When and How to Treat Possible Cannabis Use Disorder.

Cannabis (marijuana) is a drug product derived from the plant Cannabis sativa. Cannabinoid is a general term for all chemical constituents of the cannabis plant. Legalization of marijuana in numerous US states, the availability of cannabis of higher potency, and the emergence of synthetic cannabinoids may have contributed to increased demand for related medical services. The most effective available treatments for cannabis use disorder are psychosocial approaches. There is no pharmacotherapy approved treatment. This article reviews the current state of knowledge regarding effective treatments for cannabis use disorder.

Coping strategies as a mediator of internet-delivered psychosocial treatment: Secondary analysis from a NIDA CTN multisite effectiveness trial.

OBJECTIVE: Coping strategies are a predictor of abstinence among patients with substance use disorders. However, little is known regarding the role of coping strategies in the effectiveness of the Community Reinforcement Approach (CRA). Using data from a 12week randomized control trial assessing the effectiveness of the Therapeutic Education System (TES), an internet-delivered version of the CRA combined with contingency management, we tested the role of coping strategies as a mediator of treatment effectiveness. METHODS: 507 participants entering 10 outpatient addiction treatment programs received either treatment-as-usual (TAU), a counselor-delivered treatment (Arm 1), or reduced TAU plus TES wherein 2h of TAU per week were replaced by TES (Arm 2). Abstinence from drugs and alcohol was evaluated using urine toxicology and self-report. Coping strategies were measured using the Coping Strategies Scale-Brief Version. Mediation analyses were done following Baron and Kenny's and path analysis approaches. RESULTS: The average baseline coping strategies scores were not significantly different between the two treatment arms. Overall, TES intervention was significantly associated with higher coping strategies scores when accounting for baseline scores (F1,1342=8.3, p=0.004). Additionally, higher coping strategies scores at week 12 were associated with an increased likelihood of abstinence during the last 4weeks of the treatment, while accounting for treatment assignment and baseline abstinence. The effect of TES intervention on abstinence was no longer significant after controlling for coping strategies scores at week 12. CONCLUSION: Our results support the importance of coping skills as a partial mediator of the effectiveness of an internet-version of the CRA combined with contingency management.

Examining the link between psychological distress, mental health disorders and sharing behaviors among cocaine users.

BACKGROUND: Psychiatric problems and cocaine use are associated with heightened vulnerability for HIV and Hepatitis C infections. Little is known regarding the relationship between psychiatric symptoms, psychiatric diagnoses and injection risk behaviors among cocaine users. We examined the association between psychological distress and injection material sharing among cocaine users, while accounting for comorbid anxious and mood disorders. METHODS: Participants included cocaine users who inject drugs recruited in a prospective cohort study in Montreal, Canada. Diagnosis of mood and anxiety disorders in the year preceding baseline were established using the Composite International Diagnostic Interview (CIDI) questionnaire. Psychological distress based on the Kessler scale and injection material sharing in the past 3months were assessed at baseline and at each of the five follow-up visits at 3-month intervals. Statistical analyses were conducted using generalized estimation equation. RESULTS: Of the 387 participants (84.5% male; 80.1%, ≥30y.o.), 35% reported severe psychological distress, 43% qualified for an anxiety disorder diagnosis and 29% for a mood disorder diagnosis at baseline. Psychological distress was not associated with any injection risk behavior when adjusting for socio-demographic and psychiatric disorders. Participants with anxiety disorders were more likely to share needle (adjusted odds ratio: 1.89, 95% CI: 1.17-3.03). Sharing of injection material other than needle was not associated with psychiatric disorders or with psychological distress in multivariate analyses. CONCLUSIONS: Anxiety disorders are associated with needle sharing among cocaine users. Our results suggest the importance of screening for anxiety disorders as part of preventive interventions to decrease blood-borne viruses' transmission.

Expectations, observations, and the cognitive processes that bind them: expert assessment of examinee performance.

