Canadian Network Research Articles

Evaluating the Clinical Feasibility of an Artificial Intelligence-Powered, Web-Based Clinical Decision Support System for the Treatment of Depression in Adults: Longitudinal Feasibility Study.

BackgroundApproximately two-thirds of patients with major depressive disorder do not achieve remission during their first treatment. There has been increasing interest in the use of digital, artificial intelligence–powered clinical decision support systems (CDSSs) to assist physicians in their treatment selection and management, improving the personalization and use of best practices such as measurement-based care. Previous literature shows that for digital mental health tools to be successful, the tool must be easy for patients and physicians to use and feasible within existing clinical workflows.ObjectiveThis study aims to examine the feasibility of an artificial intelligence–powered CDSS, which combines the operationalized 2016 Canadian Network for Mood and Anxiety Treatments guidelines with a neural network–based individualized treatment remission prediction.MethodsOwing to the COVID-19 pandemic, the study was adapted to be completed entirely remotely. A total of 7 physicians recruited outpatients diagnosed with major depressive disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. Patients completed a minimum of one visit without the CDSS (baseline) and 2 subsequent visits where the CDSS was used by the physician (visits 1 and 2). The primary outcome of interest was change in appointment length after the introduction of the CDSS as a proxy for feasibility. Feasibility and acceptability data were collected through self-report questionnaires and semistructured interviews.ResultsData were collected between January and November 2020. A total of 17 patients were enrolled in the study; of the 17 patients, 14 (82%) completed the study. There was no significant difference in appointment length between visits (introduction of the tool did not increase appointment length; F2,24=0.805; mean squared error 58.08; P=.46). In total, 92% (12/13) of patients and 71% (5/7) of physicians felt that the tool was easy to use; 62% (8/13) of patients and 71% (5/7) of physicians rated that they trusted the CDSS. Of the 13 patients, 6 (46%) felt that the patient-clinician relationship significantly or somewhat improved, whereas 7 (54%) felt that it did not change.ConclusionsOur findings confirm that the integration of the tool does not significantly increase appointment length and suggest that the CDSS is easy to use and may have positive effects on the patient-physician relationship for some patients. The CDSS is feasible and ready for effectiveness studies.Trial RegistrationClinicalTrials.gov NCT04061642; http://clinicaltrials.gov/ct2/show/NCT04061642

Exploring parity in female authorship of pharmacoepidemiology articles: A case study of the Canadian Network for Observational Drug Effect Studies and its citing articles.

The Canadian Network for Observational Drug Effect Studies (CNODES) studies the benefits and risks of post-market drugs and evaluates its research mobilization efforts for accountability, demonstrating value, and learning. As part of these evaluation efforts, and acknowledging gender disparity in authorship across many academic disciplines, CNODES examined the relationship between gender and authorship in its own journal articles and the literature citing them. CNODES articles (published 2012-2017) and all citing articles were identified and extracted using Scopus. Scopus author IDs were used to extract full names and a web service (www.genderapi.com) was used to estimate gender, converting all probabilities <80% to "indeterminate." T-tests and visualizations were used to compare the proportion of females between CNODES and the citing literature. Twenty-eight CNODES articles and 463 citing articles were identified. The mean number of authors per article was 9.5 in CNODES articles and 5.7 in the citing literature. CNODES articles had a female authorship rate of 36%, compared to 29% in the citing literature (7% difference, 95% CI: [1%, 13%]). There were no female authors in 14% of CNODES articles versus 36% of the citing literature. Women were first authors in 25% and corresponding authors in 14% of CNODES articles. This analysis provides a benchmark and method to monitor progress in female parity in pharmacoepidemiology authorship. Further work is needed to determine and address barriers and facilitators to women's recruitment and advancement in the field of pharmacoepidemiology.

Use of a point-of-care web-based application to enhance adherence to the CANMAT and ISBD 2018 guidelines for the management of bipolar disorder.

