Process-based Interventions Research Articles

Development, feasibility, and acceptability of a process based intervention to decrease internalized ageism

ABSTRACT A lifetime of exposure to ageism may be internalized in older adults, and these ageist beliefs that are directed inwards can have severe consequences. However, research on reducing internalized ageism is scarce. To address this, we designed and implemented a six-week online process-based intervention to reduce internalized ageism and to assess its feasibility. The intervention utilized a process-based therapy approach targeting psychological, behavioral, and physiological pathways through which internalized ageism negatively impacts health, as specified by stereotype embodiment theory. Intervention components included education, acceptance and commitment therapy techniques, and attributional retraining. A total of 81 older adult participants participated in the feasibility study. Most participants rated each session and the overall program as very useful after each session (average program usefulness rating of 4.54/5). Participants also attributed a wide range of novel behaviors to this intervention and stated that they felt it changed their perspectives on ageism and/or internalized ageism. Results from this study provide a promising foundation from which to advance research on interventions that address internalized ageism – a problem that has severe consequences on the health and well-being of growing numbers of older adults globally.

Exploring Biomedical Waste Management Practices Among Healthcare Professionals: A Study From a Tertiary Care Teaching Hospital in Eastern India.

The generation of biomedical waste (BMW) in hospitals presents a significant hazard to both healthcare workers (HCWs) and the environment. The management of BMW is a challenge regarding inappropriate behavior among HCWs, leading to improper segregation of the BMW, which deserves attention.The indiscriminate BMW management issue in India has attracted the attention of the highest judicial bodies. The rise in the incidence of needle stick injuries is a severe threat to waste handlers and is mainly due to improper segregation practices. This study aimed to identify the challenges in BMW management in the institute and develop a strategy to improve the knowledge and practices of healthcare professionals (HCPs) in BMW management. A process-based intervention was developed and implemented that involved facility inspection rounds, focused group discussions with HCWs, preparation of information, education, and communication (IEC) materials, signage, staff training, and improved infrastructure and supplies for waste collection. A questionnaire-based evaluation of the staff's knowledge of BMW management was conducted, and the impact of the intervention was assessed from the hospital infection control audit reports. Multiple reasons for poor compliance with BMW segregation practices were identified, and it improved from 57% to 91% with interventions. A significant difference was noted in the knowledge level of staff before and after the interventions.Post-intervention score was highest among the nurses (98.5%), followed by sanitation staff (92.7%), doctors (89.25%), and paramedics (81.7%). Incorrect segregation practices of BMW and incidents of occupational exposure to blood and body fluids are reduced with interventions in the study. Robust supply chain management with regular training of staff is vital to ensure compliance in BMW management.

Reimagine Aging: A Process-Based Intervention to Decrease Internalized Ageism

Objectives Exposure to ageism may be internalized in older adults, and this can have severe consequences. However, little research has addressed reducing internalized ageism. Thus, Reimagine Aging, a 6-week process-based intervention to reduce internalized ageism, was designed and implemented, using education, acceptance and commitment therapy, and attributional retraining to target theoretically based mechanisms of change. Methods Seventy-two older adults (M = 70.4 years, SD = 6.4 years) participated in Reimagine Aging, consented to participate in this robust single-sample pilot study, and provided valid data. Participants completed questionnaires prior to, immediately following, and 2 months after the intervention. Results Participants’ self-perceptions of aging ( η p 2 =0.37, p < .001) and perceptions of older adults ( η p 2 =0.27, p < .001) became significantly more positive, associated with large effect sizes. Furthermore, these positive gains were mediated by increases in psychological flexibility, mindfulness, and perceived control. Discussion This study provides initial support for this process-based intervention targeting a reduction of internalized ageism. Clinical Implications This program has the potential to reduce the negative impact internalized ageism has on the health of older adults. Furthermore, it provides novel insights into intervention targets and tools that may be useful in achieving this reduction.

Comment on Lundh (2023).

