After 2014 acne jacket buy cheap dapsone 100mg online, significant increases in multigene panel testing were observed across all insurance types (P = 0 acne solutions dapsone 100 mg without prescription. This increase was most significant among patients with private insurance and Medicaid plans (P < 0 skin care 1 month before marriage buy 100mg dapsone otc. Method: Insurance status and patterns of genetic testing at the hereditary breast and ovarian cancer center at a single institution between January 1 skin care bandung purchase dapsone 100mg on line, 2013 acne keloid treatment buy generic dapsone 100mg on-line, and December 31 acne fulminans discount dapsone 100 mg on-line, 2016 in New York were reviewed skin care 90036 cheap dapsone 100mg online. Insurance status was characterized and confirmed as private acne tool order 100mg dapsone overnight delivery, Medicare, Medicaid, and uninsured. Comparisons among insurance status, testing type, and clinical outcomes based on genetic testing results were evaluated before and after January 1, 2014, which was utilized as a timeframe to allow for incorporation of health care expansion in New York. With insurance expansion, more cost-effective testing platforms, and improved access to comprehensive genetic testing for all patients, cost and insurance status should not be obstacles for genetic testing. The median age was 48 years (range 1894 years); 50% were female; 47% were married; and 64% identified as white. Responders were from 51/62 New York counties, 64% from urban areas and 50% from upstate. Seventy percent reported some college education or higher, and 39% reported a household income >$75,000/year. Conclusion: We identified specific knowledge gaps that vary between culturally diverse populations. These data were Method: the 2018 Empire State Poll was the 16th annual survey of New York state residents older than 18 years, conducted by the Survey Research Institute of Cornell University from February to April 2018. It is a compilation study of community, economic, and social science questions submitted by academic researchers. Pelvic radiation therapy appears to reduce the incidence of vaginal cuff recurrence. Lymphadenectomy was performed in 85% of patients, although nodal metastasis was only demonstrated in 1 of 11. Percentage of tumor comprising undifferentiated carcinoma and tumor size did not appear to effect outcomes. Eight patients were treated with both chemotherapy and radiation, 2 with chemotherapy alone, and 1 with vaginal brachytherapy alone, and 2 received no adjuvant therapy. The only case of a vaginal apex recurrence was in a patient with advanced disease who did not receive primary pelvic radiation. Patient demographics, adjuvant treatments, recurrence, and survival data were obtained. Ancestry, based on subpopulation structure analysis, was performed using 2 different software packages. Subpopulation structure, or admixture, was compared between both groups using these two methods. In contrast, our institution revealed only 1 Objective: We hypothesize that tumor samples derived from patients from different subpopulations may have different genetic backgrounds, and this different ancestry or admixture may interfere with validation and generalizability of genomic studies. Admixture would have to be accounted for in genomic studies if we want them to be applicable to a broader population. Although 30-day mortality rates did not vary significantly among the three groups (P = 0. Descriptive statistics were computed, and continuous variables were assessed for normality. The evaluated data included women with invasive, grade 1, serous carcinoma of the ovary and peritoneum. Our objective was to evaluate the effect of race and ethnicity on treatment outcomes in this disease. Although there was no difference in stage distribution by race, blacks were less likely to receive chemotherapy than whites (64. While almost half of cases are diagnosed by age 45 years, significant age and race disparities remain with these populations more likely to be diagnosed with metastatic disease. These findings may have implications for future screening and treatment strategies, especially given the increasing rates of cervical adenocarcinoma. While women with AdC were overall more likely to be white, privately insured, and of higher income and education levels (P < 0. We used log binomial regression to evaluate trends in histology, demographics, and stage over time. We stratified by age and race and included patient (insurance status, income, high school education, urban/rural, distance traveled for care, Charlson comorbidity score), and hospital characteristics (region, academic center) as covariates. During the baseline telephone questionnaire, participants were asked to self-report a history of hypertension, hyperlipidemia, and diabetes and any current medication use. The relationship between hypertension, hyperlipidemia, diabetes, and medications taken for these conditions was determined using multivariate logistic regression, with adjustment for appropriate confounders. Women diagnosed with ovarian, fallopian tube, or primary peritoneal cancer who underwent surgery involving oophorectomy from 2011 to 2015 were analyzed. Surgical volume was determined by grouping hospitals into quartiles based on the number of cases they performed annually. Extended cytoreduction was defined as surgery of the colon, small intestine, liver, diaphragm, spleen, gastric resection, ileostomy, or colostomy. Logistic regression assessed independent predictors for receiving extended cytoreduction. Objective: To achieve complete surgical cytoreduction in ovarian cancer, tumor debulking with extended procedures beyond hysterectomy and bilateral salpingo-oophorectomy are often needed. This study examines disparities in patients receiving extended cytoreduction in relation to hospital surgical volume. Patients who received care at hospitals with higher surgical volume were more likely to receive extended cytoreduction. Independent predictors of receiving extended surgical cytoreduction in patients with ovarian, fallopian tube, and primary peritoneal cancer. Patients more likely to receive extended cytoreduction were the following: white (71. The cohort was 64% white, 23% black, 8% Asian/Pacific Islander, and 4% Native American/other/unknown. White women were more likely to be treated in New England, compared with black women in the East South Central, and Asian women in the Pacific region (P = 0. Only 6 facilities reported treating an average of more than 1 patient per year, and 53% of the women treated were at a facility reporting only 1 treated patient over the 11-year period of the study. Race, education, urban/rural location, and insurance were not associated with survival. Patient demographics, tumor characteristics, and treatment-related outcomes were reviewed. Morbidly obese patients are less likely to undergo lymphadenectomy regardless of risk group. Recent studies demonstrate that 85%96% of patients with a gynecologic malignancy utilize the internet as a health resource. Providers can refer patients to educational materials produced by major medical associations available on their websites. We evaluated differences in survival using Kaplan-Meier curves and a multivariate Cox proportional hazards model. We stratified by age and race and included patient (insurance status, income, high school education, urban/rural, distance traveled for care, Charlson comorbidity score) and hospital covariates (region, academic center). Objective: We sought to analyze trends in the treatment and survival of women with adenocarcinoma (AdC) of the cervix Results: There were 14,829 women with AdC, 7,319 (49%) early-stage, 6,633 (45%) locally advanced, and 877 (6%) metastatic disease. For early-stage AdC, 82% received surgery alone; 7% surgery and radiation; 6% surgery and chemoradiation; 2% chemoradiation; 2% surgery and chemotherapy; and 1% radiation alone. For locally advanced AdC, 42% received concurrent chemoradiation; 20% surgery and chemoradiation; 15% surgery alone; 8% radiation alone; 6% surgery and radiation; 5% surgery and chemotherapy; and 2% chemotherapy. For metastatic AdC, 26% received chemotherapy alone; 16% surgery and chemoradiation; 15% surgery and chemotherapy; 15% radiation along; 10% radiation alone; 8% surgery alone, and 9% no treatment. Conclusion: While survival has overall improved over time for women diagnosed with AdC, significant age and race disparities exist in treatment and survival. Survival in Adenocarcinoma of the Cervix by Stage, 2004-2015 1450 - Poster Session Factors influencing time interval between diagnosis and primary surgical management of endometrial cancer K. While the ideal interval for best clinical outcomes is not well defined, data suggest worse survival for women with intervals >6 weeks. Univariate and multivariate logistic regression analyses were completed to evaluate outcomes and the impact of clinical factors on time interval between diagnosis and Hyst. On univariate analysis, the factors significantly associated with time delay were outside referral (P < 0. Improved understanding of such factors provides insight and opportunity to seek required support that advocates for timely cancer care for all. We aim to find variables that are predictive of neutropenic-related events including dose delays and reductions and febrile neutropenia. Method: We retrospectively reviewed chemotherapy records for all patients undergoing neoadjuvant or adjuvant first-line chemotherapy, as well as chemo-naпve patients receiving first-line chemotherapy for recurrence between the years 2013 and 2017. A total of 53 patients experienced neutropenia-related events with 41 dose delays, 17 dose reductions, and 8 neutropenic fevers. Given that black race is associated with lower normal neutrophil count at baseline, proper patient counseling for prevention of neutropenic infections as well as a lower threshold to implement granulocyte colony stimulating factors may be considered to avoid treatment disruptions. Further investigation is needed to validate this finding in a larger population, as well as its implication for clinical outcomes. Both groups were equally likely to undergo cytoreductive surgery, minimally invasive surgery. Insurance and marital status were not associated with inferior survival independent of race. Utilizing the search terms under the National Institutes of Health recommended "Studies by Topics," gynecological oncology studies were identified. Randomized control trials were selected based on intervention and randomization criteria. Objective: the aim of our review was to ascertain factors associated with the successful completion of a randomized control trial in gynecological oncology. Results: A total of 1,031 gynecological oncology research studies were registered on clinicaltrials. As of September 1, 2018, just over half (150, 52%) of all randomized control trials were successfully completed (average length 43 months). Completed randomized control trials were more likely to be performed at centers outside the United States (P < 0. Interventional drug and device trials were significantly less likely to be completed (P < 0. While industry was more likely Conclusion: Prospective randomized trials are essential for establishing the standard of care in clinical medicine. Herein we have identified factors associated with successful and timely completion of gynecologic oncology randomized clinical trials. Disconcertingly, only half of all randomized control trials that make it through the conception and design process to database registration are completed. This high failure rate suggests large hurdles are inhibiting the completion of gynecologic oncology research studies. Research into barriers of successful completion of randomized control trials is needed so that inhibitory factors can be mitigated. The objective of this investigation was to understand the practice patterns for recurrent and persistent endometrial cancer following conventional therapy. Method: A multicenter review was conducted of all endometrial cancer cases from January 2008 through December 2015. Patient demographics, surgical characteristics, and medical therapy were collected for all patients who received adjuvant chemotherapy or developed recurrent disease. Recurrence and survival were correlated utilizing parametric and nonparametric testing. Survival was calculated utilizing the Kaplan-Meier and Cox proportional hazards methodologies. Results: Of 2,363 women, 570 (24%) presented with high-grade or nonendometrioid histology. Weekly