Targeted Assessment and Context-Tailored Implementation of Change Strategies (TACTICS) to increase evidence based psychotherapy in military behavioral health clinics: Design of a cluster-randomized stepped-wedge implementation study.

BACKGROUND: Despite efforts by the U.S. Department of Defense to train behavioral health (BH) providers in evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), numerous barriers limit EBP implementation. A context-tailored implementation approach called TACTICS (Targeted Assessment and Context-Tailored Implementation of Change Strategies) holds promise for increasing the use of EBPs such as prolonged exposure therapy (PE) in military treatment facilities. TACTICS combines a needs assessment, a rubric for selecting implementation strategies based on local barriers, an implementation toolkit, and external facilitation to support local champions and their implementation teams in enacting changes. This paper describes the rationale for and design of a study that will evaluate whether TACTICS can increase implementation of PE for PTSD and improve patient outcomes in military BH clinics relative to provider training in PE alone. METHODS: The study is a multi-site, cluster randomized, stepped-wedge trial, with the military treatment facility as the unit of analysis. Eight facilities undergo a provider-training phase, followed by 5 months of TACTICS implementation. The timing of TACTICS at each facility is randomly assigned to begin 9, 14, or 19 months after beginning the provider-training phase. Primary analyses will compare the proportion of PTSD patients receiving PE and patients' mean improvement in PTSD symptoms before and after the onset of TACTICS. DISCUSSION: TACTICS endeavors to balance standardization of empirically-supported implementation strategies with the flexibility of application necessary for success across varied clinical settings. If successful, TACTICS may represent a systematic and scalable method of promoting and supporting EBP implementation. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT03663452.

Synthesis and characterization of thiol-acrylate hydrogels using a base-catalyzed Michael addition for 3D cell culture applications.

There is significant interest in developing new approaches for culturing mammalian cells in a three-dimensional (3D) environment due to the fact that it better recapitulates the in vivo environment. The goal of this work was to develop thiol-acrylate, biodegradable hydrogels that possess highly tunable properties to support in vitro 3D culture. Six different hydrogel formulations were synthesized using two readily available monomers, a trithiol (ETTMP 1300 [ethoxylated trimethylolpropane tri(3-mercaptopropionate) 1300]) and a diacrylate (PEGDA 700 [polyethylene glycol diacrylate 700]), polymerized by a base-catalyzed Michael addition reaction. The resultant hydrogels were homogeneous, hydrophilic, and biodegradable. Different mechanical properties such as gelation time, storage modulus (or the elasticity G'), swelling ratio, and rate of degradation were tuned by varying the weight percentage of polymer, the molar ratio of thiol-to-acrylate groups, and the pH of the solution. Cytocompatibility was assessed using two model breast cancer cell lines by both 2D and 3D cell culturing approaches. The hydrogel formulations with a thiol-to-acrylate molar ratio of 1.05 were found to be optimal for both 2D and 3D cultures with MDA-MB-231 cellular aggregates found to be viable after 17 days of 3D continuous culture. Finally, MCF7 cells were observed to form 3D spheroids up to 600 µm in diameter as proof of principle for the thiol-acrylate hydrogel to function as a scaffold for in vitro 3D cell culture. A comparison of the different mechanical properties of the six hydrogel formulations coupled with in vitro cell culture results and findings from previously published hydrogels conclude that the thiol-acrylate hydrogels have significant potential as a scaffold for 3D cell culture.

PTSD Symptoms Experienced and Coping Tactics Used by Crime Scene Investigators in the United States.

Few investigations have assessed the prevalence of posttraumatic stress experiences among Crime Scene Investigators (CSIs). We recruited a nationwide sample of 225 CSIs to complete online questionnaires assessing PTSD symptoms, use of specific coping tactics, perceived social support, trait resilience, and demographics. Seven symptoms had been experienced by at least 50% of participants during the previous month, and 9.3% had total checklist scores suggestive of PTSD. A significant regression analysis revealed that higher PTSD scores were associated with drinking alcohol more frequently to deal with stress, admitting more frequently one could not deal with stress and not trying to do so, lower social support, getting angry and letting emotions out more frequently, lower resilience, and finding comfort in one's religious beliefs. Given the proportions of CSIs that experience exposure-related stress, more should be done to mitigate the prevalence and severity of these symptoms.

