The learning collaborative (LC), a multi-component training and implementation model, is one promising approach to address the need for increased availability of trauma-focused evidence-based ...practices. The current study used data from four cohorts of a statewide LC on Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) to 1) evaluate pre- to post-LC changes in therapists' perceived competence in delivering TF-CBT and 2) explore therapist and contextual factors related to therapists’ perceived TF-CBT competence. Therapists (
N
= 237) completed pre- and post-LC measures of practice information, interprofessional collaboration, organizational climate, and TF-CBT knowledge, perceived competence, and use. Findings indicated therapists’ perceived TF-CBT competence significantly increased, pre- to post-LC (
d
= 1.31), with greater use of trauma-focused practices at pre-training and more TF-CBT training cases completed predicting greater pre- to post-LC gains in perceived TF-CBT competence. These findings highlight the need to assist therapists in identifying and completing training cases to promote competence and implementation.
To assess the efficacy of Bounce Back Now (BBN), a modular, Web-based intervention for disaster-affected adolescents and their parents.
A population-based randomized controlled trial used ...address-based sampling to enroll 2,000 adolescents and parents from communities affected by tornadoes in Joplin, MO, and several areas in Alabama. Data collection via baseline and follow-up semi-structured telephone interviews was completed between September 2011 and August 2013. All families were invited to access the BBN study Web portal irrespective of mental health status at baseline. Families who accessed the Web portal were assigned randomly to 1 of 3 groups: BBN, which featured modules for adolescents and parents targeting adolescents' mental health symptoms; BBN plus additional modules targeting parents' mental health symptoms; or assessment only. The primary outcomes were adolescent symptoms of posttraumatic stress disorder (PTSD) and depression.
Nearly 50% of families accessed the Web portal. Intent-to-treat analyses revealed time × condition interactions for PTSD symptoms (B = -0.24, SE = 0.08, p < .01) and depressive symptoms (B = -0.23, SE = 0.09, p < .01). Post hoc comparisons revealed fewer PTSD and depressive symptoms for adolescents in the experimental versus control conditions at 12-month follow-up (PTSD: B = -0.36, SE = 0.19, p = .06; depressive symptoms: B = -0.42, SE = 0.19, p = 0.03). A time × condition interaction also was found that favored the BBN versus BBN + parent self-help condition for PTSD symptoms (B = 0.30, SE = 0.12, p = .02) but not depressive symptoms (B = 0.12, SE = 0.12, p = .33).
Results supported the feasibility and initial efficacy of BBN as a scalable disaster mental health intervention for adolescents. Technology-based solutions have tremendous potential value if found to reduce the mental health burden of disasters.
Web-based Intervention for Disaster-Affected Youth and Families; http://clinicaltrials.gov; NCT01606514.
Dating violence is an important but understudied public health concern in adolescents. This study sought to examine the lifetime prevalence of serious forms of dating violence in 12- to 17- ...year-olds, risk and protective factors associated with dating violence, and the relation between dating violence and mental health.
A nationally representative sample of adolescents (N = 3,614) completed a telephone-based interview that assessed serious forms of dating violence (i.e., sexual assault, physical assault, and/or drug/alcohol-facilitated rape perpetrated by a girlfriend, boyfriend, or other dating partner).
Prevalence of dating violence was 1.6% (2.7% of girls, 0.6% of boys), equating to approximately 400,000 adolescents in the U.S. population. Risk factors included older age, female sex, experience of other potentially traumatic events, and experience of recent life stressors. Findings also suggested that dating violence is associated with posttraumatic stress disorder and major depressive episode after controlling for demographic variables, other traumatic stressors, and stressful events.
These findings indicate that dating violence is a significant public health problem in adolescent populations that should be addressed through early detection, prevention, and intervention.
Child abuse and neglect (CAN) is prevalent, associated with long-term adversities, and often undetected. Primary care settings offer a unique opportunity to identify CAN and facilitate referrals, ...when warranted. Electronic health records (EHR) contain extensive information to support healthcare decisions, yet time constraints preclude most providers from thorough EHR reviews that could indicate CAN. Strategies that summarize EHR data to identify CAN and convey this to providers has potential to mitigate CAN-related sequelae. This study used expert review/consensus and Natural Language Processing (NLP) to develop and test a lexicon to characterize children who have experienced or are at risk for CAN and compared machine learning methods to the lexicon + NLP approach to determine the algorithm's performance for identifying CAN.
Study investigators identified 90 CAN terms and invited an interdisciplinary group of child abuse experts for review and validation. We then used NLP to develop pipelines to finalize the CAN lexicon. Data for pipeline development and refinement were drawn from a randomly selected sample of EHR from patients seen at pediatric primary care clinics within a U.S. academic health center. To explore a machine learning approach for CAN identification, we used Support Vector Machine algorithms.