paclitaxel (14%) followed by trial enrollment (13%) was the most common chemotherapy regimen. The number of chemotherapy lines was not significantly correlated with survival after recurrence. Results: Of 3,036 patients included in this study, the median age was 63 (range 1795) years; 42%, 40. Conclusion: the location of distant metastases and outcomes in cervical, endometrial, and ovarian cancer patients differs. These results may have significant implications toward metastatic workup of these gynecologic cancers and drug treatments focused on treating the metastatic site. Analyses were performed using KaplanMeier and multivariate Cox proportional hazard methods. Hepatectomy should be considered in select patients with single lesions and metachronous disease. Twenty-three patients (68%) underwent liver resection as part of recurrent disease and 11 (32%) as part of initial treatment. Major grade 34 complications were identified in 7 patients (21%); in 3 patients (9%) complications were directly associated with the liver resection. One patient (3%) died within 90 days after hepatectomy due to progression of disease. Method: Patients who underwent a resection of parenchymal liver metastasis from uterine malignancies between 1993 and 2017 were identified from our database. A Cox proportional hazards model was used to evaluate the independent association between the different clinicopathological factors and outcomes. Objective: Parenchymal liver resection for liver metastasis of uterine malignancies is not well studied. The objective of our study was to evaluate the role of hepatectomy for liver metastasis of uterine origin. Five-year survival estimates are near or below 50%, in contrast to almost 90% among U. Multicountry results are Results: Two-year outcomes on the 200 women enrolled in the Zambian cohort were generated using descriptive statistics and Cox proportional hazards regression analysis. As of May 2018, almost one-third (59 women) of the cohort had died, yielding 1- and 2-year survival rates of 73% and 55%, respectively. Sixty-two percent of women were out of window or had no documented history of Pap screening. Among Hispanic women, 21% initiated the vaccine with at least one dose; 15% completed the regimen. In addition, only 32% of women meet compliance for cervical cancer screening compared to the national average of 69%. Results: Among 80 women recruited thus far, 55% had at least one unmet basic need, with a higher prevalence among urban than rural participants (mean 1. The most prevalent needs included money for unexpected expenses (53%), utilities (20%), transportation (18%), and family needs. Compared to the 4 months preceding study initiation, colposcopy adherence improved from 50% (urban) and 51% (rural) to Method: Women were recruited to our prospective, multicenter pilot study from September 2017 to August 2018 from two academic colposcopy referral centers-low-income rural and low-income urban. Basic needs (safety, housing, family, financial, transportation, child care) were assessed via a phone survey prior to their scheduled colposcopy visit and were considered unmet if unlikely to be resolved in the next month. Once the first 25 patients were enrolled at each site (phase 1, n = 50), allowing for protocol standardization, the navigator intervention was offered to participants who screened positive for an unmet need (phase 2, target goal n = 50). Objective: To identify unmet basic needs among women with an abnormal Pap test and explore the acceptability and effectiveness of a basic needs navigator to address these needs to improve adherence to initial colposcopy visit. The overwhelming majority of patients (99%) reported it was acceptable to inquire about basic needs, and 57% reported feeling fine/relieved when answering the survey. To date, 13 subjects have been contacted by the navigator (phase 2); of these, 93% reported that the navigator was helpful and that they would recommend this service to a family member/friend. Yet only 58% thought that addressing their unmet needs specifically helped them get to their clinic appointment. Implementing patient telephone reminders for abnormal Pap follow-up that includes personalized assistance with unmet basic needs may help patients meet their needs and improve colposcopy adherence. This may ultimately help reduce cervical cancer rates in these high-risk populations. A referral to the clinical genetics service is sent at the same time; however, patients do not meet with genetics until after results are reported. This eliminated several steps in the traditional pathway that were thought to be potential barriers to patient access, as well as unnecessarily affecting timely results and inflating cost. Demographic, treatment, outcomes, and genetic testing data were abstracted from the available medical records. Pretest counseling in the oncology clinic was sufficient, with no increase in additional pretest counseling, and therefore an associated overall decrease in patient encounters. The median time from diagnosis to post-test counseling was reduced from 496 to 258 days (P < 0. There was no difference in the proportion of patients requiring additional pretesting counseling (24% vs 16%, P = 0. The most frequent searches in each category and those terms related to ovarian cancer awareness month were then individually analyzed. Unlike surveys, in which participants may feel compelled to answer in what is perceived to be the "correct" way or to be swayed by the question itself, individuals are incentivized to ask Google exactly what they are interested in to get the best answer. In this study, we analyzed trends in public interest in ovarian cancer awareness month and its impact on ovarian cancer-related terms.
So when you hear a client say "I will never see life the same acne 7 dpo buy dapsone 100mg on-line," this expression should trigger further exploration into how life is different skin care advice buy dapsone 100 mg free shipping, what meaning has been assigned to the trauma acne 12 weeks pregnant discount dapsone 100mg line, and how the individual has changed his or her perception of self acne quitting smoking dapsone 100 mg discount, others skin care myths generic 100mg dapsone with visa, and the future acne near mouth purchase dapsone 100mg on-line. In her situation acne around nose effective 100 mg dapsone, a random stranger provided a moment that challenged an assumption generated from the trauma skin care vegetables buy generic dapsone 100 mg online. For others, counseling may be helpful in identifying how beliefs and thoughts about self, others, and the world have changed since the event and how to rework them to move beyond the trauma. It is important to understand that the meaning that an individual attaches to the event(s) can either undermine the healing process. The fol lowing questions can help behavioral health staff members introduce topics surrounding assump tions, beliefs, interpretations, and meanings related to trauma: · In what ways has your life been different since the trauma? However, many factors influence individual responses to trauma; it is not just individual characteristics. Failing to recognize that multiple factors aside from individual attributes and history influence experiences during and after trauma can lead to blaming the victim for having traumatic stress. Remember that the effects of trauma are cu mulative; therefore, a later trauma that out wardly appears less severe may have more impact upon an individual than a trauma that occurred years earlier. Conversely, individuals who have experienced earlier traumas may have developed effective coping strategies or report positive outcomes as they have learned to adjust to the consequences of the trauma(s). This outcome is often referred to as posttrau matic growth or psychological growth. Clients in behavioral health treatment who have histories of trauma can respond negative ly to or seem disinterested in treatment efforts. They may become uncomfortable in groups that emphasize personal sharing; likewise, an individual who experiences brief bouts of dis sociation (a reaction of some trauma survivors) may be misunderstood by others in treatment and seen as uninterested. Providers need to History of prior psychological trauma People with histories of prior psychological trauma appear to be the most susceptible to severe traumatic responses (Nishith, Mechanic, & Resick, 2000; Vogt, Bruce, Street, & Stafford, 2007), particularly if they have avoided addressing past traumas. Because minimization, dissociation, and avoidance are common defenses for many trauma survivors, prior traumas are not always consciously avail able, and when they are, memories can be distorted to avoid painful affects. History of resilience Resilience-the ability to thrive despite nega tive life experiences and heal from traumatic events-is related to the internal strengths and environmental supports of an individual. The ability to thrive beyond the trauma is associated with individual factors as well as situational and contextual factors. There are not only one or two primary factors that make an individual resilient; many factors contribute to the development of resilience. There is little research to indicate that there are specific traits predictive of resilience; instead, it appears that more general characteristics influ ence resilience, including neurobiology (Feder, Charney, & Collins, 2011), flexibility in adapt ing to change, beliefs prior to trauma, sense of self-efficacy, and ability to experience positive emotions (Bonanno & Mancini, 2011). Sociodemographic Factors Demographic variables are not good predic tors of who will experience trauma and subse quent traumatic stress reactions. Gender, age, race and ethnicity, sexual orientation, marital status, occupation, income, and education can all have some influence, but not enough to determine who should or should not receive screening for trauma and traumatic stress symptoms. Less is known about gender differences with subclini cal traumatic stress reactions. There are also other gender differences, such as the types of trauma experienced by men and women. Women are more likely to experience physical and sexual assault, whereas men are most like ly to experience combat and crime victimiza tion and to witness killings and serious injuries (Breslau, 2002; Kimerling, Ouimette, & Weitlauf, 2007; Tolin & Foa, 2006). Women in military service are subject to the same risks as men and are also at a greater risk for mili tary sexual trauma. Perpetrators of trau mas against men are often strangers, but wom en are more likely to know the perpetrator. History of mental disorders the correlations among traumatic stress, sub stance use disorders, and co-occurring mental disorders are well known. According to the Diagnostic and Statistical Manual of Mental Dis orders, Fifth Edition (American Psychiatric Association, 2013a), traumatic stress reactions are linked to higher rates of mood, substancerelated, anxiety, trauma, stress-related, and other mental disorders, each of which can pre cede, follow, or emerge concurrently with trauma itself. A co-occurring mental disorder is a significant determinant of whether an individual can successfully address and resolve trauma as it emerges from the past or occurs in the present. Age is not particularly important in predicting exposure to trauma, yet at no age is one immune to the risk. However, trauma that occurs in the earlier and midlife years appears to have greater impact on people for different reasons. For younger individuals, the trauma can affect developmental processes, attach ment, emotional regulation, life assumptions, cognitive interpretations of later experiences, and so forth (for additional resources, visit the National Child Traumatic Stress Network;. For adults in midlife, trauma may have a greater impact due to the enhanced stress or burden of care that often characterizes this stage of life-caring for their children and their parents at the same time. Older adults are as likely as younger adults to recover quickly from trauma, yet they may have greater vulnerabilities, including their ability to survive without injury and their ability to address the current trauma without psychological interference from earlier stress ful or traumatic events. Older people are natu rally more likely to have had a history of trauma because they have lived longer, thus creating greater vulnerability to the effects of cumulative trauma. Race, ethnicity, and culture the potential for trauma exists in all major racial and ethnic groups in American