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PURPOSE: Given the need to develop and validate effective implementation models that lead to sustainable improvements, we prospectively examined changes in attitudes, behaviors, and perceived organizational support during and after statewide Community-Based Learning Collaboratives (CBLCs) promoting trauma-focused evidence-based practices (EBPs). METHODS: Participants (N = 857; i.e., 492 clinicians, 218 brokers, and 139 senior leaders) from 10 CBLCs completed surveys pre- and post-CBLC; a subsample (n = 146) completed a follow-up survey approximately two years post-CBLC. RESULTS: Results indicated (a) medium, sustained increases in clinician-reported use of trauma-focused EBPs, (b) medium to large, sustained increases in perceived organizational support for trauma-focused EBPs, and (c) trivial to small, sustained increases in perceived organizational support for EBPs broadly. In contrast, clinician-reported overall attitudes towards EBPs decreased to a trivial degree pre- to post-CBLC, but then increased to a small, statistically significant degree from post-CBLC to follow-up. Notably, the degree of perceived improvements in organizational support for general and trauma-focused EBPs varied by professional role. CONCLUSIONS: Findings suggest the CBLC implementation strategies may both increase and sustain provider practices and organizational support towards EBPs, particularly those EBPs a CBLC explicitly targets.

Background: Developing pragmatic assessment tools to measure clinician use of evidence-based practices is critical to advancing implementation of evidence-based practices in mental health. This case study details our community-partnered process of developing the Therapy Process Observation Coding Scale-Self-Reported Therapist Intervention Fidelity for Youth (TPOCS-SeRTIFY), a pragmatic, clinician-report instrument to measure cognitive behavioral therapy (CBT) delivery. Approach: We describe a five-step community-partnered development process. Initial goals were to create a self-report instrument that paralleled an existing direct observation measure of clinician delivery of CBT use to facilitate later assessment of measure performance. Cognitive interviews with community clinicians ( n = 6) and consultation with CBT experts ( n = 6) were used to enhance interpretability and usability as part of an iterative refinement process. The instrument was administered to 247 community clinicians along with an established self-reported measure of clinician delivery of CBT and other treatments to assess preliminary psychometric performance. Preliminary psychometrics were promising. Conclusion: Our community-partnered development process showed promising success and can guide future development of pragmatic implementation measures both to facilitate measurement of ongoing implementation efforts and future research aimed at building learning mental health systems. Plain language summary Developing brief, user-friendly, and accurate tools to measure how therapists deliver cognitive behavioral therapy (CBT) in routine practice is important for advancing the reach of CBT into community settings. To date, developing such “pragmatic” measures has been difficult. There is little known about how researchers can best develop these types of assessment tools so that they (1) are easy for clinicians in practice to use and (2) provide valid and useful information about implementation outcomes. As a result, there are few well-validated measures in existence that measure therapist use of CBT that are feasible for use in community practice. This paper contributes to the literature by describing our community-partnered process for developing a measure of therapist use of CBT (Therapy Process Observation Coding Scale -Self-Reported Therapist Intervention Fidelity for Youth; TPOCS-SeRTIFY). This descriptive case study outlines the community-partnered approach we took to develop this measure. This case study will contribute to future research by serving as a guide to others aiming to develop pragmatic implementation measures. In addition, the TPOCS-SeRTIFY is a pragmatic measure of clinician use of CBT that holds promise for its use by both researchers and clinicians to measure the success of CBT implementation efforts.

The objective of this paper is to design and fabricate a low stiffness cantilever with an enclosed nanofluidic channel. This paper addresses the primary challenge of current hollow cantilever design, and introduces the use of a thermally decomposable polymer as the enabling technology to form a reduced stiffness, and thus higher sensitivity, cantilever. A numerical stiffness model is first developed to identify the critical geometric parameters necessary for structural soundness and bendability. A new sacrificial material is then introduced to cantilever fabrication that uses a low temperature top coat layer of plasma enhanced chemical vapor deposition nitride. Experimental measurement of the film’s internal stress and the resulting bending radius of a composite cantilever are used to characterize residual stress from film deposition as a new design parameter, unique to this method, which was mitigated by a thorough analysis of the combined effect of film properties and cantilever mechanics. A numerical model is developed for optimizing cantilever geometry and refining film process parameters to minimize the internal stress of the cantilever, whilst achieving a low stiffness, high sensitivity, and composite nanofluidic atomic force microscopy cantilever. [2017-0047]

Background: Pain on the day after caesarean section is often treated with controlled-release oxycodone to supplement the decline in analgesia from intrathecal opioids. Evidence suggests that caesarean birth is a biopsychosocial experience where a comprehensive approach is needed that promotes control and participation in pain management. Objectives: This study compared immediate-release oxycodone integrated with supportive educational strategies to controlled-release oxycodone. A follow-up phase aimed to explore pain over three months. Design: This study was a two-group parallel randomised controlled trial. Setting: A metropolitan hospital in Australia with a birthing suite, operating rooms, and a postnatal unit. Participants: English-speaking women scheduled for elective caesarean section were mailed trial information. Exclusion criteria included contraindications to intrathecal analgesia, herpes simplex infection, a history of chronic pain, opioid tolerance, or substance abuse. A total of 131 participants were recruited and randomised out of 298 eligible participants. Methods: Group allocation was undertaken using sequentially numbered opaque sealed envelopes. The nurse practitioner intervention commenced on the day after surgery with immediate-release oxycodone alongside supportive strategies. The control group received scheduled doses of controlled-release oxycodone. All participants could request additional oxycodone or tramadol. Primary outcomes were pain intensity and secondary outcomes included patient global impression of change, pain interference, opioid consumption, and maternal perception of control. A follow-up phase evaluated pain outcomes over three months. Results: The final sample size was 122, with 61 participants in each group. Pain intensity scores were analysed by linear mixed regression models. There were no statistical differences over 24 hours between the control and intervention groups at rest (p = 0.40, 95% CI -4.8 mm, 11.9 mm) or on sitting or moving (p = 0.561, 95% CI -15.2 mm, 8.3 mm). Patient global impression of change was significant over three hours (p = 0.014, OR = 2.5, 95% CI 1.2, 5.3). The intervention group reported less pain interference while consuming less oxycodone (p < 0.05). There was no difference between groups in terms of perceived control over pain management (p = 0.273, 95% CI -16.2 mm, 4.6 mm). The follow-up analysis graded 5.9% of participants as experiencing severe pain interference. Chronic pain following caesarean was associated with postnatal depression (p < 0.001). Conclusions: The research showed that a nurse practitioner intervention can improve pain management following caesarean section. The results underscore the influence of biological, psychological, and social factors on acute pain. Hence, this study reinforces the need for a biopsychosocial approach to acute pain management following caesarean delivery.

