Advancing environmental health sciences through implementation science.

BACKGROUND: Environmental health sciences have identified and characterized a range of environmental exposures and their associated risk for disease, as well as informed the development of interventions, including recommendations, guidelines, and policies for mitigating exposure. However, these interventions only serve to mitigate exposures and prevent disease if they are effectively disseminated, adopted, implemented, and sustained. MAIN BODY: Numerous studies have documented the enormous time lag between research and practice, noting that dissemination and implementation are not passive processes but rely on active and intentional strategies. Implementation science seeks to build the knowledge base for understanding strategies to effectively disseminate and implement evidence and evidence-based interventions, and thus, bridge the research-to-practice gap. CONCLUSION: Environmental health researchers are well positioned to advance health promotion and disease prevention by incorporating implementation science into their work. This article describes the rationale for and key components of implementation science and articulates opportunities to build upon existing efforts to advance environmental health supported by the National Institute of Environmental Health Sciences and National Institutes of Health broadly.

A new species of Euclymene (Maldanidae, Annelida) from Brazil, with new combinations, and phylogenetic implications for Euclymeninae.

Maldanids are tube-building polychaetes, known as bamboo-worms; inhabit diverse marine regions throughout the world. The subfamily Euclymeninae was proposed to include forms with anal and cephalic plates, a funnel-shaped pygidium, and a terminal anus. Euclymene, the type genus of Euclymeninae, has about 18 valid species. Euclymene vidali sp. nov. is defined and members of the species described from Northeastern Brazil. Members of this species have 23 chaetigers, and one pre-pygidial achaetous segment; nuchal grooves extend through three quarters of the cephalic plate, and there is one acicular spine with a denticulate tip. Euclymene africana, and E. watsoni, are here recognized, respectively, as Isocirrus africana comb. nov., and I. watsoni comb. nov. Three monotypic genera are invalid: Macroclymenella, Eupraxillella, and Pseudoclyemene; their species should be recognized as Clymenella stewartensis com. nov., Praxillella antarctica com. nov., and Praxillela quadrilobata com. nov., respectively. An identification key and a comparative table for all species of Euclymene are provided. A comparative table for all genera of Euclymeninae is also furnished. The paraphyletic status of Euclymene and Euclymeninae is discussed. The taxon Maldanoplaca is not code compliant and should only be regarded as an informal name.

Engaging patients and caregivers to establish priorities for the management of diabetic foot ulcers.

OBJECTIVE: Effective diabetic foot ulcer (DFU) care has been stymied by a lack of input from patients and caregivers, reducing treatment adherence and overall quality of care. Our objectives were to capture the patient and caregiver perspectives on experiencing a DFU and to improve prioritization of patient-centered outcomes. METHODS: A DFU-related stakeholder group was formed at an urban tertiary care center. Seven group meetings were held across 4 months, each lasting ∼1 hour. The meeting facilitator used semistructured questions to guide each discussion. The topics assessed the challenges of the current DFU care system and identified the outcomes most important to stakeholders. The meetings were audio recorded and transcribed. Directed and conventional content analyses were used to identify key themes. RESULTS: Six patients with diabetes (five with an active DFU), 3 family caregivers, and 1 Wound Clinic staff member participated in the stakeholder group meetings. The mean patient age was 61 years, four (67%) were women, five (83%) were either African American or Hispanic, and the mean hemoglobin A1c was 8.3%. Of the five patients with a DFU, three had previously required lower extremity endovascular treatment and four had undergone at least one minor foot amputation. Overall, stakeholders described how poor communication between medical personnel and patients made the DFU experience difficult. They felt overwhelmed by the complexity of DFU care and were persistently frustrated by inconsistent medical recommendations. Limited resources further exacerbated their frustrations and barriers to care. To improve DFU management, the stakeholders suggested a centralized healthcare delivery pathway with timely access to a coordinated, multidisciplinary DFU team. The clinical outcomes most valued by stakeholders were (1) avoiding amputation and (2) maintaining or improving health-related quality of life, which included independent mobility, pain control, and mental health. From these themes, we developed a conceptual model to inform DFU care pathways. CONCLUSIONS: Current DFU management lacks adequate care coordination. Multidisciplinary approaches tailored to the self-identified needs of patients and caregivers could improve adherence. Future DFU-related comparative effectiveness studies will benefit from direct stakeholder engagement and are required to evaluate the efficacy of incorporating patient-centered goals into the design of a multidisciplinary DFU care delivery system.

