A Formative Evaluation of Two Evidence‐Based Psychotherapies for PTSD in VA Residential Treatment Programs

Between July 2008 and March 2011, 38 U.S. Department of Veterans Affairs (VA) residential treatment programs for posttraumatic stress disorder (PTSD) participated in a formative evaluation of their programmatic services, including evidenced‐based treatments (EBTs). Face‐to‐face qualitative interviews were conducted with over 250 staff by an independent psychologist along with onsite participant observations. This evaluation coincided with a national VA dissemination initiative to train providers in two EBTs for PTSD: prolonged exposure (PE) and cognitive processing therapy (CPT). A substantial proportion of eligible (based on professional background) residential treatment providers received training in PE (37.4%) or CPT (64.2%), with 9.5% completing case consultation or becoming national trainers in each therapy respectively. In semistructured interviews, providers reported that their clinical programs had adopted these EBTs at varying levels ranging from no adoption to every patient receiving the full protocol. Suggestions for improving the adoption of PE and CPT are noted, including distilling manualized treatments to essential common elements.     

Changes in Implementation of Two Evidence‐Based Psychotherapies for PTSD in VA Residential Treatment Programs: A National Investigation

There has been little investigation of the natural course of evidence‐based treatments (EBTs) over time following the draw‐down of initial implementation efforts. Thus, we undertook qualitative interviews with the providers at 38 U.S. Department of Veterans Affairs’ residential treatment programs for posttraumatic stress disorder (PTSD) to understand implementation and adaptation of 2 EBTs, prolonged exposure (PE), and cognitive processing therapy (CPT), at 2 time points over a 4‐year period. The number of providers trained in the therapies and level of training improved over time. At baseline, of the 179 providers eligible per VA training requirements, 65 (36.4%) had received VA training in PE and 111 (62.0%) in CPT with 17 (9.5%) completing case consultation or becoming national trainers in both PE and CPT. By follow‐up, of the increased number of 190 eligible providers, 87 (45.8%) had received VA training in PE and 135 (71.1%) in CPT, with 69 (36.3%) and 81 (42.6%) achieving certification, respectively. Twenty‐two programs (57.9%) reported no change in PE use between baseline and follow‐up, whereas 16 (42.1%) reported an increase. Twenty‐four (63.2%) programs reported no change in their use of CPT between baseline and follow‐up, 12 (31.6%) programs experienced an increase, and 2 (5.2%) programs experienced a decrease in use. A significant number of providers indicated that they made modifications to the manuals (e.g., tailoring, lengthening). Reasons for adaptations are discussed. The need to dedicate time and resources toward the implementation of EBTs is noted.     

医院开展居丧护理服务概述

较多发生在医院的死亡患者是因突发严重疾病、创伤或事故。突然发生、无法预料的死亡会使丧亲者产生更为强烈的悲伤反应，如不能有效应对则影响丧亲者身心健康，产生身心并发症。居丧护理干预措施可帮助丧亲者有效应对悲伤和失去，最大限度地降低由于恶性悲伤反应所带来的负性生理和心理反应。本文阐述了医院提供居丧护理服务的重要性和必要性以及医院居丧护理服务的内容及采取的相应措施。     

医院开展居丧护理服务概述

较多发生在医院的死亡患者是因突发严重疾病、创伤或事故.突然发生、无法预料的死亡会使丧亲者产生更为强烈的悲伤反应,如不能有效应对则影响丧亲者身心健康,产生身心并发症.居丧护理干预措施可帮助丧亲者有效应对悲伤和失去,最大限度地降低由于恶性悲伤反应所带来的负性生理和心理反应.本文阐述了医院提供居丧护理服务的重要性和必要性以及医院居丧护理服务的内容及采取的相应措施.     

Outpatient Mastectomy: Factors Influencing Patient Selection and Predictors of Return to Care

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Evidence‐based development of liver allocation: a review

Liver transplantation has undergone a rapid evolution from a high‐risk experimental procedure to a mainstream therapy for thousands of patients with a wide range of hepatic diseases. Its increasing success has been accompanied by progressive imbalance between organ donor supply and the patients who might benefit. Where demand outstrips supply in transplantation, a system of organ allocation is inevitably required to make the wisest use of the available, but scarce, organs. Early attempts to rationally allocate donor livers were particularly hampered by lack of available and suitable data, leading to imperfect solutions that created or exacerbated inequities in the system. The advent and maturation of evidence‐based predictors of waiting list mortality risk led to more objective criteria for liver allocation, aided by the increasing availability of data on large numbers of patients. Until now, the vast majority of allocation systems for liver transplantation have relied on estimation of waiting list mortality. Evidence‐based allocation systems that incorporate measures of post‐transplant outcomes are conceptually attractive and these transplant benefit‐based allocation systems have been developed, modeled, and subjected to computer simulation. Future implementations of benefit‐based liver allocation await continued refinement and additional debate in the transplant community.     

