Pause for effect: A 10-s interviewer wait time gives children time to respond to open-ended prompts.

When researchers and helping professionals interview children about a target event, how long should they tolerate silence before delivering another prompt? In other words, at what point are children so unlikely to begin talking again that continued silence would likely be unproductive? To test the reasonableness of a 10-s wait time guideline during open-ended prompting, we analyzed the wait times of research assistants (N = 7) who interviewed with a 10-s guideline, timed how quickly children responded to prompts, and also timed pauses within children's event narratives. In our sample (105 conversations with children aged 4-8 years), interviewers complied fully with the 10-s rule in the majority of interviews, children often paused for longer than 5 s before beginning to talk about the event or continuing a narrative, and more than 96% of children's pauses that were followed by event information fell within the 10-s window. These findings show that the 10-s wait time was a practical guideline that gave children time to respond without peppering interviews with uncomfortably long pauses. We conclude that adding wait time guidelines to protocols for interviewing children, and augmenting guidelines with wait time training for research assistants and helping professionals, could improve the quality of information obtained from children and advance our understanding of age differences in event memory.

Geographic and specialty distribution of US physicians trained to treat opioid use disorder.

PURPOSE: The United States is experiencing an epidemic of opioid-related deaths driven by excessive prescribing of opioids, misuse of prescription drugs, and increased use of heroin. Buprenorphine-naloxone is an effective treatment for opioid use disorder and can be provided in office-based settings, but this treatment is unavailable to many patients who could benefit. We sought to describe the geographic distribution and specialties of physicians obtaining waivers from the Drug Enforcement Administration (DEA) to prescribe buprenorphine-naloxone to treat opioid use disorder and to identify potential shortages of physicians. METHODS: We linked physicians authorized to prescribe buprenorphine on the July 2012 DEA Drug Addiction Treatment Act (DATA) Waived Physician List to the American Medical Association Physician Masterfile to determine their age, specialty, rural-urban status, and location. We then mapped the location of these physicians and determined their supply for all US counties. RESULTS: Sixteen percent of psychiatrists had received a DEA DATA waiver (41.6% of all physicians with waivers) but practiced primarily in urban areas. Only 3.0% of primary care physicians, the largest group of physicians in rural America, had received waivers. Most US counties therefore had no physicians who had obtained waivers to prescribe buprenorphine-naloxone, resulting in more than 30 million persons who were living in counties without access to buprenorphine treatment. CONCLUSIONS: In the United States opioid use and related unintentional lethal overdoses continue to rise, particularly in rural areas. Increasing access to office-based treatment of opioid use disorder--particularly in rural America--is a promising strategy to address rising rates of opioid use disorder and unintentional lethal overdoses.

Barriers to primary care physicians prescribing buprenorphine.

PURPOSE: Despite the efficacy of buprenorphine-naloxone for the treatment of opioid use disorders, few physicians in Washington State use this clinical tool. To address the acute need for this service, a Rural Opioid Addiction Management Project trained 120 Washington physicians in 2010-2011 to use buprenorphine. We conducted this study to determine what proportion of those trained physicians began prescribing this treatment and identify barriers to incorporating this approach into outpatient practice. METHODS: We interviewed 92 of 120 physicians (77%), obtaining demographic information, current prescribing status, clinic characteristics, and barriers to prescribing buprenorphine. Residents and 7 physicians who were prescribing buprenorphine at the time of the course were excluded from the study. We analyzed the responses of the 78 remaining respondents. RESULTS: Almost all respondents reported positive attitudes toward buprenorphine, but only 22 (28%) reported prescribing buprenorphine. Most (95%, n = 21) new prescribers were family physicians. Physicians who prescribed buprenorphine were more likely to have partners who had received a waiver to prescribe buprenorphine. A lack of institutional support was associated with not prescribing the medication (P = .04). A lack of mental health and psychosocial support was the most frequently cited barrier by both those who prescribe and who do not prescribe buprenorphine. CONCLUSION: Interventions before and after training are needed to increase the number of physicians who offer buprenorphine for treatment of addiction. Targeting physicians in clinics that agree in advance to institute services, coupled with technical assistance after they have completed their training, their clinical teams, and their administrations is likely to help more physicians become active providers of this highly effective outpatient treatment.

PROTOCOL: Interview and interrogation methods and their effects on true and false confessions: An update and extension.

