976 Traumatic Damage to The Liver Capsule: An Unusual Cause of Small Bowel Obstruction

A 57-year-old man presented to the emergency department with severe abdominal pain. Three months prior to presentation, he had sustained blunt trauma to his right side whilst cycling but had not sought medical attention. On admission, a CT scan showed small bowel obstruction and he underwent an emergency laparotomy. Intraoperatively, a subcapsular liver haematoma was identified, with incarcerated, necrotic small bowel within the liver capsule. The patient underwent deroofing of the haematoma with an omental patch and a small bowel resection with primary anastomosis.

Small bowel obstruction is a common presentation in A&E and is responsible for half of emergency laparotomies in the UK each year. Although hepatic haematomas are also a relatively common complication of blunt trauma to the abdomen, associated bowel herniation into the liver capsule is very unusual. We believe this is the first time such a case of small bowel obstruction has been reported in the literature and we discuss details of operative management and highlight key learning points.

Trial of Prazosin for Post-Traumatic Stress Disorder in Military Veterans

BACKGROUND

In randomized trials, prazosin, an α₁-adrenoreceptor antagonist, has been effective in alleviating nightmares associated with post-traumatic stress disorder (PTSD) in military veterans.

METHODS

We recruited veterans from 13 Department of Veterans Affairs medical centers who had chronic PTSD and reported frequent nightmares. Participants were randomly assigned to receive prazosin or placebo for 26 weeks; the drug or placebo was administered in escalating divided doses over the course of 5 weeks to a daily maximum of 20 mg in men and 12 mg in women. After week 10, participants continued to receive prazosin or placebo in a double-blind fashion for an additional 16 weeks. The three primary outcome measures were the change in score from baseline to 10 weeks on the Clinician-Administered PTSD Scale (CAPS) item B2 ("recurrent distressing dreams"; scores range from 0 to 8, with higher scores indicating more frequent and more distressing dreams); the change in score from baseline to 10 weeks on the Pittsburgh Sleep Quality Index (PSQI; scores range from 0 to 21, with higher scores indicating worse sleep quality); and the Clinical Global Impression of Change (CGIC) score at 10 weeks (scores range from 1 to 7, with lower scores indicating greater improvement and a score of 4 indicating no change).

RESULTS

A total of 304 participants underwent randomization; 152 were assigned to prazosin, and 152 to placebo. At 10 weeks, there were no significant differences between the prazosin group and the placebo group in the mean change from baseline in the CAPS item B2 score (between-group difference, 0.2; 95% confidence interval [CI], -0.3 to 0.8; P=0.38), in the mean change in PSQI score (between-group difference, 0.1; 95% CI, -0.9 to 1.1; P=0.80), or in the CGIC score (between-group difference, 0; 95% CI, -0.3 to 0.3; P=0.96). There were no significant differences in these measures at 26 weeks (a secondary outcome) or in other secondary outcomes. At 10 weeks, the mean difference between the prazosin group and the placebo group in the change from baseline in supine systolic blood pressure was a decrease of 6.7 mm Hg. The adverse event of new or worsening suicidal ideation occurred in 8% of the participants assigned to prazosin versus 15% of those assigned to placebo.

CONCLUSIONS

In this trial involving military veterans who had chronic PTSD, prazosin did not alleviate distressing dreams or improve sleep quality. (Funded by the Department of Veterans Affairs Cooperative Studies Program; PACT ClinicalTrials.gov number, NCT00532493 .).

Smoking-induced affect modulation in nonwithdrawn smokers with posttraumatic stress disorder, depression, and in those with no psychiatric disorder

This research sought to determine whether smoking influences affect by means other than withdrawal reduction. Little previous evidence suggests such an effect. We surmised that such an effect would be especially apparent in posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), 2 disorders that are frequently comorbid with smoking and that involve dysregulated affect. Participants were U.S. veterans who were regular smokers (N = 159): 52 with PTSD (58% with comorbid MDD), 51 with MDD, and 56 controls with no psychiatric disorder. During 3 positive and 3 negative mood induction trials (scheduled over 2 sessions), nonwithdrawn participants smoked either a nicotine-containing cigarette (NIC+), a nicotine-free cigarette (NIC-), or held a pen. Positive and negative affect were each measured before and after mood induction. Results showed a significant 2-way interaction of Smoking Condition × Time on negative affect during the negative mood induction (F(6, 576) = 2.41, p = .03) in those with PTSD and controls. In these groups, both NIC+ and NIC-, relative to pen, produced lower negative affect ratings after the negative mood induction. There was also a 2-way interaction of Smoking Condition × Time on positive affect response to the positive mood induction among those with PTSD and controls (F(6, 564) = 3.17, p = .005) and among MDD and controls (F(6, 564) = 2.27, p = .036). Among all smokers, NIC+ enhanced the magnitude and duration of positive affect more than did NIC-. Results revealed affect modulation outside the context of withdrawal relief; such effects may motivate smoking among those with psychiatric diagnoses, and among smokers in general. (PsycINFO Database Record

Integrating smoking cessation into mental health care for post-traumatic stress disorder

Background Post-traumatic stress disorder (PTSD) is associated with a high prevalence of smoking, heavy cigarette consumption and low cessation rates.

Purpose This manuscript describes the design of a randomized, multisite effectiveness trial to test whether integrating smoking cessation treatment into mental health care (integrated care) improves prolonged abstinence rates among veterans with PTSD, compared with referral to specialized smoking cessation clinics (usual standard of care). Secondary objectives are to assess the cost-effectiveness of integrated care relative to usual standard of care, identify treatment variables that mediate differences between conditions in outcome and determine whether smoking cessation is associated with worsening PTSD and/or depression.

Methods Following randomization, subjects (projected n = 1400) from 10 Veterans Health Administration (VHA) medical centers complete follow-up assessments every three or six months for up to four years. Endpoints include 1-year prolonged abstinence at 18 months postrandomization, 7- and 30-day point-prevalence abstinence and measures of depression, PTSD and economic outcomes.

Results This study is unique in providing the largest scale test of the feasibility and effectiveness of having mental health clinicians implement evidence-based smoking cessation treatment in psychiatric care settings for veterans with PTSD. It incorporates methodological features that are desirable for cessation treatment trials, including: a) assessment of clinically meaningful long-term smoking outcomes; b) a manual guiding delivery of the experimental intervention; c) independent ratings of clinician competence and treatment adherence and d) methods for training clinicians that would enhance implementation of tobacco cessation treatment in large health care systems.

Limitations Use of an exclusively VHA sample with few females limits generalizability. Conclusions The process for meeting challenges in designing this study may provide planning of other large-scale clinical effectiveness trials in tobacco control.