In this commentary of Lundh's (2023) article, we point to an individualized process-based approach for the future of psychotherapy. The traditional nomothetic research paradigm is limiting our understanding of processes of change, oversimplifying psychological phenomena, and neglecting individual dynamics. In contrast, a process-based approach calls for ideographic methodologies, departing from the latent-disease paradigm toward process-based interventions. Process-based research promises avenues for enhancing intervention science and a deeper comprehension about psychopathology and therapeutic mechanisms, in a comprehensive, personalized, and holistic manner.

A narrative review of mechanisms linking romantic relationship experiences to sleep quality.

Although a significant body of research has revealed associations between romantic relationship experiences and sleep quality, there has not been clarity regarding the mechanisms underlying such associations. Toward this end, we review the existing studies that have tested mechanisms linking romantic relationship experiences to sleep quality. Guided by both theory and existing research, we organize our review around five key categories of mechanisms that may explain associations between romantic relationship experiences and sleep quality: emotional/affective responses, self-perceptions, social perceptions, self-regulation, and biological functioning. Our review of the literature indicates strong evidence in support of the mediating effects of emotional/affective mechanisms (e.g. emotions and mood states) in explaining associations between various aspects of romantic relationships (e.g. relationship satisfaction, partner conflicts, and attachment orientation) and sleep quality. Although there is ample theoretical support for the other mechanisms proposed, and although all proposed mechanisms have been separately linked to both romantic relationship experiences and sleep quality, few studies have directly tested them, pointing to profitable directions for future research. Understanding underlying mechanisms will enable the development of wise, process-based interventions that target specific mechanisms to improve couple members' sleep quality and romantic relationship functioning.

Does the Five Facet Mindfulness Questionnaire measure the same constructs before and after ACT-based treatment? Examination of the longitudinal measurement invariance of the 24-item FFMQ-SF

Violations of longitudinal measurement invariance (LMI) suggest “response shifts” in individuals’ understanding and appraisal of items over time and result in misinterpretation of observed changes in outcome measures. These concerns are crucial to the validity of outcome measures and are particularly relevant in examining the effectiveness of mindfulness and other process-based interventions. In the current report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examine the LMI of the 24-item short form of the Five Factor Mindfulness Questionnaire from intake to discharge in a large, diagnostically heterogeneous sample of psychiatric patients (n = 2928) participating in an acceptance and commitment therapy-based partial hospitalization program. The original five-factor structure required correlated error terms for items with similar wording (Nonjudging of Experience and Describe scales) to achieve acceptable fit. Following these modifications, we found evidence of configural and weak invariance for all scales. We found evidence for strong invariance for Nonjudging of Experience, Nonreactivity to Inner Experiences, Describe, and Observing, but not for Acting with Awareness. Strict invariance was not supported. Results highlight the challenges of measuring constructs involving overt metacognitive processes via self-report. Implications for scale development and clinical practice are discussed.

Quiet children and adolescents: understanding and helping youth with selective mutism

Anxiety in children and adolescents can manifest itself in many ways. In the social context, some young people are so anxious that they find it impossible to express themselves. Selective mutism then becomes an obstacle to their development. Families, school, and clinics are often at a loss for information about this rare disorder. What are the keys to understanding and therapeutic levers?The multiplicity of these young people's profiles will be illustrated through the clinical vignettes of Melody (3), Jeanne (8) and Sammy (15). Reliable and effective intervention strategies and tools are presented to help children regain their ability to speak.The progress made by children who have already benefited from the help strategies which mainly combine CBT and systemic process-based interventions in individual and/or family formats, reinforces our view that these approaches deserve the interest, support and sound advice of the school.

