Health and Well-Being of Physical Trauma Survivors: Who Follows Up?

Given the growing number of physical trauma survivors, it is imperative that mental health clinicians, medical providers, researchers, and policy makers are aware of their unique biological, psychological, and social health concerns, as well as the role of their primary support persons. Resiliency theory proposes that within each individual there are protective factors and negative outcomes. This dissertation was written to help identify the protective factors and negative outcomes that impact physical trauma survivors' biological, psychological, and social health, an area of the literature that is underexplored. This dissertation includes three articles: (a) a systematic review of literature published on the protective factors and negative outcomes of traumatic musculoskeletal injury survivors, (b) a research study on the health and well-being of physical trauma survivors, and (c) a policy brief synthesizing the findings from a systematic review of the literature and descriptive quantitative study to offer policy-, programmatic-, and screening recommendations to best support physical trauma patients' BPS recovery. The research question that guided the systematic review was, "What are the biopsychosocial-spiritual (BPS-S) protective factors that impact negative health outcomes among adult survivors of traumatic musculoskeletal injuries?" According to the studies reviewed, the biological factors that impacted negative outcomes included patients who underwent longer hospitalizations and whose perceptions of their injuries were more severe reported poorer physical functioning during follow-ups. The connection between biological health and psychological health was found among physical trauma patients' whose injuries were worse (measured by hospitalization) or perceptions of injuries was worse reported higher PTSD symptom severity. Additionally, patients with psychiatric histories had a higher likelihood of worse physical functioning. A positive correlation was found between depression and PTSD at baseline and during multiple follow-up time points with higher depression scores predicting greater likelihood for manifesting PTSD. It was surprising and unfortunate that there were no studies admitted to the systematic review that evaluated social or spiritual factors of physical trauma patients. In general, the systematic review pointed to the need for more studies looking at the biopsychosocial-spiritual health factors of traumatic musculoskeletal injury survivors, particularly within the United States. Specifically, researchers reported the importance of age and time passed after the injury on negative recovery outcomes and the utilization of pharmacological interventions as a protective factor for physical trauma patients. Additional research with larger sample sizes and more diverse demographic samples are needed to further these findings. The research question that guided the dissertation research study was, "What are the health and well-being factors that impact physical trauma survivor patients' adherence to follow up appointments?" The dissertation research study found older and self-pay/uninsured patients were less likely to attend follow-up appointments. Whereas patients who experienced motor vehicle accidents or motorcycle crashes (whether it was the vehicle or pedestrian) were more likely to attend the follow-up appointments than any other modality of injury (e.g., gunshot wounds, stabbings, assaults, falls, or others), as well as patients who reported higher levels of PTSD symptoms or higher levels of general health and well-being. Upon completion of a binary logistic regression on studies' independent variables, which controlled for other factors, including patients' health insurance type (e.g., Medicaid/Medicare, private insurance, and self-pay/uninsured), race, the presence of any substances (e.g., ethanol alcohol or legal/illegal substances), the distance from the patient home to the follow-up clinic, or the injury severity score of the patient. The systematic review and dissertation research study were the inspiration for the final chapter's policy brief advocating for mandatory mental health screening, brief intervention, referral, and treatment in outpatient and inpatient trauma care facilities

Practice transformations to optimize the delivery of HIV primary care in community healthcare settings in the United States: A program implementation study.

