1
|
Litschi MA, Lancaster SL, Linkh DJ, Renno S, Neal-Walden TA, Lawless CE, Breetz AA. Evaluating Suicide Risk Stratification in Outpatient Settings: A Vignette-Based Approach. Clin Psychol Psychother 2024; 31:e2965. [PMID: 38572772 DOI: 10.1002/cpp.2965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 04/05/2024]
Abstract
Suicide risk assessment and stratification are a key suicide prevention strategy in mental health care systems that treat military service members and veterans. The aim of the current mixed-method project was to address a gap in our knowledge as to how therapists make these important clinical decisions. This manuscript reports the results of a project during which six vignettes were developed reflecting varying levels of risk according to the Rocky Mountain MIRECC Risk Stratification Table. Mental health therapists were asked to evaluate the risk level of each vignette, determine a treatment disposition, and provide justification for their ratings. The results of the study indicate that therapists can reliably evaluate risk, but that treatment planning tended to be based more on vignette-specific factors than essential features of the risk model. The qualitative findings revealed variations in the definition and perception of foundational concepts, suggesting a need for further research and training in these domains. Overall, the results support the use of vignettes as a method to assess clinical decision-making and provide several areas for further training and research.
Collapse
Affiliation(s)
- Melissa A Litschi
- Institute for Quality, Cohen Veterans Network, Stamford, Connecticut, USA
| | - Steven L Lancaster
- Institute for Quality, Cohen Veterans Network, Stamford, Connecticut, USA
| | - David J Linkh
- Institute for Quality, Cohen Veterans Network, Stamford, Connecticut, USA
| | - Stephanie Renno
- Institute for Quality, Cohen Veterans Network, Stamford, Connecticut, USA
| | | | - Claire E Lawless
- Institute for Quality, Cohen Veterans Network, Stamford, Connecticut, USA
| | - Alisa A Breetz
- Institute for Quality, Cohen Veterans Network, Stamford, Connecticut, USA
| |
Collapse
|
2
|
Pisani BA, Mullen GM, Malinowska K, Lawless CE, Mendez J, Silver MA, Radvany R, Robinson JA. Plasmapheresis with intravenous immunoglobulin G is effective in patients with elevated panel reactive antibody prior to cardiac transplantation. J Heart Lung Transplant 1999; 18:701-6. [PMID: 10452347 DOI: 10.1016/s1053-2498(99)00022-4] [Citation(s) in RCA: 109] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with a PRA >10% are considered to be at greater risk for the development of not only acute cellular and humoral rejection but also increased mortality when compared to nonsensitized patients following transplantation. All patients with a PRA >10% at our institution are treated with plasmapheresis and intravenous immunoglobulin G immediately prior to cardiac transplantation. METHODS Sixteen (Group 1) of 118 patients awaiting cardiac transplantation were found to be sensitized. These patients underwent plasmapheresis followed by 20 gm of intravenous immunoglobulin G (IVIG) immediately prior to cardiac transplantation. Group 1 was compared to the remaining 102 patients with a PRA <10% (Group 2). RESULTS Despite more patients in Group 1 having a positive crossmatch, pulmonary hypertension, and requiring mechanical circulatory support, there was no statistically significant difference in length of stay or mortality at a mean follow-up of 21.6+/-15.0 months. There was no difference in the occurrence of mild, moderate or severe cellular rejection or humoral rejection in these sensitized patients when compared to Group 2. CONCLUSIONS Pretransplant plasmapheresis followed by intravenous immunoglobulin G may be an effective therapy that obviates the need for a prospective crossmatch and allows sensitized patients to undergo cardiac transplantation. There is no increase in the post transplant length of stay, occurrence of rejection or short term mortality. Long term follow up is necessary to evaluate whether there is a difference in the development of late rejection, transplant vasculopathy and survival.
