La continuité des soins : une solution? Perspective des personnes avec comorbidité

Les auteures présentent une réflexion sur les limites actuelles du concept de continuité des soins et les difficultés que pose sa détermination du point de vue de la personne utilisatrice. Les évidences entourant ce concept sont également remises en question. Cette réflexion prend ancrage dans les résultats préliminaires d'une étude en cours portant sur la continuité des soins auprès d'une clientèle avec un double diagnostic de trouble mental et de toxicomanie.Continuity of care: a solution? Perspective of people with dual disorders The authors discuss the current limits of the concept of continuity of care and the difficulties set by its determination from the perspective of the consumer. Obvious facts around this concept are also questionned. This reflection is anchored in preliminary results of an ongoing study on continuity of care with people with a dual diagnosis of mental disorder and substance abuse.La continuidad de cuidados: ¿hasta una solución? Perspectivas de personas con comorbosidad Los autores presentan una reflexión sobre los limites actuales del concepto de continuidad de los cuidados y las dificultadas que plantean su determinación del punto de vista de la persona utilizadora. Vuelven a discutir las evidencias rodeando el concepto. Esta reflexión esta anclada en los resultados preliminarios de una investigación pendiente sobre la continuidad de los cuidados con una clientela con un diagnóstico doble de salud mental y de toxicomanía.A continuidade dos serviços de saúde seria uma solução? Perspectiva das pessoas que sofrem de co-morbidade As autoras fazem uma reflexão sobre os limites atuais do conceito de continuidade dos serviços de saúde e das dificuldades que sua determinação ocasiona do ponto de vista do usuário. Elas também questionam as evidências que envolvem este conceito. Esta reflexão baseia-se nos resultados preliminares de um estudo ainda em andamento, sobre a continuidade dos serviços de saúde junto à uma clientela com duplo diagnóstico, de problemas mentais e de toxicomania

La dépression majeure en première ligne et les impacts cliniques des stratégies d’intervention : une revue de la littérature

La dépression majeure représente un trouble mental fréquent qui s’accompagne d’un taux de morbidité et de mortalité important. Malgré cela, la dépression majeure demeure sous-diagnostiquée et sous-traitée. Sur le plan du traitement, il apparaît actuellement souhaitable pour des raisons de meilleur pronostic, de cibler résolument la rémission des symptômes dépressifs et le retour rapide au fonctionnement optimal de l’individu. L’article présente une revue systématique de la littérature sur les impacts cliniques de stratégies d’intervention qui visent l’amélioration des services offerts aux personnes atteintes de dépression majeure et consultant en première ligne. Les auteurs se basent sur 41 études qui comportent une mesure des impacts cliniques des stratégies d’intervention mises en oeuvre. L’utilisation de stratégies d’intervention complexes favorise l’obtention de résultats positifs. Les auteurs suggèrent plusieurs pistes de recherche pour améliorer les connaissances actuelles.Major or clinical depression represents a frequent mental illness that is often associated with a high level of morbidity and mortality. Yet, major depression remains under-diagnosed and under-treated. On the level of treatment, it would appear desirable for reasons of better prognosis, to aim more than the simple reduction of depressive symptoms and target their remission resolutely and the fastest return to the individual’s optimal functioning. This article presents a systematic review of the literature relating to the clinical impacts of treatment strategies aiming at the improvement of services offered to people who suffer of clinical depression and who consult in primary care. The authors summarize results drawn from 41 studies that include a measurement of the clinical impacts (reduction of symptoms, response, remission and functioning) of various treatment strategies. It appears that using complex treatment strategies favour positive outcomes. The authors propose various paths of research to further increase current knowledge.La depresión mayor representa un trastorno mental frecuente que es acompañada de una tasa de morbilidad y mortalidad importante. A pesar de ello, la depresión mayor sigue siendo subdiagnosticada y subtratada. En el plano del tratamiento, parece actualmente deseable, por razones de mejor pronóstico, buscar resueltamente la remisión de los síntomas depresivos y el retorno rápido al funcionamiento óptimo del individuo. El artículo presenta una reseña sistemática de la literatura sobre los impactos clínicos de estrategias de intervención que buscan el mejoramiento de los servicios ofrecidos a las personas que sufren de depresión mayor y que consultan en servicios de primer nivel. Los autores se basan en 41 estudios que comprenden una medida de los impactos clínicos de las estrategias de intervención implementadas. La utilización de estrategias de intervención complejas favorece la obtención de resultados positivos. Los autores sugieren varias pistas de investigación para mejorar los conocimientos actuales.A depressão maior representa um transtorno mental freqüente que é acompanhado de uma taxa de morbidade e de mortalidade importante. Apesar disso, a depressão maior continua sendo mal diagnosticada e mal tratada. No plano do tratamento, acredita-se atualmente que é desejável, para se ter um melhor prognóstico, focalizar a remissão dos sintomas depressivos e o retorno rápido ao melhor funcionamento do indivíduo. O artigo apresenta uma revista sistemática da literatura sobre os impactos clínicos de estratégias de intervenção que visam a melhoria dos serviços prestados às pessoas que sofrem de depressão maior e que consultam nos serviços primários. Os autores se baseiam em 41 estudos que comportam uma medida dos impactos clínicos das estratégias de intervenção aplicadas. A utilização de estratégias de intervenção complexas favorecem a obtenção de resultados positivos. Os autores sugerem várias pistas de pesquisa para melhorar o conhecimento atual sobre o assunto