Integrated Model for Patient-Centered Advanced Liver Disease Care.

Advanced liver disease (AdvLD) is a high-risk common condition with a progressive, highly morbid, and often fatal course. Despite effective treatments, there are substantial shortfalls in access to and use of evidence-based supportive and palliative care for AdvLD. Although patient-centered, chronic illness models that integrate early supportive and palliative care with curative treatments hold promise, there are several knowledge gaps that hinder development of an integrated model for AdvLD. We review these evidence gaps. We also describe a conceptual framework for a patient-centered approach that explicates key elements needed to improve integrated care. An integrated model of AdvLD would allow clinicians, patients, and caregivers to work collaboratively to identify treatments and other healthcare that best align with patients' priorities.

Examining cancer survivorship trajectories: Exploring the intersection between qualitative illness narratives and quantitative screening instruments.

OBJECTIVE: This article examines the associations of quantitatively refined trajectories of adjustment to cancer survivorship determined by previously published qualitative narrative analysis. METHOD: Patients completed measures of cancer-related worry (Cancer Related Worries Scale), depression (Patient Health Questionnaire-9), posttraumatic growth (Benefit Finding Scale), and open-ended survey questions 6, 12, and 18 months postdiagnosis of head and neck, esophageal, gastric, or colorectal cancer. Previously published narrative analysis revealed five distinct survivorship "paths," which were combined into four paths in the present article: Moving On, Seeing the World Differently, Taking One Day at a Time, and Never the Same. To determine the association of qualitatively determined paths with quantitatively assessed adjustment (i.e., Cancer Related Worries Scale, Patient Health Questionnaire-9, Benefit Finding Scale), we used linear multilevel modeling to regress the adjustment variables on time, path, the time-by-path interaction, and relevant covariates (age, stage, cancer site, ethnicity, and Deyo score). RESULTS: There was a significant main effect of path on cancer worry, depression, and posttraumatic growth (p < 0.02 for all). Patients in the Moving On group reported consistently low worry, depression, and growth compared to the other groups. Patients in the Seeing the World Differently and Taking One Day at a Time paths both reported moderate worry and depression; but those in the Seeing the World Differently path reported the highest posttraumatic growth, whereas patients in the Taking One Day at a Time path reported little growth. Finally, patients in the Never the Same path reported the highest worry and depression but lowest posttraumatic growth.Significance of resultsThis longitudinal study reinforces the notion that cancer survivorship is not a one-size-fits-all experience nor a dichotomized experience of "distress" or "no distress." Additionally, this hypothesis-generating study suggests future directions for potential self-report measures to help clinicians identify cancer survivors' trajectory to develop a more patient-centered survivorship care plan.

Valued life abilities among veteran cancer survivors.

BACKGROUND: When patients have multiple chronic illnesses, it is not feasible to provide disease-based care when treatments for one condition adversely affect another. Instead, health-care delivery requires a broader person-centred treatment plan based on collaborative, patient-oriented values and goals. OBJECTIVE: We examined the individual variability, thematic content, and sociodemographic correlates of valued life abilities and activities among multimorbid veterans diagnosed with life-altering cancer. SETTING AND PARTICIPANTS: Participants were 144 veterans in the 'Vet-Cares' study who completed a health-care values and goals scale 12 months after diagnosis of head and neck, gastro-oesophageal, or colorectal cancer. They had mean age of 65 years and one quarter identified as Hispanic and/or African American. DESIGN: At twelve months post-diagnosis, participants rated 16 life abilities/activities in their importance to quality of life on a 10-point Likert scale, during an in-person interview. Scale themes were validated via exploratory factor analysis and examining associations with sociodemographic variables. RESULTS: Participants rated most life abilities/activities as extremely important. Variability in responses was sufficient to identify three underlying values themes in exploratory factor analysis: self-sufficiency, enjoyment/comfort, and connection to family, friends and spirituality. Veterans with a spouse/partner rated self-sufficiency as less important. African American veterans rated connection as more important than did White veterans. CONCLUSIONS: It is feasible yet challenging to ask older, multimorbid patients to rate relative importance of values associated with life abilities/activities. Themes related to self-sufficiency, enjoyment/comfort in daily life and connection are salient and logically consistent with sociodemographic traits. Future studies should explore their role in goal-directed health care.

