Analysis of Oklahoma amputation trends and identification of risk factors to target areas for limb preservation interventions.

OBJECTIVE: Annual trends of lower extremity amputation due to end-stage chronic disease are on the rise in the United States. These amputations are leading to massive expenses for patients and the medical system. In Oklahoma, we have a high-risk population because access to care is low, the number of uninsured is high, cardiovascular health is poor, and our overall health care performance is ranked 50th in the country. But we know little about Oklahomans and their risk of limb loss. It is, therefore, imperative to look closely at this population to discover contemporary rates, trends, and state-specific risk factors for amputation due to diabetes and/or peripheral arterial disease (PAD). We hypothesize that state-specific groups will be identified as having the highest risk for limb loss and that contemporary trends in amputations are rising. To create implementable solutions to limb preservation, a baseline must be set. METHODS: We conducted a 12-consecutive-year observational study using Oklahoma's hospital discharge data. Discharges among patients 20 years or older with a primary or secondary diagnosis of diabetes and/or PAD were included. Diagnoses and amputation procedures were identified using International Classification of Disease-9 and -10 codes. Amputation rates were calculated per 1000 discharges. Trends in amputation rates were measured by annual percentage changes (APC). Prevalence ratios evaluated the differences in amputation rates across demographic groups. RESULTS: Over 5,000,000 discharges were identified from 2008 to 2019. Twenty-four percent had a diagnosis of diabetes and/or PAD. The overall amputation rate was 12 per 1000 discharges for those with diabetes and/or PAD. Diabetes and/or PAD-related amputation rates increased from 8.1 to 16.2 (APC, 6.0; 95% confidence interval [CI], 4.7-7.3). Most amputations were minor (59.5%), and although minor, increased at a faster rate compared with major amputations (minor amputation APC, 8.1; 95% CI, 6.7-9.6 vs major amputation APC, 3.1; 95% CI, 1.5-4.7); major amputations were notable in that they were significantly increasing. Amputation rates were the highest among males (16.7), American Indians (19.2), uninsured (21.2), non-married patients (12.7), and patients between 45 and 49 years of age (18.8), and calculated prevalence ratios for each were significant (P = .001) when compared within their respective category. CONCLUSIONS: Amputation rates in Oklahoma have nearly doubled in 12 years, with both major and minor amputations significantly increasing. This study describes a worsening trend, underscoring that amputations due to chronic disease is an urgent statewide health care problem. We also present imperative examples of amputation health care disparities. By defining these state-specific areas and populations at risk, we have identified areas to pursue and improve care. These distinctive risk factors will help to frame a statewide limb preservation intervention.

Navigating the Roadmap for Trauma-Informed Medical Education: Application of Undergraduate Medical Education Competencies.

BACKGROUND: Trauma is common in the United States, increases risk of long-term adverse health effects, and individuals who experience it often find seeking medical care difficult. Trauma-informed care (TIC) builds trust and fosters healing relationships between clinicians and patients; however medical education has lacked consistent training in TIC. Using recently published competencies for undergraduate medical education (UME), this manuscript provides curricular examples across 8 domains to assist faculty in developing educational content. METHODS: The authors identified published curricula for each of the 8 competency domains using a published search strategy and publicly available database. Inclusion criteria were published works focused on UME in the United States; abstracts and curricula not focused on UME were excluded. The authors used a consensus-based process to review 15 eligible curricula for mapping with the competencies. RESULTS: Of 15 published UME curricula, 11 met criteria and exemplify each of the 8 UME competency domains. Most of the available curricula fall into the Knowledge for Practice and Patient Care domains. Most were offered in the first 2 years of medical school. CONCLUSION: Competency-based medical education for TIC is new, and most current educational offerings are foundational in nature. Additional innovation is needed in the competency domains of Professionalism, Systems-Based Practice, Interprofessional Collaboration, and Personal/Professional Development. This manuscript offers a set of curricular examples that can be used to aid efforts at implementing TIC competencies in UME; future work must focus on improving assessment methods and developmental sequencing as more students are exposed to TIC principles.

