Cost Analysis of Integrated Behavioral Health in a Large Primary Care Practice.

A residency-based Family Medicine outpatient clinic chose to implement an integrated behavioral health care program in a large primary care clinic in the Southeast to improve patient access to behavioral health care. We hypothesized that embedding a BHP in a primary care setting would be a cost neutral intervention. We implemented a prospective cohort design and included expenses from both inpatient and outpatient visits. We implemented a mixed effects linear regression model to evaluate pre- and post-BHP exposure costs. A total of 1256 patients were identified in the post-BHP exposure period that had more than one-year post-exposure. After applying exclusion criteria, there were 926 patients included in analysis. These patient had an average total cost during the one-year pre-BHP exposure period of $5113 (SD = 7712) and one-year post-BHP exposure period of $5462 (SD = 7813). Our analysis shows a relatively cost neutral impact following the introduction of BHPs in a primary care setting. The results of this study provide a gauge for future planning of services.

Patient experience of an integrated care model in a family practice clinic & FQHC.

In order to investigate the patient experience of integrated behavioral health care in primary care settings, we implemented a patient cohort model from a combined site sample (N = 727) consisting of a family practice clinic and a Federally Qualified Health Center. Patient experience was measured using 12 questions from a validated measure, the Agency for Healthcare Research and Quality's Consumer Assessment of Health Care Providers and Systems (CAHPS®), Home and Community Based Services version, and six additional questions about interactions with an integrated behavioral health care team. We assessed bivariate relationships between satisfaction with integration and the clinic practice and self-reported physical health or self-reported mental/emotional health. We also utilized multiple regression to evaluate this relationship. Our analyses showed a statistically significant and small to moderate direct correlation between patients' self-reported health (both physical and mental/emotional health) and their ratings of the practice as a whole (p = .0003), such that patients who rated their physical and/or mental/emotional health as better were more likely to rate their overall satisfaction with the practice higher. The results of this study suggest that primary care patients with only mild to moderate health conditions (physical and/or mental/emotional) may experience greater satisfaction with integrated behavioral health care than patients with multiple and/or severe health conditions. In contrast, patients with multiple and/or severe health conditions may experience lower satisfaction with integrated behavioral health care and may be better served through higher levels of care.

Medical provider satisfaction with integrated care in a pediatric gastroenterology clinic.

INTRODUCTION: Benefits of behavioral health (BH) integrated care (IC) in pediatric primary care have been demonstrated (Asarnow et al., 2015). Pediatric subspecialty care treats patients with high levels of medical and psychosocial vulnerability and complexity (Samsel et al., 2017), underscoring the need for increased IC. Medical provider satisfaction (MPS) with IC is highly relevant for the utilization and expansion of these services. The purpose of this preliminary study was to examine MPS related to BH IC services in a pediatric gastroenterology clinic. METHOD: Eight pediatric gastroenterology providers working in an outpatient clinic completed a 32-item survey (adapted from Corso et al., 2016) assessing their satisfaction with integrated BH care services. Descriptive statistics were utilized to examine and summarize provider satisfaction data. RESULTS: Pediatric gastroenterology medical providers reported high levels of satisfaction with existing IC services and a preference for embedded versus colocated IC. They perceived provider-related and clinical benefits of IC, felt that addressing BH issues is important, and believed IC is a valued service. Medical providers expressed that they wanted expanded IC services, including an embedded psychologist at more locations, BH screenings for younger patients, and an electronic psychosocial screening process. DISCUSSION: The results of this study align with research findings regarding high medical provider satisfaction with IC in primary care and a preference for embedded BH services (Asarnow et al., 2015). While this preliminary study is small in scale, it is an important initial step to better understand MPS with IC in pediatric subspecialty care. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Video review of family medicine resident clinical encounters: a tool for building emotional intelligence.

Video Review (VR) is a well established educational tool for developing the practice of patient-centered care in family medicine residents. There are a number of behaviorally-based checklists that can be use in both live observation as well as VR of clinical encounters to identify and promote behaviors associated with patient-centered care, most of which also overlap with behaviors associated with Emotional Intelligence (EI). We propose a VR that is structured less on a seek-and-find of clinician behaviors and more as a self-reflective exercise of how the clinician presents in the room alongside how they were feeling during that encounter. We believe that this exercise promotes the first two skills of EI (self-awareness and self-management) and then provides a foundation on which to build the second pair of skills (social awareness and relationship management). This perspective paper offers guidance, including stepwise instruction, on how to facilitate such a VR curriculum.

