as smoking and chronic conditions.

Conclusions

As predicted by a broader literature on childhood adversity, child abuse increases the risk of mortality. The effect was significant for severe physical abuse in men, but imprecision due to a limited number of deaths may have rendered other associations non-significant. The study provides some degree of confirmation that child abuse contributes to later life mortality. Hence public health strategies that prevent child abuse and mitigate the harms of the mediators might prevent mortality.

Key messages

Witnessing intimate partner violence is just as harmful as actually experiencing physical abuse. Preventing children's exposure to violence in family is valuable in preventing mortality in adulthood. Enhancing child abuse prevention programs and mitigating the harmful effects of the mediators such as smoking, substance use, and chronic conditions is important in reducing mortality in adult life.

Comparison of venous couplers versus hand-sewn technique in free flap breast reconstruction

INTRODUCTION

Despite positive outcomes reported in the literature, some surgeons remain reluctant to the systematic use of venous couplers in free flap tissue transfer. In our institution, the use of the coupler devices for venous anastomosis in free flap breast reconstruction has yet to be adopted by all surgeons. The purpose of the study was to compare postoperative outcomes of coupler-assisted venous anastomoses with hand-sewn techniques in free flap breast reconstruction.

METHODS

An analysis of collected data was performed on cases of breast reconstruction with free tissue transfer after mastectomy in breast cancer or BRCA-positive patients from 2010 to 2016. Patients were divided into two groups: coupler device and hand-sewn. The primary outcome was survival rate of free flaps. Secondary outcomes included potential complications, as well as surgical characteristics (recipient artery/vein, coupler size, type of hand-sewn anastomosis, size of sutures, number of venous anastomoses, ischemia time, operative time) RESULTS: We included 289 cases in our study. There were no significant differences between groups in terms of post-operative complications or survival rate of the free flaps. Ischemia time was significantly lower in both immediate and delayed reconstruction cases. Operative and anesthesia times were significantly lower only in immediate unilateral cases.

CONCLUSION

Although ischemia time was reduced in the coupler group, we didn't find any significant difference in the operative and anesthesia time in the subgroup analysis, except for the group of immediate unilateral breast reconstruction. Couplers are safe and efficient; nevertheless, our study shows that their qualities cannot yet justify the disappearance of the manual sutures.

Burn patient care lost in good manufacturing practices?

Application of cell therapies in burn care started in the early 80s in specialized hospital centers world-wide. Since 2007, cell therapies have been considered as "Advanced Therapy Medicinal Products" (ATMP), so classified by European Directives along with associated Regulations by the European Parliament. Consequently, regulatory changes have transformed the standard linear clinical care pathway into a more complex one. It is important to ensure the safety of cellular therapies used for burn patients and to standardize as much as possible the cell sources and products developed using cell culture procedures. However, we can definitely affirm that concentrating the bulk of energy and resources on the implementation of Good Manufacturing Practice (GMP) alone will have a major negative impact on the care of severely burned patients world-wide. Developing fully accredited infrastructures and training personnel (required by the new directives), along with obtaining approval for clinical trials to go ahead, can be a lengthy process.We discuss whether or not these patients could benefit from cell therapies provided by standard in-hospital laboratories, thus avoiding having to meet rigid regulations concerning the use of industrial pharmaceutical products. "Hospital Exemption" could be a preferred means to offer burn patients a customized and safe product, as many adaptations may be required throughout their treatment pathway. Patients who are in need of rapid treatment will be the ones to suffer the most from regulations intended to help them.