Background Little work investigates the effect of behavioral health system efforts to increase use of evidence-based practices or how organizational characteristics moderate the effect of these efforts. The objective of this study was to investigate clinician practice change in a system encouraging implementation of evidence-based practices over 5 years and how organizational characteristics moderate this effect. We hypothesized that evidence-based techniques would increase over time, whereas use of non-evidence-based techniques would remain static. Method Using a repeated cross-sectional design, data were collected three times from 2013 to 2017 in Philadelphia’s public behavioral health system. Clinicians from 20 behavioral health outpatient clinics serving youth were surveyed three times over 5 years (n = 340; overall response rate = 60%). All organizations and clinicians were exposed to system-level support provided by the Evidence-based Practice Innovation Center from 2013 to 2017. Additionally, approximately half of the clinicians participated in city-funded evidence-based practice training initiatives. The main outcome included clinician self-reported use of cognitive-behavioral and psychodynamic techniques measured by the Therapy Procedures Checklist-Family Revised. Results Clinicians were 80% female and averaged 37.52 years of age (SD = 11.40); there were no significant differences in clinician characteristics across waves (all ps > .05). Controlling for organizational and clinician covariates, average use of CBT techniques increased by 6% from wave 1 (M = 3.18) to wave 3 (M = 3.37, p = .021, d = .29), compared to no change in psychodynamic techniques (p = .570). Each evidence-based practice training initiative in which clinicians participated predicted a 3% increase in CBT use (p = .019) but no change in psychodynamic technique use (p = .709). In organizations with more proficient cultures at baseline, clinicians exhibited greater increases in CBT use compared to organizations with less proficient cultures (8% increase vs. 2% decrease, p = .048). Conclusions System implementation of evidence-based practices is associated with modest changes in clinician practice; these effects are moderated by organizational characteristics. Findings identify preliminary targets to improve implementation.

Identifying scalable strategies for assessing fidelity is a key challenge in implementation science. However, for psychosocial interventions, the existing, reliable ways to test treatment fidelity quality are often labor intensive, and less burdensome strategies may not reflect actual clinical practice. Cognitive behavioral therapies (CBTs) provide clinicians with a set of effective core elements to help treat a multitude of disorders, which, evidence suggests, need to be delivered with fidelity to maximize potential client impact. The current “gold standard” for rating CBTs is rating recordings of therapy sessions, which is extremely time-consuming and requires a substantial amount of initial training. Although CBTs can vary based on the target disorder, one common element employed in most CBTs is the use of worksheets to identify specific behaviors and thoughts that affect a client’s ability to recover. The present study will develop and evaluate an innovative new approach to rate CBT fidelity, by developing a universal CBT scoring system based on worksheets completed in therapy sessions. To develop a scoring system for CBT worksheets, we will compile common CBT elements from a variety of CBT worksheets for a range of psychiatric disorders and create adherence and competence measures. We will collect archival worksheets from past studies to test the scoring system and assess test-retest reliability. To evaluate whether CBT worksheet scoring accurately reflects clinician fidelity, we will recruit clinicians who are engaged in a CBT for depression, anxiety, and/or posttraumatic stress disorder. Clinicians and clients will transmit routine therapy materials produced in session (e.g., worksheets, clinical notes, session recordings) to the study team after each session. We will compare observer-rated fidelity, clinical notes, and fidelity-rated worksheets to identify the most effective and efficient method to assess clinician fidelity. Clients will also be randomly assigned to either complete the CBT worksheets on paper forms or on a mobile application (app) to learn if worksheet format influences clinician and client experience or differs in terms of reflecting fidelity. Scoring fidelity using CBT worksheets may allow clinics to test fidelity in a short and effective manner, enhancing continuous quality improvement in the workplace. Clinicians and clinics can use such data to improve clinician fidelity in real time, leading to improved patient outcomes. ClinicalTrials.gov NCT03479398 . Retrospectively registered March 20, 2018.

International audience; Myeloproliferative neoplasm-related myelofibrosis is associated with cytopenic or proliferative phases, splenomegaly and constitutional symptoms. Few effective treatments are available and small series suggested that interferon could be an option for myelofibrosis therapy. We performed a retrospective study of pegylated-interferon α-2a (Peg-IFNα-2a) therapy in myelofibrosis. Sixty-two patients treated with Peg-IFNα-2a at 17 French and Belgian centres were included. Responses were determined based on the criteria established by the International Working Group for Myelofibrosis Research and Treatment. Mean follow-up was 26 months. Sixteen of 25 anaemic patients (64%) (eight concomitantly receiving recombinant erythropoietin) achieved a complete response and transfusion-independence was obtained in 5/13 patients (38*5%). Constitutional symptoms resolved in 82% of patients. All five leucopenic patients normalized their leucocyte counts, whereas a normal platelet count was obtained in 5/8 thrombocytopenic patients. Splenomegaly was reduced in 46*5% of patients, and complete resolution of thrombocytosis and leucocytosis were observed in 82*8% and 68*8% of patients, respectively. Side effects (mostly haematological) were mainly of grade 1-2. The only factor independently associated with treatment failure was a spleen enlargement of more than 6 cm below the costal margin. In conclusion, Peg-IFNα-2a induced high response rates with acceptable toxicity in a large proportion of patients with primary and secondary myelofibrosis, especially in early phases.

Identifying predictors of evidence-based practice (EBP) use, such as supervision processes and therapist characteristics, may support dissemination. Therapists (N = 57) received training and supervision in EBPs to treat community-based youth (N = 136). Supervision involving modeling and role-play predicted higher overall practice use than supervision involving discussion, and modeling predicted practice use in the next therapy session. No therapist characteristics predicted practice use, but therapist sex and age moderated the supervision and practice use relation. Supervision involving discussion predicted practice use for male therapists only, and modeling and role-play in supervision predicted practice use for older, not younger, therapists.

Quality control methods, including therapist trainingI and supervision procedures, are used to establish and maintain fidelity to a psychosocial intervention. The effectiveness and efficiency of these methods impact both the validity of research on intervention effects and the success of dissemination and implementation in routine care contexts. Quality control methods utilizing active training strategies and review of observational treatment session data are more effective than the methods that rely on passive learning. The purpose of this review was to catalogue the use of an array of quality control methods in studies of evidence-based psychosocial treatments, to evaluate how often the most potentially effective and efficient methods have been used, and to evaluate the variability in the use of these methods across different treatment models, client populations, or clinical settings. The results indicate that the most effective methods have been used to implement fewer than a quarter of the treatments studied. Variability across treatment contexts is presented and implications for future research are discussed.

Cross-laminated timber (CLT) is an engineered wood with good structural properties and it is also economically competitive with the traditional building construction materials. However, due to its low volume density combined with its high stiffness, it does not provide sufficient sound insulation, thus it is necessary to develop specific acoustic treatments in order to increase the noise reduction performance. The material's mechanical properties are required as input data to perform the vibro-acoustic analyses necessary during the design process. In this paper the elastic constants of a CLT plate are derived by fitting the real component of the experimental flexural wave velocity with Mindlin's dispersion relation for thick plates, neglecting the influence of the plate's size and boundary conditions. Furthermore, its apparent elastic and stiffness properties are derived from the same set of experimental data, for the plate considered to be thin. Under this latter assumption the orthotropic behaviour of an equivalent thin CLT plate is described by using an elliptic model and verified with experimental results.