Findings have potential to initiate system-wide change in clinical practice patterns for tobacco cessation treatment involving patients with mental disorders. Clinical Trials 2007; 4: 178—189. http://ctj.sagepub.com

Cost-Effectiveness of Integrating Tobacco Cessation Into Post-Traumatic Stress Disorder Treatment

INTRODUCTION

We examined the cost-effectiveness of smoking cessation integrated with treatment for post-traumatic stress disorder (PTSD).

METHODS

Smoking veterans receiving care for PTSD (N = 943) were randomized to care integrated with smoking cessation versus referral to a smoking cessation clinic. Smoking cessation services, health care cost and utilization, quality of life, and biochemically-verified abstinence from cigarettes were assessed over 18-months of follow-up. Clinical outcomes were combined with literature on changes in smoking status and the effect of smoking on health care cost, mortality, and quality of life in a Markov model of cost-effectiveness over a lifetime horizon. We discounted cost and outcomes at 3% per year and report costs in 2010 US dollars.

RESULTS

The mean of smoking cessation services cost was $1286 in those randomized to integrated care and $551 in those receiving standard care (P < .001). There were no significant differences in the cost of mental health services or other care. After 12 months, prolonged biochemically verified abstinence was observed in 8.9% of those randomized to integrated care and 4.5% of those randomized to standard care (P = .004). The model projected that Integrated Care added $836 in lifetime cost and generated 0.0259 quality adjusted life years (QALYs), an incremental cost-effectiveness ratio of $32 257 per QALY. It was 86.0% likely to be cost-effective compared to a threshold of $100 000/QALY.

CONCLUSIONS

Smoking cessation integrated with treatment for PTSD was cost-effective, within a broad confidence region, but less cost-effective than most other smoking cessation programs reported in the literature.

PTSD and depression symptoms are associated with binge eating among US Iraq and Afghanistan veterans

OBJECTIVE

US Iraq and Afghanistan Veterans with post-traumatic stress disorder (PTSD) and depression are at increased risk for obesity. Understanding the contribution of health behaviors to this relationship will enhance efforts to prevent and reduce obesity. Therefore, we examined the association of PTSD and depression symptoms with binge eating, a risk factor for obesity, among Iraq/Afghanistan Veterans.

METHOD

Iraq/Afghanistan Veterans were assessed at intake to the VA Puget Sound Healthcare System-Seattle post-deployment clinic (May 2004-January 2007). The Patient Health Questionnaire was used to measure depression and binge eating symptoms, and the PTSD Checklist-Military Version assessed PTSD symptoms.

RESULTS

The majority of the sample (N=332) was male (91.5%) and Caucasian (72.6%), with an average age of 31.1 (SD=8.5) years; 16.3% met depression screening criteria, 37.8% met PTSD screening criteria, and 8.4% met binge eating screening criteria. In adjusted models, those meeting depression (odds ratio (OR)=7.53; 95% CI=2.69, 21.04; p<.001) and PTSD (OR=3.37; 95% CI=1.34, 8.46; p=.01) screening criteria were more likely to meet binge eating screening criteria. Continuous measures of PTSD and depression symptom severity were also associated with meeting binge eating screening criteria (ps<.05).

CONCLUSION

PTSD and depression are common conditions among Iraq/Afghanistan Veterans. In the present study, PTSD and depression symptoms were associated with meeting binge eating screening criteria, identifying a possible pathway by which psychiatric conditions lead to disproportionate burden of overweight and obesity in this Veteran cohort. Tailored dietary behavior interventions may be needed for Iraq/Afghanistan Veterans with co-morbid obesity and psychiatric conditions.

Tobacco use trajectories among a large cohort of treated smokers with posttraumatic stress disorder

INTRODUCTION

This study identified distinct tobacco use trajectories across 18months in 943 veteran smokers with posttraumatic stress disorder (PTSD) in order to describe quit and relapse patterns, examine associations between trajectory groups on baseline characteristics and cessation service utilization, and explore group differences in mental health outcomes.

METHODS

Veterans who participated in a multisite, randomized trial of integrated smoking cessation care were grouped using k-means clustering based on reported daily tobacco use between baseline and 18months. Four trajectory clusters were identified: no reduction (62%), temporary reduction (11%), late sustained reduction (9%) and early sustained reduction (18%).

RESULTS

Median quit times in the early, late, temporary, and no reduction groups were 451, 141.5, 97, and 2days, respectively. Compared to the early reduction group, the temporary reduction group exhibited higher baseline depression (p<0.01) and anxiety (p<0.01), but did not differ in treatment received, with both groups attending significantly more cessation visits (p<0.001) and more likely to receive recommended pharmacotherapy (p<0.001) than the no reduction group between baseline and 6months. The early reduction group exhibited lower depression relative to the no reduction (p<0.01) and temporary reduction (p<0.01) groups across all assessments between baseline and 18months. Differences were not observed between groups in depressive or PTSD symptom change over time between baseline and 18months.

CONCLUSIONS

Tobacco use trajectories among treated smokers with PTSD vary distinctly. Characteristics of identified subgroups may lead to targeted interventions among smokers with PTSD and potentially other psychiatric disorders.

Use of a learning collaborative to support implementation of integrated care for smoking cessation for veterans with posttraumatic stress disorder

OBJECTIVES

We evaluated the feasibility of incorporating integrated care (IC) for smoking cessation into routine treatment for posttraumatic stress disorder (PTSD) at Department of Veterans Affairs (VA) Medical Centers and the utility of the Learning Collaborative (LC) model in facilitating implementation.

METHODS

We conducted 2 LCs aimed at implementing IC for smoking cessation using multidisciplinary teams comprising 70 staff members from 12 VA PTSD clinics. Using questionnaires, we evaluated providers' perceptions of the LC methodology and the effectiveness and feasibility of routine IC delivery. We assessed number of providers delivering and patients receiving IC using medical record data.

RESULTS

More than 85% of participating VA staff considered the LC to be an effective training and implementation platform. The majority thought IC effectively addressed an important need and could be delivered in routine PTSD care. All LC participants who planned to deliver IC did so (n=52). Within 12 months of initial training, an additional 46 locally trained providers delivered IC and 395 veterans received IC.

CONCLUSIONS

The LC model effectively facilitated rapid and broad implementation of IC. Facilitators and barriers to sustained use of IC are unknown and should be identified to understand how best to promote ongoing access to evidence-based treatment for smoking cessation in mental health populations.

