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LONDON, ON – A beneficial and cost-effective approach to mental health care that supports people as they go from hospital and back into the community is outlined in a new resource and has been recognized internationally by the World Health Organization (WHO). 

“The immediate period after discharge from hospital, usually the first month, can be one of the most vulnerable times in the life of someone experiencing a mental illness. It can be when they are most at risk of committing suicide,” explains Dr. Cheryl Forchuk, Assistant Scientific Director at Lawson Health Research Institute. “However, what we’ve seen is that there’s often a gap between when someone says ‘goodbye’ to the hospital inpatient unit and ‘hello’ to the community care provider.” 

Today during a virtual book launch, a research team from Lawson and several community organizations discussed details of a new publication from Routledge, From Therapeutic Relationships to Transitional Care: A Theoretical and Practical Roadmap, edited by Dr. Forchuk. The book combines theory, research and best practices into a “roadmap” for organizations and others worldwide coordinating services or studying mental health care systems. It includes a practical toolkit for implementing the Transitional Discharge Model (TDM), developed and tested in communities across Ontario.  

TDM was born from a participatory action project with consumers of mental health services. They identified two factors that were most important to them when they were going from hospital to the community: consistency in therapeutic relationships and a supportive peer friendship. They described it as a “safety net of relationships” that would bridge the gap between hospital and community services.  

“As a person-centred, evidence-based model, transitional discharge supports a smooth adjustment from hospital to community,” says Dr. Forchuk. “The inpatient staff continue to care for discharged clients until therapeutic relationships are established with community care providers. At the same time, we have a friendship model of peer support. These are trained people with lived experience of mental illness who have made the same journey.” 

Lance Dingman was a TDM client during the early phases of the project. “It makes a big difference when you’re able to get back to living in the community and in your own dwelling. You get to make more of your own decisions and learn about what you want to do. You grow with your experience and the guidance of others who are there to support you.”  

Later becoming a peer support coach, Dingman feels implementing TDM for mental health care is important because people can learn from each other and get healthier in the process. “As a peer support worker, I sit with people and they tell me their story. It takes me back and I know what they are going through – I was where they are. I can share my own story and tell them what I did to get better.”  

Dr. Forchuk’s team analyzed the cost of TDM after being tested in nine hospitals across Ontario, including London Health Sciences Centre and St. Joseph’s Health Care London. On average, the length of stay in hospital was reduced by almost 10 (9.8) days per admission and each site saved approximately $3.3 million per year. “People can return home sooner because a higher level of care and support is in place when they leave hospital. If all hospitals in Ontario with mental health services were able to implement our transitional discharge model, we would save $60 million per year in hospital stay costs alone while providing enhanced mental health care.”  

The TDM approach is now considered a “good practice” by WHO and was recently the only Canadian example included in its Guidance on community mental health services: Promoting person-centered and rights-based approaches. This set of publications provides information and support to all stakeholders who wish to develop or transform their mental health system and services to align with international human rights standards including the UN Convention on the Rights of Persons with Disabilities.  

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LONDON, ON – A new study from ICES, Lawson Health Research Institute and Western University suggests that injection drug users prescribed controlled-release hydromorphone are three times more likely to develop endocarditis, a serious bacterial heart infection, when compared to those prescribed other opioids. The findings, published today in The Lancet Infectious Diseases, build on growing evidence that some controlled-release opioids may lead to higher risk of infectious disease among persons who inject drugs. 

The researchers looked at de-identified Ontario health data for hospital admissions related to injection drug use between 2006 and 2015. Of 60,529 admissions, 733 patients had infective endocarditis. The team found that regions with high hydromorphone prescription rates had more than double the cases of infective endocarditis (254 cases) when compared to regions with low prescription rates (113 cases).

The study also analyzed individual prescription records and found that among persons who inject drugs, those prescribed controlled-release hydromorphone were three times more likely to develop infective endocarditis when compared to those prescribed any other opioid. There was no increased risk for those prescribed the immediate-release form of hydromorphone.

“Added to the existing data, these findings make a compelling argument for the role of controlled-release hydromorphone in the growing risk of infective endocarditis among persons who inject drugs,” says Dr. Matthew Weir, Adjunct Scientist at ICES, Associate Scientist at Lawson and Assistant Professor at Western’s Schulich School of Medicine & Dentistry. 

