Adult attachment and interpersonal problems in survivors of interpersonal trauma

Hintergrund: Studien zeigen, dass das Erleben eines frühen chronischen interpersonellen Traumas (early chronic interpersonal trauma, ECIP) mit unsicherer Bindung zu intimen Partnern(innen) im Erwachsenenalter zusammenhängt. Es wurde bisher jedoch nicht geprüft, ob dies speziell auf frühe Traumata zutrifft und welcherart die Beziehungen zwischen Traumatyp, Bindung im Erwachsenenalter und PTSD sind. Die vorliegende Studie hatte folgende Ziele: (1) Vergleich der Bindungssicherheit in einer ECIP Gruppe mit jener bei Menschen, die ein spätes (Alter ≥ 14 Jahre), ein frühes kurzzeitiges (Alter < 14 Jahre, Dauer < 1 Jahr) oder ein nicht-interpersonelles Trauma erlebt hatten, (2) Prüfung der Hypothese, dass die Bindung im Erwachsenenalter eine Mediatorvariable für den Zusammenhang zwischen dem Erleben eines interpersonellem Traumas und der Stärke von PTSD-Symptomen darstellt. Methode: Internet-User, die durch trauma- oder gesundheitsbezogene Websites rekrutiert wurden, füllten sechs Online-Fragebögen aus. Erhoben wurden die Traumageschichte, Bindung im Erwachsenenalter, interpersonelle Probleme, PTSD-Symptomstärke, sowie Anzeichen einer Depression und Borderline Persönlichkeitsstörung. Die Bindungssicherheit wurde mit dem Fragebogen Experiences in Close Relationships - Revised (ECR-R; Fraley et al., 2000) erhoben, welcher bindungsbezogene Vermeidung und Ängstlichkeit, erfasst. Ergebnisse: Insgesamt bearbeiteten 260 Personen (234 Frauen) den Fragebogen bis zum Schluss. Nach Anwendung der Ausschlusskriterien blieben 209 Personen (190 Frauen) über. Die ECIP Gruppe (n = 130) berichtete eine signifikant höhere bindungsbezogene Ängstlichkeit und Vermeidung als spät interpersonell (n = 31) oder nicht-interpersonell traumatisierte Personen (n = 24). Es gab, konträr zur Erwartung, jedoch keinen Hinweis auf einen Unterschied zur Gruppe der früh kurzzeitig interpersonell traumatisierten Personen (n = 24). Weiters war die Bindungsunsicherheit im Erwachsenenalter ein partieller Mediator des Zusammenhangs zwischen Trauma und der PTSD-Symptomstärke. Schlussfolgerung: Unsichere Bindung im Erwachsenenalter könnte eine konsistente Folge früher interpersoneller Traumata sein sowie zur Entwicklung von PTSD beitragen. Von der künftigen Forschung wird zu klären sein, ob unsichere Bindung speziell auf frühe interpersonelle Traumata zurückzuführen ist oder ob sie eine Folge der PTSD-Symptome ist, die nach einem interpersonellen Trauma auftreten.Background: Earlier research has shown that the experience of early chronic interpersonal trauma (ECIP) is related to insecure attachment to romantic partners in adulthood. However, it has not been tested to date whether this is specific for early-onset trauma and what the exact relationship is between trauma type, adult attachment and posttraumatic stress disorder (PTSD). The aims of this study were (1) to compare adult attachment in an ECIP group to that in individuals who experienced a late-onset, an early single or a non-interpersonal trauma, and (2) to test whether adult attachment mediates the relationship between the experience of interpersonal trauma and PTSD symptom severity. Material and methods: Two hundred and sixty English-speaking Internet users, recruited through trauma-or health-related websites, completed a set of online questionnaires assessing trauma history, adult attachment security, interpersonal problems, PTSD symptom severity, as well as screenings of depression and borderline personality disorder. Attachment security was assessed with the Experiences in Close Relationships Revised scale (Fraley et al., 2000) which taps the two adult attachment dimensions avoidance and anxiety. Results: Following the application of exclusion criteria, 209 individuals (190 women) remained in the sample. The early chronic interpersonal trauma group (n = 130), which included individuals sexually or physically abused in childhood, reported significantly more attachment avoidance and anxiety than the late interpersonal (n = 31) and the non-interpersonal trauma group (n = 24). However, no difference was found between early short-term (n = 24) and early chronic traumas. Furthermore, adult attachment showed to be a partial mediator of the association between trauma type and PTSD symptom severity. Conclusion: Attachment-related avoidance and anxiety in adulthood may be a consistent sequel of early interpersonal trauma and may contribute to the development of PTSD. Future research needs to test whether insecure adult attachment is a unique sequel of interpersonal trauma or whether it stems from increased PTSD symptom severity following interpersonal trauma

