Higher treatment focus diffusion in Multisystemic Therapy is associated with less functional improvement over the course of treatment.

PURPOSE: Treatment focus diffusion (TFD), dividing focus across multiple concerns during treatment, is common in public mental health care and differs from the more narrowly focused empirically supported treatments for youth reported in the literature. The present study examined whether and to what extent TFD is associated with youth functional improvement over the course of therapy. METHOD: This study utilized multi-level modeling techniques to analyze 12 consecutive years of standardized routine clinical service data from youth receiving treatment in one of two intensive in-home service settings: (a) Multisystemic Therapy (MST; n = 776 youths, 99 therapists), an implemented evidence-based treatment based on ecological theories of behavior in which therapists work with the multiple systems a youth interacts with (school, community, family), and (b) a standards-based service (n = 1854 youth, 413 therapists). Both service settings operate in the context of a publicly funded mental health care system which serves youth and families who are typically from underserved and low-income backgrounds. Majority of youth in this sample identified as multi-ethnic and male, and they, on average, were approximately 13 years old with three co-occurring diagnoses. RESULTS: A significant TFD by service format interaction on youth functional improvement (alone and in the overall model) and follow up simple effects indicated that higher TFD was associated with significantly poorer outcomes in MST. The parameter estimate for TFD on functional improvement in the standards-based service format was in the same direction, but not statistically significant. CONCLUSION: Our findings suggest that maintaining a narrower treatment focus might be beneficial to clients, particularly in implemented evidence-based treatments. Likewise, TFD could be a helpful case monitoring tool for clinicians, supervisors, and systems leaders when reviewing intensive-in-home cases.

Identifying Youth Problem Profiles and Predicting Remission Following Mental Health Treatment.

This study utilized latent profile analysis to categorize youth served by a public mental health setting into homogenous classes. Then, associations between class membership and meeting clinical criteria by the latest assessment were examined. Caregiver responses to the Ohio Scales, Short Form, Problem Severity Scale for 1090 youth completed at entry into this public mental health system were subjected to latent profile analysis. This method classifies youth into categories based on mental health problem profiles, in order to determine the degree to which these groupings are related to later mental health outcomes. The classification of youth cases that emerged was then used to predict clinical remission at or nearest end of treatment, including final Ohio Scales Problem Severity scores and a measure of day-to-day functioning, the Child and Adolescent Functional Assessment Scale (CAFAS). A four-class model was identified as best representing the data, reflecting a relatively low-risk class (63.3% of the sample), an internalizing class (23.2%), a delinquency class (8.8%), and a high-risk class (4.7%). Individuals in the internalizing and high-risk classes had lower likelihoods of achieving problem remission than those in the low-risk and delinquency classes at the time of their last completed Ohio Scales. Additionally, youth assigned to the delinquency and high-risk classes had lower likelihoods of reaching functional impairment remission than those in the internalizing and low-risk classes. Youth membership in a class based on initial problem scores can be utilized to predict clinical remission over the course of treatment in public mental health care. Such class-based predictions support other methods of predicting outcomes and can be used by clinicians to develop more informed treatment plans and to adjust treatment based on such classifications.

Greater Focus on Strengths is Associated with Successful Discharge in Youth Public Mental Health Treatment.

The positive psychology literature suggests focusing on strengths in mental health treatment improves well-being, reduces symptomology, and is linked to positive outcomes. However, there is little research on the use of strengths in treatment and their association with outcomes in youth clinical populations. The present study used multi-level modeling to examine the association between the proportional targeting of strengths and treatment outcomes for 1,841 youth ages 3-19 receiving intensive in-home services through a public mental health system. A greater percentage of targets endorsed during treatment that were strength-focused was associated with increased likelihood of successful treatment discharge, even after accounting for other predictors, including episode length, youth age, and level of impairment at treatment start. Specifically, as the percentage of strengths targeted increased from 46 to 64% of total targets endorsed, the odds of successful discharge increased by 21%. Such practice-based findings derived from aggregated data regarding services to multiethnic low-income families extend the strength-based intervention literature to include youth with significant life challenges. Study findings point to the need to develop structured interventions suitable for examination via clinical efficacy and effectiveness trials. Clinical practice, dissemination, implementation, and future research implications are discussed.