Evaluation of antimicrobial resistance profiles of Salmonella isolates from broiler chickens at slaughter in Alberta, Canada

Antimicrobial-resistant Salmonella species are threatening to become a serious public health problem. Therefore, surveillance and prudent use of antimicrobials is needed in both the agricultural and human health sectors. The aim of this study was to describe the antimicrobial susceptibility profiles of Salmonella isolates recovered from healthy broiler chickens at slaughter from November 2004 to April 2005. Salmonella isolates recovered from 36 broiler flocks in Alberta, Canada, were serotyped and tested for antimicrobial susceptibility against 15 antimicrobials. Of 272 Salmonella isolates tested, 64.0% were resistant to one or more antimicrobials, 10.0% were resistant to three or more antimicrobials, and 1.8% were resistant to five antimicrobials. All isolates were susceptible to amikacin, amoxicillin-clavulanic acid, ceftiofur, cefoxitin, ceftriaxone, ciprofloxacin, and nalidixic acid. The highest prevalence of resistance was to tetracycline (54.8%), followed by streptomycin (24.2%) and sulfisoxazole (8.4%). The most common multiantimicrobial resistance patterns were to streptomycin-tetracycline (24.3%), streptomycin-sulfisoxazole-tetracycline (6.6%), and ampicillin-streptomycin-sulfisoxazole-tetracycline (3.7%). The strongest associations were observed between resistance to kanamycin and tetracycline (odds ratio = 65.7, P = 0.001) and to ampicillin and sulfisoxazole (odds ratio = 62.9, P = 0.001). Salmonella Hadar and Salmonella Heidelberg were the two most common serovars accounting for 40.4 and 13.6% of the total isolates, respectively. Eighty-one percent and 12.7% of Salmonella Hadar isolates and 62.0 and 8.1% of Salmonella Heidelberg isolates were resistant to 1 or more and three or more antimicrobials, respectively. The flock level prevalence of resistance ranged from 5.6% for trimethoprim-sulfamethoxazole to 83.3% for tetracycline. This study provides baseline information on antimicrobial susceptibility of Salmonella isolates of broiler chickens at slaughter in Alberta that can serve as a benchmark for future research.

Mental health and somatic symptom severity are associated with reduced physical activity among US Iraq and Afghanistan veterans

OBJECTIVE

Ensuring that Iraq and Afghanistan veterans engage in adequate physical activity is essential to prevent metabolic and cardiovascular diseases, and promote psychological well-being. Identifying factors associated with physical activity in this population will yield areas for targeted interventions aimed at increasing activity.

METHOD

Correlates of meeting physical activity recommendations (≥ 150 min/week of moderate-to-vigorous physical activity [MVPA]) were examined in Iraq/Afghanistan veterans assessed at intake to VA Puget Sound Healthcare System's post-deployment health clinic (May, 2005-August, 2009; N=266).

RESULTS

The majority were male (94.3%) and Caucasian (70.7%), with an average age of 29.8 (SD=7.3) years. Participants engaged in a median of 180 weekly MVPA minutes. Among those meeting (59%) and not meeting (41%) recommendations, median weekly MVPA minutes were 540 and 0, respectively. In multivariate regression models, higher levels of depression (p=.042) and somatic (p=.018) symptom severity were associated with significantly decreased odds of meeting physical activity recommendations.

CONCLUSION

Overall, physical activity engagement among Iraq/Afghanistan veteran VA patients was above the level specified in national recommendations. Those with higher depressive and somatic symptoms were less likely to meet physical activity recommendations and may benefit from targeted physical activity promotion interventions.

PTSD and depression as predictors of physical health-related quality of life in tobacco-dependent veterans

OBJECTIVE

Smoking, depression and PTSD are related to poor physical health outcomes and health-related quality of life (HRQoL). Previous studies examining the effects of quitting smoking on HRQoL have been mixed. This study aimed to examine the effects of PTSD, depressive symptoms and smoking cessation on HRQoL in a sample receiving treatment for PTSD.

METHOD

This study utilized archival interview and self-report data from a clinical trial (VA Cooperative Study 519) that recruited tobacco dependent veterans with chronic PTSD (N=943).

RESULTS

Analyses were conducted using hierarchical linear modeling and indicated that PTSD and depressive symptoms differentially affected the various physical health status domains. Additionally, quitting smoking was associated with better self-perceived health status and social functioning.

CONCLUSION

Our findings further explain the interrelationships of PTSD, depression, and smoking in the prediction of physical HRQoL and advocate the importance of integrated care.

Smoking intensity and severity of specific symptom clusters in posttraumatic stress disorder

Smoking prevalence among patients with posttraumatic stress disorder (PTSD) is over 40%. Baseline data from the VA Cooperative Studies Program trial of integrated versus usual care for smoking cessation in veterans with PTSD (N = 863) were used in multivariate analyses of PTSD and depression severity, and 4 measures of smoking intensity: cigarettes per day (CPD), Fagerström Test for Nicotine Dependence (FTND), time to first cigarette, and expired carbon monoxide. Multivariate regression analysis showed the following significant associations: CPD with race (B = -7.16), age (B = 0.11), and emotional numbing (B =0 .16); FTND with race (B = -0.94), education (B = -0.34), emotional numbing (B = 0.04), significant distress (B = -0.12), and PHQ-9 (B = 0.04); time to first cigarette with education (B = 0.41), emotional numbing (B = -0.03), significant distress (B = 0.09), and PHQ-9 (B = -0.03); and expired carbon monoxide with race (B = -9.40). Findings suggest that among veterans with PTSD, White race and emotional numbing were most consistently related to increased smoking intensity and had more explanatory power than total PTSD symptom score. Results suggest specific PTSD symptom clusters are important to understanding smoking behavior in patients with PTSD.

Smoking outcome expectancies in military veteran smokers with posttraumatic stress disorder

INTRODUCTION

Smoking outcome expectancies were investigated in treatment-seeking military Veteran smokers with posttraumatic stress disorder (PTSD). The investigation of smoking outcome expectancies may enhance our understanding of the relationship between PTSD and cigarette smoking.

METHODS

Participants were 943 military Veterans with a diagnosis of PTSD who were current smokers enrolled in a randomized multisite effectiveness trial to test whether the integration of smoking cessation treatment into mental health care (integrated care) improves prolonged abstinence rates compared with referral to specialized smoking cessation clinics (usual care). Using confirmatory factor analysis (CFA), we evaluated the conceptual model of smoking outcome expectancies measured on the Smoking Consequences Questionnaire-Adult (SCQ-A) version. The Kraemer method of mediation analysis was used to investigate the role of smoking outcome expectancies in mediating relationships between PTSD symptoms and smoking behavior, tobacco dependence, and abstinence self-efficacy.

