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Between 2010 and 2019 the international health care organization Partners In Health (PIH) and its sister organization Zanmi Lasante (ZL) mounted a long-term response to the 2010 Haiti earthquake, focused on mental health. Over that time, implementing a Theory of Change developed in 2012, the organization successfully developed a comprehensive, sustained community mental health system in Haiti's Central Plateau and Artibonite departments, directly serving a catchment area of 1.5 million people through multiple diagnosis-specific care pathways. The resulting ZL mental health system delivered 28 184 patient visits and served 6305 discrete patients at ZL facilities between January 2016 and September 2019. The experience of developing a system of mental health services in Haiti that currently provides ongoing care to thousands of people serves as a case study in major challenges involved in global mental health delivery. The essential components of the effort to develop and sustain this community mental health system are summarized.

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BACKGROUND: An estimated 19-25% of perinatal women in low- and middle-income countries are affected by depression which, untreated, is associated with multiple health problems for mothers and children. Nonetheless, few perinatal women have access to depression care. The Thinking Healthy Programme (THP), promoted by the World Health Organization (WHO), is an evidence-based, non-specialist delivered depression intervention that addresses this care gap. However, the WHO THP manual explains intervention delivery but not the antecedents to implementation. Here, we describe a principled, planned approach leading to the implementation of THP in Lima, Peru by the non-profit organization Socios En Salud with community health workers (CHW) to inform its implementation in other settings. METHODS: The Replicating Effective Programs (REP) framework guided THP implementation, following four phases: (I) pre-conditions; (II) pre-implementation; (III) implementation; and (IV) maintenance and evolution. This paper centers on REP phases I and II, including (1) documented high perinatal depression rates in Peru; (2) designation of perinatal depression as a government priority; (3) THP Implementation Team orientation and training; (4) data collection plan development; (5) public health system coordination; (6) CHW selection and training; and (7) THP launch. RESULTS: Between December 2016 and March 2017, a THP training program was developed and seven CHW were trained to deliver the intervention to 10 perinatal women, the first of whom was enrolled on 17 April 2017. CONCLUSIONS: THP was rapidly implemented by a community-based organization with no prior experience in delivering non-specialist perinatal depression care. The steps followed may inform the implementation of THP in other settings.

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Setting: Programmes that integrate mental health care into primary care settings could reduce the global burden of mental disorders by increasing treatment availability in resource-limited settings, including Rwanda. Objective: We describe patient demographics, service use and retention of patients in care at health centres (HC) participating in an innovative primary care integration programme, compared to patients using existing district hospital-based specialised out-patient care. Design: This was a retrospective cohort study using routinely collected data from six health centres and one district hospital from October 2014 to March 2015. Results: Of 709 patients, 607 were cared for at HCs; HCs accounted for 88% of the total visits for mental disorders. Patients with psychosis used HC services more frequently, while patients with affective disorders were seen more frequently at the district hospital. Of the 68% of patients who returned to care within 90 days of their first visit, 76% had a third visit within a further 90 days. There were no significant differences in follow-up rates between clinical settings. Conclusion: This study suggests that a programme of mentorship for primary care nurses can facilitate the decentralisation of out-patient mental health care from specialised district hospital mental health services to HCs in rural Rwanda.