Mental Health of Transgender Veterans of the Iraq and Afghanistan Conflicts Who Experienced Military Sexual Trauma.

Little is known about military sexual trauma (MST) in transgender veterans. To address this gap, we examined archival data regarding transgender veterans from the Iraq and Afghanistan conflicts. There were 332 transgender veterans treated at the Veterans Health Administration between 2000 and 2013 (78 men, 254 women; mean age 33.86 years), with most being non-Hispanic White. Transgender status and mental health conditions were identified using the International Classification of Diseases, 9th Revision (ICD-9; World Health Organization, 1980) codes and chart review. Men and women were analyzed separately, using contingency tables and χ2 testing for categorical variables and t tests for continuous variables. Likelihood of having a mental health condition and MST were examined using logistic regression. Among the 15% of participants who experienced MST, MST was associated with the likelihood of posttraumatic stress disorder, adjusted OR = 6.09, 95% confidence interval (CI) [1.22, 30.44] and personality disorder, OR = 3.86, 95% CI [1.05, 14.22] for men and with depressive, OR = 3.33, 95% CI [1.12, 9.93], bipolar, OR = 2.87, 95% CI [1.12, 7.44], posttraumatic stress, OR = 2.42, [1.11, 5.24], and personality disorder, OR = 4.61, 95% CI [2.02, 10.52] for women. Implications include that medical forms should include gender identity and biological gender and that MST treatment should be culturally competent.

Implementation of video telehealth to improve access to evidence-based psychotherapy for posttraumatic stress disorder.

BACKGROUND: Increasing access to psychotherapy for posttraumatic stress disorder (PTSD) is a primary focus of the Department of Veterans Affairs (VA) healthcare system. Delivery of treatment via video telehealth can expand availability of treatment and be equally effective as in-person treatment. Despite VA efforts, barriers to establishing telehealth services remain, including both provider acceptance and organizational obstacles. Thus, development of specific strategies is needed to implement video telehealth services in complex healthcare systems, like the VA. MATERIALS AND METHODS: This project was guided by the Promoting Action on Research Implementation in Health Services framework and used external facilitation to increase access to psychotherapy via video telehealth. The project was conducted at five VA Medical Centers and their associated community clinics across six states in the South Central United States. RESULTS: Over a 21-month period, 27 video telehealth clinics were established to provide greater access to evidence-based psychotherapies for PTSD. Examination of change scores showed that participating sites averaged a 3.2-fold increase in unique patients and a 6.5-fold increase in psychotherapy sessions via video telehealth for PTSD. Differences between participating and nonparticipating sites in both unique patients and encounters were significant (p=0.041 and p=0.009, respectively). Two groups emerged, separated by degree of engagement in the facilitation intervention. Facilitation was perceived as useful by providers. CONCLUSIONS: To our knowledge, this is the first prospective study of external facilitation as an implementation strategy for telehealth. Our findings suggest that external facilitation is an effective and acceptable strategy to support providers as they establish clinics and make complex practice changes, such as implementing video telehealth to deliver psychotherapy.

Reconceptualizing cancer survivorship through veterans' lived experiences.

This study assessed the biopsychosocial impact of cancer on Veteran older adult survivors by garnering their accounts of their illness experiences. A narrative analysis of 73 cancer diagnosis and treatment stories reveals five "paths” Veterans are taking 18 months postdiagnosis. These paths indicate that cancer survivorship cannot be conceptualized as a one-size-fits-all experience but rather is a process of Veterans understanding and making sense of the effects of cancer on their lives. Our future goal is to develop a screening tool to help clinicians identify a patient's "path" to tailor survivorship care to meet specific needs.

A review of implementation research funded by the National Institute on Drug Abuse, 2007-2023: Progress and opportunities.