society, yet few studies analyze the relationship of race and ethnicity to trauma exposure and/or trau matic stress reactions. Some studies show that certain racial and ethnic groups are at greater risk for specific traumas. For example, African Americans experienced higher rates of overall violence, aggravated assault, and robbery than Whites but were as likely to be victims of rape or sexual assault (Catalano, 2004). Literature reflects that diverse ethnic, racial, and cultural groups are more likely to experience adverse effects from various traumas and to meet crite ria for posttraumatic stress (Bell, 2011). Sexual orientation and gender identity Lesbian, gay, bisexual, and transgender indi viduals are likely to experience various forms of trauma associated with their sexual orienta tion, including harsh consequences from fami lies and faith traditions, higher risk of assault from casual sexual partners, hate crimes, lack of legal protection, and laws of exclusion (Brown, 2008). Gay and bisexual men as well as transgender people are more likely to expe rience victimization than lesbians and bisexual women. Dillon (2001) reported a trauma ex posure rate of 94 percent among lesbian, gay, Resilience: Cultural, Racial, and Ethnic Characteristics the following list highlights characteristics that often nurture resilience among individuals from di verse cultural, racial, and ethnic groups: · Strong kinship bonds · Respect for elders and the importance of extended family · Spirituality and religious practices. Heterosexual orienta tion is also a risk for women, as women in relationships with men are at a greater risk of being physically and sexually abused. People who are homeless Homelessness is typically defined as the lack of an adequate or regular dwelling, or having a nighttime dwelling that is a publicly or pri vately supervised institution or a place not intended for use as a dwelling. About 40 percent of men who are homeless are veterans (National Coalition for the Homeless, 2002); this percentage has grown, including the number of veterans with de pendent children (Kuhn & Nakashima, 2011). Rates of trauma symptoms are high among people who are homeless (76 to 100 percent of women and 67 percent of men; Christensen et al. People who are homeless report high levels of trauma (es pecially physical and sexual abuse in childhood or as adults) preceding their homeless status; assault, rape, and other traumas frequently happen while they are homeless. Research suggests that many women are homeless be cause they are fleeing domestic violence (National Coalition for the Homeless, 2002). Other studies suggest that women who are homeless are more likely to have histories of childhood physical and sexual abuse and to have experienced sexual assault as adults. A history of physical and/or sexual abuse is even more common among women who are home less and have a serious mental illness. Youth who are homeless, especially those who live without a parent, are likely to have experi enced physical and/or sexual abuse. Between 21 and 42 percent of youth runaways report having been sexually abused before leaving their homes; for young women, rates range from 32 to 63 percent (Administration on Children, Youth and Families, 2002). Addi tionally, data reflect elevated rates of substance abuse for youth who are homeless and have histories of abuse. More than half of people who are homeless have a lifetime prevalence of mental illness and substance use disorders. Those who are homeless have higher rates of substance abuse (84 percent of men and 58 percent of women), and substance use disorders, including alcohol and drug abuse/dependence, increase with longer lengths of homelessness (North, Eyrich, Pollio, & Spitznagel, 2004). Pro viders need to understand how trauma can affect treatment presen tation, engagement, and the outcome of behavioral health services. This chapter examines common experiences survivors may encoun ter immediately following or long after a traumatic experience. Trauma, including one-time, multiple, or long-lasting repetitive events, affects everyone differently. How an event affects an individual depends on many factors, including characteristics of the individual, the type and characteristics of the event(s), developmental processes, the meaning of the trauma, and sociocultural factors. This chapter begins with an overview of common responses, emphasizing that traumatic stress reactions are normal reactions to abnormal circumstances. It highlights common short- and long term responses to traumatic experiences in the context of individuals who may seek behavioral health services. Although reactions range in severity, even the most acute responses are natural responses to manage trauma- they are not a sign of psychopathology. Cop ing styles vary from action oriented to reflec tive and from emotionally expressive to reticent. Clinically, a response style is less im portant than the degree to which coping ef forts successfully allow one to continue 60 necessary activities, regulate emotions, sustain self-esteem, and maintain and enjoy interper sonal contacts. Initial reactions to trauma can include exhaus tion, confusion, sadness, anxiety, agitation, numbness, dissociation, confusion, physical arousal, and blunted affect. Most responses are normal in that they affect most survivors and are socially acceptable, psychologically effec tive, and self-limited. Indicators of more se vere responses include continuous distress without periods of relative calm or rest, severe dissociation symptoms, and intense intrusive recollections that continue despite a return to safety. Delayed responses to trauma can in clude persistent fatigue, sleep disorders, nightmares, fear of recurrence, anxiety focused on flashbacks, depression, and avoidance of emotions, sensations, or activities that are as sociated with the trauma, even remotely. The following sections focus on some com mon reactions across domains (emotional, physical, cognitive, behavioral, social, and de velopmental) associated with singular, multi ple, and enduring traumatic events. These reactions are often normal responses to trauma but can still be distressing to experience. Such responses are not signs of mental illness, nor do they indicate a mental disorder. Traumatic stress-related disorders comprise a specific constellation of symptoms and criteria. Beyond the initial emotional reactions during the event, those most likely to surface include anger, fear, sadness, and shame. However, individuals may encounter difficulty in identifying any of these feelings for various reasons. They might lack experience with or prior exposure to emotional expression in their family or community. They may associate strong feelings with the past trauma, thus believing that emotional expres sion is too dangerous or will lead to feeling out of control. Still others might deny that they have any feelings associated with their traumatic experiences and define their reactions as numbness or lack of emotions. Common Experiences and Responses to Trauma A variety of reactions are often reported and/or observed after trauma. Most survivors exhibit immediate reactions, yet these typically resolve without severe long-term consequences. This is because most trauma survivors are highly resilient and develop appropriate coping strategies, including the use of social sup ports, to deal with the aftermath and effects of trauma. Most recover with time, show min imal distress, and function effectively across major life areas and developmental stages. Only a small percentage of people with a history of Emotional dysregulation Some trauma survivors have difficulty regulat ing emotions such as anger, anxiety, sadness, and shame-this is more so when the trauma occurred at a young age (van der Kolk, Roth, Pelcovitz, & Mandel, 1993). In individuals who are older and functioning well 61 Trauma-Informed Care in Behavioral Health Services Exhibit 1. Self-medication-namely, substance abuse-is one of the methods that traumatized people use in an attempt to regain emotional control, although ultimately it causes even further emotional dysregulation. Other efforts toward emotional regulation can include engagement in highrisk or self-injurious behaviors, disordered eating, compulsive behaviors such as gambling or overworking, and repression or denial of emotions; however, not all behaviors associated with self-regulation are considered negative. In fact, some individuals find crea tive, healthy, and industrious ways to manage strong affect generated by trauma, such as through renewed commitment to physical activity or by creating an organization to sup port survivors of a particular trauma. Traumatic stress tends to evoke two emotional extremes: feeling either too much (over whelmed) or too little (numb) emotion. Treatment can help the client find the optimal level of emotion and assist him or her with appropriately experiencing and regulating dif ficult emotions. In treatment, the goal is to help clients learn to regulate their emotions without the use of substances or other unsafe behavior. Numbing Numbing is a biological process whereby emo tions are detached from thoughts, behaviors, and memories. Because numbing 63 Trauma-Informed Care in Behavioral Health Services Case Illustration: Sadhanna Sadhanna is a 22-year-old woman mandated to outpatient mental health and substance abuse treat ment as the alternative to incarceration. She was arrested and charged with assault after arguing and fighting with another woman on the street. At intake, Sadhanna reported a 7-year history of alcohol abuse and one depressive episode at age 18. She was surprised that she got into a fight but admit ted that she was drinking at the time of the incident. During the interview, she clearly indi cated that she did not want to attend group therapy and hear other people talk about their feelings, saying, "I learned long ago not to wear emotions on my sleeve. When asked about her own history, she denied that she had any difficulties and did not understand why she was mandated to treatment. She further denied having feelings about her abuse and did not believe that it affected her life now. Group members often commented that she did not show much empathy and maintained a flat affect, even when group discussions were emotionally charged. Thus, primary care may be the first and only door through which these individuals seek assistance for trauma-related symptoms. Common physical disorders and symptoms include somatic complaints; sleep disturbances; gastrointestinal, cardiovascular, neurological, musculoskeletal, respiratory, and dermatological disorders; urological problems; and substance use disorders. Somatization Somatization indicates a focus on bodily symptoms or dysfunctions to express emotion 64 al distress. People from certain ethnic and cultural backgrounds may initially or solely present emotional distress via physical ailments or concerns. At times, clients may remain resistant to exploring emotional content and remain focused on bodily complaints as a means of avoidance. Some clients may insist that their primary problems are physical even when medical evaluations and tests fail to con firm ailments. However, various cultures approach emotional distress through the physical realm or view emotional and physical symptoms and well being as one. It is important not to assume that clients with physical complaints are using somatization as a means to express emotional pain; they may have specific conditions or disorders that require medical attention. Part 1, Chapter 3-Understanding the Impact of Trauma Advice to Counselors: Using Information About Biology and Trauma · Educate your clients: Frame reexperiencing the event(s), hyperarousal, sleep disturbances, and other physical symptoms as physiological reactions to extreme stress. Communicate that treatment and other wellness activities can improve both psychological and physiological symptoms. You may need to refer certain clients to a psychiatrist who can evaluate them and, if warranted, prescribe psycho tropic medication to address severe symptoms. Explain links between traumatic stress symptoms and substance use disorders, if appropriate. For example, explain to clients that their symptoms are not a sign of weakness, a character flaw, being damaged, or going crazy. Support your clients and provide a message of hope-that they are not alone, they are not at fault, and recovery is possible and anticipated. Although a thorough presentation on the biological as pects of trauma is beyond the scope of this publication, what