Doing Trauma-Informed Work in a Trauma-Informed Way: Understanding Difficulties and Finding Solutions

Trauma-informed practice (TIP) is expanding as a means of improving patient safety and engagement. Accordingly, professionals and other stakeholders increasingly come together in meetings and workshops to learn about, plan and evaluate TIP in health and social care settings. However, these kinds of trauma-informed work are sometimes carried out in a way that is not itself trauma-informed - missing an opportunity to 'model the model' and risking re-traumatisation and disengagement from further trauma-informed work for some attendees. Inaccurate use of language, the desire to destigmatise, and conflation of trauma-informed and trauma-enhanced practice may all be contributing factors. Careful attention to remit and content, accuracy of language and adequate provisions around the discussion of traumatising adversities can do much to reduce the risk of psychological harm and enable our trauma-informed work to be fully enriched by those who bring lived experience that is undisclosed as well as experiences that may be extant in their roles. Issues of relationality and context are not only central to traumatisation but offer a means to avoid it, both in our work as practitioners, managers, commissioners and researchers and in the ways that we come together to plan and reflect on that TIP

Targeting sexual health services in primary care: a systematic review of the psychosocial correlates of adverse sexual health outcomes reported in probability surveys of women of reproductive age

BACKGROUND: Women using primary care vary in need for sexually transmitted infections (STIs) testing and contraception. Psychosocial correlates of these needs may be useful for targeting services. We undertook a systematic review to identify psychosocial correlates of STI acquisition, unplanned pregnancy (UP), abortion and risky sexual behaviours in general population samples of women of reproductive age. METHODS: We searched bibliographic databases for probability surveys of women aged 16-44years in the European Union, USA, Canada, Australia, UK or New Zealand undertaken January 1994-January 2014. RESULTS: Eleven papers were included. Unplanned pregnancy was associated with smoking, depression, being single and sexual debut <16years. Abortion was associated with lack of closeness to parents, leaving home at an early age, and relationship break-up. Multiple partnerships were associated with intensity of marijuana and alcohol use, and smoking. STI diagnosis was associated with relationship break-up and younger partners. Non-use of contraception was associated with smoking, obesity, relationship status, sedentary lifestyles, fatalistic pregnancy attitudes and lower alcohol use. Condom non-use was higher (at first sex) with partners 5+years older and lower (at last sex) in less stable partnerships. CONCLUSION: Psychosocial variables, particularly relationship status and smoking, may help identify women in primary care for STI testing and contraception advice and supply

Tuning of Collagen Scaffold Properties Modulates Embedded Endothelial Cell Regulatory Phenotype in Repair of Vascular Injuries In Vivo

Perivascularly implanted matrix embedded endothelial cells (MEECs) are potent regulators of inflammation and intimal hyperplasia following vascular injuries. Endothelial cells (ECs) in collagen scaffolds adopt a reparative phenotype with significant therapeutic potential. Although the biology of MEECs is increasingly understood, tuning of scaffold properties to control cell-substrate interactions is less well-studied. It is hypothesized that modulating scaffold degradation would change EC phenotype. Scaffolds with differential degradation are prepared by cross-linking and predegradation. Vascular injury increases degradation and the presence of MEECs retards injury-mediated degradation. MEECs respond to differential scaffold properties with altered viability in vivo, suppressed smooth muscle cell (SMC) proliferation in vitro, and altered interleukin-6 and matrix metalloproteinase-9 expression. When implanted perivascularly to a murine carotid wire injury, tuned scaffolds change MEEC effects on vascular repair and inflammation. Live animal imaging enables real-time tracking of cell viability, inflammation, and scaffold degradation, affording an unprecedented understanding of interactions between cells, substrate, and tissue. MEEC-treated injuries improve endothelialization and reduce SMC hyperplasia over 14 d. These data demonstrate the potent role material design plays in tuning MEEC efficacy in vivo, with implications for the design of clinical therapies.National Institutes of Health (U.S.) (Grant R01 GM 49039

Folate-Targeted Polymeric Nanoparticle Formulation of Docetaxel Is an Effective Molecularly Targeted Radiosensitizer with Efficacy Dependent on the Timing of Radiotherapy

