Exploring Factors Impacting the Implementation of Recovery-Oriented Treatment Planning on Acute Inpatient Mental Health Units.

PURPOSE: The current literature on operationalizing and implementing recovery-oriented inpatient care in diverse settings remains limited. The present study systematically examined factors affecting the implementation of one aspect of recovery-oriented care in a large and diverse national sample of Veterans Health Administration (VHA) inpatient mental health units. METHOD: VHA inpatient mental health units were scored on the Recovery-Oriented Acute Inpatient scale (RAIN). Sites scoring either one standard deviation above (n = 8; i.e., high-scoring sites) or one standard deviation below (n = 5; i.e., low-scoring sites) the mean on the RAIN factor of inpatient treatment planning subscale were included for additional analyses (N = 13). We used a qualitative approach known as emergent thematic analysis to assess the implementation of inpatient treatment planning elements (e.g., goal setting, shared decision-making) from qualitative interviews, observation notes, and chart reviews collected for the 13 sites. The analysis was guided by Normalization Process Theory. RESULTS: The eleven themes that emerged across the elements of recovery-oriented inpatient treatment planning mostly represented commonalities across sites, such as a shared treatment philosophy of acute care. However, five themes emerged as "differentiators" that distinguished high- and low-scoring sites and included veteran input, elicitation of recovery goals, the value of group programming, and the purpose of family involvement. CONCLUSION: Findings provide insight into contextual factors and processes that impacted the implementation of recovery-oriented treatment planning at these VHA inpatient mental health units. To further facilitate the implementation of recovery-oriented inpatient treatment planning elements, future research should examine staff's collective understanding of recovery-oriented inpatient care.

A National Survey of Patient Completion of Cognitive Behavioral Therapy for Chronic Pain: The Role of Therapist Characteristics, Attempt Rates, and Modification.

The implementation of evidence-based psychotherapies, including patient-level measures such as penetration and rates of successfully completing a course of therapy, has received increasing attention. While much attention has been paid to the effect of patient-level factors on implementation, relatively little attention has been paid to therapist factors (e.g., professional training, experience). OBJECTIVE: The current study explores therapists' decisions to offer a particular evidence-based psychotherapy (cognitive behavioral therapy for chronic pain; CBT-CP), whether and how they modify CBT-CP, and the relationship between these decisions and patient completion rates. METHODS: The study utilized survey responses from 141 Veterans Affairs therapists certified in CBT-CP. RESULTS: Therapists reported attempting CBT-CP with a little less than one half of their patients with chronic pain (mean = 48.8%, s.d.=35.7). Therapist were generally split between reporting modifying CBT-CP for either very few or most of their patients. After controlling for therapist characteristics and modification, therapist-reported percentage of patients with attempted CBT-CP was positively associated with completion rates, t (111) = 4.57, p<.001. CONCLUSIONS: Therapists who attempt CBT-CP more frequently may experience better completion rates, perhaps due to practice effects or contextual factors that support both attempts and completion. Future research should examine this relationship using objective measures of attempt rates and completion.

A Comparative Effectiveness Trial to Reduce Burnout and Improve Quality of Care.

Clinician burnout is presumed to negatively impact healthcare quality; yet scant research has rigorously addressed this hypothesis. Using a mixed-methods, randomized, comparative effectiveness design, we tested two competing approaches to improve care-one addressing clinician burnout and the other addressing how clinicians interact with consumers-with 192 clinicians and 469 consumers at two community mental health centers. Although qualitative reports were promising, we found no comparative effectiveness for either intervention on burnout, patient-centered processes, or other outcomes. Discussion includes identifying ways to strengthen approaches to clinician burnout.

Unilateral Phrenic Nerve Palsy in Infants with Congenital Zika Syndrome.

