Implementation of a countywide adult suicide review commission: Development, lessons learned, and recommendations.

INTRODUCTION: Fatality review is a public health approach designed to inform efforts to prevent fatalities of a certain kind (e.g., suicide, homicide) or in a specific setting or population (e.g., hospitals, youth). Despite extensive literature on fatality review generally, the literature on suicide review teams specifically is scant. The aim of this paper is to: describe the implementation of a local adult suicide review commission, detail examples of initial outcomes and recommendations developed by the commission, and provide recommendations and/or best practices for how to develop and implement an adult suicide review team. METHODS: We utilize framing questions from the American Association of Suicidology's psychological autopsy framework. By using these guiding questions in the discussion, members are invited to explore not only the stressors that may have more immediately preceded the suicide event itself, but to situate those stressors in the context of the individual's life course. RESULTS: Several recommendations proposed by our commission have resulted in tangible outcomes and are detailed using Haddon's Matrix as a guiding prevention planning tool. IMPLICATIONS: We have highlighted the need to move beyond looking at individual-level help-seeking to focus on structural/systemic issues that result in stress or create unsafe environments for at-risk individuals.

Early venous thromboembolism chemoprophylaxis in traumatic brain injury requiring neurosurgical intervention: Safe and effective.

BACKGROUND: Traumatic brain injury patients who require neurosurgical intervention are at the highest risk of worsening intracranial hemorrhage. This subgroup of patients has frequently been excluded from prior research regarding the timing of venous thromboembolism chemoprophylaxis. This study aims to assess the efficacy and safety of early venous thromboembolism chemoprophylaxis in patients with traumatic brain injuries requiring neurosurgical interventions. METHODS: This is a single-center retrospective review (2016-2020) of traumatic brain injury patients requiring neurosurgical intervention admitted to a level I trauma center. Interventions included intracranial pressure monitoring, subdural drain, external ventricular drain, craniotomy, and craniectomy. Exclusion criteria included neurosurgical intervention after chemoprophylaxis initiation, death within 5 days of admission, and absence of chemoprophylaxis. The total population was stratified into Early (≤72 hours of intervention) versus Late (>72 hours after intervention) chemoprophylaxis initiation. RESULTS: A total of 351 patients met the inclusion criteria, of whom 204 (58%) had early chemoprophylaxis initiation. Overall, there were no significant differences in baseline and admission characteristics between cohorts. The Early chemoprophylaxis cohort had a statistically significant lower venous thromboembolism rate (5% vs 13%, P < .001) with no increased risk of worsening intracranial hemorrhage (10% vs 13%, P = .44) or neurosurgical reintervention (8% vs 10%, P = .7). On subgroup analysis, a total of 169 patients required either a craniotomy or a craniectomy before chemoprophylaxis. The Early chemoprophylaxis cohort had statistically significant lower venous thromboembolism rates (2% vs 11%, P < .001) with no increase in intracranial hemorrhage (8% vs 11%, P = .6) or repeat neurosurgical intervention (8% vs 10%, P = .77). CONCLUSION: Venous thromboembolism prophylaxis initiation within 72 hours of neurosurgical intervention is safe and effective. Further prospective research is warranted to validate the results of this study.

Predictive Factors for the Application of Pelvic Binders in the Prehospital Setting.

OBJECTIVES: Early pelvic binder placement in the field stabilizes pelvic fractures and tamponades potential hemorrhage within the pelvis. Despite known risk factors for pelvic fracture, it remains challenging to quickly triage and correctly apply a pelvic binder. We aim to develop a prediction model that exclusively uses prehospital criteria to inform the decision to place a pelvic binder. METHODS: The trauma registry was used to identify all trauma patients admitted to an urban Level I trauma center between January 2013 and December 2017. Variables collected included patient demographics, mechanism of injury, prehospital vital signs, and the presence of a pelvic fracture. Participants were randomly assigned to a training group (70%) or a validation group (30%). Univariate analyses were used to identify significant predictors for use in multivariate predictive models. RESULTS: A total of 8,480 (65% male; median age 49; median ISS 9) and 3,676 (65% male; median age 48; median ISS 9) trauma patients were randomly assigned to the training and validation groups, respectively. Univariate analysis showed significant likelihood of pelvic fracture associated with female sex, hemodynamic instability (initial systolic blood pressure < 90 mmHg), blunt injury type, specific mechanisms of injury (motor vehicle collision, motorcycle collision, pedestrian struck by motor vehicle, crushing injury, and riding an animal), impact location, and position in vehicle. Multivariate models adjusting for blunt type injury, hemodynamic instability, impact location, and position in vehicle showed that presence of two or more of these risk factors is significantly associated with presence of pelvic fracture. CONCLUSION: Establishing select prehospital criteria for the empiric application of pelvic binders for patients in the field with blunt injuries, hemodynamic instability, frontal or side motor vehicle collision impact, and non-front seat passenger may improve outcomes among patients with pelvic fractures.

