Effect of free medicine distribution on ability to make ends meet: post hoc quantitative subgroup analysis and qualitative thematic analysis.

OBJECTIVES: Out-of-pocket medication costs can contribute to financial insecurity and many Canadians have trouble affording medicines. This study aimed to determine if the effect of eliminating out-of-pocket medication costs on individual's financial security varied by gender, racialisation, income and location. DESIGN: In this post hoc subgroup analysis of the CLEAN Meds trial, a binary logistic regression model was fitted and a qualitative inductive thematic analysis of comments related to participant's ability to make ends meet was carried out. SETTING: Primary care patients in Ontario, Canada. PARTICIPANTS: Adult patients (786) who reported not being able to afford medicines during the previous 12 months. INTERVENTION: Free access to a comprehensive list of essential medicines for 24 months. PRIMARY OUTCOME MEASURE: Ability to make ends meet or afford basic necessities. RESULTS: There were no significant differences in the effect of free medicine distribution by gender (OR for male 0.82; 95% CI 0.51 to 1.33, p=0.76), age (older than 65 years OR 1.28; 95 % CI 0.62 to 2.64, p=0.73), racialisation (OR 0.85; 95 % CI 0.51 to 1.45, p=0.66), household income level (above US$30 000 per year OR 1.08; 95 % CI 0.64 to 1.80, p=0.99) or location (urban OR 0.47; 95 % CI 0.23 to 0.96, p=0.10). The main theme in the qualitative analysis was insufficient income, and there were three related themes: out-of-pocket medication expenses, cost-related non-adherence and the importance of medication coverage. In the intervention group, additional themes identified included improved health, functioning and access to basic needs. CONCLUSIONS: Providing free essential medications improved financial security across subgroups in a trial population who all had trouble affording medicines. Free access to medicines could improve health directly by improving medicine adherence and indirectly by making other necessities more accessible to people who have an insufficient income. TRIAL REGISTRATION NUMBER: NCT02744963.

From Planning to Implementation of the YouthCan IMPACT Project: a Formative Evaluation.

In order to improve the youth mental health system, there is an international movement toward developing community-based service hubs that provide integrated, collaborative care to youth. However, the implementation of multisystem collaboration is complex and can be hampered by barriers. This paper presents a formative evaluation of the YouthCan IMPACT integrated youth services project based on the Consolidated Framework for Implementation Research (CFIR), to identify facilitators and barriers to successful implementation. Results highlight that previous positive working relationships along with collaborative investment of resources from partnering organizations are essential to implement an integrated youth service model. In addition, it is important that representative members of all key stakeholder groups, including staff, youth, and caregivers, be involved in the development and execution of the project to ensure effective implementation. Attention to the facilitators and barriers to implementation may help teams seeking to implement highly collaborative, integrated models of service delivery for youth in the community.

Assaying all of the nitrogen oxides in breath modifies the interpretation of exhaled nitric oxide.

Exhaled nitric oxide (NO) assays measure the quantity of NO that emanates from the airway, not the amount of NO that is formed. Consumptive processes-including oxidation reactions-decrease the amount of gas phase NO available for exhalation. Higher oxides of nitrogen (HiNO(x)) are resulting reaction products, and are easily measured in exhaled breath condensate (EBC). We performed concurrent sampling of exhaled breath for gas phase NO and EBC HiNO(x) in controls and stable asthmatics. We identified that, mole for mole, asthma patients hourly exhale more HiNO(x) than they do NO, with a HiNO(x)/NO ratio of 1.21 (0.54-3.4). This is the reverse of the ratio found in controls, in whom the HiNO(x)/NO ratio was 0.75 (0.44-0.93), p=0.04. The sum of the hourly molar exhalation of NO and HiNO(x) was significantly higher in asthmatics (333 nmol/h (221-543) than controls (179 (138-231), p<0.001). We conclude that exhaled oxides of nitrogen are more informative when measured together as opposed to in isolation. We suggest that inflammation can be better evaluated with HiNO(x) and NO measured concurrently, and that the level of oxidation in the lung can be evaluated by comparing the easily measured ratios of HiNO(x) to NO in the exhaled breath.

Differential alterations in sympathetic neurotransmission in mesenteric arteries and veins in DOCA-salt hypertensive rats.

Sympathetic control of arteries and veins may be altered in hypertension. To test this hypothesis, constrictions of mesenteric arteries and veins caused by nerve stimulation and by norepinephrine (NE) and ATP were studied in vitro in tissues from deoxycorticosterone acetate (DOCA)-salt hypertensive and sham normotensive rats. In DOCA-salt arteries, the maximum neurogenic response was greater than that in sham arteries. The P2 receptor antagonist, pyridoxal-phosphate-6-azophenyl-2',4'-disulfonic acid (PPADS, 10 microM), greatly reduced neurogenic responses in sham but not DOCA-salt arteries. The alpha1-adrenergic receptor antagonist, prazosin (0.1 microM), inhibited responses in DOCA-salt but not sham arteries. Concentration-response curves for norepinephrine and ATP were similar in sham and DOCA-salt arteries, indicating that reactivity to sympathetic vasoconstrictor transmitters was not changed in DOCA-salt arteries. Neurogenic constrictions in sham and DOCA-salt veins were similar in amplitude, and they were completely blocked by prazosin. However, concentration-response curves for norepinephrine in DOCA-salt veins were right-shifted compared to those in sham veins. Cocaine (10 microM) and corticosterone (10 microM) caused a leftward shift in norepinephrine concentration-response curves in DOCA-salt but not sham veins. Norepinephrine content was decreased in DOCA-salt arteries and veins, and there was an increased norepinephrine transporter (NET) level in DOCA-salt veins. These data indicate that, in DOCA-salt hypertension, there is an increased norepinephrine release from sympathetic nerves associated with mesenteric arteries and veins. In arteries, this results in an increase in the amplitude of neurogenic constrictions. In veins, increased norepinephrine release maintains neurogenic constrictions in the presence of increased NET levels.