General practitioners' management of mental disorders: A rewarding practice with considerable obstacles

<p>Abstract</p> <p>Background</p> <p>Primary care improvement is the cornerstone of current reforms. Mental disorders (MDs) are a leading cause of morbidity worldwide and widespread in industrialised countries. MDs are treated mainly in primary care by general practitioners (GPs), even though the latter ability to detect, diagnose, and treat patients with MDs is often considered unsatisfactory. This article examines GPs' management of MDs in an effort to acquire more information regarding means by which GPs deal with MD cases, impact of such cases on their practices, factors that enable or hinder MD management, and patient-management strategies.</p> <p>Methods</p> <p>This study employs a mixed-method approach with emphasis on qualitative investigation. Based on a previous survey of 398 GPs in Quebec, Canada, 60 GPs representing a variety of practice settings were selected for further study. A 10-minute-long questionnaire comprising 27 items was administered, and 70-minute-long interviews were conducted. Quantitative (SPSS) and qualitative (NVivo) analyses were performed.</p> <p>Results</p> <p>At least 20% of GP visits were MD-related. GPs were comfortable managing common MDs, but not serious MDs. GPs' based their treatment of MDs on pharmacotherapy, support therapy, and psycho-education. They used clinical intuition with few clinical tools, and closely followed their patients with MDs. Practice features (salary or hourly fees payment; psycho-social teams on-site; strong informal networks), and GPs' individual characteristics (continuing medical education; exposure and interest in MDs; traits like empathy) favoured MD management. Collaboration with psychologists and psychiatrists was considered key to good MD management. Limited access to specialists, system fragmentation, and underdeveloped group practice and shared-care models were impediments. MD management was seen as burdensome because it required more time, flexibility, and emotional investment. Strategies exist to reduce the burden (one-problem-per-visit rule; longer time slots). GPs found MD practice rewarding as patients were seen as grateful and more complying with medical recommendations compared to other patients, generally leading to positive outcomes.</p> <p>Conclusions</p> <p>To improve MD management, this study highlights the importance of extending multidisciplinary GP practice settings with salary or hourly fee payment; access to psychotherapeutic and psychiatric expertise; and case-discussion training involving local networks of GPs and MD specialists that encourage both knowledge transfer and shared care.</p

Plan d’action québécois en santé mentale : contextes de mise en oeuvre et éléments d’impact sur l’organisation des services de première ligne et les modes de collaboration

Depuis 2005, le Plan d’action en santé mentale oriente le développement et l’organisation des services en santé mentale au Québec. En conjonction avec d’autres réformes modifiant l’économie générale du système de santé, il vise en particulier à favoriser une réponse adéquate aux troubles mentaux courants. Cette préoccupation appelle une transformation de l’offre de services en première ligne. Une analyse de différents contextes dans lesquels opèrent ces changements permet une réflexion sur les principaux facteurs susceptibles d’influencer l’actualisation de certaines propositions du Plan d’action et sur l’évolution des modes de collaboration, un pré requis à la mise en place des réseaux locaux de services.Since 2005, the Mental Health Action Plan maps out development and reorganization of mental health services in Québec. With concurrent reforms affecting the overall layout of the health care system, the Action Plan especially seeks to improve the management of common mental disorders. This particular concern calls for transformations at the primary care level. Contextual analysis of contrasting settings allows the identification of the main determinants in this actual process of change and in the ways collaborative issues are addressed.Desde 2005, el Plan de Acción de Salud Mental orienta el desarrollo y la organización de los servicios de salud mental en Quebec. Junto con otras reformas que modifican la economía general del sistema de salud, el plan busca en particular favorecer una respuesta adecuada a los trastornos mentales comunes. Esta preocupación implica una transformación de la oferta de servicios de primer nivel. Un análisis de diferentes contextos en los que operan estos cambios permite una reflexión acerca de los principales factores susceptibles de influir en la actualización de ciertas proposiciones del Plan de Acción y en la evolución de las formas de colaboración, un prerrequisito para la puesta en marcha de las redes locales de servicios.Desde 2005, o Plano de Ação em Saúde Mental orienta o desenvolvimento e a organização dos serviços em saúde mental no Quebec. Em conjunto com outras reformas que modificam a economia geral do sistema de saúde, ele visa principalmente favorecer uma resposta adequada aos transtornos mentais correntes. Esta preocupação demanda uma transformação da oferta de serviços primários. Uma análise de diferentes contextos nos quais operam estas mudanças permite uma reflexão sobre os principais fatores susceptíveis de influenciar a atualização de algumas propostas do Plano de Ação e sobre a evolução dos modos de colaboração, um pré-requisito para a criação das redes locais de serviços

