Housing Stability and Neurocognitive Functioning in Homeless Adults With Mental Illness: A Subgroup Analysis of the At Home/Chez Soi Study.

Objective: This study examined the association of housing stability with neurocognitive outcomes of a well-characterized sample of homeless adults with mental illness over 18 months and sought to identify demographic and clinical variables associated with changes in neurocognitive functioning. Method: A total of 902 participants in the At Home/Chez Soi study completed neuropsychological measures 6 and 24 months after study enrollment to assess neurocognitive functioning, specifically verbal learning and memory, cognitive flexibility, and complex processing speed. Multivariable linear regression was performed to assess the association of housing stability with changes in neurocognitive functioning between 6 and 24 months and to examine the effect of demographic and clinical variables on changes in neurocognitive functioning. Results: Overall neurocognitive impairment remained high over the study period (70% at 6 months and 67% at 24 months) with a small but significant improvement in the proportion of those experiencing more severe impairment (54% vs. 49% p < 0.002). Housing stability was not associated with any of the neuropsychological measures or domains examined; improvement in neurocognitive functioning was associated with younger age, and bipolar affective disorder at baseline. Conclusions: The high prevalence and persistence of overall neurocognitive impairment in our sample suggests targeted approaches to improve neurocognitive functioning merit consideration as part of health interventions to improve everyday functioning and outcomes for this population. Further efforts are needed to identify potential modifiable factors that contribute to improvement in cognitive functioning in homeless adults with mental illness.

Exploring oral health and hygiene practices in the Algonquin community of Rapid Lake, Quebec.

INTRODUCTION: Early childhood caries (ECC), a disease characterized by tooth decay in the primary teeth of children, has become particularly burdensome in Aboriginal communities in Canada. Prevalence estimates of ECC range between 50% and 100%. Most concerning are the severe cases of ECC that require treatment with restorative surgery under general anesthesia. These surgeries often displace children and families from their local communities to specialty hospitals for treatment; further, they are very costly to dental insurance payers such as the government. This study used community-based participatory research (CBPR) to explore oral health and hygiene practices in the Algonquin community of Rapid Lake, Quebec. A key goal of the study was to create a culturally adapted activity to promote children's oral health and hygiene practices. METHODS: Focused ethnography was used to explore oral health beliefs and practices, and factors related to child oral health promotion with community members. Participants included children, parents, educators, healthcare workers, youth workers and elders. Semi-structured interviews were conducted with key informants. Following, two focus group interviews were conducted: one with parents and one with school children. All data were audio-recorded, transcribed and analyzed iteratively using thematic analysis. Preliminary findings were then used to develop oral health promoting activities for children in the community. These activities were designed in collaboration with community workers. RESULTS: Three main themes emerged from the analysis: (1) a gap existed between oral health knowledge and oral health behaviors; (2) challenges for oral health promotion included attitudes and beliefs, access, and priorities; and (3) parents needed to be further integrated into health promotion strategies. Key outcomes included: (1) the development of Eagles & Otters, a game designed to increase children's oral health knowledge; (2) an activity sheet to promote child oral health behaviors in the home; and (3) increased capacity in oral health promotion in local youth, community research partners and the student researcher. CONCLUSIONS: The findings of this study highlight the importance of both local and broader systemic interventions to promote children's oral health. At the local level, child oral health and hygiene was promoted through the development of activities designed to increase children's oral health knowledge and behaviors both at school and in the home where parents were directly implicated. Systemic level interventions are needed to address factors related to the social determinants of health, including cultural traditions, economic security, food security, and housing status. These factors contribute to overall health and enable the necessary conditions to promote and sustain oral health.

Variation in long-term antipsychotic polypharmacy and high-dose prescribing across physicians and hospitals.