is currently known is that exposure to trauma leads to a cascade of bio logical changes and stress responses. Hyperarousal and sleep disturbances A common symptom that arises from trau matic experiences is hyperarousal (also called hypervigilance). It is characterized by sleep disturbances, muscle tension, and a lower threshold for startle responses and can persist years after trauma occurs. I can easily get startled if a leaf blows across my path or if my children scream while playing in the yard. The best way I can describe how I experience life is by comparing it to watching a scary, suspenseful movie-anxiously waiting for something to happen, palms sweating, heart pounding, on the edge of your chair. Sometimes, hyperarousal can produce overreactions to situations perceived as dangerous when, in fact, the circumstances are safe. Along with hyperarousal, sleep disturbances are very common in individuals who have ex perienced trauma. They can come in the form of early awakening, restless sleep, difficulty falling asleep, and nightmares. Sleep disturb Cognitions and Trauma ances are most persistent among individuals who have trauma-related stress; the disturb ances sometimes remain resistant to interven tion long after other traumatic stress symptoms have been successfully treated. Numerous strategies are available beyond medication, including good sleep hygiene practices, cognitive rehearsals of nightmares, relaxation strategies, and nutrition. From the outset, trauma challeng es the just-world or core life assumptions that the following examples reflect some of the types of cognitive or thought-process changes that can occur in response to traumatic stress. Cognitive errors: Misinterpreting a current situation as dangerous because it resembles, even re motely, a previous trauma. Other similar reactions mirror idealization; traumatic bonding is an emotional attachment that develops (in part to secure survival) between perpetrators who engage in interpersonal trauma and their victims, and Stockholm syn drome involves compassion and loyalty toward hostage takers (de Fabrique, Van Hasselt, Vecchi, & Romano, 2007). Trauma-induced hallucinations or delusions: Experiencing hallucinations and delusions that, although they are biological in origin, contain cognitions that are congruent with trauma content. Intrusive thoughts and memories: Experiencing, without warning or desire, thoughts and memories associated with the trauma. These intrusive thoughts and memories can easily trigger strong emo tional and behavioral reactions, as if the trauma was recurring in the present. The intrusive thoughts and memories can come rapidly, referred to as flooding, and can be disruptive at the time of their occurrence. If an individual experiences a trigger, he or she may have an increase in intrusive thoughts and memories for a while. For instance, individuals who inadvertently are retraumatized due to program or clinical practices may have a surge of intrusive thoughts of past trauma, thus mak ing it difficult for them to discern what is happening now versus what happened then. Whenever counseling focuses on trauma, it is likely that the client will experience some intrusive thoughts and memories.
The premature contraction leads to a decrease in stroke volume acne hyperpigmentation discount dapsone 100 mg with mastercard, which is balanced by an increase in stroke volume after the compensatory pause on the following beat skin care uk generic 100mg dapsone visa. They may also occur as a result of direct irritation from central catheters and guidewires acne 404 nuke generic 100 mg dapsone with mastercard. It can be well tolerated by some patients acne used cash buy 100mg dapsone fast delivery, but often is associated with symptoms of cardiac failure such as dyspnea acne 7 year old buy 100mg dapsone free shipping, syncope skin care guide purchase dapsone 100 mg visa, hypotension acne keloidalis nuchae surgery discount dapsone 100 mg line, and oliguria acne with mirena cheap dapsone 100mg fast delivery. There is no associated pulse as the ventricle does not contract in an organized manner. It is associated with ischemic cardiac disease and is thought to be caused by reentry circuits and abnormal automaticity. Knowing the answers to the questions below will help guide pharmacologic and electrophysiologic treatment, and suggest underlying causes to treat. The mainstay of therapy is treating the underlying cause or removing the offending agent. Other chronotropic agents such as dopamine and isoproterenol can be used to treat symptomatic bradycardia as an alternative to epinephrine. Tachycardia Treatment of tachydysrhythmias should be focused on correcting underlying causes. Treatment is aimed at suppressing automaticity, prolonging the effective refractory time, and facilitating normal impulse conduction. This causes prolongation of the 192 myocardial action potential and refractory period, as well as decreasing the effect of circulating stress hormones (decreasing intracellular calcium). Amiodarone has a very long half-life (approximately 60 days), and patients must be loaded to reach meaningful levels quickly. It has a delayed peak effect (up to 6 hours), and a narrow therapeutic index (especially in the setting of hypokalemia). Synchronized cardioversion refers to the delivery of an electrical current to the myocardium synchronized to the R wave. This allows the delivered shock to safely depolarize all excitable tissue simultaneously, resetting all myocardial tissue to the same refractory period. This is thought to allow the dominant pacemaker cells to resume function and thereby suppress areas of ectopy and reentry. Complications of cardioversion include embolic events (particularly in atrial fibrillation), skin burns, myocardial dysfunction, dysrhythmias, and transient hypotension from myocardial stunning. Defibrillation refers to the non-synchronized delivery of massive amounts of energy with the intent of depolarizing all of the myocardium simultaneously. If the energy is insufficient to completely affect all cardiac tissue, areas of fibrillation will remain and the heart will revert back after the refractory period. In addition, it seems that with time, ventricular fibrillation is more difficult to convert. Dobrev D, Nattel S: New antiarrhythmic drugs for treatment of atrial fibrillation. A 61 year-old man is post-operative day number two following a mitral valve repair. On post-operative day one, she is found to have an altered mental status and is having difficulty breathing while lying flat. Early recognition and therapeutic intervention of acute myocardial ischemia is critical to reducing morbidity and mortality. Physiology the energy demands of the heart are determined by oxygen supply and demand. Myocardial ischemia or infarction can occur any time myocardial oxygen demand exceeds supply. In the post-operative patient, this can be due to either the A 55 year old morbidly obese woman is status post elective gastric bypass surgery. The difference between aortic diastolic and left ventricular end diastolic pressures determines the coronary perfusion pressure to the left ventricle. In the left ventricle, due to high systolic transmural pressures, perfusion of the subendocardium occurs exclusively during diastole. Because of its lower ventricular pressure, the right ventricle is perfused throughout the cardiac cycle (in patients with normal right heart physiology). When ventricular end diastolic pressure exceeds aortic diastolic pressure, myocardial ischemia can occur. Additionally, as the heart rate increases, less time is spent in diastole, thereby decreasing coronary perfusion via decreased supply (and increased demand see below). Finally, blood that reaches the myocardium must be adequately oxygenated in order to fuel metabolism and prevent ischemia. Lynch, medical illustratorderivative work: Fred the Oyster (talk)adaption and further labeling: Mikael Hдggstrцm Coronary. This is the most variation in the human body and meets, or exceeds, the maximal demand of contracting skeletal muscle. As the number or force of cardiac myocyte contractions increase, the oxygen demand increases. Hypercoagulable state from postoperative inflammation and activation of the coagulation cascade 3. In addition to altering the balance of myocardial oxygen supply and demand directly, these changes predispose individuals with atherosclerosis to plaque rupture. Chest pain may be masked by analgesics and intubated patients often cannot communicate symptoms. Furthermore, symptoms can often be attributed to many other causes in a post-operative patient. Echocardiography can also be useful in the assessment of regional wall motion, valve function and overall cardiac function. Regional wall motion abnormalities, corresponding to the coronary anatomy, are especially helpful if there is a prior study available for comparison. Echocardiography also allows noninvasive measurements of some hemodynamic parameters, including right and left sided pressures and cardiac output. Once a diagnosis of myocardial ischemia is made, cardiac catheterization and angiography are used to identify the anatomic location of the culprit atherosclerotic lesion (Figure 3). Sinus bradycardia, junctional bradycardia with or without ventricular escape, and complete heart block. Tachyarrhythmias: occur when ischemia leads to irritability of the myocardium and disorganized transmission of electrical impulses. Acute heart failure: occurs when impaired myocardial function reduces cardiac output. Therapy Oxygen: improves oxygen content of arterial blood, theoretically increasing supply, and remains standard of care despite lack of evidence for reduced morbidity or mortality. Morphine: decreases sympathetic outflow which decreases heart rate, causes decreased preload and afterload secondary to histamine release b. Aspirin (cyclooxygenase inhibitor) reduces mortality and is used as immediate therapy ii. Administered as an infusion acutely until long-term anticoagulation is established f. G2b3a inhibitors (abciximab, eptifibatide, tirofiban): antagonize platelet G2b3a-receptors, inhibiting fibrin binding to platelets and platelet aggregation. Statins: reduce inflammation, improve endothelial function, reverse prothrombotic states, and reduce atherosclerotic plaque volume. High intensity statin therapy (atorvastatin 80 mg) reduces early recurrent ischemic events compared to moderate therapy (40 mg) or placebo. Inotropes (milrinone, dobutamine, epinephrine): increase myocardial contractility, increasing cardiac output ii. Vasopressors (norepinephrine, phenylephrine, vasopressin): increase peripheral vascular resistance to increase mean aortic diastolic pressure and coronary perfusion pressure. Vasodilators (nitroprusside, nicardipine): reduce afterload to allow forward flow 2. Percutaneous coronary intervention: restores coronary flow in 9095% of Ml patients with a "door-to-balloon" time of 202 less than 90 minutes. Transvenous pacemaker: Emergency transvenous leads may be placed to facilitate temporary external pacemaking for unstable bradyarrhythmia. Temporary devices may need to be replaced with a permanent device as destination therapy or a bridge to transplant if cardiac function does not improve. High risk for complications including bleeding, infection, ischemia, stroke, and compartment syndrome iii. Deflates during systole, creating negative aortic pressure and decreasing afterload iii. Practice alert for the perioperative management of patients with coronary artery stents: a report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Brown C, Joshi B, Faraday N, et al: Emergency cardiac surgery in patients with acute coronary syndromes: a review of the evidence and perioperative implications of medical and mechanical therapeutics. Which of the following will most improve the balance of myocardial oxygen supply and demand? How does the treatment of myocardial infarction differ in postoperative patients as compared to the general population? Post-operative patients are at higher risk for infection from indwelling devices such as transvenous pacemakers or ventricular assist devices b. Inotropes have been shown to impair anastomotic healing and should not be administered to post-operative patients d. The most common valvular lesion is degenerative aortic stenosis followed by mitral regurgitation. Preoperative physical examination demonstrated a 4/6 systolic ejection murmur, but the emergent nature of the case dictated immediate operative intervention without cardiac work up. Transthoracic echo demonstrated aortic valve gradient