VA Roseburg Healthcare System

AIMS: Clinical trials test the safety and efficacy of behavioral and pharmacological interventions in drug-dependent individuals. However, there is no consensus about the most appropriate outcome(s) to consider in determining treatment efficacy or on the most appropriate methods for assessing selected outcome(s). We summarize the discussion and recommendations of treatment and research experts, convened by the US National Institute on Drug Abuse, to select appropriate primary outcomes for drug dependence treatment clinical trials, and in particular the feasibility of selecting a common outcome to be included in all or most trials. METHODS: A brief history of outcomes employed in prior drug dependence treatment research, incorporating perspectives from tobacco and alcohol research, is included. The relative merits and limitations of focusing on drug-taking behavior, as measured by self-report and qualitative or quantitative biological markers, are evaluated. RESULTS: Drug-taking behavior, measured ideally by a combination of self-report and biological indicators, is seen as the most appropriate proximal primary outcome in drug dependence treatment clinical trials. CONCLUSIONS: We conclude that the most appropriate outcome will vary as a function of salient variables inherent in the clinical trial, such as the type of intervention, its target, treatment goals (e.g. abstinence or reduction of use) and the perspective being taken (e.g. researcher, clinical program, patient, society). It is recommended that a decision process, based on such trial variables, be developed to guide the selection of primary and secondary outcomes as well as the methods to assess them.

Characteristics of efficient (high turnover) and effective (low return rate) psychiatric units were examined. Nursing staff and patients tended to attribute negative characteristics to efficient units. Effective programs, on the other hand, were characterized as having motivated professional staff and active participant roles for both nursing staff and patients.

A retrospective analysis of factors influencing survival in patients with primary lymphoma of bone (PLB) treated at a single institution was performed. The records of 30 eligible patients were evaluated for overall survival (OS) as related to age, sex, stage, International Prognostic Index (IPI) score, number of sites involved and type of treatment. There was a significant difference in OS in patients with IPI scores of low (L) and low intermediate (LI) versus high intermediate (HI) (P = 0.0035), regardless of stage. Sex, age, stage and number of sites did not have a significant influence on OS. There was a statistically significant difference in OS favouring use of combined chemotherapy (with or without rituximab) and radiation compared with either modality alone (P = 0.02). The addition of rituximab resulted in a non-significant trend towards improved OS (P = 0.11). With a median follow up of 49 months, 73% of patients are alive 5 years from diagnosis.

BACKGROUND: Illicit use of buprenorphine has increased in the U.S., but our understanding of its use remains limited. This study aims to explore Web-forum discussions about the use of buprenorphine to self-treat opioid withdrawal symptoms. METHODS: PREDOSE, a novel Semantic Web platform, was used to extract relevant posts from a Web-forum that allows free discussions on illicit drugs. First, we extract information about the total number of buprenorphine-related posts per year between 2005 and 2013. Second, PREDOSE was used to identify all posts that potentially contained discussions about buprenorphine and opioid withdrawal. A total number of 1,217 posts that contained these terms were extracted and entered into NVivo data base. A random sample of 404 (33%) posts was selected and content analyzed. RESULTS: Buprenorphine-related posts increased over time, peaking in 2011. The posts were about equally divided between those that expressed positive and negative views about the effectiveness of buprenorphine in relieving withdrawal symptoms. Web-forum participants emphasized that buprenorphine's effectiveness may become compromised because of the "size of a person habit," and/or when users repeatedly switch back and forth between buprenorphine and other illicit opioids. Most posts reported use of significantly lower amounts of buprenorphine (≤2 mg) than doses used in standard treatment. Concomitant use of other psychoactive substances was also commonly reported, which may present significant health risks. CONCLUSIONS: Our findings highlight the usefulness of Web-based data in drug abuse research and add new information about lay beliefs about buprenorphine that may help inform prevention and policy measures.

