Improving Resiliency in U.S. Air Force Healthcare Personnel: A Randomized Preventive Trial.

INTRODUCTION: The effectiveness of the Stress Management and Resilience Training (SMART) with U.S. military personnel has not been reported in the literature. The purpose of this study was to examine the effectiveness of SMART in increasing resilience in Air Force healthcare personnel. MATERIALS AND METHODS: We conducted a pilot, randomized preventive trial with active component Air Force healthcare personnel. SMART was offered via an in-person, 2-h training session delivered through face-to-face or synchronous video teleconference training, or via a self-paced, computer-based training. A baseline survey included demographics questions and the Connor-Davidson-10 Resilience Scale (CD-10), Perceived Stress Scale (PSS), Generalized Anxiety Disorder Scale (GAD-7), and overall quality of life (QOL) measure. Follow-up surveys with the CD-10, PSS, GAD-7, and quality of life were sent to participants at 12, 18, and 24 weeks after completing SMART. RESULTS: Fifty-six service members completed the baseline assessment and were randomized to either the in-person modality (comprised of video teleconference or face-to-face training) or the computer-based training modality, and 49 participants completed SMART. Significant increases in median CD-10 scores were observed among all participants, showing a 4-point (14%), 6-point (21%), and 5-point (17%) increase at week-12, -18, and -24, respectively, from the baseline. A significant overall decrease in median PSS scores from baseline were observed, with 5.5-points (22%), 7.81-points (32%), and 8.5-points (35%) decrease at 12, 18, and 24 weeks post-SMART, respectively. CONCLUSIONS: In this pilot study, SMART demonstrated significant and meaningful improvements in self-reported CD-10 and PSS-14 scores at 12, 18, and 24 weeks post-training completion. A future replication of the study is necessary to evaluate the effectiveness of SMART on a larger scale.

Inpatient Care Utilization and Epidemiology of Hirschsprung Disease: Analysis of the National Inpatient Sample.

BACKGROUND/OBJECTIVES: Hirschsprung disease (HD) is associated with significant morbidities including long-term bowel dysfunction. The aim of this study was to update national and regional trends in the inpatient care utilization and epidemiology of HD in the United States between 2009 and 2014 using the National Inpatient Sample (NIS) database. METHODS: We identified all pediatric admissions with a diagnosis of HD within the NIS from 2009 through 2014. We analyzed HD discharges with respect to various demographic and clinical factors, specifically trends and group differences in inflation-adjusted cost of hospitalization, procedures, co-morbidities, hospital mortality, and length of stay (LOS). A modified Cochrane-Armitage trend test was used to analyze trends for dichotomous outcome variables, and regression analyses were conducted for continuous and binary variables. RESULTS: National estimates of HD-discharges showed no significant trend between 2009 and 2014 ( P = 0.27), with estimated relative incidence ranging from 46 to 70 per 100,000 pediatric discharges. Inflation-adjusted cost of hospitalization increased by $1137 (SE $326) per year ( P = 0.0005). Pull-through procedures in neonatal age group increased from 33.0% in 2009 to 36.5% in 2014 ( P = 0.003). Hospital mortality has remained stable between 0.4% and 1.0% ( P = 0.598). LOS decreased by 0.23 days per year ( P = 0.036). CONCLUSION: Increasing cost of HD-related hospitalization despite decreasing LOS was observed in this cohort. Stable rate of hospitalizations with increasing proportions of pull-through procedures among neonates was noted. Future studies and development of protocols to standardize patient care could improve outcomes and healthcare spending.

The Role of Substance Use and Resiliency Factors on Suicidal Ideation among Middle School Students.

BACKGROUND: Suicidal ideation, an important risk factor for suicide, is strongly associated with substance use. Factors such as family cohesion, connection with friends, and social support can be protective against suicidal behaviors. The purpose of this study was to explore the association between suicidal ideation, substance use, and resiliency factors among middle school students. METHODS: The 2013 New Mexico Youth Risk and Resiliency Survey provided the data for this analysis. Suicidal ideation was defined as affirmative responses to questions about thoughts of killing oneself and/or making a suicide plan. We used logistic regression to explore the association between suicidal ideation, substance use, and resiliency factors. RESULTS: Overall, 23% of students reported suicidal ideation. Among girls, having a caring friend was associated with lower odds of suicidal ideation only among those not using other drugs. Among boys, having a caring friend decreased the odds of suicidal ideation regardless of substance use. CONCLUSIONS: Suicidal ideation is prevalent among middle school children. Substance abuse is associated with suicidal ideation; however, individual and community support can be protective. Interventions aimed at reducing suicidal behaviors among middle school students should account for the impact of substance use and help strengthen social support.