While clinical guidelines exist for the management of bipolar disorder (BD), there are significant challenges to their widespread dissemination and implementation in clinical practice. The Canadian Network of Mood and Anxiety Treatment Improving Patient Care and Outcomes in the Treatment of Bipolar Disorder (C-IMPACT BD) web-based application was developed for use at the point-of-care to improve adherence to guidelines for evidence-based pharmacological management of BD. C-IMPACT BD uses a point-of-care practice assessment which, via adaptive questioning of patient-specific information, text/video descriptions of the guidelines, and pop-up prompts delivers personalized, evidence-based treatment recommendations for patients with BD. In order to inform quality improvement of the newly developed tool, a sample of Canadian physicians were invited to use the application and record its influence on their prescribing behavior. Of 375 patients with bipolar I (BD-I) or bipolar II (BD-II) disorder for whom a point-of-care practice assessment was completed, a change in therapy was considered for 225 (60.0%). Prior to completing the assessment, 59.6% of these patients were receiving first-line therapy recommended for their phase of illness. Following the assessment, the overall number of patients for whom a first-line recommended therapy was being considered increased significantly to 76.9% (p=0.0001). Outcomes suggest that the C-IMPACT BD web-based application has the potential to improve physician adherence to clinical treatment guidelines. Formal research investigations are warranted to explore the impact of this tool on physician prescribing behavior and patient outcomes.

Wait-there's evidence for that? Integrative medicine treatments for major depressive disorder.

Depression is one of the most common mental health disorders and currently affects over 17 million Americans. Up to two-thirds of patients with depression in the United States will seek complementary and alternative or integrative medical treatments and thus medical providers who treat depression should understand that many integrative medical treatments have evidence of efficacy either as monotherapies or as add-on adjuncts to other treatments. This review references guidelines from the Canadian Network for Mood and Anxiety Treatments and Michigan Medicine, along with an updated literature review, to provide a framework for reviewing medications or herbal formulation, as well as other therapies, which have evidence in the treatment of depression. In general, St. John's Wort, Omega-3 Fatty Acids, S-adenosyl-L-methionine, and crocus sativus (saffron) have the highest levels of evidence in the treatment of mild-to-moderate depression. Acetyl-l-carnitine, l-methylfolate, DHEA, and lavender have a moderate level of evidence in treating depression, whereas Vitamin D, one of the most common supplements in the United States, does not have evidence in treating depression. Of the non-medication-based therapies, exercise, light therapy, yoga, acupuncture, and probiotics have evidence in the treatment of depression, whereas a full review of dietary modifications for depression was out of scope for this article.

Direct-acting antiviral treatment uptake and sustained virological response outcomes are not affected by alcohol use: ACANUHCanalysis.

Alcohol use and hepatitis C virus (HCV) are two leading causes of liver disease. Alcohol use is prevalent among the HCV-infected population and accelerates the progression of HCV-related liver disease. Despite barriers to care faced by HCV-infected patients who use alcohol, few studies have analyzed uptake of direct-acting antiviral (DAA) treatment. We compared rates of treatment uptake and sustained virological response (SVR) between patients with and without alcohol use. Prospective data were obtained from the Canadian Network Undertaking against Hepatitis C (CANUHC) cohort. Consenting patients assessed for DAA treatment between January 2016 and December 2019 were included. Demographic and clinical characteristics were compared between patients with and without alcohol use by means of t-tests, χ2 tests, and Fisher's Exact Tests. Univariate and multivariate analyses were used to determine predictors of SVR and treatment initiation. Current alcohol use was reported for 217 of 725 (30%) patients. The proportion of patients initiating DAA treatment did not vary by alcohol use status (82% versus 83%; p= 0.99). SVR rate was similar between patients with alcohol use and patients without alcohol use (92% versus 94%; p= 0.45). Univariate and multivariate analysis found no association between alcohol use and SVR or treatment initiation. Patients engaged in HCV treatment have highly favourable treatment uptake and outcomes regardless of alcohol use. Public health interventions should be directed toward facilitating access to care for all patients irrespective of alcohol use. Research into high-level alcohol use and DAA outcomes is needed.

Treatment of mixed depression with theta-burst stimulation (TBS): results from a double-blind, randomized, sham-controlled clinical trial.

