Effect of continuous post-operative lidocaine infusion in an enhanced recovery program on opioid use following gynecologic oncology surgery.

OBJECTIVE: To determine the effectiveness of implementing an Enhanced Recovery After Surgery (ERAS) program, including continuous intraoperative and postoperative intravenous (IV) lidocaine infusion, on perioperative opioid use. METHODS: This was a single-institution retrospective pre- post- cohort study. Consecutive patients undergoing planned laparotomy for known or potential gynecologic malignancy were identified after implementation of an ERAS program and compared to a historical cohort. Opioid use was calculated as morphine milligram equivalents (MMEs). Cohorts were compared using bivariate tests. RESULTS: A total of 215 patients were included in the final analysis, 101 patients received surgery before ERAS implementation and 114 received surgery after. A reduction in total opioid use was observed in ERAS patients compared with historical controls (MME 26.5 [9.6-60.8] versus 194.5 [123.8-266.8], p<0.001). Length of stay (LOS) was reduced by 25% in the ERAS cohort (median 3 days, range 2-26, versus 4 days, range 2-18; p<0.001). Within the ERAS cohort, 64.9% received IV lidocaine for the planned 48 hours, and 5.6% had the infusion discontinued early. Within the ERAS cohort, patients who received IV lidocaine infusion used less opioids compared to those who did not (median 16.9, range 5.6-55.1, versus 46.2, range 23.2-76.1; p<0.002). CONCLUSION: An ERAS program including a continuous IV lidocaine infusion as the opioid-sparing analgesic strategy was noted to be safe and effective, leading to decreased opioid consumption and LOS compared with a historic cohort. Additionally, lidocaine infusion was noted to decrease opioid consumption even among patients already receiving other ERAS interventions.

Successful management of stage IV epithelioid trophoblastic tumor using multimodality treatment: A case report.

Epithelioid trophoblastic tumor (ETT) is a rare variant of gestational trophoblastic neoplasia (GTN) that develops from chorionic-type intermediate trophoblast, is more resistant to chemotherapy than choriocarcinoma, and presents with metastatic disease in 25-35% of cases. We report a case of a 32-year-old who presented one week postpartum with severe abdominal pain and was found to have profound anemia and an elevated hCG level. CT scans and MRI revealed bleeding from hepatic masses, multiple hemorrhagic pulmonary nodules, a 7 cm uterine mass, and brain metastases. She underwent emergent hepatic embolization, was started on induction chemotherapy with weekly low-dose etoposide and cisplatin followed by a transition to etoposide, high-dose methotrexate, actinomycin D, etoposide, and cisplatin (HD EMA-EP), received stereotactic brain radiotherapy, and subsequently underwent minimally-invasive hysterectomy. She remains disease free over one year after the completion of treatment. An aggressive multimodal treatment approach employing etoposide/cisplatin-based chemotherapy as well as surgical procedures to control hemorrhage or excise resistant disease, and radiotherapy for brain metastases can result in successful treatment of stage IV ETT.

Where Does It Begin? Community-Based Therapists' Intentions for Treating Non-comorbid Youth.

This study examined patterns and predictors of 79 public sector therapists' practice element (PE) intentions for treating hypothetical single problem area youth with either anxiety or disruptive behavior problems. Analyses of intention profiles suggested that PE intentions varied by diagnosis and included both a majority of practices derived from the evidence base (PDEBs) and a large number of practices with minimal evidence support (PMESs) for each problem area. Hierarchical multiple regression results indicated the only significant predictor of higher PDEB intentions for both problem areas was reporting more PMES intentions. Implications for community-based research and implementation efforts are discussed.

A History of Child and Adolescent Treatment Through a Distillation Lens: Looking Back to Move Forward.

Youth psychosocial treatments have proliferated over many decades and the time is ripe to examine the unique contribution of these treatments. Six hundred eighty-nine randomized clinical trials were examined from the PracticeWise Evidence-Based Services Database, an ongoing data source of youth psychosocial literature. A number of studies, treatment protocols, and practice elements across 11 youth problem areas (e.g., anxiety) from 1966 to 2016 are provided. Using distillation methodology, we compared the relationship between new treatment protocols and the identification of new practice elements within each problem area over time. Anxiety, disruptive behavior, attention/hyperactivity, and depression were the most studied problem areas, whereas suicide, eating disorders, and mania were least studied. While identification of new practice elements leveled off, studies continued to increase over time. For some problem areas, unique practice elements have not been identified for over a decade. Future studies examining treatment innovation and implications for behavioral health are discussed.

A Psychometric Evaluation of the Intention Scale for Providers-Direct Items.

This study examined the psychometric properties of the Intention Scale for Providers-Direct Items (ISP-D; 16 items), a questionnaire for assessing therapists' evidence-based practice attitudes, subjective norms, perceived behavioral control, and behavioral intentions. Participants were community mental health providers from the State of Hawaii. A confirmatory factor analysis provided support for a revised 14-item ISP-D measure that fits the data reasonably well. Subscales of this revised ISP-D demonstrated acceptable to good internal consistency, with the exception of the Perceived Behavioral Control subscale. The majority of convergent validity correlation patterns between the ISP-D and related constructs were significant and in predicted directions.

