Moving towards trauma informed care. A model of research and practice.

Context: Cork Simon Community offers care, accommodation and support for almost 1200 people annually. The current unprecedented housing crisis is pushing people into homelessness and preventing people from leaving homelessness. With increasing demands on resources those who are often the most vulnerable struggle to navigate systems and services and thus consideration of service design and delivery is required in order to maximise a service user’s ability to engage effectively. There is a growing body of research that argues that trauma informed care (TIC) improves outputs for both staff and the people they serve. Aims & Method: The aim of this project is threefold; (a) establish the prevalence of trauma within Cork Simon Community (b) assess Cork Simon Community’s capacity for Trauma Informed Care (c) ascertain the implications of the findings for clinical and non-clinical interventions within homeless settings. This aim was addressed by completing three research studies. Trauma awareness training was also delivered to 120+ staff and data regarding capacity for TIC was collected at 6 training dates. 1. Establish service users’ levels of early childhood trauma (ACE’s) 2. Establish staff/volunteers levels of vicarious trauma (ProQOL) 3. Complete agency trauma informed assessment The model (Fig. 1.0) offered an integrated exploration of the experiences of service users, and staff in parallel with the organisation they operating within. The information gained from these micro and macro perspectives informed the content of the trauma training as a means of amplifying existing strengths while shoring up skills and service deficits. Fig 1.0 Model of TIC Implementation vi Findings & Conclusions: The results of the ACE study revealed that there are significant levels of childhood trauma in the Service Users who participated in the research and that SU’s were experiencing a range of negative health related behaviours as a result of substance misuse, homelessness and associated behaviours. The results of the staff audit for secondary trauma revealed that there is considerable satisfaction with the work among staff but that there is a trauma contagion effect and that one quarter of the staff surveyed reported signs of secondary traumatic stress with 12% reporting indicators of burn out. The implementation of TIC and a re-evaluation of staff supervision and self-care processes can mitigate this. An agency self- assessment for capacity for TIC revealed that in the main many of the organisations existing policies and procedures are operating from a place that provides for working with deeply traumatised people. There were some areas for improvement and these were mostly constrained by resource issues. There were a number of issues identified that are beyond the organisations control as they are dictated by national policies such as intake paperwork that is not strengths based and a policy of ‘centre of interest’1 that disregards a persons’ choices which may well be dictated by an avoidance of memories of trauma situations. Organisations that work with people experiencing homelessness should advocate for greater resources and changes to national policies that conflict with strengths based trauma informed approaches. A number of recommendations have been provided

Factors Associated with Revision Surgery after Internal Fixation of Hip Fractures

Background: Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. Methods: We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. Results: Factors associated with increased risk of revision surgery included: female sex, [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.25-2.50; P = 0.001], higher body mass index (fo

The thiol -mediated modification of radiation induced DNA strand break induction and cell survival after irradiation

This dissertation addresses the mechanism by which thiol compounds can modify cellular radiation response. The differential radiation response between aerobic and hypoxic conditions is well established for the experimental endpoints of cell and DNA damage and is commonly known as the Oxygen Effect or the oxygen Enhancement Ratio (OER). intracellular non-protein thiol compounds had been presumed responsible for enhanced cell survival or reduced DNA damage after irradiation in hypoxic conditions. The use of a fluorescent thiol binding agent to quantify the dominant non-protein thiol compound glutathione (GSH) against the background of protein thiols in individual cells with flow cytometry has been done. It was found that cell line specific variability interfered with uniform GSH quantitation by flow cytometry unless a membrane permeabilization technique was employed. Measurement of GSH content of cells dissociated from 9L rodent tumors invalidated the clinical utility of this assay due to irreversible thiol depletion during the disaggregation process. The DNA damage work presented herein utilizes three different DNA damage assays: alkaline elution, neutral elution and Pulsed Field gel electrophoresis (PFGE), to demonstrate an important role for nuclear protein thiols. Isolated nuclei were prepared by two different methods wherein non-protein thiols were virtually eliminated, yet a measurable OER was still evident. Under these circumstances, it was possible to conclude that nuclear protein thiols play a much more important role in the production of the OER than had been suspected. Further work to identify the principle proteins involved in this process is planned. Regarding cell survival after irradiation, this dissertation utilizes a novel technique of cell suspension culture wherein human colon tumor (HCT-116 line) cells were irradiated at 37°C with continuous monitoring of oxygen tension and very accurate intracellular thiol measurements combined with traditional survival techniques to reveal an unexpectedly significant role for cysteine as a cellular radiation protector. This work strongly supports the clinical significance of high cysteine content in rodent tumors by this laboratory

The thiol -mediated modification of radiation induced DNA strand break induction and cell survival after irradiation

