Mental health therapists' perceived barriers to addressing intimate partner violence and suicide.

INTRODUCTION: Intimate partner violence (IPV) and suicide are pressing public health issues, yet their intersection in mental health care settings is understudied. We conducted a qualitative study to characterize mental health therapists' personal and system barriers in preparation for an upcoming training curriculum seeking to help patients address these interconnected issues. METHOD: We partnered with an urban community mental health center in New York to facilitate focus groups grounded in community-based participatory research principles. Twenty-three therapists formed 3 focus groups. Participant responses were audio-recorded, transcribed, and coded using Bronfenbrenner's socioecological model. We performed a primary qualitative framework analysis, coding for therapist barriers in addressing the intersection of IPV-suicide at individual, relational, community, and societal levels. RESULTS: Therapists perceived numerous barriers in all 4 domains. Individually, some struggled with feelings of helplessness and a lack of appropriate training. At the relational level, therapists expressed apprehension about harming the therapeutic relationship by discussing IPV and suicide at length. From a community perspective, therapists voiced concerns for clients' limited local access to support systems and financial resources. Societal barriers included policy-related limitations such as length of appointment times. DISCUSSION: Community mental health center therapists face considerable barriers working with patients affected by IPV and suicide. The socioecological model is a fitting framework for understanding multisystem barriers at individual, relational, community, and societal levels. A better understanding of these challenges is critical for advancing therapist education, enhancing patient outcomes, and improving health systems. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The Effects of Fault-Zone Cementation on Groundwater Flow at the Field Scale.

Fault zones are an important control on fluid flow, affecting groundwater supply, contaminant migration, and carbon storage. However, most models of fault seal do not consider fault zone cementation, despite the recognition that it is common and can dramatically reduce permeability. In order to study the field-scale hydrogeologic effects of fault zone cementation, we conducted a series of aquifer pumping tests in wells installed within tens of meters of the variably cemented Loma Blanca Fault, a normal fault in the Rio Grande Rift. In the southern half of the study area, the fault zone is cemented by calcite; the cemented zone is 2-8 m wide. In the center of the study area, the cemented fault zone is truncated at a buttress unconformity that laterally separates hydrostratigraphic units with a ∼40X difference in permeability. The fault zone north of the unconformity is not cemented. Constant rate pumping tests indicate that where the fault is cemented, it is a barrier to groundwater flow. This is an important demonstration that a fault with no clay in its core and similar sediment on both sides can be a barrier to groundwater flow by virtue of its cementation; most conceptual models for the hydrogeology of faults would predict that it would not be a barrier to groundwater flow. Additionally, the lateral permeability heterogeneity across the unconformity imposes another important control on the local flow field. This permeability discontinuity acts as either a no-flow boundary or a constant head boundary, depending on the location of pumping.

Effects of Kainic Acid-Induced Auditory Nerve Damage on Envelope-Following Responses in the Budgerigar (Melopsittacus undulatus).

Sensorineural hearing loss is a prevalent problem that adversely impacts quality of life by compromising interpersonal communication. While hair cell damage is readily detectable with the clinical audiogram, this traditional diagnostic tool appears inadequate to detect lost afferent connections between inner hair cells and auditory nerve (AN) fibers, known as cochlear synaptopathy. The envelope-following response (EFR) is a scalp-recorded response to amplitude modulation, a critical acoustic feature of speech. Because EFRs can have greater amplitude than wave I of the auditory brainstem response (ABR; i.e., the AN-generated component) in humans, the EFR may provide a more sensitive way to detect cochlear synaptopathy. We explored the effects of kainate- (kainic acid) induced excitotoxic AN injury on EFRs and ABRs in the budgerigar (Melopsittacus undulatus), a parakeet species used in studies of complex sound discrimination. Kainate reduced ABR wave I by 65-75 % across animals while leaving otoacoustic emissions unaffected or mildly enhanced, consistent with substantial and selective AN synaptic loss. Compared to wave I loss, EFRs showed similar or greater percent reduction following kainate for amplitude-modulation frequencies from 380 to 940 Hz and slightly less reduction from 80 to 120 Hz. In contrast, forebrain-generated middle latency responses showed no consistent change post-kainate, potentially due to elevated "central gain" in the time period following AN damage. EFR reduction in all modulation frequency ranges was highly correlated with wave I reduction, though within-animal effect sizes were greater for higher modulation frequencies. These results suggest that even low-frequency EFRs generated primarily by central auditory nuclei might provide a useful noninvasive tool for detecting synaptic injury clinically.

"They didn't give up on me": a women's transitions clinic from the perspective of re-entering women.

