A Randomized Controlled Trial Evaluating the Effectiveness of Supported Employment Integrated in Primary Care

OBJECTIVES

Mental health issues can cause serious problems in occupational functioning, including higher rates of unemployment. Individual placement and support (IPS) is an evidence-based supported employment intervention that is typically integrated within a mental health setting; however, many primary care patients view referral to a mental health clinic as stigmatizing. Thus, this study examined whether delivery of IPS in a primary care setting provides an effective treatment option and avoids unnecessary delays in obtaining competitive employment.

METHODS

U.S. military veterans (N=119) who had a diagnosis in a broad range of nonpsychotic psychiatric disorders and who were receiving care from Veterans Health Administration (VHA) patient-aligned care teams were prospectively randomly assigned to IPS (N=58) or standard VHA non-IPS vocational rehabilitation (VR) (N=61). The primary outcome was achievement of steady worker status, defined as holding a competitive job for ≥6 months of the 12-month follow-up.

RESULTS

As hypothesized, a significantly greater proportion of IPS participants achieved steady worker status (45%), compared with VR participants (25%) (p=0.02; odds ratio=2.49, 95% confidence interval=1.14-5.43). On average, the IPS participants worked significantly more weeks (p=0.003) and earned significantly more income (p=0.033) from competitive jobs, compared with VR participants.

CONCLUSIONS

The results provide supporting evidence for offering IPS within primary care with the aim of restoring meaningful and sustained competitive employment for veterans living with a mental disorder. Such modifications could improve veterans' vocational outcomes, moving a significantly greater number of disabled veterans back to full and productive lives in the community.

The methods and baseline characteristics of a VA randomized controlled study evaluating supported employment provided in primary care patient aligned care teams

BACKGROUND

This article describes the design and baseline sample of a single-site trial comparing Individual Placement and Support (IPS) supported employment delivered within a Veterans Health Administration (VHA) primary care Patient Aligned Care Team (PACT) to treatment-as-usual vocational rehabilitation (TAU-VR) that includes transitional work.

METHODS

Unemployed U.S. military veterans receiving care in a VHA PACT who were seeking competitive work, otherwise eligible for vocational rehabilitation, and diagnosed with a mental health condition other than a psychotic or bipolar I disorder were prospectively randomized to receive either IPS or TAU-VR. Employment outcomes and measures of quality of life, self-esteem, and community reintegration are being collected for 12 months.

RESULTS

The participant sample (n = 119) is comprised of 17.6% female, 73.1% African-Americans, and 1.7% Hispanic. Average age is 38.2 (SD ± 8.41) years; 80.7% served in the military since 2001; 78% are receiving or applying for U.S. Department of Veterans Affairs (VA) service-connected disability; 26.9% have not held a competitive job in the past 3 years; and the average length of pre-randomization unemployment is 1.4 (SD ± 2.3) years.

CONCLUSIONS

Unique design features include evaluating the efficacy of evidenced-based IPS within the primary care setting, having broad diagnostic eligibility, and defining the primary outcome criterion as "steady employment", i.e. holding a competitive job for ≥26 weeks of the 12-month follow-up period. The findings illustrate the characteristics of a primary care veteran sample in need of employment services.

TRIAL REGISTRATION

www.clinicaltrials.gov Identifier: NCT02400736.

Effect of Evidence-Based Supported Employment vs Transitional Work on Achieving Steady Work Among Veterans With Posttraumatic Stress Disorder: A Randomized Clinical Trial

IMPORTANCE

Posttraumatic stress disorder (PTSD) often interferes with a person's ability to obtain or sustain employment, which leads to premature exit from the labor force and reduced income.

OBJECTIVE

To determine whether individual placement and support (IPS)-supported employment is more effective than stepwise vocational rehabilitation involving transitional work assignments at helping veterans with PTSD attain steady, competitive employment.

DESIGN, SETTING, AND PARTICIPANTS

The Veterans Individual Placement and Support Toward Advancing Recovery (VIP-STAR) study was a prospective, multisite, randomized clinical trial that included 541 unemployed veterans with PTSD at 12 Veterans Affairs medical centers. Data were collected from December 23, 2013, to May 3, 2017. Intent-to-treat analysis was performed.

INTERVENTIONS

Individual placement and support is a supported employment intervention that rapidly engages people with disabilities in community job development to obtain work based on their individual job preferences. Transitional work is a stepwise vocational rehabilitation intervention that assigns people temporarily to noncompetitive jobs as preparation for competitive employment in the community.

