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.

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.

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.

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.

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.

Ethical Framework for Nutrition Support Resource Allocation During Shortages: Lessons From COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic has impacted all aspects of our population. The "Troubling Trichotomy" of what can be done technologically, what should be done ethically, and what must be done legally is a reality during these unusual circumstances. Recent ethical considerations regarding allocation of scarce resources, such as mechanical ventilators, have been proposed. These can apply to other disciplines such as nutrition support, although decisions regarding nutrition support have a diminished potential for devastating outcomes. The principal values and goals leading to an ethical framework for a uniform, fair, and objective approach are reviewed in this article, with a focus on nutrition support. Some historical aspects of shortages in nutrition supplies and products during normal circumstances, as well as others during national crises, are outlined. The development and implementation of protocols using a scoring system seems best addressed by multidisciplinary ethics and triage committees with synergistic but disparate functions. Triage committees should alleviate the burdens of unilateral decisions by the healthcare team caring for patients. The treating team should make every attempt to have patients and the public at large update or execute/develop advance directives. Legal considerations, as the third component of the Troubling Trichotomy, are of some concern when rationing care. The likelihood that criminal or civil charges could be brought against individual healthcare professionals or institutions can be minimized, if fair protocols are uniformly applied and deliberations well documented.

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.

Field evaluation of sequential hand wipes for flame retardant exposure in an electronics recycling facility.

Flame retardants have been associated with endocrine disorders, thyroid disruption, reproductive toxicity, and immunological interference. Through dismantling and recycling electronics and electric products, flame retardants can be released into the air and settle on work surfaces which may lead to dermal exposure. Hand wipe sampling is commonly used to evaluate dermal exposure. This study assesses the removal efficiency of wipes on the hands of recycling employees, and to compare the efficacy of two common surface wipe sampling materials. We used three sequential hand wipes and quantified the percentage of flame retardants that was removed by each hand wipe in the sequence. Two common wipe materials (gauze and twill) were used to compare the ability to remove flame retardants. The wipes were collected from 12 employees at a U.S. electronics recycling facility immediately at the end of their shift, prior to washing their hands. Results show that although the first wipe removed the highest median percent of the sum of the three wipes for most flame retardants, there was a wide range of the percentages of total individual flame retardants removed by both gauze (4%-98%) or twill hand wipe (1%-89%). Approximately half of the flame retardants a high percentage (>50%) removed by the second and third wipes. This suggests that a single wipe is not sufficient to characterize the extent of dermal contamination. The average of the total amount of flame retardants removed by twill wipes was greater than the average using gauze, but the difference was not statistically significant.

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.

Treatment-as-usual therapy targets for comorbid youth disproportionately focus on externalizing problems.

This study examined whether psychological treatment for youth with comorbid externalizing and internalizing disorders targets externalizing rather than internalizing pathology. Therapist-reported treatment targets for youth (N = 679) with (a) only internalizing diagnoses (n = 195); (b) only externalizing diagnoses (n = 314); (c) a primary internalizing diagnosis and at least 1 additional externalizing diagnosis (n = 75); and (d) a primary externalizing diagnosis and at least 1 additional internalizing diagnosis (n = 95) receiving treatment-as-usual in a public mental health system of care were examined. Treatment targets that appeared significantly more often in the externalizing-only and internalizing-only diagnostic groups were empirically determined, and a derived proportional measure of these targets was analyzed across all 4 diagnostic groups, controlling for effects of additional client and treatment characteristics. As required by the target selection method, the proportion of externalizing targets selected in treatment was greatest for youth with externalizing-only diagnoses and least for youth with internalizing-only diagnoses. Importantly, the co-occurrence of a secondary externalizing disorder with a primary internalizing disorder resulted in a large increase in the proportion of externalizing targets endorsed, whereas the co-occurrence of an internalizing disorder with a primary externalizing disorder resulted in a comparatively small decrease in the proportion of externalizing targets endorsed. Results persisted despite several covariates also predicting increased focus on externalizing targets, including male gender and younger age. These findings suggest that community therapists tend to prioritize externalizing over internalizing problems during treatment for such comorbid youth. Implications for practice, research and dissemination/implementation efforts are discussed. (PsycINFO Database Record

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.

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.

Consumer attitudes towards evidence based mental health services among American mental health consumers.

The Consumer Attitudes towards Evidence Based Services (CAEBS) scale is a 29-item questionnaire designed to assess public views on the role of science in helping to guide mental health treatment. The aim of the current study was to assess the Factor structure the CAEBS in an online sample of adults seeking information about mental health services. The CAEBS was administered to a nationwide sample of participants from websites offering classified advertisements for mental health related study participation (n = 312). An Exploratory Factor Analysis (EFA) suggested four factors based on 26 of the items: Beliefs Regarding Therapists' Practices, Attitudes about Mental Health Policy, Negative Personal-Level Attitudes toward EBPs, and Negative Societal-Level Attitudes towards EBPs. In order to increase consumer empowerment within the mental health-care system and develop policies supporting EBP usage, mental health professionals need to increase communication with the public to address these concerns and leverage positive attitudes.

Diesel Surrogate Fuels for Engine Testing and Chemical-Kinetic Modeling: Compositions and Properties.

The primary objectives of this work were to formulate, blend, and characterize a set of four ultralow-sulfur diesel surrogate fuels in quantities sufficient to enable their study in single-cylinder-engine and combustion-vessel experiments. The surrogate fuels feature increasing levels of compositional accuracy (i.e., increasing exactness in matching hydrocarbon structural characteristics) relative to the single target diesel fuel upon which the surrogate fuels are based. This approach was taken to assist in determining the minimum level of surrogate-fuel compositional accuracy that is required to adequately emulate the performance characteristics of the target fuel under different combustion modes. For each of the four surrogate fuels, an approximately 30 L batch was blended, and a number of the physical and chemical properties were measured. This work documents the surrogate-fuel creation process and the results of the property measurements.

Positive and Negative Affect in Clinic-Referred Youth With ADHD.

OBJECTIVE: To examine self-reported positive affect (PA) and negative affect (NA) among youth with ADHD (only and comorbid) and other non-ADHD-referred youth in an ethnically diverse clinical sample. METHOD: Semi-structured interviews identified 80 pure ADHD, 284 ADHD plus one or more comorbidities, and 730 non-ADHD youth (e.g., other diagnoses or no diagnosis). The Positive and Negative Affect Scale-Children (PANAS-C) was used to assess affective states. RESULTS: Even after controlling for the influence of potential confounds, youth with only ADHD reported higher PA and lower NA than other clinic-referred youth. The ADHD-comorbid group reported higher PA than the "non-ADHD" group, but these groups did not differ on level of NA. ADHD subtype did not influence results. CONCLUSION: Among clinic-referred youth, ADHD is associated with higher levels of PA and when there are no comorbid disorders, lower levels of NA.

An Exploratory Factor Analysis of the Knowledge of Evidence-Based Services Questionnaire.

Recent developments for disseminating and implementing evidence-based practices (EBPs) have emphasized the importance of increasing therapists' knowledge of such techniques. However, systematic efforts to measure knowledge in therapists serving youth have mostly relied on poorly researched study-specific measures. This study investigated the structure of EBP knowledge in a large sample of youth community therapists (N = 240) via a therapist report instrument emphasizing therapeutic commonalities across various types of treatment approaches. Findings supported a three-factor structure of knowledge with scores on factors varying by therapists' primary practice setting and education level. The relationships between therapist knowledge of and attitudes towards EBPs are also discussed.