A Potent and Selective Inhibitor of Cdc42 GTPase

Cdc42, a member of the Rho family of GTPases, has been shown to play a role in cell adhesion, cytoskeletal arrangement, phagocytosis and cell motility and migration, in addition to a host of other diverse biological processes. The function of Rho-family GTPases in disease pathogenesis has been well established and identification of small, cell permeable molecules that selectively and reversibly regulate Rho GTPases is of high scientific and potentially therapeutic interest. There has been limited success in identifying inhibitors that specifically interact with small Rho family GTPases. The identified probe, ML141 (CID-2950007), is demonstrated to be a potent, selective and reversible non-competitive inhibitor of Cdc42 GTPase suitable for in vitro assays, with low micromolar potency and selectivity against other members of the Rho family of GTPases (Rac1, Rab2, Rab7). Given the highly complementary nature of the function of the Rho family GTPases, Cdc42 selective inhibitors such as those reported here should help untangle the roles of the proteins in this family

Characterization of a Cdc42 Protein Inhibitor and Its Use as a Molecular Probe

Cdc42 plays important roles in cytoskeleton organization, cell cycle progression, signal transduction, and vesicle trafficking. Overactive Cdc42 has been implicated in the pathology of cancers, immune diseases, and neuronal disorders. Therefore, Cdc42 inhibitors would be useful in probing molecular pathways and could have therapeutic potential. Previous inhibitors have lacked selectivity and trended toward toxicity. We report here the characterization of a Cdc42-selective guanine nucleotide binding lead inhibitor that was identified by high throughput screening. A second active analog was identified via structure-activity relationship studies. The compounds demonstrated excellent selectivity with no inhibition toward Rho and Rac in the same GTPase family. Biochemical characterization showed that the compounds act as noncompetitive allosteric inhibitors. When tested in cellular assays, the lead compound inhibited Cdc42-related filopodia formation and cell migration. The lead compound was also used to clarify the involvement of Cdc42 in the Sin Nombre virus internalization and the signaling pathway of integrin VLA-4. Together, these data present the characterization of a novel Cdc42-selective allosteric inhibitor and a related analog, the use of which will facilitate drug development targeting Cdc42-related diseases and molecular pathway studies that involve GTPases.This work was supported by National Science Foundation (NSF) Grant MCB0956027 and National Institutes of Health Grant R03 MH081231-01 from the Molecular Libraries Program (to A. W. N.); University of New Mexico Center for Molecular Discovery Molecular Libraries Probe Production Centers (UNMCMD MLPCN) National Institutes of Health Grants U54MH084690 and R01HL081062 (to L. A. S.); UNM National Center for Research Resources (NCRR) Grant 5P20RR016480 (to L. G. H.); National Institutes of Health Grant R21 CA170375-01 through the NCI (to A. W. N., L. G. H., and J. E. G.); National Institutes of Health Grants NS066429 and AI092130 (to T. B.); and University of Kansas Specialized Chemistry Center (KUSCC) MLPCN National Institutes of Health Grant U54HG005031 (to J. A.)