Practices Derived from the Evidence Base for Depression Predict Disruptive Behavior Progress in Adolescent Community Mental Health Care.

Disruptive behavior problems develop along multiple causal pathways and are associated with a wide variety of co-occurring problems, including mood disorders. In usual care, effective treatment practices for youth disruptive behavior might differ from what the efficacy research suggests, given treatment setting and population demographic differences. The current study examined whether practices derived from the evidence base for disruptive behavior and/or depressed mood predicted progress on disruptive behavior problems in an adolescent usual care sample. Monthly clinical data, including therapeutic practices, treatment targets, and progress on selected treatment targets, for 1210 youth ages 13-17 who received intensive in-home services and were treated for disruptive behavior problems were examined utilizing multilevel modeling techniques. Practices derived from the evidence base for only depressed mood and practices derived from both disruptive behavior and depressed mood literatures predicted disruptive behavior progress, while practices derived from only the disruptive behavior evidence-based literature did not. All five practice elements exclusive to depressed mood treatment predicted positive disruptive behavior progress, while two of eleven disruptive behavior practices and four of seven practices derived from both problem areas predicted positive progress. Findings held when other predictors were included as covariates, including youth age and functional impairment. Although directionality remains unclear and further research is vital, usual care settings might present barriers to disruptive behavior treatment as prescribed by the evidence base, and youth-focused treatments based on depressed mood treatments merit further examination as a potentially promising route to effective treatment in such settings.

Do Treatment Plans Matter? Moving From Recommendations to Action.

We investigated whether a service-planning document outlining recommendations for what providers should address in treatment (i.e., targets) and the associated clinical techniques they should employ (i.e., practices) influenced the targets and practices that providers reported actually implementing during the subsequent treatment episode. Participants included 94 youths ages 4 to 17 (M = 13.57, SD = 3.59) who received community-based mental health services from the Hawai'i Child and Adolescent Mental Health Division. Data on targets and practices were compared across initial Mental Health Treatment Plans and Monthly Treatment and Progress Summaries. Data were analyzed using two-level, generalized mixed effects models with two-way cross-classification or linear mixed effects models. Providers were more likely to report the use of targets and practices in treatment if they were included within the treatment plan. In addition, the more closely targets addressed during treatment followed the recommended targets from the treatment plan, the more closely implemented practices followed the recommended practices listed in the treatment plan. Furthermore, as providers shifted their focus to different targets, a shift in their use of practices was also evident over time. Last, practices for which there is demonstrated efficacy for particular targets were more likely to be used. Service planning documents appear to help organize care; however, results also suggest possible limitations to the current system. These findings highlight potential areas for improvement in planning and care delivery.

Factor Analysis of Therapist-Identified Treatment Targets in Community-Based Children's Mental Health.

The present study used exploratory and confirmatory factor analyses to identify underlying latent factors affecting variation in community therapists' endorsement of treatment targets. As part of a statewide practice management program, therapist completed monthly reports of treatment targets (up to 10 per month) for a sample of youth (n = 790) receiving intensive in-home therapy. Nearly 75 % of youth were diagnosed with multiple co-occurring disorders. Five factors emerged: Disinhibition, Societal Rules Evasion, Social Engagement Deficits, Emotional Distress, and Management of Biodevelopmental Outcomes. Using logistic regression, primary diagnosis predicted therapist selection of Disinhibition and Emotional Distress targets. Client age predicted endorsement of Societal Rules Evasion targets. Practice-to-research implications are discussed.

Disruptive Behavior Treatment Progress as a Function of Therapy Focus and Youth Diagnosis in a Community Mental Health Setting.

Monthly disruptive behavior treatment progress for 613 youth ages 7-18 receiving intensive in-home services was examined. Multilevel modeling indicated carrying a depressive mood diagnosis predicted less disruptive behavior progress compared to youth with only externalizing diagnoses. Paradoxically, more monthly focus on disruptive behavior treatment targets predicted lower concurrent progress ratings, while greater focus on depressive mood targets predicted greater disruptive behavior progress for youth with a depressive mood diagnosis. Findings held when other predictors of disruptive behavior progress were included as covariates, including episode length, youth age, and functional impairment. Treatment and research implications are discussed.