Effectiveness of Trauma-Informed Care Implementation in Health Care Settings: Systematic Review of Reviews and Realist Synthesis.

PURPOSE: Given the ubiquity of traumatic exposures and the profound impact of trauma on health, a trauma-informed care (TIC) approach in health care is critical. TIC seeks to promote safety within health care and prevent retraumatization. The lack of systems-level data has been a major barrier to TIC implementation. This study aimed to understand the mechanisms and outcomes effective in implementing TIC across health systems using a systematic review of reviews and realist synthesis. METHODS: A systematic search of MEDLINE, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Applied Social Science Index & Abstracts identified reviews addressing TIC in health care published in the last 10 years in peer-reviewed journals. Realist synthesis methodology was used to develop context-mechanism-outcome configurations. Thematic analysis was performed to generate a framework for the mechanisms of implementation that produce successful TIC outcomes. RESULTS: Sixteen articles featuring varied review types were included. The results, highlighting the strategies that lead to improved outcomes for patients and systems, were mapped to SAMHSA's 10 TIC implementation domains, including engagement and involvement; training and workforce development; cross-sector collaboration; screening, assessment, and treatment services; governance and leadership; policy; evaluation; progress monitoring and quality assurance; financing; and physical environment. CONCLUSION: The findings support the use of SAMHSA's 10 implementation domains in varied health care contexts to facilitate effective TIC processes. Future work should continue to evaluate the effectiveness of TIC approaches and may consider how health equity and strengths-based approaches fit within SAMHSA's framework.

Use of Metaphor as an Explanation Tool in Adverse Childhood Experiences Simulation Training.

INTRODUCTION: Adverse childhood experiences (ACEs) have profound implications for adult health. Health care practitioners need effective communication tools for trauma-sensitive inquiries with patients. This study aimed to describe characteristics of effective metaphor use by health care trainees when discussing ACEs and health with adult patients, and to provide example metaphors for clinicians to use to sensitively address ACEs. METHODS: Trainees engaged in a videorecorded simulation as part of a model to teach health care practitioners communication skills related to ACEs. Videos were identified in which the trainee used a metaphor to help explain ACEs during the encounter. Encounter segments that used metaphors were transcribed and metaphor type, duration, and recurrence were coded using a standardized rubric. Each metaphor was scored for effectiveness and basic statistical analysis was conducted. RESULTS: Of the 122 videos reviewed, 24 types of metaphors were used, with the most common being the overloaded backpack (n = 24). Mean metaphor duration was 37 s (SD = 24 s). Metaphors rated as effective were shorter and less variable in duration (31.8 s, SD = 14.7 s) than those rated as ineffective (39 s, SD = 34 s). No one metaphor performed significantly better and most of the metaphors were evaluated as being adequate or effective. CONCLUSION: Literary devices like metaphors may be efficient and effective explanatory tools to improve clinician communication skills and patient understanding in addressing sensitive topics, such as ACEs. Minimal time investment is required to employ metaphors in ACEs discussions. The authors found no single metaphor that to be clearly superior, indicating that patient-centered metaphor use may improve communication between clinicians and patients who experienced childhood trauma.

Roadmap for Trauma-Informed Medical Education: Introducing an Essential Competency Set.