Remedial interventions for developmental dyslexia: Comparing the rhythmic reading training to the “Abilmente” approach

The possibility of using rhythmic auditory interventions for addressing dyslexia-related difficulties has been empirically explored by several investigations, with encouraging results. Such findings inspired the design of a novel rhythm-based intervention, Rhythmic Reading Training (RRT), specifically designed for students with developmental dyslexia (DD). To measure RRT efficacy, a clinical trial with an active-controlled design was carried out. More precisely, RRT combined with music games was contrasted with a personalized multi-componential treatment of DD of proven efficacy, namely, the Abilmente approach. Thirty-two children and preadolescents with DD received either one of the two interventions under the supervision of a specialized trainer. Immediate- and medium-term effects on reading skills did not differ between the two interventions. The analysis of the specific contribution of each methodology showed that the Abilmente approach was more effective in improving text reading, while RRT induced more consistent maintenance of all reading sub-processes 4 weeks after the end of the treatment. Consistent with previous research, the rhythmic intervention showed more consistent effects on reading speed. These results confirmed the efficacy of a unimodal process-based intervention such as RRT in inducing global reading effects comparable with those following a personalized multi-componential intervention.

The therapeutic alliance in acceptance and commitment therapy

Acceptance and Commitment Therapy (ACT) is a process-based intervention that promotes psychological flexibility by implementing six core processes. These include acceptance and awareness as well values and behavior change processes. Still, the primary vehicle for implementing these processes is the therapeutic relationship. Underscoring the importance of the relationship is paramount – it is the context in which the interventions emerge, allowing the therapist to shape psychological flexibility directly. We argue that the therapeutic alliance (TA) is co-created and is a critical factor contributing to the effectiveness of ACT. This paper focuses on the TA as a vital part of ACT treatment. We discuss the therapeutic alliance from an ACT perspective, explore different roles in implementing ACT, and conclude with a clinical case illustration. We more specifically focus on how the TA alliance and the therapeutic relationship can be a vehicle of change in ACT.

Effect of Rehabilitation Nutrition Care Process on Physical Function in Lung Cancer Cachexia: A Case Report

Patients with cancer cachexia have poor adherence to treatment, which affects their prognosis. Currently, there are many studies on the effects of rehabilitation on cancer cachexia, but there is a lack of evidence on the effects of nutrition therapy alone or in combination with rehabilitation and nutrition therapy. This article describes a case in which rehabilitation nutrition care process was effective in a patient with lung cancer who developed cancer cachexia. A 68-year-old woman was hospitalized for treatment of lung adenocarcinoma. The patient had moderate malnutrition, sarcopenia, and cachexia at the time of admission, so the authors intervened according to rehabilitation nutrition care process. The physiotherapist mainly prescribed resistance training and aerobic exercise, 40-60 minutes a day, 5-6 days a week. And the dietitian provided oral nutritional supplements (100 kcal, branched-chain amino acid: 3.0 g) in addition to hospital food and adjusted the patient's energy intake to 26.96-33.05 kcal/kg/day and protein intake to 1.07-1.14 g/kg/day. Comparing the initial evaluation with the discharge, nutritional status, such as body mass index and skeletal muscle mass, and physical functions, such as maximum grip strength, gait speed, and functional independence measure (motor items), were improved. Rehabilitation nutrition care process-based interventions may improve nutritional status and physical functions more than exercise therapy alone in patients with lung cancer cachexia.

Intervention optimization for crowd emotional contagion

When emergencies occur, negative emotional contagion produced in crowds makes people irrational, resulting in stampedes and crushes. The intervention of crowd emotional contagion is an efficient method for avoiding serious accidents and ensuring the safety of people’s lives and properties. However, it is a challenging problem to provide an optimized intervention scheme for crowd emotional contagion because the appropriate intervention intensity is hard to achieve, e.g., too little intervention cannot restrain the outbreak of emotion, while excessive intervention will lead to the waste of manpower and material resources. Moreover, stochastic evolutionary characteristics of emotional contagion have further aggravated this problem since it is difficult to describe the stochastic changes in emotional contagion accurately. To solve this problem, we propose an intervention optimization scheme for crowd emotional contagion to maximize the number of uninfected individuals while minimizing the intervention cost. First, we construct a stochastic event-based emotional contagion (SEEC) model to capture the stochastic evolution characteristics of emotional contagion. Based on SEEC, we then propose a Hawkes process-based intervention (HPI) model to quantify the intervention intensity. Next, we formulate the intervention optimization as a problem of maximizing the ratio of the expected number of individuals being intervened to the cost of manual intervention. Finally, we propose an intervention optimization-artificial bee colony (IO-ABC) algorithm to heuristically solve the optimization problem. The experimental results show that our method can effectively intervene in emotional contagion.