Current Patterns of Prehospital Trauma Care in Kampala,Uganda and the Feasibility of a Lay-First-Responder Training Program

Background  

Uganda currently has no organized prehospital emergency system. We sought to measure the current burden of injury seen by lay people in Kampala, Uganda and to determine the feasibility of a lay first-responder training program.     

Predictors of Treatment Engagement in Ethnically Diverse,Urban Children Receiving Treatment for Trauma Exposure

Keeping traditionally underrepresented children and their families engaged in treatment until completion is a major challenge for many community‐based mental health clinics. The current study used data collected as part of the National Child Traumatic Stress Network Core Data Set to examine whether racial/ethnic disparities exist in treatment duration and completion in children seeking treatment for trauma exposure. We then explored whether disparities persist after accounting for other variables associated with children's social contexts and the treatment setting. The sample included 562 ethnically diverse children receiving services from a child abuse prevention and treatment agency in Southern California. The results indicated that African American children had significantly shorter trauma‐informed treatment duration and higher rates of premature termination than Spanish‐speaking Latino children. These disparities persisted even with other variables associated with treatment duration and completion (e.g., child's age, level of functional impairment, and receipt of group and field services) in the model. Implications and future directions for research and practice are discussed.     

Predictors of Initiation and Engagement of Cognitive Processing Therapy Among Veterans With PTSD Enrolled in Collaborative Care

Collaborative care (CC) increases access to evidence‐based pharmacotherapy and psychotherapy. The study aim was to identify the characteristics of rural veterans receiving a telemedicine‐based CC intervention for posttraumatic stress disorder (PTSD) who initiated and engaged in cognitive processing therapy (CPT) delivered via interactive video. Veterans diagnosed with PTSD were recruited from 11 community‐based outpatient clinics (N = 133). Chart abstraction identified all mental health encounters received during the 12‐month study. General linear mixed models were used to identify characteristics that predicted CPT initiation and engagement (attendance at 8 or more sessions). For initiation, higher PTSD severity according to the Clinician Administered PTSD Scale (d = ?0.39, p = .038) and opt‐out recruitment (vs. self‐referral; d = ?0.49, p = .010) were negative predictors. For engagement, major depression (d = ?1.32, p = .006) was a negative predictor whereas a pending claim for military service connected disability (d = 2.02, p = .008) was a positive predictor. In general, veterans enrolled in CC initiated and engaged in CPT at higher rates than usual care. Those with more severe symptoms and comorbidity, however, were at risk of not starting or completing CPT.     

Psychophysiological Predictors of Working Alliance Among Treatment‐Seeking Women With Complex Trauma Exposure

Research has established that trauma‐related symptoms may impede the formation of a strong working alliance (i.e., interpersonal connection, trust, and shared goals between therapist and client). As the alliance is critical in trauma‐focused therapy, we studied how clients’ pretherapy factors, including symptoms and psychophysiological arousal, predict treatment alliance. We examined symptoms and physiological responses in 27 women who had exposure to extreme interpersonal violence; all of whom were enrolled in therapy. All had symptoms consistent with a diagnosis of posttraumatic stress disorder. Clients completed measures of working alliance and were assessed before and after treatment on measures of symptoms and autonomic arousal. Autonomic assessment included measures of skin conductance and respiratory sinus arrhythmia (RSA), taken during baseline, while viewing positive and then trauma‐related slides, and during recovery. Higher alliance ratings were predicted by lower pretherapy skin conductance during trauma slides (r = ?.41, p = .049) and recovery (r = ?.44, p = .047) and higher RSA during baseline (r = .47, p = .027) and positive slides (r = .43, p = .044). Findings remained significant even after partialling pretherapy symptoms. These data on a high‐need but understudied population suggest that sympathetic and parasympathetic arousal may help traumatized clients effectively engage in therapy, further supporting the role of parasympathetic activity in social engagement.     

A Preliminary Study of an Internet‐Based Intervention for OEF/OIF Veterans Presenting for VA Specialty PTSD Care

This preliminary study sought to evaluate the feasibility and potential effectiveness of a cognitive–behavioral, web‐based intervention for posttraumatic stress in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans who are not able to participate, or not eligible to participate, in evidence‐based posttraumatic stress disorder (PTSD) treatments. The study used an uncontrolled pre‐posttest design with a sample of 24 OEF/OIF veterans presenting to a VA PTSD specialty clinic. Participants used the afterdeployment.org, Post‐Traumatic Stress (PTS) Workshop, which was supplemented with brief weekly telephone calls. Half of the participants (n = 12) completed at least 5 of the 8 workshop sessions. At posttreatment, 40.0% of completers demonstrated reliable reductions on PTSD symptoms and overall d = 1.04. Treatment satisfaction and acceptability was generally positive based on Likert ratings. This web‐based intervention for PTS appears to be a feasible and potentially helpful intervention for veterans who may not otherwise receive psychosocial interventions. Given the minimal resources required and the potential reach, this web‐based intervention could be a viable addition to services provided to OEF/OIF veterans seeking PTSD specialty care. Efforts to further develop and more rigorously evaluate this approach are warranted.     