Trends in Adult Suicide Rates in Milwaukee County, Wisconsin, 2002 through 2020.

BACKGROUND: Monitoring suicide rates is an important public health strategy to inform prevention efforts. We describe rates of adult suicide in Milwaukee County, Wisconsin, over a 19-year period. METHODS: Data on all adult suicides from 2002 through 2020 (n = 981) were obtained from the Milwaukee County Medical Examiner's Office. Subpopulation rates were identified using the Wisconsin Interactive Statistics on Health System. RESULTS: Suicide rates increased significantly over the study period, with disproportionate increases among Black and Latinx residents. DISCUSSION: Expanded prevention efforts are needed to reverse this concerning trend. Further research should guide development of culturally relevant interventions, provide data for the equitable allocation of limited resources.

Suicide Data in Trauma Centers: Implications of Imprecision.

BACKGROUND: Trauma registries exist to provide data for evaluating the quality of care of trauma patients. These data facilitate research and can be used for outreach, planning, and improvement in trauma patient outcomes. However, the accuracy of registry data related to suicide has not been well studied. OBJECTIVE: This study sought to evaluate the accuracy of current trauma registry coding practices related to labeling injury as a suicide attempt among patients presenting to a Level I trauma center after self-inflicted injury. METHODS: We conducted a single-center, retrospective cohort analysis of a Level I trauma center trauma registry on all patients with self-inflicted injuries from 2011 to 2021. Manual chart review was used to identify cases wherein patients' injuries were categorized as suicidal despite the absence of suicidal intent. RESULTS: During this 11-year period, 537 patients were identified as having presented to the trauma center for traumatic self-inflicted injuries. Manual chart review revealed that 16% of these patients were incorrectly categorized as having attempted suicide despite their self-inflicted injury lacking suicidal intent (e.g., accidents, nonsuicidal self-harm). CONCLUSION: We found that 16% of trauma registry patients were overcategorized as having attempted suicide. Trauma registry data are an important source of information for activities related to injury prevention in trauma centers. Imprecise coding of self-inflicted injury may lead to poorly targeted programs and interventions due to incorrectly represented injury causes and patterns in trauma patient populations, including suicide prevention.

Psychiatric comorbidity in emergency general surgery patients: a prospective observational study.

Objectives: Annually, approximately 27 million individuals in the United States are admitted to hospitals for emergency general surgery (EGS). Approximately 50% develop postoperative complications and 22% require unplanned readmission within 90 days, highlighting a need to understand factors impacting well-being and recovery. Psychiatric comorbidity can impact medical treatment adherence, cost, and premature mortality risk. Despite the severity of illness in EGS, there is limited research on psychiatric comorbidity in EGS patients. Thus, the purpose of the current study was to characterize EGS patient mental health and to assess its relationship with pain, social support, and healthcare utilization (ie, length of stay, readmission). Methods: Adult EGS patients were screened for participation during hospitalization. Inclusion criteria included: (1) 18 years or older, (2) communicate fluently in English, and (3) assessed within 7 days of admission. Participants (n=95) completed assessment, which included a structured clinical diagnostic interview. Record review captured medical variables, including length of stay, discharge disposition, narcotic prescription, and 90-day readmission rates. Results: Ninety-five patients completed the assessment, and 31.6% met criteria for at least one current psychiatric diagnosis; 21.3% with a major depressive episode, 9.6% with a substance use disorder, and 7.5% with post-traumatic stress disorder (PTSD). Lower perceived social support and greater pain severity and interference were significantly related to more severe depression and anxiety. Depression was associated with longer length of stay, and those with PTSD were more likely to be re-admitted. Conclusion: The EGS patient sample exhibited psychiatric disorder rates greater than the general public, particularly regarding depression and anxiety. Screening protocols and incorporation of psychological and social interventions may assist in recovery following EGS. Level of evidence: Level II, prognostic.