Opioids are often manufactured as controlled-release or ‘slow-release’ capsules to prevent rapid absorption of the drug. Properties in the capsules help to spread pain relief over a longer period of time.

This is the latest in a series of studies from the research team that suggest some controlled-release opioids may be leading to increased risk of infectious disease among persons who inject drugs. 

In one study, they demonstrated that polymer-coated beads used to provide the slow-release property make controlled-release hydromorphone difficult to dissolve. They found equipment used to dissolve the drug retains up to 45 per cent of the initial dose, leading injection drugs users to save and reuse equipment.

With frequent re-handling of equipment, there are multiple opportunities for bacterial and viral contamination. The team found that HIV and a dangerous bacterium called Staphylococcus aureus are more likely to survive in equipment used to prepare controlled-release hydromorphone since added chemicals that make the drug slow-release promote survival of bacteria and viruses. 

“There’s been a global increase in infectious diseases among persons who inject drugs and our research suggests that controlled-release prescription opioids may be a major culprit,” says Dr. Michael Silverman, Associate Scientist at Lawson and Associate Professor at Schulich Medicine & Dentistry. “We now have evidence that suggests the injection of controlled-release hydromorphone is increasing the spread of HIV, hepatitis C and endocarditis in Canada.” 

The team believes these findings could also explain the increase in infectious complications in the USA and other countries where controlled-release hydromorphone is not on the market.  There are other controlled-release opioids, such as controlled-release morphine, that use a similar slow-release mechanism and may carry similar risks.

“It’s important that people are aware of the infectious risks of injecting opioids and, if necessary, practice harm reduction techniques,” says Dr. Silverman. “We’ve found you can use a cigarette lighter to destroy bacteria and viruses by heating the cooker used to prepare the drug for about 10 seconds or until the mixture bubbles. We’ve termed the technique ‘cook your wash.’” 

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Equipment used by persons who inject drugs

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Cooker with lighter (demonstrating the ‘Cook your wash’ technique)

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Dr. Michael Silverman

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Dr. Matthew Weir

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LONDON, ON – A new study from Lawson Health Research Institute and Western University suggests that fecal transplants could be used as a treatment for non-alcoholic fatty liver disease (NAFLD). The randomized controlled trial published in The American Journal of Gastroenterology found that fecal transplants in patients with NAFLD result in a reduction in how easily pathogens and other unwanted molecules pass through the human gut and into circulation, known as intestinal permeability. The results could have implications for the treatment of numerous conditions including metabolic syndrome and autoimmune diseases. 

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“Intestinal permeability plays a role in the development of metabolic syndrome which is a major cause of coronary and cerebrovascular disease. It has also been associated with autoimmune diseases like multiple sclerosis (MS), rheumatoid arthritis, systemic lupus and type 1 diabetes,” explains Dr. Michael Silverman, Associate Scientist at Lawson and Professor at Western’s Schulich School of Medicine & Dentistry.

Many NAFLD patients have increased intestinal permeability which triggers inflammation, increased fat in the liver, insulin resistance and elevated levels of triglycerides in the blood. The human microbiome – the diverse collection of microbes in our body – is thought to play a role. Previous studies have shown differences between the gut microbiome of NAFLD patients compared to healthy individuals. 

“Our team wondered whether we could change the gut microbiome of NAFLD patients to reduce intestinal permeability,” says Dr. Jeremy Burton, Lawson Scientist and Associate Professor at Schulich Medicine & Dentistry.

The trial included 21 NAFLD patients from London Health Sciences Centre (LHSC) and St. Joseph’s Health Care London. Patients were randomized to receive a fecal transplant using stool from a healthy donor or a placebo (the patient’s own stool). Fecal material was delivered to the small intestine using endoscopy. Patients were followed for six months to assess changes to their gut microbiome, intestinal permeability, percentage of liver fat and insulin resistance. 

While the researchers found no changes in percentage of liver fat or insulin resistance, they observed significant reduction in intestinal permeability in those patients who had elevated intestinal permeability at the study’s start (seven patients in total). They also observed changes to the gut microbiome in all patients who received a fecal transplant from a healthy donor. 

“Our study demonstrates that intestinal permeability can be improved through fecal transplant from a healthy donor,” says Dr. Laura Craven, a recent PhD graduate from Schulich Medicine & Dentistry and first author on the published study. “This suggests that fecal transplant could be used as an early intervention in the treatment of NAFLD to reduce intestinal permeability and prevent inflammation”

“Our findings have implications for other conditions too,” adds Dr. Silverman, who is also Chair/Chief of Infectious Diseases at Western, LHSC and St. Joseph’s. “Changing the gut microbiome could hold promise in preventing and treating metabolic syndrome and autoimmune diseases associated with increased gut permeability.”