RESULTS

The CFA supported the 10-factor structure of the SCQ-A in smokers with PTSD. Relationships between measures of PTSD symptoms and tobacco dependence were mediated by the smoking outcome expectancy regarding negative affect reduction. This same smoking outcome expectancy mediated relationships between PTSD symptoms and smoking abstinence self-efficacy.

CONCLUSIONS

The findings support the use of the SCQ-A as a valid measure of smoking outcome expectancies in military Veteran smokers with PTSD. Moreover, they suggest that smoking outcome expectancies may play an important role in explaining the relationship between PTSD and cigarette smoking.

Integrating tobacco cessation into mental health care for posttraumatic stress disorder: a randomized controlled trial

CONTEXT

Most smokers with mental illness do not receive tobacco cessation treatment.

OBJECTIVE

To determine whether integrating smoking cessation treatment into mental health care for veterans with posttraumatic stress disorder (PTSD) improves long-term smoking abstinence rates.

DESIGN, SETTING, AND PATIENTS

A randomized controlled trial of 943 smokers with military-related PTSD who were recruited from outpatient PTSD clinics at 10 Veterans Affairs medical centers and followed up for 18 to 48 months between November 2004 and July 2009.

INTERVENTION

Smoking cessation treatment integrated within mental health care for PTSD delivered by mental health clinicians (integrated care [IC]) vs referral to Veterans Affairs smoking cessation clinics (SCC). Patients received smoking cessation treatment within 3 months of study enrollment.

MAIN OUTCOME MEASURES

Smoking outcomes included 12-month bioverified prolonged abstinence (primary outcome) and 7- and 30-day point prevalence abstinence assessed at 3-month intervals. Amount of smoking cessation medications and counseling sessions delivered were tested as mediators of outcome. Posttraumatic stress disorder and depression were repeatedly assessed using the PTSD Checklist and Patient Health Questionnaire 9, respectively, to determine if IC participation or quitting smoking worsened psychiatric status.

RESULTS

Integrated care was better than SCC on prolonged abstinence (8.9% vs 4.5%; adjusted odds ratio, 2.26; 95% confidence interval [CI], 1.30-3.91; P = .004). Differences between IC vs SCC were largest at 6 months for 7-day point prevalence abstinence (78/472 [16.5%] vs 34/471 [7.2%], P < .001) and remained significant at 18 months (86/472 [18.2%] vs 51/471 [10.8%], P < .001). Number of counseling sessions received and days of cessation medication used explained 39.1% of the treatment effect. Between baseline and 18 months, psychiatric status did not differ between treatment conditions. Posttraumatic stress disorder symptoms for quitters and nonquitters improved. Nonquitters worsened slightly on the Patient Health Questionnaire 9 relative to quitters (differences ranged between 0.4 and 2.1, P = .03), whose scores did not change over time.

CONCLUSION

Among smokers with military-related PTSD, integrating smoking cessation treatment into mental health care compared with referral to specialized cessation treatment resulted in greater prolonged abstinence.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00118534.

Does PTSD moderate the relationship between social support and suicide risk in Iraq and Afghanistan War Veterans seeking mental health treatment?

OBJECTIVE

This study examined posttraumatic stress disorder (PTSD) as a potential moderating variable in the relationship between social support and elevated suicide risk in a sample of treatment-seeking Iraq and Afghanistan War Veterans.

METHOD

As part of routine care, self-reported marital status, satisfaction with social networks, PTSD, and recent suicidality were assessed in Veterans (N=431) referred for mental health services at a large Veteran Affairs Medical Center. Logistic regression analyses were conducted using this cross-sectional data sample to test predictions of diminished influence of social support on suicide risk in Veterans reporting PTSD.

RESULTS

Thirteen percent of Veterans were classified as being at elevated risk for suicide. Married Veterans were less likely to be at elevated suicide risk relative to unmarried Veterans and Veterans reporting greater satisfaction with their social networks were less likely to be at elevated risk relative to Veterans reporting lower satisfaction. Satisfaction with social networks was protective for suicide risk in PTSD and non-PTSD cases, but was significantly less protective for veterans reporting PTSD.

CONCLUSIONS

Veterans who are married and Veterans who report greater satisfaction with social networks are less likely to endorse suicidal thoughts or behaviors suggestive of elevated suicide risk. However, the presence of PTSD may diminish the protective influence of social networks among treatment-seeking Veterans.

Behavioral activation as a primary care-based treatment for PTSD and depression among returning veterans

This preliminary study examined treatment-satisfaction and potential therapeutic benefits of Behavioral Activation as a primary care-based treatment for posttraumatic stress disorder (PTSD) and depression among Iraq and Afghanistan War veterans. Eight veterans were enrolled, 6 completed at least 4 sessions, and 5 veterans completed posttreatment and 3-month follow-up assessments after receiving 5-8 weekly sessions of Behavioral Activation delivered in a specialty postdeployment primary care clinic. Significant and meaningful reductions in PTSD symptoms were found on structured clinical assessments and self-report measures. Posttraumatic stress disorder treatment gains (measured by structured clinical assessments) were maintained at 3-month follow-up. The majority of veterans demonstrated meaningful improvements on depression and quality of life and veterans reported a high satisfaction with treatment.

Evaluation of associations between feed withdrawal and other management factors with Salmonella contamination of broiler chickens at slaughter in Alberta

Salmonellosis is one of the most common bacterial foodborne diseases of public health concern in industrialized countries. Poultry products are considered an important source of Salmonella-related foodborne disease in humans. This study was undertaken to evaluate the relationship between various management factors including feed withdrawal and transportation time with Salmonella contamination in crops, ceca, and carcasses of broiler chickens at slaughter in Alberta. Using a two-stage sampling procedure, 30 matched crop and cecal samples before evisceration and an additional 30 neck skin samples after final wash of broiler chickens were collected at slaughter. A questionnaire was administered at the time of sampling to collect information on flock management risk factors. Cecal contents were individually screened with Salmonella-specific real-time PCR to detect positive flocks, and all cecal, crop, and neck skin samples from positive flocks were processed further for Salmonella isolation and characterization. The flock prevalence of Salmonella was 57.1% and within-flock prevalence of Salmonella for positive flocks was 17.2, 8.1, and 53.9% for ceca, crops, and neck skins, respectively. Salmonella Hadar was the most common serovar identified from crops, ceca, and neck skins of broiler chickens tested. Longer transport (P = 0.04 for neck skins) and waiting time in-plant (P = 0.04 for crops, P = 0.03 for ceca) were identified as important risk factors for Salmonella contamination of broiler chickens at slaughter. Salmonella contamination of broiler chickens could potentially be minimized by reducing waiting time in-plant for flocks with longer transport time.

Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans

Posttraumatic stress disorder (PTSD) was examined as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans (N = 407) referred to Veterans Affairs mental health care. The authors also examined if risk for suicidal ideation was increased by the presence of comorbid mental disorders in veterans with PTSD. Veterans who screened positive for PTSD were more than 4 times as likely to endorse suicidal ideation relative to non-PTSD veterans. Among veterans who screened positive for PTSD (n = 202), the risk for suicidal ideation was 5.7 times greater in veterans who screened positive for two or more comorbid disorders relative to veterans with PTSD only. Findings are relevant to identifying risk for suicide behaviors in Iraq and Afghanistan War veterans.

Influence of PTSD symptom clusters on smoking status among help-seeking Iraq and Afghanistan veterans

INTRODUCTION

Despite the strong association between smoking and posttraumatic stress disorder (PTSD), mechanisms influencing smoking in this population remain unclear. Previous smoking research has largely examined PTSD as a homogenous syndrome despite the fact that PTSD is composed of four distinct symptom clusters (i.e., reexperiencing, effortful avoidance, emotional numbing, and hyperarousal). Examination of the relationship between smoking and PTSD symptom clusters may increase understanding of mechanisms influencing comorbidity between smoking and PTSD. The goals of the present study were to (a) examine the influence of overall PTSD symptom severity on likelihood of smoking and smoking heaviness and (b) examine the influence of each PTSD symptom cluster on smoking.

METHODS

Participants (N = 439) were Operation Iraqi Freedom/Operation Enduring Freedom combat veterans referred to VA mental health services.

RESULTS

Multinomial logistic regression was chosen to accommodate a three-level outcome, in which the likelihood of being a nonsmoker was compared with (a) light smoking (1-9 cigarettes/day), (b) moderate smoking (10-19 cigarettes/day), and (c) heavy smoking (> or =20 cigarettes/day). Results showed that veterans with higher levels of overall PTSD symptomatology were more likely to endorse heavy smoking (Wald = 4.56, p = .03, odds ratio [OR] = 1.65). Veterans endorsing high levels of emotional numbing were also more likely to endorse heavy smoking (Wald = 6.49, p = .01, OR = 1.81); all other PTSD symptom clusters were unrelated to smoking.

DISCUSSION

The association between emotional numbing and heavy daily smoking suggests that veterans with PTSD may smoke to overcome emotional blunting following trauma exposure.

Supplementation of diets for lactating sows with zinc amino acid complex and gastric nutriment-intubation of suckling pigs with zinc methionine on mineral status, intestinal morphology and bacterial translocation in lipopolysaccharide-challenged weaned pigs

Sixty-four pigs from 16 sows were used to evaluate addition of zinc amino acid complex (ZnAA) to lactating sows and gastric nutriment-intubation of zinc methionine (ZnMet) to suckling pigs on mineral status, intestinal morphology and bacterial translocation after weaning. Sows were fed a barley-based diet supplying 120 ppm zinc (Zn; control) or the control diet supplemented with 240 ppm Zn from ZnAA. At birth, day-10 and day-21 (weaning) of age, pigs from each litter were nutriment-intubated with 5 ml of an electrolyte solution without or with 40 mg Zn from ZnMet. At weaning, 24 h prior to the collection of small and large intestinal lymph nodes and sections of the duodenum, jejunum and ileum, the pigs received an intramuscular injection of saline without or with 150 microg/kg body weight of Escherichia coli O26:B6 lipopolysaccharide (LPS). With the exception of a tendency (p = 0.09) for lower serum concentration of copper in pigs at weaning from ZnAA-supplemented sows, there were no differences (p > 0.1) than for pigs from control-fed sows for mineral status or intestinal morphology. Nutriment-intubation of ZnMet increased serum (p = 0.001) and liver (p = 0.003) Zn concentrations, number of goblet cells per 250 microm length of jejunal villous epithelium (p = 0.001) and tended (p = 0.06) to enhance jejunum mucosa thickness. Interactive effects (p < 0.05) for higher jejunal villi height and villi:crypt ratio and increased ileal goblet cell counts were apparent for pigs from ZnAA-supplemented sows that also received nutriment-intubation of ZnMet. Challenge with LPS increased (p = 0.05) ileal villous width. Nutriment-intubation of ZnMet decreased (p = 0.05) anaerobic bacteria colony forming unit counts in the large intestinal mesenteric lymph nodes. In conclusion, nutriment-intubation of ZnMet increased serum and liver tissue concentrations of Zn and resulted in limited improvement to intestinal morphology of weaned pigs.

Supplementation of diets for gestating sows with zinc amino acid complex and gastric intubation of suckling pigs with zinc-methionine on mineral status, intestinal morphology and bacterial translocation in lipopolysaccharide-challenged early-weaned pigs

Eighty male pigs from 20 litters were used to evaluate dietary addition of 250mg/kg of Zn from zinc amino acid complex (ZnAA) to sows during the last trimester of gestation and gastric intubation of 40mg Zn from soluble zinc methionine (ZnMet) to suckling pigs at birth and on day 7 and 14 (weaning) on small intestinal morphology, Zn status and bacterial translocation in early-weaned pigs. At weaning, pigs were challenged with an intramuscular injection of saline without or with 120microg/kg BW of lipopolysaccharide (LPS; from Escherichia coli O26:B6) and were euthanized 24h later prior to collection of intestinal lymph nodes and small intestinal sections. Zinc concentration in serum 7 days after birth and at weaning were higher in pigs from ZnAA-supplemented sows and those receiving gastric intubation with ZnMet (P=0.05 and P<0.0001, respectively). Post-weaning liver tissue concentrations for Zn (P<0.0001) and Fe (P=0.04) were higher and for Cu lower (P<0.0001) in pigs intubated with ZnMet. Pigs from ZnAA-supplemented compared with control-fed sows tended (P<0.1) to have increased villi height and villus:crypt ratio in the jejunum and higher (P=0.1) goblet cell counts in the ileum. Goblet cell counts of ZnMet-intubated (P=0.03) and LPS-challenged pigs (P=0.05) were also higher in the jejunum. Supplementation of ZnAA to gestating sows increased (P=0.04) E. coli colony forming unit counts in the small intestinal mesenteric lymph nodes of early-weaned pigs. In conclusion, dietary addition of ZnAA to gestating sows and gastric intubation of ZnMet improved Zn status of suckling pigs.