Screening and intervention for intimate partner violence at trauma centers and emergency departments: an evidence-based systematic review from the Eastern Association for the Surgery of Trauma.

Background: Intimate partner violence (IPV) is a serious public health issue with a substantial burden on society. Screening and intervention practices vary widely and there are no standard guidelines. Our objective was to review research on current practices for IPV prevention in emergency departments and trauma centers in the USA and provide evidenced-based recommendations. Methods: An evidence-based systematic review of the literature was conducted to address screening and intervention for IPV in adult trauma and emergency department patients. The Grading of Recommendations, Assessment, Development and Evaluations methodology was used to determine the quality of evidence. Studies were included if they addressed our prespecified population, intervention, control, and outcomes questions. Case reports, editorials, and abstracts were excluded from review. Results: Seven studies met inclusion criteria. All seven were centered around screening for IPV; none addressed interventions when abuse was identified. Screening instruments varied across studies. Although it is unclear if one tool is more accurate than others, significantly more victims were identified when screening protocols were implemented compared with non-standardized approaches to identifying IPV victims. Conclusion: Overall, there were very limited data addressing the topic of IPV screening and intervention in emergency medical settings, and the quality of the evidence was low. With likely low risk and a significant potential benefit, we conditionally recommend implementation of a screening protocol to identify victims of IPV in adults treated in the emergency department and trauma centers. Although the purpose of screening would ultimately be to provide resources for victims, no studies that assessed distinct interventions met our inclusion criteria. Therefore, we cannot make specific recommendations related to IPV interventions. PROSPERO registration number: CRD42020219517.

Facets of emotion dysregulation differentially predict depression and PTSD symptom severity following traumatic injury.

Background: Emotion dysregulation is a hallmark characteristic of psychopathology following trauma. Yet, emotion dysregulation is multifaceted, and little is known about which aspects of emotion dysregulation predict depression and posttraumatic stress disorder (PTSD) symptom severity following traumatic injury.Objective: The aim of this longitudinal study was to evaluate how facets of dysregulation differentially predicted the severity of PTSD symptom clusters and depressive symptoms six months after a traumatic injury requiring medical treatment.Methods: Traumatically injured adults (N = 99) presenting to a Level 1 trauma centre completed a measure of emotion dysregulation 2 weeks post-injury, and PTSD and depression were assessed at 2-weeks and 6 months later.Results: Using stepwise regressions controlling for baseline symptoms, age, gender, race, and injury severity, results showed baseline emotion dysregulation significantly predicted the four symptom clusters of PTSD 6 months post-injury. Notably, hyperarousal symptoms and negative alterations in mood and cognition were predicted by a lack of clarity. On the other hand, depressive symptoms were significantly predicted by difficulty accessing emotion regulation strategies.Conclusion: Results highlight that specific facets of emotion dysregulation predict PTSD and depression symptom severity differentially after injury. Indeed, lack of emotional clarity appears to predict PTSD symptomatology, suggesting a potential mechanism driving worsening symptoms. Lack of clarity could also be detrimental to engagement in PTSD treatment. Conversely, lack of regulation strategies may represent a sense of helplessness in managing depression after trauma. As such, future research should elucidate whether interventions targeting aspects of emotion dysregulation based on symptom presentations are useful in treating PTSD and depression following injury.

Specific facets of emotion dysregulation are differentially associated with PTSD symptom clusters and depression symptom severity after injury.Findings suggest that targeting lack of emotional clarity may be critical for patients with prominent hyperarousal and trauma-related changes in mood and cognitions (i.e. two PTSD symptom clusters).Patients with depressive symptoms following trauma may especially benefit from the development of emotion regulation strategies.