Implementing advance care planning in routine nursing home care : the development of the theory-based ACP+ program

Background While various initiatives have been taken to improve advance care planning in nursing homes, it is difficult to find enough details about interventions to allow comparison, replication and translation into practice. Objectives We report on the development and description of the ACP+ program, a multi-component theory-based program that aims to implement advance care planning into routine nursing home care. We aimed to 1) specify how intervention components can be delivered; 2) evaluate the feasibility and acceptability of the program; 3) describe the final program in a standardized manner. Design To develop and model the intervention, we applied multiple study methods including a literature review, expert discussions and individual and group interviews with nursing home staff and management. We recruited participants through convenience sampling. Setting and participants Management and staff (n = 17) from five nursing homes in Flanders (Belgium), a multidisciplinary expert group and a palliative care nurse-trainer. Methods The work was carried out by means of 1) operationalization of key intervention components identified as part of a previously developed theory on how advance care planning is expected to lead to its desired outcomes in nursing homes into specific activities and materials, through expert discussions and review of existing advance care planning programs; 2) evaluation of feasibility and acceptability of the program through interviews with nursing home management and staff and expert revisions; and 3) standardized description of the final program according to the TIDieR checklist. During step 2, we used thematic analysis. Results The original program with nine key components was expanded to include ten intervention components, 22 activities and 17 materials to support delivery into routine nursing home care. The final ACP+ program includes ongoing training and coaching, management engagement, different roles and responsibilities in organizing advance care planning, conversations, documentation and information transfer, integration of advance care planning into multidisciplinary meetings, auditing, and tailoring to the specific setting. These components are to be implemented stepwise throughout an intervention period. The program involves the entire nursing home workforce. The support of an external trainer decreases as nursing home staff become more autonomous in organizing advance care planning. Conclusions The multicomponent ACP+ program involves residents, family, and the different groups of people working in the nursing home. It is deemed feasible and acceptable by nursing home staff and management. The findings presented in this paper, alongside results of the subsequent randomized controlled cluster trial, can facilitate comparison, replicability and translation of the intervention into practice

Validation of the Retinopathy of Prematurity Activity Scale (ROP-ActS) using retrospective clinical data

Acta Ophthalmologica published by John Wiley &amp; Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation. Purpose: The International Neonatal Consortium recently published a proposed retinopathy of prematurity (ROP) activity scale intended for use in clinical trials after validation. The aim of this study was to validate the ROP activity scale (ROP-ActS) in a ROP screened cohort with protocol based collected data by evaluating the ability of the ROP-Act scores to predict ROP treatment. In addition, we aimed to evaluate the scale’s sensitivity characteristic of disease severity by studying association with gestational age (GA) in comparison with conventionally used ROP stage and zone. Methods: A cohort of 535 preterm infants with 3324 ROP examinations with an end-point of ROP treatment or end of screening in Gothenburg, Sweden, was included. Median GA was 28.1\ua0weeks, 47.5% were girls, and 74 (13.8%) infants were treated for ROP. The validation was performed by estimating probabilities for ROP treatment, and by applying logistic and linear regression. Results: The original ROP-ActS was overall well-ordered with respect to ability to predict ROP treatment but could be improved by re-ordering score 3 (zone II stage 1) and 5 (zone III stage 3) based on our clinical cohort data. The modified ROP-ActS was superior to ROP stage and zone in the prediction analysis of ROP treatment. Modified ROP-ActS was more strongly related to GA than currently used ROP stage, but not zone. Conclusion: In the studied cohort, the modified ROP-ActS could better predict ROP treatment compared to ROP stage and zone. Retinopathy of Prematurity Activity Scale (ROP-ActS) had a superior sensitivity characteristic studied through association to GA than conventionally used ROP stage

Timely short-term specialised palliative care service intervention for frail older people and their family carers in primary care : study protocol for a pilot randomised controlled trial

Introduction There is limited evidence regarding the effectiveness of timely integration of short-term specialised palliative care services for older people in primary care. Using a Theory of Change approach, we developed such an intervention, the Frailty+ intervention. We present the protocol of a pilot randomised controlled trial (RCT) with a process evaluation that aims to assess the feasibility and preliminary effectiveness of the Frailty+ intervention. Methods and analysis We will conduct a pilot RCT in Flanders, Belgium. Frail older people who are discharged to home from hospital will be identified and recruited. Seventy-six will be randomly assigned either to the control group (standard care) or the intervention group (Frailty+ intervention alongside standard care). Data will be collected from patients and family carers. At the core of the Frailty+ intervention is the provision of timely short-term specialised palliative care facilitated by a nurse from the specialised palliative home care service over a period of 8 weeks. We will assess feasibility in terms of recruitment, randomisation, acceptability of the intervention, retention in the programme and data completion. The primary outcome for assessing preliminary effectiveness is a mean score across five key symptoms that are amenable to change (ie, breathlessness, pain, anxiety, constipation, fatigue), measured at baseline and 8 weeks post-baseline. The process evaluation will be conducted in the intervention group only, with measurements at 8-11 weeks post-baseline to evaluate implementation, mechanisms of change and contextual factors. Ethics and dissemination The study has been approved by the ethics committee of University Hospital Ghent. Results will be used to inform the design of a full-scale RCT and will be published in a peer-reviewed, open access journal