BACKGROUND: Women recently released from incarceration have increased rates of co-occurring substance use, physical health, and mental health disorders. During re-entry, they face challenges navigating needed health services and social services stemming from these problems. Women's Initiative Supporting Health Transitions Clinic (WISH-TC) is a primary care program that facilitates treatment access for re-entering women. Strategies include support and navigation assistance from peer community health workers. METHODS: Thirteen participants, of whom 11 had a substance use disorder, completed semi-structured interviews about their experiences in WISH-TC as part of a process evaluation. We conducted a qualitative framework analysis informed by self-determination theory. RESULTS: WISH-TC supported autonomy as staff helped motivate women to work toward personal health goals. Women were empowered to have their health needs met, and consequently, prioritized attending clinic. Regarding competence, WISH-TC built upon women's existing knowledge to increase their health literacy and better understand their individual health needs. Relatedness support, both prior to re-entry and ongoing with clinic staff, was key in women's satisfaction with their care. The clinic made procedural changes in response to the interviews, including providing orientation for the patients and training the clinic in trauma-informed practices. CONCLUSIONS: Our findings highlight the potential of a program for re-entering women, including those with substance use disorders to strengthen their abilities to navigate complex healthcare and societal systems. WISH-TC helped women feel supported, motivated, and competent to address their substance use, physical, and mental health conditions.

Outcomes among pregnant recently incarcerated women attending a reentry transitions clinic.

This mixed methods retrospective case series and qualitative descriptive study describes pregnancy outcomes during the postincarceration period. A retrospective case series via electronic medical record chart review from a subset of women attending a postincarceration primary care clinic with a condition of interest (pregnancy) described demographics, substance use, diagnoses, and pregnancy outcomes. We compared 27 pregnant to 79 nonpregnant women and contextualized quantitative data with qualitative descriptive vignettes. Twenty-seven women completed 29 pregnancies (2 women with 2 deliveries each), all of which were unplanned; there were 11 live births, 8 pregnant at study closure, 7 miscarriages, and 3 terminations. Although substance use history was high, rates were higher among nonpregnant women (92% vs 74%). Among the 5 births, 4 tested positive for substance use during pregnancy. All 11 infants had pregnancy or delivery complications. Although 7 of the 10 pregnant women with live births had prior pregnancy complications, only 4 were placed in a special care obstetrics clinic. Although unplanned pregnancies were common, most births did not demonstrate maternal substance use. All live births had pregnancy or delivery complications, but few were accepted to specialist prenatal care, suggesting potential considerations for recently incarcerated women.

IDENTIFYING PREDICTORS OF SUBSTANCE USE AND RECIDIVISM OUTCOME TRAJECTORIES AMONG DRUG TREATMENT COURT CLIENTS.

Drug treatment court (DTC) is a diversion program for individuals with drug-related crimes. However, the DTC literature is conflicting with regard to substance use and recidivism outcomes. This study examines factors associated with improved client outcome trajectories among a multisite, national DTC sample. We conducted a secondary analysis of 2,295 participants using the Global Appraisal of Individual Needs assessment tool. Participants in community-based treatment comprised a nonequivalent comparison group. Zero-inflated Poisson (ZIP) regression examined client sociodemographics in relation to substance use and rearrest at 6-month follow-up. Employed DTC clients were more likely to abstain from substances, but among all study participants, higher baseline use, male gender, and employment predicted substance use. Similarly, among DTC clients, older age and employment predicted no rearrests, but among all study participants, older and employed individuals had worse arrest outcome trajectories. Future work is needed to better understand how client characteristics may inform individualized treatment approaches.

Does a Primary Health Clinic for Formerly Incarcerated Women Increase Linkage to Care?

OBJECTIVE: This study examined a primary care-based program to address the health needs of women recently released from incarceration by facilitating access to primary medical, mental health, and substance use disorder (SUD) treatment. STUDY DESIGN: Peer community health workers recruited women released from incarceration within the past 9 months into the Women's Initiative Supporting Health Transitions Clinic (WISH-TC). Located within an urban academic medical center, WISH-TC uses cultural, gender, and trauma-specific strategies grounded in the self-determination theory of motivation. Data abstracted from intake forms and medical charts were examined using bivariate and multivariable regression analyses. RESULTS: Of the 200 women recruited, 100 attended the program at least once. Most (83.0%) did not have a primary care provider before enrollment. Conditions more prevalent than in the general population included psychiatric disorders (94.0%), substance use (90.0%), intimate partner violence (66.0%), chronic pain (66.0%), and hepatitis C infection (12.0%). Patients received screening and vaccinations (65.9%-87.0%), mental health treatment (91.5%), and SUD treatment (64.0%). Logistic regression revealed that receipt of mental health treatment was associated with number of psychiatric (adjusted odds ratio [AOR], = 4.09; p < .01), and social/behavioral problems (AOR, 2.67; p = .04), and higher median income (AOR, 1.07; p = .05); African American race predicted lower receipt of SUD treatment (AOR, 0.08; p < .01). CONCLUSIONS: An innovative primary care transitions program successfully helped women recently released from incarceration to receive medical, mental health, and SUD treatment. Primary care settings with specialty programs, including community health workers, may provide a venue to screen, assess, and help recently incarcerated women access needed care.