AbstractCorporate social responsibility (CSR) has been a topic of interest to both practitioners and researchers in the forest products sector. However, the existing literature falls short of examining the connections between CSR implementation and firm cultures, a key link to further our understanding for CSR implementation. This current study investigates the relationship between firm cultures and CSR implementation in the global forest, paper & packaging industry companies. Specifically, the authors propose firm cultures, including market orientation, learning orientation and innovativeness potentially support CSR implementation. Also, innovativeness is proposed to mediate the market orientation-CSR and learning orientation-CSR relationships. Data are collected through a mail survey with responses from 58 companies (87 individuals) of the Top 100 global forest, paper & packaging industry companies, identified by PricewaterhouseCoopers in its 2008 Global Forest, Paper & Packaging Industry Survey. Results confirm the hypothesized relationships between market orientation and CSR and learning orientation and CSR. However, the proposed mediating effect of innovativeness is not significant.Keywords: market orientationlearning orientationCSR implementationinnovativeness AcknowledgementsFinancial support from Center for Wood Utilization Research, USDA CSREES Special Research Grant Program is gratefully acknowledged. The authors also would like to extend our appreciation to the reviewers for the insightful comments.

The Interagency Fuels Treatment Decision Support System (IFTDSS) is a web-based software and data integration framework that organizes fire and fuels software applications into a single online application. IFTDSS is designed to make fuels treatment planning and analysis more efficient and effective. In IFTDSS, users can simulate fire behavior and fire effects using the scientific algorithms and processes found in desktop applications including FlamMap, Behave, FOFEM, and Consume. Strategic-level goals of IF-TDSS are to This paper discusses the tools and processes IFTDSS offers to fire, fuels, and resource managers responsible for planning fuels treatment within a framework of hazard analysis and risk assessment. We outline how fire and fuels treatment planners can use IFTDSS to identify areas of high hazard and risk, evaluate the potential burning risk and hazard level for valued resources (values at risk) within the area of interest, and simulate the effectiveness of fuels treatments in reducing the potential harm to values at risk.

BACKGROUND: The importance of conducting substance use disorder treatment research in real-world settings is now well recognized. While this approach to clinical trials research offers a variety of benefits, challenges also arise. Selecting high-quality sites to participate is critical to recruitment, retention, and overall trial performance when conducting multi-site, community-based clinical trials of treatments for substance use disorders. OBJECTIVES: Over the past 10 years, the National Institute on Drug Abuse-sponsored National Drug Abuse Treatment Clinical Trials Network (CTN) has strived to conduct high-quality, well-managed clinical trials. This includes developing methods for site selection to be used by investigators conducting CTN trials. METHODS: We review site selection strategies from two community-based multi-site clinical trials conducted under the auspices of the National Drug Abuse Treatment Clinical Trials Network. RESULTS: Issues relevant to site selection include the clinical trial design, availability of appropriate clinical population, and organizational attributes of potential clinical research sites. Site selection strategies include reviewing regional epidemiologic data, collecting standard site selection surveys, evaluating clinic data on existing patient populations, and site selection interviews and visits. CONCLUSION: This article describes considerations for selecting research sites and identifies specific strategies to employ when selecting community-based sites for participation in clinical trials.

In spite of the mechanistic links between forest floor fuels and fire behaviour and effects, little information is available on their composition and structure. We collected fuels from well-developed forest floors in four long-unburned Jeffrey pine (Pinus jeffreyi)–white fir (Abies concolor) forests in the Lake Tahoe Basin in California and Nevada. We measured forest floor (litter, fermentation and humus, where present) load, depth, bulk density and mineral ash content at the base of each tree, near the crown drip line and beyond the crown in open gaps (n = 40 Jeffrey pine, 40 white fir). We found substantial variability in composition between the two conifers’ forest floor fuels and across species. Forest floor was mounded near tree stems, with the majority of the depth (and mass) composed of fermentation fuels. Humus was present across spatial locations, but was patchier with increasing distance from trees. Ash content varied between trees (fir > pine) and with depth (humus > fermentation > litter). Results highlight the high spatial variation in forest floor fuels and underscore the need for building a greater understanding of forest floor fuels in long-unburned sites.

BACKGROUND: Increasingly, new HIV infections among people who use drugs are attributed to sexual risk behavior. However, HIV prevention research targeting persons with opioid dependence continues to focus on drug injection practices. Moreover, despite the rising prevalence of prescription opioid dependence in the United States, little is known about HIV risk in this population. METHODS: This study examined the prevalence of sexual risk behavior among patients with opioid dependence who primarily use prescription opioids for non-medical purposes. As part of a multi-site clinical trial, participants (N = 653) completed a baseline assessment that included the Risk Behavior Survey. RESULTS: In the past month, 74% were sexually active. Of these, most had opposite sex partners (97.3%) and vaginal intercourse (97.1%); anal intercourse was uncommon (3.1%). The majority reported unprotected intercourse (76.5%), but few had multiple partners (11.3%). Unprotected intercourse was associated with history of other substance dependence (adjusted odds ratio [AOR] = 1.73), and having multiple partners was associated with concurrent cocaine use (AOR = 2.54). Injection drug use in the past month was rare (2.5%). CONCLUSIONS: While the majority of sexually active participants engaged in unprotected intercourse, the proportion with multiple sex partners was low relative to other samples of persons who use illicit drugs. Among persons with non-medical prescription opioid dependence, those who concurrently use other substances may be at elevated risk for HIV infection. Comprehensive assessment of substance abuse history among individuals dependent upon prescription opioids is critical for identifying patients who may require additional clinical interventions to reduce HIV sexual risk behavior.

