Iraq and Afghanistan veterans: national findings from VA residential treatment programs.

A quality improvement effort was undertaken in Department of Veterans Affairs' (VA) residential treatment programs for Posttraumatic Stress Disorder (PTSD) across the United States. Qualitative interviews were conducted with over 250 directors, providers, and staff during site visits of 38 programs. The aims of this report are to describe clinical issues and distinctive challenges in working with veterans from Iraq and Afghanistan and approaches to addressing their needs. Providers indicated that the most commonly reported problems were: acute PTSD symptomatology; other complex mental health symptom presentations; broad readjustment problems; and difficulty with time demands of and readiness for intensive treatment. Additional concerns included working with active duty personnel and mixing different eras in therapy. Programmatic solutions address structure (e.g., blended versus era-specific therapy), content (e.g., physical activity), and adaptations (e.g., inclusion of family; shortened length of stay). Clinical implications for VA managers and policy makers as well as non-VA health care systems and individual health care providers are noted.

A formative evaluation of two evidence-based psychotherapies for PTSD in VA residential treatment programs.

Between July 2008 and March 2011, 38 U.S. Department of Veterans Affairs (VA) residential treatment programs for posttraumatic stress disorder (PTSD) participated in a formative evaluation of their programmatic services, including evidenced-based treatments (EBTs). Face-to-face qualitative interviews were conducted with over 250 staff by an independent psychologist along with onsite participant observations. This evaluation coincided with a national VA dissemination initiative to train providers in two EBTs for PTSD: prolonged exposure (PE) and cognitive processing therapy (CPT). A substantial proportion of eligible (based on professional background) residential treatment providers received training in PE (37.4%) or CPT (64.2%), with 9.5% completing case consultation or becoming national trainers in each therapy respectively. In semistructured interviews, providers reported that their clinical programs had adopted these EBTs at varying levels ranging from no adoption to every patient receiving the full protocol. Suggestions for improving the adoption of PE and CPT are noted, including distilling manualized treatments to essential common elements.

Measurement of a model of implementation for health care: toward a testable theory.

BACKGROUND: Greenhalgh et al. used a considerable evidence-base to develop a comprehensive model of implementation of innovations in healthcare organizations [1]. However, these authors did not fully operationalize their model, making it difficult to test formally. The present paper represents a first step in operationalizing Greenhalgh et al.'s model by providing background, rationale, working definitions, and measurement of key constructs. METHODS: A systematic review of the literature was conducted for key words representing 53 separate sub-constructs from six of the model's broad constructs. Using an iterative process, we reviewed existing measures and utilized or adapted items. Where no one measure was deemed appropriate, we developed other items to measure the constructs through consensus. RESULTS: The review and iterative process of team consensus identified three types of data that can been used to operationalize the constructs in the model: survey items, interview questions, and administrative data. Specific examples of each of these are reported. CONCLUSION: Despite limitations, the mixed-methods approach to measurement using the survey, interview measure, and administrative data can facilitate research on implementation by providing investigators with a measurement tool that captures most of the constructs identified by the Greenhalgh model. These measures are currently being used to collect data concerning the implementation of two evidence-based psychotherapies disseminated nationally within Department of Veterans Affairs. Testing of psychometric properties and subsequent refinement should enhance the utility of the measures.

Older women survivors of physical and sexual violence: a systematic review of the quantitative literature.

BACKGROUND: This systematic review synthesizes the quantitative empirical literature concerning older women survivors of physical and sexual assault. METHODS: A literature search was conducted using a range of scholarly databases. Information is presented here on the prevalence, correlates, and consequences of these types of interpersonal violence in older women. Additionally, age-related differences in prevalence, psychiatric distress, and characteristics of violence, including information on perpetrators, are reviewed. RESULTS: Overall, older women report lower lifetime and past year rates of physical and sexual assault and associated negative psychologic consequences compared to younger and middle-aged women. Additionally, older women who experienced interpersonal violence report greater psychiatric distress, including posttraumatic stress disorder (PTSD), than older women who have not experienced such events. CONCLUSIONS: Some women who have been physically or sexually assaulted decades earlier in life continue to report significant levels of PTSD well into older adulthood. Gaps in the literature, including lack of information on ethnicity and culture, are presented, and future research directions are proposed.