MAIN OUTCOMES AND MEASURES

A priori hypotheses were that, compared with those in transitional work, more participants in the IPS group would become steady workers (primary) and earn more income from competitive jobs (secondary) over 18 months. Steady worker was defined as holding a competitive job for at least 50% of the 18-month follow-up period.

RESULTS

A total of 541 participants (n = 271 IPS; n = 270 transitional work) were randomized. Mean (SD) age was 42.2 (11) years; 99 (18.3%) were women, 274 (50.6%) were white, 225 (41.6%) were African American, and 90 (16.6%) were of Hispanic, Spanish, or Latino ethnicity. More participants in the IPS group achieved steady employment than in the transitional work group (105 [38.7%] vs 63 [23.3%]; odds ratio, 2.14; 95% CI, 1.46-3.14). A higher proportion of IPS participants attained any competitive job (186 [68.6%] vs 154 [57.0%]; P = .005) and had higher cumulative earnings from competitive jobs (median [interquartile range] $7290 [$23 174] in IPS vs $1886 [$17 167] in transitional work; P = .004).

CONCLUSIONS AND RELEVANCE

This multisite trial demonstrated significantly greater effectiveness of IPS-supported employment over stepwise transitional work vocational rehabilitation for veterans living with chronic PTSD. The results provide supporting evidence for increasing access to IPS for veterans living with PTSD.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01817712.

Veterans individual placement and support towards advancing recovery: Methods and baseline clinical characteristics of a multisite study

OBJECTIVE

This article describes the methodology and the baseline characteristics of veterans with posttraumatic stress disorder (PTSD) enrolled in a multisite trial comparing supported employment individual placement and support (IPS) to a stepwise vocational transitional work program (TWP).

METHOD

The Veterans Affairs Cooperative Studies Program randomized 541 veterans with PTSD across 12 Veterans Affairs Medical Centers to either IPS or TWP. Demographic and clinical characteristics were evaluated at baseline.

RESULTS

Participants averaged 42 (SD ± 11) years of age and had PTSD for 13 (SD ± 11) years. The group was comprised of 18% female, 42% African Americans, and 16% Latino participants. Approximately 60% of participants served in the military since 2001, 89% were receiving or applying for service-connected disability, 60% had PTSD from nonsexual combat-related trauma, and 17% had PTSD from military sexual trauma. One third had not held a competitive job in the past 3 years; the average length of unemployment was 2.8 (SD ± 4) years. Unique study features included the focus on veterans with PTSD, a comparison of a promising practice with a usual-care practice, and the outcome criterion of achieving steady competitive employment. Conclusions and Implication for Practice: This study is the first large-scale randomized trial of IPS in a PTSD population. These baseline findings illustrate the characteristics of the study sample, which are representative of a veteran population in need of vocational rehabilitation services and can be used to help guide the implementation of tailored veteran-centered programs. (PsycINFO Database Record

Vocational rehabilitation in spinal cord injury: what vocational service activities are associated with employment program outcome?

BACKGROUND

Designing effective vocational programs for persons with spinal cord injury (SCI) is essential for improving return to work outcome following injury. The relationship between specific vocational services and positive employment outcome has not been empirically studied.

OBJECTIVE

To examine the association of specific vocational service activities as predictors of employment.

METHOD

Secondary analysis of a randomized, controlled trial of evidence-based supported employment (EBSE) with 12-month follow-up data among 81 Veteran participants with SCI.

RESULTS

Primary activities recorded were vocational counseling (23.9%) and vocational case management (23.8%). As expected, job development and employment supports were the most time-consuming activities per appointment. Though the amount of time spent in weekly appointments did not differ by employment outcome, participants obtaining competitive employment averaged significantly more individual activities per appointment. Further, for these participants, job development or placement and employment follow-along or supports were more likely to occur and vocational counseling was less likely to occur. Community-based employment services, including job development or placement and employment follow-along or supports as part of a supported employment model, were associated with competitive employment outcomes. Office-based vocational counseling services, which are common to general models of vocational rehabilitation, were associated with a lack of employment.

CONCLUSIONS

Vocational services that actively engage Veterans with SCI in job seeking and acquisition and that provide on-the-job support are more likely to lead to employment than general vocational counseling that involves only job preparation.

Impact of social challenges on gaining employment for veterans with posttraumatic stress disorder: an exploratory moderator analysis

OBJECTIVE

To explore whether psychosocial challenges impact effects of vocational rehabilitation in Veterans with Posttraumatic Stress Disorder (PTSD).