In the last decades, new materials and new technologies which satisfy sustainability and energy efficiency demands have been developed for the building construction market. Lightweight structures are becoming increasingly popular, but it has been shown that they cannot provide satisfactory sound insulation to meet the regulation requirements. Therefore a proper acoustic treatment needs to be specifically designed, considering both airborne and structure-borne sound sources. Cross-laminated timber (CLT) elements, for example, have had great success in the last twenty years, both in Europe and North America. CLT plates, due to their peculiar sub-structure, very often exhibit an orthotropic behavior: they have different stiffness properties along their two principle directions. In this paper two prediction models to evaluate the radiation efficiency, due to mechanical excitation, and the sound transmission loss of an orthotropic CLT plate are presented. The main purpose of these simplified models is to provi...

Fidelity measurement is critical for testing the effectiveness and implementation in practice of psychosocial interventions. Adherence is a critical component of fidelity. The purposes of this review were to catalogue adherence measurement methods and assess existing evidence for the valid and reliable use of the scores that they generate and the feasibility of their use in routine care settings. A systematic literature search identified articles published between 1980-2008 reporting studies of evidence-based psychosocial treatments for child or adult mental health problems, including mention of adherence or fidelity assessment. Coders abstracted data on the measurement methods and clinical contexts of their use. Three hundred forty-one articles were reviewed, in which 249 unique adherence measurement methods were identified. These methods assessed many treatment models, although more than half (59%) assessed cognitive behavioral treatments. The measurement methods were used in studies with diverse clientele and clinicians. The majority (71.5%) of methods were observational. Information about psychometric properties was reported for 35% of the measurement methods, but adherence-outcomes relationships were reported for only 10%. Approximately 1/3 of the measures were used in community-based settings. Many adherence measurement methods have been used in treatment research; however, little reliability and validity evidence exists for the use of these methods. That some methods were used in routine care settings suggests the feasibility of their use in practice; however, information about the operational details of measurement, scoring, and reporting is sorely needed to inform and evaluate strategies to embed fidelity measurement in implementation support and monitoring systems.

OBJECTIVE This article reports outcomes from the Child STEPs randomized effectiveness trial conducted over a 2-year period to gauge the longer term impact of protocol design on the effectiveness of evidence-based treatment procedures. METHOD An ethnoracially diverse sample of 174 youths ages 7- 13 (N = 121 boys) whose primary clinical concerns involved diagnoses or clinical elevations related to anxiety, depression, or disruptive behavior were treated by community therapists randomly assigned to 1 of 3 conditions: (a) standard, which involved the use of 1 or more of 3 manualized evidence-based treatments, (b) modular, which involved a single modular protocol (Modular Approach to Treatment of Children With Anxiety, Depression, or Conduct Problems; MATCH) having clinical procedures similar to the standard condition but flexibly selected and sequenced using a guiding clinical algorithm, and (c) usual care. RESULTS As measured with combined Child Behavior Checklist and Youth Self-Report Total Problems, Internalizing, and Externalizing scales, the rate of improvement for youths in the modular condition was significantly better than for those in usual care. On a measure of functional impairment (Brief Impairment Scale), no significant differences were found among the 3 conditions. Analysis of service utilization also showed no significant differences among conditions, with almost half of youths receiving some additional services in the 1st year after beginning treatment, and roughly one third of youths in the 2nd year. CONCLUSIONS Overall, these results extend prior findings, supporting incremental benefits of MATCH over usual care over a 2-year period.

This randomized trial will compare three methods of assessing fidelity to cognitive-behavioral therapy (CBT) for youth to identify the most accurate and cost-effective method. The three methods include self-report (i.e., therapist completes a self-report measure on the CBT interventions used in session while circumventing some of the typical barriers to self-report), chart-stimulated recall (i.e., therapist reports on the CBT interventions used in session via an interview with a trained rater, and with the chart to assist him/her) and behavioral rehearsal (i.e., therapist demonstrates the CBT interventions used in session via a role-play with a trained rater). Direct observation will be used as the gold-standard comparison for each of the three methods. This trial will recruit 135 therapists in approximately 12 community agencies in the City of Philadelphia. Therapists will be randomized to one of the three conditions. Each therapist will provide data from three unique sessions, for a total of 405 sessions. All sessions will be audio-recorded and coded using the Therapy Process Observational Coding System for Child Psychotherapy-Revised Strategies scale. This will enable comparison of each measurement approach to direct observation of therapist session behavior to determine which most accurately assesses fidelity. Cost data associated with each method will be gathered. To gather stakeholder perspectives of each measurement method, we will use purposive sampling to recruit 12 therapists from each condition (total of 36 therapists) and 12 supervisors to participate in semi-structured qualitative interviews. Results will provide needed information on how to accurately and cost-effectively measure therapist fidelity to CBT for youth, as well as important information about stakeholder perspectives with regard to each measurement method. Findings will inform fidelity measurement practices in future implementation studies as well as in clinical practice. NCT02820623 , June 3rd, 2016.

A1 Introduction to the 8th Annual Conference on the Science of Dissemination and Implementation: Optimizing Personal and Population Health David Chambers1, Lisa Simpson2 1Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Rockville, MD, 20850, USA; 2AcademyHealth, Washington, DC, 20036, USA For the second year in a row, we are pleased to be able to share the proceedings of the Annual Conference on the Science of Dissemination and Implementation in Health, a large meeting reflecting the expanding and evolving research field that seeks to optimize the use of evidence, interventions, and tools from health research within the myriad of settings where people receive health care, make health-related decisions, and increase knowledge of influences on the health of the population. We once again benefitted from a strong partnership, co-led by AcademyHealth and the National Institutes of Health (NIH), with co-sponsorship from the Agency for Healthcare Research and Quality (AHRQ), the Patient Centered Outcomes Research Institute (PCORI), the Robert Wood Johnson Foundation (RWJF), the US Department of Veterans Affairs (VA), and the WT Grant Foundation. In addition, we benefitted from the collaboration of staff from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). NIH and AcademyHealth again co-led the program planning committee, which focused on the development of the plenary sessions, and convened a scientific advisory panel to suggest speakers and advise on the overall conference development. The planning committee identified four key areas around which to focus the plenary panels and keynote address. Dr. America Bracho, M.D., M.P.H., Executive Director of Latino Health Access in Orange County, California, spoke about the opportunities for implementation science to inform efforts to improve community health and engage underserved populations. The three plenary panels each focused on a significant future direction for dissemination and implementation (D & I) research: the interface between D&I science and population health, emerging opportunities for global implementation science, and the challenges around implementation of precision medicine. The plenary sessions were complemented by facilitated lunchtime discussions on the same three topics, which offered participants an opportunity to identify key research questions for each and brainstorm next steps. Synopses of the lunchtime discussions are included in this supplement. Given the overwhelming success of the 2014 conference and the large number of abstracts received in 2014 (660), the program planning committee identified eight program tracks for abstract submitters to respond to, and through which the concurrent sessions of the conference would be organized. These tracks—Behavioral Health, Big Data and Technology for Dissemination and Implementation Research, Clinical Care Settings, Global Dissemination and Implementation, Promoting Health Equity and Eliminating Disparities, Health Policy Dissemination and Implementation, Prevention and Public Health, and Models, Measures and Methods— were designed to enable conference participants to follow a consistent theme across the multiple sessions of the conference and form the structure of this supplement. The call for abstracts, including individual paper presentations, individual posters and panel presentations, resulted in 515 submissions, spread across the eight thematic tracks. Over one hundred reviewers devoted their time to ensuring a comprehensive and expert review, and reviews were conducted within each track and coordinated by the track leads. For the final program, 64 oral presentations, 12 panels, and 263 posters were presented over the two-day meeting. Slides for the oral presentations and panels (with the agreement of the authors) were posted on the conference website (http://diconference.academyhealth.org/archives/2015archives) and all abstracts were included on the conference webapp (https://academyhealth.confex.com/academyhealth/2015di/meetingapp.cgi). This supplement has compiled the abstracts for presented papers, panel sessions, and lunchtime discussions from the 8th Annual Meeting on the Science of Dissemination and Implementation in Health: Optimizing Personal and Population Health. We are pleased to have the abstracts from the conference together in one volume once again, and look forward to the 9th Annual meeting, scheduled for December in Washington, D.C.