Contexte : Les programmes qui intègrent les soins de santé mentale dans les structures de soins de santé primaires pourraient réduire le fardeau mondial des troubles mentaux en augmentant la disponibilité du traitement dans des contextes de ressources limitées, notamment au Rwanda.Objectif : Nous décrivons les caractéristiques démographiques des patients, leur utilisation des services et la rétention des patients en traitement dans les centres de santé (HC) participant à un programme innovant d'intégration dans les soins de santé primaires, comparés aux patients recourant aux consultations spécialisées existantes, basées dans les hôpitaux de district.Schéma : Une étude rétrospective de cohorte basée sur des données recueillies en routine dans six centres de santé et dans un hôpital de district, entre octobre 2014 et mars 2015.Résultats : De 709 patients, 607 ont été soignés dans les HC et les HC ont totalisé 88% de l'ensemble des consultations pour troubles mentaux. Les patients atteints de psychose ont plus souvent utilisé les services des HC, tandis que les patients atteints de troubles affectifs ont été plus souvent vus à l'hôpital de district. De 68% des patients qui sont revenus dans les 90 jours suivant leur première consultation, 76% ont eu une troisième consultation au cours des 90 jours suivants. Il n'y a pas eu de différences significatives en termes de taux de suivi entre les deux contextes cliniques.Conclusion : Cette étude suggère qu'un programme de tutorat destiné aux infirmiers de soins de santé primaires peut faciliter la décentralisation de la prise en charge de la santé mentale en consultation externe des services de santé mentale des hôpitaux spécialisés de district vers les HC dans le Rwanda rural.

Marco de referencia: Los programas que integran la atención de la salud mental al entorno de la atención primaria podrían reducir la carga mundial de morbilidad por trastornos mentales, al aumentar la disponibilidad del tratamiento en los medios con escasos recursos, por ejemplo en Rwanda.Objetivo: Se describen las características demográficas, la utilización de los servicios y la retención en la atención, de los pacientes atendidos en los centros de salud que participan en un programa innovador de atención primaria y se comparan con los pacientes que acuden a la consulta ambulatoria especializada que se presta en un hospital distrital.Método: Fue este un estudio de cohortes retrospectivo a partir de los datos recogidos de manera sistemática en seis centros de salud y un hospital distrital, de octubre del 2014 a marzo del 2015.Resultados: De los 709 pacientes, se atendieron 607 en los centros de salud y estos centros realizaron el 88% del total de consultas por trastornos mentales. Los pacientes con trastornos psicóticos utilizaban con mayor frecuencia los servicios en los centros de salud, pero los pacientes con trastornos del afecto se atendían con mayor frecuencia en el hospital distrital. El 68% de los pacientes regresaron al servicio de atención en los 90 días que siguieron a su primera consulta y el 76% de ellos acudió a una tercera consulta en los siguientes 90 días. No se observaron diferencias significativas en las tasas de seguimiento en los diferentes entornos clínicos.Conclusión: Los resultados del presente estudio ponen de manifiesto que un programa tutorial dirigido al personal de enfermería de los centros de atención primaria puede facilitar la descentralización de la atención ambulatoria de los pacientes con trastornos de salud mental, desde el hospital distrital con servicios especializados hacia los centros de salud en zonas rurales de Rwanda.

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Mental disorders and alcohol/drug use worsen treatment outcomes for multidrug-resistant tuberculosis (TB), but data are lacking for extensively drug-resistant (XDR) TB. We investigated the association of baseline mental disorders and alcohol/drug use on XDR-TB treatment outcomes in a retrospective study of 53 XDR-TB Peruvian patients during 2010-2012. Logistic regression estimated the odds ratios for unfavourable XDR-TB treatment outcomes. Overall treatment success was 25%. Mental disorders and drug/alcohol use were found in respectively 22.4% and 20.4% of patients; neither were associated with unfavourable treatment outcomes. Future research should explore the relationship between mental health and drug/alcohol use in XDR-TB treatment outcomes.

Les troubles mentaux et la consommation d'alcool/de drogue entravent le résultat du traitement de la tuberculose multirésistante (TB-MDR), mais on manque de données pour la TB ultrarésistante (TB-XDR). Nous avons examiné l'association de troubles mentaux préexistants et de consommation d'alcool/de drogue sur le résultat du traitement de la TB-XDR dans une étude rétrospective de 53 patients péruviens atteints de TB-XDR en 2010­2012. Une régression logistique a estimé les odds ratios de résultat défavorable du traitement de la TB-XDR. Le taux d'ensemble de succès du traitement a été de 25%. Des troubles mentaux et une consommation d'alcool/de drogue ont été constatés chez respectivement 22,4% et 20,4% des patients ; aucun n'a été associé à un résultat défavorable du traitement. Des recherches ultérieures devraient explorer la relation entre santé mentale et consommation de drogue/alcool et leur impact sur le traitement de la TB-XDR.