"Our commonality is our past:" a qualitative analysis of re-entry community health workers' meaningful experiences.

BACKGROUND: Re-entry community health workers (CHWs) are individuals who connect diverse community residents at risk for chronic health issues such as Hepatitis C virus and cardiovascular disease with post-prison healthcare and re-entry services. While the utilization of CHWs has been documented in other marginalized populations, there is little knowledge surrounding the work of re-entry CHWs with individuals released from incarceration. Specifically, CHWs' experiences and perceptions of the uniqueness of their efforts to link individuals to healthcare have not been documented systematically. This study explored what is meaningful to formerly incarcerated CHWs as they work with released individuals. METHODS: The authors conducted a qualitative thematic analysis of twelve meaningful experiences written by re-entry CHWs employed by the Transitions Clinic Network who attended a CHW training program during a conference in San Francisco, CA. Study participants were encouraged to recount meaningful CHW experiences and motivations for working with re-entry populations in a manner consistent with journal-based qualitative analysis techniques. Narratives were coded using an iterative process and subsequently organized according to themes in ATLAS.ti. Study personnel came to consensus with coding and major themes. RESULTS: The narratives highlighted thought processes and meaning related to re-entry CHWs' work helping patients navigate complex social services for successful re-integration. Six major themes emerged from the analysis: advocacy and support, empathy relating to a personal history of incarceration, giving back, professional satisfaction and responsibilities, resiliency and educational advancement, and experiences of social inequities related to race. Re-entry CHWs described former incarceration, employment, and social justice as sources of meaning for assisting justice-involved individuals receive effective, efficient, and high-quality healthcare. CONCLUSIONS: Health clinics for individuals released from incarceration provide a unique setting that links high risk patients to needed care and professionalizes career opportunities for formerly incarcerated re-entry CHWs. The commonality of past correctional involvement is a strong indicator of the meaning and perceived effectiveness re-entry CHWs find in working with individuals leaving prison. Expansion of reimbursable visits with re-entry CHWs in transitions clinics designed for re-entering individuals is worthy of further consideration.

Meeting health and psychological needs of women in drug treatment court.

We explored healthcare-related experiences of women drug court participants through combining context from the socio-ecological model with motivation needs for health behavior as indicated by self-determination theory. Five focus groups with 8 women drug court participants, 8 court staff, and 9 community service providers were examined using qualitative framework analysis. Themes emerged across the socio-ecological model and were cross-mapped with self-determination theory-defined motivation needs for autonomy, relatedness, and competence. Socio-ecological levels contained experiences either supporting or eroding women's motivation needs: (1) intrapersonal challenges participants termed an "evil cycle" of relapse, recidivism, trauma, and life challenges; (2) interpersonal context of parenting and stigma involving features of this "evil cycle"; (3) institutions with logistical barriers to legal and medical assistance; (4) community resources inadequate to support living and employment needs. Self-determination theory helps explain motivation required to address the women's healthcare needs and multiple demands at all levels of the socio-ecological model.

Institutional variation in the surgical treatment of breast cancer: a study of the NCCN.

OBJECTIVE: To investigate the relationship between supply of subspecialty care and type of procedure preferentially performed for early stage breast cancer. BACKGROUND: Three surgical options exist for early stage breast cancer: (1) breast conserving surgery (BCS), (2) mastectomy with reconstruction (RECON), and (3) mastectomy alone. Current guidelines recommend that surgical treatment decisions should be based on patient preference if a patient is eligible for all 3. However, studies demonstrate persistent variation in the use of BCS and RECON. METHODS: Patients undergoing an operation for DCIS or stage I or II breast cancer at NCCN institutions between 2000 and 2006 were identified. Institutional procedure rates were determined. Spearman correlations measured the association between procedure types. Patient-level logistic regression models investigated predictors of procedure type and association with institutional supply of subspecialty care. RESULTS: Among 10,607 patients, 19% had mastectomy alone, 60% BCS, and 21% RECON. The institutional rate of BCS and RECON were strongly correlated (r = -0.80, P = 0.02). Institution was more important than all patient factors except age in predicting receipt of RECON or BCS. RECON was more likely for patients treated at an institution with a greater supply of reconstructive surgeons or where patients live further from radiation facilities. RECON was less likely at institutions with longer waiting times for surgery with reconstruction. CONCLUSIONS: Even within the NCCN, a consortium of multidisciplinary cancer centers, the use of BCS and mastectomy with reconstruction substantially varies by institution and correlates with the supply of subspecialty care.