Hemodynamic findings of spontaneously recanalized coronary thrombus.

This case presented is a patient with non-ST elevation myocardial infarction with angiographic non-flow limiting linear opacity in coronary artery with fractional flow reserve in ischemic range secondary to recanalized organized thrombus.

Prevalence, prognosis, and therapeutic implications of unrecognized left ventricular systolic dysfunction in patients with anemia and chronic kidney disease.

The prevalence and outcomes of unrecognized left ventricular dysfunction (ULVSD) in patients with anemia and chronic kidney disease (CKD) is not known. The authors determined whether anemia (hemoglobin <13 g/L) and CKD (glomerular filtration rate <60 mL/min) are risk factors for ULVSD (ejection fraction <35%, no known heart failure [HF]) and to determine its impact on clinical outcomes. A total of 1358 patients without history of HF undergoing gated myocardial perfusion single photon emission computed tomography for evaluation of suspected coronary artery disease were followed for a mean of 2.15 ± 0.8 years. End points were death and heart failure hospitalization (HFH). Patients were divided into 4 groups (I: no anemia/no CKD, n=752; II: CKD/no anemia, n=285; III: anemia/no CKD, n=153; IV: anemia+CKD, n=168). Compared with group I, LVSD was significantly more common in group IV (11.3% vs 4%; P=.0009). Death and HFH were significantly higher in group IV compared with group I (death rate for group I: 3.5% per year vs group IV: 12% per year; P<.0001) (HFH rate for group I: 1.5% per year vs group IV: 8% per year, P<.0001). Among patients with ejection fraction <35%, presence of anemia+CKD was associated with a relative risk of 2.48 (95% confidence interval, 1.13-5.4; P=.02) for death compared with group I. Among patients with ULVSD, only 65% were taking angiotensin enzyme inhibitors/angiotensin receptor blockers and ß-blockers. ULVSD was almost 3 times more common in patients with anemia+CKD compared with those without and was associated with a significantly higher risk of death and HFH. It may therefore be beneficial to screen patients with anemia and CKD for ULVSD, since early therapy may improve outcomes.

Imaging diagnosis--nasal septal and laryngeal cyst-like malformationsin a Thoroughbred weanling colt diagnosed using ultrasonography and magnetic resonance imaging.

A foal was examined for abnormal upper airway noise. Endoscopically, there were narrowed nasal passages and an extralumenal mass of the cranial trachea. Using ultrasonography and magnetic resonance (MR) imaging of the larynx and cranial cervical trachea, irregular margins of the laryngeal cartilages and first tracheal ring containing areas consistent with fluid were identified. In MR images, a widened nasal septum was seen that contained material consistent with fluid. Postmortem examination confirmed the diagnosis of nasal septal, laryngeal, and cranial cervical tracheal cyst-like lesions. This is a unique congenital condition, in which premortem imaging was instrumental in defining the abnormalities.

Scintillation proximity assay for DNA binding by human p53.

Many DNA binding proteins are known to regulate gene expression. When that binding is altered, a disease state can result. A common method for measuring DNA binding, namely electrophoretic mobility shift assay (EMSA) is often used but it is not amenable to rapid screening of many samples. As an alternative method, we have developed a DNA binding assay for the tumor suppressor protein p53 in a 96-well microtiter plate format using scintillation proximity assay (SPA) beads. We have shown this assay to be sensitive (as little as 0.5 ng p53 can be detected), quick (assay completed in as little as 15 min), and easily quantitated using a microtiter plate scintillation counter We also used the assay to analyze the kinetics of the DNA binding to p53. The specificity of this p53 DNA binding SPA was confirmed using competition by oligonucleotides either from the same gene or from mutated versions of this sequence. Thus, SPA is a good alternative to gel shift assays for DNA binding and may be useful for the analysis of multiple tumor cell samples or for high-throughput screens for compounds affecting DNA binding by proteins of interest.