Predictors of Fracture While on Treatment With Oral Bisphosphonates: A Population‐Based Cohort Study

Although oral bisphosphonates (BPs) are highly effective in preventing fractures, some patients will fracture while on treatment. We identified predictors of such fractures in a population‐based cohort of incident users of oral BPs. We screened the Sistema d‘Informació per al Desenvolupament de l‘Investigació en Atenció Primària (SIDIAP) database to identify new users of oral BPs in 2006–2007. SIDIAP includes pharmacy invoice data and primary care electronic medical records for a representative 5 million people in Catalonia (Spain). Exclusion criteria were the following: Paget disease; <40 years of age; and any antiosteoporosis treatment in the previous year. A priori defined risk factors included age, gender, body mass index, vitamin D deficiency, smoking, alcohol drinking, preexisting comorbidities, and medications. Fractures were considered if they appeared at least 6 months after treatment initiation. “Fractures while on treatment” were defined as those occurring among participants persisting for at least 6 months and with an overall high compliance (medication possession ratio ≥80%). Fine and Gray survival models accounting for competing risk with therapy discontinuation were fitted to identify key predictors. Only 7449 of 21,385 (34.8%) participants completed >6 months of therapy. Incidence of fracture while on treatment was 3.4/100 person‐years (95% confidence interval [CI], 3.1–3.7). Predictors of these among patients persisting and adhering to treatment included: older age (subhazard ratio [SHR] for 60 to <80 years, 2.18 [95% CI, 1.70–2.80]; for ≥80 years, 2.5 [95% CI, 1.82–3.43]); previous fracture (1.75 [95% CI, 1.39–2.20] and 2.49 [95% CI, 1.98–3.13], in the last 6 months and longer, respectively); underweight, 2.11 (95% CI, 1.14–3.92); inflammatory arthritis, 1.46 (95% CI, 1.02–2.10); use of proton pump inhibitors (PPIs), 1.22 (95% CI, 1.02–1.46); and vitamin D deficiency, 2.69 (95% CI, 1.27–5.72). Even among high compliers, 3.4% of oral BP users will fracture every year. Older age, underweight, vitamin D deficiency, PPI use, previous fracture, and inflammatory arthritides increase risk. Monitoring strategies and/or alternative therapies should be considered for these patients. © 2014 American Society for Bone and Mineral Research.     

Improving Trauma Care in Low- and Middle-Income Countries by Implementing a Standardized Trauma Protocol

Background

Standardized trauma protocols (STPs) have reduced morbidity and mortality in mature trauma systems. Most hospitals in low- and middle-income countries (LMICs) have not yet implemented such protocols, often due to financial and logistic limitations. We report preliminary findings from a trauma quality improvement (QI) initiative, using and evaluating the impact of a low-cost STP in an LMIC university hospital.

Methods

We developed an STP based on generally accepted best practices and damage control resuscitation. It was designed for the resources available at the test institution. The Neiva University Hospital (NUH) is a tertiary care hospital and level I trauma center in Neiva, Colombia. As in most LMIC hospitals, there was no trauma information data system at NUH. Therefore, we adapted an administrative electronic database to capture clinically relevant information of adult patients who were hospitalized or died in the emergency department (ED) between August 2010 and June 2012 with an International Classification of Diseases, 10th revision (ICD-10) diagnoses indicating trauma (S00–Y98). Interventions that were recommended in the STP were compared in these two groups. Length of hospital stay (LOS) and mortality were also examined.

Results

A total of 4,324 patients were included, of whom, 2,457 patients were in the pre-protocol period and 1,867 were in the post-protocol period. The use of several interventions increased: blood product transfusions in the ED (1.0 vs. 2.7 %; p < 0.001), use of hypertonic fluids in hypotensive patients (3.2 vs. 8.9 %; p < 0.001), placement of Foley catheters (11.1 vs. 13.8 %; p = 0.007), arterial blood gas draws (16.6 vs. 26.4 %; p < 0.001), tetanus vaccinations (19.3 vs. 26.0 %; p < 0.001), placement of multiple large bore peripheral catheters (29.5 vs. 34.7 %; p < 0.001), prophylactic antibiotics (34.9 vs. 38.0 %; p = 0.035), and the use of analgesics (64.5 vs. 68.0 %; p = 0.016). Other interventions also trended upwards. Length of stay (LOS) decreased for both surgical and non-surgical patients (surgical 13.4 vs. 11.8 days; p = 0.017; non-surgical 4.4 vs. 3.8 days; p = 0.059). All-cause mortality of trauma patients decreased (3.9 vs. 2.9 %; p = 0.088).

Conclusions

The institution of an STP at a university hospital in an LMIC has increased the use of vital interventions while decreasing overall LOS for all-cause trauma patients.