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Lianne Jeffs,1–3 Trevor Jamieson,4,5 Marianne Saragosa,5 Geetha Mukerji,3,5,6 Arsh K Jain,7 Rachel Man,7 Laura Desveaux,3,5 James Shaw,3,5 Payal Agarwal,5,8 Jennifer M Hensel,5,9 Maria Maione,10 Megan Nguyen,5 Nike Onabajo,5 R Sacha Bhatia3,5,11 1Sinai Health System, Toronto, ON M5G 1X5, Canada; 2Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, ON M5G 1WB, Canada; 3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1B2, Canada; 4Department of Medicine, University of Toronto, Division of General Internal Medicine, St Michael’s Hospital, Women’s College Hospital, Toronto, ON M5G 1WB, Canada; 5Institute for Health System Solutions and Virtual Care (WIHV), Women’s College Hospital, Toronto, ON M5S 1B2, Canada; 6Women’s College Hospital, Toronto, ON M5S 1B2, Canada; 7London Health Sciences Centre, London, ON N6A 5W9, Canada; 8Department of Family and Community Medicine, Women’s College Hospital, University of Toronto, Toronto, ON M5S 1B2, Canada; 9Department of Psychiatry, University of Toronto, Women’s College Hospital, Women’s College Research Institute, Women’s College Hospital, Toronto, ON M5S 1B2, Canada; 10St Michael’s Hospital, Toronto, ON M5G 1WB, Canada; 11University Health Network, Toronto, ON M5S 1B2, Canada Background: Although there is a growing body of literature on the outcomes and impacts of remote home management with peritoneal dialysis (PD) patients, less is understood how this virtual care solution impacts the quality and efficiency of the healthcare system care. In this context, a study was undertaken to understand the perceptions of patients and their caregivers, healthcare providers, health system decision makers, and vendors associated with a remote monitoring and tracking solution aimed at enhancing the outcomes and experiences of chronic kidney disease (CKD) patients receiving PD at home. Methods: A qualitative design using semi-structured interviews with 25 stakeholders was used in this study. Narrative data were analyzed by a thematic analysis approach. Results: The following two themes emerged from the data: (1) leveraging data to monitor and intervene to keep patients safe and (2) increasing efficiencies and having control over supplies. Discussion: Our study findings elucidated the ability of patients (and in some cases, caregivers) to monitor and trend their data and order and track directly on-line their dialysis supplies were key to their active participation in managing their CKD and keeping them safe at home. Their active participation and functionality of the virtual care solution also led to enhanced efficiencies (eg, process faster, easier, convenient, time savings) for both patients and healthcare providers. Conclusion: The virtual care solution showed promising signs of a patient-centric approach and may serve as a blueprint for other virtual care solutions for chronic disease management. Keywords: peritoneal dialysis, chronic kidney disease, virtual care, qualitative research, patient centric care

Background: Ongoing psychiatric follow-up and medication adherence improve outcomes for patients with psychotic disorders. Due to COVID-19, outpatient care may have been disrupted, impacting healthcare utilization., Methods: A retrospective population-wide study was conducted for adults in Manitoba, Canada. Medication adherence and healthcare utilization were examined from 2019 to 2021. The presence of a diagnosed psychotic disorder was identified in the five years before the index date in each year. The LAI and clozapine cohorts consisted of those who received at least two prescriptions in each year 180 days before the March 20th index date. The change in adherence was measured using the average Medication Possession Ratio. Healthcare utilization rates were compared using Generalized Estimating Equation models., Results: There were no significant differences between LAI and clozapine discontinuation rates before and during the pandemic. In the LAI cohort, general practitioner visits decreased significantly (-3.5 %, p = 0.039) across four quarters of 2021 versus 2019. All-cause hospitalizations decreased by 16.8 % in 2020 versus 2019 (p = 0.0055), while psychiatric hospitalizations decreased by 18.7 % across four quarters in 2020 (p = 0.0052) and 13.7 % in 2021 (p = 0.0425), versus 2019 in the LAI cohort. There was a significant transition to virtual care during the first wave of COVID-19 (71 % in clozapine, 51 % in LAI cohorts). Trends in total outpatient visits and non-psychiatric hospitalizations remained stable., Conclusion: COVID-19 had no substantial impact on LAI and clozapine discontinuation rates for patients previously adherent. Outpatient care remained stable, with a significant proportion of visits being done virtually at the outset of the pandemic., Competing Interests: Declaration of competing interest The authors of the paper do not have any conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Objective: To assess the experience of virtual care among both patients and physicians across a range of clinical scenarios during the COVID-19 pandemic., Methods: A web-based survey was disseminated to patients and physicians through a variety of media and healthcare communications from May 2020 to July 2021. Demographic details and attitudes across a range of virtual care domains were collected. Quantitative responses were analyzed descriptively. Open-text responses were gathered to contrast when a virtual visit was superior or inferior to an in-person one, and a thematic content analysis was used., Results: There were 197 patients and 93 physician respondents, representing a range of demographic and practice characteristics. Patients noted several benefits of virtual care and felt it should continue to be available. Physicians felt they could do a lot of their care virtually. Common themes related to the superiority of virtual care were for "quick" visits, reviewing test results, chronic disease monitoring, and medication needs. Virtual care was less ideal when a physical exam was needed, and was not perceived as a good fit for an individual's cultural, language, or emotional needs. Certain conditions were identified as both ideal and non-ideal for the virtual format (e.g. mental healthcare)., Discussion: Certain situations are more amenable to virtual care with personal preferences among both patients and physicians. Future priorities should ensure that virtual care is effective across the range of clinical situations in which it may be used and that both virtual and in-person options are equally available to those who want them., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: JH has received consulting fees from the Health Sciences Centre Foundation for work on virtual care planning. JS receives an honorarium from UPTODATE for a chapter on PTSD., (© The Author(s) 2024.)

COVID-19 has affected healthcare in profound and unprecedented ways, distorting the experiences of patients and healthcare professionals (HCPs) alike. One area that has received little attention is how COVID-19 affected HCPs caring for dying patients. The goal of this study was to examine the experiences of HCPs working with dying patients during the COVID-19 pandemic. Between July 2020-July 2021, we recruited HCPs (N = 25) across Canada. We conducted semi-structured interviews, using a qualitative study design rooted in constructivist grounded theory methodology. The core themes identified were the impact of the pandemic on care utilization , the impact of infection control measures on provision of care , moral distress in the workplace , impact on psychological wellbeing , and adaptive strategies to help HCPs manage emotions and navigate pandemic imposed changes . This is the first Canadian study to qualitatively examine the experiences of HCPs providing care to dying patients during the COVID-19 pandemic. Implications include informing supportive strategies and shaping policies for HCPs providing palliative care.

Objective: The COVID-19 pandemic motivated rapid expansion of virtual care. In Winnipeg, Canada, the authors launched a virtual psychiatric acute care ward (vWARD) to divert patients from hospitalization through daily remote treatment by a psychiatry team using telephone or videoconferencing. This study examined vWARD patient characteristics, predictors of transfer to a hospital, use of acute care postdischarge, and costs of the vWARD compared with in-person hospitalization., Methods: Data for all vWARD admissions from March 23, 2020, to April 30, 2021, were retrieved from program documents and electronic records. Emergency department visits and hospitalizations in the 6 months before admission and the 30 days after discharge were documented. Logistic regression identified factors associated with transfer to a hospital. Thirty-day acute care use after discharge was modeled with Kaplan-Meier curves. A break-even cost analysis was generated with data for usual hospital-based care., Results: The 132 vWARD admissions represented a diverse demographic and clinical population. Overall, 57% involved suicidal behavior, and 29% involved psychosis or mania. Seventeen admissions (13%) were transferred to a hospital. Only presence of psychosis or mania significantly predicted transfer (OR=34.2, 95% CI=3.3-354.6). Eight individuals were hospitalized in the 30 days postdischarge (cumulative survival=0.93). vWARD costs were lower than usual care across several scenarios., Conclusions: A virtual ward is a feasible, effective, and potentially cost-saving intervention to manage acute psychiatric crises in the community and avoid hospitalization. It has benefits for both the health system and the individual who prefers to receive care at home., Competing Interests: The authors report no financial relationships with commercial interests.

Background: Group medical visits (GMVs) have strong evidence of acceptability and effectiveness in the management of chronic medical diseases. Adaptation of GMVs for psychiatric care has potential to increase access, decrease stigma and save costs. Despite promise, this model has not been widely adopted., Methods: A novel GMV pilot was implemented for psychiatric care post-crisis among patients with primary mood or anxiety disorders who required medication management. Participants filled out PHQ-9 and GAD-7 scales at each visit in order to track their progress. After discharge, charts were reviewed for demographics, medication changes and symptom changes. Patient characteristics were compared between those who attended and those who didn't. Changes in total PHQ-9 and GAD-7 scores among attendees were assessed with paired t -tests., Results: Forty-eight patients were enrolled between October 2017 and the end of December 2018, 41 of whom consented to participate. Of those, 10 did not attend, 8 attended but did not complete, and 23 completed. Baseline PHQ-9 and GAD-7 scores did not differ significantly between groups. Significant and meaningful reductions in PHQ-9 and GAD-7 scores from baseline to last visit attended occurred among those who attended at least 1 visit (decrease of 5.13 and 5.26 points, respectively)., Conclusions: This GMV pilot demonstrated feasibility of the model as well as positive outcomes for patients recruited in a post-crisis setting. This model has the potential to increase access to psychiatric care in the face of limited resources, however the failure of the pilot to sustain highlights challenges to be addressed in future pivots., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Palay, Bolton, Sareen and Hensel.)