BACKGROUND: The ongoing and evolving overdose epidemic highlights the need to translate research results into routine clinical practice to address urgent service delivery needs. Implementation science is a relatively new discipline intended to develop systematic, replicable, scalable strategies to accelerate this translation. This article presents a comprehensive review of implementation research funded by the National Institute on Drug Abuse (NIDA). METHODS: The study identified all NIDA-funded research grants awarded in fiscal years 2007 through 2023 in treatment services or prevention research (n = 1111) and screened them to find those with a pre-specified implementation science component (n = 248). Using the text of the grant application, two reviewers independently coded the key characteristics of each study. RESULTS: The characteristics of these grants, and trends over time, are described, and priority gap areas are identified. NIDA's implementation research grants have demonstrated increasing rigor in design and measurement. CONCLUSIONS: Growth in the portfolio has been driven in part by NIDA's investments in research-practice partnerships in the criminal-legal system, and by recent efforts to address the overdose epidemic.

Cancer survivor rehabilitation and recovery: protocol for the Veterans Cancer Rehabilitation Study (Vet-CaRes).

BACKGROUND: Cancer survivors are a rapidly growing and aging population in the U.S., but there are many challenges associated with the survivorship experience such as functional disabilities and psychosocial distress. When viewed next to the general population, Veterans are especially at risk for these challenges as they are older and have a high incidence of co-morbid conditions. While the Institute of Medicine (IOM) has called for further cancer survivorship research to address these challenges, we still know little about this experience from the perspective of aging Veterans. METHODS/DESIGN: We conducted a longitudinal, mixed-methods study over the course of three and a half years at the Boston and Houston VA Medical Centers. We recruited 170 Veterans diagnosed with head and neck, colorectal and esophageal/gastric cancers that were identified from the VA tumor registry. Veterans completed three in-depth interviews, conducted at 6, 12 and 18 months after pathology confirmation, measuring the physical, social and psychological factors related to cancer survivorship. The longitudinal design allowed us to assess any changes in cancer related disability and distress over time. DISCUSSION: Weekly teleconference study team meetings were a key aspect to the research process. Issues related to recruitment, data management and analysis, and the dissemination of research results was discussed. Interviewers presented detailed case reports of completed interviews that allowed us to refine our interview protocols. We also discussed issues relevant to the Veteran population of which we were previously unaware and some of the challenges of the research process itself. This novel study produced a robust data set that documents the functional and psychosocial cancer survivorship experiences of aging Veterans. The longitudinal design will help us more fully understand the recovery patterns for this specific population, and identify the unique needs and gaps in health services.

Spatiotemporal distribution and population structure of Monokalliapseudes schubarti (Tanaidacea: Kalliapseudidae) in an estuary in Southern Brazil.

Monokalliapseudes schubarti is an endemic tanaidacean microcrustacean from southeastern Brazil to Uruguay inhabiting low energy estuaries. Saco da Fazenda is located in the estuary of the Itajaí-Açú River, state of Santa Catarina, Brazil. It is exposed to strong anthropic impact and receives intensive flows of domestic wastewater, solid residues, and drainage activities. Specimens of M. schubarti were collected monthly, in the intertidal and subtidal regions of Saco da Fazenda, in four stations defined as a function of the physiography of the environment during the period of July 2003 to June 2004. Fecundity values were high, with continuous reproductive activity during the whole period of study. The greatest population densities were observed in the intertidal region, where they are nevertheless intensely consumed by birds, swimming crabs, and fish. This species represents a fundamental link in the food chain of Saco da Fazenda, transferring energy from the detritus level to higher trophic levels. Habitat disturbance and high organic matter may represent factors controlling the distribution of populations of M. schubarti. For this reason, the species may be used to monitor anthropic effects in estuarine areas.

An Overview of Rhodoliths: Ecological Importance and Conservation Emergency.

Red calcareous algae create bio-aggregations ecosystems constituted by carbonate calcium, with two main morphotypes: geniculate and non-geniculate structures (rhodoliths may form bio-encrustations on hard substrata or unattached nodules). This study presents a bibliographic review of the order Corallinales (specifically, rhodoliths), highlighting on morphology, ecology, diversity, related organisms, major anthropogenic influences on climate change and current conservation initiatives. These habitats are often widespread geographically and bathymetrically, occurring in the photic zone from the intertidal area to depths of 270 m. Due to its diverse morphology, this group offers a special biogenic environment that is favourable to epiphyte algae and a number of marine invertebrates. They also include holobiont microbiota made up of tiny eukaryotes, bacteria and viruses. The morphology of red calcareous algae and outside environmental conditions are thought to be the key forces regulating faunistic communities in algae reefs. The impacts of climate change, particularly those related to acidification, might substantially jeopardise the survival of the Corallinales. Despite the significance of these ecosystems, there are a number of anthropogenic stresses on them. Since there have been few attempts to conserve them, programs aimed at their conservation and management need to closely monitor their habitats, research the communities they are linked with and assess the effects they have on the environment.