Nanoparticle (NP) chemotherapeutics hold great potential as radiosensitizers. Their unique properties, such as preferential accumulation in tumors and their ability to target tumors through molecular targeting ligands, are ideally suited for radiosensitization. We aimed to develop a molecularly targeted nanoparticle formulation of docetaxel (Dtxl) and evaluate its property as a radiosensitizer. Using a biodegradable and biocompatible lipid-polymer NP platform and folate as a molecular targeting ligand, we engineered a folate-targeted nanoparticle (FT-NP) formulation of Dtxl. These NPs have sizes of 72±4 nm and surface charges of −42±8 mV. Using folate receptor over-expressing KB cells and folate receptor low HTB-43 cells, we showed folate-mediated intracellular uptake of NPs. In vitro radiosensitization studies initially showed FT-NP is less effective than Dtxl as a radiosensitizer. However, the radiosensitization efficacy is dependent on the timing of radiotherapy. In vitro radiosensitization conducted with irradiation given at the optimal time (24 hours) showed FT-NP Dtxl is as effective as Dtxl. When FT-NP Dtxl is compared to Dtxl and non-targeted nanoparticle (NT-NP) Dtxl in vivo, FT-NP was found to be significantly more effective than Dtxl or NT-NP Dtxl as a radiosensitizer. We also confirmed that radiosensitization is dependent on timing of irradiation in vivo. In summary, FT-NP Dtxl is an effective radiosensitizer in folate-receptor over-expressing tumor cells. Time of irradiation is critical in achieving maximal efficacy with this nanoparticle platform. To the best of our knowledge, our report is the first to demonstrate the potential of molecularly targeted NPs as a promising new class of radiosensitizers

Abstracts from the NIHR INVOLVE Conference 2017

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Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study

BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN: A multicentre observational study. SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348

Trauma and resilience informed research principles and practice:A framework to improve the inclusion and experience of disadvantaged populations in health and social care research

Trauma, socio-economic, cultural and structural issues are associated with poor outcomes for most health conditions and may also make research participation difficult and onerous, perpetuating intervention-generated inequalities by generating evidence from those least in need. Trauma-informed and resilience-informed approaches to care may help address these concerns across health and social care research. These approaches take an empowerment-based response to adversity, and are suitable for integration and extension as Trauma and Resilience Informed Research Principles and Practice (TRIRPP) for studies beyond the topics of resilience and trauma. Four TRIRPP aims were identified: addressing the adversity context that may underpin the lives of research participants and the phenomenon under study; improving study accessibility and acceptability for individuals and populations facing adversity; recognising and addressing traumatisation in potential participants; and recognising and promoting resilience. Recommendations include interview participant control of recording devices, over-sampling of under-represented populations in population surveys, and actively seeking to engage disenfranchised individuals in patient and public involvement from design to dissemination. The practice of research has the power to address adversity and trauma or to perpetuate it at both an individual and a societal level. It is feasible and worthwhile to integrate trauma-informed and resilience-informed approaches across research topics and designs. Further work should extend the TRIRPP recommendations and evaluate their use

Interventions to support reproductive and mental health among care leavers: A systematic review

Compared to other teenagers, young care leavers tend to have poorer sexual/reproductive and mental health; mental health difficulties may increase risk for poor sexual/reproductive health. This systematic review addresses a gap in knowledge regarding the effectiveness of existing interventions that support care leavers’ sexual/reproductive health (e.g., contraception, pregnancy choices, early parenting). Eight published articles spanning six interventions were eligible. Interventions were associated with improvements in a range of sexual/reproductive health measures (e.g., sexual health knowledge; knowledge of where to get support; attitudes to sexual health practices), with some indicative improvements in self-esteem. However, some studies suggested these improvements may not be sustained. Interventions tended to include a broad age range, with limited programmes specifically aimed at care leavers. While some programmes focused on attitudes toward reproductive health and pregnancy (i.e., contraception), we identified no programme focusing on parenthood choice. We also identified no sexual/reproductive health programme that targeted or assessed associated mental health problems, despite evidence of associations between sexual health and mental health difficulties. Findings suggest that care leavers may benefit from specific sexual/reproductive health supports, but further evidence is needed. Findings also indicate a need for more holistic supports that integrate mental health supports with reproductive/sexual health and consider care leaver decision-making