Background: Winnipeg, Canada operates a 16-bed subacute unit, the Crisis Stabilization Unit (CSU), for voluntary patients in crisis not requiring hospital admission. The virtual CSU (vCSU) launched in March 2020 as an adjunct to the in-person CSU during the COVID-19 pandemic, providing the same resources virtually, allowing patients to remain at home., Methods: Program data were collected for vCSU admissions between April 1, 2020 and April 7, 2021 ( n  = 266) to examine patient characteristics and discharge outcomes. Data were retrieved from the electronic patient record (EPR) for both in-person and vCSU admissions during the same period for comparison ( n  = 712). vCSU admissions ( n  = 191) were summarized by patient demographics, clinical factors/outcomes, and compared on the same measures to in-person CSU admissions ( n  = 521) using binary logistic regression., Results: 30.1% of patients admitted to the vCSU received initial mental health assessment virtually (phone/videoconference), therefore receiving all care at home. Clinical symptoms at assessment included depression/anxiety (39.0%), psychosis/mania (2.7%), suicidal behaviour/self-harm (27.4%), psychosocial event/stressor (19.8%). Average stay was 4.9 days. Compared to the in-person CSU, vCSU referrals were associated with the absence of psychosis [odds ratio (OR).40, 95% confidence interval (CI).18-0.89] and no prior 1-year contact with referral site (OR.43, 95% CI.28-0.64). Those living farther away from the referral site were more likely to receive a vCSU referral., Conclusion: The vCSU model is feasible for a diverse group of patients experiencing mental health crises. Future work is needed to better determine who the model is right for and examine longer term outcomes., (© 2023 Pullia, Clavio, Bolton, Hunzinger, Svenne and Hensel.)

Objectives: The aim of this study was to investigate physician benzodiazepine (BZD) self-use pre-COVID-19 pandemic and to examine changes in BZD self-use during the first year of the pandemic., Design: Population-based retrospective cohort study using linked routinely collected administrative health data comparing the first year of the pandemic to the period before the pandemic., Setting: Province of Ontario, Canada between March 2016 and March 2021., Participants: INTERVENTION: Onset of the COVID-19 pandemic in March 2020., Outcomes Measures: The primary outcome measure was the receipt of one or more prescriptions for BZD, which was captured via the Narcotics Monitoring System., Results: In a cohort of 30 798 physicians (mean age 42, 47.8% women), we found that during the year before the pandemic, 4.4% of physicians had 1 or more BZD prescriptions. Older physicians (6.8% aged 50+ years), female physicians (5.1%) and physicians with a prior mental health (MH) diagnosis (12.4%) were more likely than younger (3.7% aged <50 years), male physicians (3.8%) and physicians without a prior MH diagnosis (2.9%) to have received 1 or more BZD prescriptions. The first year of the COVID-19 pandemic was associated with a 10.5% decrease (adjusted OR (aOR) 0.85, 95% CI: 0.80 to 0.91) in the number of physicians with 1 or more BZD prescriptions compared with the year before the pandemic. Female physicians were less likely to reduce BZD self-use (aOR female =0.90, 95% CI: 0.83 to 0.98) compared with male physicians (aOR male =0.79, 95% CI: 0.72 to 0.87, p interaction =0.046 during the pandemic. Physicians presenting with an incident MH visit had higher odds of filling a BZD prescription during COVID-19 compared with the prior year., Conclusions: Physicians' BZD prescriptions decreased during the first year of the COVID-19 pandemic in Ontario, Canada. These findings suggest that previously reported increases in mental distress and MH visits among physicians during the pandemic did not lead to greater self-use of BZDs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The Coronavirus Disease 2019 (COVID-19) pandemic has exacerbated mental health challenges among physicians and non-physicians. However, it is unclear if the worsening mental health among physicians is due to specific occupational stressors, reflective of general societal stressors during the pandemic, or a combination. We evaluated the difference in mental health and addictions health service use between physicians and non-physicians, before and during the COVID-19 pandemic., Methods and Findings: We conducted a population-based cohort study in Ontario, Canada between March 11, 2017 and August 11, 2021 using data collected from Ontario's universal health system. Physicians were identified using registrations with the College of Physicians and Surgeons of Ontario between 1990 and 2020. Participants included 41,814 physicians and 12,054,070 non-physicians. We compared the first 18 months of the COVID-19 pandemic (March 11, 2020 to August 11, 2021) to the period before COVID-19 pandemic (March 11, 2017 to February 11, 2020). The primary outcome was mental health and addiction outpatient visits overall and subdivided into virtual versus in-person, psychiatrists versus family medicine and general practice clinicians. We used generalized estimating equations for the analyses. Pre-pandemic, after adjustment for age and sex, physicians had higher rates of psychiatry visits (aIRR 3.91 95% CI 3.55 to 4.30) and lower rates of family medicine visits (aIRR 0.62 95% CI 0.58 to 0.66) compared to non-physicians. During the first 18 months of the COVID-19 pandemic, the rate of outpatient mental health and addiction (MHA) visits increased by 23.2% in physicians (888.4 pre versus 1,094.7 during per 1,000 person-years, aIRR 1.39 95% CI 1.28 to 1.51) and 9.8% in non-physicians (615.5 pre versus 675.9 during per 1,000 person-years, aIRR 1.12 95% CI 1.09 to 1.14). Outpatient MHA and virtual care visits increased more among physicians than non-physicians during the first 18 months of the pandemic. Limitations include residual confounding between physician and non-physicians and challenges differentiating whether observed increases in MHA visits during the pandemic are due to stressors or changes in health care access., Conclusions: The first 18 months of the COVID-19 pandemic was associated with a larger increase in outpatient MHA visits in physicians than non-physicians. These findings suggest physicians may have had larger negative mental health during COVID-19 than the general population and highlight the need for increased access to mental health services and system level changes to promote physician wellness., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: MS received speaker fees from AstraZeneca and PT is supported by a Physicians’ Services Incorporated Graham Farquharson Knowledge Translation fellowship. CGL is a CO-PI on a physician wellness grant from the Mach-Gaennslen Foundation matched by the Ottawa Hospital. TM, CGL, CS – The opinions and conclusions expressed are the writers’ own and are not those of the Canadian Medical Association. DTM, RLR, EM, NJ, JH, AXG – These authors have declared that no competing interests exist., (Copyright: © 2023 Myran et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

This study aimed to examine the needs of clients accessing a community mental health crisis stabilization unit (CSU) in Winnipeg, Canada. Sociodemographics, service connections, and need were assessed among CSU clients. The Camberwell Assessment of Need Short Appraisal Schedule - Patient (CANSAS-P) was administered to differentiate need domains that were met and unmet. An ordinal regression examined sociodemographics and level of total unmet need; client characteristics were correlated with unmet need. In total, 271 questionnaires were analyzed. On average, respondents had 6.2 areas of unmet need, with "psychosocial distress" (n = 186, 68.6%), "safety to self" (n = 140, 51.7%), "company" (n = 139, 51.3%), and "physical health" (n = 124, 45.8%) being reported most often. Higher level of unmet need was predicted by disability income and absence of income. Overall, CSU clients had high rates of unmet need reflecting important determinants of health. This information can inform community mental health crisis service delivery to positively impact mental health recovery., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The COVID-19 pandemic was accompanied by the accelerated uptake of virtual care, leading to a proliferation of virtual ward models as alternatives to facility-based care. Early in the pandemic, our program implemented a virtual mental health crisis ward (vWard) to provide options for individuals requiring intense psychiatric and/or crisis support but who preferred to remain in the community and were deemed safe to do so., Objective: The aim of this study was to identify early learnings from the vWard, which was implemented rapidly in a resource-constrained environment, to inform the future state should it be sustained beyond the pandemic., Methods: Mixed methods of data collection were used to evaluate provider perspectives on the vWard, develop archetypes for individuals who are a good fit for the vWard model, and create a driver diagram. Data sources included an anonymous survey of clinical and managerial staff involved in the vWard, a service planning workshop, and program discharge forms for all individuals admitted between March 2020 and April 2021. Survey responses were coded for themes under categories of "benefits" and "challenges." Discharge forms where the team indicated that the vWard was a good fit for an individual were examined for characteristics common to these admissions. These findings were reviewed in the service planning workshop and refined with input from the participants into patient archetypes. A driver diagram was created for the future state., Results: Survey respondents (N=60) represented diverse roles in crisis services and the vWard team. Ten providers took part in the service planning workshop. A total of 467 discharge forms were reviewed. The vWard was felt to be a model that worked by 39 survey respondents, one respondent felt it did not work, and the remaining participants had no response. Several benefits for the individual and the system were identified alongside challenges, including certain processes and materials related to the nature of rapid implementation during the pandemic, and others due to lack of fit for certain individuals. The model was felt to be a good fit for 67.5% of admissions. Four patient archetypes representing a good fit with the model were developed. The driver diagram connected the program aim with primary drivers of (1) reduce barriers to care; (2) improve outcomes; and (3) provide collaborative, patient- and family-centered care to secondary drivers and interventions that leveraged virtual technology among other crisis care interventions., Conclusions: Despite some challenges, the vWard demonstrated high levels of provider acceptance and a range of mechanisms by which the model works for a variety of patient archetypes. These early learnings provide a foundation for growth, sustainability, and spread of this model going forward beyond the pandemic., (©Katherine Lee, Shay-Lee Bolton, Ravit Shterenberg, James M Bolton, Jennifer M Hensel. Originally published in JMIR Formative Research (https://formative.jmir.org), 04.11.2022.)