Post-traumatic stress disorder and smoking: a systematic review

We conducted a systematic review of what is known about the relationship between post-traumatic stress disorder (PTSD) and smoking to guide research on underlying mechanisms and to facilitate the development of evidence-based tobacco treatments for this population of smokers. We searched Medline, PsychINFO, and the Cochrane Central Register of Controlled Trials and identified 45 studies for review that presented primary data on PTSD and smoking. Smoking rates were high among clinical samples with PTSD (40%-86%) as well as nonclinical populations with PTSD (34%-61%). Most studies showed a positive relationship between PTSD and smoking and nicotine dependence, with odds ratios ranging between 2.04 and 4.52. Findings also suggest that PTSD, rather than trauma exposure itself, is more influential for increasing risk of smoking. A small but growing literature has examined psychological factors related to smoking initiation and maintenance and the overlapping neurobiology of PTSD and nicotine dependence. Observational studies indicate that smokers with PTSD have lower quit rates than do smokers without PTSD. Yet a few tobacco cessation treatment trials in smokers with PTSD have achieved quit rates comparable with controlled trials of smokers without mental disorders. In conclusion, the evidence points to a causal relationship between PTSD and smoking that may be bidirectional. Specific PTSD symptoms may contribute to smoking and disrupt cessation attempts. Intervention studies that test behavioral and pharmacological interventions designed specifically for use in patients with PTSD are needed to reduce morbidity and mortality in this population.

Integrating tobacco cessation treatment into mental health care for patients with posttraumatic stress disorder

The integration of tobacco cessation treatment into mental health care for posttraumatic stress disorder (PTSD), known as Integrated Care (IC), was evaluated in an uncontrolled feasibility and effectiveness study. Veterans (N = 107) in PTSD treatment at two outpatient clinics received IC delivered by mental health practitioners. Outcomes were seven-day point prevalence abstinence measured at two, four, six, and nine months post-enrollment and repeated seven-day point prevalence abstinence (RPPA) obtained across three consecutive assessment intervals (four, six, and nine months). Abstinence rates at the four assessment intervals were 28%, 23%, 25%, and 18%, respectively, and RPPA was 15%. The number of IC sessions and a previous quit history greater than six months predicted RPPA. Stopping smoking was not associated with worsening PTSD or depression.

Specificity of patients' satisfaction with the delivery and outcome of treatment

This study investigated the hypotheses that the general disposition to be satisfied is more influential than the nature of service delivery in determining satisfaction with treatment, and that there is a specificity to satisfaction with the delivery of care and with clinical outcome of care that makes their ratings distinct. Data were obtained by questionnaire at intake into treatment and 4 months later from 154 male veterans. There were statistically significant relationships between the general disposition to be satisfied and satisfaction with treatment, but they had only a trivial effect on the relationships between treatment satisfaction and other variables. There was, however, a specificity to satisfaction ratings such that a major feature of the delivery of care, the experience of friendliness and caring from staff, was related more highly to satisfaction with care than to satisfaction with outcome, while measures of clinical outcome were related more highly to satisfaction with outcome than to satisfaction with care. A general disposition to be satisfied, therefore, appears not to have a major biasing effect on satisfaction with treatment. Further, patients appear to make valid differentiations between satisfaction with the delivery of care and the clinical outcome of care when their attention is focused specifically on satisfaction with these features.

Longitudinal analysis of the relationship between symptoms and quality of life in veterans treated for posttraumatic stress disorder

This study examined how change in posttraumatic stress disorder (PTSD) symptoms relates to change in quality of life. The sample consisted of 325 male Vietnam veterans with chronic PTSD who participated in a randomized trial of group psychotherapy. Latent growth modeling was used to test for synchronous effects of PTSD symptom change on psychosocial and physical health-related quality of life within the same time period and lagged effects of initial PTSD symptom change on later change in quality of life. PTSD symptoms were associated with reduced quality of life before treatment. There were synchronous effects of symptom change on change in quality of life but no significant lagged effects. Results indicate the importance of measuring quality of life in future investigations of PTSD treatment.

Anxiety sensitivity and depression: mechanisms for understanding somatic complaints in veterans with posttraumatic stress disorder

A study was conducted among 45 male veterans seeking inpatient treatment for posttraumatic stress disorder (PTSD) to test whether the relationship between PTSD and somatic complaints was accounted for by depression and anxiety sensitivity. Posttraumatic stress disorder symptom severity, depression symptom severity, and anxiety sensitivity were each positively and significantly related to veterans' self-reported severity of somatic complaints. Results of hierarchical regression analyses indicated that anxiety sensitivity and depression severity account for the relationship between PTSD and veterans' somatic complaints, suggesting PTSD influences somatic complaints by virtue of underlying symptoms of depression and anxiety sensitivity.

A pilot study of behavioral activation for veterans with posttraumatic stress disorder

A pilot study was conducted to investigate the feasibility and effectiveness of behavioral activation (BA) therapy for veterans with posttraumatic stress disorder (PTSD). Eleven veterans seeking treatment at a Veterans Administration outpatient PTSD clinic were enrolled in the study protocol, consisting of 16-weekly individual sessions of BA. Nine veterans completed the protocol, one participant completed 15 sessions, and one dropped out after one session. Clinician-rated PTSD symptom severity showed significant pre- to posttreatment improvement and was associated with a moderate effect size. A number of participants also were improved on measures of depression and quality of life, but changes did not reach statistical significance. Findings suggest that BA is a well-tolerated, potentially beneficial intervention for veterans with chronic symptoms of PTSD.

Improving the rates of quitting smoking for veterans with posttraumatic stress disorder

OBJECTIVE

Smoking is highly prevalent and refractory among people with posttraumatic stress disorder (PTSD). This study aimed to improve the rate of quitting smoking for veterans with PTSD by integrating treatment for nicotine dependence into mental health care.

METHOD

Smokers undergoing treatment for PTSD (N=66) were randomly assigned to 1) tobacco use treatment delivered by mental health providers and integrated with psychiatric care (integrated care) versus 2) cessation treatment delivered separately from PTSD care by smoking-cessation specialists (usual standard of care). Seven-day point prevalence abstinence was the primary outcome, measured at 2, 4, 6, and 9 months after random assignment. Data were analyzed by using a generalized estimating equations approach following the intent-to-treat principle.

RESULTS

Subjects assigned to integrated care were five times more likely than subjects undergoing the usual standard of care to abstain from smoking across follow-up assessment intervals (odds ratio=5.23). Subjects in the integrated care condition were significantly more likely than subjects in usual standard of care to receive transdermal nicotine and nicotine gum. They also received a greater number of smoking-cessation counseling sessions. Stopping smoking was not associated with worsening symptoms of PTSD or depression.