Collapse
Affiliation(s)
- B A Pisani
- Department of Cardiology, Loyola University of Chicago at the Medical Center, Maywood, Illinois 60153, USA
| | | | | | | | | | | | | | | |
Collapse
|
3
|
Mullen GM, Silver MA, Malinowska K, Lawless CE, Lichtenberg RC, Barath PC, O'Keefe PJ, Robinson JA, Yeldandi V. Effective oral ganciclovir prophylaxis against cytomegalovirus disease in heart transplant recipients. Transplant Proc 1998; 30:4110-2. [PMID: 9865316 DOI: 10.1016/s0041-1345(98)01361-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The presented data show the combined sequential use of i.v. G for 14 days followed by PO G for 90 days is a much more effective prophylaxis for CMVD after heart transplantation than use of i.v. G for 14 days followed by PO A for 90 days. A need for hospitalization due to CMVD is significantly reduced by this new strategy. The follow-up in group II is shorter than in group I but is now at least 6 months in group II, without any new cases in the first 6 months after cardiac transplantation. Some currently unknown adverse effect of prolonged PO G, which may be present, is not identified in this analysis.
Collapse
Affiliation(s)
- G M Mullen
- Loyola University Health System, Department of Medicine/Division of Cardiology, Maywood, Illinois 60153, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Erickson KW, Costanzo-Nordin MR, O'Sullivan EJ, Johnson MR, Zucker MJ, Pifarré R, Lawless CE, Robinson JA, Scanlon PJ. Influence of preoperative transpulmonary gradient on late mortality after orthotopic heart transplantation. J Heart Transplant 1990; 9:526-37. [PMID: 2231091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
We reviewed the transpulmonary gradient, pulmonary arterial systolic pressure, pulmonary vascular resistance (Wood units), and pulmonary vascular resistance index (Wood units X Body surface area), recorded preoperatively in 109 recipients aged 44.6 +/- 13.5 (mean +/- SD) years who underwent orthotopic heart transplantation between March 1984 and March 1988, to identify which measure of pulmonary hypertension most accurately predicts poor outcome after orthotopic heart transplantation. These recipients were followed up as many as 57 (24.7 +/- 14.5) months after their transplant procedure. Preoperative hemodynamic values were as follows: transpulmonary gradient, 10.4 +/- 4.7 mm Hg; pulmonary artery systolic pressure, 53.6 +/- 14.8 mm Hg; pulmonary vascular resistance, 2.7 +/- 1.8 Wood units; pulmonary vascular resistance index, 4.9 +/- 2.7. Nineteen recipients died within 1 year after orthotopic heart transplantation. Causes of death were acute rejection (8), chronic rejection (1), infection (2), nonspecific orthotopic heart transplant failure (4), bowel ischemia (1), pancreatitis (1), lymphoma (1), and liver failure (1). Preoperative pulmonary arterial systolic pressure, pulmonary vascular resistance, and pulmonary vascular resistance index were not predictive of 1-month, 6-month, or 1-year mortality. One-month mortality rates of orthotopic heart transplant recipients with transpulmonary gradient greater than or equal to 12 mm Hg and of those with transpulmonary gradient less than 12 mm Hg were not significantly different (11% vs 3%; p = 0.12). The 6-month mortality rate of orthotopic heart transplant recipients with transpulmonary gradient greater than or equal to 12 mm Hg, however, was five times greater than that of orthotopic heart transplant recipients with transpulmonary gradient less than 12 mm Hg (24% vs 5%; p = 0.003), and 12-month mortality of orthotopic heart transplant recipients with transpulmonary gradient greater than or equal to 12 mm Hg was increased sevenfold when compared with that of orthotopic heart transplant recipients with transpulmonary gradient less than 12 mm Hg (36% vs 5%; p = 0.0005). These results suggest that presently used measures of pulmonary hypertension do not predict mortality in the first month after orthotopic heart transplantation, but that elevated preoperative transpulmonary gradient is associated with a significant increase in mortality at 6 and 12 months after orthotopic heart transplantation. Prospective randomized trials are needed to determined whether extended preload and afterload reduction before and/or after transplant will favorably influence long-term prognosis of orthotopic heart transplant recipients with elevated preoperative transpulmonary gradient.