Assessing the Effect of Training on the Cognition and Brain of Older Adults: Protocol for a Three-Arm Randomized Double-Blind Controlled Trial (ACTOP).

BackgroundTo prevent age-related cognitive impairment, many intervention programs offer exercises targeting different central cognitive processes. However, the effects of different process-based training programs are rarely compared within equivalent experimental designs.ObjectiveUsing a randomized double-blind controlled trial, this project aims to examine and compare the impact of 2 process-based interventions, inhibition and updating, on the cognition and brain of older adults.MethodsA total of 90 healthy older adults were randomly assigned to 1 of 3 training conditions: (1) inhibition (Stroop-like exercises), (2) updating (N-back-type exercises), and (3) control active (quiz game exercise). Training was provided in 12 half-hour sessions over 4 weeks. First, the performance gain observed will be measured on the trained tasks. We will then determine the extent of transfer of gain on (1) untrained tasks that rely on the same cognitive process, (2) complex working memory (WM) measurements hypothesized to involve 1 of the 2 trained processes, and (3) virtual reality tasks that were designed to mimic real-life situations that require WM. We will assess whether training increases cortical volume given that the volume of the cortex is determined by cortical area and thickness in regions known to be involved in WM or changes task-related brain activation patterns measured with functional magnetic resonance imaging. Dose effects will be examined by measuring outcomes at different time points during training. We will also determine whether individual characteristics moderate the effect of training on cognitive and cerebral outcomes. Finally, we will evaluate whether training reduces the age-related deficit on transfer and brain outcomes, by comparing study participants to a group of 30 younger adults.ResultsThe project was funded in January 2017; enrollment began in October 2017 and data collection was completed in April 2019. Data analysis has begun in June 2020 and the first results should be published by the end of 2020 or early 2021.ConclusionsThe results of this study will help understand the relative efficacy of 2 attentional control interventions on the cognition and the brain of older adults, as well as the moderating role of individual characteristics on training efficiency and transfer.Trial RegistrationClinicalTrials.gov NCT03532113; https://clinicaltrials.gov/ct2/show/NCT03532113International Registered Report Identifier (IRRID)DERR1-10.2196/20430

A randomised controlled trial of metacognitive training for psychosis, depression, and belief flexibility

BackgroundMetacognitive training (MCT) has been shown to be effective in reducing psychotic symptoms, including delusions. However, less is known on whether MCT, or its specific modules, are effective in ameliorating reasoning biases e.g. belief flexibility. As inflexibility in appraisal has been associated with psychosis and major depressive disorder (MDD), this study examined the efficacy of a 4-session MCT on delusions, depression, and belief flexibility, in two clinical groups (Psychosis and Depression). MethodsThis study adopted a single-blind randomised controlled design, with patients with schizophrenia spectrum disorders (and delusions) and patients with MDD being randomised, respectively, into the MCT condition or a treatment-as-usual (TAU) condition. The MCT intervention consisted of specific modules targeting belief flexibility. Participants were assessed before and after treatment, and at 1- and 6-month follow-ups. ResultsAmong the 113 participants, 27 patients with psychosis and 29 patients with MDD attended MCT. There were significant improvements in psychotic symptoms, especially delusions, for the Psychosis group, and in depressive symptoms for the MDD group. Symptom improvements following MCT were of large effect sizes, were significantly greater than TAU, and persisted at 6-month. Belief flexibility also improved in both groups, although changes were smaller in size and were not significantly greater than TAU. LimitationsAn active control condition was not included. ConclusionsThis study demonstrated large and stable symptom reductions in delusions and depression, and smaller (yet stable) improvement in belief flexibility across groups, following a 4-session MCT, carrying implications for transdiagnostic process-based interventions and their mechanisms of change.