Reliable Change and Outcome Trajectories Across Levels of Care in a Mental Health System for Youth.

Knowledge of mental health treatment outcome trajectories across various service types can be valuable for both system- and client-level decision-making. Using longitudinal youth functional impairment scores across 2807 treatment episodes, this study examined outcome trajectories and estimated the number of months required for reliable change across nine major services (or levels of care). Results indicate logarithmic improvement trajectories for a majority of levels of care and significant differences in time until improvement ranging from 4 to 12 months. Findings can guide system-level policies on lengths of treatment and service authorizations and provide expected treatment response data for client-level treatment decisions.

Systemic exposure to PAHs and benzene in firefighters suppressing controlled structure fires.

Turnout gear provides protection against dermal exposure to contaminants during firefighting; however, the level of protection is unknown. We explored the dermal contribution to the systemic dose of polycyclic aromatic hydrocarbons (PAHs) and other aromatic hydrocarbons in firefighters during suppression and overhaul of controlled structure burns. The study was organized into two rounds, three controlled burns per round, and five firefighters per burn. The firefighters wore new or laundered turnout gear tested before each burn to ensure lack of PAH contamination. To ensure that any increase in systemic PAH levels after the burn was the result of dermal rather than inhalation exposure, the firefighters did not remove their self-contained breathing apparatus until overhaul was completed and they were >30 m upwind from the burn structure. Specimens were collected before and at intervals after the burn for biomarker analysis. Urine was analyzed for phenanthrene equivalents using enzyme-linked immunosorbent assay and a benzene metabolite (s-phenylmercapturic acid) using liquid chromatography/tandem mass spectrometry; both were adjusted by creatinine. Exhaled breath collected on thermal desorption tubes was analyzed for PAHs and other aromatic hydrocarbons using gas chromatography/mass spectrometry. We collected personal air samples during the burn and skin wipe samples (corn oil medium) on several body sites before and after the burn. The air and wipe samples were analyzed for PAHs using a liquid chromatography with photodiode array detection. We explored possible changes in external exposures or biomarkers over time and the relationships between these variables using non-parametric sign tests and Spearman tests, respectively. We found significantly elevated (P < 0.05) post-exposure breath concentrations of benzene compared with pre-exposure concentrations for both rounds. We also found significantly elevated post-exposure levels of PAHs on the neck compared with pre-exposure levels for round 1. We found statistically significant positive correlations between external exposures (i.e. personal air concentrations of PAHs) and biomarkers (i.e. change in urinary PAH metabolite levels in round 1 and change in breath concentrations of benzene in round 2). The results suggest that firefighters wearing full protective ensembles absorbed combustion products into their bodies. The PAHs most likely entered firefighters' bodies through their skin, with the neck being the primary site of exposure and absorption due to the lower level of dermal protection afforded by hoods. Aromatic hydrocarbons could have been absorbed dermally during firefighting or inhaled during the doffing of gear that was off-gassing contaminants.

Engineering youth service system infrastructure: Hawaii's continued efforts at large-scale implementation through knowledge management strategies.

Hawaii's Child and Adolescent Mental Health Division provides a unique illustration of a youth public mental health system with a long and successful history of large-scale quality improvement initiatives. Many advances are linked to flexibly organizing and applying knowledge gained from the scientific literature and move beyond installing a limited number of brand-named treatment approaches that might be directly relevant only to a small handful of system youth. This article takes a knowledge-to-action perspective and outlines five knowledge management strategies currently under way in Hawaii. Each strategy represents one component of a larger coordinated effort at engineering a service system focused on delivering both brand-named treatment approaches and complimentary strategies informed by the evidence base. The five knowledge management examples are (a) a set of modular-based professional training activities for currently practicing therapists, (b) an outreach initiative for supporting youth evidence-based practices training at Hawaii's mental health-related professional programs, (c) an effort to increase consumer knowledge of and demand for youth evidence-based practices, (d) a practice and progress agency performance feedback system, and (e) a sampling of system-level research studies focused on understanding treatment as usual. We end by outlining a small set of lessons learned and a longer term vision for embedding these efforts into the system's infrastructure.