Concordance with NCCN Colorectal Cancer Guidelines and ASCO/NCCN Quality Measures: an NCCN institutional analysis.

BACKGROUND: The National Comprehensive Cancer Network (NCCN) Outcomes Database was created to assess concordance to evidence- and consensus-based guidelines and to measure adherence to quality measures on an ongoing basis. The Colorectal Cancer Database began in 2005 as a collaboration among 8 NCCN centers. METHODS: Newly diagnosed colon and rectal cancer patients presenting to 1 of 8 NCCN centers between September 1, 2005, and May 21, 2008, were eligible for analysis of concordance with NCCN treatment guidelines for colorectal cancer and with a set of quality metrics jointly developed by ASCO and NCCN in 2007. Adherence rates were determined for each metric. Center-specific rates were benchmarked against mean concordance rates for all participating centers. RESULTS: A total of 3443 patients were evaluable. Mean concordance rates with NCCN colorectal cancer guidelines and ASCO/NCCN quality measures were generally high ( >or= 90%). However, relatively low mean concordance rates were noted for adjuvant chemotherapy treatment recommendations within 9 months of diagnosis of stage II to III rectal cancer (81%), and neoadjuvant chemoradiation in clinical T4 rectal primaries (83%). These low rates of concordance seemed to be consistent across centers. CONCLUSIONS: Adherence to guidelines and quality measures is generally high at institutions participating in the NCCN colorectal cancer database. Lack of documentation, patient refusal, delayed treatment initiation, and lack of consensus about whether treatment was essential were the primary reasons for nonconcordance. Measurement of concordance and the reasons for nonconcordance enable participating centers to understand and improve their care delivery systems.

Factors associated with guideline-concordant use of radiotherapy after mastectomy in the national comprehensive cancer network.

PURPOSE: We examined the rates and determinants of appropriate and inappropriate use of postmastectomy radiotherapy (PMRT), as defined by the National Comprehensive Cancer Network (NCCN) practice guidelines, among women with Stage I-II breast cancer (American Joint Committee on Cancer, 5th edition). METHODS AND MATERIALS: Using clinical characteristics, 1,620 consecutive patients at eight NCCN institutions who had undergone mastectomy between July 1997 and June 2002 were classified into three cohorts according to whether the guidelines (1) recommended PMRT, (2) recommended against PMRT, or (3) made no definitive PMRT recommendation. We defined the absence of PMRT in the first cohort as underuse and receipt of PMRT in the second cohort as overuse. Multivariate logistic regression analysis was applied to investigate the association of clinical and sociodemographic factors with PMRT. RESULTS: Overall, 23.8% of patients received PMRT. This included 199 (83.6%) of 238 in the "recommend PMRT" cohort, 58 (5.6%) of 1,029 in the "recommend against PMRT" cohort, and 127 (38.6%) of 329 in the "consider PMRT" cohort. The only factor associated with underuse in the "recommend PMRT" cohort was nonreceipt of chemotherapy (odds ratio [OR], 0.08; p <0.0001). In addition to tumor characteristics, the factors associated with overuse in the "recommend against PMRT" cohort included age <50 years (OR, 2.28; p = 0.048), NCCN institution (OR, 1.04-8.29; p = 0.026), higher education (OR, 3.49; p = 0.001), and no reconstructive surgery (OR, 2.44; p = 0.019). The factors associated with PMRT in the "consider PMRT" cohort included NCCN institution (OR, 1.1-9.01; p <0.0001), age <50 years (OR, 2.26; p = 0.041), and tumor characteristics. CONCLUSION: The results of our study have shown that concordance with definitive treatment guidelines was high. However, when current evidence does not support a definitive recommendation for PMRT, treatment decisions appear to be influenced, not only by patient age and clinical characteristics, but also by institution-specific patterns of care.

Comparing outcomes of cataract surgery: challenges and opportunities.