Life disruption, life continuation: contrasting themes in the lives of African-American elders with advanced heart failure.

This study addresses the need for more information about how urban African-American elders experience advanced heart failure. Participants included 35 African Americans aged 60 and over with advanced heart failure, identified through records from a community hospital in Detroit, Michigan. Four focus groups (n = 13) and 22 individual interviews were conducted. We used thematic analysis to examine qualitative focus groups and interviews. Themes identified included life disruption, which encompassed the sub-themes of living scared, making sense of heart failure, and limiting activities. Resuming life was a contrasting theme involving culturally relevant coping strategies, and included the sub-themes of resiliency, spirituality, and self-care that helped patients regain and maintain a sense of self amid serious illness. Participants faced numerous challenges and invoked a variety of strategies to cope with their illness, and their stories of struggles, hardship, and resilience can serve as a model for others struggling with advanced illness.

Veteran stroke survivors' lived experiences after being discharged home: a phenomenological study.

BACKGROUND: Stroke is a leading cause of disability in adults and third cause of death in the United States. Survivors face challenges postdischarge, including risks in self-management (SM) following prescribed regimens. Although SM education can help develop skills to control risk factors for stroke recurrence, little is known about lived experiences of patients adopting SM. AIMS: To examine Veterans' lived poststroke experiences after discharge and their experiences in SM goal setting/attainment. METHODS: Patients within one year of discharge from a Veterans Administration Medical Center in the United States with two risk factors for stroke recurrence were enrolled and received an SM workbook. Eight patients were interviewed (six males, two females; mean age 62: range 45-80). Part I concerned lived experience. Part II described experiences with goal setting and attainment. Data were analyzed inductively, identifying common experiences. Deductive analysis described goal setting and attainment. Transcript reviews identified SM themes and strategies. RESULTS: Lived experiences included 1) uncertainty about life, 2) anger and frustration, and 3) healthcare system challenges. Coping skills and setting goals to manage risks were critical for physical and emotional functioning. CONCLUSIONS: SM coping and goal setting aided recovery and improved life quality among Veterans after stroke. SM interventions assisted in regaining physical and emotional function. Findings may help in design of interventions for survivors, using SM and goal setting and attainment.IMPLICATIONS FOR REHABILITATIONSeveral implications for clinical practice were identified:Providers should acknowledge Veterans' challenges and struggles after their stroke and help Veterans to re-establish social identity, enhance self-esteem and improve mood.More emphasis should be given to the Veterans' caregivers' availability and willingness to help with their loved one's recovery, work reinstatement status and financial struggles.Recognition of the importance of the social context of recovery after a stroke is important, as nonmedical social interaction is often overlooked.Improvements are needed in the area of providers working with social workers and physical, occupational and mental health therapists to arrange more inpatient and outpatient treatments, including more frequent home visits.Veterans should be strongly encouraged to attend self-management diabetes education classes and smoking cessation and weight-loss programs offered for free within the Veterans Health Administration system.Self-management strategies using goal-setting and attainment concepts may assist individuals with stroke to regain physical and emotional functions, subsequently preventing another stroke.

Factors Affecting Adoption of Coordinated Anxiety Learning and Management (CALM) in Veterans' Affairs Community-Based Outpatient Clinics.