Since the first identification of neonatal microcephaly cases associated with congenital Zika virus infection in Brazil in 2015, a distinctive constellation of clinical features of congenital Zika syndrome has been described. Fetal brain disruption sequence is hypothesized to underlie the devastating effects of the virus on the central nervous system. However, little is known about the effects of congenital Zika virus infection on the peripheral nervous system. We describe a series of 4 cases of right unilateral diaphragmatic paralysis in infants with congenital Zika syndrome suggesting peripheral nervous system involvement and Zika virus as a unique congenital infectious cause of this finding. All the patients described also had arthrogryposis (including talipes equinovarus) and died from complications related to progressive respiratory failure.

INTERACT in VA Community Living Centers (CLCs): Training and Implementation Strategies.

Studies have shown that hospitalizations of nursing home (NH) residents lead to complications and poorer quality of life. The Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement (QI) Program assists licensed NH staff in avoiding such hospitalizations. INTERACT aims to improve the management of acute changes in residents' conditions by providing tools to help staff recognize subtle changes in condition, improve communication, and implement QI strategies. INTERACT has been vetted by national clinical leaders and experts in long term care (LTC). Multiple NHs have implemented INTERACT and it has been adopted in Canada, the United Kingdom, and Singapore. QI initiatives involve adaptation to the organizational context in which it is being implemented. We report adaptation of the INTERACT QI program and implementation training into Veteran Affairs (VA) Community Living Centers (CLCs) (VA equivalent NH) and summarize the efforts to introduce and train nursing leadership to integrate the intervention into selected CLCs.

Marital quality, depressive symptoms, and the metabolic syndrome: a couples structural model.

The indirect association of marital quality with metabolic syndrome (MetS) through depressive symptoms was examined in 301 middle-aged and older couples. MetS components (i.e., waist circumference, blood pressure, blood draws to assess triglycerides, HDL cholesterol, and fasting glucose) were assessed following a 12-h fast, and were treated as a continuous latent variable for analyses. In structural equation modeling of this indirect effect, overall model fit was good, and husbands' and wives' marital quality was associated with MetS only through depressive symptoms. Joint tests of the parameters indicated that gender did not moderate this association. The best fitting, most parsimonious model, after nested model comparisons, was one in which husbands' and wives' indirect paths were equated. Overall, marital quality was related to MetS through its relationship to depressive symptoms for men and women. Associations of marital quality and depression with MetS may overlap, and couple-based approaches to psychosocial risk factors for cardiovascular disease may be useful in future research.

Desulfovibrio legallii prosthetic shoulder joint infection and review of antimicrobial susceptibility and clinical characteristics of Desulfovibrio infections.

We describe a case of shoulder hemiarthroplasty infection with Desulfovibrio legallii. Antimicrobial susceptibilities of 36 Desulfovibrio isolates are presented. Metronidazole and carbapenems exhibited reliable activity, although piperacillin-tazobactam did not. Eleven previous cases of Desulfovibrio infection are reviewed; most arose from a gastrointestinal tract-related source.

An Investigation of Employment Hope as a Key Factor Influencing Perceptions of Subjective Recovery among Adults with Serious Mental Illness Seeking Community Work.

INTRODUCTION: Employment is an important contributor to recovery in people with serious mental illness (SMI), yet studies have not explored how subjective elements of employment hope contribute to perceptions of global recovery in this population. METHODS: The current study examined the relationship between employment hope and subjective recovery in 276 unemployed adults with SMI participating in a multi-site clinical trial of a cognitive behavioral group intervention tailored toward work and combined with vocational rehabilitation. Participants had diagnoses of schizophrenia spectrum, bipolar, depressive, and posttraumatic stress disorders, and were receiving services at three Veterans Affairs healthcare facilities in the United States. Data were collected at study baseline. Linear regression analysis examined the relationship between employment hope (Short Employment Hope Scale; EHS-14) and subjective recovery (Recovery Assessment Scale; RAS) after controlling for psychiatric symptom severity and mental-health-related burden on daily life. RESULTS: After accounting for covariates, employment hope significantly contributed to the regression model explaining subjective recovery. The overall model of predictor variables explained 52.5% of the variance in recovery. The results further explore the relationships between EHS-14 and RAS subscales. CONCLUSIONS: The findings suggest that employment hope is a key intervention target to bolster subjective recovery in this vulnerable population.