Evaluation of the Retinopathy of Prematurity Activity Scale (ROP-ActS) in a randomised controlled trial aiming for prevention of severe ROP : A substudy of the Mega Donna Mega trial

Objective The current grading of retinopathy of prematurity (ROP) does not sufficiently discriminate disease severity for evaluation of trial interventions. The published ROP Activity Scales (original: ROP-ActS and modified: mROP-ActS), describing increasing severity of ROP, versus the categorical variables severe ROP, stage, zone and plus disease were evaluated as discriminators of the effect of an ROP preventive treatment. Methods and analysis The Mega Donna Mega trial investigated ROP in infants born <28-week gestational age (GA), randomised to arachidonic acid (AA) and docosahexaenoic acid (DHA) supplementation or no supplementation. Of 207 infants, 86% with finalised ROP screening were included in this substudy. ROP-ActS versus standard variables were evaluated using Fisher’s non-parametric permutation test, multivariable logistic and linear regression and marginal fractional response models. Results The AA:DHA group (n=84) and the control group (n=93) were well balanced. The maximum ROP-ActS measurement was numerically but not significantly lower in the AA:DHA group (mean: 4.0 (95% CI 2.9 to 5.0)) versus the control group (mean: 5.3 (95% CI 4.1 to 6.4)), p=0.11. In infants with any ROP, the corresponding scale measurements were 6.8 (95% CI 5.4 to 8.2) and 8.7 (95% CI 7.5 to 10.0), p=0.039. Longitudinal profiles of the scale were visually distinguished for the categories of sex and GA for the intervention versus control. Conclusions The preventive effect of AA:DHA supplementation versus no supplementation was better discriminated by the trial’s primary outcome, severe ROP, than by ROP-ActS. The sensitivity and the linear qualities of ROP-ActS require further validations on large data sets and perhaps modifications. Trial registration number NCT03201588

Primary palliative care for older people in three European countries : a mortality follow-back quality study

Background Many older people with serious chronic illnesses experience complex health problems for which palliative care is indicated. We aimed to examine the quality of primary palliative care for people aged 65-84 years and those 85 years and older who died non-suddenly in three European countries. Methods This is a nationwide representative mortality follow-back study. General practitioners (GPs) belonging to epidemiological surveillance networks in Belgium (BE), Italy (IT) and Spain (ES) (2013-2015) registered weekly all deaths in their practices. We included deaths of people aged 65 and excluded sudden deaths judged by GPs. We applied a validated set of quality indicators. Results GPs registered 3496 deaths, of which 2329 were non-sudden (1126 aged 65-84, 1203 aged 85+). GPs in BE (reference category) reported higher scores than IT across almost all indicators. Differences with ES were not consistent. The score in BE particularly differed from IT on GP-patient communication (aged 65-84: 61% in BE vs 20% in IT (OR=0.12, 95% CI 0.07 to 0.20) aged 85+: 47% in BE vs 9% in IT (OR=0.09, 95% CI 0.05 to 0.16)). Between BE and ES, we identified a large difference in involvement of palliative care services (aged 65-84: 62% in BE vs 89% in ES (OR=4.81, 95% CI 2.41 to 9.61) aged 85+: 61% in BE vs 77% in ES (OR=3.1, 95% CI 1.71 to 5.53)). Conclusions Considerable country differences were identified in the quality of primary palliative care for older people. The data suggest room for improvement across all countries, particularly regarding pain measurement, GP-patient communication and multidisciplinary meetings

Evaluation of the Retinopathy of Prematurity Activity Scale (ROP-ActS) in a randomised controlled trial aiming for prevention of severe ROP: A substudy of the Mega Donna Mega trial