Background: The coronavirus pandemic necessitated the rapid transition to virtual care. At a 24-h walk-in mental health Crisis Response Centre (CRC) in Winnipeg, Canada we adapted crisis mental health assessments to be offered virtually while the crisis centre also remained open to in person visits. Little is known about the sustainability of virtual visits in the presence of comparable in person care, and which visits are more likely to be done virtually, particularly in the crisis setting., Methods: An analysis of visits to the CRC from the first local lockdown on March 19, 2020 through the third local wave with heightened public health restrictions in June 2021. Analysis of Variance was used to compare the proportion of visits occurring virtually (telephone or videoconference) during the first wave of heightened public health restrictions (lockdown 1) and subsequent lockdowns as well as the in-between periods. A binary logistic regression examined visit, sociodemographic and clinical factors associated with receipt of a virtual visit compared to an in person visit over the first year of the pandemic., Results: Out of 5,357 visits, 993 (18.5%) occurred virtually. There was a significant difference in proportion of virtual visits across the pandemic time periods (F(4, 62) = 8.56, p < .001). The proportion of visits occurring virtually was highest during lockdown 1 (mean 32.6% by week), with no differences between the other time periods. Receipt of a virtual visit was significantly associated with daytime weekday visits, age, non-male gender, living further away from the CRC, no prior year contact with the CRC, and visits that did not feature suicidal behaviour, substance use, psychosis or cognitive impairment., Conclusions: A large proportion of virtual care occurring at the outset of the pandemic reflects public anxiety and care avoidance paired with health system rapid transformation. The use of virtual visits reduced over subsequent pandemic periods but was sustained at a meaningful level. Specific visit, sociodemographic and clinical characteristics are more likely to be present in visits occurring virtually compared to those in person. These results can help to inform the future planning and delivery of virtual crisis care., (© 2022. The Author(s).)

Objective: The life course of children and adolescents with mental disorders is an important area of investigation, yet it remains understudied. This study provides a first-ever comprehensive examination of the relationship between child and adolescent mental disorders and subsequent suicidal and adverse social outcomes in early adulthood using population-based data., Methods: De-identified administrative databases were used to create a birth cohort of 60,838 residents of Manitoba born between April 1980 to March 1985 who were followed until March 2015. Unadjusted and adjusted hazard ratios (aHRs) and odds ratios (aORs) were calculated to determine associations between physician-diagnosed mental disorders in childhood or adolescence and a range of adverse early adulthood (ages 18 to 35) outcomes., Results: Diagnoses of mood/anxiety disorders, attention-deficit hyperactivity disorder, substance use disorder, conduct disorder, psychotic disorder, personality disorders in childhood or adolescence were associated with having the same diagnoses in adulthood. These mental disorder diagnoses in childhood/adolescence were strongly associated with an increased risk of suicidal behaviors and adverse adult social outcomes in adulthood. Similarly, suicide attempts in adolescence conferred an increased risk in adulthood of suicide death (aHR: 3.6; 95% confidence interval [CI]: 1.9-6.9), suicide attempts (aHR: 6.2; CI: 5.0-7.6), social housing use (aHR: 1.7; CI 1.4-2.1), income assistance (aHR: 1.8; CI 1.6-2.1), criminal accusation (aHR: 2.2; CI 2.0-2.5), criminal victimization (aHR:2.5; CI 2.2-2.7), and not completing high school (aOR: 3.1; CI: 2.5-3.9)., Conclusion: Mental disorders diagnosed in childhood and adolescence are important risk factors not only for mental disorders in adulthood but also for a range of early adult adversity. These findings provide an evidence-based prognosis of children's long-term well-being and a rationale for ensuring timely access to mental health services. Better population-level mental health promotion and early intervention for children and adolescents with mental disorders are promising for improving future adult outcomes.

Background: To determine if self-reported baseline psychological distress moderates the association between lifetime psychiatric diagnosis and weight loss 1 year after bariatric surgery. An exploratory analysis assessed change in psychological distress from baseline on weight loss at 1 year., Methods: A retrospective cohort study using data from the Ontario Bariatric Registry for all individuals undergoing surgery between January 1, 2012, and December 31, 2018, with a complete baseline psychological assessment and 1-year post-operative weight recorded (N = 11,159). Multiple linear regressions assessed the relationship between psychiatric diagnosis and percentage of excess body mass index loss (%EBMIL) at 1-year post-surgery, controlling for baseline body mass index, socio-demographics, medical co-morbidities, and surgical complications. Baseline psychological distress, measured with the EQ-5D-5L anxiety/depression rating, was examined as a moderator of this relationship. %EBMIL was separately regressed on change in psychological distress from baseline to 1 year, controlling for psychiatric diagnosis., Results: In the adjusted model, psychiatric diagnosis was associated with lower %EBMIL at 1 year (B =  - 1.00, P = .008). Baseline psychological distress was not a moderator, but had a significant main effect on %EBMIL (B =  - .84, P = .001). Those who experienced a decrease in psychological distress at 1 year, or remained low throughout, fared better than those who increased or had persistently high symptoms., Conclusions: These findings support use of a self-report assessment for psychological distress prior to bariatric surgery. Addressing active psychological distress prior to and/or following surgery may increase the likelihood of successful outcomes., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: Understand the relationship between criminal accusations, victimization, and mental disorders at a population level using administrative data from Manitoba, Canada., Method: Residents aged 18 to 64 between April 1, 2007, and March 31, 2012 ( N = 793,024) with hospital- and physician-diagnosed mental disorders were compared to those without. Overall and per-person rates of criminal accusations and reported victimization in the 2011/2012 fiscal year were examined. Relative risks were calculated, adjusting for age, sex, income, and presence of a substance use disorder. The overlap between diagnosed mental disorders, accusations, and victimization with a χ 2 test of independence was studied., Results: Twenty-four percent ( n = 188,693) of the population had a mental disorder over the 5-year time frame. Four to fifteen percent of those with a mental disorder had a criminal accusation, compared to 2.4% of the referent group. Individuals with mental disorders, especially psychotic or personality disorders, were often living in low-income, urban neighborhoods. The adjusted relative risk of accusations and victimization remained 2 to 5 times higher in those with mental disorders compared to the referent group. Criminal accusations and victimization were most prevalent among individuals with a history of attempted suicide (15.2% had an accusation and 8.1% were victims). The risk of victimization in the same year as a criminal accusation was significantly increased among those with mental disorders compared to those without (χ 2 = 211.8, P < 0.001)., Conclusions: Individuals with mental disorders are at elevated risk of both criminal involvement and victimization. The identification of these multiply-stigmatized individuals may lead to better intervention and support.

Physician assistants (PAs) are a growing group of healthcare providers who could facilitate the adoption of electronic healthcare (e-Health) into practice. In 2018, we conducted a Canada-wide web-based survey study of practicing PAs and student PAs regarding their current exposure to e-Health, as well as their perceived value for its use and interest in future adoption. For this study, e-Health was defined as technology that allows direct communication between patients and healthcare providers or facilitates patient self-management for the purpose of assessment and management. We focused on telehealth, direct messaging (e.g. text, email), patient-directed web-based applications (apps) and patient-provider shared web-based apps. Survey responses were analysed descriptively and compared between practicing and student PAs with Chi-square tests of independence. We also examined correlations between age, exposure, perceived value and interest in future adoption for practicing PAs and student PAs separately. About 186 respondents completed the survey; 145 practicing PAs and 39 student PAs. Fewer than half of respondents had exposure to the studied e-Health modalities. Compared to practicing PAs, student PAs more often perceived value in e-Health and expressed interest in its expanded adoption. In both groups, perceived value frequently correlated significantly with interest in adoption. Student PAs report little formal education during their training, and both practicing PAs and student PAs note a need for infrastructure support, and general knowledge about what is available and safe in order to enable them to expand their use of e-Health in practice. The most interest is present for patient-directed apps and patient-provider shared apps. With workload and remuneration barriers to physician adoption of e-Health, salary-based PAs could have a role in facilitating the integration of e-Health solutions into practice. Additional awareness, exposure and support for PAs to do so are required., (© 2020 John Wiley & Sons Ltd.)