The investigator-generated list of 90 CAN terms were reviewed and validated by 25 invited experts, resulting in a final pool of 133 terms. NLP utilized a randomly selected sample of 14,393 clinical notes from 153 patients to test the lexicon, and .03% of notes were identified as CAN positive. CAN identification varied by clinical note type, with few differences found by provider type (physicians versus nurses, social workers, etc.). An evaluation of the final NLP pipelines indicated 93.8% positive CAN rate for the training set and 71.4% for the test set, with decreased precision attributed primarily to false positives. For the machine learning approach, SVM pipeline performance was 92% for CAN + and 100% for non-CAN, indicating higher sensitivity than specificity.
The NLP algorithm's development and refinement suggest that innovative tools can identify youth at risk for CAN. The next key step is to refine the NLP algorithm to eventually funnel this information to care providers to guide clinical decision making.
Successful implementation depends on the transfer of knowledge and expertise among clinicians, which can occur when professionals seek advice from one another. This study examines advice-seeking ...patterns among mental health clinicians participating in learning collaboratives (a multi-component implementation and quality improvement strategy) to implement trauma-focused cognitive behavioral therapy (TF-CBT). We apply transactive memory system theory, which explains how professionals access and retrieve knowledge, to examine factors associated with the evolution of advice-seeking relationships during implementation. Our aim is to unpack learning collaboratives' mechanisms by investigating how and why advice-seeking networks change, which may help us understand how implementation strategies can best target networks.
Using social network analysis and a pretest-post-test design, we examined patterns in general and treatment-specific advice-seeking among 146 participants (including five clinical experts) from 27 agencies participating in a regional scale-up of TF-CBT. Surveys were administered in-person at the first and last of three in-person learning sessions (10 months apart) that comprise a core component of learning collaboratives. Participants nominated up to five individuals from whom they seek general and treatment-specific advice. Exponential random graph models (ERGMs) tested the likelihood of maintaining or forming advice-seeking relationships based on indicators of expertise quality, accessibility, need, and prior advice-seeking relationships.
Participants formed or maintained advice-seeking relationships with those who possess perceived expertise (e.g., learning collaborative faculty experts, supervisors, and those with greater field experience than themselves). Participants also tended to seek advice from those within the same organization and with similar disciplinary training, highlighting the importance of expertise accessibility. Prior relationships and network structural features were associated with advice-seeking, indicating that participants built on existing social ties. Advice-seeking did not vary based on participants' role or experience.
Given the importance of accessible clinical expertise and ongoing supervision for delivering treatment with fidelity, learning collaboratives may support implementation by promoting clinicians' awareness of and access to others' expertise, especially those with substantial expertise to share (e.g., faculty experts and supervisors). Future controlled studies are needed to verify the effectiveness of learning collaboratives for building networks that connect clinicians and experts and for improving implementation.
A protocol is prescribed for clinical reference dosimetry of external beam radiation therapy using photon beams with nominal energies between
60
Co
and 50 MV and electron beams with nominal energies ...between 4 and 50 MeV. The protocol was written by Task Group 51 (TG-51) of the Radiation Therapy Committee of the American Association of Physicists in Medicine (AAPM) and has been formally approved by the AAPM for clinical use. The protocol uses ion chambers with absorbed-dose-to-water calibration factors,
N
D,w
60
Co
,
which are traceable to national primary standards, and the equation
D
w
Q
=Mk
Q
N
D,w
60
Co
,
where
Q
is the beam quality of the clinical beam,
D
w
Q
is the absorbed dose to water at the point of measurement of the ion chamber placed under reference conditions,
M
is the fully corrected ion chamber reading, and
k
Q
is the quality conversion factor which converts the calibration factor for a
60
Co
beam to that for a beam of quality
Q.
Values of
k
Q
are presented as a function of
Q
for many ion chambers. The value of
M
is given by
M=P
ion
P
TP
P
elec
P
pol
M
raw
,
where
M
raw
is the raw, uncorrected ion chamber reading and
P
ion
corrects for ion recombination,
P
TP
for temperature and pressure variations,
P
elec
for inaccuracy of the electrometer if calibrated separately, and
P
pol
for chamber polarity effects. Beam quality,
Q,
is specified (i) for photon beams, by
%dd(10)
x
,
the photon component of the percentage depth dose at 10 cm depth for a field size of
10×10
cm
2
on the surface of a phantom at an SSD of 100 cm and (ii) for electron beams, by
R
50
,
the depth at which the absorbed-dose falls to 50% of the maximum dose in a beam with field size
⩾10×10
cm
2
on the surface of the phantom
(⩾20×20
cm
2
for
R
50
>8.5
cm) at an SSD of 100 cm.
R
50
is determined directly from the measured value of
I
50
,
the depth at which the ionization falls to 50% of its maximum value. All clinical reference dosimetry is performed in a water phantom. The reference depth for calibration purposes is 10 cm for photon beams and
0.6R
50
−0.1
cm for electron beams. For photon beams clinical reference dosimetry is performed in either an SSD or SAD setup with a
10×10
cm
2
field size defined on the phantom surface for an SSD setup or at the depth of the detector for an SAD setup. For electron beams clinical reference dosimetry is performed with a field size of
⩾10×10
cm
2
(⩾20×20
cm
2
for
R
50
>8.5
cm) at an SSD between 90 and 110 cm. This protocol represents a major simplification compared to the AAPM’s TG-21 protocol in the sense that large tables of stopping-power ratios and mass-energy absorption coefficients are not needed and the user does not need to calculate any theoretical dosimetry factors. Worksheets for various situations are presented along with a list of equipment required.