CONCLUSIONS

Smoking-cessation interventions can be safely incorporated into routine mental health care for PTSD and are more effective than treatment delivered separately by a specialized smoking-cessation clinic. Integrating cessation treatment into psychiatric care may have the potential for improving smoking quit rates in other populations of chronically mentally ill smokers.

Predicting Costs of Veterans Affairs Health Care in Gulf War Veterans with Medically Unexplained Physical Symptoms

Measures of post-traumatic stress disorder (PTSD) and depression were used to predict Veterans Affairs outpatient treatment costs among Persian Gulf War veterans with medically unexplained physical symptoms. Patients (N = 206) enrolled in a Veterans Affairs primary care clinic for Persian Gulf War veterans completed study assessments at the initial appointment or at a proximal follow-up visit. Costs of care for mental health, medical, and pharmacy services for these veterans were computed for the subsequent 6-month period. Depression and PTSD symptoms explained a significant share of variance in costs of mental health care and pharmacy services, after adjustment for covariates. None of the mental status measures was significantly related to costs of medical care. Models using global measures of mental health status were as robust as models using disorder-specific measures of PTSD and depression in predicting mental health care and pharmacy costs. The implications of these findings for anticipating costs of care for Persian Gulf War veterans are discussed.

Gulf War Veterans’ Illnesses: A Pilot Study of the Relationship of Illness Beliefs to Symptom Severity and Functional Health Status

This investigation describes the illness beliefs of veterans regarding their Gulf War-related health concerns and investigates the relationship of these illness beliefs to physical and mental health functioning. Gulf War veterans (N = 583) presenting for evaluation at a Veteran's Affairs and Department of Defense facility completed self-report measures of symptom-related beliefs, psychosocial distress, and functional status. Hierarchical multiple regression analyses were performed to determine the extent that symptom-related beliefs impacted symptom-reporting and functional status independent of demographic factors and psychiatric illness. Several beliefs predicted physical symptom reporting and functional impairment in physical health and mental health domains after controlling for demographic variables and psychiatric illness. Gulf War veterans' illness beliefs may impact clinical outcomes. Discussing illness beliefs and providing accurate information is an important component of medical care for Gulf War veterans.

Comparing traditional and Rasch analyses of the Mississippi PTSD Scale: revealing limitations of reverse-scored items

This study examined whether Rasch analysis could provide more information than true score theory (TST) in determining the usefulness of reverse-scored items in the Mississippi Scale for Posttraumatic Stress Disorder (M-PTSD). Subjects were 803 individuals in inpatient PTSD units at 10 VA sites. TST indicated that the M-PTSD performed well and could be improved slightly by deleting one item. Factor analysis using raw scores indicated that the reverse-scored items formed the second factor and had poor relationships with normally scored items. However, since item-total correlations supported their usefulness, they were kept. The subsequent Rasch analysis indicated that five of the seven worst fitting items were reverse-scored items. We concluded that using reversed items with disturbed patients can cause confusion that reduces reliability. Deleting them improved validity without loss of reliability. The study supports the use of Rasch analysis over TST in health research since it indicated ways to reduce respondent burden while maintaining reliability and improving validity.

Pre-operative short-course radiotherapy is associated with faecal incontinence after anterior resection

OBJECTIVE

To determine the contribution of total mesorectal excision (TME), short-course pre-operative radiotherapy (SCRT), the level of the anastomosis and other putative contributory factors to the incidence and degree of faecal incontinence after anterior resection of the rectum.

PATIENTS AND METHODS

Survivors of anterior resection of the rectum performed between February 1996 and February 2001, with a functioning anastomosis, were asked to complete a telephone questionnaire regarding their current bowel habit. Faecal incontinence was scored using the St. Mark's Incontinence Score.

RESULTS

The median age of 124 patients who completed the questionnaire was 76 years. Of these, 104 patients had neoplastic disease, 66 (53%) patients exhibited some degree of incontinence, median St. Marks' Score 6, interquartile range 3-10. There was a significant association between the anastomotic level, and the St. Mark's Score (P < 0.0001, linear regression). Male sex (P = 0.047), SCRT (P = 0.0014) and an anastomotic leak (P = 0.038) were associated with significantly higher incontinence scores. Age, splenic flexure mobilization, TME, anastomotic configuration or use of a temporary stoma had no detectable independent effect on incontinence scores.

CONCLUSIONS

Poor functional outcome following anterior resection was associated with a low anastomosis, SCRT or an anastomotic leak. The finding that SCRT was a predictor of postoperative incontinence emphasizes the need for stringent patient selection for this treatment modality.

Screening for post-traumatic stress disorder in female Veteran's Affairs patients: validation of the PTSD checklist

We evaluated the screening validity of a self-report measure for post traumatic stress disorder (PTSD), the PTSD Checklist (PCL), in female Veterans Affairs (VA) patients. All women seen for care at the VA Puget Sound Health Care system from October 1996-January 1999 (n=2,545) were invited to participate in a research interview. Participants (n=282) completed the 17-item PCL, followed by a gold standard diagnostic interview for PTSD, the Clinician Administered PTSD Scale (CAPS). Thirty-six percent of the participants (n=100) met CAPS diagnostic criteria for current PTSD. Receiver Operating Characteristic (ROC) analysis was used to evaluate the screening performance of the PCL. The area under the ROC curve was 0.86 (95% CI 0.82-0.90). A PCL score of 38 optimized the performance of the PCL as a screening test (sensitivity 0.79, specificity 0.79). The PCL performed well as a screening measure for the detection of PTSD in female VA patients.

The medical and surgical management of chronic anal fissure

Major advances in our understanding of the mechanisms involved in chronic anal fissure have allowed the introduction of many new medical therapies for this condition. The literature about current treatment modalities licensed for anal fissure and those novel therapies still under evaluation has been reviewed. These new treatments are examined in the context of traditional surgical management of the disease and a future treatment algorithm suggested.

Are veterans seeking Veterans Affairs' primary care as healthy as those seeking Department of Defense primary care? A look at Gulf War veterans' symptoms and functional status

OBJECTIVE

This study compared Gulf War veterans seeking VA primary care with Gulf War veterans seeking treatment from a Department of Defense primary care clinic on measures of physical symptoms, psychiatric complaints, and functional status. Additionally, the association between employment status and health was examined.

METHODS

Analysis was based on the responses of consecutive patients attending the Gulf War Primary Care clinics at either the VA Puget Sound Health Care System in Seattle, WA (N= 223), or the Walter Reed Army Medical Center in Washington, DC (N= 153), between March 1998 and September 1999.

