Synchronous Telehealth Yoga and Cognitive Processing Group Therapies for Women Veterans with Posttraumatic Stress Disorder: A Multisite Randomized Controlled Trial Adapted for COVID-19.

Background: Providing care over telehealth grew slowly until the COVID-19 pandemic. Since the onset of the COVID-19 pandemic, providing mental health care was readily adapted to virtual means; however, clinical trial research is nascent in adapting methods and procedures to the virtual world. Methods: We present protocol modifications to pivot a multisite randomized controlled trial study, conducted at Southeastern and Pacific Northwestern Veterans Affairs Health Care Systems, from being conducted in-person to virtually, following the onset of the COVID-19 pandemic. We measured outcomes of posttraumatic stress disorder (PTSD) symptoms and psychophysiological markers of stress among female Veterans with PTSD secondary to military sexual trauma. We collected qualitative data about provider and participant experiences with telehealth. Results: Across sites, 200 participants were consented (48 virtually), 132 were randomized (28 to virtual groups), and 117 completed data collection and treatment (69 completed all or some data collection or treatment virtually). Conclusions: The pivots made for this study were in response to the COVID-19 pandemic and offer innovative procedures leveraging technology and contributing to the broader landscape of conducting research virtually. Clinical Trials Number: NCT02640690.

Yoga vs Cognitive Processing Therapy for Military Sexual Trauma-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial.

Importance: First-line treatment for posttraumatic stress disorder (PTSD) in the US Department of Veterans Affairs (VA), ie, trauma-focused therapy, while effective, is limited by low treatment initiation, high dropout, and high treatment refraction. Objective: To evaluate the effectiveness of Trauma Center Trauma-Sensitive Yoga (TCTSY) vs first-line cognitive processing therapy (CPT) in women veterans with PTSD related to military sexual trauma (MST) and the hypothesis that PTSD outcomes would differ between the interventions. Design, Setting, and Participants: This multisite randomized clinical trial was conducted from December 1, 2015, to April 30, 2022, within 2 VA health care systems located in the southeast and northwest. Women veterans aged 22 to 71 years with MST-related PTSD were enrolled and randomized to TCTSY or CPT. Interventions: The TCTSY intervention (Hatha-style yoga focusing on interoception and empowerment) consisted of 10 weekly, 60-minute group sessions, and the CPT intervention (cognitive-based therapy targeting modification of negative posttraumatic thoughts) consisted of 12 weekly, 90-minute group sessions. Main Outcome and Measures: Sociodemographic data were collected via self-report survey. The primary outcome, PTSD symptom severity, was assessed using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and PTSD Checklist for DSM-5 (PCL-5). Assessments were conducted at baseline, midintervention, 2 weeks post intervention, and 3 months post intervention. Results: Of 200 women veterans who consented to participate, the intent-to-treat sample comprised 131 participants (mean [SD] age, 48.2 [11.2] years), with 72 randomized to TCTSY and 59 randomized to CPT. Treatment was completed by 47 participants (65.3%) in the TCTSY group and 27 (45.8%) in the CPT group, a 42.6% higher treatment completion rate in the TCTSY group (P = .03). Both treatment groups improved over time on the CAPS-5 (mean [SD] scores at baseline: 36.73 [8.79] for TCTSY and 35.52 [7.49] for CPT; mean [SD] scores at 3 months: 24.03 [11.55] for TCTSY and 22.15 [13.56]) and the PCL-5 (mean [SD] scores at baseline: 49.62 [12.19] for TCTSY and 48.69 [13.62] for CPT; mean [SD] scores at 3 months: 36.97 [17.74] for TCTSY and 31.76 [12.47]) (P < .001 for time effects). None of the group effects or group-by-time effects were significant. Equivalence analyses of change scores were not significantly different between the TCTSY and CPT groups, and the two one-sided test intervals fell within the equivalence bounds of plus or minus 10 for CAPS-5 for all follow-up time points. Conclusions and Relevance: In this comparative effectiveness randomized clinical trial, TCTSY was equivalent to CPT in reducing PTSD symptom severity, with both groups improving significantly. The higher treatment completion rate for TCTSY indicates its higher acceptability as an effective and acceptable PTSD treatment for women veterans with PTSD related to MST that could address current VA PTSD treatment limitations. Trial Registration: ClinicalTrials.gov Identifier: NCT02640690.

Retention Strategies for Medications for Opioid Use Disorder in Adults: A Rapid Evidence Review.

OBJECTIVES: Although medications for opioid use disorder (MOUD) save lives, treatment retention remains challenging. Identification of interventions to improve MOUD retention is of interest to policymakers and researchers. On behalf of the Agency for Healthcare Research and Quality, we conducted a rapid evidence review on interventions to improve MOUD retention. METHODS: We searched MEDLINE and the Cochrane Library from February 2009 through August 2019 for systematic reviews and randomized trials of care settings, services, logistical support, contingency management, health information technology (IT), extended-release (XR) formulations, and psychosocial interventions that assessed retention at least 3 months. RESULTS: Two systematic reviews and 39 primary studies were included; most did not focus on retention as the primary outcome. Initiating MOUD in soon-to-be-released incarcerated people improved retention following release. Contingency management may improve retention using antagonist but not agonist MOUD. Retention with interventions integrating medical, psychiatric, social services, or IT did not differ from in-person treatment-as-usual approaches. Retention was comparable with XR- compared to daily buprenorphine formulations and conflicting with XR-naltrexone monthly injection compared to daily buprenorphine. Most psychosocial interventions did not improve retention. DISCUSSION: Consistent but sparse evidence supports criminal justice prerelease MOUD initiation, and contingency management interventions for antagonist MOUD. Integrating MOUD with medical, psychiatric, social services, delivering through IT, or administering via XR-MOUD formulations did not worsen retention. Fewer than half of the studies we identified focused on retention as a primary outcome. Studies used different measures of retention, making it difficult to compare effectiveness. Additional inquiry into the causes of low retention would inform future interventions.Registration: PROSPERO: CRD42019134739.

Rectal Foreign Body Removal in the Emergency Department: A Case Report.

INTRODUCTION: Rectal foreign bodies (RFB) pose a challenge to emergency physicians. Patients are not often forthcoming, which can lead to delays to intervention. Thus, RFBs require a heightened clinical suspicion. In the emergency department (ED), extraction may require creative methods to prevent need for surgical intervention. CASE REPORT: The authors present a case of a successful extraction of a RFB in the ED and review of the literature. CONCLUSION: Retained RFBs are an unusually problematic reason for an ED visit. Thus, it is important for emergency physicians to be comfortable managing such cases appropriately.