BACKGROUND: There is an increasing demand for routine assessment of surgical outcomes. However, for assessments to be valid, it is essential to understand the influence of patient characteristics on outcomes. The VF-14 visual function instrument offers a possible means of monitoring outcomes of cataract surgery. This article examines lessons learned in the course of an attempt to do this. METHODS: One thousand and ninety-eight patients (41 per cent male and 59 per cent female) undergoing cataract extraction in 29 private hospitals within the British United Provident Association (BUPA) chain in the United Kingdom completed the VF-14 before and at 4 months following surgery. Outcome was measured in terms of absolute post-operative score achieved. The demographic factors associated with post-operative VF-14 score were examined using multivariate analysis, adjusting for baseline score. RESULTS: Women undergoing cataract extraction had worse pre-operative visual function than men. Post-operative VF-14 score was stable as the age of the patient increased, until age 85, after which it declined. The reduction in final outcome in older people was explained in part by their worse post-operative scores but also was associated with increasing age independent of pre-operative score. CONCLUSION: First, although many patients undergoing cataract extraction at an advanced age will achieve excellent results, older age does reduce the outcome that can be expected. Consequently, comparisons of performance of units or surgeons undertaking cataract surgery must take account of the age spectrum being treated. It is not enough simply to add a health status measure to an existing administrative database. Further research is needed to understand the reasons for the poorer outcomes at older ages, in particular the role of co-existing eye disease and development of data systems must take account of the additional information required to make appropriate adjustments.

Trends in breast cancer presentation and care according to age in a single institution.

BACKGROUND: This study sought to determine the differences in presentation and treatment of young women (< or =40 years of age) with breast cancer. METHODS: A prospective database was analyzed for differences in presentation and care in breast cancer patients < or =40 and >40 years of age. RESULTS: The study group consisted of 1685 women. Younger women were more likely to present with a palpable mass, have estrogen receptor/progesterone receptor (ER/PR)-negative tumors, and have more advanced disease at presentation. Although there was no difference in breast conservation rates, younger women were more likely to have postmastectomy reconstruction. Younger women were more likely to receive chemotherapy, even with node-negative tumors less than 1 cm in diameter (37% vs. 13%, P = 0.01). CONCLUSIONS: The presentation of younger women with breast cancer differs from that of older women. Although the surgical management is similar, adjuvant therapy differs, with younger women more likely to be treated with chemotherapy.

Numerical implementation of a backward probabilistic model of ground water contamination.

Backward location and travel time probabilities can be used to characterize known and unknown sources or prior positions of ground water contamination. Backward location probability describes the position of the observed contamination at some time in the past; backward travel time probability describes the amount of time prior to observation that the contamination was released from its source or was at a particular upgradient location. The governing equation for backward probabilities is the adjoint of the governing equation for contaminant transport, but with new load terms. Numerical codes that have been written to solve the forward equations of contaminant transport, e.g., the advection-dispersion equation, can also be used to solve the adjoint equation for location and travel time probabilities; however, the interpretation of the results is different and some new approximations must be made for the load terms. We present the governing equations for backward location and travel time probabilities, and provide appropriate numerical approximations for these load terms using the cell-centered finite difference method, one of the most popular numerical methods in ground water hydrology. We discuss some additional numerical considerations for the backward model including boundary conditions, reversal of the flow field, and interpretation of the results. We illustrate the implementation of the backward probability model using hypothetical examples in one- and two-dimensional domains. We also present a three-dimensional application of a pump-and-treat remediation capture zone delineation at the Massachusetts Military Reservation. The illustrations are performed using MODFLOW-96 for flow simulations and MT3DMS for transport simulations.

Backward location and travel time probabilities for a decaying contaminant in an aquifer.

Backward location and travel time probabilities can be used to determine the prior position of contamination in an aquifer. These probabilities, which are related to adjoint states of concentration, can be used to improve characterization of known sources of groundwater contamination, to identify previously unknown contamination sources, and to delineate capture zones. The first contribution of this paper is to extend the adjoint model to the case of a decaying solute (first-order decay), and to describe two different interpretations of backward probabilities. The conventional interpretation accounts for the probability that a contaminant particle could decay before reaching the detection location. The other interpretation is conditioned on the fact that the detected contaminant particle actually reached the detection location, despite this possibility of decay. In either case, travel time probabilities are skewed toward earlier travel times, relative to a conservative solute. The second contribution of this paper is to verify the load term for a monitoring well observation. We provide examples using one-dimensional models and hypothetical aquifers. We employ an infinite domain in order to verify the monitoring well load. This new but simple one-dimensional adjoint solution can also be used to verify higher-dimensional numerical models of backward location and travel time probabilities. We employ a semi-infinite domain to illustrate the effect of decay on backward models of pumping well probabilistic capture zones. Decay causes the capture zones to fall closer to the well.