BackgroundThe United States HIV care workforce is shrinking, which could complicate service delivery to people living with HIV (PLWH). In this study, we examined the impact of practice transformations, defined as efficiencies in structures and delivery of care, on demonstration project sites within the Workforce Capacity Building Initiative, a Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program Special Projects of National Significance (SPNS).Methods and findingsData were collected at 14 demonstration project sites in 7 states and the District of Columbia. Organizational assessments were completed at sites once before and 4 times after implementation. They captured 3 transformation approaches: maximizing the HIV care workforce (efforts to increase the number of existing healthcare workforce members involved in the care of PLWH), share-the-care (team-based care giving more responsibility to midlevel providers and staff), and enhancing client engagement in primary HIV care to reduce emergency and inpatient care (e.g., care coordination). We also obtained Ryan White HIV/AIDS Program Services Reports (RSRs) from sites for calendar years (CYs) 2014-2016, corresponding to before, during, and after transformation. The RSR include data on client retention in HIV care, prescription of antiretroviral therapy (ART), and viral suppression. We used generalized estimating equation (GEE) models to analyze changes among sites implementing each practice transformation approach. The demonstration projects had a mean of 18.5 prescribing providers (SD = 23.5). They reported data on more than 13,500 clients per year (mean = 969/site, SD = 1,351). Demographic characteristics remained similar over time. In 2014, a majority of clients were male (71% versus 28% female and 0.2% transgender), with a mean age of 47 (interquartile range [IQR] 37-54). Racial/ethnic characteristics (48% African American, 31% Hispanic/Latino, 14% white) and HIV risk varied (31% men who have sex with men; 31% heterosexual men and women; 7% injection drug use). A substantial minority was on Medicaid (41%). Across sites, there was significant uptake in practices consistent with maximizing the HIV care workforce (18% increase, p < 0.001), share-the-care (25% increase, p < 0.001), and facilitating patient engagement in HIV primary care (13% increase, p < 0.001). There were also significant improvements over time in retention in HIV care (adjusted odds ratio [aOR] = 1.03; 95% confidence interval [CI] 1.02-1.04; p < 0.001), ART prescription levels (aOR = 1.01; 95% CI 1.00-1.01; p < 0.001), and viral suppression (aOR = 1.03; 95% CI 1.02-1.04; p < 0.001). All outcomes improved at sites that implemented transformations to maximize the HIV care workforce or improve client engagement. At sites that implemented share-the-care practices, only retention in care and viral suppression outcomes improved. Study limitations included use of demonstration project sites funded by the Ryan White HIV/AIDS Program (RWHAP), which tend to have better HIV outcomes than other US clinics; varying practice transformation designs; lack of a true control condition; and a potential Hawthorne effect because site teams were aware of the evaluation.ConclusionsIn this study, we found that practice transformations are a potential strategy for addressing anticipated workforce challenges among those providing care to PLWH. They hold the promise of optimizing the use of personnel and ensuring the delivery of care to all in need while potentially enhancing HIV care continuum outcomes

Gait Analysis of Teenagers and Young Adults Diagnosed with Autism & Severe Verbal Communication Disorders

Both movement differences and disorders are common within autism spectrum disorders (ASD). These differences have wide and heterogeneous variability among different ages and sub-groups all diagnosed with ASD. Gait was studied in a more homogeneously identified group of nine teenagers and young adults who scored as “severe” in both measures of verbal communication and overall rating of Autism on the Childhood Autism Rating Scales (CARS). The ASD individuals were compared to a group of typically developing university undergraduates of similar ages. All participants walked a distance of 6-meters across a GAITRite (GR) electronic walkway for six trials. The ASD and comparison groups differed widely on many spatiotemporal aspects of gait including: step and stride length, foot positioning, cadence, velocity, step time, gait cycle time, swing time, stance time, and single and double support time. Moreover, the two groups differed in the percentage of the total gait cycle in each of these phases. The qualitative rating of “Body Use” on the CARS also indicated severe levels of unusual body movement for all of the ASD participants. These findings demonstrate that older teens and young adults with “severe” forms of Verbal Communication Impairments and Autism differ widely in their gait from typically developing individuals. The differences found in the current investigation are far more pronounced compared to previous findings with younger and/or less severely involved individuals diagnosed with ASD as compared to typically developing controls. As such, these data may be a useful anchor-point in understanding the trajectory of development of gait specifically and motor functions generally.

Two-Legged Hopping in Autism Spectrum Disorders

Sensory processing deficits are common within autism spectrum disorders (ASD). Deficits have a heterogeneous dispersion across the spectrum and multimodal processing tasks are thought to magnify integration difficulties. Two-legged hopping in place in sync with an auditory cue (2.3, 3.0 Hz) was studied in a group of six individuals with expressive language impaired ASD (ELI-ASD) and an age-matched control group. Vertical ground reaction force data were collected and discrete Fourier transforms were utilized to determine dominant hopping cadence. Effective leg stiffness was computed through a mass-spring model representation. The ELI-ASD group were unsuccessful in matching their hopping cadence (2.21 ± 0.30 hops·s−1, 2.35 ± 0.41 hops·s−1) to either auditory cue with greater deviations at the 3.0 Hz cue. In contrast, the control group was able to match hopping cadence (2.35 ± 0.06 hops·s−1, 3.02 ± 0.10 hops·s−1) to either cue via an adjustment of effective leg stiffness. The ELI-ASD group demonstrated a varied response with an interquartile range (IQR) in excess of 0.5 hops·s−1 as compared to the control group with an IQR \u3c 0.03 hops·s−1. Several sensorimotor mechanisms could explain the inability of participants with ELI-ASD to modulate motor output to match an external auditory cue. These results suggest that a multimodal gross motor task can (1) discriminate performance among a group of individuals with severe autism, and (2) could be a useful quantitative tool for evaluating motor performance in individuals with ASD individuals