More than 10 million people are imprisoned around the world, with many more who encounter the justice system. However, most studies examining the mental health burden in the justice system have examined only incarcerated individuals, with few looking at both criminal offending and victimization at the population-level. This study aimed to describe the population-level prevalence of mental disorders among the entirety of justice-involved individuals in a Canadian sample. The study was conducted using linked health and justice administrative data for all residents of Manitoba, Canada ages 18-64 between April 1, 2007 and March 31, 2012. All justice involvement (crime accusations and victimizations) and inpatient and outpatient mental disorder diagnoses (mood/anxiety, substance use, psychotic, personality disorders and suicidal behavior) were retrieved. Five-year age- and sex-adjusted prevalence of mental disorders and suicidal behaviour among those with any crime accusation and any victimization were compared to the general population of Manitoba. The study found that age- and sex-adjusted prevalence of any mental disorder was significantly higher among both adults accused of a crime and those victimized (38.9% and 38.6%, respectively) compared to the general population (26.1%). Rate ratios for specific mental disorders and suicidal behaviour were 1.4-3.6 among those accused of a crime, and 1.4-3.7 among those who were victims, compared to the general population. These findings highlight the need for urgent and expanded attention to this intersection of vulnerability. Victimization is especially an area of justice-related health that requires more attention., Competing Interests: Declaration of Competing Interest The authors declare no competing interests., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: To compare the rate of mental disorders (i.e., mood and anxiety, substance use, psychotic disorders) and suicide attempts within the same group of women across the pre-pregnancy, pregnancy, and postpartum periods, and between this perinatal cohort and a non-perinatal reference group., Method: Data were from an administrative repository of residents in Manitoba, Canada. The perinatal cohort consisted of women aged 18 to 45 years who experienced > 1 live birth pregnancy between 2011 and 2014 ( n = 45,362). Pre-pregnancy, pregnancy, and postpartum periods were defined over consecutive 40-week intervals. The non-perinatal cohort consisted of age-matched women with no pregnancies during the same period ( n = 139,705). A reference 40-week interval was defined from the individual's birthdate in the year they entered the cohort. Rate ratios of diagnosed mental disorders were adjusted (aRR) for demographic factors, parity, and mental health history., Results: Within the perinatal cohort, pregnancy was associated with a lower rate of diagnosed mood or anxiety disorder, substance use disorder, and suicide attempt relative to pre-pregnancy (aRR range, 0.22-0.82). Pregnancy also had lower rates of all outcomes compared with the postpartum period (aRR, 0.44-0.87). Postpartum had a higher rate of psychotic disorder compared with pre-pregnancy (aRR, 1.61; 95% CI, 1.17-2.21), but a lower rate of mood or anxiety disorder and suicide attempt. Compared with non-perinatal women, pregnancy was associated with lower rates of all outcomes (aRR range, 0.25-0.87)., Conclusions: Compared with a non-perinatal period, the rate of a diagnosed mental disorder is lower during pregnancy but begins to rise in the postpartum period, highlighting an important period for early identification and rapid access to intervention.

A significant minority of unspecified psychosis presentations progress to schizophrenia. Clinical risk factors can inform targeted referral to specialized treatment programs, but few population studies have examined this. In this study, we used health administrative data for a population-based cohort from Manitoba, Canada to characterize the risk and identify vulnerable subgroups for a future diagnosis of schizophrenia after a diagnosis of unspecified psychotic disorder. Individuals aged 13-60 years with an inpatient or outpatient diagnosis of unspecified psychotic disorder between April 1, 2007 and March 31, 2012, and without any prior diagnosis of schizophrenia or related disorder, were identified (N = 3, 289). The primary outcome was a diagnosis of schizophrenia recorded after the index diagnosis of unspecified psychotic disorder and before March 31, 2015. Adjusted hazard ratios were computed controlling for age, sex, urbanicity, income, prior diagnosis of unspecified psychotic disorder, provider making the diagnosis, prior 12-month psychiatric hospitalization, and prior 12-month diagnoses of mood, anxiety, substance use, or personality disorders, and substance-induced psychosis. A classification tree identified vulnerable subgroups. The cumulative risk of a future diagnosis of schizophrenia was 26% during the follow-up period (mean 4.5 years), with a mean time to diagnosis of 2.0 years. The most vulnerable subgroup was diagnosed by a psychiatrist, younger than 27 years, without a mood or anxiety disorder, male, and residing in a low-income neighborhood; the rate of a subsequent schizophrenia diagnosis was 61.2%. These results support that identification of specific sociodemographic and clinical factors can help clinicians counsel and intervene with those at highest risk., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Purpose of Review: This review summarizes digital health solutions being used for Indigenous mental well-being, with emphasis on available evidence and examples reported in the literature. We also describe our own local experience with a rural telemental health service for Indigenous youth and discuss the unique opportunities and challenges., Recent Findings: Digital health solutions can be grouped into three main categories: (1) remote access to specialists, (2) building and supporting local capacity, and (3) patient-directed interventions. Limited evidence exists for the majority of digital solutions specifically in Indigenous contexts, although examples and pilot projects have been described. Telemental health has the strongest evidence, along with a growing evidence for web-based applications, largely led by Australia. Other digital approaches remain areas of promise requiring additional study. Co-design and service integration and respect for Indigenous history and ideologies are essential for success. While the use of digital health solutions for Indigenous mental well-being holds promise, there is a limited evidence base for most of them. Future efforts to expand the use of digital solutions in this population should adhere to best practices for the delivery of Indigenous health services.

Background: Web-based self-directed mental health applications are rapidly emerging to address health service gaps and unmet needs for information and support., Objective: The aim of this study was to determine if a multicomponent, moderated Web-based mental health application could benefit individuals with mental health symptoms severe enough to warrant specialized mental health care., Methods: A multicenter, pragmatic randomized controlled trial was conducted across several outpatient mental health programs affiliated with 3 hospital programs in Ontario, Canada. Individuals referred to or receiving treatment, aged 16 years or older, with access to the internet and an email address, and having the ability to navigate a Web-based mental health application were eligible. A total of 812 participants were randomized 2:1 to receive immediate (immediate treatment group, ITG) or delayed (delayed treatment group, DTG) access for 3 months to the Big White Wall (BWW), a multicomponent Web-based mental health intervention based in the United Kingdom and New Zealand. The primary outcome was the total score on the Recovery Assessment Scale, revised (RAS-r) which measures mental health recovery. Secondary outcomes were total scores on the Patient Health Questionnaire-9 item (PHQ-9), the Generalized Anxiety Disorder Questionnaire-7 item (GAD-7), the EuroQOL 5-dimension quality of life questionnaire (EQ-5D-5L), and the Community Integration Questionnaire. An exploratory analysis examined the association between actual BWW use (categorized into quartiles) and outcomes among study completers., Results: Intervention participants achieved small, statistically significant increases in adjusted RAS-r score (4.97 points, 95% CI 2.90 to 7.05), and decreases in PHQ-9 score (-1.83 points, 95% CI -2.85 to -0.82) and GAD-7 score (-1.55 points, 95% CI -2.42 to -0.70). Follow-up was achieved for 55% (446/812) at 3 months, 48% (260/542) of ITG participants and 69% (186/270) of DTG participants. Only 58% (312/542) of ITG participants logged on more than once. Some higher BWW user groups had significantly greater improvements in PHQ-9 and GAD-7 relative to the lowest use group., Conclusions: The Web-based application may be beneficial; however, many participants did not engage in an ongoing way. This has implications for patient selection and engagement as well as delivery and funding structures for similar Web-based interventions., Trial Registration: ClinicalTrials.gov NCT02896894; https://clinicaltrials.gov/ct2/show/NCT02896894 (Archived by WebCite at http://www.webcitation.org/78LIpnuRO)., (©Jennifer M Hensel, James Shaw, Noah M Ivers, Laura Desveaux, Simone N Vigod, Ashley Cohen, Nike Onabajo, Payal Agarwal, Geetha Mukerji, Rebecca Yang, Megan Nguyen, Zachary Bouck, Ivy Wong, Lianne Jeffs, Trevor Jamieson, R Sacha Bhatia. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 04.06.2019.)

Background: Depression and anxiety during the postpartum period are common, with psychotherapy often being the preferred method of treatment. However, psychological, physical, and social barriers prevent women from receiving appropriate and timely psychotherapy. The option of receiving psychotherapy through videoconferencing (VC) during the postpartum period presents an opportunity for more accessible and flexible care., Objective: The aim of this study was to assess the feasibility, acceptability, and preliminary effectiveness of optional VC added to usual office-based psychotherapy, with a psychotherapist during the postpartum period., Methods: We conducted a pilot randomized controlled trial with 1:1 randomization to office-based care (treatment as usual; TAU) or office-based care with the option of VC (treatment as usual plus videoconferencing; TAU-VC) for psychotherapy during the postpartum period. We assessed the ability to recruit and retain postpartum women into the study from an urban perinatal mental health program offering postpartum psychotherapy, and we evaluated the uptake, acceptability, and satisfaction with VC as an addition to in-person psychotherapy. We also compared therapy attendance using therapist logs and symptoms between treatment groups. Symptoms were assessed at baseline and 3 months postrandomization with the Edinburgh Postnatal Depression Scale, Generalized Anxiety Disorder 7-item, and Parental Stress Scale. Furthermore, 3-month scores were compared between groups with intention-to-treat linear mixed-effects models controlling for baseline score., Results: We enrolled 38 participants into the study, with 19 participants in each treatment group. Attendance data were available for all participants, with follow-up symptom measures available for 25 out of 38 participants (66%). Among the 19 TAU-VC participants, 14 participants (74%) utilized VC at least once. Most participants were highly satisfied with the VC option, and they reported average savings of Can $26 and 2.5 hours in travel and childcare expenses and time per appointment. There were no significant differences between the 2 groups for psychotherapy attendance or symptoms., Conclusions: The option of VC appears to be an acceptable method of receiving psychotherapy for postpartum women, with benefits described in costs and time savings. On the basis of this small pilot sample, there were no significant differences in outcomes between office-based care with or without the option of VC. This study has demonstrated the feasibility of such a program in an urban center, which suggests that a larger study would be beneficial to provide evidence that is more conclusive., (©Rebecca Yang, Simone N Vigod, Jennifer M Hensel. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 20.05.2019.)