Allergic reactions to gadodiamide following interventional spinal procedures: a report of 4 cases.

Gadodiamide is currently considered a safe alternative for use in interventional spinal procedures in persons with a documented allergic response to iodine-based contrast dyes and with adequate renal function. The most common reactions to gadodiamide are nausea, emesis, and headache. These reactions usually are self-limited and are reported to occur in less than 1% of patients. We report the cases of 4 patients who developed an allergic reaction to gadodiamide, 3 of whom presented within the same week, after minimally invasive interventional spinal procedures at an outpatient private practice facility. Furthermore, 3 of the 4 patients had previously been exposed to gadodiamide during prior interventional spinal procedures without reaction, and the fourth patient had a reaction on the first exposure. The clinical presentation was manifested as a rash in 3 of the 4 patients, whereas the fourth patient experienced fevers and rigors along with rash. Because the injections of gadodiamide were not administered in succession, different vials of gadodiamide were used in each patient, and the injections were given by different clinicians at different spinal levels, we hypothesize that these patients experienced an allergic reaction, rather than contamination of the gadodiamide solution. These cases may call into question the safety of gadodiamide as an alternative contrast agent.

Verbal and physical aggression in World War II former prisoners of war: role of posttraumatic stress disorder and depression.

This study examined the relationship among posttraumatic stress disorder (PTSD), depression, and intimate partner relationship aggression in a community sample of World War II (WWII) male military former prisoners of war (POWs). Sixty percent of these POWs reported verbal aggression in their marriages, and 12% endorsed physical aggression. Both verbal and physical aggression were significantly correlated to the severity of captivity trauma and to PTSD symptoms. Posttraumatic stress disorder symptoms significantly mediated the relationship between severity of trauma and both verbal and physical aggression. Depression was a significant moderator of the relationship between PTSD and both physical and verbal aggression. Theoretical and clinical implications are suggested.

Prosthetic management of the partial foot amputee.

Partial foot amputations provide advantages and challenges to the patient confronting loss of limb and the rehabilitation team. The partial foot amputation offers the potential for retention of plantar load-bearing tissues that are capable of tolerating the forces involved in weight bearing; this can allow the patient to ambulate with or without a prosthesis. Because of the complexity of the foot-ankle complex and the multiple types of partial foot amputations encountered, choosing the appropriate prosthesis can be challenging. This article explains some of the rationale and common options available for the different levels of amputation.

Assessment and psychological treatment of posttraumatic stress disorder in older adults.

Knowledge regarding the assessment and treatment of posttraumatic stress disorder in older adults continues to be limited in both psychological research and practice. This article provides a summary of this literature. In particular, the psychometric properties of several posttraumatic stress disorder assessment measures in their use with older individuals are reviewed. Although the evidence base on effective treatments for posttraumatic stress disorder in older adults is virtually nonexistent, this article highlights the innovative clinical endeavors that have been conducted in this regard. Explicit suggestions for best practices are made.

Identifying and managing shoulder pain in competitive swimmers: how to minimize training flaws and other risks.

Shoulder pain resulting from glenohumeral instability is common among competitive swimmers. The biomechanics inherent to swimming promote muscular imbalances that stress the capsuloligamentous structures and contribute to shoulder instability. Most swimmers respond favorably to conservative treatment of rest and rehabilitation, while a small percentage may ultimately require surgical intervention. Swimmers who respond well to rehabilitation have a better prognosis for a successful return to swimming than those who require surgery. Overall, education in proper stroke and training techniques can minimize the likelihood that a competitive swimmer will experience disabling shoulder pain.