Research has established that trauma is nearly universal and a root cause of numerous health and social problems, including 6 of the 10 leading causes of death, with devastating consequences across the life course. Scientific evidence now recognizes the complex injurious nature of structural and historical trauma (i.e., racism, discrimination, sexism, poverty, and community violence). Meanwhile, many physicians and trainees grapple with their own trauma histories and face direct and secondary traumatization on the job. These findings substantiate the profound impact of trauma on the brain and body and why trauma training is critical to the education and practice of physicians. However, a critical lag remains in translating essential research insights into clinical teaching and care. Recognizing this gap, the National Collaborative on Trauma-Informed Health Care Education and Research (TIHCER) formed a task force charged with developing and validating a summary of core trauma-related knowledge and skills for physicians. In 2022, TIHCER released the first-ever validated set of trauma-informed care competencies for undergraduate medical education. The task force focused on undergraduate medical education so that all physicians would be taught these foundational concepts and skills from the outset of training, recognizing that faculty development is needed to achieve this goal. In this Scholarly Perspective, the authors offer a roadmap for implementation of trauma-informed care competencies starting with medical school leadership, a faculty-student advisory committee, and sample resources. Medical schools can use the trauma-informed care competencies as a scaffold to customize integration of curricular content (what is taught) and efforts to transform the learning and clinical environments (how it is taught). Using the lens of trauma will ground undergraduate medical training in the latest science about the pathophysiology of disease and provide a framework to address many of our greatest challenges, including health disparities and professional burnout.

Adverse childhood experience categories and subjective cognitive decline in adulthood: an analysis of the Behavioral Risk Factor Surveillance System.

CONTEXT: Adverse childhood experiences (ACEs) negatively impact health outcomes later in life, in a dose-dependent relationship; however, little is known about the impact of the individual ACE categories and subjective cognitive decline (SCD) later in life. OBJECTIVES: The aim of this study was to determine the associations among the eight ACEs and SCD. METHODS: We analyzed data from two cycles of the Behavioral Risk Factor Surveillance System (BRFSS; 2019-2020). We assessed the accumulation of ACEs and their association with SCD, and among individuals reporting only one ACE, we utilized logistic regression to compare the likelihood of reporting SCD and symptomology among the eight categories of adversity. RESULTS: Among included respondents, 10.14% reported experiencing SCD. More ACEs were reported among those with SCD (mean, 2.61; SD, 2.56) compared to those without SCD (mean, 1.44; SD, 1.91). Those with higher ACE scores were significantly less likely to have spoken with a healthcare provider about their cognitive decline. Individuals reporting one ACE of either family mental illness, family substance abuse, family incarceration, emotional abuse, or physical abuse had significantly greater odds of reporting memory loss compared to individuals with no ACEs. CONCLUSIONS: Having multiple ACEs was significantly associated with higher odds of SCD and associated limitation of social activity and was inversely associated with getting help when it is needed. Further, many ACE categories were associated with SCD - a novel addition to the literature and the methodology utilized herein. Interventions focused on improving cognitive health and preventing cognitive decline should consider the potential role of ACEs among affected populations.

Detecting and Addressing Trauma-related Sequelae in Primary Care.

Objective: The associations between the sequelae of complex trauma symptoms and adult health status, patient engagement in treatment, and the potential impacts on primary care providers are underappreciated despite the potential for adverse outcomes. This study examined the correlations among adult primary care patients' reports of posttraumatic stress symptoms (PTSS), adverse childhood experiences (ACE), and the impacts of social determinants of health (SDH) with provider diagnoses in the electronic health record.Methods: Patients in 3 primary care clinics were surveyed. Self-report measures included demographics, trauma symptoms, ACE, and SDH elements. Participant health status and diagnoses were obtained from their electronic health records.Results: The final sample of 354 participants reported high levels of trauma including PTSS and ACE. Educational attainment, health literacy, material hardship, access to health care, and ACE were all statistically associated with reports of PTSS (P < .05 for all). Despite the prevalence of symptoms and adverse experiences reported by the participants, only 5% were diagnosed with a trauma-related disorder in the electronic health record.Conclusions: Data analyses revealed a significant discrepancy between participants' reports of symptoms with a diagnosis of posttraumatic stress disorder by their primary care doctor. Trauma-impacted patients often present with complicated health problems that may influence the encounter in negative ways, including diminishing the primary care doctor's sense of efficacy and competency if they are not addressed effectively in the encounter. The common nature of ACE, PTSS, and SDH effects indicate that both patients and physicians would benefit from detection and training in strategies for routinely implementing trauma-informed practices.

An evaluation of a simulation and video-based training program to address adverse childhood experiences.