Family, School, and Peer Support Are Associated With Rates of Violence Victimization and Self-Harm Among Gender Minority and Cisgender Youth.

PURPOSE: Gender minority (GM) youth experience high rates of violence, and research on protective factors to reduce violence victimization and self-harm is lacking. The purpose of this study was to determine how family, school, peer, and community support influenced rates of violence victimization and self-harm among GM and cisgender adolescents. METHODS: This research uses data from the 2017 New Mexico Youth Risk and Resiliency Survey (N = 18,451). The main independent variable was gender, dichotomized into GM and cisgender, and the secondary independent variables were family, school, community, and peer support. Dependent variables were sexual and dating violence, suicide attempts, and nonsuicidal self-injury. Logistic regression models were built for the four dependent variables, including demographics, support scores, and interaction terms between gender and support. RESULTS: Six percent of high school students in New Mexico identified as GM are unsure of their gender. GM students experienced higher rates of violence and self-harm and lower levels of support than cisgender students. Among all students, family support was associated with lower odds of sexual violence and self-harm, while school support was associated with lower odds of dating violence and nonsuicidal self-injury. There were significant interactions between gender, violence, and support. The protective effects of support were less pronounced for GM students than for cisgender students. CONCLUSIONS: Family and school support are associated with lower rates of some forms of violence and self-harm among adolescents. Additional support may be necessary to reduce harm among GM adolescents, who are at higher risk for violence and its sequelae.

Effectiveness of Peer-Delivered Trauma Treatment in a Rural Community: A Randomized Non-inferiority Trial.

This randomized controlled non-inferiority trial explored the effectiveness of Seeking Safety (SS) delivered by peer providers compared to its delivery by licensed behavioral health clinicians. The study enrolled 291 adults with PTSD and/or substance use disorders. Data were collected at 3 and 6-months post start of treatment. With respect to long-term outcomes, at 6 months PTSD symptoms decreased by 5.1 points [95% CI (- 9.0, - 1.1)] and by 4.9 points [95% CI (- 8.6, - 1.1)] and coping skills increased by 5.5 points [95% CI (0.4, 10.6)] and by 5.6 points [95% CI (0.8, 10.4)], in the peer- and clinician-led groups, respectively. This study demonstrated non-inferiority of peer-delivered SS compared to clinician-delivered SS for reducing PTSD symptoms and similar outcomes for both groups with respect to coping skills. A confirmatory study on the effectiveness of peer-delivered trauma-specific services is warranted, especially given the potential for increasing access to such treatment in underserved rural communities.

Heterodyne I: Enhancing sonochemical efficiency through application of the heterodyne effect: An initial study.

Relatively little is known concerning the application of concurrent and coaxial multi-frequency ultrasound on the facilitation of chemical reactivity. When two or more acoustic frequencies are input into a solution, frequencies corresponding to the sum of the frequencies with an amplitude related to the difference between the two frequencies (both known in acoustics as heterodyne frequencies) are produced. Given the fact that cavitation dynamics are dependent upon frequency and power among other variables, the generation of additional waves should produce a situation where the cavitation bubbles produced by the two coincident frequencies are out of resonance with the heterodyne frequency, resulting in an increase in cavitation collapse efficiency. The resulting cavitation efficiency is expected to be higher than that which is observed from the simple sum of the acoustic energy transferred from each single frequency. As such, the energy and cavitation efficiency of this technique for bond breakage and formation is expected to be significantly higher than using either a single ultrasonic frequency or two frequencies acting separately. In this study we have embarked on a comparison of the efficacy of heterodyne sonochemistry with more traditional single-frequency or dual frequency ultrasound where the heterodyne frequency is zero. As a prototypical reaction, we have explored the effects of multi-frequency ultrasound on the degradation of acid orange, a common industrial colorant. An increase in the degradation rate by a factor of 500% was observed using incident frequencies of 305 and 310 kHz heterodyne ultrasound (5 kHz heterodyne) compared with what would be expected theoretically were the two frequencies to act independently. Reasons for the increase in efficiency are discussed.

Perceived helpfulness of peer-delivered trauma specific treatment: A randomized controlled trial.