An Exploratory Feasibility Study of Incorporating Volunteering Into Treatment for Adolescent Depression and Anxiety.

Community volunteering is an under-utilized, at least under-researched, strategy to supplement existing treatment for affective disorders. We present findings from a feasibility study incorporating community volunteering into clinical treatment for depression and anxiety among adolescents and young adults. This exploratory pilot study had four aims: to investigate recruitment feasibility; to describe participants' experiences with volunteering; to explore psychosocial assets by which volunteering might decrease depressive and anxiety symptoms; and to document preliminary changes in mental health outcomes before and after the volunteering intervention. Interviews and surveys were employed with participants (N = 9; ages 14-20, Mage = 16 years old; eight women and one man) newly diagnosed with: mild to moderate depression (single episode), mild to moderate anxiety, or adjustment disorder. Recruitment was feasible overall, successes and challenges are discussed. Experiences with volunteering were very positive. Qualitative findings revealed perceived positive effects of volunteering on mood and well-being such as helping with social anxiety and being a positive distraction. Qualitative findings revealed several psychosocial assets that improved related to volunteering (e.g., sense of purpose/meaning and sense of community). On average, participants reported a 19% decrease in depressive symptoms from the pre-survey (before volunteering) to the post-survey (after volunteering). Although more research is warranted, the implication of this study for practicing psychologists treating adolescents and young adults for mild to moderate depression and/or anxiety is that they may wish to consider incorporating community volunteer activities into treatment. Volunteering was a desirable activity for interested participants in treatment for affective disorders.

Micro- and nanoparticles self-assembly for virtually defect-free, adjustable monolayers.

As chips further shrink toward smaller scales, fabrication processes based on the self-assembly of individual particles into patterns or structures are often sought. One of the most popular techniques for two-dimensional assembly (self-assembled monolayers) is based on capillary forces acting on particles placed at a liquid interface. Capillarity-induced clustering, however, has several limitations: it applies to relatively large (radius > approximately 10 microm) particles only, the clustering is usually non-defect-free and lacks long-range order, and the lattice spacing cannot be adjusted. The goal of the present article is to show that these shortcomings can be addressed by using an external electric field normal to the interface. The resulting self-assembly is capable of controlling the lattice spacing statically or dynamically, forming virtually defect-free monolayers, and manipulating a broad range of particle sizes and types including nanoparticles and electrically neutral particles.

Incorporating Volunteering Into Treatment for Depression Among Adolescents: Developmental and Clinical Considerations.

Volunteering, or taking part in unpaid work for the benefit of others, can be a powerful positive experience with returns to both individual well-being and community projects. Volunteering is positively associated with mental health in observational studies with community samples but has not been systematically examined as a potential part of treatment interventions with clinical adolescent samples. In this manuscript, we review the empirical evidence base connecting volunteerism to mental health and well-being, outline potential mechanisms based in the theoretical literature from developmental science, and discuss the existing clinical approaches that support community volunteering as a part of treatment. Drawing on this review, we propose that including volunteering as a component of clinical treatment approaches for adolescent depression can be a powerful intervention for adolescents.

Launching a Medication-Assisted Treatment in an Outpatient Office-Based Practice.

Background: Opioid use and overdose are escalating in the United States. Primary care providers are in a strategic position to assess patients for medication-assisted treatment (MAT). Objectives: To describe the implementation of MAT in an integrated primary care residency clinic and assess provider comfort levels with evaluating patients for high-risk opioid use, conduct crucial conversations about MAT treatment options and referral to MAT for evaluation and treatment. Methods: As part of a Primary Care Training and Enhancement grant through Health Resources and Services Administration, we used an implementation process to allow for optimal clinic flow. The process included assessment of patient populations, identifying a provider champion, organizing multidisciplinary team, engaging a practice facilitator, designing clinic model and infrastructure, creating the electronic health record order sets along with provider and staff training. Providers responded to brief questions to evaluate comfort levels in 3 domains: identifying high-risk opioid use, conducting crucial conversations about treatment options and referral to MAT for evaluation and treatment. Discussion: Incorporating MAT within an integrated primary care clinic and residency program with waiver training for residents was a successful and innovative program. The availability of MAT provided a solution for patients that could benefit from this type of treatment. MAT presence gave providers the opportunity to refer these patients for treatment that had not previously been as accessible. Conclusion: An integrated primary care practice with an embedded MAT can be successful with an organized structure to optimize clinic flow.

