Neuropsychological Evaluation in Traumatic Brain Injury.

Neuropsychological evaluations can be helpful in the aftermath of traumatic brain injury. Cognitive functioning is assessed using standardized assessment tools and by comparing an individual's scores on testing to normative data. These evaluations examine objective cognitive functioning as well as other factors that have been shown to influence performance on cognitive tests (eg, psychiatric conditions, sleep) in an attempt to answer a specific question from referring providers. Referral questions may focus on the extent of impairment, the trajectory of recovery, or ability to return to work, sport, or the other previous activity.

Comparing effectiveness of residential versus intensive virtual treatment for veterans with posttraumatic stress disorder.

OBJECTIVE: During the COVID-19 pandemic, restrictions imposed on residential treatment programs necessitated rapid implementation of virtual treatment delivery. Posttraumatic stress disorder (PTSD) Residential Rehabilitation Treatment Programs (P-RRTP) are a key mental health treatment for Veterans with PTSD who require more intensive interventions than outpatient care. During the pandemic, the W. G. (Bill) Hefner VA Healthcare System developed and implemented a Virtual Intensive Outpatient Program for PTSD (VIOPP) to meet the needs of the Veteran population. The purpose of this analysis was to compare the effectiveness of VIOPP to P-RRTP. METHOD: Analyses included N = 370 Veterans, n = 193 who completed P-RRTP between January 2018 to April 2020 and n = 177 who completed VIOPP between June 2020 and November 2022 and provided pre- and posttreatment scores. Pre- and posttreatment scores of the PTSD Checklist for DSM-5 (PCL-5) were available for all patients. Pre- and posttreatment depressive symptom scores from the Nine-item Patient Health Questionnaire (PHQ-9) were available for n = 254 Veterans. Paired and independent samples t tests evaluated differences in change scores overall and by treatment modality (residential vs. virtual). RESULTS: Results indicated a significant decrease in PCL-5 scores regardless of treatment modality, p < .001. Despite beginning VIOPP with significantly higher PCL-5 scores than P-RRTP, there were no significant differences in PCL-5 change scores between virtual (M = -16.94) and residential treatment (M = -17.10), p = .910. PHQ-9 scores also decreased significantly for both treatment groups. CONCLUSION: These analyses suggest that intensive virtual treatment has similar effectiveness to residential treatment for PTSD. This supports the development of intensive virtual interventions as viable alternatives to residential treatments and a valuable component within the continuum of PTSD care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Quality of life after pancreatoduodenectomy: Is the outcome predetermined by the diagnosis?

BACKGROUND AND OBJECTIVES: Non-physiological factors tied to the disease process may drive the diminished quality of life (QoL) after pancreatoduodenectomy (PD). We compared postoperative QoL among patients undergoing PD for either benign or malignant pathology. METHODS: From 2012 to 2021, 228 patients underwent PD in a large healthcare system. Eighty-two patients (36.0%) were interviewed using the EORTC QLQ-C30 questionnaire. A minimum of 6 months after surgery was required for the survey. QoL outcomes were compared based on diagnosis (benign vs. malignant). RESULTS: Patient mean age was 65 years (21-82), and forty-seven (57%) were men. Most patients underwent surgery for cancer, 76% (n = 62). Grade B postoperative pancreatic fistula incidence was higher in benign cases (30% vs. 6.5%, p = 0.024). Weight loss was more common in malignancy (79% vs. 50%, p = 0.016). Carcinoma patients felt less useful, hopeful, reported less control of their life and certainty of the future, and were less satisfied with their appearance. Carcinoma patients also reported diminished memory, fear of relapse, and greater financial burden. CONCLUSIONS: Long-term QoL is inferior in PD patients with carcinoma and is driven by the psychological and socioeconomic implications of malignancy. Supportive resources for pancreas cancer patients should be evaluated and optimized.

Time doesn't heal all: PTSD symptoms exacerbate the relationship between age and pain intensity.

Objective: Posttraumatic stress disorder (PTSD) symptoms and pain interfere with daily functioning and quality of life for many combat Veterans. As individuals age, pain symptoms tend to increase whereas PTSD symptoms tend to decrease. PTSD symptoms exacerbate pain, but the nature of this relationship across the aging process is unclear. The purpose of this study was to determine how PTSD symptoms affect the association between age and pain intensity. Methods: Participants in this cross-sectional study included 450 Veterans (80% male) who served after September 11, 2001. PTSD and pain intensity ratings were assessed by the PTSD Checklist for DSM-5 (PCL-5) and the Brief Pain Inventory (BPI), respectively. Hierarchical multiple linear regression evaluated main and interaction effects between age, PTSD symptoms, and pain intensity. Results: Age (B = 0.04, p < 0.001) and PTSD symptoms (B = 0.05, p < 0.001) were positively associated with pain intensity. Age and PTSD symptoms were inversely correlated (r = -0.16, p < 0.001). PTSD symptoms exacerbated the relationship between age and pain intensity (ΔR2 = 0.01, p = 0.036). Specifically, when greater PTSD symptoms were reported at older ages, pain intensity was significantly higher. Conclusion: Results of these analyses suggests that age is important when considering the effects of PTSD symptoms on pain intensity ratings. Specifically, pain intensity ratings are higher in older Veterans with PTSD symptoms. These findings underscore the importance for clinical providers to evaluate trauma history and PTSD symptoms in older Veterans reporting pain symptoms.