METHODS

A post hoc exploratory analysis of possible moderators of treatment was conducted on outcomes from a randomized, controlled trial of Individual Placement and Support in Veterans with PTSD.

RESULTS

When examining groups within each moderator, there was a greater IPS supportive employment benefit in gaining competitive employment for those with inadequate transportation (number needed to treat [NNT] = 1.5) and inadequate housing (NNT = 1.5) compared with the main finding of the pilot study (NNT = 2.07). Compared with the main finding of the pilot study, there was no greater advantage of IPS for those with adequate transportation (NNT = 2.4) or adequate housing (NNT = 2.4). Compared with the main finding in the pilot study, those without a family care burden had a greater benefit from IPS (NNT = 1.4) and those with family care burden had a reduced treatment effect (NNT = 3.3).

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

These results are exploratory and are not intended to guide clinical decision-making, but rather offer a potentially useful strategy in the design of larger trials of IPS.

A randomized controlled trial of supported employment among veterans with posttraumatic stress disorder

OBJECTIVE

Posttraumatic stress disorder (PTSD) is a potentially disabling mental illness that can cause occupational dysfunction. Although vocational rehabilitation is often prescribed for patients with PTSD, standard vocational services are far from adequate in helping them obtain and maintain competitive employment. This study is the first to examine the outcome of evidence-based supported employment for veterans with PTSD.

METHODS

Unemployed veterans with PTSD were randomly assigned to either individual placement and support (IPS) supported employment (N = 42) or a Veterans Health Administration Vocational Rehabilitation Program (VRP) treatment as usual (N = 43). Employment rates and occupational outcomes were followed for 12 months.

RESULTS

During the 12-month study, 76% of the IPS participants gained competitive employment, compared with 28% of the VRP participants (number needed to treat = 2.07; χ(2) = 19.84, df = 1, p<.001). Veterans assigned to IPS also worked substantially more weeks than those assigned to VRP (42% versus 16% of the eligible weeks, respectively; Mann-Whitney z test p<.001) and earned higher 12-month income (mean ± SD income of $9,264 ± $13,294 for IPS versus $2,601 ± $6,009 for VRP; Mann-Whitney z test p<.001) during the 12-month period.

CONCLUSIONS

Veterans with PTSD who received IPS were 2.7 times more likely to gain competitive employment than those who received VRP. Because work is central to recovery, these results should assist stakeholders in planning improved services for veterans with PTSD.

Frequency rhythmic electrical modulation system (FREMS) on H-reflex amplitudes in healthy subjects

AIM

Changes in the amplitude of Hoffmann reflex (H-reflex) may reflect variations in the characteristics of the largely monosynaptic circuitry that is explored and are a possible target for diagnostic and physical therapeutic intervention. However, previous attempts to induce predictable changes in the H-reflex amplitude by transcutaneous electrical nervous stimulation (TENS) have generally failed. Previous workers applied fixed frequency in the low- (2-5 Hz) or in the high- (100 Hz) field, but they did not attempt to vary frequency and/or impulse duration in time.

METHODS

We evaluated the effect of a new type of painless electric stimulation, i.e. frequency rhythmic electrical modulation system (FREMS). FREMS is characterized by the use of transcutaneous electric pulses with sequentially modulated frequency (f: 1-39 Hz) and width (w: 10-40 micro s) at constant, perceptive threshold voltage (approximately 150 V). FREMS was applied at the abductor hallucis muscle (AHM), as conditioning stimulus of the H-reflex which was recorded ipsilaterally at the soleus muscle, according to the classic method, in 10 normal volunteers (age range 21-40 years).

RESULTS

H-reflex amplitude was substantially decreased (-50%) during FREMS and H-reflex amplitude variations were influenced by w/f variation in time during FREMS subphase C in a predictable way (r(2)=0.43; P<0.001). Our results suggest an effective ability of FREMS to modulate H reflex amplitude.

CONCLUSIONS

The ability to achieve large and predictable changes of the H-reflex amplitude simply by modulating both frequency and duration of a conditioning painless electrical stimulation offers new possibilities for the treatment of diseases characterized by motoneuron excitability abnormalities.

A simple method to find a robust output feedback controller by random search approach

This paper presents a simple but effective method for finding a robust output feedback controller via a random search algorithm. The convergence of this algorithm can be guaranteed. Moreover, the probability to find a solution as well as the number of random trials can be estimated. The robustness of the closed-loop system is improved by the minimization of a given cost function reflecting the performance of the controller for a set of plants. Simulation studies are used to demonstrate the effectiveness of the proposed method.