Los trastornos mentales y el consumo de alcohol y de drogas agravan los desenlaces terapéuticos de la tuberculosis multidrogorresistente (TB-MDR), pero no existen datos en cuanto a la TB extremadamente resistente (TB-XDR). En un estudio retrospectivo en 53 pacientes peruianos que padecieron TB-XDR del 2010 al 2012, se investigó la asociación de la presencia inicial de trastornos mentales y consumo de alcohol o drogas con los desenlaces del tratamiento de la TB-XDR. Mediante un modelo de regresión logística se calcularon los cocientes de posibilidades de desenlaces terapéuticos desfavorables. La tasa global de éxito terapéutico fue de 25%. Se encontró que el 22,4% de los pacientes sufría trastornos mentales y el 20,4% consumía alcohol o drogas; ninguna de estas características se asoció con desenlaces desfavorables del tratamiento. Nuevas investigaciones tendrán que explorar la correlación que existe entre la salud mental y el consumo de alcohol o drogas y los desenlaces terapéuticos de la TB-XDR.

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BACKGROUND: Engagement and training of educators in student mental health holds promise for promoting access to care as a task sharing strategy but has not been well-studied in low-income regions. METHODS: We used a prospective and convergent mixed methods design to evaluate a customized school mental health 2½ day training for teachers in rural Haiti (n = 22) as the initial component of formative research developing a school-based intervention to promote student mental health. Training prepared teachers to respond to student mental health needs by providing psychoeducational and practical support to facilitate access to care. We examined level of participation and evaluated feasibility, acceptability, and perceived effectiveness by calculating mean scores on self-report Likert-style items eliciting participant experience. We examined effectiveness of the training on improving mental health knowledge and attitudes by comparing mean scores on an assessment administered pre- and post-training. Finally, we examined self-report written open-ended responses and focus group discussion (FGD) interview data bearing on perceived feasibility, acceptability, and effectiveness to contextualize participant ratings of training and to identify recommendations for enhancing the utility of mental health training locally for educators. RESULTS: Mean scores of knowledge and attitudes significantly improved between the pre-test and post-tests; e.g., knowledge improved from 58% correct at baseline to 68% correct on the second post-test (p = 0.039). Mean ratings of the training were favorable across all categories and FGD data demonstrated widespread participant endorsement of training acceptability and effectiveness; participants recommended extending the duration and number of training sessions. CONCLUSIONS: Findings support feasibility, acceptability, and a limited scope of effectiveness of brief mental health training for secondary school teachers in Haiti. Further development of approaches to engage teachers in promoting school mental health through training is warranted.

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Elastin has been demonstrated in the wall of the retinal arteries in or immediately adjacent to the optic disc of adult Macaca mulatta using the immunogold labelling technique with delta-elastin antibody. Since elastin is thought to provide elasticity to the walls of these vessels, perhaps its presence in the retinal arteries plays a role in contractility and regulation of blood flow throughout the retinal vascular system.

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A case of congenital miosis associated with myopia and cataract is described. Tissue obtained at iridectomy was examined with the electron microscope and compared with a specimen of normal iris. The miotic iris was found to be hypoplastic and to display differences in the cellular density of the stroma. The contractile processes of the dilator myoepithelium were conspicuously absent from the underlying stroma, and the existing myofibrils were much disarranged.