Sex, Diabetes Status and Cognition: Findings from the Study of Longevity in Diabetes

INTRODUCTION: Women comprise two-thirds of people with dementia, making female sex a significant dementia risk factor. Both type 1 diabetes (T1D) and type 2 diabetes (T2D) are known dementia risk factors with an increasing global incidence. Understanding whether subtle sex differences persist in cognitive function prior to dementia in the context of diabetes may help elucidate the magnitude of sex effects on dementia risk. RESEARCH DESIGN AND METHODS: We examined cross-sectional data from the Study of Longevity in Diabetes (SOLID), a prospective cohort study of members of Kaiser Permanente Northern California aged 60 years and older with T1D (n=758), T2D (n=232) and without either T1D or T2D (n=247). We used factor analysis to generate summary scores of cognitive domains and used regression analyses to examine the associations between sex and cognition adjusting for sociodemographic and cardiovascular confounders. RESULTS: We included 1237 participants (630 women and 607 men) with mean age 68 years. By design, the distribution of men and women in T1D, T2D and no diabetes was similar. Women had better cognitive performance than men in global cognition (β=0.21, 95% CI 0.16 to 0.26), language (β=0.08, 95% CI 0.004 to 0.15), executive function (β=0.13, 95% CI 0.05 to 0.20), episodic verbal memory (β=0.68, 95% CI 0.59 to 0.77) and attention (β=0.20, 95% CI 0.11 to 0.28) but not in episodic visual memory (β=0.006, 95% CI -0.07 to 0.09) adjusting for age and education independent of diabetes status. We did not find an interaction between sex and diabetes status for any of the cognitive outcomes. CONCLUSIONS: Women in late mid-life have better cognitive performance than men in many cognitive domains independent of the presence of T1D or T2D. Further work is required to understand whether these differences change over time or in older cohorts and to understand their relationship to subsequent dementia

Distribution of Terrestrially Derived Dissolved Organic Matter on the Southeastern United States Continental Shelf

Dissolved lignin-derived compounds in seawater indicate the presence of organic matter originating from vascular plants and therefore from terrestrial (upland and coastal marsh) ecosystems. We used a hydrophobic resin to concentrate lignin-rich humic substances and to determine concentrations of lignin oxidation products (vanillyl lignin phenols) for waters of the continental shelf of the southeastern U.S. Lignin phenol concentrations ranged from 0.05 to 4.2µg liter‒1 and accounted for 0.002–0.13% of the total dissolved organic carbon (DOC) pool in continental shelf waters. Dissolved lignin concentrations were generally highest near the shore and in those areas receiving greatest river and marsh discharge. Concentrations varied on both short-term (weekly) and seasonal time scales, however, indicating that the contribution of terrestrially derived dissolved organic matter to the C budget of the shelf is quite variable. Salinity (\u3e 31‰) was significantly correlated (negatively) with lignin phenol concentrations during three of four cruises, suggesting largely conservative mixing of lignin-derived material on the shelf In selected rivers and salt marshes contributing terrestrially derived organic matter to the continental shelf, lignin phenol C accounted for 0.14–1.0% of the DOC. A simple mixing model which assumes no biological or physical sinks of lignin-derived material during transport from terrestrial sources to the shelf predicts that an average of 6–36% of nearshore DOC derives from terrestrial ecosystems, depending on whether the terrestrial end-member (lignin source) is assumed to be a river or a salt marsh, while 5–26% of inner shelf DOC and 3–18% of mid- to outer-shelf DOC is of terrestrial origin

Bacterial transcriptional response to labile exometabolites from photosynthetic picoeukaryote Micromonas commoda