Patient Views of Behavioral Health Providers in Primary Care: A Qualitative Study of 2 Southeastern Clinics.

BACKGROUND: Limited research is available around patient experience of integrated behavioral health care in primary care settings. OBJECTIVE: We sought to identify the major themes through which patients described their integrated behavioral health care experiences as a means of informing and improving clinic processes of integrated health care delivery. METHODS: We captured viewpoints from 16 patients who experienced an integrated behavioral health care model from 2 primary care clinics and completed at least 3 visits with a behavioral health provider (BHP). Using grounded theory analyses, we coded and analyzed transcriptions for emergent themes. ANALYSIS: The interview process yielded 3 major themes related to the BHP including (a) the BHPs' clinic presence made behavioral health care more convenient and accessible, (b) BHPs worked within time and program limitations, and (c) BHPs helped with coping, wellness, and patient-care team communication. CONCLUSION: The BHPs serving in a large primary care practice and a Federally Qualified Health Center played an important role in connecting patients with behavioral health care and improving care team collaboration, both in terms of communication within the team and between the team and the patient/family.

Electrohydrodynamic removal of particles from drop surfaces.

A uniform electric field is used for cleaning drops of the particles they often carry on their surface. In a first step, particles migrate to either the drop's poles or equator. This is due to the presence of an electrostatic force for which an analytical expression is derived. In a second step, particles concentrated near the poles are released into the ambient liquid via tip streaming, and those near the equator are removed by stretching the drop and breaking it into several droplets. In the latter case, particles are all concentrated in a small middle daughter droplet.

Tailored mixing inside a translating droplet.

Tailored mixing inside individual droplets could be useful to ensure that reactions within microscopic discrete fluid volumes, which are used as microreactors in "digital microfluidic" applications, take place in a controlled fashion. In this paper we consider a translating spherical liquid drop to which we impose a time periodic rigid-body rotation. Such a rotation not only induces mixing via chaotic advection, which operates through the stretching and folding of material lines, but also offers the possibility of tuning the mixing by controlling the location and size of the mixing region. Tuned mixing is achieved by judiciously adjusting the amplitude and frequency of the rotation, which are determined by using a resonance condition and following the evolution of adiabatic invariants. As the size of the mixing region is increased, complete mixing within the drop is obtained.

Biopsychosocial-Spiritual Factors Impacting Referral to and Participation in Cardiac Rehabilitation for African American Patients: A SYSTEMATIC REVIEW.

PURPOSE: The purposes of this systematic review were to (1) review the literature related to the demographic and biopsychosocial-spiritual factors impacting cardiac rehabilitation (CR) referral and participation of African American patients with cardiovascular disease (CVD); (2) identify barriers and facilitators to CR referral and participation for this population; (3) identify gaps in the literature; and (4) make recommendations for future research studies and interventions. METHODS: The Cooper 7-step protocol for research synthesis was followed to formulate a research question and search MEDLINE via PubMed, PsycINFO via EBSCO, and CINAHL via EBSCO. A second reviewer repeated the searches performed by the first author in the initial review. RESULTS: A total of 1640 articles identified using the search strategy yielded 7 articles that fit the search criteria. Most studies measured demographic or social factors. Two studies measured biological factors, 1 study measured psychological factors, and no study measured spiritual factors. CONCLUSIONS: According to the studies reviewed, African American patients with CVD were less likely to receive a CR referral, more likely to enroll in CR with more cardiovascular risk factors, and less likely to participate in and complete CR due to factors related to low socioeconomic status (eg, lack of insurance, work conflicts, lower level of education) than non-Hispanic white patients. Further research is needed on the interaction between demographic/biopsychosocial-spiritual factors and referral to and participation of African Americans in CR in order to ensure that interventions fit the needs of this particular population.

Influence of preload reserve on stroke volume response to exercise in patients with left ventricular systolic dysfunction: a Doppler echocardiographic study.