Pharmaceutical dust exposure at pharmacies using automatic dispensing machines: a preliminary study.

Automatic dispensing machines (ADMs) used in pharmacies concentrate and dispense large volumes of pharmaceuticals, including uncoated tablets that can shed dust. We evaluated 43 employees' exposures to pharmaceutical dust at three pharmacies where ADMs were used. We used an optical particle counter to identify tasks that generated pharmaceutical dust. We collected 72 inhalable dust air samples in or near the employees' breathing zones. In addition to gravimetric analysis, our contract laboratory used internal methods involving liquid chromatography to analyze these samples for active pharmaceutical ingredients (APIs) and/or lactose, an inactive filler in tablets. We had to choose samples for these additional analyses because many methods used different extraction solvents. We selected 57 samples for analysis of lactose. We used real-time particle monitoring results, observations, and information from employees on the dustiness of pharmaceuticals to select 28 samples (including 13 samples that were analyzed for lactose) for analysis of specific APIs. Pharmaceutical dust was generated during a variety of tasks like emptying and refilling of ADM canisters. Using compressed air to clean canisters and manual count machines produced the overall highest peak number concentrations (19,000-580,000 particles/L) of smallest particles (count median aerodynamic diameter ≤ 2 µm). Employees who refilled, cleaned, or repaired ADM canisters, or hand filled prescriptions were exposed to higher median air concentrations of lactose (5.0-12 µg/m(3)) than employees who did other jobs (0.04-1.3 µg/m(3)), such as administrative/office work, labeling/packaging, and verifying prescriptions. We detected 10 APIs in air, including lisinopril, a drug prescribed for high blood pressure, levothyroxine, a drug prescribed for hypothyroidism, and methotrexate, a hazardous drug prescribed for cancer and other disorders. Three air concentrations of lisinopril (1.8-2.7 µg/m(3)) exceeded the lower bound of the manufacturer's hazard control band (1-10 µg/m(3)). All other API air concentrations were below applicable occupational exposure limits. Our findings indicate that some pharmacy employees are exposed to multiple APIs and that measures are needed to control those exposures.

Community-based treatment for youth with co- and multimorbid disruptive behavior disorders.

Little is known about the types of psychotherapeutic practices delivered to youth with comorbid and multimorbid diagnoses in community settings. The present study, based on therapists' self-reported practices with 569 youth diagnosed with a disruptive behavior disorder (ODD or CD), examined whether specific therapeutic practice applications varied as a function of the number and type of comorbid disorders. While type of comorbid disorder (AD/HD or internalizing) did not predict therapists' practices, youth with more than two diagnoses (multimorbid) received treatment characterized by a more diverse set and a higher dosage of practices.

Frequency, level, and rate of improvement for treatment targets in a children's mental health community-based intensive in-home therapeutic setting.

Frequency, level, and rate of improvement on 48 therapist-identified treatment targets were examined for 790 youth in usual care receiving intensive in-home services. Targets related to disruptive behavior, depressive mood, and functional impairment were most common. Overall, targets attained moderate levels of improvement and reached maximum gains in approximately three months. Targets associated with disruptive behavior and depressive mood disorders showed significantly greater improvement than those associated with ADHD. Anxiety-related targets improved quickest and significantly faster than disruptive behavior targets. Outcomes for targets within the same diagnostic group also varied substantially. Practice and implementation implications are discussed.

Nutrition support teams: Institution, evolution, and innovation.

