Missouri Department of Mental Health

ABSTRACT Background Peer support workers (PSWs) are essential to the substance use treatment and recovery system, though they often lack access to professional development that accounts for the personal recovery experiences PSWs utilize in their work. Methods This study is an evaluation of a series of five training modules for PSWs designed in collaboration with PSW consultants. Evaluation consisted of pre-/posttest knowledge questions and qualitative feedback from individuals who completed all five modules. Results Knowledge scores increased for all five modules. Qualitative feedback was largely positive, with participants suggesting that integrating PSWs into the module development team made the finished product more relevant to PSWs. Conclusions Findings affirmed the importance of providing training designed by and for PSWs working with people with substance use disorders and suggested that PSW confidence can be improved through targeted training. This training development model demonstrates promise for future substance use training programs for PSWs.

High salt intake is associated with hypertension, which is a leading modifiable risk factor for cardiovascular disease. To assess the association of a government-led, multisectoral, and population-based intervention with reduced salt intake and blood pressure in Shandong Province, China. This cross-sectional study used data from the Shandong-Ministry of Health Action on Salt and Hypertension (SMASH) program, a 5-year intervention to reduce sodium consumption in Shandong Province, China. Two representative samples of adults (aged 18-69 years) were surveyed in 2011 (15 350 preintervention participants) and 2016 (16 490 postintervention participants) to examine changes in blood pressure, and knowledge, attitudes, and behaviors related to sodium intake. Urine samples were collected from random subsamples (2024 preintervention participants and 1675 postintervention participants) for measuring sodium and potassium excretion. Data were analyzed from January 20, 2017, to April 9, 2019. Media campaigns, distribution of scaled salt spoons, promotion of low-sodium products in markets and restaurants, and activities to support household sodium reduction and school-based sodium reduction education. The primary outcome was change in urinary sodium excretion. Secondary outcomes were changes in potassium excretion, blood pressure, and knowledge, attitudes, and behaviors. Outcomes were adjusted for likely confounders. Means (95% CIs) and percentages were weighted. Among 15 350 participants in 2011, 7683 (50.4%) were men and the mean age was 40.7 years (95% CI, 40.2-41.2 years); among 16 490 participants in 2016, 8077 (50.7%) were men and the mean age was 42.8 years (95% CI, 42.5-43.1 years). Among participants with 24-hour urine samples, 1060 (51.8%) were men and the mean age was 40.9 years (95% CI, 40.5-41.3 years) in 2011 and 836 (50.7%) were men and the mean age was 40.7 years (95% CI, 40.1-41.4 years) in 2016. The 24-hour urinary sodium excretion decreased 25% from 5338 mg per day (95% CI, 5065-5612 mg per day) in 2011 to 4013 mg per day (95% CI, 3837-4190 mg per day) in 2016 (P < .001), and potassium excretion increased 15% from 1607 mg per day (95% CI, 1511-1704 mg per day) to 1850 mg per day (95% CI, 1771-1929 mg per day) (P < .001). Adjusted mean systolic blood pressure among all participants decreased from 131.8 mm Hg (95% CI, 129.8-133.8 mm Hg) to 130.0 mm Hg (95% CI, 127.7-132.4 mm Hg) (P = .04), and diastolic blood pressure decreased from 83.9 mm Hg (95% CI, 82.6-85.1 mm Hg) to 80.8 mm Hg (95% CI, 79.4-82.1 mm Hg) (P < .001). Knowledge, attitudes, and behaviors associated with dietary sodium reduction and hypertension improved significantly. The findings suggest that a government-led and population-based intervention in Shandong, China, was associated with significant decreases in dietary sodium intake and a modest reduction in blood pressure. The results of SMASH may have implications for sodium reduction and blood pressure control in other regions of China and worldwide.

Several state Medicaid reforms are under way, but the relative performance of different approaches is unclear. To compare the performance of Oregon's and Colorado's Medicaid Accountable Care Organization (ACO) models. Oregon initiated its Medicaid transformation in 2012, supported by a $1.9 billion investment from the federal government, moving most Medicaid enrollees into 16 Coordinated Care Organizations, which managed care within a global budget. Colorado initiated its Medicaid Accountable Care Collaborative in 2011, creating 7 Regional Care Collaborative Organizations that received funding to coordinate care with providers and connect Medicaid enrollees with community services. Data spanning July 1, 2010, through December 31, 2014 (18 months before intervention and 24 months after intervention, treating 2012 as a transition year) were analyzed for 452 371 Oregon and 330 511 Colorado Medicaid enrollees, assessing changes in outcomes using difference-in-differences analyses of regional focus, primary care homes, and care coordination. Oregon's Coordinated Care Organization model was more comprehensive in its reform goals and in the imposition of downside financial risk. Regional focus, primary care homes, and care coordination in Medicaid ACOs. Performance on claims-based measures of standardized expenditures and utilization for selected services, access, preventable hospitalizations, and appropriateness of care. In a total of 782 882 Medicaid enrollees, 45.0% were male, with mean (SD) age 16.74 (14.41) years. Standardized expenditures for selected services declined in both states during the 2010-2014 period, but these decreases were not significantly different between the 2 states. Oregon's model was associated with reductions in emergency department visits (-6.28 per 1000 beneficiary-months; 95% CI, -10.51 to -2.05) and primary care visits (-15.09 visits per 1000 beneficiary-months; 95% CI, -26.57 to -3.61), improvements in acute preventable hospital admissions (-1.01 admissions per 1000 beneficiary-months; 95% CI, -1.61 to -0.42), 3 of 4 measures of access (well-child visits, ages 3-6 years, 2.69%; 95% CI, 1.20% to 4.19%; adolescent well-care visits, 6.77%; 95% CI, 5.22% to 8.32%; and adult access to preventive ambulatory care, 1.26%; 95% CI, 0.28% to 2.25%), and 1 of 4 measures of appropriateness of care (avoidance of head imaging for uncomplicated headache, 2.59%; 95% CI, 1.35% to 3.83%). Two years into implementation, Oregon's and Colorado's Medicaid ACO models exhibited similar performance on standardized expenditures for selected services. Oregon's model, marked by a large federal investment and movement to global budgets, was associated with improvements in some measures of utilization, access, and quality, but Colorado's model paralleled Oregon's on several other metrics.