Background: Early research in the area of virtual care solutions with peritoneal dialysis (PD) patients has focused on evaluating the outcomes and impact of these solutions. There has been less attention focused on understanding the factors influencing the uptake, usability, and scalability of virtual care for chronic kidney disease (CKD) patients receiving PD at home., Objective: In this context, a study was undertaken to (1) assess and understand the factors influencing the uptake of a virtual care solution and (2) provide recommendations for the scalability of a virtual care solution aimed at enhancing CKD patients' outcomes and experiences., Methods: This study used a qualitative design with semistructured interviews and a thematic analysis approach. A total of 25 stakeholders-6 patients and 3 caregivers, 6 health care providers, 2 vendors, and 8 health system decision makers-participated in this study., Results: The following three primary mechanisms emerged to influence the usability of the virtual care solution: (1) receiving hands-on training and ongoing communication from a supportive team, (2) adapting to meet user needs and embedding them into workflow, and (3) being influenced by patient and caregiver characteristics. Further, two overarching recommendations were developed for considerations around scalability: (1) co-design locally, embed into the daily workflow, and deploy over time and (2) share the benefits and build the case., Conclusions: Study findings can be used by key stakeholders in their future efforts to enhance the implementation, uptake, and scalability of virtual care solutions for CKD and managing PD at home., (©Lianne Jeffs, Trevor Jamieson, Marianne Saragosa, Geetha Mukerji, Arsh K Jain, Rachel Man, Laura Desveaux, James Shaw, Payal Agarwal, Jennifer M Hensel, Maria Maione, Nike Onabajo, Megan Nguyen, R Bhatia. Originally published in JMIR Human Factors (http://humanfactors.jmir.org), 16.04.2019.)

Background: Web-based mental health applications may be beneficial, but adoption is often low leaving optimal implementation and payment models unclear. This study examined which users were interested in extended access to a web-based application beyond an initial 3-month trial period and evaluated if an additional 3 months of access was beneficial., Methods: This study was a concealed extension of a multi-center, pragmatic randomized controlled trial that assessed the benefit of 3 months of access to the Big White Wall (BWW), an anonymous web-based moderated, multi-component mental health application offering self-directed activities and peer support. Trial participants were 16 years of age or older, recruited from hospital-affiliated mental health programs. Participants who received access to the intervention in the main trial and completed 3-month outcome assessments were offered participation. We compared those who were and were not interested in an extension of the intervention, and re-randomized consenting participants 1:1 to receive extended access or not over the subsequent 3 months. Use of the intervention was monitored in the extension group and outcomes were measured at 3 months after re-randomization in both groups. The primary outcome was mental health recovery as assessed by total score on the Recovery Assessment Scale (RAS-r), as in the main trial. Linear mixed models were used to examine the time by group interaction to assess for differences in responses over the 3-month extension study., Results: Of 233 main trial participants who responded, 119 (51.1%) indicated an interest in receiving extended BWW access. Those who were interested had significantly higher baseline anxiety symptoms compared to those who were not interested. Of the 119, 112 were re-randomized (55 to extended access, 57 to discontinuation). Only 21 of the 55 extended access participants (38.2%) used the intervention during the extension period. Change in RAS-r scores over time was not significantly different between groups (time by group, F(1,77) = 1.02; P = .31)., Conclusions: Only half of eligible participants were interested in extended access to the intervention with decreasing use over time, and no evidence of added benefit. These findings have implications for implementation and payment models for this type of web-based mental health intervention., Trial Registration: Clinicaltrials.gov NCT02896894 . Registered retrospectively on September 12, 2016.

Background: As the increasing prevalence of type 2 diabetes mellitus has put pressure on health systems to appropriately manage these patients, there have been a growing number of mobile apps designed to improve the self-management of diabetes. One such app, BlueStar, has been shown to significantly reduce hemoglobin A 1c (HbA 1c ) levels in small studies and is the first app in the United States to receive Food and Drug Administration approval as a mobile prescription therapy. However, the impact of the app across real-world population among different clinical sites and health systems remains unclear., Objective: The primary objective of this study was to conduct a pragmatic randomized controlled trial of the BlueStar mobile app to determine if app usage leads to improved HbA 1c levels among diverse participants in real-life clinical contexts. We hypothesized that this mobile app would improve self-management and HbA 1c levels compared with controls., Methods: The study consisted of a multicenter pragmatic randomized controlled trial. Overall, 110 participants randomized to the immediate treatment group (ITG) received the intervention for 6 months, and 113 participants randomized to the wait-list control (WLC) group received usual care for the first 3 months and then received the intervention for 3 months. The primary outcome was glucose control measured by HbA 1c levels at 3 months. Secondary outcomes assessed intervention impact on patient self-management, experience of care, and self-reported health utilization using validated scales, including the Problem Areas in Diabetes, the Summary of Diabetes Self-Care Activities, and the EuroQol-5D. Intervention usage data were collected directly from the app., Results: The results of an analysis of covariance controlling for baseline HbA 1c levels did not show evidence of intervention impact on HbA 1c levels at 3 months (mean difference [ITG-WLC] -0.42, 95% CI -1.05 to 0.21; P=.19). Similarly, there was no intervention effect on secondary outcomes measuring diabetes self-efficacy, quality of life, and health care utilization behaviors. An exploratory analysis of 57 ITG participants investigating the impact of app usage on HbA 1c levels showed that each additional day of app use corresponded with a 0.016-point decrease in participants' 3-month HbA 1c levels (95% CI -0.03 to -0.003). App usage varied significantly by site, as participants from 1 site logged in to the app a median of 36 days over 14 weeks (interquartile range [IQR] 10.5-124); those at another site used the app significantly less (median 9; IQR 6-51)., Conclusions: The results showed no difference between intervention and control arms for the primary clinical outcome of glycemic control measured by HbA 1c levels. Although there was low usage of the app among participants, results indicate contextual factors, particularly site, had a significant impact on overall usage. Future research into the patient and site-specific factors that increase app utilization are needed., Trial Registration: Clinicaltrials.gov NCT02813343; https://clinicaltrials.gov/ct2/show/NCT02813343 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT02813343)., (©Payal Agarwal, Geetha Mukerji, Laura Desveaux, Noah M Ivers, Onil Bhattacharyya, Jennifer M Hensel, James Shaw, Zachary Bouck, Trevor Jamieson, Nike Onabajo, Madeline Cooper, Husayn Marani, Lianne Jeffs, R Sacha Bhatia. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 10.01.2019.)

Objective: The role of mental illness and addiction in acute care use for chronic medical conditions that are sensitive to ambulatory care management requires focussed attention. This study examines how mental illness or addiction affects risk for repeat hospitalization and/or emergency department use for ambulatory care-sensitive conditions (ACSCs) among high-cost users of medical care., Method: A retrospective, population-based cohort study using data from Ontario, Canada. Among the top 10% of medical care users ranked by cost, we determined rates of any and repeat care use (hospitalizations and emergency department [ED] visits) between April 1, 2011, and March 31, 2012, for 14 consensus established ACSCs and compared them between those with and without diagnosed mental illness or addiction during the 2 years prior. Risk ratios were adjusted (aRR) for age, sex, residence, and income quintile., Results: Among 314,936 high-cost users, 35.9% had a mental illness or addiction. Compared to those without, individuals with mental illness or addiction were more likely to have an ED visit or hospitalization for any ACSC (22.8% vs. 19.6%; aRR, 1.21; 95% confidence interval [CI], 1.20-1.23). They were also more likely to have repeat ED visits or hospitalizations for the same ACSC (6.2% vs. 4.4% of those without; aRR, 1.48; 95% CI, 1.44-1.53). These associations were stronger in stratifications by mental illness diagnostic subgroup, particularly for those with a major mental illness., Conclusions: The presence of mental illness and addiction among high-cost users of medical services may represent an unmet need for quality ambulatory and primary care.

Purpose: Depression comorbid with cardiovascular disease is associated with higher rates of morbidity and mortality, with studies suggesting that this is especially true among women. This study examined depressive symptoms and their relationship to cardiac risk factors among women referred to a women's cardiac rehabilitation and primary prevention program., Methods: A secondary analysis of data collected between 2004 and 2014 for 1075 women who completed a baseline assessment at the Women's Cardiovascular Health Initiative, a women-only cardiac rehabilitation and prevention program in Toronto, Canada. Descriptive statistics for sociodemographic variables, quality of life (SF-36), and cardiac risk factors were stratified by depression symptom severity using cutoff scores from the Beck Depression Inventory-2nd version (BDI-II) and compared with analysis of variance and χ statistics. Prevalence of antidepressant use among those with moderate to high depressive symptoms was assessed as an indicator of under- or untreated depression., Results: Overall, 38.6% of women scored above the BDI-II cutoff for depression; 23.6% in the moderate or severe range. Socioeconomic status and quality of life decreased with increasing depression severity. Body mass index increased with depressive severity (P < .001), as did the percentage of individuals with below target age predicted fitness (P < .001). Only 39.0% of women in the moderate and severe BDI-II groups were taking antidepressants., Conclusion: In this sample, we found a significant prevalence of untreated and undertreated depressive symptoms among women with, or at high risk of developing, cardiovascular disease. Additional strategies are needed to identify these patients early and link them to appropriate treatment.