The historical institution, evolution, and innovations of nutrition support teams (NSTs) over the past six decades are presented. Focused aspects of the transition to transdisciplinary and patient-centered care, NST membership, leadership, and the future of NSTs are further discussed. NSTs were instituted to address the need for the safe implementation and management of parenteral nutrition, developed in the late 1960s, which requires the expertise of individuals working collaboratively in a multidisciplinary fashion. In 1976, the American Society for Parenteral and Enteral Nutrition (ASPEN) was established using the multidisciplinary model. In 1983, the United States established the inpatient prospective payment system with associated diagnosis-related groupings, which altered the provision of nutrition support in hospitals with funded NSTs. The number of funded NSTs has waxed and waned since; yet hospitals and healthcare have adapted, as additional education and experience grew, primarily through ASPEN's efforts. Nutrition support was not administered in some instances by the "core of four" (physician, nurse, dietitian, pharmacist). The functions may be carried out by a member of the core of four not associated with the parent discipline, in accordance with licensure/privileging. This cross-functioning has evolved into the adaptation of the concept of transdisciplinarity, emphasizing function over form, supported and enhanced by "top-of-license" practice. In some institutions, nutrition support has been incorporated into other healthcare teams. Future innovations will assist NSTs in providing the right nutrition support for the right patient in the right way at the right time, recognizing that nutrition care is a human right.

Thioredoxin reductase 1 protects against chemically induced hepatocarcinogenesis via control of cellular redox homeostasis.

Thioredoxin reductase 1 (TR1) controls the redox state of protein thiols in mammalian cells and has been shown to have roles in both preventing and promoting cancer. To define the role of this selenoenzyme in hepatocellular carcinoma development, we examined tumor incidence in the liver of mice with tissue-specific knockout of mouse TR1 subjected to the liver carcinogen, diethylnitrosamine (DEN). TR1-deficient livers manifested ~90% tumor incidence compared with ~16% in control livers. The TR1-dependent effect was observed independent of sex, and, in control mice, tumorigenesis did not affect the expression of TR1. On the other hand, we observed upregulation of another selenoenzyme, glutathione peroxidase 2 (GPx2), and components of the glutathione (GSH) system, including those that generate reduced GSH. Overall, this study shows that TR1 protects against chemically induced hepatocarcinogenesis via the control of the cellular redox state, whereas its role in promoting this type of cancer is minimal.

An after-school dance and lifestyle education program reduces risk factors for heart disease and diabetes in elementary school children.

BACKGROUND: Forty-three percent of New York City's (NYC) school-age children are overweight or obese, placing them at risk for heart disease and type 2 diabetes mellitus (T2DM). OBJECTIVE: The objective of this study was to determine if an intensive after-school dance and lifestyle education program would reduce risk factors for heart disease, T2DM, and improve lifestyle choices. SUBJECTS: Subject include 64 fourth- and fifth-grade students at an elementary school in NYC. METHODS: Students received freestyle dance and lifestyle classes for 16 weeks and were evaluated for changes in body composition, endurance, biochemical measurements, and lifestyle choices. RESULTS: Significant improvements in BMI percentiles were found among children in the overweight and obese categories as well as in endurance and biochemical measurements that reflect heart disease and diabetes risk. Improvement was also reported in lifestyle choices. CONCLUSION: An intensive after-school dance and lifestyle education program can reduce risk factors for heart disease and T2DM and improve lifestyle choices among elementary school children.

Comparison of work-related symptoms and visual contrast sensitivity between employees at a severely water-damaged school and a school without significant water damage.

BACKGROUND: The National Institute for Occupational Safety and Health (NIOSH) conducted a health hazard evaluation (HHE) of a water-damaged school in New Orleans (NO), Louisiana. Our aim in this evaluation was to document employee health effects related to exposure to the water-damaged school, and to determine if VCS testing could serve as a biomarker of effect for occupants who experienced adverse health effects in a water-damaged building. METHODS: NIOSH physicians and staff administered a work history and medical questionnaire, conducted visual contrast sensitivity (VCS) testing, and collected sticky-tape, air, and dust samples at the school. Counting, culturing, and/or a DNA-based technology, called mold-specific quantitative PCR (MSQPCR), were also used to quantify the molds. A similar health and environmental evaluation was performed at a comparable school in Cincinnati, Ohio which was not water-damaged. RESULTS: Extensive mold contamination was documented in the water-damaged school and employees (n = 95) had higher prevalences of work-related rashes and nasal, lower respiratory, and constitutional symptoms than those at the comparison school (n = 110). VCS values across all spatial frequencies were lower among employees at the water-damaged school. CONCLUSIONS: Employees exposed to an extensively water-damaged environment reported adverse health effects, including rashes and nasal, lower respiratory, and constitutional symptoms. VCS values were lower in the employees at the water-damaged school, but we do not recommend using it in evaluation of people exposed to mold. Am. J. Ind. Med. 55:844-854, 2012. This article is a U.S. Government work and is in the public domain in the USA.