Competence and adherence in an acceptance and values-based intervention: Effects on treatment outcome and early changes in depression

BackgroundThe present study investigated competence and adherence in an acceptance- and values-based intervention and their impact on the outcomes of treatment and early changes in depression. MethodA total of 74 sessions delivered by novice therapists (n = 37) were rated for overall competence and adherence to treatment manual, as well as for process-specific components of acceptance and commitment therapy (ACT) using the ACT Adherence Scale (Plumb & Vilardaga, 2010). The relationships between (a) competence and adherence, (b) treatment outcome, and (c) early therapeutic changes among patients diagnosed with major depressive disorder (n = 37) were explored. ResultsHigher competence and better adherence to ACT were associated with larger overall changes in depressive symptoms (r = 0.37 and r = 0.39, respectively). Specifically, the more frequently and extensively the therapists addressed committed action during their intervention, the larger the overall changes in depression and psychological flexibility. The regression analyses suggested that close to 40% of variation in overall changes in depressive symptoms was explained by an early change in depressive symptoms and adherence to the ACT model, in which early change was the strongest predictor. When early change was not included in the regression model, both competence and adherence in ACT explained 13–14% of variation in overall changes in depression. Competence and adherence were not associated with overall change in psychological flexibility. DiscussionThe present study suggests that competence and adherence in ACT may be associated with favorable outcomes of treatment in depression. We call for further evidence and discussion about competence and adherence in process-based interventions.

Enhanced Recovery After Surgery: Past, Present, and Future

Surgical site infection (SSI), particularly in colorectal surgery, continues to cause substantial morbidity and cost. Both process- and product-based interventions have been proposed and implemented. No cost-effectiveness analysis of such interventions has been published.This study used a decision-analytic model to evaluate the cost-effectiveness of strategies for the prevention of SSI. Costs, utilities, and transition probabilities were obtained from literature review. We used a lifetime time horizon, captured with explicit event modeling for a year plus quantification of enduring health outcomes. We represented costs in 2017 US dollars and health effects in Quality-Adjusted Life Years (QALYs). Deterministic and probabilistic sensitivity analyses were performed.Both process- and device-based strategies were dominant—clinically superior and also less expensive—compared with no intervention. Two types of double-ring wound protection barrier devices with greater anticontamination functionality were found to be both clinically superior and cost-saving compared with bundled process measures and simpler single-ring devices. Gains in QALYs were 230 per 1000 patients, and cost savings were 2.2 million dollars per 1000 patients, driven primarily by the high cost of SSI.We found process-based interventions and wound protection devices to be superior to no intervention in the prevention of SSI. Double ring devices offered a distinct advantage over simpler devices, with small reductions in SSI risk leading to substantial cost savings. Further innovation in device-based wound protection devices may offer increased prevention of SSI at acceptable cost-effectiveness levels.

Interventions and Innovation to Prevent Surgical Site Infection in Colorectal Surgery: A Cost-Effectiveness Analysis

BackgroundSurgical site infection (SSI), particularly in colorectal surgery, continues to cause substantial morbidity and cost. Both process- and product-based interventions have been proposed and implemented. No cost-effectiveness analysis of such interventions has been published. Materials and methodsThis study used a decision-analytic model to evaluate the cost-effectiveness of strategies for the prevention of SSI. Costs, utilities, and transition probabilities were obtained from literature review. We used a lifetime time horizon, captured with explicit event modeling for a year plus quantification of enduring health outcomes. We represented costs in 2017 US dollars and health effects in Quality-Adjusted Life Years (QALYs). Deterministic and probabilistic sensitivity analyses were performed. ResultsBoth process- and device-based strategies were dominant—clinically superior and also less expensive—compared with no intervention. Two types of double-ring wound protection barrier devices with greater anticontamination functionality were found to be both clinically superior and cost-saving compared with bundled process measures and simpler single-ring devices. Gains in QALYs were 230 per 1000 patients, and cost savings were 2.2 million dollars per 1000 patients, driven primarily by the high cost of SSI. ConclusionsWe found process-based interventions and wound protection devices to be superior to no intervention in the prevention of SSI. Double ring devices offered a distinct advantage over simpler devices, with small reductions in SSI risk leading to substantial cost savings. Further innovation in device-based wound protection devices may offer increased prevention of SSI at acceptable cost-effectiveness levels.