Adverse Childhood Experiences (ACEs) are multiple sources of maltreatment and household dysfunction with tremendous impact on health. A trauma-informed (TI) approach is preferred when working with patients with ACEs. The Professional ACEs-Informed Training for Health© (PATH©) educational program and simulation experience using standardized patients (SP) was developed to help healthcare professionals address ACEs with adults. PATH© is a 3-4 hour curriculum comprised of lecture and discussion, video-based demonstration, simulation experience, and debriefing. It was first developed for primary care (PC) residents in family medicine and internal medicine, and subsequently modified for occupational therapy (OT) and physical therapy (PT) students. This study evaluates a preliminary dataset focusing on PATH© skills of PC residents and OT and PT students during simulation. Recordings of 53 learner-SP encounters from 15 OT and PT students and 38 PC residents were coded using standardized behavioral codes. A subset of ten recordings of PC residents who participated in simulations in the first and fourth year of the training program allowed for evaluation of training outcomes over time. Results showed that medical residents and OT and PT students demonstrated skills during SP encounters congruent with TI training on addressing ACEs with adults, particularly in explaining ACEs, demonstrating empathy, collaborative treatment planning, and stigma reduction. PC residents showed both positive and negative changes in PATH©-specific skills from year 1 to 4 of the training program. This study supports the PATH© model and simulation-based training in preparing clinicians to address ACEs with adults and provides insight into further curriculum improvement.

Using Social Simulation to Teach Rehabilitation Science Students About Adverse Childhood Experiences and Trauma Informed Care.

Recent research has identified the relationships between adverse childhood experiences (ACEs) and adult adoption of health risk behaviors, negative health outcomes, and measures of well-being. Given these findings, it is important to consider training models that educate allied health students about the relevance of ACEs to adult health across a myriad of practice settings and equip them with the skills necessary to help patients with a history of ACEs. Physical therapy (PT) and occupational therapy (OT) are key members of the health care team, well positioned to address ACEs with their patients. This study reports on the evaluation of an innovative simulation-based training program, Professional ACE-Informed Training for Health Professionals (PATH), conducted with 26 second-year PT and OT students. Pre- and post-training measures consisted of the General Self-Efficacy Scale, Adult Hope Scale, and a test of knowledge and familiarity with ACEs and trauma-informed care (TIC). Results indicate that self-efficacy, hope, and knowledge of ACEs and TIC increased from pre- to post-tests for both PT and OT students. Qualitative results demonstrate that PT and OT students appreciated participating in the training model and learned a great deal from their experiences; however, they would like even more information and instruction on how to work effectively with patients who have a history of ACEs. Implications of this study and a discussion of the importance of continuing and expanding such training in rehabilitation sciences education and training are provided.

Adverse Childhood Experiences, Other Psychosocial Sources of Adversity, and Quality of Life in Vulnerable Primary Care Patients.

INTRODUCTION: Adults who had adverse childhood experiences (ACEs) have increased risk of negative health outcomes. Despite the prevalence of ACEs, literature is scarce on quality of life (QOL) and ACEs in disadvantaged primary care populations. OBJECTIVE: To examine the prevalence of ACEs and association with chronic health problems and QOL in disadvantaged primary care patients in Oklahoma. METHODS: During a primary care visit, adults completed a questionnaire measuring demographics, ACEs, current health status and well-being, sources of support and adversity, and QOL. A physician investigator reviewed participants' health records, recording the incidence of 32 diagnoses commonly associated with chronic health problems. RESULTS: The survey was completed by 354 patients. Forty-three percent received disability benefits and 71% were unemployed. More than 37% reported 4 or more ACEs, and 35.5% had 0 or 1 ACE.The amount of health problems ranged from 0 to 11 and increased with the number of reported ACEs. The mean number of health problems for each ACE level was as follows: ACEs 0 to 1 had 3.01 problems (95% confidence interval = 2.96-3.88), ACEs 2 to 3 had 3.42 problems (95% confidence interval = 2.96-3.88), and ACEs 4 and above had 4.18 problems (95% confidence interval = 3.72-4.64). ACEs were significantly related to QOL. CONCLUSION: This disadvantaged primary care population had high numbers of ACEs. ACEs correlated with increasing numbers of health problems and worse QOL. Enhanced awareness and action are needed to reduce health disparities and improve outcomes in similar populations.