To describe the prevalence and nature of sex trade in a clinic-based sample of young women and to evaluate associations with sexual and reproductive health.A cross-sectional survey was conducted with women aged 16-29 years (n=1277) presenting to family-planning clinics in Northern California, USA.Overall, 8.1% of respondents indicated a lifetime history of trading sex for money or other resources. Sex trade was associated with unintended pregnancy (adjusted risk ratio [ARR] 1.27; 95% confidence interval [CI], 1.09-1.48), multiple abortions (ARR 1.63; 95% CI, 1.19-2.23), STI diagnosis (ARR 1.46; 95% CI, 1.27-1.68), and unwanted sex (vaginal ARR 3.64; 95% CI, 2.39-5.56; anal ARR 4.99; 95% CI, 2.17-11.50). Of the women ever involved in sex trade, 12 (37.3%) reported that their first such experience was before they were 18 years of age.Approximately 1 in 12 participants had been involved in sex trade, illustrating the presence of patients with this history within the family-planning clinical setting. Sex trade was associated with multiple indicators of poor sexual and reproductive health. Family-planning clinics may represent an underused mechanism for engaging this high-risk population.

The pharmacologically active compound (33% reduction in rabbit intraocular pressure recovery rate assay) 1-ethyl-6-fluoro-1,2,3,4-tetrahydroquinoline (MC4), which showed ocular hypotensive action and had optimum physicochemical properties, was characterized for its ocular absorption and distribution properties to better understand its in vivo potency in comparison with an inactive compound, N-ethyl-1,4-benzoxazine (MC1). Tissue distribution to various ocular tissues was determined after absorption by both corneal and conjunctival- scleral routes, following administration by the “topical infusion” technique. The rank order of penetration for both the compounds was cornea > iris-ciliary body > aqueous humor > lens > conjunctiva-sclera. Overall, MC4 had significantly higher concentrations than MC1 in various ocular tissues, but particularly in the iris-ciliary body, which is the site of action (biophase). Ocular disposition studies of the active compound MC4 were then conducted to characterize its elimination kinetics, and the pharmacokinetic parameters were determined by non- compartmental and moment analysis using equations specific to “topical infusion” technique: first-order absorption rate constant, 4.1 × 10 − 4 min − 1 ; elimination rate constant, 0.012 min − 1 ; mean residence time, 39.6 min; steady-state volume of distribution, 0.721 mL; and aqueous humor ocular clearance, 8.44 μL/min. The results were consistent with the conclusion that MC4 is well absorbed and distributed to the active site.

Background Reproductive control including pregnancy coercion (coercion by male partners to become pregnant) and birth control sabotage (partner interference with contraception) may be associated with partner violence and risk for unintended pregnancy among young adult females utilizing family planning clinic services. Study Design A cross-sectional survey was administered to females ages 16–29 years seeking care in five family planning clinics in Northern California ( N =1278). Results Fifty-three percent of respondents reported physical or sexual partner violence, 19% reported experiencing pregnancy coercion and 15% reported birth control sabotage. One third of respondents reporting partner violence (35%) also reported reproductive control. Both pregnancy coercion and birth control sabotage were associated with unintended pregnancy (AOR 1.83, 95% CI 1.36–2.46, and AOR 1.58, 95% CI 1.14–2.20, respectively). In analyses stratified by partner violence exposure, associations of reproductive control with unintended pregnancy persisted only among women with a history of partner violence. Conclusions Pregnancy coercion and birth control sabotage are common among young women utilizing family planning clinics, and in the context of partner violence, are associated with increased risk for unintended pregnancy.

Objective: A randomized trial assessed the effectiveness of a 2-level strategy for implementing evidence-based mental health treatments for delinquent youth. Method: A 2 × 2 design encompassing 14 rural Appalachian counties included 2 factors: (a) the random assignment of delinquent youth within each county to a multisystemic therapy (MST) program or usual services and (b) the random assignment of counties to the ARC (for availability, responsiveness, and continuity) organizational intervention for implementing effective community-based mental health services. The design created 4 treatment conditions (MST plus ARC, MST only, ARC only, control). Outcome measures for 615 youth who were 69% male, 91% Caucasian, and aged 9―17 years included the Child Behavior Checklist and out-of-home placements. Results: A multilevel, mixed-effects, regression analysis of 6-month treatment outcomes found that youth total problem behavior in the MST plus ARC condition was at a nonclinical level and significantly lower than in other conditions. Total problem behavior was equivalent and at nonclinical levels in all conditions by the 18-month follow-up, but youth in the MST plus ARC condition entered out-of-home placements at a significantly lower rate (16%) than youth in the control condition (34%). Conclusions: Two-level strategies that combine an organizational intervention such as ARC and an evidence-based treatment such as MST are promising approaches to implementing effective community-based mental health services. More research is needed to understand how such strategies can be used effectively in a variety of organizational contexts and with other types of evidence-based treatments.

Purpose Calcium ions are highly versatile spacial and temporal intracellular signals of non-excitable cells and have an important impact on nearly every aspect of cellular life controlling cell growth, metabolism, fluid secretion, information processing, transcription, apoptosis, and motility. Neurons and glia respond to stimuli, including neurotransmitters, neuromodulators, and hormones, which increase the intracellular calcium concentration. The function of intracellular calcium in gliomas is unknown. Lots of daily used drugs may act via receptors that can be linked to the intracellular calcium system and therefore could influence glioma biology. Methods Glioma cells were loaded with the calcium ion sensitive dye Fura 2-AM. Subsequently, cells were stimulated with 25 different medical drugs for 30 s. The increase of free intracellular calcium ions was measured and calculated by a microscope–camera–computer-unit. Results Except for the buffer solution HEPES that served as negative control and for the cortisol derivative dexamethasone, all other 24 tested drugs induced a rise of intracellular calcium ions. The cellular calcium responses were classified into seven functional groups. The tested substances activated several types of calcium channels and receptors. Conclusions Our study impressively demonstrates that medical drugs are potent inducers of intracellular calcium signals. Totally unexpected, the results show a high amount of functional cellular receptors and channels on glioma cells, which could be responsible for certain biological effects like migration and cell growth. This calcium imaging study proves the usability of the calcium imaging as a screening system for functional receptors on human glioma cells.