Objective The current grading of retinopathy of prematurity (ROP) does not sufficiently discriminate disease severity for evaluation of trial interventions. The published ROP Activity Scales (original: ROP-ActS and modified: mROP-ActS), describing increasing severity of ROP, versus the categorical variables severe ROP, stage, zone and plus disease were evaluated as discriminators of the effect of an ROP preventive treatment. Methods and analysis The Mega Donna Mega trial investigated ROP in infants born &lt;28-week gestational age (GA), randomised to arachidonic acid (AA) and docosahexaenoic acid (DHA) supplementation or no supplementation. Of 207 infants, 86% with finalised ROP screening were included in this substudy. ROP-ActS versus standard variables were evaluated using Fisher\u27s non-parametric permutation test, multivariable logistic and linear regression and marginal fractional response models. Results The AA:DHA group (n=84) and the control group (n=93) were well balanced. The maximum ROP-ActS measurement was numerically but not significantly lower in the AA:DHA group (mean: 4.0 (95% CI 2.9 to 5.0)) versus the control group (mean: 5.3 (95% CI 4.1 to 6.4)), p=0.11. In infants with any ROP, the corresponding scale measurements were 6.8 (95% CI 5.4 to 8.2) and 8.7 (95% CI 7.5 to 10.0), p=0.039. Longitudinal profiles of the scale were visually distinguished for the categories of sex and GA for the intervention versus control. Conclusions The preventive effect of AA:DHA supplementation versus no supplementation was better discriminated by the trial\u27s primary outcome, severe ROP, than by ROP-ActS. The sensitivity and the linear qualities of ROP-ActS require further validations on large data sets and perhaps modifications. Trial registration number NCT03201588

Physical restraining of nursing home residents in the last week of life : an epidemiological study in six European countries

Background: End-of-life care in nursing homes holds several risk factors for the use of physical restraints on residents, a practice shown to be neither safe nor effective. Objectives: To determine the frequency of physical limb and/or trunk restraint use in the last week of life of nursing home residents in six European countries and its association with country, resident and nursing home characteristics. Design: Epidemiological survey study. Setting: Proportionally stratified random sample of nursing homes in Belgium (BE), England (ENG), Finland (FI), Italy (IT), the Netherlands (NL), and Poland (PL). Participants: Nursing home staff (nurses or care assistants). Methods: In all participating nursing homes, we identified all residents who died during the three months prior to measurements. The staff member most involved in each resident's care indicated in a structured questionnaire whether trunk and/or limb restraints were used on that resident during the last week of life 'daily', 'less frequently than daily' or not used'. Results: In 322 nursing homes, staff returned questionnaires regarding 1384 deceased residents (response rate 81%). Limb and/or trunk restraints were used "daily" in the last week of life in 8% (BE), 1% (ENG), 4% (FI), 12% (IT), 0% (NL), and 0.4% (PL) of residents; and "less frequently than daily" in 4% (BE), 0% (ENG), 0.4% (FI), 6% (IT), 0% (NL), and 3.5% (PL) of residents. Restraint use was associated with country (p = 0.020) and inversely associated with residents' age (p = 0.017; odds ratio 0.96, 95% confidence interval 0.93 to 0.99). Restraint use was not significantly associated with resident's gender, dementia, functional status, staffing level, or the level of dependency of residents within the nursing home. Conclusions: In all but one of the six countries studied, staff reported that nursing home residents were restrained through limb and/or trunk restraints in the last week of life. The proportion of restrained residents was highest in Italy and Belgium. Organizational and resident characteristics may not be relevant predictors of restraint use at the end of life in this setting. National policy that explicitly discourages physical restraints in nursing home care and suggests alternative practices may be an important component of strategies to prevent their use. (C) 2019 The Author(s). Published by Elsevier Ltd

Implementing the theory-based advance care planning ACP+ programme for nursing homes : study protocol for a cluster randomised controlled trial and process evaluation

Background Research has highlighted the need for improving the implementation of advance care planning (ACP) in nursing homes. We developed a theory-based multicomponent ACP intervention (the ACP+ programme) aimed at supporting nursing home staff with the implementation of ACP into routine nursing home care. We describe here the protocol of a cluster randomised controlled trial (RCT) that aims to evaluate the effects of ACP+ on nursing home staff and volunteer level outcomes and its underlying processes of change. Methods We will conduct a cluster RCT in Flanders, Belgium. Fourteen eligible nursing homes will be pair-matched and one from each pair will be randomised to either continue care and education as usual or to receive the ACP+ programme (a multicomponent programme which is delivered stepwise over an eight-month period with the help of an external trainer). Primary outcomes are: nursing home care staff's knowledge of, and self-efficacy regarding ACP. Secondary outcomes are: 1) nursing home care staff's attitudes towards ACP and ACP practices; 2) support staff's and volunteer's ACP practices and 3) support staff's and volunteers' self-efficacy. Measurements will be performed at baseline and eight months post-measurement, using structured self-reported questionnaires. A process evaluation will accompany the outcome evaluation in the intervention group, with measurements throughout and post-intervention to assess implementation, mechanisms of impact and context and will be carried out using a mixed-methods design. Discussion There is little high-quality evidence regarding the effectiveness and underlying processes of change of ACP in nursing homes. This combined outcome and process evaluation of the ACP+ programme aims to contribute to building the necessary evidence to improve ACP and its uptake for nursing home residents and their family