Dissolved primary production released into seawater by marine phytoplankton is a major source of carbon fueling heterotrophic bacterial production in the ocean. The composition of the organic compounds released by healthy phytoplankton is poorly known and difficult to assess with existing chemical methods. Here, expression of transporter and catabolic genes by three model marine bacteria (Ruegeria pomeroyi DSS-3, Stenotrophomonas sp. SKA14, and Polaribacter dokdonensis MED152) was used as a biological sensor of metabolites released from the picoeukaryote Micromonas commoda RCC299. Bacterial expression responses indicated that the three species together recognized 38 picoeukaryote metabolites. This was consistent with the Micromonas expression of genes for starch metabolism and synthesis of peptidoglycan-like intermediates. A comparison of the hypothesized Micromonas exometabolite pool with that of the diatom Thalassiosira pseudonana CCMP1335, analyzed previously with the same biological sensor method, indicated that both phytoplankton released organic acids, nucleosides, and amino acids, but differed in polysaccharide and organic nitrogen release. Future ocean conditions are expected to favor picoeukaryotic phytoplankton over larger-celled microphytoplankton. Results from this study suggest that such a shift could alter the substrate pool available to heterotrophic bacterioplankton

Newborn survival: a multi-country analysis of a decade of change

Neonatal deaths account for 40% of global under-five mortality and are ever more important if we are to achieve the Millennium Development Goal 4 (MDG 4) on child survival. We applied a results framework to evaluate global and national changes for neonatal mortality rates (NMR), healthy behaviours, intervention coverage, health system change, and inputs including funding, while considering contextual changes. The average annual rate of reduction of NMR globally accelerated between 2000 and 2010 (2.1% per year) compared with the 1990s, but was slower than the reduction in mortality of children aged 1-59 months (2.9% per year) and maternal mortality (4.2% per year). Regional variation of NMR change ranged from 3.0% per year in developed countries to 1.5% per year in sub-Saharan Africa. Some countries have made remarkable progress despite major challenges. Our statistical analysis identifies inter-country predictors of NMR reduction including high baseline NMR, and changes in income or fertility. Changes in intervention or package coverage did not appear to be important predictors in any region, but coverage data are lacking for several neonatal-specific interventions. Mortality due to neonatal infection deaths, notably tetanus, decreased, and deaths from complications of preterm birth are increasingly important. Official development assistance for maternal, newborn and child health doubled from 2003 to 2008, yet by 2008 only 6% of this aid mentioned newborns, and a mere 0.1% (US$4.56m) exclusively targeted newborn care. The amount of newborn survival data and the evidence based increased, as did recognition in donor funding. Over this decade, NMR reduction seems more related to change in context, such as socio-economic factors, than to increasing intervention coverage. High impact cost-effective interventions hold great potential to save newborn lives especially in the highest burden countries. Accelerating progress requires data-driven investments and addressing context-specific implementation realitie

Growth-stage-related shifts in phytoplankton endometabolome composition set the stage for bacterial heterotrophy

Phytoplankton-derived metabolites fuel a large fraction of heterotrophic bacterial production in the global ocean, yet methodological challenges have limited our understanding of the organic molecules transferred between these microbial groups. In an experimental bloom study consisting of three heterotrophic marine bacteria growing together with the diatom Thalassiosira pseudonana, we concurrently measured diatom endometabolites (i.e., potential exometabolite supply) by nuclear magnetic resonance (NMR) spectroscopy and bacterial gene expression (i.e., potential exometabolite uptake) by metatranscriptomic sequencing. Twenty-two diatom endometabolites were annotated, with nine increasing in internal concentration in the late stage of the bloom, eight decreasing, and five showing no variation through the bloom progression. Some metabolite changes could be linked to shifts in diatom gene expression, as well as to shifts in bacterial community composition and their expression of substrate uptake and catabolism genes. Yet an overall low match indicated that endometabolome concentration was not a good predictor of exometabolite availability, and that complex physiological and ecological interactions underlie metabolite exchange. Six diatom endometabolites accumulated to higher concentrations in the bacterial co-cultures compared to axenic cultures, suggesting a bacterial influence on rates of synthesis or release of glutamate, arginine, leucine, 2,3-dihydroxypropane-1-sulfonate, glucose, and glycerol-3-phosphate. Better understanding of phytoplankton metabolite production, release, and transfer to assembled bacterial communities is key to untangling this nearly invisible yet pivotal step in ocean carbon cycling