Associations between belief inflexibility and dimensions of delusions: A meta‐analytic review of two approaches to assessing belief flexibility

Belief inflexibility has been suggested to maintain delusions. Different measures of assessing belief inflexibility have been developed, and it remains unclear whether patients with delusions display belief inflexibility similarly across measures. As delusions consist of multiple dimensions, the aim of this meta-analytic review was to examine how belief inflexibility is related to different aspects of delusions (conviction, distress, and preoccupation) and to compare these associations between interview-based and task-based measures of belief inflexibility. We conducted a systematic database search (PsycINFO, PsycARTICLES, PubMed, and MEDLINE) and identified relevant articles using the following search items: belief*, delusion*, or overvalued idea*; psychosis or schizo*; flexib*, inflexib*, change, revision, or update. Meta-analyses were conducted for each dimension of delusions and were reported according to the PRISMA guidelines. A total of 16 studies, with a total sample of 1,065, were included in the analysis. Belief inflexibility was associated with global severity of delusions (Hedges' g=0.452, p<.001). Specifically, all dimensions of delusions were significantly associated with belief inflexibility (conviction: Hedges' g=0.678, p<.001; preoccupation: Hedges' g=0.274, p=.002; distress: Hedges' g=0.200, p=.025). There was no significant heterogeneity across studies for each dimension. Preliminary subgroup analysis did not find any significant between-measure differences in the relationship between belief inflexibility and overall severity of delusions. Belief inflexibility, across measures, was robustly associated with delusions, with a particularly strong association for delusional conviction. Our results carried implications for process-based interventions for delusions. Positive clinical implications Belief inflexibility is consistently associated with the maintenance of delusions. Assessing belief inflexibility in routine clinical practice will inform psychological interventions for patients with persistent delusions. Interview- and task-based measures of belief inflexibility may be used complementarily to facilitate our understanding of this reasoning bias. Aetiological factors may be more closely associated with some aspects of delusions than the others. In line with a multidimensional view of delusions, interventions targeting different dimensions of delusions may have different therapeutic emphases. Limitations The current review focused on three core dimensions of delusions only (conviction, preoccupation, distress). Other ways of dissecting delusions are possible. Comparisons between the two measures of belief inflexibility may benefit from further research.

Elimination of waste: creation of a successful Lean colonoscopy program at an academic medical center.

Lean processes involve streamlining methods and maximizing efficiency. Well established in the manufacturing industry, they are increasingly being applied to health care. The objective of this study was to determine feasibility and effectiveness of applying Lean principles to an academic medical center colonoscopy unit. Lean process improvement involved training endoscopy personnel, observing patients, mapping the value stream, analyzing patient flow, designing and implementing new processes, and finally re-observing the process. Our primary endpoint was total colonoscopy time (minutes from check-in to discharge) with secondary endpoints of individual segment times and unit colonoscopy capacity. A total of 217 patients were included (November 2013-May 2014), with 107 pre-Lean and 110 post-Lean intervention. Pre-Lean total colonoscopy time was 134min. After implementation of the Lean process, mean colonoscopy time decreased by 10% to 121min (p=0.01). The three steps of the process affected by the Lean intervention (time to achieve adequate sedation, time to recovery, and time to discharge) decreased from 3.7 to 2.4min (p<0.01), 4.0 to 3.4min (p=0.09), and 41.2 to 35.4min (p=0.05), respectively. Overall, unit capacity of colonoscopies increased from 39.6 per day to 43.6. Post-Lean patient satisfaction surveys demonstrated an average score of 4.5/5.0 (n=73) regarding waiting time, 4.9/5.0 (n=60) regarding how favorably this experienced compared to prior colonoscopy experiences, and 4.9/5.0 (n=74) regarding professionalism of staff. One hundred percentage of respondents (n=69) stated they would recommend our institution to a friend for colonoscopy. With no additional utilization of resources, a single Lean process improvement cycle increased productivity and capacity of our colonoscopy unit. We expect this to result in increased patient access and revenue while maintaining patient satisfaction. We believe these results are widely generalizable to other colonoscopy units as well as other process-based interventions in health care.