Comprehensive Framework of Firearm Violence Survivor Care: A Review.

Importance: Firearm violence is a public health crisis placing significant burden on individuals, communities, and health care systems. After firearm injury, there is increased risk of poor health, disability, and psychopathology. The newest 2022 guidelines from the American College of Surgeons Committee on Trauma require that all trauma centers screen for risk of psychopathology and provide referral to intervention. Yet, implementing these guidelines in ways that are responsive to the unique needs of communities and specific patient populations, such as after firearm violence, is challenging. Observations: The current review highlights important considerations and presents a model for trauma centers to provide comprehensive care to survivors of firearm injury. This model highlights the need to enhance standard practice to provide patient-centered, trauma-informed care, as well as integrate inpatient and outpatient psychological services to address psychosocial needs. Further, incorporation of violence prevention programming better addresses firearm injury as a public health concern. Conclusions and Relevance: Using research to guide a framework for trauma centers in comprehensive care after firearm violence, we can prevent complications to physical and psychological recovery for this population. Health systems must acknowledge the socioecological context of firearm violence and provide more comprehensive care in the hospital and after discharge, to improve long-term recovery and serve as a means of tertiary prevention of firearm violence.

Disparities in disposition from trauma centers to inpatient psychiatric treatment in a national sample of patients with self-inflicted injury.

BACKGROUND: Surgery providers are integral to the treatment of patients with self-inflicted injuries. Patient disposition (eg, home, inpatient psychiatric treatment, rehabilitation) is important to long-term outcomes, but little is known about factors influencing disposition after discharge following traumatic self-inflicted injury. We tested whether patient or injury characteristics were associated with disposition after treatment for self-inflicted injury. METHODS: National Trauma Data Bank query for self-inflicted injuries from 2010 to 2018. RESULTS: There were 77,731 patients treated for self-inflicted injuries during the study period. Discharge home was the most common disposition (45%), and those without insurance were less likely to discharge to inpatient psychiatric treatment than those with insurance. Racial minority patients were less likely to discharge to inpatient psychiatric treatment (18.9%) than nonminority patients (23.8%, P < .001). Additionally, patients discharged to inpatient psychiatric treatment had significantly lower injury severity score (7.24 ± 7.5) than those who did not (8.69 ± 9.1, P < .001). CONCLUSION: Racial/ethnic minority patients and those without insurance were significantly less likely to discharge to an inpatient psychiatric facility after treatment at a trauma center for self-inflicted injury. Future research is needed to evaluate the internal factors (eg, trauma center practices) and external factors (eg, inpatient psychiatric facilities not accepting patients with wound care needs) driving disposition variability.

Life threat during assaultive trauma: Critical posttraumatic stress disorder risk factors for injured patients.

BACKGROUND: Rates of posttraumatic stress disorder (PTSD) among injury survivors are higher relative to the general population, supporting the need to identify those most at risk for PTSD following injury given negative impact of PTSD on recovery. Perceived life threat and assaultive trauma are consistent risk factors for subsequent PTSD development, although less work has explored them in combination. The current study evaluated whether trauma type (assaultive vs. nonassaultive) and perceived life threat, together, led to greater PTSD symptoms 1 month and 6 months postinjury. METHODS: Participants included adult injured trauma survivors admitted to a level 1 trauma center. While hospitalized, perceived life threat during trauma was assessed and mechanism of injury was collected via record review and was collapsed into two categories: assaultive and nonassaultive. The Clinician-Administered PTSD Scale (Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]) was administered at 1 month (N = 137) and 6 months (N = 220) after injury. RESULTS: The four symptoms clusters of PTSD (intrusions, avoidance, hyperarousal, and negative mood/cognitions) were examined using four 2 (time) × 2 (life threat) × 2 (trauma type) mixed methods analyses of variance to assess differences based on risk factors and time. Results showed significant interaction effects of life threat, trauma type, and time for intrusive symptoms and avoidance symptoms. Individuals with life threat during assaultive traumas maintained heightened intrusive symptoms across time and increased avoidance at 6 months. On the other hand, participants with either life threat or assaultive traumas had decreased symptoms at 6 months. CONCLUSION: Experiencing assaultive trauma and life threat led to greater symptoms of PTSD. Individuals with assaultive traumas who experienced life threat may represent a specific at-risk group following injury. Avoidance can protract functional impairment and impede access to care, negatively impacting recovery. This study highlights a need to assess for these peritrauma factors during hospitalization and supports early intervention targeting avoidance and intrusive symptoms in this group. LEVEL OF EVIDENCE: Prognostic/Epidemiologic, Level IV.