Recovery-oriented inpatient mental health care and readmission.

OBJECTIVE: This article examines the relationship between inpatient mental health units' adherence to recovery-oriented care and 30-day patient readmission. METHOD: The sample included patients admitted to one of 34 Veterans Health Administration inpatient mental health units. Recovery-oriented care was assessed using interviews and site visits. Patient characteristics and readmission data were derived from administrative data. FINDINGS: Overall recovery orientation was not associated with readmission. Exploratory analyses found higher scores on a subsample of items pertaining to inpatient therapeutic programming were associated with lower patient readmissions. Additionally, patients with more prior service use and substance abuse or personality disorders were more likely to be readmitted. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: A growing body of literature supports the association between psychotherapeutic services in inpatient units and better patient outcomes. However, further research is needed to examine this association. More work is needed to develop appropriate psychotherapy services for the inpatient setting and support their implementation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Affiliation and control during marital disagreement, history of divorce, and asymptomatic coronary artery calcification in older couples.

OBJECTIVE: To examine behavioral observations of affiliation (ie, warmth versus hostility) and control (ie, dominance versus submissiveness) and prior divorce as predictors of coronary artery calcification (CAC) in older couples. In some but not all studies, marital disruption and low marital quality have been shown to confer risk of coronary artery disease (CAD). Inconsistencies might reflect limitations of self-reports of marital quality compared with behavioral observations. Also, aspects of marital quality related to CAD might differ for men and women. METHODS: Couples underwent computed tomography scans for CAC and marital assessments, including observations of laboratory-based disagreement. Participants were 154 couples (mean age, 63.5 years; mean length of marriage, 36.4 years) free of prior diagnosis of CAD. RESULTS: Controlling traditional risk factors, we found behavioral measures of affiliation (low warmth) accounted for 6.2% of variance in CAC for women, p < .01, but not for men. Controlling behavior (dominance) accounted for 6.0% of variance in CAC for men, p < .02, but not for women. Behavioral measures were related to self-reports of marital quality, but the latter were unrelated to CAC. History of divorce predicted CAC for men and women. CONCLUSIONS: History of divorce and behavioral--but not self-report--measures of marital quality were related to CAD, such that low warmth and high dominance conferred risk for women and men, respectively. Prior research might underestimate the role of marital quality in CAD by relying on global self-reports of this risk factor.

Recovery-oriented acute inpatient mental health care: Operationalization and measurement.

OBJECTIVE: The current article describes efforts to develop and test a measure of recovery-oriented inpatient care. METHOD: The Recovery-oriented Acute INpatient (RAIN) scale was based on prior literature and current Veterans Health Administration (VHA) policy and resources and further revised based on data collection from 34 VHA acute inpatient units. RESULTS: A final scale of 23, behaviorally anchored items demonstrated a four-factor structure including the following factors: inpatient treatment planning, outpatient treatment planning, group programming, and milieu. While several items require additional revision to address psychometric concerns, the scale demonstrated adequate model fit and was consistent with prior literature on recovery-oriented inpatient care. Conclusions and Implementations for Practice: The RAIN scale represents an important tool for future implementation and empirical study of recovery-oriented inpatient care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Treatment-resistant meningitis leading to the diagnosis of Currarino syndrome: a case report.

A 20-day-old female infant developed fever. Sepsis evaluation revealed cerebrospinal fluid (CSF) pleocytosis and a modestly decreased CSF glucose. After 48 hours of broad-spectrum antibiotics, the infant remained febrile. Repeat CSF analysis showed increased pleocytosis and a very low glucose value. Subsequently, a rectothecal fistula and sacral abnormalities were found, leading to the diagnosis of Currarino syndrome. Parameningeal foci should be considered in treatment-resistant meningitis.

Conflict and collaboration in middle-aged and older couples: II. Cardiovascular reactivity during marital interaction.