Peer providers have been associated with positive outcomes in behavioral health, but little is known about the perceived helpfulness of their services. We used a mixed-methods randomized controlled trial to compare the perceived helpfulness of seeking safety (SS) led by peer providers compared to its delivery by licensed behavioral health clinicians (including both a licensed alcohol and drug abuse counselor and licensed clinical mental health counselor). Participants (N = 278) rated the helpfulness of 12 SS topics at the end of every session. A subset (n = 245) of participants also rated the helpfulness of SS overall and its treatment components; 3 and 6 months following their first SS group. We also collected qualitative data to inform our understanding of the ways perceived helpfulness varied among participants in peer-led (PL) and clinician-led (CL) groups. Ratings of overall and topic-specific helpfulness were high among both groups, and while ratings were slightly higher among participants in PL groups, the difference was not significant. Participants in PL-SS rated certain treatment components significantly more helpful compared to participants in CL-SS, including the focus on learning coping skills (81.6% PL vs. 64.9% CL, p = .020) and safety as a priority of treatment (81.6% PL vs. 61.5% CL, p = .006). Because of the homogeneity of helpfulness ratings, the relationship between perceived helpfulness and treatment retention and outcomes could not be examined. Future research on this association is warranted. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Economic Impact of the Statewide Implementation of an Evidence-Based Treatment: Multisystemic Therapy in New Mexico.

Several states have made considerable investments into large-scale implementation of evidence-based treatments (EBTs), yet little is known about key success indicators for these implementation efforts such as cost and sustainability. To that end, the present study examined the economic impact of statewide implementation of multisystemic therapy (MST; Henggeler, Schoenwald, Borduin, Rowland, & Cuningham, 2009), a family- and community-based behavioral EBT for serious juvenile offenders in New Mexico. Participants were 1,869 youth who received MST across 23 teams during the study period. We conducted a cost-benefit analysis using metrics from state data sources that compared the cost of MST to its benefits (i.e., avoided expenses from pre- to posttreatment) in two domains: (a) behavioral health services (i.e., Medicaid claims) and (b) juvenile crime (i.e., taxpayer expenses, tangible and intangible expenses to crime victims). MST costs were based on Medicaid claims, which were reimbursed at an enhanced billing rate that was intended to cover expenses for both clinical and implementation (e.g., training, quality assurance) activities. Results suggest that implementation of MST in New Mexico over the 7-year study period may have produced net benefits, through 2 years posttreatment, of more than $4,643 per youth in avoided behavioral health claims and $15,019 per youth through reductions in juvenile crime. Stated differently, every dollar that New Mexico spent on MST appeared to have returned $3.34 for a total benefit of $64.2 million over the course of the study. We discuss implications of these findings for policymakers, administrators, and researchers who are interested in increasing the sustainability of complex EBTs in community settings.

State Legislative Approach to Enumerating Behavioral Health Workforce Shortages: Lessons Learned in New Mexico.

Nationally, the behavioral health workforce is in crisis because of a lack of resources, culturally responsive services, quality clinical supervision, sufficient training in evidence-based practices, and targeted recruitment and retention. Disparities in access to behavioral health care are particularly significant in New Mexico, where 25% of the population live in rural areas, and behavioral health shortages are among the highest in the nation. Additionally, as a Medicaid expansion state, New Mexico providers experience increased demand for services at a time when the state is challenged with limited workforce capacity. To address this issue, the Health Care Work Force Data Collection, Analysis and Policy Act was legislatively enacted in 2011 to systematically survey all state licensed health professionals to determine reasons for the healthcare shortage and address the shortage through policy. The Act was amended in 2012 to transfer all data to the University of New Mexico Health Sciences Center. In 2015, a total of 4,488 behavioral health providers completed a survey as a mandatory part of their license renewal. Findings from the survey indicate a dearth of licensed behavioral health providers representative of the populations served, limited access to services via Medicaid and Medicare payer sources, limited access to providers working in public health settings, and limited access to Health Information Technology. This paper describes the workforce context in New Mexico, the purpose of the legislation, the analytic findings from the survey, the policies implemented as a result of these efforts, lessons learned, and a discussion of the relevancy of the New Mexico model for other states. SUPPLEMENT INFORMATION: This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

Carbapenem-Nonsusceptible Acinetobacter baumannii, 8 US Metropolitan Areas, 2012-2015.

In healthcare settings, Acinetobacter spp. bacteria commonly demonstrate antimicrobial resistance, making them a major treatment challenge. Nearly half of Acinetobacter organisms from clinical cultures in the United States are nonsusceptible to carbapenem antimicrobial drugs. During 2012-2015, we conducted laboratory- and population-based surveillance in selected metropolitan areas in Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee to determine the incidence of carbapenem-nonsusceptible A. baumannii cultured from urine or normally sterile sites and to describe the demographic and clinical characteristics of patients and cases. We identified 621 cases in 537 patients; crude annual incidence was 1.2 cases/100,000 persons. Among 598 cases for which complete data were available, 528 (88.3%) occurred among patients with exposure to a healthcare facility during the preceding year; 506 (84.6%) patients had an indwelling device. Although incidence was lower than for other healthcare-associated pathogens, cases were associated with substantial illness and death.