OBJECTIVES: This study evaluated the role of preload reserve in the stroke volume response to exercise in patients with left ventricular systolic dysfunction by assessing the relation between stroke volume and late left ventricular diastolic filling during exercise. BACKGROUND: In patients with left ventricular diastolic dysfunction, the absence of left ventricular distension is the fundamental mechanism explaining the nonaugmentation of stroke volume during exercise. METHODS: In 32 patients with left ventricular systolic dysfunction and 16 healthy control subjects, mitral and aortic velocities were recorded by Doppler echocardiography at rest and during submaximal supine bicycle exercise. Stroke volume, peak early (E) and late (A) mitral velocities, A/E ratio and end-diastolic filling were measured at rest and during exercise. RESULTS: Stroke volume increased significantly in control subjects but did not change in patients. Peak early mitral velocity increased significantly and to the same extent in both groups, whereas peak late mitral velocity and end-diastolic filling increased significantly in both groups but more so in control subjects; the A/E ratio increased significantly in control subjects but did not change in patients. In addition, stroke volume correlated significantly with peak late mitral velocity during exercise in patients (r = 0.72, p < 0.001). CONCLUSIONS: Compared with control subjects, patients with left ventricular systolic dysfunction exhibited limited increases in both stroke volume and late left ventricular filling during exercise. Furthermore, their stroke volume response correlated with the capacity of the left ventricle to increase late diastolic filling, that is, preload reserve.

Trapping force on a finite-sized particle in a dielectrophoretic cage.

The point dipole (PD) model is routinely used for estimating the dielectrophoretic (DEP) force acting on a particle placed in the nonuniform electric fields of dielectrophoresis devices, such as square cages. We show that if the particle size is much smaller than the dielectrophoretic cage size, the PD model accurately approximates the actual DEP force, computed numerically using the Maxwell stress tensor method. However, when the two sizes are comparable, the actual DEP force differs significantly in both magnitude and direction from that given by the PD model.

Inhibition of herpes simplex virus type 1 ribonucleotide reductase by substituted tetrapeptide derivatives.

It is known that peptides corresponding to the C-terminus of the small subunit of herpes simplex virus type 1 and 2 ribonucleotide reductase can inhibit enzymatic activity by preventing the association of the enzyme's two subunits. In a quest for smaller, more potent inhibitors, we have conducted a structure activity investigation based on the pentapeptide H-Val-Val-Asn-Asp-Leu-OH. Potency increases of up to 4000 times (IC50 0.18 microM) have been achieved in an enzymatic assay by a combination of modifying the N-terminal valine to a diethylacetyl group, adding a methyl group to the beta-carbon of the adjacent valine, dialkylating the asparagine side-chain nitrogen and dimethylating the beta-carbon of the aspartic acid residue. In addition the relative contribution of various inhibitor functionalities to inhibitor potency has been investigated.

A computerised enzyme immunosensor: application for the determination of antigens.

The present report gives preliminary results of a new sensitive method for the amperometric determination of antigens in serum. This method, developed from the biological model 'hepatitis B surface antigen antibodies' is less time-consuming than most immunochemical techniques, and eliminates many inconveniences arising from use of isotopes. Specific antibodies immobilised onto a gelatin membrane are applied in a solid phase 'sandwich' procedure. The antibodies are labelled with glucose oxidase. The measurement consists of an immunological process and an enzymatic reaction. The second part is carried out by fixing the active membrane onto a pO2 electrode. The sensor is immersed in a standard glucose solution and a signal is obtained by measuring the consumption of oxygen due to the enzyme reaction. This response is correlated to the antigen concentration of the sample. It is a function of both the diffusional and the reactional characteristics of the active layer. Under software conditions, the signal is sampled when the stationary state is obtained. The difference between initial signal and the stationary state signal is measured and compared with the pre-set calibration curve. Use of the computerised enzyme immunosensor could easily be extended to assay of other antigens and haptens that are usually determined by radioimmunoassay.

[Third angioplasty, and after that?]. / La troisième angioplastie, et après?