Performance-based assessment (PBA) is a valued assessment approach in medical education, be it in a clerkship, residency, or practice context. Raters are intrinsic to PBA and the increased use of PBA has lead to an increased interest in rater cognition. Although several researchers have tackled factors that may influence the variability in rater judgment, the critical examination of rater observation of performance and the translation of that data into judgements are being investigated. The purpose of this study was to qualitatively investigate the cognitive processes of raters, and to create a framework that conceptualizes those processes when raters assess a complex performance. We conducted semi-structured interviews with 11 faculty members (nominated as excellent assessors) from a Department of Medicine to investigate how raters observe, interpret, and translate performance into judgments. The transcribed verbal protocols were analyzed using Constructivist Grounded Theory in order to develop a theoretical model of raters' assessment processes. Several themes emerged from the data and were grouped according to three macro-level themes describing how the raters balance two sources of data [(1) external sources of information and (2) internal/personal sources of information] by relying on specific cognitive processes to assess an examinee performance. The results from our study demonstrate that assessment is a difficult cognitive task that involves nuance using specific cognitive processes to weigh external and internal data against each other. Our data clearly draws attention to the constant struggle between objectivity and subjectivity that is observed in assessment as illustrated by the importance given to nuancing the examinee's observed performance.

Portraying persons who inject drugs recently infected with hepatitis C accessing antiviral treatment: a cluster analysis.

Objectives. To empirically determine a categorization of people who inject drug (PWIDs) recently infected with hepatitis C virus (HCV), in order to identify profiles most likely associated with early HCV treatment uptake. Methods. The study population was composed of HIV-negative PWIDs with a documented recent HCV infection. Eligibility criteria included being 18 years old or over, and having injected drugs in the previous 6 months preceding the estimated date of HCV exposure. Participant classification was carried out using a TwoStep cluster analysis. Results. From September 2007 to December 2011, 76 participants were included in the study. 60 participants were eligible for HCV treatment. Twenty-one participants initiated HCV treatment. The cluster analysis yielded 4 classes: class 1: Lukewarm health seekers dismissing HCV treatment offer; class 2: multisubstance users willing to shake off the hell; class 3: PWIDs unlinked to health service use; class 4: health seeker PWIDs willing to reverse the fate. Conclusion. Profiles generated by our analysis suggest that prior health care utilization, a key element for treatment uptake, differs between older and younger PWIDs. Such profiles could inform the development of targeted strategies to improve health outcomes and reduce HCV infection among PWIDs.

Process of implementing collaborative care and its impacts on the provision of care and rehabilitation services to patients with a moderate or severe traumatic brain injury.

OBJECTIVE: The introduction of new services in a rehabilitation center is a unique opportunity to introduce a new model of care and services between two institutions. A hospital and a rehabilitation center experienced a clinical management model inspired by an American approach - collaborative care. The purpose of this study was to describe the implementation of this approach and to provide a perception of the quality of care and services provided to patients with moderate or severe traumatic brain injury and to their caregivers. MATERIALS AND METHODS: In this qualitative study, individual semistructured interviews were conducted with patients and their caregivers in the hospital and rehabilitation center where the patients were treated. Individual semistructured interviews were conducted with administrators, and two focus groups were held with clinicians before and after the implementation. RESULTS AND CONCLUSION: Ten days' waiting time were saved with the collaborative approach. Implementing the collaborative care approach has been found to have several benefits, including improved communication, coordination of services between institutions, and better preparation, awareness, and involvement of patients and their families. Administrators, clinicians, patients, and caregivers expressed their opinions on the organization of care and services, the needs and expectations of patients and their caregivers, their participation in terms of roles and responsibilities, their perception of continuity of care, their satisfaction with the care process, and their suggestions for improvements.

The role of the assessor: exploring the clinical supervisor's skill set.