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This is a morphological analysis of the inner blood-retina barrier in various segments of the retinal vasculature in the eye of Macaque monkeys. The primary aims of this study are to identify the components of the walls of the arteries, central capillaries, peripheral capillaries and veins of the retina using light and electron microscopy, and to compare and contrast junctional morphology as revealed by thin section electron microscopy and freeze-fracture. The walls of these vascular segments are composed of continuous endothelium, muscle cells or pericytes, and connective tissue. Endothelial cells are joined by tight and gap junctions. In freeze-fracture replicas, tight junctions consist of a continuous, complex network of branching and anastomosing strands which do not possess free endings. The intramembrane strands of tight junction remain preferentially associated with the outer membrane leaflet or E-face of the endothelial plasma membrane and sit at the bottom of linear strands or grooves. However, particles and fragments of the intramembrane strands may be avulsed from the E-face during the fracture process and are associated with ridges on the inner membrane leaflet or P-face. The total number of plasmalemmal vesicles per unit area of endothelial cell for each vascular segment in thin sections is less than non-barrier endothelium, but greater than barrier endothelium. The paucity of plasmalemmal vesicles and the complexity of the tight junctional network contribute to the barrier function of the retinal vascular endothelium.

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Thin-section electron microscopy and freeze fracture were used in the analysis of the intercellular junctions between fibroblasts in connective tissues of the eye of Macaca mulatta, M. fascicularis, and M. arctoides. Fibroblasts located in the subconjunctival loose connective tissue, anterior sclera, scleral spur, iris stroma, ciliary body stroma, and posterior choroid were jointed by three kinds of junctions. Gap junctions were of different sizes and frequently composed of a small number of connexons organized in polygonal aggregates or linear arrays. Tight junctions were represented by isolated strands and never composed a continuous belt around the cells. Intermediate junctions were seen in thin sections but did not have any representation in the interior of the plasma membrane. It remains to be established whether, as is the case in other tissues, pathologic conditions of the eye are accompanied by some changes in the morphology and distribution of intercellular junctions between fibroblasts.

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In the ciliary epithelium of normal Rhesus monkeys, groups or islands of cells are present in which an intense secretory activity takes place. This is distinct from activity in aqueous humour production. In these regions of the epithelium the cytoplasm of the nonpigmented cells contains a well developed rough endoplasmic reticulum, numerous Golgi complexes and secretory granules containing an amorphous material of variable density. This material is discharged by a process of exocytosis into the intercellular spaces between the facing apices of the nonpigmented and pigmented cells and from here it percolates into the intercellular spaces between pigmented cells. The endothelial cells of the fenestrated capillaries located underneath these regions of actively secreting nonpigmented cells frequently contain, in their cytoplasm, granules of moderately dense material, suggesting a transport from the ciliary body stroma into the blood stream. Upon stimulation with pilocarpine the secretory activity of the nonpigmented cells is greatly increased and the intercellular spaces of the epithelium, including the ciliary channels, are frequently dilated and contain abundant osmiophilic material. These morphological observations suggest that, in addition to actively transporting aqueous humour, the ciliary epithelium produces a secretory material that diffuses into the ciliary body stroma and possibly enters into the blood stream across the walls of the fenestrated vessels.

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The authors have studied the distribution of anionic and cationic sites on both luminal and abluminal endothelial aspects of iridial vessels in Macaca mulatta and Macaca fascicularis. With the animals in general anesthesia, anionic ferritin (AF) and cationic ferritin (CF) were either injected intravenam or perfused at known intraocular pressure (15-20 mmHg) through the anterior chamber. AF introduced intravenam was retained in the vessels' lumen. The tight junctions between the endothelial cells were impermeable and the plasmalemmal vesicles did not transport tracer to the iridial stroma. In contrast, when perfused through the anterior chamber, AF was present in the vessels' lumen. Here again the tight junctions between the endothelial cells were impermeable, but AF was contained within a great number of plasmalemmal vesicles. Iridial vessels were impermeable to CF perfused into the lumen, but a continuous layer of CF particles was found to adhere to the luminal plasma membrane. When perfused through the anterior chamber, CF was bound to the proteoglycans associated with collagen fibrils of the iridial stroma and basal laminae of stromal, pericytic, and endothelial cells but was never found in the vessels' lumen. These results indicate that different electrical charges are associated with the plasmalemmal vesicles on the luminal and abluminal fronts of iridial vessels. The authors suggest that in these vessels a unidirectional vesicular transport is responsible for the selective movement of anionic organic substances from the tissues of the eye to the bloodstream.