The authors studied retrospectively a series of 39 patients with a documented second restenosis after coronary angioplasty between January 1987 and November 1992, 33 of whom (31 men, 2 women) underwent a third procedure. The artery dilated was the left anterior descending (n = 17 including 9 proximal stenoses), the right coronary (n = 10), the left circumflex or its branches (n = 5) and the left main stem (n = 1). The lesions were confirmed to one vessel in 25 cases (75%) and affected two vessels in 8 cases (25%). The third angioplasty procedure was performed on a single artery in all cases. The average left ventricular ejection fraction was 60% (43%-75%). The diameter of the dilated artery was over 3.25 mm in 24% of cases (8/33). The primary success rate was 100% without any complications. The average period between the first and second angioplasties was 16 +/- 10 weeks, and between the second and third angioplasties 19 +/- 12 weeks. Angioplastic controls of the 3rd angioplasty were performed in 25 cases (75%). A third restenosis (n = 7) was treated by surgical bypass (n = 1), repeat angioplasty (n = 4), endocoronary stenting (n = 1) or medically (n = 1), with a global follow-up of 22 months (2-56 months), 2 patients underwent coronary bypass grafting, 2 have residual angina (contralateral lesion which could not be dilated), 1 had an infarct in the territory of an undilated artery, and 28 (85%) were asymptomatic. The restenosis rate after the third angioplasty procedure was 28% (7/25).(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnostic value of myocardial thallium stress scintigraphy in the detection of coronary artery disease in patients undergoing chronic hemodialysis]. / Valeur diagnostique de la scintigraphie myocardique au thallium sous stimulation dans la détection de la maladie coronarienne chez l'hémodialysé chronique.

Atherosclerotic heart disease is the leading cause of death in patients with end stage renal disease, but its non invasive detection remains difficult because of a low efficacy of exercise testing. The aim of the study was to evaluate diagnostic accuracy of thallium myocardial imaging after dipyridamole combined with exercise. Forty two chronic dialysis patients (34 men, 8 women) aged 55 +/- 11 years (range: 36 to 75) without symptom of angina nor myocardial infarction were studied. In each patient, an echocardiography, a myocardial scintigraphy with dipyridamole combined with symptom-limited exercise, and coronarography were performed. A coronary heart disease was diagnosed by coronarography in 10 patients (4.5 and 1 respectively with 1, 2 and 3 vessels diseased). Echocardiography detected a left ventricular hypertrophy (LVH) in 26 patients and a regional asynergia in 14 patients. A positive scintigraphy was present in 11 patients. Three false-positive and 2 false-negative on scintigraphy were noted. Sensibility, specificity, positive predictive value and negative predictive value were respectively evaluated at 80, 73, 73 and 93%. All the five patients with either false-positive or false-negative scintigraphy exhibited a LVH. CONCLUSION. In chronic dialysis patients, coronary heart disease may be detected by thallium myocardial imaging after dipyridamole combined with exercise.

Dynamic study of how the bacterial breakdown of plant cell walls allows the reconstitution of efficient hemicellulasic cocktails.

Designing more efficient mixtures of enzymes is necessary to produce molecules of interest from biomass lignocellulosic fractionation. The present study aims to investigate the strategies used by the thermophilic and hemicellulolytic bacterium Thermobacillus xylanilyticus to fractionate wheat bran and wheat straw during its growth. Results demonstrated ratios and levels of hemicellulases produced varied during growth on both biomasses. Xylanase activity was mainly produced during stationary stages of growth whereas esterase and arabinosidase activities were detected earlier. This enzymatic profile is correlated with the expression pattern of genes encoding four hemicellulases (two xylanases, one arabinosidase and one esterase) produced by T. xylanilyticus during growth. Based on identification of the bacterial strategy, the synergistic efficiency of the four hemicellulases during the hydrolysis of both substrates was evaluated. The four hemicellulases worked together with high degree of synergy and released high amounts of xylose, arabinose and phenolic acids from wheat bran and wheat straw.

Combination of ammonia and xylanase pretreatments: impact on enzymatic xylan and cellulose recovery from wheat straw.

Soaking in aqueous ammonia (SSA) and/or xylanase pretreatments were developed on wheat straw. Both pretreatments were conducted at high-solids conditions: 15% and 20%, respectively, for SSA and xylanase pretreatments. SSA pretreatment led to the solubilisation of 38%, 12% and 11% of acid insoluble lignin, xylan and glucan, respectively. In case of xylanase pretreatment, 20% of xylan were removed from native wheat straw. When pretreatments were applied consecutively (SSA and xylanase) on straw, 56% of xylans were hydrolysed and a rapid reduction of media viscosity occurred. The enzymatic hydrolysis of cellulose with cellulases was evaluated from the different combinations of pretreated wheat straw. Cellulose hydrolysis was improved by 2.1, 2.2 and 2.9, respectively, for xylanase, SSA and SSA/xylanase pretreated straw. Xylans from untreated and pretreated wheat straws were also solubilised with cellulases. Chemical analysis of pretreated straw residues in connection with yields of cellulose hydrolysis highlighted the role of phenolic acids, acetyl content and cellulose crystallinity for cellulase efficiency.