Background: The use of electronic consultation (e-consult) between primary care providers (PCPs) and psychiatrists has potential, given the high prevalence of mental health issues in primary care and problematic access to specialist care. Utilization and uptake, however, appears to be lower than would be expected., Objective: This study aimed to examine actual utilization of e-consult between PCPs and psychiatrists and investigate the perceptions of PCPs about this form of psychiatric advice to inform how to optimize the utility and thereby the uptake of this service., Methods: In this mixed-methods study, we conducted a chart review of psychiatry e-consults (N=37) over 2 platforms during early implementation in Ontario, Canada, as well as 3 group interviews and 1 individual interview with PCPs (N=10) with variable experience levels and from a range of practice settings. The chart review assessed response times and referral content including the type of request, referral attachments, and consultant responses. Interviews explored the perceptions of the PCPs about the uses and barriers of psychiatry e-consult. Thematic content analysis of interview data identified common themes as well as themes unique to different provider profiles (eg, experienced PCPs vs new PCPs and rural vs urban practice). On the basis of interpretation of the quantitative and qualitative findings, we developed recommendations for the optimization of psychiatry e-consultation services., Results: During the study period, psychiatry e-consults comprised 3.66% (49/1339) of all e-consults submitted on the studied platforms. Among the e-consults reviewed, different psychiatric diagnoses were represented: 70% of requests (26/37) queried about medication safety or side effects, whereas 59% (22/37) asked about psychiatric symptom management. Moreover, 81% (30/37) of e-consults were answered within 24 hours, and 65% (24/37) were addressed in a single exchange. Themes from the interview data included psychiatry having a complexity that differentiates it from other specialties and may limit the utility of e-consult, other than for psychopharmacology advice. Variability in awareness exists in the way e-consultation could be used in psychiatry, with new PCPs feeling unsure about the appropriateness of a question. In general, new PCPs and PCPs practicing in rural areas were more receptive to psychiatry e-consult. PCPs viewed e-consult as an opportunity to collaborate and desired that it be integrated with other available services. Recommendations include the need for appropriate specialist staffing to address a wide range of requests, adequate education to referrers regarding the use of psychiatry e-consult, and the need to integrate psychiatry e-consult with other geographically relevant services, given the complexity of psychiatric issues., Conclusions: E-consult is a viable and timely way for PCPs to get much-needed psychiatric advice. For optimizing its utility and uptake, e-consult needs to be integrated into reliable care pathways with adequate referrer and consultant preparation., (©Jennifer M Hensel, Rebecca Yang, Minnie Rai, Valerie H Taylor. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 06.04.2018.)

Objective: To understand whether high-cost users of medical care with and without comorbid mental illness or addiction differ in terms of their sociodemographic and health characteristics. Unique characteristics would warrant different considerations for interventions and service design aimed at reducing unnecessary health care utilization and associated costs., Methods: From the top 10% of Ontarians ranked by total medical care costs during fiscal year 2011/2012 (N = 314,936), prior 2-year mental illness or addiction diagnoses were determined from administrative data. Sociodemographics, medical illness characteristics, medical costs, and utilization were compared between those high-cost users of medical care with and without comorbid mental illness or addiction. Odds of being a frequent user of inpatient (≥3 admissions) and emergency (≥5 visits) services were compared between groups, adjusting for age, sex, socioeconomic status and medical illness characteristics., Results: High-cost users of medical care with comorbid mental illness or addiction were younger, had a lower socioeconomic status, had greater historical medical morbidity, and had higher total medical care costs (mean excess of $2,031/user) than those without. They were more likely to be frequent users of inpatient (12.8% vs 10.2%; adjusted OR, 1.14; 95% CI: 1.12-1.17) and emergency (8.4% vs 4.8%; adjusted OR, 1.55; 95% CI: 1.50-1.59) services. Effect sizes were larger in major mood, psychotic, and substance use disorder subgroups., Conclusions: High-cost medical care users with mental illness or addiction have unique characteristics with respect to sociodemographics and service utilization patterns to consider in interventions and policies for this patient group., (Copyright © 2018 Academy of Consultation-Liaison Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Management of diabetes through improved glycemic control and risk factor modification can help prevent long-term complications. Much diabetes management is self-management, in which healthcare providers play a supporting role. Well-designed e-Health solutions targeting behavior change can improve a range of measures, including glycemic control, perceived health, and a reduction in hospitalizations., Methods: The primary objective of this study is to evaluate if a mobile application designed to improve self-management among patients with type 2 diabetes (T2DM) improves glycemic control compared to usual care. The secondary objectives are to determine the effects on patient experience and health system costs; evaluate how and why the intervention worked as observed; and gain insight into considerations for system-wide scale-up. This pragmatic, randomized, wait-list-control trial will recruit adult participants from three Diabetes Education Programs in Ontario, Canada. The primary outcome is glycemic control (measured by HbA1c). Secondary outcomes include patient-reported outcomes and patient-reported experience measures, health system utilization, and intervention usability. The primary outcome will be analyzed using an ANCOVA, with continuous secondary outcomes analyzed using Poisson regression. Direct observations will be conducted of the implementation and application-specific training sessions provided to each site. Semi-structured interviews will be conducted with participants, healthcare providers, organizational leaders, and system stakeholders as part of the embedded process evaluation. Thematic analysis will be applied to the qualitative data in order to describe the relationships between (a) key contextual factors, (b) the mechanisms by which they effect the implementation of the intervention, and (c) the impact on the outcomes of the intervention, according to the principles of Realist Evaluation., Discussion: The use of mobile health and virtual tools is on the rise in health care, but the evidence of their effectiveness is mixed and their evaluation is often lacking key contextual data. Results from this study will provide much needed information about the clinical and cost-effectiveness of a mobile application to improve diabetes self-management. The process evaluation will provide valuable insight into the contextual factors that influence the application effectiveness, which will inform the potential for adoption and scale., Trial Registration: Clinicaltrials.gov NCT02813343 . Registered on 24 June 2016 (retrospectively registered). Trial Sponsor: Ontario Telemedicine Network.

Background: Mental illness is a substantial and rising contributor to the global burden of disease. Access to and utilization of mental health care, however, is limited by structural barriers such as specialist availability, time, out-of-pocket costs, and attitudinal barriers including stigma. Innovative solutions like virtual care are rapidly entering the health care domain. The advancement and adoption of virtual care for mental health, however, often occurs in the absence of rigorous evaluation and adequate planning for sustainability and spread., Methods: A pragmatic randomized controlled trial with a nested comparative effectiveness arm, and concurrent realist process evaluation to examine acceptability, effectiveness, and cost-effectiveness of the Big White Wall (BWW) online platform for mental health self-management and peer support among individuals aged 16 and older who are accessing mental health services in Ontario, Canada. Participants will be randomized to 3 months of BWW or treatment as usual. At the end of the 3 months, participants in the intervention group will have the opportunity to opt-in to an intervention extension arm. Those who opt-in will be randomized to receive an additional 3 months of BWW or no additional intervention. The primary outcome is recovery at 3 months as measured by the Recovery Assessment Scale-revised (RAS-r). Secondary outcomes include symptoms of depression and anxiety measured with the Personal Health Questionnaire-9 item (PHQ-9) and the Generalized Anxiety Disorder Questionnaire-7 item (GAD-7) respectively, quality of life measured with the EQ-5D-5L, and community integration assessed with the Community Integration Questionnaire. Cost-effectiveness evaluations will account for the cost of the intervention and direct health care costs. Qualitative interviews with participants and stakeholders will be conducted throughout., Discussion: Understanding the impact of virtual strategies, such as BWW, on patient outcomes and experience, and health system costs is essential for informing whether and how health system decision-makers can support these strategies system-wide. This requires clear evidence of effectiveness and an understanding of how the intervention works, for whom, and under what circumstances. This study will produce such effectiveness data for BWW, while simultaneously exploring the characteristics and experiences of users for whom this and similar online interventions could be helpful., Trial Registration: Clinicaltrials.gov NCT02896894 . Registered on 31 August 2016 (retrospectively registered).