BACKGROUND: Measurement of cognitive behavioural therapy (CBT) competency is often resource intensive. A popular emerging alternative to independent observers' ratings is using other perspectives for rating competency. AIMS: This pilot study compared ratings of CBT competency from four perspectives - patient, therapist, supervisor and independent observer using the Cognitive Therapy Scale (CTS). METHOD: Patients (n = 12, 75% female, mean age 30.5 years) and therapists (n = 5, female, mean age 26.6 years) completed the CTS after therapy sessions, and clinical supervisor and independent observers rated recordings of the same session. RESULTS: Analyses of variance revealed that therapist average CTS competency ratings were not different from supervisor ratings, and supervisor ratings were not different from independent observer ratings; however, therapist ratings were higher than independent observer ratings and patient ratings were higher than all other raters. CONCLUSIONS: Raters differed in competency ratings. Implications for potential use and adaptation of CBT competency measurement methods to enhance training and implementation are discussed.

1. Domestic violence is a major public health problem requiring committed, coordinated community response. 2. Domestic violence is a significant cause of morbidity and mortality for women and children in the United States. 3. EMS personnel play a frontline role in the critical response and prevention of domestic violence. 4. EMS education and training are requisite for safe, effective responses to domestic violence in rural communities.

Abstract With the increasing interest in the use of biomass for energy, conventional and alternative delivery systems are being evaluated for transporting biomass generated from harvest residuals on steep terrain in the Pacific Northwest. Conventional delivery systems include chipping or grinding of harvest residues (comminution) at the landing or a satellite yard in the forest and transporting the material with chip trucks to a power facility. To address some of the challenges of conventional methods of transporting biomass in steep terrain, chip van manufacturers have been making trailer modifications to increase vehicle maneuverability on forest roads. To evaluate the proper van configurations for implementing a successful biomass transportation system, planners should understand the limitations of the various chip van options. We present guidelines for designing new roads and evaluating existing road systems for chip truck access to forest residuals, as well as some practical field assessment procedures to evaluate accessibility on existing roads.

INTRODUCTION: eScreening is a mobile health technology resource for veterans and staff to support Veterans Health Administration initiatives such as early identification of health problems, shared decision-making, and measurement-based care. METHODS: We conducted an exploratory mixed methods retrospective study with newly enrolling post-9/11 veterans to (1) understand eScreening user experience and obtain practical feedback on the technology to guide improvements, (2) assess veteran satisfaction with eScreening following improvements to the technology, and (3) examine veteran characteristics associated with eScreening satisfaction. Focus group data were collected on user experience with eScreening from a sample of veterans who participated in an eScreening pilot. Guided by a user-centered design approach, findings informed improvements to the technology. Survey data were subsequently collected from a large cohort of veterans to assess satisfaction with the improved program. Questionnaire data were also collected to examine variables associated with eScreening satisfaction. Qualitative focus group data were analyzed using content analysis. Descriptive statistics were used to characterize sociodemographic variables, questionnaires, and satisfaction ratings. Correlations were run to examine the relationship between certain veteran characteristics (eg, age, resiliency, anxiety, insomnia, post-traumatic stress disorder, somatic symptoms, depression, pain) and satisfaction with eScreening. All research activities were conducted at VA San Diego Healthcare System and approved by the Institutional Review Board. RESULTS: Focus group data revealed that veterans were largely satisfied with eScreening, but they suggested some improvements (eg, to interface functionality), which were integrated into an updated version of eScreening. Following these changes, survey data revealed that veterans were highly satisfied with eScreening, including its usability, information security, and impact on health services. There were statistically significant, though not clinically meaningful relationships between health-related characteristics and satisfaction with eScreening. However, millennials showed significantly higher satisfaction ratings compared with non-millennials. CONCLUSIONS: These findings support the use of patient experiences and feedback to aide product development. In addition, post-9/11 veterans support the use of eScreening to assist health screening. However, evaluating the eScreening program in more diverse veteran groups and Veterans Affairs settings is needed to improve the generalizability of these findings to the larger veteran population.