Marital strain confers risk of cardiovascular disease (CVD), perhaps though cardiovascular reactivity (CVR) to stressful marital interactions. CVR to marital stressors may differ between middle-age and older adults, and types of marital interactions that evoke CVR may also differ across these age groups, as relationship contexts and stressors differ with age. The authors examined cardiovascular responses to a marital conflict discussion and collaborative problem solving in 300 middle-aged and older married couples. Marital conflict evoked greater increases in blood pressure, cardiac output, and cardiac sympathetic activation than did collaboration. Older couples displayed smaller heart rate responses to conflict than did middle-aged couples but larger blood pressure responses to collaboration-especially in older men. These effects were maintained during a posttask recovery period. Women did not display greater CVR than men on any measure or in either interaction context, though they did display greater parasympathetic withdrawal. CVR to marital conflict could contribute to the association of marital strain with CVD for middle-aged and older men and women, but other age-related marital contexts (e.g., collaboration among older couples) may also contribute to this mechanism.

Conflict and collaboration in middle-aged and older couples: I. Age differences in agency and communion during marital interaction.

Prior theory and research regarding age differences in marital interaction suggest that older couples display and experience more positivity and less negativity than middle-aged couples. However, studies of overt behavior in older couples are relatively rare and have emphasized disagreement, neglecting other important contexts for older couples such as collaboration during everyday problem solving. Further, the affiliation or communion dimension of social interaction (i.e., warmth vs. hostility) is commonly assessed but not the control or agency dimension (e.g., dominance vs. submissiveness). The present study examined affect, cognitive appraisals, and overt behavior during disagreement (i.e., discussing a current conflict) and collaboration (i.e., planning errands) in 300 middle-aged and older married couples. Older couples reported less negative affect during disagreement and rated spouses as warmer than did middle-aged couples. However, these effects were eliminated when older couples' greater marital satisfaction was controlled. For observed behavior, older couples displayed little evidence of greater positivity and reduced negativity-especially women. During collaboration, older couples displayed a unique blend of warmth and control, suggesting a greater focus on emotional and social concerns during problem solving.

Measuring Quality of Care in Community Mental Health: Validation of Concordant Clinician and Client Quality-of-Care Scales.

Measuring quality of care can transform care, but few tools exist to measure quality from the client's perspective. The aim of this study was to create concordant clinician and client self-report quality-of-care scales in a sample of community mental health clinicians (n = 189) and clients (n = 469). The client scale had three distinct factors (Person-Centered Care, Negative Staff Interactions, and Inattentive Care), while the clinician scale had two: Person-Centered Care and Discordant Care. Both versions demonstrated adequate internal consistency and validity with measures related to satisfaction and the therapeutic relationship. These measures are promising, brief quality assessment tools.

Empiric antibiotic therapy for acute osteoarticular infections with suspected methicillin-resistant Staphylococcus aureus or Kingella.

The bacterial agents causing bone and joint infections have been changing. Currently, methicillin-resistant Staphylococcus aureus (MRSA) and Kingella kingae are emerging pathogens. For treatment of MRSA infections, clindamycin, vancomycin, and linezolid are commonly prescribed antibiotics. Kingella are sensitive to most penicillins and cephalosporins. Because MRSA osteoarticular infections tend to be severe, longer periods of antibiotic treatment with more frequent monitoring of inflammatory markers are sometimes required to obtain a complete cure with no residual complications. To assist management, we have included a clinical decision tree with antibiotic treatment protocols.

Associations of self-reports versus spouse ratings of negative affectivity, dominance, and affiliation with coronary artery disease: where should we look and who should we ask when studying personality and health?