School based mental health services for children in poverty can capitalize on schools’ inherent capacity to support development and bridge home and neighborhood ecologies. We propose an ecological model informed by public health and organizational theories to refocus school based services in poor communities on the core function of schools to promote learning. We describe how coalescing mental health resources around school goals includes a focus on universal programming, mobilizing indigenous school and community resources, and supporting core teaching technologies. We suggest an iterative research–practice approach to program adaptation and implementation as a means toward advancing science and developing healthy children.

This article describes the journey toward evidence-based transport and implementation in usual care settings of Multisystemic Therapy (MST) for youth with drug abuse and behavioral problems (Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998). Research and experience informing the design of the MST transport strategy, progress in evaluating its viability and validity, and implications for future research are described. Findings from transportability research indicate that the MST transport strategy supports the cultivation of therapist, supervisor, and consultant adherence in usual care settings; that such adherence is a consistent predictor of short- and long-term outcomes in such settings; and that clinician and organizational factors also affect adherence and outcomes. These findings have important implications for the transport of other evidence-based practices to usual care settings.

The purpose of this article is to consider, through the lenses of theory and research on technology transfer and the adoption and implementation of innovation, the international transport of evidence-based psychosocial treatments for youth, using Multisystemic Therapy (MST) as an example. MST is a well-validated family and community-based approach originally developed in the United States to treat serious juvenile offenders. This article describes challenges to MST transport internationally by virtue of the political, legal, economic, and cultural contexts in different nations. Modifications used to address these challenges and facilitate the international implementation of MST are described and pertain to pre-implementation processes, clinical staff, training materials and procedures, and clinical service delivery.

Children and adolescents treated for general delinquency problems and rated by caregivers as having sexual behavior problems (N = 696) were compared with youth from the same sample with no sexual behavior problems (N = 1185). Treatment outcome through 12-months post-treatment follow-up and criminal offense rates through an average 48-month post-treatment follow-up were compared for both groups. It was hypothesized that youth with any sexual behavior problems (SBP) would improve significantly over time but would continue to evidence greater psychopathology than youth with no sexual behavior problems (NSBP). These hypotheses were supported. Specifically, both groups evidenced significant improvement on parent-reported treatment outcomes, although the SBP group exhibited more behavior problems, relative to the NSBP group through follow-up. It was further hypothesized that youth with sexual behavior problems would not differ from youth with no sexual behavior problems in rates of future sexual or non-sexual offenses. These hypotheses were also supported. Specifically, SBP group membership was not a significant predictive factor in analyses modeling future offending in general or future person offenses. Few youth in either group had sexual offenses (1.5% and 1.9% for the SBP and NSBP groups, respectively). The importance of these findings for clinical and policy decision-making is discussed.

The papers in this special issue describe research undertaken by the MacArthur Foundation-funded Research Network on Youth Mental Health. The project is designed to understand the challenges of implementing evidence-based treatments in community-based mental health practices. This Introduction and the following articles describe the impetus and conceptual framework underlying one cluster of the Network’s activity—i.e., the Clinic Systems Project (CSP). The CSP studies examined the organizational and service system environments in a large national sample of community mental health and affiliated organizations that provide services to children. The main goal is to identify leverage points for, and barriers to, the adoption and implementation of evidence-based practices for children.

Addressing the science-service gap, we examined in this study the amenability of a large heterogeneous sample of community-based therapists in the state mental health and substance abuse treatment sectors to learn about an evidence-based practice (EBP) for adolescent substance abuse (i.e., contingency management [CM]) when such learning was supported administratively and logistically. Leadership in most (44 of 50) public sector agencies supported practitioner recruitment, and 432 of 543 eligible practitioners subsequently attended a 1-day workshop in CM. Workshop attendance was predicted by organizational factors but not by practitioner demographic characteristics, professional background, attitudes toward EBPs, or service sector. Moreover, the primary reason for workshop attendance was to improve services for adolescent clients; the primary barriers to attendance, for those who did not attend, were practical in nature and not due to theoretical incompatibility. The findings demonstrate a considerable amount of interest practitioners showed in both the substance abuse and mental health sectors in learning about an EBP.

The aim of this study was to assess experiences of acute surgical pain by patient description of pain intensity and patient satisfaction with peri-operative pain management in a variety of adult surgical patients prior to the appointment of an acute pain nurse in a hospital in Queensland, Australia.One hundred and seventeen patients who underwent various surgical procedures were surveyed using a pain rating scale (0-10) and a scale assessing their perceptions of the treatment they received for their post-operative pain.The results provide baseline data about the adequacy of acute pain management within the hospital prior to the implementation of an acute pain service and an acute pain nurse. Overall, patients reported considerable pain postoperatively, yet were satisfied with the way their pain was treated.These findings are consistent with previous research highlighting that acute pain management continues to be a serious clinical issue and that high satisfaction ratings should be viewed with suspicion. The study supports the need for a stronger clinical focus on managing acute pain, with suggested areas for improvement including better educational support for patients, clinician education and thorough assessment and planning throughout the patients' experience.

In this article, we respond to a recent paper published in Children and Youth Services Review, in which Dr. Julia Littell concluded that multisystemic therapy (MST), a family- and evidence-based treatment of serious juvenile offenders, does not reduce rates of rearrest or incarceration and does not improve family relations. Dr. Littell's conclusion is contrasted with those of highly respected reviewers and federal entities that are entirely independent of MST developers and researchers. Moreover, we describe how Dr. Littell's conceptual and methodological analyses have misinterpreted and misrepresented MST research studies and reflect poor appreciation for the conduct of community-based research with challenging clinical populations; the distinctions between efficacy, effectiveness, and transportability research; the nuances of conducting meta-analyses; the importance of treatment fidelity to internal validity; and the fact that not all outcome studies are asking the same conceptual questions. Finally, the implications of Dr. Littell's contentions are noted.

The authors conducted a cost analysis for multisystemic therapy, an evidence-based treatment that is used as an intensive community-based alternative to the hospitalization of youths presenting with psychiatric emergencies.Data from a randomized clinical trial that compared multisystemic therapy with usual inpatient services followed by community aftercare were used to compare Medicaid costs and clinical outcomes during a four-month period postreferral and a 12-month follow-up period. Data were from 115 families receiving Medicaid (out of 156 families in the clinical trial).During the four months postreferral, multisystemic therapy was associated with an average net savings per youth treated of $1,617 compared with usual services. Costs during the 12-month follow-up period were similar between treatments. Multisystemic therapy demonstrated better short-term cost-effectiveness for each of the clinical outcomes (externalizing behavior, internalizing behavior, and global severity of symptoms) than did usual inpatient care and community aftercare. The two treatments demonstrated equivalent long-term cost-effectiveness.Among youths presenting with psychiatric emergencies, multisystemic therapy was associated with better outcomes at a lower cost during the initial postreferral period and with equivalent costs and outcomes during the 12-month follow-up period.

A public health perspective on the dissemination of empirically supported treatments is articulated, and the implications of this perspective for the foci of dissemination efforts and research are discussed. Strategies targeting multiple levels of the practice context, including payers and policy makers, will likely be needed to cultivate and sustain the demand for evidence-based treatments and to support the implementation of such treatments with fidelity. A continuous quality improvement system is recommended to document and improve the implementation and outcomes of evidence-based treatments delivered in community practice settings.