Collapse
Affiliation(s)
- K W Erickson
- Section of Cardiology, Hines Veterans Administration Medical Center, Ill
| | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Giardina JJ, Malinowska K, Pifarre R, Hwang MH, Robinson JA, Loeb HS, Lawless CE. Use of cyclosporine in the mouse heterotopic heart transplant model. J Heart Transplant 1990; 9:106-13. [PMID: 2319367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We refined the mouse ear-heart transplant model developed by Fulmer and coworkers and tested cyclosporine as a sole immunosuppressive agent in this model. Three-week-old CBA mice were used as heart recipients, and unsexed newborn BALB/c mice were used as heart donors. The heart grafts were examined for visible pulsations at 10-fold to 20-fold magnification daily for the first 10 days and every other day thereafter. Graft electrocardiograms were also obtained on the same schedule. Preliminary studies had established that a dose of 15 mg/kg/day was the optimal cyclosporine dose in our model. This dose was administered subcutaneously to each of two treatment groups. Group 2 received this dose for the entire 30-day experimental period. Group 3 received this dose for the first 16 days of the experimental period. Group 1 consisted of allografts receiving no immunosuppression. Group 1 grafts showed evidence of initial successful engraftment by day 7; however, by day 13 none of the grafts remained viable. In group 2, 19 of 23 grafts remained viable for the entire experimental period. In group 3, all of the grafts remained viable until day 17 (after day 16 cyclosporine was discontinued) and rapidly lost evidence of viability thereafter. By day 21, none of the grafts in group 3 remained viable. Survival curves for the three groups as determined by electrocardiogram and visible pulsations were constructed, and the differences between the curves were significant (p = 0.001). The results of this study demonstrate the potential usefulness of the ear-heart transplantation model in screening immunosuppressive agents.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- J J Giardina
- Loyola University Stritch School of Medicine, Maywood, Ill
| | | | | | | | | | | | | |
Collapse
|
6
|
|
7
|
Zbilut JP, Murdock DK, Lawson L, Lawless CE, Von Dreele MM, Porges SW. Use of power spectral analysis of respiratory sinus arrhythmia to detect graft rejection. J Heart Transplant 1988; 7:280-8. [PMID: 3049978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Some evidence has suggested that graft rejection in heart transplant recipients is accompanied by sinus node dysfunction. To test this hypothesis the electrocardiograms of 21 orthotopic heart transplant recipients receiving cyclosporine were recorded at regularly scheduled biopsies. This resulted in 105 good quality recordings of at least 10 minutes each. All exhibited normal sinus rhythm. These recordings were then processed through patented digital routines that calculated the power spectrum of the RR intervals. All recordings exhibited Mayer wave and respiratory sinus arrhythmia (RSA) periodicities. Peak spectral power of RSA (PSP-RSA) demonstrated good repeatability at 2 weeks (r = 0.81). A paired t test comparing the baseline PSP-RSA in eight subjects who experienced rejection episodes with their individual average PSP-RSA during periods of rejection revealed a significant decrease (p = 0.039). As a global measure, PSP-RSA greater than 1 (natural logarithmic scales) demonstrated a sensitivity of 1.0, specificity of 0.42, positive predictive value of 0.22, and negative predictive value of 1.0. These tentative results demonstrate that PSP-RSA may be a sensitive, noninvasive marker for graft rejection of heart transplant patients receiving cyclosporine for immunosuppression. A larger, more extensive study needs to be conducted to confirm these results.
Collapse
Affiliation(s)
- J P Zbilut
- Department of OR/Surgical Nursing, Rush University, Chicago, Illinois 60612
| | | | | | | | | | | |
Collapse
|
8
|
Uretsky BF, Lawless CE, Verbalis JG, Valdes AM, Kolesar JA, Reddy PS. Combined therapy with dobutamine and amrinone in severe heart failure. Improved hemodynamics and increased activation of the renin-angiotensin system with combined intravenous therapy. Chest 1987; 92:657-62. [PMID: 3308346 DOI: 10.1378/chest.92.4.657] [Citation(s) in RCA: 62] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The hemodynamic and hormonal responses to dobutamine alone and with the addition of amrinone were studied in ten patients with severe heart failure. Dobutamine significantly increased heart rate, cardiac index, and stroke volume index and significantly decreased mean right atrial and systemic arterial pressures and systemic and pulmonary vascular resistance. The addition of amrinone further decreased significantly mean right atrial, pulmonary arterial, and pulmonary arterial wedge pressures and systemic vascular resistance, while heart rate rose. The response of the cardiac index was variable, increasing in seven and decreasing in three patients. Plasma renin activity rose significantly with dobutamine and further increased with amrinone. We conclude that in most patients with severe heart failure, amrinone, when combined with dobutamine, improves hemodynamics. The further increase in heart rate, variable effects on the cardiac index, and marked activation of the renin-angiotensin system suggest caution and potential limitations in the use of this combination.