of 55 mmHg and valve surface area of 0. Recent advancements in surgical and non-invasive techniques have allowed many, who were previously considered inoperable, the opportunity for surgical repair. It is common for multiple disorders to coexist, making management even more challenging. Patients with an existing valvular heart lesion who present with an acute insult (systemic inflammatory response syndrome, sepsis, hemorrhage, etc. The following discussion aims at providing basic understanding of the causes of valvular heart disorders that are frequently encountered in critically ill patients, as well as diagnostic and therapeutic interventions. Pathophysiology In the elderly, degenerative calcification causes thickening and or fusion of the valve leaflets. Persistent contraction against a fixed resistance stimulates hypertrophy of the left ventricular wall resulting in diastolic dysfunction. Physical exam findings include: soft ejection murmur, diminished aortic component of S2, and pulsus parvus et tardus. Doppler echocardiography can be used to assess the severity by measuring maximum jet velocity and mean transvalvular gradient, which allows calculation of aortic valve area. Left heart catheterization can be used to calculate transvalvular gradient and valve area. An alpha agonist such as phenylephrine is the agent of choice in the setting of hypotension since it maintains diastolic filling time by reflexively lowering the heart rate. Norepinephrine might be advantageous in patients with decreased ejection fraction due to its beta-1 activity. Maintaining sinus rhythm and avoidance of tachycardia are important to maximize filling time and cardiac output. Thus, immediate cardioversion is necessary in the setting of supraventricular arrhythmias causing hemodynamic instability. Percutaneous balloon valvuloplasty may also be considered, although it is typically done for palliation in patients too frail for any of the aforementioned interventions. Pathophysiology Aortic regurgitation can develop in two ways: abnormalities of aortic valve leaflets (calcific degeneration, bicuspid valve, destruction from endocarditis, rheumatic heart disease) and aortic disease (aneurysm of ascending aorta, aortic dissection). Physical findings include a diastolic murmur, wide pulse pressure, and diastolic hypotension. Echocardiography may demonstrate thickened valve leaflets, flail leaflets, a prolapsed valve, vegetations, and/ or aortic root dilatation. Echocardiography will show a regurgitant jet across the aortic valve on color flow Doppler. Management Afterload reduction is paramount in order to maintain cardiac output, reduce left ventricular wall stress, and reduce the regurgitant fraction. Inflation of the balloon during diastole will cause massive overload to the left ventricle causing acute decompensation. Pathophysiology Rheumatic heart disease is the most common cause of mitral stenosis. This leads to underfilling of the left ventricle with pressure and volume overload of the left atrium. Chronic underfilling of the left ventricle may lead to myocardial atrophy, wall thinning, and reduced systolic function. Chronic pressure and volume overload of the left atrium may lead to atrial fibrillation, pulmonary congestion, and pulmonary hypertension. Diagnosis Symptoms include signs associated with pulmonary congestion, including dyspnea, orthopnea, and coughing. Management Acute decompensation usually presents with an inciting event such as pregnancy, sepsis, or new onset atrial fibrillation. Pulmonary congestion is a hallmark feature and is treated with diuretics and respiratory support. Atrial fibrillation must be controlled and anticoagulation should be initiated, if indicated. Norepinephrine should be used with caution since it may increase left atrial pressure. Patients with pulmonary hypertension and/or right ventricular failure may benefit from pulmonary vasodilators. The mitral valve leaflets will often prolapse or flail depending whether the chordae are elongated or ruptured. Physical exam findings include tachycardia and a holosystolic murmur at the apex radiating to the axilla. Acute decompensation is usually secondary to myocardial infarction, torn chordae, or dehiscence of a mitral prosthesis. Mitral valve anatomy will determine the optimal surgical approach but repair is often preferred to replacement. Tricuspid regurgitation is most commonly functional in nature as a consequence of right ventricular failure from advanced leftsided disease leading to pulmonary hypertension, right ventricular dilatation and tricuspid annular dilatation. Structural tricuspid valve disease resulting from endocarditis, rheumatic disease, or carcinoid disease will often cause right ventricular volume overload. Diagnosis 210 Symptoms may include fatigue, ascites, and lower extremity edema if right ventricular failure is severe. Clinical findings include systolic murmur that increases with inspiration, increased central venous pressure, and pulsatile liver. It uses intermittent balloon inflation in the thoracic aorta to both increase coronary perfusion and increase cardiac output through afterload reduction. A mobile console drives inflation of the balloon with helium gas, which is easily absorbable in the bloodstream in the event of balloon rupture. Precise timing of inflation and correct sizing of the balloon are important for optimal augmentation. The balloon sits in the descending thoracic aorta about 2 cm distal to the takeoff of the left subclavian artery (Figure 1). Additional confirmation of proper placement can be had by obtaining a chest x-ray. Inflation of the balloon occurs during diastole, displacing blood to the proximal aorta and augmenting coronary perfusion. Coronary Perfusion: In normal physiologic conditions, coronary autoregulation occurs by vasoconstriction or dilation Figure 5. Autoregulation may be impaired in the perfusion territory of a critical, subtotal stenosis, in ischemic myocardium, or in patients with mean arterial pressures below the autoregulatory range. Balloon length should extend from just distal to the left subclavian artery to above the renal arteries. The closer the balloon is to the aortic valve, the greater the diastolic pressure augmentation. A balloon that is too large increases vascular morbidity, while a balloon that is too small is less effective. Precise timing of balloon inflation and deflation is vital for hemodynamic optimization. Poor tracing, electrical interference, or arrhythmia may affect balloon triggering. Aortic pressure waveform triggering: Deflation occurs just prior to the upstroke which corresponds to aortic valve opening. An augmentation ratio of 1:1 provides the most assistance, and 1:3 augmentation provides minimal support. Late deflation causes increased afterload and increased length of isovolumetric contraction. Early deflation leads to suboptimal coronary perfusion and potential for retrograde coronary and carotid blood flow as well as suboptimal afterload reduction. Aortic abnormalities: Anything other than mild aortic regurgitation is a contraindication, as diastolic balloon inflation will worsen the degree of aortic regurgitation. Aortic dissection, clinically significant aneurysm, or presence of aortic stents are also contraindications. Hemorrhage, sepsis, peripheral neuropathy can be associated with any indwelling groin catheter. Severe peripheral vascular disease or aortic disease increases the risk of arterial thromboembolism. Other contraindications are uncontrolled sepsis, cancer with metastases, or severe coagulopathy.
We present preliminary data from the initial 12 patients who have participated in this clinicaltrials acne en la espalda discount 100mg dapsone amex. Conclusion: Further prospective investigations are needed to identify a patient cohort amenable to a minimally invasive interval debulking approach skin care careers purchase dapsone 100mg free shipping. We are continuing to accrue patients and following oncologic outcomes in this study skin care tips for winter purchase dapsone 100mg overnight delivery. Data collection is ongoing but was evaluated 1 month after implementation to assess completion and accuracy skin care careers cheap dapsone 100mg amex. Seven (64%) had disease-related morbidities skin care 29 year old buy dapsone 100 mg mastercard, including metastasis acne used cash best 100 mg dapsone, pulmonary embolus skin care advice purchase 100mg dapsone with mastercard, uncontrolled hypertension skin care greenville sc generic dapsone 100mg otc, sepsis, and blood loss anemia. Two (18%) had isolated vital sign abnormalities in the immediate postoperative period that resolved spontaneously. Of those 27 patients, none were readmitted or brought to the office for Foley reinsertion. Prolonged use of a Foley catheter postoperatively due to high rate of lower genitourinary tract dysfunction (8%80%) is common practice for suspected autonomic nerve injury with dissection. Patient demographics and clinical-pathologic data were abstracted from medical records. Exclusion criteria were neuroendocrine carcinoma, node positive cervical cancer, and immunosuppression. We sought to examine the recurrence rates and sites of recurrence among women with early-stage cervical cancer who underwent a radical hysterectomy by either laparoscopic or open approach at our institution. Fifty-seven women met criteria for recurrence (intermediate risk) and underwent adjuvant radiation therapy. Conclusion: After initiation of an advanced surgical recovery program designed to decrease narcotic use, there were significant decreases both in postoperative opioid use and in chronic opioid use at 90 days. Method: Medical records were examined for the last 50 patients undergoing radical complete debulking for ovarian cancer before initiation of the program and for the first 75 patients after the initiation of the program. Demographics, use of opioids before surgery, and prolonged use of narcotics (90 days after surgery) were also collected. There were no differences in radical procedures required for complete cytoreduction between the groups including bowel resections, diaphragm stripping/resection, liver wedge resections, or splenectomies. Method: Medical records were examined for the last 50 patients undergoing radical complete debulking for ovarian cancer before and first 75 patients after the beginning of the program. Method: this was a retrospective cohort study of all elderly patients (70 years old) with endometrial cancer in one university-affiliated medical center (20092017). We excluded patients who underwent vaginal hysterectomy or conventional laparoscopy. Our primary outcome was defined as perioperative outcome and complications that included operation time, anesthesia duration, estimated blood loss, intraoperative complications (excessive blood loss, bowel or urinary tract injury), length of stay, postoperative complications (blood transfusion, surgical site infection, fever, ileus, and re-laparotomy), and rates of readmission. There were no differences between groups in rates of adjuvant radiotherapy or chemotherapy (P > 0. In spite of the potentially more morbid procedure, these patients have lower perioperative complications, with shorter hospital stay, compared to laparotomy. Further studies are ongoing to better quantify, predict, and decrease opioid requirements in this population. Palliative Care and Patient Reported Outcomes 1606 - Poster Session Clinical outcomes using modern radiotherapy techniques in the palliative treatment of bleeding gynecological malignancies S. Method: Consecutive female patients who were referred for refractory vaginal bleeding from gynecologic cancers were identified retrospectively. Results: Between October 2015 and April 2018, 28 patients received radiotherapy to a median dose of 30 Gy (range 1566. Radiotherapy volume was limited to gross tumor plus margin in most cases (n = 22), but regional nodes were included in patients treated with definitive intent (n = 6). Six patients (21%) experienced recurrent bleeding at a median interval of 15 months. Factors not predictive of recurrent bleeding were total radiation dose, dose per fraction, and radiation technique (P > 0. Two (7%) grade 3+ toxicities were observed (vaginal fistula and small bowel obstruction). Conclusion: Conformal palliative radiotherapy is highly effective at controlling vaginal bleeding secondary to gynecologic malignancies. Patients who live longer are at higher risk of recurrent bleeding, warranting additional study to find a durable treatment regimen in selected patients with favorable