RESULTS

After controlling for demographic variables, Gulf War veterans who sought VA care reported significantly more anxiety and PTSD symptoms than active duty military personnel. The groups did not differ on somatic complaints or summary scores from the SF-36. Employment status was significantly, independently, and consistently associated with greater psychiatric symptoms, physical symptoms, and decreased functional status.

CONCLUSIONS

Our findings reveal important differences in health status between veterans seeking primary care at a VA and a Department of Defense facility, differences that are in part related to employment status. Both groups report symptoms of psychiatric distress and decreased functional status, though VA patients are more impaired. Research findings based on clinical samples of veterans at VA sites may not generalize to Gulf War veterans still on active duty (and vice versa).

Biological markers and diagnostic accuracy in the genetics of posttraumatic stress disorder

Family and twin studies suggest a substantial genetic contribution to the etiology of posttraumatic stress disorder (PTSD). Identification of the nature of this genetic contribution should enhance understanding of the pathophysiology of PTSD and suggest improved therapeutic strategies for its treatment. However, a broadly defined phenotype, specific requirement for an environmental exposure and high frequency of comorbid psychiatric illness all complicate genetic studies of PTSD. It is likely that genetic heterogeneity, incomplete penetrance, pleiotropy and the involvement of more than one gene all constitute formidable obstacles to the genetic analysis of PTSD. One way to circumvent these problems is to perform genetic analysis of traits associated with PTSD, rather than PTSD itself, an approach that has been fruitful for other diseases with complex modes of inheritance. Hypothalamic-pituitary-adrenal axis hypofunction, physiologic markers of increased arousal, and increased acoustic startle response are all potential PTSD-associated traits that might be susceptible to genetic analysis. However, the capacity of these traits to distinguish PTSD from non-PTSD patients and their familial pattern must be better defined before they can be employed in genetic studies.

Clinician Attributions for Symptoms and Treatment of Gulf War–Related Health Concerns

BACKGROUND

Several clinical syndromes are defined solely on the basis of symptoms, absent an identifiable medical etiology. When evaluating and treating individuals with these syndromes, clinicians' beliefs might shape decisions regarding referral, diagnostic testing, and treatment. To assess clinician beliefs about the etiology and treatment of "Gulf War illness," we surveyed a sample of general internal medicine clinicians (GIMCs) and mental health clinicians (MHCs).

METHODS

Clinicians (77 GIMCs and 214 MHCs) at the Veterans Affairs Puget Sound Health Care System, Seattle, Wash, and the Veterans Affairs Medical Center in Portland, Ore, responded to a mailed survey of their beliefs about Gulf War illness.

RESULTS

Compared with GIMCs, MHCs were more likely to believe that Gulf War illness was the result of a "physical disorder" and that symptoms resulted from viruses or bacteria, immunizations, exposure to toxins, chemical weapons, or a combination of toxins and stress (P <.05). Conversely, GIMCs were more likely than MHCs to believe that Gulf War illness was a "mental disorder" and that symptoms were due to stress or posttraumatic stress disorder (P <.05). In addition, MHCs were more likely to endorse biological interventions to treat Gulf War illness (P <.01), whereas GIMCs were more likely to endorse psychological interventions.

CONCLUSIONS

Clinicians' beliefs about the etiology and effective treatment of Gulf War illness vary and thus might contribute to the multiple referrals often reported by Gulf War veterans. Health care models for Gulf War veterans and others with symptom-based disorders necessitate collaborative interdisciplinary approaches.

Effects of an outreach intervention on use of mental health services by veterans with posttraumatic stress disorder

OBJECTIVE

The study examined the effectiveness of an outreach intervention designed to increase access to mental health treatment among veterans disabled by chronic posttraumatic stress disorder (PTSD) and identified patient-reported barriers to care associated with failure to seek the treatment offered.

METHODS

Participants were 594 male Vietnam veterans who were not enrolled in mental health care at a Department of Veterans Affairs (VA) medical center but who were receiving VA disability benefits for PTSD. Half the sample was randomly assigned to an outreach intervention, and the other half was assigned to a control group. Veterans in the intervention group received a mailing that included a brochure describing PTSD treatment available at an urban VA medical center, along with a letter informing them about how to access care. Participants in the intervention group were subsequently telephoned by a study coordinator who encouraged them to enroll in PTSD treatment and who administered a survey assessing barriers to care.

RESULTS

Veterans in the intervention group were significantly more likely than those in the control group to schedule an intake appointment (28 percent versus 7 percent), attend the intake (23 percent versus 7 percent), and enroll in treatment (19 percent versus 6 percent). Several patient-identified barriers were associated with failure to seek VA mental health care, such as personal obligations that prevented clinic attendance, inconvenient clinic hours, and current receipt of mental health treatment from a non-VA provider.

CONCLUSIONS

Utilization of mental health services among underserved veterans with PTSD can be increased by an inexpensive outreach intervention, which may be useful with other chronically mentally ill populations.

Analysis of violent behavior in Vietnam combat veteran psychiatric inpatients with posttraumatic stress disorder

This study tested the hypothesis that male Vietnam veterans seeking inpatient treatment for PTSD (n = 228) exhibit more violent behavior compared with a mixed diagnostic group of male psychiatric inpatients without PTSD (n = 64) and a community sample of Vietnam veterans with PTSD not undergoing inpatient treatment (n = 273). Violent acts assessed included property destruction, threats without a weapon, physical fighting, and threats with a weapon. PTSD inpatients engaged in more types of violent behavior than both comparison conditions. Correlates of violence among PTSD inpatients included PTSD symptom severity and, to a lesser degree, measures of substance abuse. These findings justify routine assessment of violent behavior among inpatient with PTSD, as well as application of specialized interventions for anger dyscontrol and aggression.

Imitation and prior classroom contact as determinants of reciprocal self-disclosure

The reciprocity effect in self-disclosure research was tested by controlling for the effects of content imitation and prior degree of contact with the experimenter. Written self-disclosures and objective checklist responses were obtained from 165 subjects on a questionnaire soliciting their reasons for reading non-assigned books. The experimenter disclosed in writing to half the subjects his reasons for reading non-assigned books (these reasons matched two of the checklist reasons); the remaining subjects did not receive the experimenter's disclosure. No content imitation of the experimenter's self-disclosure was found in either checklist or essay responses. No reciprocity effect was found: the experimenter's disclosure and no-disclosure groups did not differ significantly in the length or intimacy of their written disclosures. However, subjects having prior contact with the experimenter as professor wrote longer and more personal essays than subjects unfamiliar with the experimenter, suggesting that the experimenter-subject relationship may be a potent variable in self-disclosure research.