Collapse
Affiliation(s)
- B F Uretsky
- Department of Medicine, University of Pittsburgh
| | | | | | | | | | | |
Collapse
|
9
|
|
10
|
Murdock DK, Collins EG, Lawless CE, Molnar Z, Scanlon PJ, Pifarre R. Rejection of the transplanted heart. Heart Lung 1987; 16:237-45. [PMID: 3553082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
11
|
Murdock DK, Lawless CE, Collins E. More on influenza A and pneumonitis. IMJ Ill Med J 1987; 171:18. [PMID: 2879819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|
12
|
Murdock DK, Lawless CE, Loeb HS, Scanlon PJ, Pifarré R. The effect of heart transplantation on Cheyne-Stokes respiration associated with congestive heart failure. J Heart Transplant 1986; 5:336-7. [PMID: 3305828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Cheyne-Stokes respiration occasionally accompanies the terminal stages of congestive heart failure. We describe this association in a patient requiring heart transplantation. The gradual abatement of Cheyne-Stokes respiration after transplantation supports the delayed circulatory time theory as the mechanism for Cheyne-Stokes respiration in these patients.
Collapse
|
13
|
Pacold I, Hwang MH, Lawless CE, Diamond P, Scanlon PJ, Loeb HS. Effects of indomethacin on coronary hemodynamics, myocardial metabolism and anginal threshold in coronary artery disease. Am J Cardiol 1986; 57:912-5. [PMID: 3515896 DOI: 10.1016/0002-9149(86)90729-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The effects of orally administered indomethacin or placebo on coronary hemodynamics were studied in 23 patients with coronary artery disease. After indomethacin administration the systemic arterial pressure increased by 12 +/- 4% and the myocardial oxygen consumption by 24 +/- 11%. Coronary sinus flow did not change and coronary vascular resistance increased slightly. Oxygen saturation of the arterial blood did not change, but coronary sinus saturation decreased substantially. Hemodynamic values returned to normal 150 minutes after administration of indomethacin. During rapid atrial pacing, coronary sinus flow increased 79 +/- 14% above the rest value when pacing was done before indomethacin administration; only a 56 +/- 12% increase was seen when pacing was repeated after indomethacin. Peak heart rate achieved during atrial pacing, severity of angina and the degree of ST-segment depression were not altered by indomethacin treatment. Orally administered indomethacin has a mild coronary vasoconstrictive effect that does not interfere substantially with the expected increase in myocardial blood flow during rapid atrial pacing. Anginal threshold is not altered by orally administered indomethacin.
Collapse
|
14
|
|
15
|
Lawless CE, Sapsford RN, Pallis C, Hallidie-Smith KA. Ischemic injury to the brachial plexus following subclavian flap aortoplasty. J Thorac Cardiovasc Surg 1982; 84:779-82. [PMID: 7132418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
An ischemic brachial plexus lesion developed 6 days postoperatively in an infant undergoing subclavian flap aortoplasty for coarctation. To our knowledge, this complication has never been previously reported. Types of postoperative brachial plexus lesions are discussed. The blood supply to the brachial plexus is described. An ischemic lesion of the plexus should be suspected when brachial palsy follows operations that involve sacrifice of the subclavian artery.
Collapse
|
16
|
Lawless CE, Smith EE, Hallidie-Smith K, Sapsford RN. The modified blalock-taussig shunt using microporous expanded polytetrafluoroethylene (PTFE). J Cardiovasc Surg (Torino) 1982; 23:287-92. [PMID: 7107686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
From May 1977 to February 1981, 36 modified Blalock-Taussig shunts were performed in 34 patients for a variety of cyanotic congenital cardiac lesions. Microporous expanded PTFE was utilised as a conduit between the subclavian artery and the ipsilateral pulmonary artery. Graft diameter was 4 mm in 15 cases, 6 mm in 17 cases, and 8 mm in the remaining 4. Age at time of operation ranged from one day to 22 years. Fourteen shunts were performed in infants less than one year old. Overall operative mortality was 5.5 per cent. There were 6 shunt failures (16.6%) and all were the smallest diameter graft. Overall actuarial shunt survival at 2 years was 81.2 per cent. This shunt has all the advantages of the original Blalock-Taussig procedure. In addition, it preserves the integrity of the subclavian artery and minimizes the technical problems associated with the classical shunt. It is the procedure of choice at our hospital.
Collapse
|