BACKGROUND: Technology-based self-assessment (TB-SA) benefits patients and providers and has shown feasibility, ease of use, efficiency, and cost savings. A promising TB-SA, the VA eScreening program, has shown promise for the efficient and effective collection of mental and physical health information. To assist adoption of eScreening by healthcare providers, we assessed technology-related as well as individual- and system-level factors that might influence the implementation of eScreening in four diverse VA clinics. METHODS: This was a mixed-method, pre-post, quasi-experimental study originally designed as a quality improvement project. The clinics were selected to represent a range of environments that could potentially benefit from TB-SA and that made use of the variety eScreening functions. Because of limited resources, the implementation strategy consisted of staff education, training, and technical support as needed. Data was collected using pre- and post-implementation interviews or focus groups of leadership and clinical staff, eScreening usage data, and post-implementation surveys. Data was gathered on: 1) usability of eScreening; 2) knowledge about and acceptability and 3) facilitators and barriers to the successful implementation of eScreening. RESULTS: Overall, staff feedback about eScreening was positive. Knowledge about eScreening ranged widely between the clinics. Nearly all staff felt eScreening would fit well into their clinical setting at pre-implementation; however some felt it was a poor fit with emergent cases and older adults at post-implementation. Lack of adequate personnel support and perceived leadership support were barriers to implementation. Adequate training and technical assistance were cited as important facilitators. One clinic fully implemented eScreening, two partially implemented, and one clinic did not implement eScreening as part of normal practice after 6 months as measured by usage data and self-report. Organizational engagement survey scores were higher among clinics with full or partial implementation and low in the clinic that did not implement. CONCLUSIONS: Despite some added work load for some staff and perceived lack of leadership support, eScreening was at least partially implemented in three clinics. The technology itself posed no barriers in any of the settings. An implementation strategy that accounts for increased work burden and includes accountability may help in future eScreening implementation efforts. Note. This abstract was previously published (e.g., Annals of Behavioral Medicine 53: S1-S842, 2019).

BACKGROUND: It is a challenge to educators to assist nursing staff in maintaining up-to-date knowledge of pain assessment and management. METHOD: A learning game, "The Pain Game," was developed to deliver information on current practices and standards related to patient pain assessment and management. RESULTS: The advantages of using this gaming technique included minimal instructor preparation time, low cost materials, inclusion of participants as peer teachers, and a high level of participant involvement in the learning process. CONCLUSIONS: The Pain Game has been a well-received educational activity. Not only did knowledge acquisition occur, but the game also provided an enjoyable alternative to more traditional content delivery methods.

BACKGROUND: The Veterans Health Administration (VHA) developed a comprehensive mobile screening technology (eScreening) that provides customized and automated self-report health screening via mobile tablet for veterans seen in VHA settings. There is agreement about the value of health technology, but limited knowledge of how best to broadly implement and scale up health technologies. Quality improvement (QI) methods may offer solutions to overcome barriers related to broad scale implementation of technology in health systems. We aimed to develop a process guide for eScreening implementation in VHA clinics to automate self-report screening of mental health symptoms and psychosocial challenges. METHODS: This was a two-phase, mixed methods implementation project building on an adapted quality improvement method. In phase one, we adapted and conducted an RPIW to develop a generalizable process guide for eScreening implementation (eScreening Playbook). In phase two, we integrated the eScreening Playbook and RPIW with additional strategies of training and facilitation to create a multicomponent implementation strategy (MCIS) for eScreening. We then piloted the MCIS in two VHA sites. Quantitative eScreening pre-implementation survey data and qualitative implementation process "mini interviews" were collected from individuals at each of the two sites who participated in the implementation process. Survey data were characterized using descriptive statistics, and interview data were independently coded using a rapid qualitative analytic approach. RESULTS: Pilot data showed overall satisfaction and usefulness of our MCIS approach and identified some challenges, solutions, and potential adaptations across sites. Both sites used the components of the MCIS, but site 2 elected not to include the RPIW. Survey data revealed positive responses related to eScreening from staff at both sites. Interview data exposed implementation challenges related to the technology, support, and education at both sites. Workflow and staffing resource challenges were only reported by site 2. CONCLUSIONS: Our use of RPIW and other QI methods to both develop a playbook and an implementation strategy for eScreening has created a testable implementation process to employ automated, patient-facing assessment. The efficient collection and communication of patient information have the potential to greatly improve access to and quality of healthcare.