BACKGROUND: Clinical supervisors have several different responsibilities. Although their responsibilities as an assessor are important, little is known about what skill set should be acquired for this role and how to foster their development. Documenting assessor skills to study their acquisition and development is critical. METHODS: A web survey based on the principles of Appreciative Inquiry was distributed to faculty members and residents from a Department of Medicine at a Canadian University. Participants were asked to list five and then to identify five (from a list of 10) characteristics or skills demonstrated by clinical supervisors recognised for their excellent assessment skills. RESULTS: Seventeen per cent of faculty members and 23 per cent of residents completed the survey. Fairness is perceived as a key characteristic of an excellent assessor. Faculty members consider that appropriate medical knowledge and skills are important. Residents expressed the importance of appropriate feedback. Both groups indicated the importance of direct observation as a basis for assessment. DISCUSSION: This study offers preliminary insights into the characteristics of excellent assessors. Given the importance of assessment in the daily activities of clinical supervisors, research efforts should strive to better characterise this role in the hopes of increasing the quality and accuracy of assessment.

Students' self-explanations while solving unfamiliar cases: the role of biomedical knowledge.

OBJECTIVE: General guidelines for teaching clinical reasoning have received much attention, despite a paucity of instructional approaches with demonstrated effectiveness. As suggested in a recent experimental study, self-explanation while solving clinical cases may be an effective strategy to foster reasoning in clinical clerks dealing with less familiar cases. However, the mechanisms that mediate this benefit have not been specifically investigated. The aim of this study was to explore the types of knowledge used by students when solving familiar and less familiar clinical cases with self-explanation. METHODS: In a previous study, 36 third-year medical students diagnosed familiar and less familiar clinical cases either by engaging in self-explanation or not. Based on an analysis of previously collected data, the present study compared the content of self-explanation protocols generated by seven randomly selected students while solving four familiar and four less familiar cases. In total, 56 verbal protocols (28 familiar and 28 less familiar) were segmented and coded using the following categories: paraphrases, biomedical inferences, clinical inferences, monitoring statements and errors. RESULTS: Students provided more self-explanation segments from less familiar cases (M = 275.29) than from familiar cases (M = 248.71, p = 0.046). They provided significantly more paraphrases (p = 0.001) and made more errors (p = 0.008). A significant interaction was found between familiarity and the type of inferences (biomedical versus clinical, p = 0.016). When self-explaining less familiar cases, students provided significantly more biomedical inferences than familiar cases. CONCLUSIONS: Lack of familiarity with a case seems to stimulate medical students to engage in more extensive thinking during self-explanation. Less familiar cases seem to activate students' biomedical knowledge, which in turn helps them to create new links between biomedical and clinical knowledge, and eventually construct a more coherent mental representation of diseases. This may clarify the previously found positive effect that self-explanation has on the diagnosis of unfamiliar cases.

Risk of myocardial infarction in canadian patients with psoriasis: a retrospective cohort study.

BACKGROUND: Studies have shown that psoriatic patients are at increased risk for myocardial infarction (MI) and stroke. There is a lack of data on MI risk in Canadian psoriatic patients. OBJECTIVE: To compare MI risk in Canadian psoriatic patients to that in control patients. METHODS: This was a retrospective cohort study using Quebec's health insurance database (2005-2010) comparing MI risk in psoriatic patients to that in matched controls. Severe psoriasis was defined as any diagnosed psoriatic patient who used phototherapy or oral or injectable psoriasis treatments. Adjustments were made for several MI risk factors. RESULTS: There were 31,421 patients in the psoriasis population, of which 5,159 had severe psoriasis. The unadjusted MI incidence rate per 1,000 person-years was 4.88 (95% confidence interval [95% CI] 4.50-5.20), 5.58 (95% CI 5.10-6.10), and 5.32 (95% CI 4.40-6.40) for the control and mild and severe psoriasis groups, respectively. After adjustments, the hazard ratio of MI was significantly higher for psoriatic patients than for controls (1.17; 95% CI 1.04-1.31). The hazard ratio was also significantly higher than for controls in the mild psoriasis group (1.18; 95% CI 1.05-1.33) but not in the severe psoriasis group (1.16; 95% CI 0.94-1.42). CONCLUSION: The relative MI risk is higher for Canadian psoriatic patients than for controls.