This is the protocol for a Campbell systematic review. The objective is to assess the effects of interrogation approach on confession outcomes for criminal (mock) suspects.

The Deleterious Effect of Victimization on Just World Beliefs.

Being a victim of a violent crime is a traumatic experience. Sexual victimization, in particular, may be powerful enough to change presumably stable worldviews like just world beliefs. Across two large samples, we examined the influence of sexual victimization on just world beliefs. Results of Study 1 (N = 727) indicated that victims of sexual aggression had significantly lower levels of just world beliefs compared to nonvictims. Other researchers have claimed that sexual aggression is a uniquely intense traumatic event. Therefore, in a second study, we examined (a) whether just world belief endorsement was associated with the frequency of victimization, and (b) whether sexual aggression was unique in its effect on just world belief endorsement compared to other crimes such as physical assault. Results of Study 2 (N = 2,011) indicated that multiple incidents of victimization did not meaningfully impact just world beliefs compared to a single instance and just world belief endorsement was not significantly different across victims of sexual aggression, robbery, physical assault, or arson. An exploratory analysis, however, indicated there was a significant difference in victims' behavior such that victims of sexual aggression were the least likely to have reported the crime. We end with a discussion of how the present research can advance our understanding of just world belief ideology and discuss the practical implications for professionals working with and studying victims of violent crimes.

Bounded Blame: The Effects of Victim-Perpetrator Relationship and Victimization History on Judgments of Sexual Violence.

Individuals often tend to irrationally blame victims for their plight. This research incorporated a bounded rationality framework to examine first-person perspectives (rather than third-person) of both victims' and nonvictims' perceptions and judgments of acquaintance and stranger sexual violence. Upon completing individual difference measures, including a just-world belief assessment, participants (N = 296) were randomly assigned to read a scenario in which the vignette victim was either acquainted with or had no prior relationship with the perpetrator. Then, taking the perspective of the vignette victim, participants offered four judgments: the likelihood of reporting the crime, self-blame, perceived control, and sympathy expected from others. Results showed that instances of acquaintance sexual violence were judged more negatively than instances of stranger sexual violence. Moreover, participants who had previously experienced sexual violence reported more negative judgments than nonvictims (except for sympathy expected from others). An exploratory path analysis indicated that as nonvictims', but not victims', just-world beliefs became stronger, they indicated a higher willingness to report the crime, perceived more control over the situation, and expected more sympathy from others. We end with a discussion of how the present research can advance our understanding of sexual violence by using a bounded rationality framework and discuss the practical implications that the observed effects have for professionals in the legal system, outside observers, and victims themselves.

Out-of-pocket health care expenditures, by insurance status, 2007-10.

Out-of-pocket health care spending in the United States totaled $306.2 billion in 2010 and represented 11.8 percent of total national health expenditures, according to the Centers for Medicare and Medicaid Services' National Health Expenditure Accounts. Spending by people with employer-sponsored health insurance and those covered by Medicare accounted for over 80 percent of total out-of-pocket spending. People without comprehensive medical coverage accounted for less than 8 percent of all out-of-pocket expenditures in 2010. Between 2007 and 2010 per person out-of-pocket spending grew most rapidly for people primarily covered by employer-sponsored insurance and declined for people primarily covered by Medicare and those without coverage.

Who prescribes buprenorphine for rural patients? The impact of specialty, location and practice type in Washington State.

We determined the specialty, geographic location, practice type and treatment capacity of waivered clinicians in Washington State. We utilized the April 2011 Drug Enforcement Agency roster of all waivered buprenorphine prescribers and cross-referenced the data with information from the American Medical Association and online resources. Waivered physicians, as compared to Washington State physicians overall, are more likely to be primary care providers, be older, less likely to be younger than 35 years, and more likely to be female. Isolated rural areas have the lowest provider to population ratios. Ten counties lack either a buprenorphine provider or a methadone clinic. In rural areas, waivered physicians work predominately in federally-subsidized safety-net settings, which underscores the need for continued governmental support of primary care and mental health in these settings.

Project ECHO: a model for complex, chronic care in the Pacific Northwest region of the United States.