Mixed depression is probably different in terms of clinical course and response to treatment. Repetitive transcranial magnetic stimulation (rTMS) is well established in non-mixed depression, and theta-burst stimulation (TBS) protocol is replacing conventional protocols because of noninferiority and reduced delivery time. However, TBS has not been adequately studied in mixed states. This study was a double-blind, six-week, sham-controlled, and randomized clinical trial of bilateral TBS targeting the right and left dorsolateral prefrontal cortex, respectively. Adults with bipolar and major depressive disorder experiencing an acute mixed depression were eligible if they had not benefited from a first- or second-line treatment for acute unipolar or bipolar depression recommended by the Canadian Network for Mood and Anxiety Treatments. Out of 100 patients included, 90 composed modified intention-to-treat sample, which was patients that completed at least one week of the intervention. There were no significant differences in Montgomery-Asberg depression rating scale score changes (least squares mean difference between groups at week 3, -0.06 [95% CI, - 3.39 to 3.51; P = 0.97] in favor of sham TBS). Response and remission rates per MADRS were also not statistically different among active and sham groups (35.7% vs. 43.7%, and 28.5% vs. 37.5% respectively at week 6, ps > 0.51). No other analyses from baseline to weeks 3 or 6 revealed significant time x group interaction or mean differences among groups in the mITT sample. Bilateral TBS targeting the DLPFC is not efficacious as an add-on treatment of acute bipolar and unipolar mixed depression. ClinicalTrials.govIdentifier: NCT04123301.

Innovative praxis for environmental learning in Canadian faculties of education

AbstractThis article explores innovative praxis in Environmental and Sustainability Education (ESE) in four preservice teacher education programmes in Canada. ESE is finding its way into teacher education in a variety of innovative and interdisciplinary ways, as both part of mainstream programmes and in their co-curricular margins. Using a case study approach, each case builds on unique connections to Indigenous education, art education, cultural learning or educational gardening, which supports a variety of differing aspects in relation to ESE. These cases share a common theme of building relationships at the heart of ESE teaching and learning in the mainstream and the margins of the academy. Brought together through a Canadian network of faculty, researchers, policy-makers and community educators that was formed in 2016, these cases demonstrate a deep commitment and imaginative capacity for embedding ESE in Canada’s teacher education systems.

Introduction

The aim and scope of the Journal of Australian, Canadian and Aotearoa New Zealand Studies (JACANZS) is to publish articles in various disciplines (history, politics, literature, law, anthropology, and Indigenous studies) on one or more of the following countries; Australia, Canada, and Aotearoa New Zealand, with a core focus on articles that are comparative in their geographic remit for example Australia and Aotearoa New Zealand, or Australia and Canada. The creation of the journal responds to a lack of journals that collectively publish across the fields of Australian, Canadian, and Aotearoa New Zealand studies from multi and interdisciplinary perspectives. It also followed the creation of the Australian, Canadian and New Zealand Studies Network (ACNZSN) to reflect the work and membership of the network.

Expanding the target audience for management guidelines: Co-development of the patient and family guide to the CANMAT and ISBD bipolar disorder guidelines.

The Canadian Network for Mood and Anxiety Treatments (CANMAT) and the International Society for Bipolar Disorders (ISBD) have continued their longstanding collaboration in developing new guidelines for the management of patients with bipolar disorder (BD). These highly-cited guidelines have been published and translated into several languages, and are a key resource to clinicians, educators, and academics around the world.

The Canadian Network for Research in Schizophrenia and Psychoses: A Nationally Focused Approach to Psychosis and Schizophrenia Research.

The Canadian Network for Research in Schizophrenia and Psychoses: A Nationally Focused Approach to Psychosis and Schizophrenia Research.

Reader Comment Regarding “Efficacy of Brodalumab for Moderate to Severe Plaque Psoriasis: A Canadian Network Meta-Analysis”

Reader Comment Regarding “Efficacy of Brodalumab for Moderate to Severe Plaque Psoriasis: A Canadian Network Meta-Analysis”

Annual Meeting of the Canadian Association for the Study of the Liver (CASL), the Canadian Network on Hepatitis C (CANHEPC) and the Canadian Association of Hepatology Nurses (CAHN) 2021 Abstracts.

Annual Meeting of the Canadian Association for the Study of the Liver (CASL), the Canadian Network on Hepatitis C (CANHEPC) and the Canadian Association of Hepatology Nurses (CAHN) 2021 Abstracts.

Commentary on the Canadian Network for Mood and Anxiety Treatments (CANMAT) Task Force Recommendations for the Use of Racemic Ketamine in Adults with Major Depressive Disorder.