A longitudinal analysis of peer-delivered permanent supportive housing: Impact of housing on mental and overall health in an ethnically diverse population.

Permanent supportive housing (PSH) is an evidence-based health intervention for persons experiencing homelessness, but the impact of individual mechanisms within this intervention on health requires further research. This study examines the longitudinal impact of the mechanism of supportive housing within a peer-delivered PSH model on overall health and mental health (as measured by psychological distress and self-report of bothersome symptoms) outcomes in an ethnically diverse population. The 237 participants in the study included persons who were homeless or at risk of homelessness and who also had been diagnosed with a serious mental illness. Sixty-one percent of all participants received supportive housing. All 3 outcomes were significantly associated with quality of life indicators, recovery, and social connectedness. In addition, overall health was significantly associated with employment, age, and psychological distress. Psychological distress was associated with gender, type of housing, and history of violence or trauma. Experiencing bothersome symptoms was associated with drug use, history of violence or trauma, and psychological distress. Longitudinal models of these 3 outcomes showed that supportive housing was significantly associated with good to excellent health 6 months after baseline (odds ratio = 3.11, 95% confidence interval [1.12, 8.66]). The models also demonstrated that the supportive housing and comparison groups experienced decreased psychological distress after baseline. The results of this study demonstrate the importance of supportive housing within the context of PSH, particularly for the overall health of participants, and the positive overall impact of PSH on mental health in a diverse population. (PsycINFO Database Record

Sexual Violence Among Youth in New Mexico: Risk and Resiliency Factors That Impact Behavioral Health Outcomes.

Research has consistently demonstrated a relationship between history of forced sex and poor behavioral health outcomes. The objectives of this study were to describe this relationship among high school students and to explore the impact of resiliency factors. Using data from the 2013 New Mexico Youth Risk and Resiliency Survey, we found that history of forced sex was associated with negative behavioral health outcomes for males and females, regardless of sexual orientation and disability status. Furthermore, the presence of a caring adult at home appeared to reduce the risk of substance abuse and suicidality among students with and without a history of forced sex.

Epidemiology of Carbapenem-Resistant Enterobacteriaceae in 7 US Communities, 2012-2013.

IMPORTANCE: Carbapenem-resistant Enterobacteriaceae (CRE) are increasingly reported worldwide as a cause of infections with high-mortality rates. Assessment of the US epidemiology of CRE is needed to inform national prevention efforts. OBJECTIVE: To determine the population-based CRE incidence and describe the characteristics and resistance mechanism associated with isolates from 7 US geographical areas. DESIGN, SETTING, AND PARTICIPANTS: Population- and laboratory-based active surveillance of CRE conducted among individuals living in 1 of 7 US metropolitan areas in Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, and Oregon. Cases of CRE were defined as carbapenem-nonsusceptible (excluding ertapenem) and extended-spectrum cephalosporin-resistant Escherichia coli, Enterobacter aerogenes, Enterobacter cloacae complex, Klebsiella pneumoniae, or Klebsiella oxytoca that were recovered from sterile-site or urine cultures during 2012-2013. Case records were reviewed and molecular typing for common carbapenemases was performed. EXPOSURES: Demographics, comorbidities, health care exposures, and culture source and location. MAIN OUTCOMES AND MEASURES: Population-based CRE incidence, site-specific standardized incidence ratios (adjusted for age and race), and clinical and microbiological characteristics. RESULTS: Among 599 CRE cases in 481 individuals, 520 (86.8%; 95% CI, 84.1%-89.5%) were isolated from urine and 68 (11.4%; 95% CI, 8.8%-13.9%) from blood. The median age was 66 years (95% CI, 62.1-65.4 years) and 284 (59.0%; 95% CI, 54.6%-63.5%) were female. The overall annual CRE incidence rate per 100<000 population was 2.93 (95% CI, 2.65-3.23). The CRE standardized incidence ratio was significantly higher than predicted for the sites in Georgia (1.65 [95% CI, 1.20-2.25]; P < .001), Maryland (1.44 [95% CI, 1.06-1.96]; P = .001), and New York (1.42 [95% CI, 1.05-1.92]; P = .048), and significantly lower than predicted for the sites in Colorado (0.53 [95% CI, 0.39-0.71]; P < .001), New Mexico (0.41 [95% CI, 0.30-0.55]; P = .01), and Oregon (0.28 [95% CI, 0.21-0.38]; P < .001). Most cases occurred in individuals with prior hospitalizations (399/531 [75.1%; 95% CI, 71.4%-78.8%]) or indwelling devices (382/525 [72.8%; 95% CI, 68.9%-76.6%]); 180 of 322 (55.9%; 95% CI, 50.0%-60.8%) admitted cases resulted in a discharge to a long-term care setting. Death occurred in 51 (9.0%; 95% CI, 6.6%-11.4%) cases, including in 25 of 91 cases (27.5%; 95% CI, 18.1%-36.8%) with CRE isolated from normally sterile sites. Of 188 isolates tested, 90 (47.9%; 95% CI, 40.6%-55.1%) produced a carbapenemase. CONCLUSIONS AND RELEVANCE: In this population- and laboratory-based active surveillance system in 7 states, the incidence of CRE was 2.93 per 100<000 population. Most CRE cases were isolated from a urine source, and were associated with high prevalence of prior hospitalizations or indwelling devices, and discharge to long-term care settings.