This dissertation addresses the mechanism by which thiol compounds can modify cellular radiation response. The differential radiation response between aerobic and hypoxic conditions is well established for the experimental endpoints of cell and DNA damage and is commonly known as the Oxygen Effect or the oxygen Enhancement Ratio (OER). intracellular non-protein thiol compounds had been presumed responsible for enhanced cell survival or reduced DNA damage after irradiation in hypoxic conditions. The use of a fluorescent thiol binding agent to quantify the dominant non-protein thiol compound glutathione (GSH) against the background of protein thiols in individual cells with flow cytometry has been done. It was found that cell line specific variability interfered with uniform GSH quantitation by flow cytometry unless a membrane permeabilization technique was employed. Measurement of GSH content of cells dissociated from 9L rodent tumors invalidated the clinical utility of this assay due to irreversible thiol depletion during the disaggregation process. The DNA damage work presented herein utilizes three different DNA damage assays: alkaline elution, neutral elution and Pulsed Field gel electrophoresis (PFGE), to demonstrate an important role for nuclear protein thiols. Isolated nuclei were prepared by two different methods wherein non-protein thiols were virtually eliminated, yet a measurable OER was still evident. Under these circumstances, it was possible to conclude that nuclear protein thiols play a much more important role in the production of the OER than had been suspected. Further work to identify the principle proteins involved in this process is planned. Regarding cell survival after irradiation, this dissertation utilizes a novel technique of cell suspension culture wherein human colon tumor (HCT-116 line) cells were irradiated at 37°C with continuous monitoring of oxygen tension and very accurate intracellular thiol measurements combined with traditional survival techniques to reveal an unexpectedly significant role for cysteine as a cellular radiation protector. This work strongly supports the clinical significance of high cysteine content in rodent tumors by this laboratory

Moving towards trauma informed care. A model of research and practice.

Context: Cork Simon Community offers care, accommodation and support for almost 1200 people annually. The current unprecedented housing crisis is pushing people into homelessness and preventing people from leaving homelessness. With increasing demands on resources those who are often the most vulnerable struggle to navigate systems and services and thus consideration of service design and delivery is required in order to maximise a service user’s ability to engage effectively. There is a growing body of research that argues that trauma informed care (TIC) improves outputs for both staff and the people they serve. Aims & Method: The aim of this project is threefold; (a) establish the prevalence of trauma within Cork Simon Community (b) assess Cork Simon Community’s capacity for Trauma Informed Care (c) ascertain the implications of the findings for clinical and non-clinical interventions within homeless settings. This aim was addressed by completing three research studies. Trauma awareness training was also delivered to 120+ staff and data regarding capacity for TIC was collected at 6 training dates. 1. Establish service users’ levels of early childhood trauma (ACE’s) 2. Establish staff/volunteers levels of vicarious trauma (ProQOL) 3. Complete agency trauma informed assessment The model (Fig. 1.0) offered an integrated exploration of the experiences of service users, and staff in parallel with the organisation they operating within. The information gained from these micro and macro perspectives informed the content of the trauma training as a means of amplifying existing strengths while shoring up skills and service deficits. Fig 1.0 Model of TIC Implementation vi Findings & Conclusions: The results of the ACE study revealed that there are significant levels of childhood trauma in the Service Users who participated in the research and that SU’s were experiencing a range of negative health related behaviours as a result of substance misuse, homelessness and associated behaviours. The results of the staff audit for secondary trauma revealed that there is considerable satisfaction with the work among staff but that there is a trauma contagion effect and that one quarter of the staff surveyed reported signs of secondary traumatic stress with 12% reporting indicators of burn out. The implementation of TIC and a re-evaluation of staff supervision and self-care processes can mitigate this. An agency self- assessment for capacity for TIC revealed that in the main many of the organisations existing policies and procedures are operating from a place that provides for working with deeply traumatised people. There were some areas for improvement and these were mostly constrained by resource issues. There were a number of issues identified that are beyond the organisations control as they are dictated by national policies such as intake paperwork that is not strengths based and a policy of ‘centre of interest’1 that disregards a persons’ choices which may well be dictated by an avoidance of memories of trauma situations. Organisations that work with people experiencing homelessness should advocate for greater resources and changes to national policies that conflict with strengths based trauma informed approaches. A number of recommendations have been provided

Supplementary Table 1

Bacterial reads assigned to the genus level in all samples analyzed, as identified by sample ID and subject ID. Samples have been pre-filtered for singleton OTUs and sub-sampled at a depth of 1,500 sequences.<br

Fracture fixation in the operative management of hip fractures (FAITH) : an international, multicentre, randomised controlled trial

Background Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. Methods For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Findings Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0·83, 95% CI 0·63–1·09; p=0·18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1·91, 1·06–3·44; p=0·0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0·82; appendix); these events included pulmonary embolism (two patients [<1%] vs four [1%] patients; p=0·41) and sepsis (seven [1%] vs six [1%]; p=0·79). Interpretation In terms of reoperation rates the sliding hip screw shows no advantage, but some groups of patients (smokers and those with displaced or base of neck fractures) might do better with a sliding hip screw than with cancellous screws. Funding National Institutes of Health, Canadian Institutes of Health Research, Stichting NutsOhra, Netherlands Organisation for Health Research and Development, Physicians' Services Incorporated

Fracture fixation in the operative management of hip fractures (FAITH) : an international, multicentre, randomised controlled trial

Background Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. Methods For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Findings Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0·83, 95% CI 0·63–1·09; p=0·18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1·91, 1·06–3·44; p=0·0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0·82; appendix); these events included pulmonary embolism (two patients [<1%] vs four [1%] patients; p=0·41) and sepsis (seven [1%] vs six [1%]; p=0·79). Interpretation In terms of reoperation rates the sliding hip screw shows no advantage, but some groups of patients (smokers and those with displaced or base of neck fractures) might do better with a sliding hip screw than with cancellous screws. Funding National Institutes of Health, Canadian Institutes of Health Research, Stichting NutsOhra, Netherlands Organisation for Health Research and Development, Physicians' Services Incorporated