To report a case of extrapyramidal reaction associated with a dosage increase of clozapine. A 44-year-old white man with a 20-year history of chronic paranoid schizophrenia was admitted to an inpatient psychiatric facility. His prior medications restarted on admission were clozapine 650 mg at bedtime, haloperidol 10 mg at bedtime, clonazepam 2 mg/d, and aspirin 325 mg/d. Two days after admission (hospital day 3), clozapine and clonazepam were discontinued, and he was prescribed haloperidol 5 mg every morning and 10 mg every evening. Stabilization occurred over the following 24 days, with progressively lower dosages of haloperidol and increasing dosages of clozapine. Haloperidol was discontinued on day 24. On day 47, the patient was agitated and making bizarre statements; thus, the morning dose of clozapine was increased by 50 mg (total 450 mg/d). On day 48 at 2200, a dystonic reaction was diagnosed; he received intramuscular diphenhydramine 50 mg, which caused the reaction to subside. At the time of the adverse reaction, he was prescribed clozapine 450 mg/d, vitamin E 400 IU three times daily, aspirin 325 mg/d, and acetaminophen, milk of magnesia, and Maalox as needed. Although the risk of extrapyramidal symptoms (EPS) is significantly lower with clozapine than with conventional agents, elevated clozapine blood concentrations have been reported to cause EPS; other reports have cited severe dystonias and dyskinesias on abrupt clozapine withdrawal. Considering the medications prescribed at the time and the discontinuation of haloperidol 24 days before the event, clozapine was the most likely cause of the extrapyramidal reaction. Regardless of anticipated safety associated with novel antipsychotics such as clozapine, reports of dystonic reactions must be taken into account and patients monitored appropriately.

To determine the relationship among neuropsychological variables, vocational outcomes, and vocational costs for Missouri Division of Vocational Rehabilitation (MO-DVR) clients with traumatic brain injury (TBI). Clients referred for neuropsychological evaluations were followed until DVR case closure. Subjects were grouped according to the following DVR status at case closure: Successfully Employed, Services Interrupted, and No Services Provided. Spearman correlations with Bonferroni corrections were calculated to determine relationships among variables, and Kruskal-Wallis nonparametric one-way analyses of variance (ANOVAs) were conducted to evaluate differences in DVR group status in terms of neuropsychological variables and DVR costs. All evaluations were completed through a Midwestern university neuropsychology laboratory. 110 consecutively referred DVR clients with nonacute TBI referred for neuropsychological evaluation. Absolute level (ie, raw/standard scores) of neuropsychological functioning and relative degree of decline in: intelligence (WAIS-R), memory (WMS-R General and Delayed Memory Indices), attention (WMS-R Attention Index), speed of processing (Trails A), and cognitive flexibility (Trails B); DVR costs at closure. 1) Surprisingly, the Successfully Employed group had significantly greater neuropsychological impairments; 2) Greater decline in delayed memory was associated with higher DVR costs (r = -0.30, P <.05); and 3) More indices of relative decline were significantly correlated with vocational outcomes (5/6) than were indices of absolute functioning (3/6). DVR is effective in providing services to individuals with the most significant neuropsychological deficits; it is important to consider both absolute level of functioning and relative decline in functioning when evaluating TBI.

Based on the discussion of NMS, certain conclusions may be reached in regard to this patient. In the psychiatric setting, agitation and confusion alone are not suggestive of NMS. However in this patient, the symptoms of agitation, the rapid development of EPS symptoms unresponsive to anticholinergic therapy, autonomic changes (tachycardia, diaphoresis, and incontinence), and elevated CPK, met most of the diagnostic criteria described in Table VI. However, this case may have described an atypical presentation of NMS because of the absence of temperature increases during the onset of symptoms and the 7-week hospitalization for NMS. The patient's later onset of temperature elevations was a result of an aspiration pneumonia. Pneumonia and renal failure significantly increased the morbidity and extended the course of the illness. As a result, the diagnosis and specific treatment of NMS were delayed because of atypical symptoms and complications. In this patient, treatment of NMS with bromocriptine did not start until 10 days into hospitalization. A delay in pharmacologic therapy in this patient may have contributed to persistence of symptoms. The patient showed signs of improvement on day 21 during combination bromocriptine, benztropine, and dantrolene therapy. Moreover, this case exemplifies the rigorous need for supportive therapy and adjunctive pharmacologic therapy for primary and secondary complications resulting from NMS. In conclusion, because of the wide range of risk factors and variations of NMS, a systematic approach to diagnosing and treating NMS is critical to a successful outcome. Discontinuation of antipsychotics, maintenance of supportive therapy aimed at preventing dehydration, hemodynamic, and electrolyte imbalances, and pharmacotherapy are essential in the treatment of NMS.