Epidemiology of Methicillin-Resistant Staphylococcus aureus Bloodstream Coinfection Among Adults With Candidemia in Atlanta, GA, 2008-2012.

BACKGROUND: Patients with candidemia are at risk for other invasive infections, such as methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI). OBJECTIVE: To identify the risk factors for, and outcomes of, BSI in adults with Candida spp. and MRSA at the same time or nearly the same time. DESIGN: Population-based cohort study. SETTING: Metropolitan Atlanta, March 1, 2008, through November 30, 2012. PATIENTS: All residents with Candida spp. or MRSA isolated from blood. METHODS: The Georgia Emerging Infections Program conducts active, population-based surveillance for candidemia and invasive MRSA. Medical records for patients with incident candidemia were reviewed to identify cases of MRSA coinfection, defined as incident MRSA BSI 30 days before or after candidemia. Multivariate logistic regression was performed to identify factors associated with coinfection in patients with candidemia. RESULTS: Among 2,070 adult candidemia cases, 110 (5.3%) had coinfection within 30 days. Among these 110 coinfections, MRSA BSI usually preceded candidemia (60.9%; n=67) or occurred on the same day (20.0%; n=22). The incidence of coinfection per 100,000 population decreased from 1.12 to 0.53 between 2009 and 2012, paralleling the decreased incidence of all MRSA BSIs and candidemia. Thirty-day mortality was similarly high between coinfection cases and candidemia alone (45.2% vs 36.0%, P=.10). Only nursing home residence (odds ratio, 1.72 [95% CI, 1.03-2.86]) predicted coinfection. CONCLUSIONS: A small but important proportion of patients with candidemia have MRSA coinfection, suggesting that heightened awareness is warranted after 1 major BSI pathogen is identified. Nursing home residents should be targeted in BSI prevention efforts.

Querying automated antibiotic susceptibility testing instruments: a novel population-based active surveillance method for multidrug-resistant gram-negative bacilli.

OBJECTIVE: To describe the implementation of a population-based surveillance system for multidrug-resistant gram-negative bacilli (MDR-GNB). DESIGN: Population-based active surveillance by the Georgia Emerging Infections Program. SETTING: Metropolitan Atlanta, starting November 2010. PATIENTS: Residents with MDR-GNB isolated from urine or a normally sterile site culture. METHODS: Surveillance was implemented in 3 phases: (1) surveying laboratory antibiotic susceptibility testing practices, (2) piloting surveillance to estimate the proportion of GNB that were MDR, and (3) maintaining ongoing active surveillance for carbapenem-nonsusceptible Enterobacteriaceae and Acinetobacter baumannii using the 2010 Clinical and Laboratory Standards Institute (CLSI) breakpoints. Pilot surveillance required developing and installing queries for GNB on the 3 types of automated testing instruments (ATIs), such as MicroScan, in Atlanta's clinical laboratories. Ongoing surveillance included establishing a process to extract data from ATIs consistently, review charts, manage data, and provide feedback to laboratories. RESULTS: Output from laboratory information systems typically used for surveillance would not reliably capture the CLSI breakpoints, but queries developed for the 3 ATIs did. In November 2010, 0.9% of Enterobacteriaceae isolates and 35.7% of A. baumannii isolates from 21 laboratories were carbapenem nonsusceptible. Over a 5-month period, 82 Enterobacteriaceae and 59 A. baumannii were identified as carbapenem nonsusceptible. CONCLUSIONS: Directly querying ATIs, a novel method of active surveillance for MDR-GNB, proved to be a reliable, sustainable, and accurate method that required moderate initial investment and modest maintenance. Ongoing surveillance is critical to assess the burden of and changes in MDR-GNB to inform prevention efforts.