Background: Studies worldwide have reported an increased prevalence of abuse histories among bariatric surgery candidates. The impact of abuse history on weight loss after surgery has not been examined in Canada., Objectives: Determine the prevalence of abuse and its impact on postoperative outcomes in Ontario, Canada., Setting: Data from the Ontario Bariatric Registry., Methods: A retrospective cohort study of laparoscopic gastric bypass and sleeve gastrectomy surgeries from 2010 to 2014, for which any follow-up data were available (N = 6016). Weight loss outcomes at 3 months (n = 5147), 6 months (n = 4749), and 1 year (n = 4024) were compared between those with and without a self-reported history of any of emotional, physical or sexual abuse and those with and without a history of sexual abuse specifically. Mixed repeated measures models were adjusted for age, sex, type of surgery, and baseline body mass index. One-year postoperative occurrence of revisions or repairs, hospitalization, and death were also examined., Results: The prevalence of documented abuse was 21.5%. Emotional abuse was most common (13.1%), followed by sexual abuse (10.6%), then physical abuse (8.9%). There was no significant association between presence of abuse history and weight loss at any time point in repeated measures analyses., Conclusion: Abuse histories are common in bariatric surgery candidates in Ontario, but at a lower prevalence than what has been reported elsewhere. History of abuse does not appear to affect weight loss out to 1 year postoperatively and may alert providers to offer additional support perioperatively and postoperatively, particularly in the setting of psychiatric co-morbidity., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: With rising availability and use of Internet and mobile technology in society, the demand and need for its integration into health care is growing. Despite great potential within mental health care and growing uptake, there is still little evidence to guide how these tools should be integrated into traditional care, and for whom., Objective: To examine factors that might inform how e-communication should be implemented in our local outpatient mental health program, including barriers to traditional office-based care, patient preferences, and patient concerns., Methods: We conducted a survey in the waiting room of our outpatient mental health program located in an urban, academic ambulatory hospital. The survey assessed (1) age, mobile phone ownership, and general e-communication usage, (2) barriers to attending office-based appointments, (3) preferences for, and interest in, e-communication for mental health care, and (4) concerns about e-communication use for mental health care. We analyzed the data descriptively and examined associations between the presence of barriers, identifying as a social media user, and interest level in e-communication., Results: Respondents (N=68) were predominantly in the age range of 25-54 years. The rate of mobile phone ownership was 91% (62/68), and 59% (40/68) of respondents identified as social media users. There was very low existing use of e-communication between providers and patients, with high levels of interest endorsed by survey respondents. Respondents expressed an interest in using e-communication with their provider to share updates and get feedback, coordinate care, and get general information. In regression analysis, both a barrier to care and identifying as a social media user were significantly associated with e-communication interest (P=.03 and P=.003, respectively). E-communication interest was highest among people who both had a barrier to office-based care and were a social media user. Despite high interest, there were also many concerns including privacy and loss of in-person contact., Conclusions: A high burden of barriers to attending office-based care paired with a high interest in e-communication supports the integration of e-communication within our outpatient services. There may be early adopters to target: those with identified barriers to office-based care and who are active on social media. There is also a need for caution and preservation of existing services for those who choose not to, or cannot, access e-services.

Objective: To quantify the burden of mental illness and addiction among high-costing users of medical services (HCUs) using population-level data from Ontario, and compare to a referent group of nonusers., Method: We conducted a population-level cohort study using health administrative data from fiscal year 2011-2012 for all Ontarians with valid health insurance as of April 1, 2011 (N = 10,909,351). Individuals were grouped based on medical costs for hospital, emergency, home, complex continuing, and rehabilitation care in 2011-2012: top 1%, top 2% to 5%, top 6% to 50%, bottom 50%, and a zero-cost nonuser group. The rate of diagnosed psychotic, major mood, and substance use disorders in each group was compared to the zero-cost referent group with adjusted odds ratios (AORs) for age, sex, and socioeconomic status. A sensitivity analysis included anxiety and other disorders., Results: Mental illness and addiction rates increased across cost groups affecting 17.0% of the top 1% of users versus 5.7% of the zero-cost group (AOR, 3.70; 95% confidence interval [CI], 3.59 to 3.81). This finding was most pronounced for psychotic disorders (3.7% vs. 0.7%; AOR, 5.07; 95% CI, 4.77 to 5.38) and persisted for mood disorders (10.0% vs. 3.3%; AOR, 3.52; 95% CI, 3.39 to 3.66) and substance use disorders (7.0% vs. 2.3%; AOR, 3.82; 95% CI, 3.66 to 3.99). When anxiety and other disorders were included, the rate of mental illness was 39.3% in the top 1% compared to 21.3% (AOR, 2.39; 95% CI, 2.34 to 2.45)., Conclusions: A high burden of mental illness and addiction among HCUs warrants its consideration in the design and delivery of services targeting HCUs., (© The Author(s) 2016.)

Aim: The aim of this study was to fill a gap in the literature by examining agreement on need as rated by clients and their key workers from first-episode psychosis early intervention programmes. Compared with adult populations and more chronic courses of illness, these clients may have unique needs given the onset of their illness in adolescence or early adulthood., Methods: Needs agreement between clients and key workers was assessed using the Camberwell Assessment of Need in a sample of 188 client-key worker pairs recruited from six early intervention programmes in Ontario, Canada. Ratings were assessed with percentage agreement and prevalence-adjusted Cohen's kappa., Results: At the aggregate level, both clients and key workers rated a mean of 2.6 unmet needs. Compared with other diagnoses, key workers rated significantly more unmet need in clients with primary psychotic disorders. Agreement between individual client and key worker ratings was highest (adjusted κ > 0.85) in the domains of telephone, risk to others, child care and accommodation. Lowest agreement (adjusted κ < 0.4) was found in the domains of psychological distress, sexual expression, company, daytime activities and intimate relationships., Conclusions: While congruence is present in concrete domains, there is substantial variability in how clients and their key workers perceive need in more personal areas. The initial focus of care may necessarily be on needs such as shelter, food and treatment; however, subsequent care should incorporate a shared assessment of need to support strong relationships with providers and ongoing engagement in treatment., (© 2014 Wiley Publishing Asia Pty Ltd.)

Integrating care for physical health and behavioural health (mental health and addictions) has been a longstanding challenge, although research supports the clinical and cost effectiveness of integrated care for many clients. In one such model, primary care (PC) physicians work with specialist physicians and non-physician providers (NPPs) to provide mental health and addictions care in PC settings. This Ontario, Canada-focused policy analysis draws on research evidence to examine potential barriers and enablers to this model of integrated care, focusing on mental health. Funding challenges pertain to incentivizing PC physicians to select patients with mental illness, include NPPs on the treatment team, and collaborate with specialist providers. Legal/regulatory challenges pertain to NPP scopes of practice for prescribing and counselling. Integrated care also requires revising the role of the physician and distribution of functions among the team. Policy support to integrate addictions treatment in PC may face similar challenges but requires further exploration.

Revisions to the posttraumatic stress disorder (PTSD) diagnostic criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) clarify that secondary exposure can lead to the development of impairing symptoms requiring treatment. Historically known as secondary traumatic stress (STS), this reaction occurs through repeatedly hearing the details of traumatic events experienced by others. Professionals who work therapeutically with trauma victims may be at particular risk for this exposure. This meta-analysis of 38 published studies examines 17 risk factors for STS among professionals indirectly exposed to trauma through their therapeutic work with trauma victims. Small significant effect sizes were found for trauma caseload volume (r = .16), caseload frequency (r = .12), caseload ratio (r = .19), and having a personal trauma history (r = .19). Small negative effect sizes were found for work support (r = -.17) and social support (r = -.26). Demographic variables appear to be less implicated although more work is needed that examines the role of gender in the context of particular personal traumas. Caseload frequency and personal trauma effect sizes were moderated by year of publication. Future work should examine the measurement of STS and associated impairment, understudied risk factors, and effective interventions., (Copyright © 2015 International Society for Traumatic Stress Studies.)

There is evidence to suggest that people with serious mental illness (SMI) have lower access to tertiary care than patients without SMI, particularly when care is complex. Barriers are present at the level of the individual, providers, and the health care system. High levels of co-morbidity and the associated health care costs, along with a growing focus on facilitating equal access to quality care for all, urges health care systems to address existing gaps. Some interventions have been successful at improving access to primary care for patients with SMI, but relatively little research has focused on access to complex interventions. This paper summarizes the scope of the problem regarding access to complex tertiary medical care among people with SMI. Barriers are discussed and potential solutions are proposed. Policies and programs must be developed, implemented, and evaluated to determine cost-effectiveness and impact on outcomes.

Many direct support providers (DSPs) are exposed to aggressive behaviour in their work supporting adults with developmental disabilities service recipients. This is a work environment factor that has been linked to job burnout. The objective of this study was to examine the impact of positive work factors on emotional exhaustion (EE) among DSPs who are exposed to aggressive behaviour. Survey responses from 671 DSPs who were working in community service settings for adults with developmental disabilities, and were exposed to aggressive behaviour at least monthly were examined. Hierarchical linear regression examined the direct contribution and moderating role of positive work factors (self-efficacy for dealing with aggression and work contributions) on EE measured with the Maslach Burnout Inventory-Human Services Survey, after controlling for demographics, occupational variables, exposure to aggression and negative emotional reactions to aggression. Results showed that younger age, more experience, more depression/anger emotions in response to aggression, lower self-efficacy and low positive work contributions were significantly associated with EE. Positive work motivation was a moderator of exposure to aggression and EE. When work motivations were low, DSPs were more negatively affected by higher exposure to aggression. These findings suggest that in addition to addressing the negative emotional reactions to the aggressive behaviour encountered at work, it is also important to foster positive work factors which may be protective against EE., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Experiencing aggressive behaviour has been associated with increased stress and turnover among staff who support adults with intellectual disabilities. Incident perception is a strong predictor of psychological outcomes after trauma but has not been studied in this staff group. This study clustered exposure to aggression and endorsement of emotional difficulties among 386 community residential group home staff and evaluated the contribution of four behavioural topographies to staff-rated perceived severity. Staff exposure varied considerably. Perceived severity correlated with subjective emotional difficulties. High perceived severity was associated with daily exposure, aggression towards others causing injury, and property aggression causing injury or damage. Therefore, the role the staff plays, whether a witness or target, may impact their experience.