Commentary on the Canadian Network for Mood and Anxiety Treatments (CANMAT) Task Force Recommendations for the Use of Racemic Ketamine in Adults with Major Depressive Disorder.

Efficacy of Active vs Sham Intermittent Theta Burst Transcranial Magnetic Stimulation for Patients With Bipolar Depression

Major depressive episodes in bipolar disorder are common and debilitating. Repetitive transcranial magnetic stimulation is well established in the treatment of major depressive disorder, and the intermittent theta burst stimulation (iTBS) protocol is replacing conventional protocols because of noninferiority and reduced delivery time. However, iTBS has not been adequately studied in bipolar disorder and, therefore, its efficacy is uncertain. To determine whether iTBS to the left dorsolateral prefrontal cortex (LDLPFC) is safe and efficacious in the treatment of acute bipolar depression. This study was a double-blind, 4-week, randomized clinical trial of iTBS targeting the LDLPFC. Two Canadian academic centers recruited patients between 2016 and 2020. Adults with bipolar disorder type I or type II experiencing an acute major depressive episode were eligible if they had not benefited from a first-line treatment for acute bipolar depression recommended by the Canadian Network for Mood and Anxiety Treatments and were currently treated with a mood stabilizer, an atypical antipsychotic, or their combination. Seventy-one participants were assessed for eligibility, and 37 were randomized to daily sham iTBS or active iTBS using a random number sequence, stratified according to current pharmacotherapy. Data analysis was performed from April to September 2020. Four weeks of daily active iTBS (120% resting motor threshold) or sham iTBS to the LDLPFC. Nonresponders were eligible for 4 weeks of open-label iTBS. The primary outcome was the change in score on the Montgomery-Asberg Depression Rating Scale from baseline to study end. Secondary outcomes included clinical response, remission, and treatment-emergent mania or hypomania. The trial was terminated for futility after 37 participants (23 women [62%]; mean [SD] age, 43.86 [13.87] years; age range, 20-68 years) were randomized, 19 to sham iTBS and 18 to active iTBS. There were no significant differences in Montgomery-Asberg Depression Rating Scale score changes (least squares mean difference between groups, -1.36 [95% CI, -8.92 to 6.19; P = .91] in favor of sham iTBS), and rates of clinical response were low in both the double-blind phase (3 of 19 participants [15.8%] in the sham iTBS group and 3 of 18 participants [16.7%] in the active iTBS group) and open-label phase (5 of 21 participants [23.8%]). One active iTBS participant had a treatment emergent hypomania, and a second episode occurred during open-label treatment. iTBS targeting the LDLPFC is not efficacious in the treatment of acute bipolar depression in patients receiving antimanic or mood stabilizing agents. Additional research is required to understand how transcranial magnetic stimulation treatment protocols differ in efficacy between unipolar and bipolar depression. ClinicalTrials.gov Identifier: NCT02749006.

Editorial introductions.

Editorial introductions.

Editorial introductions.

Editorial introductions.

The concurrent use of two long-acting injectables in the maintenance treatment of bipolar disorder.

Bipolar disorder is a serious condition that can cause significant impairment in patients' lives. As such, it is important to ensure good treatment and management of the condition. However, adherence to pharmacological treatment is a significant problem, and risks of non-adherence include hospitalization and suicide. Both antipsychotic medications and mood stabilisers are recommended for the maintenance treatment of bipolar disorder. According to the Canadian Network for Mood and Anxiety Treatment (CANMAT) 2018 guidelines, psychoeducation should be provided initially to reduce non-adherence to medication. If this is ineffective, long-acting injectable (LAI) antipsychotics should be considered (1). The CANMAT guidelines also state that most patients with bipolar disorder will require short or long-term combination treatment to address acute or subsyndromal symptoms and to reduce rates of recurrence. To our knowledge, this is the first case presentation that examines the combination of two antipsychotic LAIs for maintenance treatment of bipolar disorder. We describe two patients with bipolar disorder, with a history of multiple relapses due to non-adherence to oral medications, who were maintained on both Paliperidone 150mg and Aripiprazole 400mg LAIs once every 4 weeks.

The Canadian Network for Mood and Anxiety Treatments (CANMAT) Task Force Recommendations for the Use of Racemic Ketamine in Adults with Major Depressive Disorder: Recommandations Du Groupe De Travail Du Réseau Canadien Pour Les Traitements De L'humeur Et De L'anxiété (Canmat) Concernant L'utilisation De La Kétamine Racémique Chez Les Adultes Souffrant De Trouble Dépressif Majeur.