Improving the accessibility and effectiveness of community mental health services for children has been a national concern for more than a decade (National Advisory Mental Health Council, 2001). In a seminal study, secondary data analysis of three nationally representative household surveys indicated that nearly 80% of low-income youth in need of mental health services did not receive services in the preceding 12 months, with rates approaching 90% for uninsured families (Kataoka, Zhang, & Wells, 2002). Lack of access to services is especially problematic in urban, low-income communities with high rates of nonattendance at initial appointments and rates below 10% for attendance at as few as four sessions (see McKay & Bannon, 2004). Infrequent use of mental health services has been attributed to stigma (Dempster, Wildman, & Keating, 2013) and concrete obstacles, such as inaccessible locations, lack of information about services, and social isolation (Harrison, McKay, & Bannon, 2004). Concentrated urban poverty also is associated with high risk of substantial mental health difficulties for youth (Cappella, Frazier, Atkins, Schoenwald, & Glisson, 2008). A longitudinal analysis of a large nationally representative sample of youth indicated a robust relation between neighborhood disadvantage and conduct problems over and above a series of family and individual risk factors (Goodnight, et al., 2012). Relatedly, exposure to community violence, affecting almost 80% of urban children (U.S. Department of Justice, 2003), is associated with poor academic performance (McCoy, Roy, & Sirkman, 2013) mediated by depression and disruptive behavior (Borofsky, Kellerman, Baucom, Oliver, & Margolin, 2013). A public health framework offers promise for organizing the design and delivery of more accessible and appropriately targeted services to children living in urban poverty. Within a public health framework, universal intervention strategies are deployed to attenuate risk factors and related behavior problems, while targeted interventions are simultaneously deployed for high-risk cases (Stiffman, Stelk, Evans, & Atkins, 2010). If delivered in those contexts naturally inhabited by children and families – primarily school and home – and focused on specific aspects of those contexts affecting child learning and behavior, service models encompassing such interventions also could be more effective and sustainable (Atkins & Frazier, 2011). In this study, we examined a service delivery model, Links to Learning (L2L), which involved the integration and delivery of universal and targeted interventions focused on supporting schooling for children with disruptive behavior disorders living in urban low-income communities. School-Based Mental Health Services Schools are the de facto providers of mental health services for children and youth (Farmer, Burns, Phillips, Angold, & Costello 2003; Green et al., 2013), providing an estimated 70% to 80% of psychosocial services (Rones & Hoagwood, 2000). However, the primary modality for school-based services, individual counseling (Foster et al., 2005), is largely ineffective for children with disruptive behavior disorders, which comprise the majority of school referrals (Farmer, Compton, Burns, & Robertson, 2002; Foster et al., 2005). This is especially evident for children attending schools in low-income urban communities. In a recent meta-analysis examining school-based mental health programs for low-income, urban youth (Farahmand, Grant, Polo, Duffy, & DuBois, 2011), null effects were found for most outcomes (mean ES = .08), and negative effects were found for programs focused on externalizing behaviors (ES = −.11). The authors suggested that these findings reflect a lack of attention to the many stressors apparent in low-income urban schools and proposed that effective services would require an integration of the school ecology into program planning and implementation. A second meta-analysis of programs based in community mental health settings serving low income urban youth (Farahmand et al., 2012) found positive effects for programs that supported parents or provided other community supports (mean ES = .38), and null effects for programs focused on direct services to youth (mean ES = .03). These findings suggest that individually focused services are contraindicated for low-income youth with disruptive behavior and that interventions are likely to be more impactful when they can be deployed in, and alter, family and community contexts. In the present study, we implemented and examined a model in which community mental health staff worked directly with parents and teachers in low-income urban schools to enhance children’s school success. Predictors of Children’s Learning: Teachers and Parents Informed by evidence supporting the effectiveness of focusing mental health services on the empirical predictors of youth offending (Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998), we constructed a model focusing mental health services on the empirical predictors of children’s learning to impact children’s school success (see Cappella et al., 2008). An extensive literature documents that children’s academic learning is compromised in urban low-income schools, with profound and growing gaps between poor and nonpoor U.S. children (Reardon, 2011). This has important implications given that academic achievement is a hallmark of children’s sense of competence (Masten & Curtis, 2000), and critical to social and emotional adjustment (Roeser, Eccles, & Freedman-Doan, 1999). Academic achievement can operate as a protective factor for urban children (Freudenberg & Ruglis, 2007), and is associated with positive relationships with peers, teachers, and parents, and improved classroom behavior (Atkins, Hoagwood, Kutash, & Seidman, 2010). In addition, a direct focus on schooling by mental health providers could bridge educational and mental health systems, and provide additional resources to struggling urban schools (Ringeisen, Henderson, & Hoagwood, 2003). Reviews of the educational literature reveal that teachers and parents contribute uniquely to children’s learning. Specifically, three components of teacher practices most significantly impact children’s learning: Effective instruction, classroom management, and teacher outreach to parents (Stringfield, 1994). Similarly, parent communication with teachers, homework support, and reading at home are associated with improved learning (Jeynes, 2005). These classroom and family predictors of learning were the focus of the mental health service model developed for this study (Cappella et al., 2008). Diffusion of Innovation: Teacher Key Opinion Leaders and Parent Advocates Diffusion theory posits that key opinion leaders (KOLs) spread innovations as a function of their influential role within their social network (Rogers, 1995). In the first study applying diffusion theory to urban schools (Atkins et al., 2008), KOL teachers, working with mental health providers (MHPs), promoted higher rates of teachers’ self-reported use of recommended interventions than consultation from MHPs without KOL support. These results supported an expanded role for KOL teachers for the dissemination of school-based mental health interventions. Similarly, involving parents with similar characteristics and experiences as the parents of children referred for services can reduce stigma, enhance participation in services, and influence behavior change due to shared experiences and reduced social distance (Frazier, Abdul-Adil, Atkins, Gathright, & Jackson, 2007; Hoagwood et al., 2010). The Current Study We examined the extent to which a mental health model, Links to Learning (L2L), focused on the key predictors of student learning and delivered by community mental health providers aligned with parent advocates and KOL teachers, would lead to greater reductions in children’s disruptive behavior at home and school as compared to mental health services-as-usual (SAU). Moderators included baseline child and family characteristics. This three-year longitudinal study utilized a multi-method, multi-informant design consisting of classroom observations, teacher report, parent report, and direct assessment of academic performance with random assignment of schools to L2L or assisted referral to community based SAU.

In this commentary I suggest that some conceptual confusion has characterized the migration of least restrictive alternative from its legal origins to the realm of children's mental health. Suggestions regarding clarification of terminology are made, as are propositions regarding the type of research needed to develop systems of care in which effective treatments are delivered in the least restrictive setting possible.

Patient-initiated partner notification of sexually transmitted infection (STI), i.e. patients informing their sexual partners of a diagnosis, is a cornerstone of STI prevention. Growing evidence suggests that women exposed to intimate partner violence (IPV) may fear such notification, or face negative consequences in response to STI disclosure. The current study assessed associations of IPV with fear of partner notification, and experiences of partner notification, among adolescent and young adult female family planning clinic patients. Women aged 16–29 years attending five family planning clinics in Northern California, USA ( n = 1282) participated in a cross-sectional survey. A history of physical or sexual IPV was associated with fear of partner notification. Moreover, participants exposed to IPV were more likely to have partners say that it was not from them or otherwise accuse them of cheating in response to partner notification. Such partners were less likely to seek indicated STI treatment or testing. Current findings suggest that partner notification for STI may be compromised by IPV. Clinical practices and policies to support effective partner notification should include IPV assessment, and provide mechanisms to address related fears concerning partner notification.