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The two elements of the double cones in the chicken retina (Gallus gallus domesticus) are joined by a specialized junction located at the level of the myoid of the principal cone and the perikaryon of the accessory cone, in close proximity to the outer limiting membrane. In thin sections, the plasma membranes of the two elements of the cones are seen to approach each other closely being separated by a cleft of 3 to 11 nm; short gap junctions are interposed. A layer of fine filamentous material is constantly present on the cytoplasmic side of the plasma membranes. In replicas of freeze-fractured retinas the junction appears as a fascia composed of small polygonal gap junctions connected to one another by linear gap junctions. Solitary arrays of gap junctional particles are also present. In close proximity to the gap junctions the membrane matrix appears devoid of intramembrane particles. We conclude that the elements of the double cones are connected to one another by gap junctions with associated intermediate junction. The presence of gap junctions suggests that the two elements of the double cones are electrically coupled.

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We have either introduced into the vitreous space or perfused through the anterior chamber of macaque monkey eyes two anionic tracers, anionic ferritin (AF) and horseradish peroxidase (HRP) and a cationic probe, cationic ferritin (CF). We have observed that the anionic molecules, but not the cationic one, are transported to the blood stream by plasmalemmal vesicles of the endothelial cells in both the retinal and the iridial vasculature. We suggest that a variety of organic anions of different MW which are commonly present in the eye tissues may be returned to the blood by the same morphological mechanism.

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Extrinsic eye muscles are very different from other skeletal muscles with regard to the morphology of their fibers and response to drugs. In addition, they are provided with an unusually rich blood supply. Since it had been previously reported that the capillaries of extraocular muscles are, at least in part, of the fenestrated type, a feature unusual for skeletal muscles, we have analyzed the morphology of these vessels in macaque monkeys and tested their permeability properties with horseradish peroxidase (HRP). Our study of the blood capillaries in the superior rectus muscle and levator palpebrae superioris in Macaca mulatta and M. fascicularis has demonstrated that these vessels are morphologically similar to the capillaries of other skeletal muscles. Furthermore, when HRP is introduced intravenam, it is transported out of the vessels by a vesicular transcellular mechanism. When HRP is injected in the interstitial spaces of the muscles, it is returned to the lumen by an identical vesicular transcellular transport. Thus, a bidirectional movement of macromolecules can take place across the walls of these vessels, and such a movement is not different from that previously reported for other skeletal muscles.

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The anterior chamber of adult Rhesus monkeys (Macaca mulatta) was perfused with a radio-opaque contrast medium (Amipaque; mol. wt 789 daltons) at controlled intraocular pressure (IOP), and its subsequent distribution examined by computed tomography. In the living monkey no contrast medium was detectable outside the anterior chamber, even after prolonged (8 hr) perfusion. However, if the animal was then killed, and the IOP maintained artificially at its previous level, opacity appeared immediately throughout the anterior segment. Subsequent scans showed the contrast medium to diffuse into the anterior orbital tissues, and to move posteriorward through the globe wall and extraocular muscles. None entered the vitreous body and very little progressed behind the point at which the extraocular muscles exited from Tenon's capsule. Elevation of IOP did not appear to accelerate this posterior diffusion. It is inferred that in vivo contrast medium passing into the posterior, non-conventional aqueous drainage pathway is cleared immediately by the circulating blood in the uvea and possibly also the extraocular muscle. Tenon's capsule may provide a barrier to further intra-orbital diffusion.