La participation des personnes utilisatrices aux exercices de planification et d'organisation des services de santé mentale au Québec / Participação dos usuários no planejamento e organização dos serviços de saúde mental no Quebec

Cet article documente la manière dont s'est renouvelé et s'est transformé au fil du temps le projet de faire participer les usagers aux exercices de planification et d'organisation des services de santé mentale au Québec (Canada). Pour ce faire, les auteurs reviennent sur l'ensemble des documents ministériels qui ont traité de cette question et dégage, pour les principaux moment-clés, les principales modalités de participation des usagers.

Este artigo documenta a forma como se renovou e se transformou, ao longo do tempo, o projeto de participação dos usuários no planejamento e organização dos serviços de Saúde Mental no Quebec (Canadá). Para isso, os autores reavaliaram todo o conjunto de documentos ministeriais que trataram desta questão e retiraram, para os momentos-chaves, as principais modalidades de participação dos usuários.

A randomized study comparing the combination of nbUVB and etanercept to etanercept monotherapy in patients with psoriasis who do not exhibit an excellent response after 12 weeks of etanercept.

BACKGROUND: There is a lack of data on the combination of phototherapy with etanercept in patients who have not shown an excellent response to etanercept monotherapy. OBJECTIVES: To study the combination of narrow-band ultraviolet B (nbUVB) phototherapy with etanercept in patients not demonstrating an improvement of 90% in their Psoriasis Area Severity Index (PASI-90) after 12 weeks of etanercept. PATIENTS AND METHODS: Psoriatic patients not reaching PASI-90 after 12 weeks of etanercept therapy were randomized (1:1) to receive either etanercept (50 mg once a week) monotherapy or in combination with nbUVB three times weekly for periods of 4 weeks. RESULTS: Seventy-five patients were randomized. Only 21.6% of patients achieved adherence of 80% or more for nbUVB treatments. At week 24, PASI-90 was reached by 16.2% of patients in the etanercept plus nbUVB group when compared with 15.8% of patients in the etanercept monotherapy group (p = 1.000). In patients with high adherence to nbUVB, the PASI-90 at week 16 was 42.9% for etanercept with nbUVB when compared with 3.4% for etanercept monotherapy (p = 0.018). Both treatments were well tolerated. CONCLUSION: Addition of nbUVB after 12 weeks of etanercept did not significantly improve the clinical response except for a subset of patients with high adherence to nbUVB. CLINICAL TRIALS REGISTRATION NUMBER: NCT00640393.

Randomized trial comparing a chemical peel containing a lipophilic hydroxy acid derivative of salicylic acid with a salicylic acid peel in subjects with comedonal acne.

BACKGROUND: Lipohydroxyacid is a lipophilic derivative of salicylic acid with comedolytic properties. OBJECTIVES: To compare lipohydroxyacid and salicylic acid peels in subjects with comedonal acne. METHODS: In this split face, randomized study, 20 subjects with comedonal acne received lipohydroxyacid peels on one side of the face, while the other side was treated with salicylic acid peels. A total of six peels at 2-week intervals were performed. Efficacy was evaluated by counting noninflammatory and inflammatory lesions and by performing a global change in acne assessment. Safety was assessed by evaluating adverse events, global tolerance, and the presence of erythema, scaling, and dryness. RESULTS: There was a statistically significant decrease of 55.6% and 48.5% from baseline to Day 98 in the mean number of noninflammatory lesions for the sides treated with lipohydroxyacid and salicylic acid peels, respectively (P < 0.001). There was no significant difference in the degree of reduction in noninflammatory lesions between the two peels. There was no significant reduction in the number of inflammatory lesions. Both peels were generally very well tolerated. CONCLUSION: This study suggests that lipohydroxyacid peels can be beneficial to subjects with comedonal acne.