Patients with major depressive disorder often have limited response to first-line and second-line medications; hence, novel pharmacological treatments are needed for treatment-resistant depression (TRD). Ketamine, an N-methyl-d-aspartate (NMDA) receptor antagonist, has demonstrated rapid antidepressant effects in patients with TRD. The Canadian Network for Mood and Anxiety Treatments (CANMAT) convened a task force to review the evidence for efficacy and safety of racemic ketamine and to provide recommendations for its use in clinical practice. A systematic review was conducted with computerized search of electronic databases up to January 31, 2020 using combinations of search terms, inspection of bibliographies, and review of other ketamine guidelines and consensus statements. The level of evidence and lines of treatment were assigned according to CANMAT criteria. Recommendations were given in question-answer format. Intravenous (IV) racemic ketamine given as a single infusion has Level 1 evidence for efficacy in adults with TRD. The evidence for multiple infusions, given as an acute series or as ongoing maintenance treatment, is limited to Level 3. Adverse events associated with ketamine infusions include behavioral (e.g., dissociative symptoms) and physiological (e.g., hypertension) events. There is only Level 3 or 4 evidence for non-IV formulations of racemic ketamine. Consensus recommendations are given for clinical administration of IV ketamine including patient selection, facility and personnel issues, monitoring, and maintaining response. Single-dose IV racemic ketamine is a third-line recommendation for adults with TRD. The need for repeated and maintenance ketamine infusions should be carefully assessed on a case-by-case basis with consideration of potential risks and benefits. Because of limited evidence for efficacy and risk for misuse and diversion, the use of oral and other formulations of racemic ketamine should be limited to specialists with ketamine-prescribing expertise and affiliations with tertiary or specialized centers.

The 9th Canadian Symposium on Hepatitis C Virus: Advances in HCV research and treatment towards elimination.

Hepatitis C virus (HCV) elimination has evolved into a coordinated global effort. Canada, with more than 250,000 chronically infected individuals, is among the countries leading this effort. The 9th Canadian Symposium on HCV, held in February 2020, thus established and addressed its theme, 'advances in HCV research and treatment towards elimination', by gathering together basic scientists, clinicians, epidemiologists, social scientists, and community members interested in HCV research in Canada. Plenary sessions showcased topical research from prominent international and national researchers, complemented by select abstract presentations. This event was hosted by the Canadian Network on Hepatitis C (CanHepC), with support from the Public Health Agency of Canada and the Canadian Institutes of Health Research and in partnership with the Canadian Liver Meeting. CanHepC has an established record in HCV research by its members and in its advocacy activities to address the care, treatment, diagnosis, and immediate and long-term needs of those affected by HCV infection. Many challenges remain in tackling chronic HCV infection, such as the need for a vaccine; difficult-to-treat populations and unknown aspects of patient subgroups, including pregnant women and children; vulnerable people; and issues distinct to Indigenous peoples. There is also increasing concern about long-term clinical outcomes after successful treatment, with the rise in comorbidities such as diabetes, cardiovascular disease, and fatty liver disease and the remaining risk for hepatocellular carcinoma in cirrhotic individuals. The symposium addressed these topics in highlighting research advances that will collectively play an important role in eliminating HCV and minimizing subsequent health challenges.

Conducting an international curriculum review meeting in the age of COVID-19

The Canadian Network for International Surgery (CNIS) hosted a workshop in May of 2020 with a goal of critically evaluating Trauma Team Training courses. The workshop was held virtually because of the coronavirus disease 2019 (COVID-19) pandemic. Twenty-three participants attended from 8 countries: Canada, Guyana, Kenya, Nigeria, Switzerland, Tanzania, Uganda and the United States. More participants were able to attend the virtual meeting than the traditional in-person meetings. Web-based videoconference software was used, participants presented prerecorded PowerPoint videos, and questions were raised using a written chat. The review proved successful, with discussions and recommendations for improvements surrounding course quality, lecture content, skills sessions, curriculum variations and clinical practical scenarios. The CNIS's successful experience conducting an online curriculum review involving international participants may prove useful to others proceeding with collaborative projects during the COVID-19 pandemic.