Farmer Suicide in Wisconsin: A Qualitative Analysis.

PURPOSE: There is a need to address suicide among farmers in the United States and understand what contributes to suicide among American farmers. The purpose of this qualitative study is to analyze narrative data to uncover circumstances that were present in the lives of farmers who died by suicide. METHODS: This study leverages data available in the National Violent Death Reporting System. For this study, we examined all suicides that occurred in Wisconsin between the years 2012 and 2016 and were extracted from the Wisconsin Violent Death Reporting System. Decedents were manually sorted by the "usual occupation" variable in order to identify farmers. FINDINGS: During the study period, 73 farmers died, most of whom were White, non-Hispanic males. Four themes were identified in the thematic analysis: stymied by physical health issues, grief from loss of relationships, ready access to firearms in rural Wisconsin, and the burden of farming and the farm. CONCLUSIONS: The findings from this study demonstrate how unique contextual factors lead to suicide among farmers. This study has implications for suicide prevention among farmers. Primarily, there is a need to address the accessibility of firearms, as their availability in a time of crisis has lethal consequences. However, suicide prevention programming that addresses access to lethal means must take the sociocultural context of rural America into consideration. These findings should also be considered as applied to health care providers that serve rural communities. Suicide risk assessment and management should consider stressors unique to farmers.

Qualitative investigation of factors impacting pre-exposure prophylaxis initiation and adherence in sexual minority men.

INTRODUCTION: Men who have sex with men continue to account for the majority of new HIV infections in the United States. Many of those with new infections are unaware that they have HIV. Preventative measures continue to be essential in reducing new infections, with pre-exposure prophylaxis (PrEP) being widely recommended. OBJECTIVES: The overall aim of this qualitative study is to explore the impact of stigma, patient-provider dynamics and patient perception of PrEP on men's engagement with PrEP in a primary care setting. METHODS: The Consensual Qualitative Research Methodology (Hill, 2012) was used to explore the experiences of 14 men receiving care for PrEP at a Family Medicine clinic in the Midwest. Semistructured interviews were conducted to allow for depth of understanding of individuals' experience. RESULTS: Four major domains were identified: motivation to pursue PrEP, barriers and adherence to care, beliefs about how PrEP is perceived by others and experiences discussing sexual health and PrEP with providers. CONCLUSION: It is important to better understand factors contributing to the pursuit of and adherence to HIV prevention measures and HIV care. Further, health systems and providers are encouraged to consider opportunities in terms of how their practice can destigmatize PrEP use and offer a welcoming environment for those pursuing HIV prevention. PATIENT OR PUBLIC CONTRIBUTION: Patients were involved in the study through their participation in semistructured interviews, which provided the data analysed for this study. There was no additional participation beyond the one-time interview or follow-up poststudy. Their interviews helped contribute to our better understanding of the needs and experiences of those receiving PrEP-related care.

Validation of the Injured Trauma Survivor Screen: An American Association for the Surgery of Trauma multi-institutional trial.