Aims and Objectives: To compare exposure to client aggressive behaviour, perceived self-efficacy in managing this behaviour and burnout between community residential group home and specialised hospital inpatient staff who provide care for adults with intellectual disabilities (ID). To assess the mediating role of aggression exposure on burnout in these two staff groups., Background: Aggressive behaviour is a common indication for admission to hospital so these staff typically experience more frequent and severe forms compared to staff working in the community. There have been mixed results in few studies examining burnout and perceived self-efficacy between these two groups., Design: This study used a demographically matched sample of cross-sectional survey data from community residential group home and hospital staff who care for adults with ID in Ontario, Canada., Methods: Exposure to aggression, perceived self-efficacy and burnout were compared for 42 matched pairs using descriptive statistics. A mediation analysis was used to examine the role of aggression severity in the relationship between care setting and burnout., Results: Hospital staff were exposed to more severe client aggression and scored higher in emotional exhaustion (EE). There were no differences in perceived self-efficacy. Severity of aggression was a partial mediator of the higher EE among hospital staff., Conclusions: Exposure to more severe forms of client aggression among hospital staff contributes, at least in part, to them feeling more emotionally exhausted. This study contributes to further understanding exposure to aggression in these different settings and the impact it can have on emotional outcomes., Relevance to Clinical Practice: There may be a role for policy and resource development aimed at reducing aggression and preventing or managing the associated emotional consequences. This is particularly true in hospitals, where aggression is most severe., (© 2013 John Wiley & Sons Ltd.)

Background: Studies have shown that staff who support adults with intellectual disabilities (ID) are exposed to challenging behaviour in their work including client aggression. Exposure to aggressive behaviour has been associated with staff stress and burnout. Study samples have been small however, and there has been very little data exploring this issue among North American staff., Methods: A cross-sectional survey which included demographics, measures of frequency and severity (including perceived severity and a standardised severity score) of exposure to client aggression and the Maslach Burnout Inventory - Human Services Survey (MBI-HSS) was completed by 926 community staff who support adults with ID in Ontario, Canada. Relationships between demographic variables and exposure to aggression were examined with descriptive statistics. Pearson correlations were used to analyse exposure variables and MBI-HSS scores., Results: Nearly all staff reported being exposed to client aggression in the prior 6 months. Mean MBI-HSS scores were comparable to previously published data in similar populations with the exception of a higher score in the personal accomplishment domain. All measures of exposure to aggression were significantly positively correlated with MBI-HSS scores in the emotional exhaustion and depersonalisation dimensions of burnout., Conclusions: The prevalence of burnout in this North American sample is comparable to what has been reported in similar populations in other locations, although these staff may have a higher sense of accomplishment with regard to their work. Findings from this large sample support the evidence that exposure to client aggression affects staff emotional well-being but is by no means the only important factor. Further study is needed to explore the differences and similarities reported here as well as other contributing factors which will guide the implementation of effective strategies to improve staff well-being., (© 2011 The Authors. Journal of Intellectual Disability Research © 2011 Blackwell Publishing Ltd.)

Background: Psychological morbidity following trauma occurring in the workplace can impact return to work but few studies have investigated this., Methods: This study was a secondary analysis of administrative data from a specialized workers' compensation board psychological trauma program in Toronto, Canada. Unadjusted and adjusted logistic regression analyses were used to examine factors associated with working status at the time of assessment for workers referred within 1 year of traumatic event., Results: Having a disrupted marriage (OR = 3.06, 95% CI 1.14-8.20), sustaining a permanently impairing physical injury (OR = 2.76, 95% CI 1.01-7.55) and the presence of secondary psychiatric diagnoses (OR = 2.55, 95% CI 1.34-4.83) were significantly associated with not working at the time of assessment. When the analyses were subset to workers without permanently impairing physical injuries, only the presence of additional psychiatric diagnoses was significantly associated with not working (OR = 3.81, 95% CI 1.48-9.83)., Conclusions: Return to work after trauma can be a complicated and difficult to treat problem. Social supports, physical rehabilitation and treatment of complex mental health problems likely play a crucial role in improving outcomes., (Copyright © 2011 Wiley-Liss, Inc.)

Purpose: Endorectal coil (ERC) magnetic resonance imaging (MRI) provides superior visualization of the prostate compared with computed tomography at the expense of deformation. This study aimed to develop a multiorgan finite element deformable method, Morfeus, to accurately co-register these images for radiotherapy planning., Methods: Patients with prostate cancer underwent fiducial marker implantation and computed tomography simulation for radiotherapy planning. A series of axial MRI scans were acquired with and without an ERC. The prostate, bladder, rectum, and pubic bones were manually segmented and assigned linear elastic material properties. Morfeus mapped the surface of the bladder and rectum between two imaged states, calculating the deformation of the prostate through biomechanical properties. The accuracy of deformation was measured as fiducial marker error and residual surface deformation between the inferred and actual prostate. The deformation map was inverted to deform from 100 cm(3) to no coil., Results: The data from 19 patients were analyzed. Significant prostate deformation occurred with the ERC (mean intrapatient range, 0.88 +/- 0.25 cm). The mean vector error in fiducial marker position (n = 57) was 0.22 +/- 0.09 cm, and the mean vector residual surface deformation (n = 19) was 0.15 +/- 0.06 cm for deformation from no coil to 100-cm(3) ERC, with an image vector resolution of 0.22 cm. Accurately deformed MRI scans improved soft-tissue resolution of the anatomy for radiotherapy planning., Conclusions: This method of multiorgan deformable registration enabled accurate co-registration of ERC-MRI scans with computed tomography treatment planning images. Superior structural detail was visible on ERC-MRI, which has potential for improving target delineation.

Background: Rural regions of industrialized nations are experiencing a crisis in health care access, reflecting a high disease burden and a low physician supply. The maldistribution of physicians stems partly from the low rate of entry into medical school of applicants from rural backgrounds., Methods: We analyzed applicants to the University of Toronto medical school in 2005 (n = 2052) to test for possible institutional bias against rural applicants and possible applicant bias against the institution. The designation of rurality was assigned using the Statistics Canada classification of residential postal codes to detect residence in communities with a population of fewer than 10,000 people., Results: Consistent with past reports, rural applicants were under-represented (n = 93, 4.5% of applicants relative to 20% of baseline population). Rural applicants, on average, were equally competitive with urban applicants as measured by grades, test scores, and interviews. Rural applicants were just as likely as urban applicants to be offered admission (17% vs 14%, p = 0.43), indicating no large bias from the institution. Rural applicants, however, were more than twice as likely to decline the admission offer (69% vs 24%, p < 0.001), indicating a large bias against the institution. This discrepancy was not explained by financial disparity and was not confined to those applicants most likely to receive invitations to other schools., Conclusions: Programs to increase physician supply in rural areas need to address students' concealed preferences that are established before enrolment. Medical schools, in particular, need to encourage more rural students to apply and to persuade those offered admission to accept.

Diverse studies have shown that magnetic fields can affect behavioral and physiological functions. Previously, we have shown that sinusoidal extremely low frequency magnetic fields and specific pulsed magnetic fields (Cnps) can produce alterations in the analgesia-related behavior of the land snail. Here, we have extended these studies to show an induction of analgesia in mice equivalent to a moderate dose of morphine (5 mg/kg), and the effect of both Cnp exposure and morphine injection on some open-field activity. Cnp exposure was found to prolong the response latency to a nociceptive thermal stimulus (hot plate). Cnp+morphine offset the increased movement activity found with morphine alone. These results suggest that pulsed magnetic fields can induce analgesic behavior in mice without the side effects often associated with opiates like morphine.

Abdominoplasty is a popular body-contouring procedure. In this study the authors review retrospectively 199 abdominoplasty patients during a 15-year period to identify factors that affect overall outcome. Patients included 190 women and 9 men. The complication rate was 32% with few major complications (1.4%). The revision rate was 43%, and was related to fine-tuning the aesthetic appearance. Patients were divided into four groups based on tobacco use and history of diabetes and hypertension. There was no significant difference in revision rates or major complications between the subgroups. Minor complication rates, however, were significantly higher in smokers and patients with diabetes and/or hypertension. Complication and revision rates in patients undergoing intra-abdominal procedures combined with abdominoplasty were not significantly different from those patients undergoing abdominoplasty alone. A patient survey revealed symptom improvement in 95% of patients. Eighty-six percent of patients were satisfied with their result, and 86% would recommend abdominoplasty to a friend. The authors conclude that abdominoplasty is a safe and satisfying procedure, whether performed alone or in conjunction with another procedure. Patients are pleased with the outcome and have improvement in their symptoms, with minimal health risk. There is, however, a significant incidence of minor complications, related primarily to wound healing. These complications are increased significantly in smokers and patients with diabetes and/or hypertension. Revision rates are not different significantly between the subgroups. When complications do occur or revisions are required, they are minor and managed easily in an office setting.