The team hopes to next conduct a large multi-centre trial to further investigate FMT as an intervention for NAFLD and as a therapy to reduce intestinal permeability. 

NAFLD is an obesity-related disorder and is the second-leading cause of liver transplant in North America. While reversible if treated early, its progression can lead to liver failure or cancer. Current therapies are not overly effective and the prevalence of NAFLD is increasing. 

Dr. Silverman is a pioneer in the field of fecal transplants, including their use as a treatment for Clostridioides difficile (C. diff). He is involved in multiple studies examining the potential of fecal transplants as treatments or supportive therapies for numerous conditions including multiple sclerosis (MS) and different types of cancer.

“In order to conduct this research, we need stool donors,” notes Dr. Silverman. “By donating your poop, you can help us assess the value of fecal transplants to treat a variety of diseases.”

The team is in need of young, healthy stool donors for fecal transplants. All donors are required to go through a screening process. Those interested in becoming a stool donor can contact Dr. Seema Nair Parvathy, Research Coordinator, Fecal Transplant Program, at 519-646-6100 ext. 61726.

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Stool samples being prepared in the lab.

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Dr. Michael Silverman (left) and Dr. Jeremy Burton (right)

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Dr. Laura Craven

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LONDON, ON - A new study led by Western University and Lawson Health Research Institute has found that most patients entering hospital intensive care units (ICU) for non-brain-related injuries or ailments also suffer from some level of related cognitive dysfunction that currently goes undetected in most cases. 

The findings were published today in the influential scientific journal, PLOS One.  

Many patients spend time in the ICU for reasons that have nothing to do with a known brain injury, and most health care providers and caregivers don’t have any evidence to believe there is an issue with the brain. For example, a patient may have had a traumatic injury that does not involve the brain, yet still requires breathing support to enable surgeons to fix damaged organs, they may have issues with their heart or lungs, they may contract a serious infection, or they may simply be recovering from a surgical procedure like an organ transplant that has nothing directly to do with their brain. 

For the study, Western researchers from the Schulich School of Medicine & Dentistry and the Brain and Mind Institute and researchers from Lawson assessed 20 such patients as they left the ICU and every single patient had detectible cognitive deficits in two or more cognitive areas of investigation, including memory, attention, decision-making and reasoning. Again, this is in spite of the fact that, on the face of it, they had no clear brain injury.

The discovery was made using online tests, developed by renowned Western neuroscientist Adrian Owen and his teams at the Brain and Mind Institute and BrainsCAN, which were originally designed to examine cognitive ability in patients following brain injuries but for this purpose, are being used to detect cognitive deficits in people who have spent time in an intensive care unit without a diagnosed brain injury. 

“Many people spend time in an intensive care unit following a brain injury and, of course, they often experience deficits in memory, attention, decision-making and other cognitive functions as a result,” explains Owen, a professor at Schulich Medicine & Dentistry. “In this study, we were interested to see how patients without a specific brain injury fair after leaving the ICU. The results were astonishing.”

Why cognitive ability declines even in non-brain related visits to the ICU likely varies from patient to patient, but Dr. Kimia Honarmand from Schulich Medicine & Dentistry says the lesson to be learned is that many conditions affect brain function, even though they might not directly involve the brain. 

“If you are having trouble breathing, your brain may be starved of oxygen. If you have a serious infection, the inflammation that occurs as a result of infection may affect brain function. If you are undergoing major surgery, you might be given drugs and have procedures that may affect your breathing, which in turn may affect the flow of oxygen to the brain,” explains Dr. Honarmand. “What we have shown here is that all or any of these events can lead to deficits in brain function that manifest as impairments in cognition. And healthy cognition is a vital determinant of functional recovery.”

Dr. Marat Slessarev, Lawson Scientist, says these findings can shift how the medical community treats incoming patients and more importantly, outpatients following ICU visits.   

“Historically, the clinical focus has been on just survival. But now we can begin to focus on good survival,” says Dr. Slessarev, also an associate member at the Brain and Mind Institute and an assistant professor at Schulich Medicine & Dentistry. “These sensitive tests will enable doctors to both detect cognitive impairment and track cognitive performance over time, which is the first step in developing processes for optimizing brain recovery.”