BACKGROUND: Psychological distress is common following a traumatic injury event. The Injured Trauma Survivor Screen (ITSS) was developed at a level 1 trauma center to assess for posttraumatic stress disorder (PTSD) and major depressive episode (MDE) following admission for a traumatic injury. The ITSS sensitivity and specificity were analyzed 1 to 3 and 6 to 9 months postinjury to test the validity across trauma centers. METHOD: Four level 1 trauma centers from the East, Midwest, South, and West in the United States recruited 375 eligible adult inpatients (excluded participants included those with moderate or severe traumatic brain injury, whose injury was self-inflicted, were noncommunicative, or were non-English speaking). Baseline sample (White/Caucasian, 63.2%; male, 62.4%; mean (SD) age, 45 (17.11) years; injured by motor vehicle collision, 42.4%) measurements were conducted during index hospitalization. At first follow-up, 69.6% (n = 261) were retained; at second follow-up, 61.3% (n = 230) were retained. Measurements included the ITSS, PTSD Checklist for DSM-5, Center for Epidemiologic Studies Depression Scale-Revised, and Clinician-Administered PTSD Scaled for DSM 5. RESULTS: At follow-up 1, the ITSS PTSD subscale had a sensitivity of 75% and specificity of 78.8%, and the MDE subscale had a sensitivity of 80.4% and specificity of 65.6%. At follow-up 2, the PTSD subscale had a sensitivity of 72.7% and specificity of 83.1%, and the MDE subscale had a sensitivity of 76.1% and specificity of 68.3%. A combined risk group using two symptom based measures administered at baseline produced increased specificity. CONCLUSION: The nine-item ITSS continues to be an efficient and effective risk screen for PTSD and MDE following traumatic injury requiring hospitalization. This multi-institutional validation study creates a solid foundation for further exploration of the generalizability of this screen's psychometric properties in distinct populations. LEVEL OF EVIDENCE: Prognostic study, level III.

Racial Discrimination is Associated with Acute Posttraumatic Stress Symptoms and Predicts Future Posttraumatic Stress Disorder Symptom Severity in Trauma-Exposed Black Adults in the United States.

In the United States, Black residents exposed to a traumatic event are at an increased risk of developing posttraumatic stress disorder (PTSD) and experiencing more severe symptoms compared to their non-Hispanic White counterparts. Although previous work has suggested a link between racial discrimination and PTSD symptoms, no studies have assessed this association in a sample of traumatic injury survivors. The current study investigated whether (a) past racial discrimination was associated with acute posttraumatic stress symptoms (PTSS) and (b) discrimination prospectively contributed to the prediction of future PTSD symptoms. African American and/or Black patients (N = 113) were recruited from an emergency department in southeastern Wisconsin. Patients in the acute postinjury phase (i.e., 2 weeks posttrauma) completed self-report measures, with PTSD symptoms assessed using the Clinician-Administered PTSD Scale at 6-month follow-up. Bivariate associations indicated past racial discrimination was significantly related to acute PTSS. A multiple regression analysis revealed that pretrauma exposure to racial discrimination significantly predicted PTSD symptoms at follow-up, even after controlling for age, gender, previous psychiatric diagnosis, social support, and lifetime trauma history. Our results suggest that experiences of racial discrimination add significant additional risk for PTSD symptom development following traumatic injury, R2 = .16, F(6, 106) = 3.25, p = .006. Broadly, these findings add to the body of empirical evidence and personal testimonies of Black individuals in White-centric societies asserting that racial discrimination affects mental health and overall well-being and further highlight the recent call for racism to be classified as a public health crisis.

Experiential avoidance in adolescents with borderline personality disorder: comparison with a non-BPD psychiatric group and healthy controls.

Previous research has identified experiential avoidance (EA) as related to a host of adolescent internalizing and externalizing problems, as well as borderline personality disorder, suggesting that it is a crosscutting factor for adolescent psychopathology. It remains unclear whether EA differs among adolescents with BPD compared to adolescents with other psychiatric disorders and healthy adolescents. The aims of this study were to 1) examine EA in adolescents with BPD compared to non-BPD inpatient adolescents and healthy adolescents, and 2) to evaluate whether EA has a unique relationship to borderline pathology over and above internalizing and externalizing. Self-report measures of BPD features, EA, and psychopathology were completed by 692 adolescents (64.5% female, Mage= 15.20). This sample included a group of psychiatric inpatient youth (n = 197 BPD; n = 403 non-BPD) and a group of healthy adolescents (n = 92). Results revealed that EA differed significantly across all three groups, with the highest level of EA evidenced in adolescents who had BPD. Furthermore, there was a significant, unique association between BPD symptoms and EA over afnd above internalizing and externalizing pathology. These findings pinpoint EA as an important risk marker and possible target of prevention or intervention for adolescent BPD.