Importance of public-private partnerships for nutrition support research: An ASPEN Position Paper.

Parenteral and enteral nutrition support are key components of care for various medical and physiological conditions in infants, children, and adults. Nutrition support practices have advanced over time, driven by the goals of safe and sufficient delivery of needed nutrients and improved patient outcomes. These advances have been, and continue to be, dependent on research and development studies. Such studies address aspects of enteral and parenteral nutrition support: formulations, delivery devices, health outcomes, cost-effectiveness, and related metabolism. The studies are supported by public funding from the government and by private funding from foundations and from the nutrition support industry. To build public trust in nutrition support research findings, it is important to underscore ethical research conduct and reporting of results for all studies, including those with industry sponsors. In 2019, American Society for Parenteral and Enteral Nutrition's (ASPEN's) Board of Directors established a task force to ensure integrity in nutrition support research that is done as collaborative partnerships between the public (government and individuals) and private groups (foundations, academia, and industry). In this ASPEN Position Paper, the Task Force presents principles of ethical research to guide administrators, researchers, and funders. The Task Force identifies ways to curtail bias and to minimize actual or perceived conflict of interests, as related to funding sources and research conduct. Notably, this paper includes a Position Statement to describe the Task Force's guidance on Public-Private Partnerships for research and funding. This paper has been approved by the ASPEN Board of Directors.

Changing impacts of Alaska-Aleutian subduction zone tsunamis in California under future sea-level rise.

The amplification of coastal hazards such as distant-source tsunamis under future relative sea-level rise (RSLR) is poorly constrained. In southern California, the Alaska-Aleutian subduction zone has been identified as an earthquake source region of particular concern for a worst-case scenario distant-source tsunami. Here, we explore how RSLR over the next century will influence future maximum nearshore tsunami heights (MNTH) at the Ports of Los Angeles and Long Beach. Earthquake and tsunami modeling combined with local probabilistic RSLR projections show the increased potential for more frequent, relatively low magnitude earthquakes to produce distant-source tsunamis that exceed historically observed MNTH. By 2100, under RSLR projections for a high-emissions representative concentration pathway (RCP8.5), the earthquake magnitude required to produce >1 m MNTH falls from ~Mw9.1 (required today) to Mw8.0, a magnitude that is ~6.7 times more frequent along the Alaska-Aleutian subduction zone.

Exposure to flour dust and sensitization among bakery employees.

BACKGROUND: The National Institute for Occupational Safety and Health conducted a study to determine prevalences of sensitization to bakery-associated antigens (BAAs) and work-related respiratory symptoms at a large commercial bakery. METHODS: The following measurements were carried out: personal breathing zone (PBZ) and general area (GA) monitoring for inhalable flour dust, α-amylase and wheat, a questionnaire, and blood tests for IgE specific to flour dust, wheat, α-amylase, and common aeroallergens. RESULTS: Of 186 bakery employees present during our site visit, 161 completed the questionnaire and 96 allowed their blood to be drawn. The geometric mean PBZ and GA inhalable flour dust concentrations for the lower-exposure group was 0.235 mg/m(3), and for the higher-exposure group was 3.01 mg/m(3). Employees in the higher-exposure group had significantly higher prevalences of work-related wheezing, runny nose, stuffy nose, and frequent sneezing than the lower-exposure group. The prevalence of IgE specific to wheat was significantly higher among employees who ever had a job in the higher-exposure group or in production at another bakery at both the ≥ 0.10 kU/L and the ≥ 0.35 kU/L cutoffs, and to flour dust and α-amylase at the ≥ 0.10 kU/L cutoff, compared to the lower-exposure group. CONCLUSIONS: Despite knowledge of the risks of exposure to flour being available for centuries, U.S. employees are still at risk of sensitization and respiratory symptoms from exposure to high levels of BAA.