Diagnosis of the industrial systems by fuzzy classification

The aim of this paper is to present a classifier based on a fuzzy inference system. For this classifier, we propose a parametrization method which is not necessarily based on an iterative training. This approach can be seen as a pre-parametrization which allows the determination of the rules base and the parameters of the membership functions. We also present a continuous and derivable version of the previous classifier and suggest an iterative learning algorithm based on a gradient method. An example using the learning basis IRIS, which is a benchmark for classification problems, is presented showing the performances of this classifier. Finally this classifier is applied to the diagnosis of a dc motor showing the effectiveness of this method.

A new robotic endoscope manipulator. A preliminary trial to evaluate the performance of a voice-operated industrial robot and a human assistant in several simulated and real endoscopic operations

We report our learning experience in simulated and real surgical tasks with a new voice-controlled robotic endoscope manipulator: an industrial robot with the tool-holder arm modified to support the optic and camera. The manipulator control-card programs have been rewritten to meet the needs of endoscopic surgeons. For this preliminary work, systems engineers with an additional monitor monitored, recorded, and compared the percentage effectiveness and precision of the responses of the robotic and human assistant to successive oral commands during the several different experimental surgical tasks. Simultaneously, to help develop this voice-commanded system for future, more precise robotic manipulation of surgical instruments, they measured the cartesian and spherical coordinates of successive positions of the optic. In unexpectedly difficult experimental conditions, the tireless robot proved more precise and effective than the demonstrably fatigable human: the steadier screen images of the robotic manipulations helped the surgeon tie knots in 7-0 sutures.

Clustering of autoimmune thyroid diseases in children and adolescents: a study of 66 families

Autoimmune thyroid diseases (AITD) are known to be clustered in families, but to what extent this occurs in childhood and adolescence is not well defined. In order to establish the prevalence of AITD in the siblings of affected children and adolescents, we examined 73 siblings from 66 families selected on the basis of a pediatric index patient. Sixty-six families, including a total of 146 offspring, were selected on the basis of diagnosis of chronic lymphocytic thyroiditis (CLT) (n = 55) or Graves' disease (GD) (n = 11). Among the 73 siblings examined, 20 new cases of CLT (27%) were detected. L-Thyroxine therapy was required in 4/20. History of AITD was recorded in 24/66 mothers (36%), and in two fathers. Overall in these families, considering both the index patients and the new patients, 86/141 (61%) children and adolescents were affected with AITD, with a female/male ratio of 3.3:1. Our study confirms that AITD clusters in families with a high prevalence in the siblings of affected children and adolescents. These children should be followed in order to avoid undiagnosed hypothyroidism. Prospective studies are warranted to identify predictive factors for overt thyroid disease.

Preperitoneal hernioplasty performed with needlescopic instruments (microlaparoscopy)

We treated a series of 30 patients who had a Nyhus type II, III, or IV inguinal hernia without associated pathology by laparoscopic surgery using 2-mm surgical instruments and a modified preperitoneal Dulucq technique. A 30 degrees optic was used, and the repair was reinforced by an accordion-folded, polypropylene mesh introduced through a 10-mm optic needleport. There were no postoperative complications, and all patients were discharged 24 hours after operation. At 6 months there has been no recurrence of hernia. It was evident that the 2-mm procedure produced less surgical trauma.

Simultaneous occurrence of Hodgkin's disease, nodal Langerhans' cell histiocytosis and multiple myeloma IgA(kappa)

A 35-year-old man suffered simultaneously from nodular sclerosis Hodgkin's disease (HD), Langerhans' cell histiocytosis and multiple myeloma (MM). There was no prior history of irradiation or chemotherapy, and clinically the lymphoma was confined to cervical lymph nodes. Immunohistochemically, neoplastic lymphoma cells reacted with CD15 and CD30 markers. The patient's bone marrow exhibited a diffuse infiltration by rather atypical plasma cells showing kappa immunoglobulin light-chain restriction. At 14 months after the diagnosis, after autologous bone marrow transplantation, the clinical evolution is favourable with complete remission of the diseases. This is the first time that the coexistence of these three haematological disorders has been discussed, and only the fourth documented case of simultaneous HD and MM. Speculations about the significance of this finding are discussed.