Physicians' Preferences for Communication of Pharmacist-Provided Medication Therapy Management in Community Pharmacy.

OBJECTIVES: (1) To identify physicians' preferences in regard to pharmacist-provided medication therapy management (MTM) communication in the community pharmacy setting; (2) to identify physicians' perceived barriers to communicating with a pharmacist regarding MTM; and (3) to determine whether Missouri physicians feel MTM is beneficial for their patients. METHODS: A cross-sectional prospective survey study of 2021 family and general practice physicians registered with MO HealthNet, Missouri's Medicaid program. RESULTS: The majority (52.8%) of physicians preferred MTM data to be communicated via fax. Most physicians who provided care to patients in long-term care (LTC) facilities (81.0%) preferred to be contacted at their practice location as opposed to the LTC facility. The greatest barriers to communication were lack of time and inefficient communication practices. Improved/enhanced communication was the most common suggestion for improvement in the MTM process. Approximately 67% of respondents reported MTM as beneficial or somewhat beneficial for their patients. CONCLUSIONS: Survey respondents saw value in the MTM services offered by pharmacists. However, pharmacists should use the identified preferences and barriers to improve their currently utilized communication practices in hopes of increasing acceptance of recommendations. Ultimately, this may assist MTM providers in working collaboratively with patients' physicians.

Rural health systems' perceptions of referral to community pharmacists during transitions of care.

OBJECTIVES: To identify rural health systems' perceptions of value, benefits, barriers, and opportunities associated with community pharmacist involvement in patient transitions of care. SETTING: Rural health systems in northwest and central Missouri. PRACTICE DESCRIPTION AND INNOVATION: Qualitative descriptive study of key informant interviews with self-identified decision makers of rural health systems within a 50-mile radius of 15 independent community pharmacy chain locations. EVALUATION: Interviews were recorded, transcribed, and coded to evaluate themes in participant responses. RESULTS: Fifteen interviews were conducted at 8 rural health systems. Participants expressed significant value in community pharmacist involvement in transitions of care and highlighted several benefits, barriers, and opportunities related to potential collaboration. Benefits that were identified included medication monitoring, resource for patient information, and desire among health care providers to work with community pharmacists. Barriers included legal and regulatory issues with referral, communication, and prescriber utilization. Opportunities described included: patient education, monitoring, and follow-up; targeted interventions; medication access assistance; bedside medication delivery; and collaboration between community pharmacies and health care entities. CONCLUSION: Rural health system informants perceived community pharmacy involvement to be valuable and were receptive to collaboration during transitional care to improve patient outcomes. They highlighted barriers to overcome to truly incorporate community pharmacists into the transitional care arena. Understanding these rural health systems' perceptions can guide community pharmacies in developing collaborative relationships and patient care services to assist with care transitions.

First empirical evaluation of the link between attachment, social cognition and borderline features in adolescents.

OBJECTIVE: Several developmental models of borderline personality disorder (BPD) emphasize the role of disrupted interpersonal relationships or insecure attachment. As yet, attachment quality and the mechanisms by which insecure attachment relates to borderline features in adolescents have not been investigated. In this study, we used a multiple mediational approach to examine the cross-sectional interplay between attachment, social cognition (in particular hypermentalizing), emotion dysregulation, and borderline features in adolescence, controlling for internalizing and externalizing symptoms. METHODS: The sample included 259 consecutive admissions to an adolescent inpatient unit (Mage=15.42, SD=1.43; 63.1% female). The Child Attachment Interview (CAI) was used to obtain a dimensional index of overall coherence of the attachment narrative. An experimental task was used to assess hypermentalizing, alongside self-report measures of emotion dyregulation and BPD. RESULTS: Our findings suggested that, in a multiple mediation model, hypermentalizing and emotion dysregulation together mediated the relation between attachment coherence and borderline features, but that this effect was driven by hypermentalizing; that is, emotion dysregulation failed to mediate the link between attachment coherence and borderline features while hypermentalizing demonstrated mediational effects. CONCLUSIONS: The study provides the first empirical evidence of well-established theoretical approaches to the development of BPD.