A simulation and video-based training program to address adverse childhood experiences.

Adverse childhood experiences (ACEs) are 10 categories of childhood abuse and maltreatment, which have a dose-response relationship with common adult health concerns seen in primary care including health risk behaviors, chronic disease, and mental illness. Many of the ACEs-associated biopsychosocial risk factors are modifiable. However, physicians may not address these issues for fear of opening "Pandora's Box", that is, a source of extensive problems for which they are not sufficiently prepared with training, resources, or time. Residents need training in how to conduct trauma-focused conversations within the limited scope of an office visit. To address this need, a 4-hour simulation and video-based training program was developed for primary care residents about how to conduct brief interventions connecting their patients' current health concerns with their experiences of ACEs. Resident participants have evaluated this program as preparatory for real-life encounters and as being designed to allow for educational mastery. This article describes a workshop presenting this training program which was given at the 37th Annual Behavioral Science Forum in Family Medicine. Five skills targeted in the program were presented and a demonstration was made of the components, that is, didactics, provider and patient videos, simulated patient encounters, trainee feedback, and facilitated discussion that encompasses targeted skills, clinical implementation, and self-care. Companion tools were shared, including the syllabus, evaluation rubric, and provider and patient resources. Participants practiced trainee feedback and discussed the challenges in implementation.

Primary care-based interventions for intimate partner violence: a systematic review.

CONTEXT: Primary care providers are uniquely positioned to respond to patients' disclosure of intimate partner violence (IPV). However, the research on primary care-based IPV interventions has not been systematically synthesized, making it difficult for providers, policymakers, and researchers to understand how to effectively intervene in the primary care setting. This systematic review summarizes primary care-based interventions for patients experiencing IPV. EVIDENCE ACQUISITION: PubMed, PsycINFO, and CINAHL were searched from their start through September 2012; this search was augmented by bibliographic review and consultation with experts. Eligible studies included English-language, peer-reviewed articles that assessed patient-level impact of IPV interventions that originated from patients' visits to a primary care provider. EVIDENCE SYNTHESIS: Of 80 potentially eligible studies, 17 met eligibility criteria. The majority of interventions recruited women from reproductive care sites. Interventions tended to be brief, delivered by nonphysicians, and focused on empowerment, empathetic listening, discussion of the cycle of violence and safety, and referral to community-based resources. Thirteen studies demonstrated at least one intervention-related benefit. Six of 11 articles measuring IPV persistence found reductions in future violence; two of five measuring safety-promoting behaviors found increases; and six of ten measuring IPV/community resource referrals found enhanced use. Some studies also documented health improvements. CONCLUSIONS: The majority of studies demonstrated patient-level benefit subsequent to primary care IPV interventions, with IPV/community referrals the most common positively affected outcome.

Cannabinoid hyperemesis syndrome: literature review and proposed diagnosis and treatment algorithm.

Cannabinoid hyperemesis syndrome (CHS) is characterized by cyclic vomiting and compulsive bathing behaviors in chronic cannabis users. Patients are typically diagnosed with CHS only after multiple and extensive medical evaluations, consequently without a clear etiology of their symptoms or treatment plan leading to symptomatic improvement. Increased healthcare provider awareness of CHS as a cause of nausea, vomiting, and abdominal pain coupled with an attentiveness to focused history taking-especially noting symptomatic improvement with prolonged exposure to hot showers or baths-can lead to effective treatment through cannabis cessation. We propose a diagnosis and treatment algorithm for physicians to follow when evaluating patients presenting with nausea, vomiting, and abdominal pain who are suspected to suffer from CHS.