The current study investigated relations among ethnic similarity in caregiver-therapist pairs of youth participating in Multisystemic Therapy, therapist adherence, and youth long-term behavioral and criminal outcomes. Participants were 1,979 youth and families treated by 429 therapists across provider organizations in 45 sites. Relations were found, independently, and in the presence of ethnic similarity, between adherence and reductions in youth externalizing and internalizing behavior problems 1-year posttreatment and youth criminal charges 4 years posttreatment. Relations between ethnic similarity and outcomes were found only for reductions in youth externalizing behavior problems and not when adherence was included in the model. Adherence ratings were higher, however, in ethnically similar caregiver-therapist pairs, and evidence was found that this increased adherence predicted slightly better outcomes for youth. Implications for further research and clinical practice are considered.

The authors identify and define key aspects of the progression from research on the efficacy of a new intervention to its dissemination. They highlight the role of transportability questions that arise in that progression and illustrate key conceptual and design features that differentiate efficacy, effectiveness, and dissemination research. An ongoing study of the transportability of multisystemic therapy is used to illustrate independent and interdependent aspects of effectiveness, transportability, and dissemination studies. Variables relevant to the progression from treatment efficacy to dissemination include features of the intervention itself as well as variables pertaining to the practitioner, client, model of service delivery, organization, and service system. The authors provide examples of how some of these variables are relevant to the transportability of different types of interventions. They also discuss sample research questions, study designs, and challenges to be anticipated in the arena of transportability research.

Objective: The experiences of clinicians in regard to initial and longterm intention to use evidence-based treatments were examined in order to better understand factors involved in implementation of innovative treatments. Methods: Ethnographic methods of participant observation and extended semistructured interviews with four trainers, six clinical supervisors, and 52 clinicians at five agencies in Honolulu and six in Boston were used to understand treatment implementation in the Clinic Treatment Project, a randomized effectiveness trial of evidencebased treatments for depression, anxiety, and conduct problems of children. Grounded-theory analytic methods were used to analyze field notes, interview transcripts, and meeting minutes. Results: Three patterns in regard to long-term intention to implement the treatments were evident: application of the treatments with fidelity, abandonment of the treatments, and selective or partial application. These patterns were perceived to be associated with three preimplementation factors: lag time between initial training in the treatment protocol and treatment use in practice, clinician engagement with the project, and clinician-treatment fit. Four additional factors were proximal outcomes of the three determinants as well as first steps of implementation: clinicians’ first impressions of the evidence-based treatments after initial use, competence in treatment use, clinician and researcher adaptability, and clinician-researcher interactions. Conclusions: Interactions between preimplementation factors and initial implementation experiences and between researchers and clinicians during the early implementation steps were related to intentions to sustain treatment. (Psychiatric Services 59:738–746, 2008)

There has been an increased interest in recent years in understanding how to implement evidence-based practices/ treatments (EBP/Ts) in community settings (Insel 2009; Proctor et al. 2009), there still remain significant progress to be made in understanding this process of ‘‘transporting EBP into community settings.’’ Furthermore, there exists a considerable gap between the real practice of community mental health and the use of these effective programs. Over time, the studies and experiences of transporting will yield invaluable information, which in turn will increase our understanding and improve the implementation of effective practices into the community setting. However, these studies are unlikely to overcome the philosophical barriers to the implementation of effective programs. In fact, if effective practices are to reach the children, adolescents, and families who struggle with mental health problems, it is important that the field find a way to build bridges across the gap between researchers and practitioners in such a way that we improve the implementation and use of EBPs in community settings. Our focus here is threefold; to define the more ‘‘actionable’’ challenges and steps that will add to implementation studies; to further the improvement of effective practices; and to identify some of the potential action steps and possible solutions that will facilitate the implementation of EBP into community settings.

Esters of ethacrynic acid and partial structural analogs were synthesized and evaluated for topical antiglaucoma activity in rabbits. Maximum activity was shown by analogs 2 and 6 (34% and 30% reduction in intraocular pressure recovery rate, respectively). Among the esters, only the ethyl ester (2) was found to be active; the methyl and n-propyl esters (1 and 3) were inactive. Analogs 1-3 were subjected to an estimation of physicochemical properties and chemical stability. However, no correlation was found to exist between the biological activity/inactivity and the physicochemical properties of the analogs. The analogs were evaluated for ex vivo hydrolysis using rabbit aqueous humor (AH), corneal (C) homogenate and iris-ciliary body (ICB) homogenate. For all tissues, the rate of enzymatic hydrolysis increased significantly with an increasing ester chain length. The ICB-mediated hydrolysis was the fastest among the three tissues for all of the analogs. The relationship between the rate constants for the tissue-mediated hydrolyses were: analog 1, ICB>C>AH; analog 2, ICB>C=AH and analog 3, ICB>AH>C. Apparent Michaelis-Menten kinetic parameters were determined for the three analogs using corneal homogenate. Analog 2 showed the highest v0 for all substrate concentrations studied. The conventional Michaelis-Menten equation did not fit the data as well as a sigmoidal model. Both fits of the data showed the fastest enzyme-mediated hydrolysis for analog 2. The parameters of the sigmoidal fit of the data correlated with the activity/inactivity of the analogs. The data indicate that the major factors responsible for the observed activity/inactivity are the differences in the corneal enzymatic hydrolysis of the esters in conjunction with the rapid dynamics of ocular prodrug absorption.

Although the search for effective methods of renal prophylaxis during aortic surgery spans many decades, definitive answers are scarce. The literature is voluminous, yet the amount of work clearly relevant to the specific clinical situation of perioperative prophylaxis is small. Given the significant morbidity and subsequent mortality involved with perioperative ARF, it is difficult to sit back and do nothing when pharmacologic agents empirically are believed to possibly benefit the patient. Care must be taken to apply data from different clinical scenarios in the literature to the situation at hand. Drugs felt to be innocuous, even in low doses, may be insidiously counterproductive or damaging if they are not managed properly. Maintaining an adequate preload and stable hemodynamics seems to be the most logical universal approach at this time. Furosemide treatment without maintaining an adequate volume status once diuresis commences may be detrimental, which is true with the diuretic effects induced by mannitol or dopamine. The tachycardia resulting from a relative hypovolemia and from the beta effects of dopamine can cause myocardial ischemia from increased oxygen demand. Low urine output does not portend a negative outcome in the face of an adequate intravascular volume any more than an induced diuresis prevents renal injury. Currently, minimization of renal ischemia and maintenance of an adequate intravascular volume and renal hemodynamics are the keys to optimizing renal outcome during aortic surgery. Other maneuvers are not definitive and should be cautiously undertaken.