Therapist and Youth Predictors of Specific Practices Derived from the Evidence-Base in Community Mental Health.

Over the past several years, youth treatment research has moved toward understanding the dissemination and implementation of evidence-based practices (EBPs). As a result, studies have focused on identifying predictors that aid in successful adoption and sustainment of EBPs. Theories of behavior change posit that therapist knowledge and attitudes play a fundamental role in EBP adoption; however, studies have produced mixed findings, which may be an artifact of broad definitions of both EBP knowledge and EBP itself. The current study was an examination of 46 youth community therapists and the extent to which varying types of knowledge and attitudes as well as youth characteristics predicted specific practices derived from the evidence-base. Results suggested that specific EBP knowledge predicted specific practices, highlighting the need for more specificity when examining predictors of EBP use. Therapists' attitudes, demographic characteristics, and youth characteristics were also significant predictors of EBP use. Future research should consider examining discrete and specific practices to better understand and predict therapists' future behavior.

Multilevel Predictors of Case Managers' Assessment Administration Behavior in a Precursor to a Measurement Feedback System.

This study examines factors associated with administration of a treatment monitoring assessment measure (the Ohio Scales) in the context of a precursor to a measurement feedback system in a youth public mental health setting. 82% of all state case managers (N = 46) completed interviews and administered at least one Ohio Scale over a 12-month period. A multi-level model accounting for variance between both case managers and their administrative offices indicated that case manager characteristics (lower self-reported burnout, more experience) and monthly caseload characteristics (fewer active cases, younger average age of youth, and increased time since initial administration) predicted increased monthly administration proportions.

Predicting Youth Improvement in Community-Based Residential Settings with Practices Derived from the Evidence-Base.

The current investigation conducted descriptive analyses on key variables in community-based residential (CBR) settings and investigated the extent to which disruptive youth between the ages of 13 and 17 years improved based on therapists' reported alignment with using practices derived from the evidence-base (PDEBs). Results from both the descriptive analyses and multilevel modeling suggested that therapists are using practices that both do and do not align with the evidence-base for disruptive youth. In addition, both PDEBs and practices with minimal evidence-support predicted or marginally predicted final average progress rating for these youth. Findings are discussed as they relate to the importance of continued exploration of treatment outcomes for CBR youth.

Insights in Public Health: The Help Your Keiki Website: Increasing Youth and Caregiver Awareness of Youth Psychosocial Mental Health Treatment.

Increasing evidence-based practice (EBP) use in community mental health is a national priority, especially given that one in five youth will suffer from mental health concerns before adulthood. Implementation science offers a unique lens for understanding EBP use that identifies barriers and facilitators of successful adoption. Consumer engagement is often overlooked as an EBP implementation strategy. In this article, we describe the State of Hawai'i Child and Adolescent Mental Health Division's innovative effort to target consumer EBP demand via the Help Your Keiki Website. Feedback from community stakeholders and website analytics converge to suggest that the most helpful content is related to finding help, normalizing concerns, and questions to ask therapists. Future outreach efforts as well as ongoing improvement and enhancement of the website are discussed.

Furthering Our Understanding of Therapist Knowledge and Attitudinal Measurement in Youth Community Mental Health.

Examining therapist evidence-based practice (EBP) knowledge seems an important step for supporting successful implementation. Advances in implementation science suggest a distinction between practice specific (i.e., knowing which practices are derived from the evidence base) and EBP process (i.e., integrating research evidence, clinical experience, client characteristics, and monitoring outcomes) knowledge. An examination of how these knowledge types are measured and relate to attitudes appears warranted. In our sample of 58 youth community therapists, both practice specific and EBP process knowledge accounted for EBP attitude scores, which varied by therapist demographic variables. Implications for measurement of therapist constructs and future research in identifying therapist predictors of EBP use and youth clinical improvement are discussed.

The Revised Child Anxiety and Depression Scale 25-Parent Version: Scale Development and Validation in a School-Based and Clinical Sample.

To help facilitate the dissemination and implementation of evidence-based assessment practices, we examined the psychometric properties of the shortened 25-item version of the Revised Child Anxiety and Depression Scale-parent report (RCADS-25-P), which was based on the same items as the previously published shortened 25-item child version. We used two independent samples of youth-a school sample ( N = 967, Grades 3-12) and clinical sample ( N = 433; 6-18 years)-to examine the factor structure, reliability, and validity of the RCADS-25-P scale scores. Results revealed that the two-factor structure (i.e., depression and broad anxiety factor) fit the data well in both the school and clinical sample. All reliability estimates, including test-retest indices, exceeded benchmark for good reliability. In the school sample, the RCADS-25-P scale scores converged significantly with related criterion measures and diverged with nonrelated criterion measures. In the clinical sample, the RCADS-25-P scale scores successfully discriminated between those with and without target problem diagnoses. In both samples, child-parent agreement indices were in the expected ranges. Normative data were also reported. The RCADS-25-P thus demonstrated robust psychometric properties across both a school and clinical sample as an effective brief screening instrument to assess for depression and anxiety in children and adolescents.