prognoses. Patients rated symptom severity and interference at its worst over 24 hours from 0 = "not present" to 10 = "as bad as you can imagine. Linear mixed effect models examined longitudinal changes in symptom burden based on whether patients were alive or died within 12 months of most recent recurrence. Median age was 63 years; 71 patients (82%) had stage lll/lV disease; 71 (82%) had serous histology; and 41 (47%) were receiving platinum-based treatment at enrollment. The most severe symptoms were fatigue, numbness, pain, sleep disturbance, and drowsiness. Patients who died reported worse symptom interference compared to patients who were alive at 12 months (3. While patients who died had consistently higher pain levels, this was in the mild range and remained stable even near the end of life. The distinctly different symptom burden trajectories trend over months and provide insight into the utility of utilizing symptom burden trends to alert patients and clinicians to symptoms on which to focus supportive care efforts. Participants were asked to rate reasons to refer patients to hospice as well as barriers to hospice referral. The highest rated reason for hospice referral was "pain or symptom control" (median 3 on 14 scale), followed by "assistance through the dying process" (median 4). Attendings were more likely than fellows to place importance on hospice referral for "nursing support" (P = 0. The highest rated barriers to hospice referral were "difficulty predicting patient death within 6 months" (median 2 on 14 scale) and "physician desire to pursue additional lines of chemotherapy" (median 2), which were both more likely to be rated higher by fellows than attending physicians (P = 0. Fellows were also more likely than staff physicians to agree that they had a "lack of time" to discuss issues of dying and hospice care (P = <0. Respondents were also asked to describe the primary role of palliative care at their institution, choosing from pain management (31%), goals of care (18%), transition to hospice (22%), and other symptom management (29%). Respondents were more likely to associate palliative care with pain and symptom management if they were fellow physicians (P = 0. Likert scale data also differed by the fellowattending divide, as fellows were more likely to agree that palliative care physicians were better communicators than gynecologic oncology physicians (P = 0. Conclusion: Many perceptions of palliative care and hospice services differed along a fellowattending divide. Forty percent of respondents thought the primary role of palliative care to be goals of care and hospice transition, highlighting a potential trend in the respondent population to late involvement of palliative care services. The American Society of Clinical Oncology defines value in cancer care as clinical benefit in the context of morbidity and costs. Our objective was to elucidate patient preferences in ovarian cancer and to ascertain what they value the most. Method: From January 2017 to May 2017, 50 patients with ovarian cancer were enrolled in this prospective study. Patients rated each attribute using a Likert scale from 1 (not important) to 5 (deeply important) and ranked them from the most important (1) to the least important (11). This was followed by progression-free survival, physical/mental well-being, permanent complications/sequelae. Chemotherapy schedule/type, assistance with care, cost of care, and logistical issues were the least important attributes. There were no differences in preferences between patients who recurred versus those who did not. The procedure is performed in conjunction with surgical staging and typically does not add complexity to the case. We advocate for discussion and consideration of this procedure in appropriately counseled, premenopausal gynecologic oncology patients. This approach is an option for patients who do not qualify for oocyte or embryo cryopreservation because of suspected ovarian malignancy or because of need to proceed with surgery expeditiously. Patients should be counseled about the possible need for experimental in vitro maturation because ovarian tissue transplantation may not be appropriate in the setting of prior malignancy. Fourteen women did not qualify for standard-of-care oocyte cryopreservation; three women were pregnant at the time of surgery. Normal ovarian tissue appropriate for cryopreservation was recovered from 13 of 15 patients (86. Method: this study was approved by the University of Pittsburgh Institutional Review Board. Overall, among patients for whom symptom improvement was available to date, 17/20 (85%) noted improvement. Four (12%) patients reported unwanted side effects, which were euphoria, dizziness, fatigue, and paranoia. Only one (3%) patient ceased medical marijuana use because of untoward adverse effects. Gynecologic cancers had lower rates of hospice utilization compared to nongynecologic cancers (14. More gynecologic cancer patients received chemotherapy within 14 days of death compared to patients with nongynecologic cancers (1. This difference was likely driven by ovarian cancer patients with rates double that of other malignancies (1. Conclusion: Patients with gynecologic cancers may have barriers in their care that delay or impede hospice enrollment and allow for continued medical treatments such as chemotherapy, even at the end of life. Further research in this area is necessary to identify explanations for this discrepancy for patients with gynecologic cancers. Objective: To examine the differences in end-of-life resource utilization among patients diagnosed with gynecologic malignancies (cervical, endometrial, or ovarian) compared to the five most prevalent nongynecologic cancers (breast, colorectal, lung, pancreatic, and prostate). End-of-life care by cancer type 263 1613 - Poster Session Outcomes after gastrostomy tubes for malignant bowel obstruction C. Future research, however, should focus on patient-reported outcomes and quality of life to assist in shared decision making. Method: this single-arm pilot study assessed user response of an electronic system designed to self-report symptoms among patients recovering from ambulatory surgery. Secondary endpoints included evaluation of postoperative patient-reported symptoms after surgery and patient satisfaction. An 8-item symptom inventory of pain, nausea, vomiting, shortness of breath, fever, swelling, discharge, and redness was developed. If responses exceeded defined thresholds of severity, alerts to health care providers were triggered. The symptom assessment method was deemed successful if 64 of 100 patients responded. Phone calls with review or adjustment of supportive medications were sufficient to address most symptoms. Most patients agreed or strongly agreed that electronic symptom tracking was helpful and easy to use and that they would recommend it to other patients. Assessment points were at baseline (T1), 46 weeks (T2), 1214 weeks (T3), and 2224 weeks (T4) after starting study treatment. Results: Of 101 patients, mean age was 55 years (range 3178 years); 68% (n = 69) were partnered; and 60% (n = 61) reported current sexual activity. Of women with measurements at both T1 and T4, 51% (n = 29) felt confident about future sexual activity at T1 compared to 68% (n = 39) at T4 (P = 0. Presence of vulvar irritation significantly improved from 48% (n = 32) at T1 to 27% (n = 18) at T4 (P < 0. Prevalence of vestibular irritation also decreased from 59% (n = 39) at T1 to 36% (n = 24) at T4 (P < 0. At T3, 72% (n = 57) of patients were deemed nonresponders (no change or worsening) and increased application from 3 to 5 times per week. Method: We conducted a randomized, comparative, multicenter trial in patients undergoing surgical intervention by gynecologic oncologists at 2 comprehensive cancer centers between April 2015 and February 2016. Distress, pain, positive affect, agency, and locus of control were measured using validated instruments at baseline, on postoperative day 1, and at the postoperative visit. The study arms were balanced with respect to core demographics, disease state, and surgical characteristics. Study arm was not a predictor of overall pain or distress scores, but it did significantly predict distress in patients with procedurally confirmed malignancy (P = 0. As shown in the left panel of Figure 1, there was a significant interaction between timepoint and study arm (P = 0. Those with lower positive affect and agency scores had higher pain and distress scores regardless of their study arm. Conclusion: Self-administered guided imagery significantly decreased distress at the time of the postoperative visit for those undergoing surgery for a procedurally confirmed gynecologic malignancy. This nonpharmaceutical intervention may be a beneficial adjunctive strategy in a comprehensive pain management plan aimed at limiting long-term narcotic abuse. Mean distress score (left) and pain score (right) at baseline (Time 0), postoperative day 1 (Time 1), and postoperative visit (Time 2) for patients with surgically confirmed gynecologic malignancies. Descriptive statistics, Pearson correlation coefficients, and linear regression were performed. Results: There were 79 participants, including 54% ovarian, 24% uterine, 16% cervical, and 5% vulvar/vaginal cancer patients. The majority of participants (58%) were receiving their first line of systemic therapy. These findings also emphasize the impact of financial toxicity on multiple domains (emotional, functional, and physical) among gynecologic cancer patients undergoing treatment. Method: Between December 2017 and July 2018, 33 patients with secondary lower extremity lymphedema underwent lymphovenous anastomosis in the groin area. All patients underwent lymphoscintigraphy to ensure accurate diagnosis of lymphatic edema. Indigocarmine (blue dye) was also injected into the thigh 10 minutes before surgery. Among these cases, 15 patients showed reduction of more than 3 cm in the circumference of the lower leg. This approach could be a reasonable choice for the treatment of secondary lymphedema refractory to complex physical therapy. All available opioid claims prescribed by gynecologic oncologists were identified. Medication type, prescription length, and other prescribing factors were recorded. Physician demographics were obtained from departmental websites and accrediting bodies. Bivariate statistical analyses including 2, Fisher exact test, and Wilcoxon rank sum test were performed to compare variables with threshold for significance set at P < 0. Linear regression modeling was also performed to examine association of gender with number of opioids prescribed. Results: A total of 494 board-certified gynecologic oncologists were included in this analysis. In 2016, gynecologic oncologists wrote 23,584 opioid prescriptions for 267,824 days of treatment (average of 9. Male physicians had significantly more opioid prescription claims than females (P < 0. A minority were high-prescribing physicians with more than 100 opioid claims (11%). Of these, the overwhelming majority were male (82%) and late career (46%, >15 years since board certification). Physicians in the South had the greatest number of opioid prescription claims and significantly more than physicians in the Northeast, who had the fewest (P < 0. Mean number of opioid claims increased with increasing years of experience (P < 0. Conclusion: Among gynecologic oncologists, there were gender-based, regional, and experience-related variations in opioid prescribing in the Medicare population in 2016. Further longitudinal studies are required to elucidate secular trends in opioid prescription practice. Objective: Opioids are the first-line treatment for moderate to severe cancer-related pain. Increased awareness of opioid prescription misuse and adverse outcomes have prompted statements on their use from multiple national medical groups. In this study we characterize national-level opioid prescription patterns among gynecologic oncologists treating Medicare beneficiaries. Participants were asked to report their insurance type, premium, deductible, and out-of-pocket maximum. Objective: the objective of this study was to evaluate the impact of patient knowledge of coverage benefits and insurance characteristics on financial toxicity among gynecologic cancer patients actively on treatment. Phone interviews were conducted that asked participants to rate each factor from "very important" to "not very important" when making decisions about their care. Objective: the objective of this study was to understand how ovarian cancer patients value financial and time costs when making decisions about their care. Results: Out of 79 participants, 5 (6%) were uninsured, which left 74 patients with evaluable responses related to insurance. The majority of participants had at least some private insurance (77%) and were covered on an individual (84%) plan.