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Researchers looking to better personalize treatment for PTSD

MEDIA RELEASE
For immediate release
January 25^th, 2022

LONDON, ON – Post-traumatic stress disorder (PTSD) is a condition that often develops in those who have experienced a traumatic event. PTSD affects close to 10 per cent of Canadians, and in some cases, can be difficult to treat. 
In a new study through Lawson Health Research Institute and Western University’s Schulich School of Medicine & Dentistry, scientists are looking at a form of treatment called deep brain reorienting (DBR) for those suffering from PTSD.

“In our study we are looking at ways of trauma processing at the foundation of the stress response,” explains Dr. Ruth Lanius, Associate Scientist at Lawson and Professor at Western’s Schulich School of Medicine & Dentistry. “When you are faced with a stressor the first thing you do is turn your attention to it, and when you do that you engage your head and neck muscles.”

DBR was developed by Scottish psychiatrist Dr. Frank Corrigan and focuses on the muscles of the shoulders, neck, head and face of patients when recalling a traumatic event. This form of trauma processing starts right at the moment the stressor is noticed by the individual, which is often quickly followed by a moment of shock.  By addressing the stressor at this level, doctors can target the foundation of where the stress response begins.

“When patients bring up a trigger in their mind, we look at what happens in terms of the tension in their head and neck.  We process that gently by asking the patient to notice and stay with that tension without trying to release it, and over time the tension usually decreases,” explains Dr. Lanius, who is also a Psychiatrist at London Health Sciences Centre. “The second part involves addressing the shock response. You turn your attention to the stressor and then notice any moments of shock that follows, which is often associated with tension behind the eyes and in the shoulders. Finally, you address the visceral sensations associated with feelings and emotions associated with the stressor.”

Dr. Lanius believes that by using DBR and focusing on muscle and visceral responses, it will help patients suffering from PTSD to process the visceral feelings associated with the trauma and its triggers.

“After this form of treatment, patients often say they feel safer and don’t see themselves negatively, like they did in the past,” says Dr. Lanius. “This is because we change those intense visceral feelings and it allows the person to reevaluate who they are and how they interact with the world.”

The research team is hoping to recruit approximately 60 people to take part in the DBR study.  Participants will undergo a psychological interview and an MRI, then eight sessions of treatments. Following those sessions, participants will have another interview and MRI to assess if any positive changes were made within the neurological networks and/or in psychological systems.

“Our hopes are to really personalize treatment for those living with PTSD,” says Dr. Lanius. “Some people have difficulty tolerating some forms of trauma processing and in my experience this treatment is a gentler approach for those individuals.”

Interested participants who have been diagnosed with PTSD can contact Suzy Southwell, Research Coordinator, at 519-685-8500 ext. 35186 or @email.

                                                                                                                                                  

MEDIA CONTACT

Celine Zadorsky, Communications & External Relations, Lawson Health Research Institute, T: 519-685-8500 ext. 75664, C: 519-619-3872

ABOUT LAWSON HEALTH RESEARCH INSTITUTE
Lawson Health Research Institute is one of Canada’s top hospital-based research institutes, tackling the most pressing challenges in health care. As the research institute of London Health Sciences Centre and St. Joseph’s Health Care London, our innovation happens where care is delivered. Lawson research teams are at the leading-edge of science with the goal of improving health and the delivery of care for patients. Working in partnership with Western University, our researchers are encouraged to pursue their curiosity, collaborate often and share their discoveries widely. Research conducted through Lawson makes a difference in the lives of patients, families and communities around the world.

ABOUT WESTERN 
Western delivers an academic experience second to none. Since 1878, The Western Experience has combined academic excellence with life-long opportunities for intellectual, social and cultural growth in order to better serve our communities. Our research excellence expands knowledge and drives discovery with real-world application. Western attracts individuals with a broad worldview, seeking to study, influence and lead in the international community.

ABOUT THE SCHULICH SCHOOL OF MEDICINE & DENTISTRY
The Schulich School of Medicine & Dentistry at Western University is one of Canada’s preeminent medical and dental schools. Established in 1881, it was one of the founding schools of Western University and is known for being the birthplace of family medicine in Canada. For more than 130 years, the School has demonstrated a commitment to academic excellence and a passion for scientific discovery.