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When horseradish peroxidase (HRP) is introduced into the blood stream it is retained in the lumen of the iridial vessels. In this paper, we report that when the same tracer is perfused into the anterior chamber of macaque monkeys, it permeates the stroma of the iris and penetrates the lumen of iridial vessels by transcellular vesicular transport. This unidirectional movement of HRP out of the eye is not inhibited by ouabain or fluoroacetate.

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When horseradish peroxidase (HRP) is introduced into the bloodstream, it is retained in the lumen of the retinal vessels (blood-retina barrier). In this paper, we report that when the same tracer is injected into the vitreous body, it penetrates the lumen of retinal vessels by transcellular vesicular transport. This unidirectional movement of macromolecules out of the eye is not inhibited by ouabain, fluoroacetate, or low temperatures.

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The vessels of the conjunctival and episcleral plexuses of Macaca mulatta eye are of the continuous type. Most of the vessels in the conjunctival plexus have the diameter of capillaries, while the vast majority of the vessels in the episcleral plexus are venules. Both types of vessels have a simple wall, which consists of an endothelium and a discontinuous layer of pericytes. The aim of this study was to establish their permeability properties to blood-borne horseradish peroxidase (HRP). After intravenous injection of HRP, in 200 microns chopper sections of the anterior segment of the eye examined with the light microscope, the subconjunctival and episcleral tissues appear intensely and diffusely stained by the reaction product. The electron microscope shows that HRP escapes from the vessels lumen by crossing the interendothelial clefts and, in addition, a great number of pinocytotic vesicles loaded with HRP are present on the luminal, tissue front and in the cytoplasm of the endothelial cells. HRP, which rapidly penetrates the loose connective tissue of the region, reaches the spaces between the cells of the conjunctival epithelium where it is finally blocked by the zonulae occludentes that connect the most superficial epithelial cells. A slow diffusion into the compact tissue of the cornea and of the sclera was also observed. Thus, under normal conditions, blood-borne macromolecules can freely diffuse into the subconjunctival and episcleral loose connective tissues. On the other hand, one can equally expect that the aqueous humor that reaches the episcleral and conjunctival blood plexuses through the canal of Schlemm and collector channels can freely diffuse into the subconjunctival spaces across the walls of these permeable vessels.

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In order to identify the structural basis of the blood aqueous barrier in the chicken eye, the morphology of the blood vessels and epithelium of the ciliary body were examined with light microscopy, conventional electron microscopy, and the freeze-fracturing technique; the permeability properties of the vessels and epithelium were tested with intravascular injection of horseradish peroxidase (HRP). The ciliary body and iris of the adult chicken are supplied principally by a single temporal long posterior ciliary artery that, by dividing into two branches, gives rise to the great circle of the iris. From this circle multiple branches reach the iris, while a few run posteriorly to the ciliary body stroma. Most of the blood supply to the ciliary body stroma is derived from vessels that return from the iris, run in the valleys between ciliary processes, and are continuous, at the ora serrata, with the veins of the vortex system. Electron microscopy shows that the vessels of the ciliary body stroma differ from their counterpart in mammals in two respects: (1) the endothelial cells are joined by simple but continuous zonulae occludentes; (2) the openings in the endothelial lining (plasmalemmal vesicles, fenestrae, and transendothelial channels) are less numerous. The walls of these vessels retard, but do not prevent the diffusion of intravenously injected HRP into the surrounding connective tissue spaces. From the ciliary body stroma, HRP diffuses into the intercellular clefts of the ciliary epithelium, but its progression toward the posterior chamber is blocked by very complex zonulae occludentes between the nonpigmented cells. Thus, in chickens as in mammals tight junctions between the nonpigmented cells of the ciliary epithelium represent the structural equivalent of the blood-aqueous barrier.

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