Specifically acne young living cheap dapsone 100 mg without prescription, if effectiveness was demonstrated by using some but not all outcomes acne blemishes order dapsone 100mg mastercard, the team did not necessarily identify gaps in all of the other possible outcomes as important evidence gaps skin care 50th and france generic 100mg dapsone free shipping. If the available evidence was thought to be generalizable acne at 40 buy dapsone 100mg mastercard, the team did not necessarily list all subpopulations or settings where studies had not been done as research gaps acne denim dapsone 100 mg on-line. Within each body of evidence acne under jaw order dapsone 100 mg otc, the team considered whether there were general methods issues that would improve future studies in that area skin care questionnaire template cheap dapsone 100 mg with mastercard. The team also notes other harms or benefits if they were mentioned in the studies reviewed skin care after 30 buy dapsone 100mg free shipping. Economic Evaluations Economic evaluations were conducted only there is sufficient or strong evidence of effectiveness of the interventions. The Task Force on Community Preventive Services Am J Prev Med 2000;18(suppl 1):35 43. Methods for systematic reviews of economic evaluations for the Guide to Community Preventive Services. Summarizing Barriers to Implementation of Interventions Barriers to implementation are summarized only if there is sufficient or strong evidence of effectiveness of the intervention. Continued Author, year, location, study design, design suitability, study quality Milne (2000) Australia Nonrandomized trial Greatest suitability Good quality 107 Follow-up interval; n; limitations F/U: 1. Continued Author, year, location, study design, design suitability, study quality Results: summary effect measures (behavioral and health outcomes only), p value, within or between groups I-2: Absolute change: 5. Continued Author, year; location; study design; design suitability; study quality Results: summary effect measures (behavioral and health outcomes only), p value, within or between groups Absolute change: 0. Continued Author, year; location; study design; design suitability; study quality Results: summary effect measures (behavioral and health outcomes only), p value, within or between groups Absolute change: Pool A: 9. C: Pre- and post-holiday questionnaires only Results: summary effect measures (behavioral and health outcomes only), p value, within or between groups Adult sun-protection behavior scores (5-point scale; 1 never, 5 always): Use sunscreen: Absolute change: 0. The guidelines presented should not be considered substitutes for individualized client care and treatment decisions. Professor of Epidemiology in Psychiatry Department of Psychiatry Washington UniversitySt. Research Assistant/Professor of Social Work Department of Psychiatry Washington University St. Associate Research Professor Center for Trauma Department of Psychology University of MissouriSt. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. A panel of non-Federal clinical researchers, clinicians, program admin istrators, and patient advocates debates and discusses their particular area of expertise until they reach a consensus on best practices. We are grateful to all who have joined with us to contribute to advances in the behavioral health field. Harding Director Center for Substance Abuse Prevention Substance Abuse and Mental Health Services Administration Paolo del Vecchio, M. Chapter 1 lays the groundwork and rationale for the implementation and provision of traumainformed services. It provides an overview of specific trauma-informed intervention and treat ment principles that guide clinicians, other behavioral health workers, and administrators in becoming trauma informed and in creating a trauma-informed organization and workforce. It covers types of trauma; distinguishes among traumas that affect individuals, groups, and communities; describes trauma characteristics; and addresses the socioecological and cultural factors that influence the impact of trauma. Chap ter 3 broadly focuses on understanding the impact of trauma, trauma-related stress reactions and associated symptoms, and common mental health and substance use disorders associated with trauma. Chapter 4 provides an introduction to screening and assessment as they relate to trauma and is devoted to screening and assessment processes and tools that are useful in evaluating trauma exposure, its effects, and client intervention and treatment needs. Chapter 5 covers clini cal issues that counselors and other behavioral health professionals may need to know and ad dress when treating clients who have histories of trauma. Chapter 6 presents information on specific treatment models for trauma, distinguishing integrated models (which address substance use disorders, mental disorders, and trauma simultaneously) from those that treat trauma alone. Advice to Counselors and/or Administrators boxes in Part 1 provide practical information for providers. Case illustrations, exhibits, and text boxes further illustrate information in the text by offering practical examples. Part 2 provides an overview of programmatic and administrative practices that will help behav ioral health program administrators increase the capacity of their organizations to deliver xv Trauma-Informed Care in Behavioral Health Services trauma-informed services. Chapter 1 examines the essential ingredients, challenges, and processes in creating and implementing trauma-informed services within an organization. Chapter 2 focuses on key development activities that support staff members, including trauma-informed training and supervision, ethics, and boundaries pertinent to responding to traumatic stress, secondary trauma, and counselor self-care. In addition, case illustrations, organizational activities, and text boxes reinforce the material presented within this section. Part 3 has three sections: an analysis of the literature, links to select abstracts of the references most central to the topic, and a general bibliography of the available literature. Behavioral health refers to a state of mental/emotional being and/or choices and actions that affect wellness. Be havioral health problems include substance abuse or misuse, alcohol and drug addiction, serious psychological distress, suicide, and mental and substance use disorders. This includes a range of problems from unhealthy stress to diagnosable and treatable diseases like serious mental illness and substance use disorders, which are often chronic in nature but from which people can and do recover. Because behavioral health conditions, taken together, are the leading causes of disa bility burden in North America, efforts to improve their prevention and treatment will benefit society as a whole. The term "consumer" stands in place of "client" in content areas that address consumer participation and determination. It is not the intent of this docu ment to ignore the relevance and historical origin of the term "consumer" among individuals who have received, been subject to , or are seeking mental health services. Instead, we choose the word "client," given that this terminology is also commonly used in substance abuse treatment services. Co-occurring disorders: When an individual has one or more mental disorders as well as one or more substance use disorders (including substance abuse), the term "co-occurring" applies. Culturally responsive behavioral health services and culturally competent providers "honor and respect the beliefs, languages, interpersonal styles, and behaviors of individuals and families receiving services. Evidence-based practices: There are many different uses of the term "evidence-based practices. A treatment is labeled "strong" if criteria are met for what Chambless and Hollon term "well-established" treatments. To attain this level, rigorous treatment outcome studies conducted by independent investigators (not just the treatment developer) are necessary. Research support is labeled "mod est" when treatments attain criteria for what Chambless and Hollon call "probably efficacious treatments. In addition, it is possible to meet the "strong" and "modest" thresholds through a series of carefully controlled single-case studies. An evidencebased practice derived from sound, science-based theories incorporates detailed and empirically supported procedures and implementation guidelines, including parameters of applications (such as for populations), inclusionary and exclusionary criteria for participation, and target interventions. Promising practices: Even though current clinical wisdom, theories, and professional and expert consensus may support certain practices, these practices may lack support from studies that are scientifically rigorous in research design and statistical analysis; available studies may be limited in number or sample size, or they may not be applicable to the current setting or population. Resilience: this term refers to the ability to bounce back or rise above adversity as an individual, family, community, or provider. Well beyond individual characteristics of hardiness, resilience includes the process of using available resources to negotiate hardship and/or the consequences of adverse events. Retraumatization: In its more literal translation, "retraumatization" means the occurrence of traumatic stress reactions and symptoms after exposure to multiple events (Duckworth & Follette, 2011). This is a significant issue for trauma survivors, both because they are at increased risk for higher rates of retraumatization, and because people who are traumatized multiple times often have more serious and chronic trauma-related symptoms than those with single traumas. In this manual, the term not only refers to the effect of being exposed to multiple events, but also implies the process of reexperiencing traumatic stress as a result of a current situation that mir rors or replicates in some way the prior traumatic experiences. Secondary trauma: Literature often uses the terms "secondary trauma," "compassion fatigue," and "vicarious traumatization" interchangeably. Although compassion fatigue and secondary trauma refer to similar physical, psychological, and cognitive changes and symptoms that behav ioral health workers may encounter when they work specifically with clients who have histories of trauma, vicarious trauma usually refers more explicitly to specific cognitive changes, such as in worldview and sense of self (Newell & MacNeil, 2010). Sec ondary trauma can occur among behavioral health service providers across all behavioral health settings and among all professionals who provide services to those who have experienced trauma. This term was chosen partly because behavioral health professionals commonly use the term substance abuse to describe any excessive use of ad dictive substances. Trauma: In this text, the term "trauma" refers to experiences that cause intense physical and psy chological stress reactions. Although many individuals report a single specific traumatic event, others, especially those seeking mental health or substance abuse services, have been ex posed to multiple or chronic traumatic events. See the "What Is Trauma" section in Part 1, Chap ter 1, for a more indepth definition and discussion of trauma. Trauma-informed: A trauma-informed approach to the delivery of behavioral health services includes an understanding of trauma and an awareness of the impact it can have across settings, services, and populations. It involves viewing trauma through an ecological and cultural lens and recognizing that context plays a significant role in how individuals perceive and process traumatic events, whether acute or chronic. It also involves vigilance in anticipating and avoiding institutional processes and individual practices that are likely to retraumatize individuals who already have histories of trauma, and it upholds the importance of consumer participation in the development, delivery, and evaluation of services. Trauma-specific treatment services: these services are evidence-based and promising practices that facilitate recovery from trauma. The term "trauma-specific services" refers to prevention, intervention, or treatment services that address