OBJECTIVES: This study had two aims: to measure the prevalence of long-term prescribing of high doses of antipsychotics and antipsychotic polypharmacy in a large Canadian province and to estimate the relative contributions of patient-, physician-, and hospital-level factors. METHODS: Government hospital discharge, physician, and pharmaceutical claims data were linked to identify individuals with schizophrenia who in 2004 had antipsychotics available to them for at least 11 months. Individuals on a high dose throughout that period, as well as individuals on multiple concurrent antipsychotics (polypharmacy), were identified. Logistic and generalized linear mixed models using patient-, physician-, and hospital-level predictors were estimated. RESULTS: Among the 12,150 individuals identified, 11.9% were on a high dose and 10.4% on antipsychotic polypharmacy continually, with 3.7% in both groups. After adjustment for potential confounders, analyses showed that systematic propensity for physicians to prescribe high doses accounted for 10.9% of the remaining unexplained variance, and physicians as a group who prescribed high doses across a hospital or psychiatry department accounted for 3.0%. For antipsychotic polypharmacy the corresponding percentages were 9.7% and 6.2%. Even after adjustment, the variation in high-dose prescribing and antipsychotic polypharmacy remained substantial. CONCLUSIONS: Long-term high-dose and antipsychotic polypharmacy prescribing appeared partly driven by some physicians' and some hospitals' propensities to prescribe in this way independently of patient characteristics. Given the weight of the evidence against high-dose prescribing and antipsychotic polypharmacy, measures addressed to physicians and hospitals most likely to prescribe high doses, antipsychotic polypharmacy, or both should be considered.

Underprescribing of clozapine and unexplained variation in use across hospitals and regions in the Canadian province of Québec.

BACKGROUND: Clozapine remains the antipsychotic of choice for people who, having met the criteria for a diagnosis of schizophrenia or a related psychotic disorder, do not respond adequately to other antipsychotic medications. Utilization rates appear highly variable across jurisdictions, with an overall tendency toward underuse. This paper describes patterns of clozapine use in the province of Québec, Canada. METHODS: Individuals with a diagnosis of schizophrenia were identified using linked government medical claims and hospitalization records for 2003 and 2004. Linked data on their filled prescriptions in 2004 were then used to determine clozapine-use rates at the level of the province, the region, and the hospital at which individuals received most of their services. Individual predictors of clozapine use were identified using logistic regression. RESULTS: Only 6.7% of the 29,155 individuals identified with schizophrenia received clozapine for six months or longer in 2004. Utilization rates ranged from 3.9 to 9.0% among regions with 1,000 or more people with schizophrenia. Over 8% of 61 hospitals did not prescribe clozapine at all. People with schizophrenia taking clozapine experienced 3.4 fewer days of hospitalization per year than those not taking clozapine-representing a cost offset of about $1,800 per year. Medication costs were higher, however, by about $3,000 per year. CONCLUSIONS: Given the increasingly clear benefits of clozapine for people who do not respond to other antipsychotics, measures to increase access to clozapine for people who can benefit from it are likely to be cost effective and are urgently needed.

The risk of lung cancer related to dietary intake of flavonoids.

It has been hypothesized that flavonoids in foods and beverages may reduce cancer risk through antioxidation, inhibition of inflammation, and other antimutagenic and antiproliferative properties. We examined associations between intake of 5 flavonoid subclasses (anthocyanidins, flavan-3-ols, flavones, flavonols, and flavanones) and lung cancer risk in a population-based case-control study in Montreal, Canada (1061 cases and 1425 controls). Flavonoid intake was estimated from a food frequency questionnaire that assessed diet 2 yr prior to diagnosis (cases) or interview (controls). Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using unconditional logistic regression. Overall, total flavonoid intake was not associated with lung cancer risk, the effect being similar regardless of sex and smoking level. However, low flavonoid intake from food, but not from beverages, was associated with an increased risk. The adjusted ORs (95% CIs) comparing the highest vs. the lowest quartiles of intake were 0.63 (0.47-0.85) for total flavonoids, 0.82 (0.61-1.11) for anthocyanidins, 0.67 (0.50-0.90) for flavan-3-ols, 0.68 (0.50-0.93) for flavones, 0.62 (0.45-0.84) for flavonols, and 0.70 (0.53-0.94) for flavanones. An inverse association with total flavone and flavanone intake was observed for squamous cell carcinoma but not adenocarcinoma. In conclusion, low flavonoid intake from food may increase lung cancer risk.