A new case of Ambras syndrome associated with a paracentric inversion (8) (q12; q22)

Ambras syndrome (AS) is a special form of congenital universal hypertrichosis described for the first time by Baumeister et al. (1). This form differs from other forms of congenital hypertrichosis in the pattern of hair distribution and its associated anomalies. The molecular-genetic cause of AS is unknown; the association of AS with a pericentric inversion (8) (p11.2; q22) described in the case of Baumeister so far has been unique in the literature. This report is the tenth with clinical signs of AS so far described in the literature and the second with an inversion in chromosome 8 and the first with evaluation of peripheral androgens. The new-born girl presented with abundant and dark hair on the face and ears, on the shoulders and on the arms; the other parts of the body were covered with fine, lightly pigmented hair. The face showed many dysmorphic features. Chromosome analysis showed a paracentric inversion of one chromosome 8. The breakpoints were localised at q12 and q22. The parental karyotypes were normal. Laboratory investigation showed normal plasma levels of testosterone, androstenedione (A), 17-hydroxyprogesterone, dehydroepiandrosterone-sulphate (DHA-S), free testosterone (FT), dihydrotestosterone (DHT) and 3alpha-androstanediol-glucuronide (3AG). Here we report a chromosomal inversion similar to that found previously not associated with alterations in androgen plasma levels.

[Cytogenetic alterations found by chromosome analysis and fish technique in two patients with variant chronic lymphocytic leukemia]

Chromosomal studies in CLL have yielded poorer results than in other blood diseases because of the low mitotic index of the B cells. The FISH technique is a very useful tool for trisomy 12 detection in interphase nuclei in CLL, although this method cannot be a substitutive for conventional cytogenetics. The FISH technique was applied in two cases of CLL by means of satellite DNA probing specific for chromosome 12 according to the Oncor S 1370-CF kit protocol. Trisomy 12 was detected, along with other chromosomal abnormalities secondary to this trisomy. Both patients had lymphocyte counts lower than 5.0 x 10(9)/L and their peripheral blood immunophenotype showed 58% lymphocytes with lambda sIg of medium density, co-expressing CD5 and unable to form rosettes with mouse red-cells. Patient no. 1 was 46,XY/47,XY + 12/47,XY + 12,5q-, and patient no. 2 was 46,XX/47,XX + 12,14q-. The presence of secondary anomalies could explain the special clinico-haematological picture, characterised by low lymphocytosis and presence of irregular nuclei in mature lymphocytes, along with the lack of CD23 expression and rosette formation with mouse red-cells. FISH technique combined with chromosome analysis may prove a useful means for diagnosing and recognising variants or specific entities within low-grade lymphoproliferative syndromes.

Indications and advantages of laparoscopy-assisted colon resection for carcinoma in elderly patients

The controversy about laparoscopy assisted colectomy for cancer is based on doubt about performing a radical resection and adequate histopathological staging. Therefore, we selected a group of patients who could profit from the accepted benefits of the technique, while avoiding its uncontrolled outcome. We operated on patients with colorectal cancer with distant metastasis and on patients over 70 years old and American Society of Anesthesia (ASA) III-IV with a high operative risk with standard surgery. The results for the first 18 patients demonstrated the following: (a) the size of the surgical specimen and the number of lymph nodes were similar to those in standard surgery; (b) no mortality and very low morbidity occurred despite the patients' advanced age, debilitated condition, and comorbid diseases; (c) minor postoperative complications occurred in five of 18 patients; (d) the hospital stay was 6-7 days for nonmetastatic patients and 9-12 days for metastatic patients; (e) the 1-year survey revealed a relapse in only one patient 9 months after the first operation.

Centroblastic transformation of chronic lymphocytic leukaemia with primary skin involvement--cutaneous presentation of Richter's syndrome

The development of a large-cell non-Hodgkin's lymphoma in a patient suffering from chronic lymphocytic leukaemia is known as Richter's syndrome, representing one of the possible anaplastic transformations of the leukaemia. Cutaneous involvement is an extremely rare event. The case of a 45-year-old man with B-cell chronic lymphocytic leukaemia is reported. Five years later multiple cutaneous nodules developed on his extremities. Biopsies of the skin showed a diffuse large-cell lymphoma, bearing the same cell surface immunoglobulin light chain isotype as the leukaemia, suggesting the original relationship between both neoplasms.

[Splenic lymphangiomatosis]

Cystic lymphangiomatosis confined to the spleen is a very rare condition. This article describes one new case and briefly reviews the literature, while providing information of wider relevance.

[Fazadinium in surgery of the gallbladder and the bile ducts]

The authors show their experience with fazadinium in the surgery of gall-bladder and biliary tract, and express an opinion of pleasured consideration about the practical effects of this drug, also deriving from the checking of the patients through the cardiovascular monitoring and pre- and postoperative hematochemical tests.