A conceptual framework for interprofessional shared decision making in home care: Protocol for a feasibility study

<p>Abstract</p> <p>Background</p> <p>Shared decision making (SDM) is fundamental to informed consent and client-centered care. So far, SDM frameworks have been limited to the client-physician dyad, even though care is increasingly delivered by interprofessional (IP) teams. IP collaboration is especially essential in home care, one of health care's most rapidly growing areas. This study will assess whether it is possible to practice SDM in IP home care.</p> <p>Methods/Design</p> <p>We will use a qualitative case study and a quantitative survey to capture the macro, meso and micro levels of stakeholders in home care. The case study will follow the knowledge-to-action process framework to evaluate the work of an IP home care team at a Quebec City health center. Sources of data will include one-on-one interviews with patients, family caregivers or surrogates and significant others, and administrators; a focus group of home care health professionals; organizational documents; and government policies and standards. The interview guide for the interviews and the focus group will explore current practices and clinical problems addressed in home care; factors that could influence the implementation of the proposed IP approach to SDM; the face and content validity of the approach; and interventions to facilitate the implementation and evaluation of the approach. The survey will ask 300 health professionals working in home care at the health center to complete a questionnaire based on the Theory of Planned Behaviour that measures their intentions to engage in an IP approach to SDM. We will use our analysis of the individual interviews, the focus group and the survey to elaborate a toolkit for implementing an IP approach to SDM in home care. Finally, we will conduct a pilot study in Alberta to assess the transferability of our findings.</p> <p>Discussion</p> <p>We believe that developing tools to implement IP SDM in home care is essential to strengthening Canada's healthcare system and furthering patient-centered care. This study will contribute to the evaluation of IP SDM delivery models in home care. It will also generate practical, policy-oriented knowledge regarding the barriers and facilitators likely to influence the practice of IP SDM in home care.</p

Les défis de la réflexivité et de la collaboration recherche-pratique : le cas de l’implantation d’une nouvelle offre de services en santé mentale en première ligne

L’évaluation d’implantation d’une nouvelle offre de services en santé mentale dans un centre de santé et de services sociaux démontre que le processus de changement doit être accompagné de la création d’espaces réflexifs au sein des équipes de travail afin de créer des conditions favorables à l’implantation. La complexité organisationnelle est un enjeu avec lequel il faut composer. Le rôle de la collaboration recherche-pratique dans ce processus d’implantation du changement est souligné afin de mieux comprendre les enjeux de la création d’espaces réflexifs dans une organisation. Alors que les espaces réflexifs prévus dans la planification initiale ne se sont pas concrétisés, l’interaction continue entre la recherche et la pratique a permis d’actualiser sous une forme inattendue les mécanismes réflexifs dans l’organisation en changement grâce aux espaces de collaboration mis en place et aux mécanismes d’application des connaissances portés par la posture épistémologique, la création d’alliances et le fonctionnement par cycle.The evaluation of the implementation process of a new mental health service in a heath and social services center demonstrates that this process must be accompanied with the creation of spaces of reflection amongst the team of workers in order to create positive conditions for implementation. Organizational complexity is an issue that needs to be taken into account. The role of research-practice collaboration in this process of implementing changes has been documented in order to better understand the challenges of opening spaces of reflection within an organization. While the spaces of reflection scheduled in the initial planning did not materialize, the ongoing interaction between research and practice allowed the mechanisms of reflection of this team to renewed themselves in an unexpected way in the midst of a process of transformation. That was made possible thanks to the spaces of collaboration that were put in place, to the mechanisms of knowledge translation carried out by the epistemological posture, to the creation of alliances and the cycle operation method

Implementation of Integrated Service Networks under the Quebec Mental Health Reform: Facilitators and Barriers associated with Different Territorial Profiles

Introduction: This study evaluates implementation of the Quebec Mental Health Reform (2005–2015), which promoted the development of integrated service networks, in 11 local service networks organized into four territorial groups according to socio-demographic characteristics and mental health services offered. Methods: Data were collected from documents concerning networks; structured questionnaires completed by 90 managers and by 16 respondent-psychiatrists; and semi-structured interviews with 102 network stakeholders. Factors associated with implementation and integration were organized according to: 1) reform characteristics; 2) implementation context; 3) organizational characteristics; and 4) integration strategies. Results: While local networks were in a process of development and expansion, none were fully integrated at the time of the study. Facilitators and barriers to implementation and integration were primarily associated with organizational characteristics. Integration was best achieved in larger networks including a general hospital with a psychiatric department, followed by networks with a psychiatric hospital. Formalized integration strategies such as service agreements, liaison officers, and joint training reduced some barriers to implementation in networks experiencing less favourable conditions. Conclusion: Strategies for the implementation of healthcare reform and integrated service networks should include sustained support and training in best-practices, adequate performance indicators and resources, formalized integration strategies to improve network coordination and suitable initiatives to promote staff retention