The Pacific Northwest of the US is a large, sparsely populated region. A telehealth programme called Project ECHO (Extension for Community Health Outcomes) was tested in this region in 2009. Weekly videoconferences were held in the areas of hepatitis C, chronic pain, integrated addictions and psychiatry, and HIV/AIDS. Rural clinicians presented cases to a panel of experts at an academic medical centre and received management advice and access to best practices. During the trial, more than 900 clinicians participated, and more than 700 patient cases were presented. At the end of June 2012, a total of 23 videoconference clinics for hepatitis C had been held, 16 clinics in addiction and psychiatry, 97 in chronic pain and 13 in HIV/AIDS. The Project ECHO model improves access to health care. It may provide a way to bring specialist care to rural areas in developing countries.

Intravaginal metronidazole gel versus metronidazole plus nystatin ovules for bacterial vaginosis: a randomized controlled trial.

OBJECTIVE: We compared metronidazole 0.75% gel (containing 37.5 mg metronidazole per dose) with ovules containing metronidazole 500 mg and nystatin 100,000 U, for intravaginal treatment of bacterial vaginosis (BV). STUDY DESIGN: In a single-blinded trial, symptomatic women with BV by both Amsel and Nugent criteria were randomly assigned to gel or ovules, once nightly for 5 nights, and asked to return 3 times after treatment. Analyses were intent-to-treat. RESULTS: Of 151 women with BV by both criteria at enrollment, 138 (91%) returned at least once. Product limit estimates for persistence or recurrence of BV at 14, 42, and 104 days were 20% (95% CI 10%-29%), 38% (95% CI 25%-48%), and 52% (95% CI 37%-63%) after gel treatment, and 4% (95% CI 0%-9%), 17% (95% CI 7%-26%), and 33% (95% CI 21%-46%) after ovule treatment ( P = .01). Among women without BV at first follow-up, subsequent intercourse without condoms independently predicted subsequent recurrence ( P

Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections.

OBJECTIVE: To draw up evidence-based guidelines to make injections safer. METHODS: A development group summarized evidence-based best practices for preventing injection-associated infections in resource-limited settings. The development process included a breakdown of the WHO reference definition of a safe injection into a list of potentially critical steps, a review of the literature for each of these steps, the formulation of best practices, and the submission of the draft document to peer review. FINDINGS: Eliminating unnecessary injections is the highest priority in preventing injection-associated infections. However, when intradermal, subcutaneous, or intramuscular injections are medically indicated, best infection control practices include the use of sterile injection equipment, the prevention of contamination of injection equipment and medication, the prevention of needle-stick injuries to the provider, and the prevention of access to used needles. CONCLUSION: The availability of best infection control practices for intradermal, subcutaneous, and intramuscular injections will provide a reference for global efforts to achieve the goal of safe and appropriate use of injections. WHO will revise the best practices five years after initial development, i.e. in 2005.

The etiology and management of genital ulcers in the Dominican Republic and Peru.

BACKGROUND: Clinical diagnosis of genital ulcers is difficult, and diagnostic tests are least available in settings where rates of disease are highest. The World Health Organization (WHO) has developed protocols for the syndromic management of genital ulcers in resource-poor settings. However, because risk factors, patterns and causes of disease, and antimicrobial susceptibilities differ from region to region and over time, they must be adapted to local situations. GOAL: The goal of this study was to determine etiologic factors, evaluate syndromic management, and compare polymerase chain reaction (PCR) testing with other diagnostic alternatives for genital ulcers among patients attending sexually transmitted disease clinics in the Dominican Republic and Peru. STUDY DESIGN: Eighty-one men with genital ulcers in the Dominican Republic and 63 in Peru underwent identical interviews and identical multiplex PCR (M-PCR) tests of genital lesion specimens for etiologic diagnoses. Algorithms for managing genital ulcers were developed. RESULTS: In the Dominican Republic, 5% were M-PCR-positive for, 26% for, and 43% for herpes simplex virus (HSV); in Peru, 10%, 5%, and 43%, respectively, were positive. The WHO algorithm for treating syphilis and chancroid had a sensitivity of 100%, a positive predictive value (PPV) of 24%, and an overtreatment rate of 76%. A modified algorithm for treating only those without vesicular lesions had 88% sensitivity and a 27% PPV, and the overtreatment rate was reduced to 58%. CONCLUSION: HSV caused 43% of genital ulcers in these populations. The modified algorithm had lower sensitivity but a reduced overtreatment rate. M-PCR testing was more sensitive than standard tests and more specific and sensitive than clinical diagnosis.