Lessons Learned in a Physician Referral to Pediatric Telemental Health Services Program.

BACKGROUND: This study explores the physician referral and engagement process of a pediatric telemental health program based in a large urban teaching children's hospital, and identifies the processes, strengths and challenges from the perspectives of Primary Care Physicians (PCPs) and telepsychiatrist consultants. METHODS: A mixed methods approach was used. This included an online survey completed by 43 PCPs in Ontario rural communities who had referred patients to the telemental health program. Qualitative interviews were conducted with 11 child/adolescent telepsychiatrists who provide consultations via teleconferencing. RESULTS: The majority of PCPs (61%) reported somewhat to moderate satisfaction with referral experiences. Challenges identified by physicians were related to communication and administration issues including: lack of timely follow-up appointments and continuity of care; lengthy referral forms; and recommendations for mental health services not accessible in their communities. Similarly, psychiatrist consultants expressed frustration with the sparse information they received from referring physicians and most significantly, the absence of appropriate service providers/professionals during the consultation to provide collateral information and ensure uptake of recommendations. CONCLUSION: Telemental health programs provide a valuable service to PCPs and their child and youth clients that could be significantly enhanced with a different consultation model. Such models of service delivery require protocols to educate PCPs, improve communication and information sharing and establish clear expectations between PCPs and telepsychiatry consultants.

CONTEXTE: Cette étude explore l'aiguillage d'un médecin et le processus de participation à un programme de télésanté mentale pédiatrique situé dans un vaste hôpital universitaire pour enfants en milieu urbain, et mentionne les processus, les forces et les difficultés du point de vue des médecins des soins de première ligne (MPL) et des télépsychiatres consultants. MÉTHODES: Une approche de méthodes mixtes a été utilisée, ce qui comprenait un sondage en ligne auquel ont répondu 43 MPL des communautés rurales de l'Ontario qui avaient aiguillé des patients au programme de télésanté mentale. Des entrevues qualitatives ont été menées auprès de 11 télépsychiatres de l'enfant et de l'adolescent qui offrent des consultations par téléconférence. RÉSULTATS: La majorité des MPL (61 %) ont déclaré une satisfaction de passable à modérée à l'égard des expériences d'aiguillage. Les difficultés identifiées par les médecins étaient liées aux enjeux de communication et d'administration, notamment l'absence de rendez-vous de suivi ponctuels et de continuité des soins; les formulaires d'aiguillage fastidieux; et les recommandations de services de santé mentale qui ne sont pas offerts dans leur communauté. De même, les psychiatres consultants ont exprimé leur frustration quant à l'information insuffisante reçue des médecins de l'aiguillage et surtout, en raison de l'absence de prestataires/professionnels appropriés durant la consultation qui apporteraient l'information collatérale et assureraient l'adoption des recommandations. CONCLUSION: Les programmes de télésanté mentale fournissent un service valable aux MPL et à leurs clients pédiatriques, mais ils pourraient être améliorés significativement par un modèle de consultation différent. Ces modèles de prestation des services exigent des protocoles pour éduquer les MPL, améliorer l'échange de communication et d'information, et établir des attentes bien définies entre MPL et consultants en télépsychiatrie.

Regulation of intracellular glucose and polyol pathway by thiamine and benfotiamine in vascular cells cultured in high glucose.

Hyperglycemia is a causal factor in the development of the vascular complications of diabetes. One of the biochemical mechanisms activated by excess glucose is the polyol pathway, the key enzyme of which, aldose reductase, transforms d-glucose into d-sorbitol, leading to imbalances of intracellular homeostasis. We aimed at verifying the effects of thiamine and benfotiamine on the polyol pathway, transketolase activity, and intracellular glucose in endothelial cells and pericytes under high ambient glucose. Human umbilical vein endothelial cells and bovine retinal pericytes were cultured in normal (5.6 mmol/liter) or high (28 mmol/liter) glucose, with or without thiamine or benfotiamine 50 or 100 mumol/liter. Transketolase and aldose reductase mRNA expression was determined by reverse transcription-PCR, and their activity was measured spectrophotometrically; sorbitol concentrations were quantified by gas chromatography-mass spectrometry and intracellular glucose concentrations by fluorescent enzyme-linked immunosorbent assay method. Thiamine and benfotiamine reduce aldose reductase mRNA expression, activity, sorbitol concentrations, and intracellular glucose while increasing the expression and activity of transketolase, for which it is a coenzyme, in human endothelial cells and bovine retinal pericytes cultured in high glucose. Thiamine and benfotiamine correct polyol pathway activation induced by high glucose in vascular cells. Activation of transketolase may shift excess glycolytic metabolites into the pentose phosphate cycle, accelerate the glycolytic flux, and reduce intracellular free glucose, thereby preventing its conversion to sorbitol. This effect on the polyol pathway, together with other beneficial effects reported for thiamine in high glucose, could justify testing thiamine as a potential approach to the prevention and/or treatment of diabetic complications.