Datasheet1_Demand management processes to improve access to cognitive-behavioral therapies for anxiety disorders: a grounded theory study.docx

IntroductionAnxiety disorders are impactful mental health conditions for which evidence-based treatments are available, notably cognitive-behavioral therapies (CBTs). Even when CBTs are available, demand-side factors limit their access, and actors in a position to perform demand management activities lack a framework to identify context-appropriate actions.MethodsWe conducted a constructivist grounded theory study in Quebec, Canada, to model demand management targets to improve access to CBTs for anxiety disorders. We recruited key informants with diverse experiences using purposeful, then theoretical sampling. We analyzed data from 18 semi-directed interviews and 20 documents through an iterative coding process centered around constant comparison.ResultsThe resulting model illustrates how actors can target clinical-administrative processes fulfilling the demand management functions of detection, evaluation, preparation, and referral to help patients progress on the path of access to CBTs.DiscussionModeling clinical-administrative processes is a promising approach to facilitate leveraging the competency of actors involved in demand management at the local level to benefit public mental health.</p

Vasopressor use following traumatic injury – A single center retrospective study

<div><p>Objectives</p><p>Vasopressors are not recommended by current trauma guidelines, but recent reports indicate that they are commonly used. We aimed to describe the early hemodynamic management of trauma patients outside densely populated urban centers.</p><p>Methods</p><p>We conducted a single-center retrospective cohort study in a Canadian regional trauma center. All adult patients treated for traumatic injury in 2013 who died within 24 hours of admission or were transferred to the intensive care unit were included. A systolic blood pressure <90 mmHg, a mean arterial pressure <60 mmHg, the use of vasopressors or ≥2 L of intravenous fluids defined hemodynamic instability. Main outcome measures were use of intravenous fluids and vasopressors prior to surgical or endovascular management.</p><p>Results</p><p>Of 111 eligible patients, 63 met our criteria for hemodynamic instability. Of these, 60 (95%) had sustained blunt injury and 22 (35%) had concomitant severe traumatic brain injury. The subgroup of patients referred from a primary or secondary hospital (20 of 63, 32%) had significantly longer transport times (243 vs. 61 min, p<0.01). Vasopressors, used in 26 patients (41%), were independently associated with severe traumatic brain injury (odds ratio 10.2, 95% CI 2.7–38.5).</p><p>Conclusions</p><p>In this cohort, most trauma patients had suffered multiple blunt injuries. Patients were likely to receive vasopressors during the early phase of trauma care, particularly if they exhibited signs of neurologic injury. While these results may be context-specific, determining the risk-benefit trade-offs of fluid resuscitation, vasopressors and permissive hypotension in specific patients subgroups constitutes a priority for trauma research going forwards.</p></div

Outcomes.

<p>Outcomes.</p

Patient flow diagram.

<p>*One patient was transferred to another hospital after the initial phase of resuscitation and could not provide outcome data. ICU—Intensive care unit, SBP—Systolic blood pressure, MAP—Mean arterial pressure.</p

Fluid volumes (mL) administered during the initial phase of resuscitation^*.

<p>Fluid volumes (mL) administered during the initial phase of resuscitation^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0176587#t003fn002" target="_blank">*</a>}.</p

Care trajectories of hemodynamically unstable patients.

<p>Care trajectories of hemodynamically unstable patients.</p

Baseline characteristics of unstable patients treated with and without vasopressors.

<p>Baseline characteristics of unstable patients treated with and without vasopressors.</p

Predictors of vasopressor use in hemodynamically unstable patients.

<p>Predictors of vasopressor use in hemodynamically unstable patients.</p