traumatic stress as well as any co-occurring disor ders (including substance use and mental disorders) that developed during or after trauma. Trauma survivor: this phrase can refer to anyone who has experienced trauma or has had a traumatic stress reaction. Knowing that the use of language and words can set the tone for recov ery or contribute to further retraumatization, it is the intent of this manual to put forth a message of hope by avoiding the term "victim" and instead using the term "survivor" when appropriate. By recognizing that traumatic experiences and their sequelae tie closely into behavioral health problems, front-line professionals and community-based programs can begin to build a traumainformed environment across the continuum of care. Key steps include meeting client needs in a safe, collaborative, and compas sionate manner; preventing treatment practices that retraumatize people with histories of trauma who are seeking help or receiving services; building on the strengths and resilience of clients in the context of their environments and communities; and endorsing trauma-informed principles in agencies through support, consulta tion, and supervision of staff. Although many people exposed to trauma demonstrate few or no lingering symptoms, those individuals who have experi enced repeated, chronic, or multiple traumas are more likely to exhibit pronounced symp toms and consequences, including substance abuse, mental illness, and health problems. Subsequently, trauma can significantly affect how an individual engages in major life areas as well as treatment. The content is adaptable across behavioral health settings that service individuals, fami lies, and communities-placing emphasis on the importance of coordinating as well as inte grating services. Whether provided by an agency or an individual provider, traumainformed services may or may not include trauma-specific services or trauma specialists (individuals who have advanced training and education to provide specific treatment inter ventions to address traumatic stress reactions). Individuals who have experienced trauma are at an elevated risk for substance use disorders, including abuse and dependence; mental health problems. Beyond the context of family, this publication does not examine or address youth and adolescent responses to trauma, youth-tailored traumainformed strategies, or trauma-specific inter ventions for youth or adolescents, because the developmental and contextual issues of these populations require specialized interventions. Providers who work with young clients who have experienced trauma should refer to the resource list in Appendix B. If you are in terested in the citations associated with topics covered in Parts 1 and 2, please consult the review of the literature provided in Part 3 (available online at store. Parts 1 and 2 are easily read and digested on their own, but it is highly recommended that you read the literature review as well. Trauma can affect people of every race, ethnicity, age, sexual ori entation, gender, psychosocial background, and geographic region. A traumatic experience can be a single event, a series of events, and/or a chronic condition. Traumas can affect indi viduals, families, groups, communities, specific cultures, and generations. Individuals may experience the traumatic event directly, witness an event, feel threat ened, or hear about an event that affects someone they know. Events may be humanmade, such as a mechanical error that causes a disaster, war, terrorism, sexual abuse, or vio lence, or they can be the products of nature. Trauma can occur at any age or developmental stage, and often, events that occur outside expected life stages are perceived as traumatic. Two peo ple may be exposed to the same event or series of events but experience and interpret these events in vastly different ways. For most, regardless of the severity of the trauma, the immediate or enduring effects of trauma are met with resili ence-the ability to rise above the circum stances or to meet the challenges with fortitude. For some people, reactions to a traumatic event are temporary, whereas others have pro longed reactions that move from acute symp toms to more severe, prolonged, or enduring mental health consequences. Others do not meet established criteria for posttraumatic stress or other mental disor ders but encounter significant trauma-related symptoms or culturally expressed symptoms of trauma. For that reason, even if an individu al does not meet diagnostic criteria for trauma-related disorders, it is important to recognize that trauma may still affect his or her life in significant ways. For more infor mation on traumatic events, trauma character istics, traumatic stress reactions, and factors that heighten or decrease the impact of trau ma, see Part 1, Chapter 2, "Trauma Aware ness," and Part 1, Chapter 3, "Understanding the Impact of Trauma. With the at tacks of September 11, 2001, and other acts of terror, the wars in Iraq and Afghanistan, disas trous hurricanes on the Gulf Coast, and sexual abuse scandals, trauma has moved to the fore front of national consciousness. However, the first National Comorbidity Study established how prevalent traumas were in the lives of the general popu lation of the United States. In the study, 61 percent of men and 51 percent of women re ported experiencing at least one trauma in their lifetime, with witnessing a trauma, being involved in a natural disaster, and/or experi encing a life-threatening accident ranking as the most common events (Kessler et al. In Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, 71. For behavioral health service providers, trauma-informed practice offers many oppor tunities. It reinforces the importance of ac quiring trauma-specific knowledge and skills to meet the specific needs of clients; of recog nizing that individuals may be affected by trauma regardless of its acknowledgment; of understanding that trauma likely affects many clients who are seeking behavioral health ser vices; and of acknowledging that organizations and providers can retraumatize clients through standard or unexamined policies and practices. Although many individuals may not identify the need to connect with their histo ries, trauma-informed services offer clients a chance to explore the impact of trauma, their strengths and creative adaptations in manag ing traumatic histories, their resilience, and the relationships among trauma, substance use, and psychological symptoms. Organizational investment in developing or improving trauma-informed services may also translate to cost effective ness, in that services are more appropriately matched to clients from the outset. Clients and staff are more apt to be empowered, invested, and satisfied if they are involved in the ongoing development and delivery of trauma-informed services. An organization also benefits from work de velopment practices through planning for, attracting, and retaining a diverse workforce of individuals who are knowledgeable about trauma and its impact. Developing a traumainformed organization involves hiring and promotional practices that attract and retain individuals who are educated and trained in trauma-informed practices on all levels of the organization, including board as well as peer support appointments. Even though investing in a traumainformed workforce does not necessarily guar antee trauma-informed practices, it is more likely that services will evolve more profi ciently to meet client, staff, and community needs. Counselors must be aware of traumarelated symptoms and disorders and how they affect clients in behavioral health treatment. All treatment staff should recognize that traumatic stress symptoms or trauma-related disorders should not preclude an individual from mental health or substance abuse treatment and that all co-occurring disorders need to be addressed on some level in the treatment plan and setting. In addition, assisting a client in achieving abstinence builds a platform upon which recovery from traumatic stress can proceed. Sub stance abuse is known to predispose people to higher rates of traumas, such as dangerous situations and accidents, while under the in fluence (Stewart & Conrod, 2003; Zinzow, Resnick, Amstadter, McCauley, Ruggiero, & Kilpatrick, 2010) and as a result of the lifestyle associated with substance abuse (Reynolds et al. In addition, people who abuse sub stances and have experienced trauma have worse treatment outcomes than those without histories of trauma (Driessen et al. Many individuals who seek treatment for substance use disorders have histories of one or more traumas. More than half of women seeking substance abuse treatment report one or more lifetime traumas (Farley, Golding, Young, Mulligan, & Minkoff, 2004; Najavits et al. Trauma and Mental Disorders People who are receiving treatment for severe mental disorders are more likely to have histo ries of trauma, including childhood physical and sexual abuse, serious accidents, homeless ness, involuntary psychiatric hospitalizations, drug overdoses, interpersonal violence, and other forms of violence. Traumatic stress increases the risk for mental illness, and findings suggest that traumatic stress increases the symptom severity of men tal illness (Spitzer, Vogel, Barnow, Freyberger & Grabe, 2007). These findings propose that traumatic stress plays a significant role in per petuating and exacerbating mental illness and suggest that trauma often precedes the devel opment of mental disorders. As with trauma and substance use disorders, there is a bidirec tional relationship; mental illness increases the risk of experiencing trauma, and trauma in creases the risk of developing psychological symptoms and mental disorders. If a system or program is to support the needs of trauma survivors, it must take a systematic approach that offers trauma-specific diagnostic and treatment services, as well as a trauma-informed environment that is able to sustain such services, while fostering positive outcomes for the clients it serves. These principles comprise a com pilation of resources, including research, theo retical papers, commentaries, and lessons learned from treatment facilities. Key elements are outlined for each principle in providing services to clients affected by trauma and to populations most likely to incur trauma. Although these principles are useful across all prevention and intervention services, settings, and populations, they are of the utmost im portance in working with people who have had traumatic experiences. Although not every client has a history of trauma, those who have substance use and mental disorders are more likely to have expe rienced trauma. Being trauma aware does not mean that you must assume everyone has a history of trauma, but rather that you antici pate the possibility from your initial contact and interactions, intake processes, and screen ing and assessment procedures. Even the most standard behavioral health practices can retraumatize an individual ex "Trauma-informed care embraces a per spective that highlights adaptation over symptoms and resilience over pathology. For example, a counselor might develop a treat ment plan recommending that a female cli ent-who has been court mandated to substance abuse treatment and was raped as an adult-attend group therapy, but without con sidering the implications, for her, of the fact that the only available group at the facility is all male and has had a low historical rate of female participation. Trauma awareness is an essential strategy for preventing this type of retraumatization; it reinforces the need for providers to reevaluate their usual practices. Fami ly members frequently experience the trau matic stress reactions of the individual family member who was traumatized. These repetitive experiences can increase the risk of secondary trauma and symptoms of mental illness among the family, heighten the risk for externalizing and internalizing behavior among children. Hence, prevention and intervention services can pro vide education and age-appropriate program ming tailored to develop coping skills and support systems. A trauma-aware workplace supports supervi sion and program practices that educate all direct service staff members on secondary trauma, encourages the processing of traumarelated content through participation in peersupported activities and clinical supervision, and provides them with professional develop ment opportunities to learn about and engage in effective coping strategies that help prevent secondary trauma or trauma-related symp toms.