PURPOSE: Two studies are presented that evaluated the Communication Supports Inventory-Children & Youth (CSI-CY), an instrument designed to facilitate the development of communication-related educational goals for students with complex communication needs (CCN). The CSI-CY incorporates a code set based on the ICF-CY. The studies were designed to determine the effect of using the CSI-CY on IEP goals for students with CCN and to evaluate consumer satisfaction. METHOD: In Study 1, sixty-one educators and speech-language pathologists were randomly assigned to either (a) provide a student's current IEP (control group) or (b) complete the CSI-CY prior to preparing a student's next IEP and to submit the new IEP (experimental group). Study 2 was a field test to generate consumer satisfaction data. RESULTS: Study 1 showed that IEP goals submitted by participants in the experimental group referenced CSI-CY-related content significantly more frequently than did those submitted by control participants. Study 2 revealed high satisfaction with the instrument. CONCLUSIONS: The code set basis of the CSI-CY extends the common language of the ICF-CY to practical educational use for children with CCN across diagnostic groups. The CSI-CY is well regarded as an instrument to inform the content of communication goals related to CCN. Implications for Rehabilitation The CSI-CY will guide rehabilitation professionals to develop goals for children with complex communication impairments. The CSI-CY is a new instrument that is based on the ICF-CY for documentation of communication goals.

Patient violence is a growing problem in healthcare institutions. Incidents of violence lead to injuries and increased operating costs. An innovative organizational approach to this problem is inclusion of interdisciplinary competency-based staff education and practice, as a key component of a comprehensive violence prevention program.Interdisciplinary competencies include a variety of behavioral responses, aimed at prevention, environmental, interpersonal, and physical interventions and postvention techniques for aggression and violence. Methods to maintain, monitor, document, and improve staff performance and skills are delineated. Organizational investment in such interdisciplinary competency-based education and practice evolves over time. Results include fewer incidents and injuries and enhanced interdisciplinary cooperation.

Split-thickness skin grafting is a very popular technique of wound closure, especially for large wounds. The success rate of a split-thickness skin graft (STSG) has consistently been in the range of 70-90%. Multiple techniques have been introduced to further improve graft survival, for example, the use of autologous platelet-rich plasma (PRP), thrombin gel, platelet-rich fibrin matrix, and negative pressure wound therapy. We evaluated the impact of PRP use on the survival of STSG through a meta-analysis. We conducted the analysis in accordance with Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) protocol and performed a literature search using the following databases: PubMed, Cochrane, and ClinicalTrials.gov. A total of 126 articles were yielded by the search, out of which four randomized controlled trials (RCTs) were included according to our eligibility criteria and irrelevant articles were excluded. The intervention group received PRP application to the wound bed before applying the graft while the control group received treatment with conventional fixation procedures (sutures and staples). We estimated the pooled odds ratio with a 95% confidence interval (CI). The total number of participants in the analysis was 460. The participants had wounds of varying etiology. Post-operative graft loss and hematoma formation were taken to be the primary and secondary outcome measures, respectively. Thirty-four participants suffered graft loss of differing extent in the control group while three participants suffered graft loss in the intervention group. The pooled odds ratio for graft loss was 0.15 (95% CI: 0.05-0.49; I2=38%; p=0.184) signifying that PRP use decreased the odds of graft loss by 85%. For our secondary outcome measure, 440 participants were studied. Forty-four participants suffered hematoma formation in the control group versus 11 in the intervention group. The pooled odds ratio for hematoma formation was calculated as 0.21 (95% CI: 0.09-0.50; I2=0%; p=0.869) signifying that PRP use decreased the odds of hematoma formation by 79%. PRP appears to significantly impact graft survival, and further studies are needed to strengthen the evidence base for its use in split-thickness skin grafting.

Noecker, Robert J. MD; Kahook, Malik Y. MD; Berke, Stanley J. MD, FACS; Nichamin, Louis D. MD; Weston, Jon-Marc MD; Mackool, Richard; Tyson, Farrell; Lima, Francisco; Kleinfeldt, Nate Author Information