Evidence-Based Practice Implementation Within a Theory of Planned Behavior Framework.

Although significant progress has been made in the identification of youth evidence-based practices, the adoption of these interventions into community-based mental health care remains limited. Dissemination and implementation (DI) research has the potential to bridge this science-practice gap in clinical psychology. The theory of planned behavior (TPB) offers a useful conceptualization of individual behavior change including behavioral intention as defined by attitudes, subjective norms, and perceived behavioral control. To facilitate application of this model to DI efforts, the current study explores perspectives about using evidence-based practice from stakeholders in the field of youth mental health (including clinical supervisors, case managers, administrators at the departments of health and education, and direct service providers in clinic-based, school-based, and intensive in-home settings) within the TPB framework. A set of instrument items was created from this rich qualitative data using a rigorous mixed-method content validation approach. Instrument items are provided for future use in DI research.

Therapist Attitudes Towards Evidence-Based Practice: A Joint Factor Analysis.

Despite the accumulated research support for the use of evidence-based practices (EBPs) with youth, these treatment approaches remain underutilized in community settings. Therapist attitudes towards EBPs play a pivotal role in their adoption and implementation of these practices. The present investigation employs joint exploratory factor analysis to evaluate the structure of two measures of therapist attitudes, the Evidence-Based Practices Attitudes Scale and the Modified Practice Attitude Scale. Results suggest three factors including (a) importance of clinical experience over EBPs, (b) clinician openness to change, and (c) problems with EBPs. Recommendations are provided for future evaluation of therapist attitudes and associated characteristics.

Facilitators and Barriers of Implementing a Measurement Feedback System in Public Youth Mental Health.

This study examines implementation facilitators and barriers of a statewide roll-out of a measurement feedback system (MFS) in a youth public mental health system. 76 % of all state care coordinators (N = 47) completed interviews, which were coded via content analysis until saturation. Facilitators (e.g., recognition of the MFS's clinical utility) and barriers (e.g., MFS's reliability and validity) emerged paralleling the Exploration, Adoption/Preparation, Implementation, and Sustainment framework outlined by Aarons et al. (Adm Policy Mental Health Mental Health Serv Res, 38:4-23, 2011). Sustainment efforts may leverage innovation fit, individual adopter, and system related facilitators.

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.

Knowledge, Attitudes, Social Desirability, and Organizational Characteristics in Youth Mental Health Services.

This project investigated the extent to which knowledge of evidence-based practices (EBPs) and organizational characteristics predicted attitudes toward EBPs, while controlling for social desirability and organization membership. Participants were 167 public sector youth practitioners. Hierarchical multiple regression analyses were conducted to determine which factors significantly predicted EBP attitudes. Findings suggested that social desirability, organization membership, and various organizational characteristics predicted EBP attitudes. Results are discussed as they relate to the importance of including social desirability in future research and identifying different factors that influence EBP attitudes across various organizations.

Balancing effectiveness with responsiveness: Therapist satisfaction across different treatment designs in the Child STEPs randomized effectiveness trial.

OBJECTIVE: To investigate the association between protocol design and therapist satisfaction in the Child STEPs Randomized Effectiveness Trial (Weisz et al., 2012). METHOD: Therapist report was obtained at the close of 145 cases seen by 77 therapists, each of whom was randomized to a Standard evidence-based treatment (EBT), modular EBT, or usual care (UC) condition. RESULTS: Analysis of satisfaction items revealed 2 correlated factors representing perceived effectiveness and perceived responsiveness of the treatments. Therapist total satisfaction scores were significantly higher for cases in the modular condition than for those in the standard EBT or UC conditions. With regard to specific dimensions, the modular and UC cases were rated significantly higher than standard EBT cases on the Responsiveness scale, whereas modular and standard EBT cases were rated significantly higher than UC on the Effectiveness scale. Finally, increases in Effectiveness scores from first to second case were significantly larger for Modular cases than for cases in both other study conditions, and increases from first to second case in Total Satisfaction scores were significantly larger for modular cases than for UC cases. CONCLUSIONS: Therapist satisfaction with a treatment approach has independent dimensions, which can vary as a function of the protocol design. By virtue of being perceived as more effective than UC and more responsive than standard EBTs, the modular protocol design was also viewed as more overall satisfying than both, and secondary analysis suggested that these results were not due to mere first impressions of the protocols.

Predictors of use of evidence-based practices for children and adolescents in usual care.

Practice data from 74 therapists providing public mental health services to 519 youth ages 5-19 were examined. Multilevel modeling suggested child and therapist characteristics predicted use of practices derived from the evidence-base (PDEB) and use of practices with minimal evidence support (PMES). Longer episode length predicted greater receipt of PDEB; older youth, males, and youth in out-of-home levels of care were more likely to receive PMES; and youth receiving an evidence-based treatment program were less likely to receive PMES. Professional specialty and theoretical orientation significantly predicted PDEB whereas therapist characteristics did not predict PMES. Implementation implications are discussed.