Metacognitive training for delusions (MCTd): effectiveness on data-gathering and belief flexibility in a Chinese sample.

Metacognitive training (MCT) was developed to promote awareness of reasoning biases among patients with schizophrenia. While MCT has been translated into 31 languages, most MCT studies were conducted in Europe, including newer evidence recommending an individualized approach of delivery. As reasoning biases covered in MCT are separable processes and are associated with different symptoms, testing the effect of selected MCT modules would help to develop a targeted and cost-effective intervention for specific symptoms and associated mechanisms. This study tested the efficacy of a four-session metacognitive training for delusions, MCTd (in Traditional Chinese with cultural adaptations, provided individually), as an adjunct to antipsychotics in reducing severity and conviction of delusions, jumping to conclusions (JTC) bias and belief inflexibility. Forty-four patients with delusions were randomized into the MCTd or the wait-list control condition. Patients on wait-list received the same MCTd after 4 weeks of treatment as usual (TAU). Assessment interviews took place before and after the treatment, and at 4-week follow-up. There was an additional baseline assessment for the controls. JTC and belief flexibility were measured by the beads tasks and the Maudsley Assessment of Delusions Scale. Attendance rate of the MCTd was satisfactory (84.5%). Compared to TAU, there was a greater reduction in psychotic symptoms, delusional severity and conviction following MCTd. There was a large treatment effect size in improvement in belief flexibility. Improvement in reaction to hypothetical contradiction predicted treatment effect in positive symptoms and delusions. JTC bias was reduced following MCTd, although the treatment effect was not significantly larger than TAU. Our results support the use of process-based interventions that target psychological mechanisms underlying specific psychotic symptoms as adjuncts to more conventional approaches.

Surgical wound classification for pediatric appendicitis remains poorly documented despite targeted interventions

Background/PurposeSurgical wound class (SWC) is used to risk-stratify surgical site infections (SSI) for quality reporting. We previously demonstrated only 8% agreement between hospital-based SWC and diagnosis-based SWC for acute appendicitis. We hypothesized that education and process-based interventions would improve hospital-based SWC reporting and the validity of SSI risk stratification. MethodsPatients (<18years old) who underwent appendectomies for acute appendicitis between January 2011 and December 2013 were included. Interventions entailed educational workshops regarding SWC for perioperative personnel and inclusion of SWC as a checkpoint in the surgical safety checklist. Thirty-day postoperative SSIs were recorded. Chi-square, Fisher’s exact test, and kappa statistic were utilized. Results995 cases were reviewed (pre-intervention=478, post-intervention=517). Weighted interrater agreement between hospital-based and diagnosis-based SWC improved from 50% to 81% (p<0.01), and weighted kappa increased from 0.16 (95% CI 0.004–0.03) to 0.29 (95% CI 0.25–0.34). Hospital-based dirty wounds were significantly associated with SSI in the post-intervention period only (p<0.01). ConclusionsAgreement between hospital-based SWC and diagnosis-based SWC significantly improved after simple interventions, and SSI risk stratification became consistent with the expected increase in disease severity. Despite these improvements, there were still substantial gaps in SWC knowledge and process.