Ketanserin, a hypotensive drug with 5-HT2 receptor antagonism, when administered by topical infusion of a 0.25% w/v solution by corneal and scleral applications, was found to lower intraocular pressure with four times more activity than its metabolite, ketanserinol. Drug and metabolite were measured periodically in the corneal epithelium, corneal stroma/endothelium, aqueous humor, iris/ciliary body, conjunctiva, sclera and lens during the infusion period (0-120 min) and the postinfusion period (120-240 min) using a fluorometric reversed-phase HPLC assay developed and verified for the research. The infusion results showed that drug entered the eye by both the corneal and scleral routes. Lateral diffusion occurred between the conjunctiva and corneal epithelium. Drug and metabolite were also detected in the untreated fellow eyes, suggesting contralateral systemic redistribution. In vitro metabolism was studied and found to occur in the corneal epithelium, iris/ciliary body and bulbar and palpebral conjunctiva but not in the corneal stroma/endothelium, aqueous humor and sclera. From noncompartmental analysis, zero-order infusion rate constants, first-order absorption constants, mean residence time, volumes of distribution at steady state (Vss) and clearance (Cle) were obtained using equations specific to the topical infusion method. Vss and Cle of aqueous humor (0.972 ml and 13.55 microl/min) were greater than aqueous humor volume (0.311 ml) and turnover rate (4.7 microl/min).

Two comprehensive community-based interventions for youth with severe emotional disorders are contrasted and compared. The interventions are multisystemic therapy (MST)—a brief but intensive, clinician-provided, and home-based treatment; and wraparound—a long-term approach to planning and coordinating the provision of both formal and informal services in the community. Both approaches are spreading rapidly across the country. As this occurs, it is important for families, clinicians, and policymakers to have sufficient information to understand the requirements and the research base for each. This paper provides a description of both MST and wraparound across multiple dimensions (i.e., origin, theory, target population, principles, role of family, cultural competence, staffing, training, quality monitoring, costs, and the evidence base). The respective similarities and differences are discussed and options for utilizing both for selected youth and families who require intensive and long-term care are explored briefly.

UNLABELLED: We studied 20 patients over the age of 65 yr undergoing prolonged peripheral vascular surgery under continuous lidocaine epidural anesthesia, anticipating that the increased hepatic metabolism caused by small-dose IV dopamine would lower plasma lidocaine concentrations. Subjects were assigned (random, double-blinded) to receive either a placebo IV infusion or dopamine, 2 microg. kg(-1). min(-1) during and for 5 h after surgery. Five minutes after the IV infusion was started, 20 mL of 2% lidocaine was injected through the epidural catheter. One-half hour later, a continuous epidural infusion of 2% lidocaine at 10 mL/h was begun. The epidural infusion was temporarily decreased to 5 mL/h or 5 mL boluses were added to maintain a T8 analgesic level. Arterial blood samples were analyzed for plasma lidocaine concentrations regularly during and for 5 h after surgery. Plasma lidocaine concentrations increased continuously during the epidural infusion and, despite wide individual variation, were similar for the two groups throughout the observation period. During the observation period, the mean maximal plasma lidocaine concentration was 5.8 +/- 2.3 microg/mL in the control group and 5.7 +/- 1.2 microg/mL in the dopamine group. However, the mean hourly lidocaine requirement during surgery was significantly different, 242 +/- 72 mg/h for control and 312 +/- 60 mg/h for dopamine patients (P < 0.03). At the end of Hour 4, the last period when all 20 patients were still receiving the epidural lidocaine infusion, the total lidocaine requirement was significantly different, 1088 +/- 191 mg for the control group and 1228 +/- 168 mg for the dopamine group (P < 0.05). Despite very large total doses of epidural lidocaine (1650 +/- 740 mg, control patients, and 1940 +/- 400, dopamine patients) mean maximal plasma concentrations remained below 6 microg/mL, and no patient exhibited signs or symptoms of toxicity. We conclude that small-dose IV dopamine increased epidural lidocaine requirements, presumably as a consequence of increased metabolism. IMPLICATIONS: We tested dopamine, a drug that increases liver metabolism of the local anesthetic lidocaine to determine if it would prevent excessively large amounts of lidocaine in the blood during prolonged epidural anesthesia in elderly patients. Dopamine did not alter the blood levels of lidocaine, but it did increase the lidocaine dose requirement to maintain adequate epidural anesthesia.

Hospitalization and out-of-home placement data for 113 youth participating in a randomized trial comparing home-based multisystemic therapy (MST; n = 57) with hospitalization(n = 56) for psychiatric crisis stabilization were analyzed following the completion of MST treatment—approximately 4 months post approval for emergency psychiatric hospitalization. Analyses showed that MST prevented any hospitalization for 57% of the participants in the MST condition and reduced the overall number of days hospitalized by 72%. Importantly, the reduction in use and length of hospitalization was not offset by increased use of other placement options, as MST reduced days in other out-of-home placements by 49%. The cost implications for the viability of MST as an alternative to hospitalization for youth presenting psychiatric emergencies are discussed.

The effectiveness of multisystemic therapy (MST) in promoting school participation among substance abusing and dependent juvenile offenders with high rates of psychiatric comorbidity was examined. Youth were randomly assigned to receive MST versus usual community-based services. Results indicated that MST (but not usual services) significantly increased school attendance at posttreatment, and that these treatment gains were maintained at the 6-month follow-up assessment. Explanations for the findings and directions for future research are discussed.

F istula formation between the trachea and the innominate artery is a rare complication of tracheostomy (1). The survival rate in patients who develop bleeding from a tracheo-innominate artery fistula (TIF) has been reported as 14.3%, and only patients who received immediate surgical treatment survived (2). Of those patients who develop a TIF, 78% do so within the first 3 wk after tracheostomy (3). One of the proposed mechanisms of fistula formation is mucosal necrosis due to pressure caused by the elbow, tip, or cuff of the tracheostomy tube (2). Clinical presentations and treatment of TIF have been described mainly in the surgical literature (1–7). However, because anesthesiologists may be involved in treating this emergency, they must be familiar with the therapeutic steps. We present a patient who developed a TIF and died as a consequence of massive hemorrhage into the tracheobronchial tree with asphyxia. We discuss potential preventative measures that should be followed to decrease the probability of formation of a tracheo-arterial fistula, as well as important diagnostic and therapeutic steps the anesthesiologist must take in managing this severe tracheostomy complication.

There are a large variety of scheduled activities and courses available to meet the continuing medical education (CME) needs of anesthesiologists. The presentation of CME material varies in format and delivery style. The reasons for attending CME activities include licensure requirements, participation in state and national societies, keeping current with technology, review of old subject material, participation as a lecturer, and other personal reasons. Funding occurs via personal funds, employer support, commercial support, or by research grants. External bodies, such as the American Council of Continuing Medical Education and the American Medical Association, have imposed guidelines in these areas. Methods to evaluate CME activities include retrospective needs analysis based on exit interviews, prospective needs assessment, focus groups, and complex systems such as the CRISIS criteria. Self-directed CME can be evaluated by data collection that identifies how quickly information is received and by the effect of this data on measurable outcome. In the future, CME will increasingly utilize simulators and multimedia computers. Multimedia can bring CME to the physician as opposed to the physician traveling to a CME site. Virtual reality and artificial intelligence are on the horizon and may interface well with the field of anesthesiology due to the technical nature of the discipline and the increasing use of computers and electronic data collection already occurring in clinical practice.