PURPOSE: Many US military veterans experience anxiety, depression, and trauma-related disorders. A major goal of the Veterans Health Administration (VHA) has been to increase access to evidence-based psychotherapies (EBPs) such as cognitive-behavioral therapy to address veterans' substantial health burden. However, despite widespread implementation of EBPs throughout the VHA, smaller clinics that often serve rural veterans face barriers to delivering these interventions. The Veterans Affairs Coordinated Anxiety Learning and Management (VA CALM) program aims to empower providers in rural areas with varying levels of training and experience in delivering EBPs to provide high-quality cognitive-behavioral therapy for anxiety, depression, and trauma-related disorders. The goal of this study was to better understand, through qualitative interviews, VHA community-based outpatient clinic providers' perspectives on implementing VA CALM. METHODS: Qualitative interviews with providers (N = 22) were conducted to understand implementation of VA CALM. Template analysis was used to organize and summarize responses. FINDINGS: Providers noted several facilitators for implementing VA CALM in rural community clinics, including its perceived effectiveness, broad applicability, and structure. Barriers to implementation included scheduling problems and patient-related barriers. CONCLUSIONS: Incorporating providers' perspectives on factors that affect implementing cognitive-behavioral therapy in this setting may inform future efforts to disseminate-implement EBPs in smaller, more remote VHA clinics.

Experiences of veterans with spinal cord injury related to annual urine screening and antibiotic use for urinary tract infections.

INTRODUCTION: Antimicrobial-resistant bacterial infections are an increasing public health threat and people with spinal cord injury (SCI) are disproportionally at higher risk. National guidelines concerning urine testing after SCI are conflicting. Unnecessary urine testing in the SCI population (with high asymptomatic bacteriuria prevalence) leads to unnecessary antimicrobial use, propagating resistant infections, especially urinary tract infections (UTIs). OBJECTIVES: (a) Describe UTI antimicrobial adherence in patients with SCI. (b) Explore SCI patient knowledge and attitudes toward current urine testing and treatment practices. DESIGN: Mixed methods. SETTING: Veterans Health Administration (VHA) patients with SCI. PARTICIPANTS: Veterans identified as having SCI seen at a VHA facility nationwide. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Self-reported medication adherence, patient beliefs and behaviors toward UTIs and antimicrobial use. RESULTS: A total of 105 Morisky Medication Adherence Scale-8 (MMAS-8) surveys were completed out of 369 distributed surveys (28% response rate). Overall, patients reported high medication adherence (mean score of 7.2/8, with 8 being a perfect adherence score). Ten qualitative interviews were completed. Themes identified include generally high adherence to prescribed antimicrobial courses and high levels of patient satisfaction with current outpatient VHA SCI bladder care. The quantitative findings converge with these themes observed in the qualitative interviews; patients were satisfied with current urine testing and treatment practices. CONCLUSIONS: Veterans with SCI are generally satisfied with their current UTI management and self-report taking antimicrobials for UTIs as prescribed. Veterans with SCI typically report high trust in their SCI providers and value their advice on bladder care management. Therefore, it is imperative for clinicians to provide evidence-based education to patients, as well as ensure that each prescribed course of antibiotics for UTI is clinically necessary. Information from this study will guide an intervention promoting appropriate urine testing and antimicrobial prescription practices by SCI providers.

A Web-Based, Population-Based Cirrhosis Identification and Management System for Improving Cirrhosis Care: Qualitative Formative Evaluation.

BACKGROUND: Cirrhosis, or scarring of the liver, is a debilitating condition that affects millions of US adults. Early identification, linkage to care, and retention of care are critical for preventing severe complications and death from cirrhosis. OBJECTIVE: The purpose of this study is to conduct a preimplementation formative evaluation to identify factors that could impact implementation of the Population-Based Cirrhosis Identification and Management System (P-CIMS) in clinics serving patients with cirrhosis. P-CIMS is a web-based informatics tool designed to facilitate patient outreach and cirrhosis care management. METHODS: Semistructured interviews were conducted between January and May 2016 with frontline providers in liver disease and primary care clinics at 3 Veterans Health Administration medical centers. A total of 10 providers were interviewed, including 8 physicians and midlevel providers from liver-related specialty clinics and 2 primary care providers who managed patients with cirrhosis. The Consolidated Framework for Implementation Research guided the development of the interview guides. Inductive consensus coding and content analysis were used to analyze transcribed interviews and abstracted coded passages, elucidated themes, and insights. RESULTS: The following themes and subthemes emerged from the analyses: outer setting: needs and resources for patients with cirrhosis; inner setting: readiness for implementation (subthemes: lack of resources, lack of leadership support), and implementation climate (subtheme: competing priorities); characteristics of individuals: role within clinic; knowledge and beliefs about P-CIMS (subtheme: perceived and realized benefits; useful features; suggestions for improvement); and perceptions of current practices in managing cirrhosis cases (subthemes: preimplementation process for identifying and linking patients to cirrhosis care; structural and social barriers to follow-up). Overall, P-CIMS was viewed as a powerful tool for improving linkage and retention, but its integration in the clinical workflow required leadership support, time, and staffing. Providers also cited the need for more intuitive interface elements to enhance usability. CONCLUSIONS: P-CIMS shows promise as a powerful tool for identifying, linking, and retaining care in patients living with cirrhosis. The current evaluation identified several improvements and advantages of P-CIMS over current care processes and provides lessons for others implementing similar population-based identification and management tools in populations with chronic disease.