Identifying the major sources of risk in disease transmission is key to designing effective controls. However, understanding of transmission dynamics across species boundaries is typically poor, ...making the design and evaluation of controls particularly challenging for zoonotic pathogens. One such global pathogen is Escherichia coli O157, which causes a serious and sometimes fatal gastrointestinal illness. Cattle are the main reservoir for E. coli O157, and vaccines for cattle now exist. However, adoption of vaccines is being delayed by conflicting responsibilities of veterinary and public health agencies, economic drivers, and because clinical trials cannot easily test interventions across species boundaries, lack of information on the public health benefits. Here, we examine transmission risk across the cattle–human species boundary and show three key results. First, supershedding of the pathogen by cattle is associated with the genetic marker stx2 . Second, by quantifying the link between shedding density in cattle and human risk, we show that only the relatively rare supershedding events contribute significantly to human risk. Third, we show that this finding has profound consequences for the public health benefits of the cattle vaccine. A naïve evaluation based on efficacy in cattle would suggest a 50% reduction in risk; however, because the vaccine targets the major source of human risk, we predict a reduction in human cases of nearly 85%. By accounting for nonlinearities in transmission across the human–animal interface, we show that adoption of these vaccines by the livestock industry could prevent substantial numbers of human E. coli O157 cases.
This study investigated two theoretical risk models predicting child maltreatment potential: (a) Belsky's (
1993
) developmental-ecological model and (b) the cumulative risk model in a sample of 610 ...caregivers (49% African American, 46% European American; 53% single) with a child between 3 and 6 years old. Results extend the literature by using a widely accepted and valid risk instrument rather than occurrence rates (e.g., reports to child protective services, observations). Results indicated Belsky's developmental-ecological model, in which risk markers were organized into three separate conceptual domains, provided a poor fit to the data. In contrast, the cumulative risk model, which included the accumulation of risk markers, was significant in predicting child abuse potential.
Radiation Therapy Oncology Group 95-17 is a prospective Phase II cooperative group trial of accelerated partial breast irradiation (APBI) alone using multicatheter brachytherapy after lumpectomy in ...select early-stage breast cancers. Tumor control and survival outcomes are reported.
Eligibility criteria included Stage I/II breast carcinoma confirmed to be <3 cm, unifocal, invasive nonlobular histology with zero to three positive axillary nodes without extracapsular extension. APBI treatment was delivered with either low-dose-rate (LDR) (45 Gy in 3.5-5 days) or high-dose-rate (HDR) brachytherapy (34 Gy in 10 twice-daily fractions over 5 days). End points evaluated included in-breast control, regional control, mastectomy-free rate, mastectomy-free survival, disease-free survival, and overall survival. The study was designed to analyze the HDR and LDR groups separately and without comparison.
Between 1997 and 2000, 100 patients were accrued and 99 were eligible; 66 treated with HDR brachytherapy and 33 treated with LDR brachytherapy. Eighty-seven patients had T1 lesions and 12 had T2 lesions. Seventy-nine were pathologically N0 and 20 were N1. Median follow-up in the HDR group is 6.14 years with the 5-year estimates of in-breast, regional, and contralateral failure rates of 3%, 5%, and 2%, respectively. The LDR group experienced similar results with a median follow-up of 6.22 years. The 5-year estimates of in-breast, regional, and contralateral failure rates of 6%, 0%, and 6%, respectively.
Patients treated with multicatheter partial breast brachytherapy in this trial experienced excellent in-breast control rates and overall outcome that compare with reports from APBI studies with similar extended follow-up.
The gall midge,
Asphondylia prosopidis
Cockerell, is considered a potential biological control agent for invasive mesquite (
Prosopis
species) populations in South Africa.
Asphondylia
species induce ...galls on mesquite plants by inserting an egg into a bud, and also carry conidia of specific fungal associates in their mycangia that are transferred into the galls. However, fungal associates have not been characterized in flower bud galls formed by
A. prosopidis
on mesquite. It is essential to identify the fungal associates in the galls formed on natural populations of mesquite prior to host specificity testing. In this study, we showed that
Botryosphaeria dothidea
(Moug. ex Fr.) Ces. & De Not. is the fungal associate in the flower bud galls on mesquite induced by
A. prosopidis
in New Mexico by characterization of the internal transcribed spacer (ITS) region. Further, isolates of
B. dothidea
in
A. prosopidis
galls formed on mesquite were genetically identical to isolates of
B. dothidea
carried by other
Asphondylia
species, particularly on the confamilial
Acacia
species in South Africa. Our result suggests that
A. prosopidis
is safe to utilize as a biological control agent for mesquite, if
A. prosopidis
shows a narrow host range in the pre-release risk assessment, since
B. dothidea
appears to be ubiquitous. To our knowledge, this is the first report of the association between
Asphondylia
species and
B. dothidea
in the United States. We anticipate that
A. prosopidis
will associate with indigenous
B. dothidea
in South Africa.
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