OBJECTIVE: Aspects of negative affect and social behavior studied as risk factors for coronary heart disease are usually examined separately and through self-reports. Using structural models of these personality domains, we tested associations of self-reports and spouse ratings of anxiety, depressive symptoms, anger, affiliation and dominance with coronary artery disease (CAD). DESIGN: In 154 healthy older couples, the authors tested cross-sectional associations with CAD of three facets of negative affectivity and two dimensions of the Interpersonal Circumplex, (IPC) using scales derived from the NEO-PI-R. MAIN OUTCOME MEASURES: CAD was quantified as Agatston scores from CT scans of coronary artery calcification (CAC). RESULTS: Self-reports were generally unrelated to CAC, whereas spouse ratings were consistently associated, largely independent of potential confounds. When considered simultaneously, anxiety and anger were related to CAC but depression was not. When considered together, both dominance and (low) affiliation were related to CAC. CONCLUSIONS: Structural models of negative affectivity and social behavior can facilitate integrative study of psychosocial risk factors. Further, self-report measures of these traits might under-estimate related CHD risk.

Labyrinthine Sequestrum: A Case Report and Review of the Literature.

OBJECTIVE: To report the presentation, diagnosis, management, and convalescence of labyrinthine sequestrum (LS) and summarize all previously published cases. PATIENT(S): Eleven-year-old female with LS. INTERVENTION(S): Multidisciplinary diagnostic evaluation and treatment. MAIN OUTCOME MEASURES: Imaging and laboratory findings, medical and surgical treatment. RESULTS: We describe a case of LS secondary to medically recalcitrant suppurative otitis media in an 11-year-old female and review all eight previously reported cases. The index patient presented after 6 months of otitis media, profound unilateral hearing loss, with symptoms suggesting meningitis. Temporal bone CT demonstrated marked bony destruction of the left otic capsule. Gadolinium-enhanced MRI showed an enhancing process with evidence of meningitis and subdural empyema. The patient was treated with surgical debridement and culture directed antibiotic therapy. Posttreatment imaging showed resolution of intracranial infection with fibrous bony healing of the otic capsule resembling fibrous dysplasia. CONCLUSION: LS is a rare form of labyrinthitis characterized by centrifugal destruction of the otic capsule. The current index case highlights the importance of combined medical and surgical treatment and describes for the first time in the literature the fibrous ossification of the otic capsule following disease resolution.

Positive and negative characteristics of marital interaction and their association with marital satisfaction in middle-aged and older couples.

The study examined age differences in positive (e.g., warm) and negative (e.g., hostile) characteristics of marital interactions between middle-aged and older couples and whether these characteristics were differentially associated with marital satisfaction by age. Spouses' perception of partners' positive and negative behavior during marital interaction was assessed in general and following disagreement and collaborative tasks. Trained observers coded spouses' positive and negative behavior during interactions. Older individuals reported higher marital satisfaction and perceived their spouse's behavior as less negative in general and more positive across all contexts than middle-aged individuals. Spouses' perceptions of their partners' positive and negative behavior independently predicted marital satisfaction for both age groups across contexts. Perceptions of partners' negative behavior in general and of both positive and negative behavior in the disagreement task were more closely associated with marital satisfaction for older spouses than for middle-aged spouses. Results point to the importance of positive and negative characteristics in marital functioning across age cohorts and indicate that such characteristics may be context dependent. Findings suggest that, in some contexts, both positive and negative characteristics are more salient for older adults.

Age, marital satisfaction, and optimism as predictors of positive sentiment override in middle-aged and older married couples.

This study examined whether positive sentiment override (greater positive appraisal of spouse's affiliative behavior than is warranted by observed behavior) occurred more frequently in older compared with middle-aged married couples and whether age differences were mediated by older adults' greater marital satisfaction when controlling for optimism. Participants included 270 middle-aged (40-50 years old) and older (60-70 years old) couples who discussed a marital disagreement and completed an errand task. Couples provided appraisals of their spouse's affiliation, and the authors coded affiliative interactions using the structural analysis of social behavior. Hierarchical multivariate linear modeling indicated that older husbands and wives viewed their spouse's behavior as more positive during disagreement interactions than did independent observers; in the errand task, only older wives demonstrated positive sentiment override. Age differences in positive sentiment override were mediated by marital satisfaction, even when controlling for optimism. The results are consistent with theories of emotion regulation, such as socioemotional selectivity theory, that suggest that older adults are biased toward the positive aspects of close relationships.