Personalized implementation of video telehealth for rural veterans (PIVOT-R).

BACKGROUND: A national shortage of mental health (MH) professionals leaves more than 90% of rural individuals without adequate access to services each year, troubling because 33% of Veterans Health Administration (VHA) enrollees live in rural areas and rural Veterans have a greater risk of suicide than urban Veterans. Additional barriers such as travel distance and cost, stigma and extreme weather or geography add to challenges of rural Veterans seeking treatment. Although the VHA has addressed this disparity by providing telemental health services, provision of services via traditional hub-and-spoke and/or establishment of regional centers has not fully addressed barriers or resource limitations. Video telehealth to home (VTH) has assisted in better addressing geographic, attitudinal and systematic barriers to in-person care; however, its uptake and implementation have been problematic. This article describes the Personalized Implementation of Video Telehealth for Rural Veterans (PIVOT-R) approach, developed in response to the unique needs of rural veterans. METHODS: We developed PIVOT, a flexible implementation strategy that is adaptive to site-specific contexts and different digital innovations and relies on a collaborative relationship between external facilitators, internal facilitators and clinical champions. We used formative evaluation (FE) to gather ongoing information about our quality improvement (QI) implementation approach of VTH. Our FE of PIVOT at rural sites provided insight into adaptations to improve rural implementation. This led to development of PIVOT-R, which explicitly focuses on rural implementation. PIVOT-R, developed from provider and patient feedback plus lessons learned during implementation, focuses on rurality as an important diversity factor and addresses relationship building, engaging the site, assessing context and infrastructure and balancing national expectations with site-level goals. During fiscal year 2018 we partnered with a VHA healthcare system in a Western mountain state to pilot the PIVOT-R approach, again using FE which included quantitative and qualitative data collection to evaluate its impact. RESULTS: PIVOT-R effectively increased uptake of VTH for MH care at the healthcare system evaluated. In fiscal year 2019 the percentage of Veterans receiving MH care via VTH at the site was 10 times greater than in fiscal year 2018, matching the mean VHA nationwide percentage and increasing by 43.24% by the end of 2019. Veteran feedback supported a positive experience by users. CONCLUSIONS: Inclusion of a comprehensive assessment of the rural system, including infrastructure and resources, greatly improves understanding of a system's specific needs and enables a tailored approach targeting relevant barriers. Our FE suggests the potential of PIVOT-R to increase VTH uptake at other rural locations and reinforces the value of telehealth technology as an important resource for rural sites.

Three new species of Androdeloscia Leistikow, 1999 (Oniscidea: Philosciidae) from the Brazilian Amazonia.

Three new species of Androdeloscia Leistikow, 1999 from the Brazilian Amazonian rainforest are described. Androdeloscia bicornuata sp. nov., A. paraleilae sp. nov., and A. micropunctata sp. nov. were distinguished from the 26 other species of the genus mainly based on the shape of male pleopod I endopod. Androdeloscia bicornuata sp. nov. differs from all the species in the genus by the complex morphology of the distal portion of the male pleopod I endopod bearing hyaline lamella and two horn-like tips. Androdeloscia paraleilae sp. nov. is characterized by the male pleopod I endopod with simple distal portion, without hyaline lamella, and apex represented by a curved tip and inner margin serrate proximally; and by the concavity on the lateral margin of the first maxilla (except for the A. leilae that is related to other listed characteristics). Androdeloscia micropunctata sp. nov. differs from the remaining species of the genus by the male pleopod I endopod with simple distal portion, without hyaline lamella, and apex truncate bearing a small acute tip in the outer corner; and 5+5 teeth on the first maxilla. Some characters related to the genus are later discussed.