Effects of ketorolac on complications and postoperative pancreatic fistula in patients undergoing pancreatectomy.

BACKGROUND: There are conflicting data on the risk of postoperative pancreatic fistula (POPF) associated with postoperative NSAID use. The primary objective of this multi-center retrospective study was to assess the relationship between ketorolac use and POPF. The secondary objective was to assess for effect of ketorolac use on overall complication rate. METHODS: Retrospective chart review of patients undergoing pancreatectomy from January 1, 2005-January 1, 2016 was performed. Data on patient factors (age, sex, comorbidities, previous surgical history etc.), operative factors (surgical procedure, estimated blood loss, pathology etc.), and outcomes (morbidities, mortality, readmission, POPF) were collected. The cohort was compared based on ketorolac use. RESULTS: The study included 464 patients. Ninety-eight (21%) patients received ketorolac during the study period. Ninety-six (21%) patients were diagnosed with POPF within 30 days. There was a significant association between ketorolac use and clinically relevant POPF (21.4 vs. 12.7%) (p = 0.04, 95% CI [1.76, 1.04-2.97]). There was no significant difference in overall morbidity or mortality between the groups. DISCUSSION: Though there was no overall increase in morbidity, there was a significant association between POPF and ketorolac use. The use of ketorolac after pancreatectomy should be judicious.

Generalized, cross-modal, and incrementing non-matching-to-sample in rats.

Same/different concept learning has been demonstrated in previous research in rats using matching- and non-matching-to-sample procedures with olfactory stimuli. In Experiment 1, rats were trained on the non-matching-to-sample procedure with either three-dimensional (3D plastic objects; n = 3) or olfactory (household spices, n = 5) stimuli, then tested for transfer to novel stimuli of the same, and then the alternate, modality. While all three rats trained with olfactory stimuli showed generalized non-matching to novel odors, only one rat learned the 3D relation and showed generalized transfer to novel objects. Importantly, in this rat the 3D non-matching relation then immediately transferred to odors. In contrast, rats trained with scents did not show transfer to novel 3D stimuli until after training with one or two 3D stimulus sets. In Experiment 2, four rats were trained on an incrementing non-matching-to-sample task featuring 3D plastic objects as stimuli (3D Span Task). Responses to session-novel stimuli resulted in reinforcement. Only two rats learned the 3D Span Task; one rat performed with high accuracy even with up to 17 session-novel objects in a session. While these findings emphasize the exceptional olfactory discrimination of rats relative to that with 3D/tactile/visual cues, they also show that relational learning can be demonstrated in another modality in this species. Further, the present study provides some evidence of cross-modal transfer of relational responding in rats.

Scaredy-cats don't succeed: behavioral traits predict problem-solving success in captive felidae.

Behavioral traits can be determined from the consistency in an animal's behaviors across time and situations. These behavioral traits may have been differentially selected in closely related species. Studying the structure of these traits across species within an order can inform a better understanding of the selection pressures under which behavior evolves. These adaptive traits are still expected to vary within individuals and might predict general cognitive capacities that facilitate survival, such as behavioral flexibility. We derived five facets (Flexible/Friendly, Fearful/Aggressive, Uninterested, Social/Playful, and Cautious) from behavioral trait assessments based on zookeeper surveys in 52 Felidae individuals representing thirteen species. We analyzed whether age, sex, species, and these facets predicted success in a multi access puzzle box-a measure of innovation. We found that Fearful/Aggressive and Cautious facets were negatively associated with success. This research provides the first test of the association between behavioral trait facets and innovation in a diverse group of captive felidae. Understanding the connection between behavioral traits and problem-solving can assist in ensuring the protection of diverse species in their natural habitats and ethical treatment in captivity.

Exploring innovative problem-solving in African lions (Panthera leo) and snow leopards (Panthera uncia).

Cognitive ability is likely linked to adaptive ability; animals use cognition to innovate and problem-solve in their physical and social environments. We investigated innovative problem-solving in two species of high conservation importance: African lions (Panthera leo; n = 6) and snow leopards (Panthera uncia; n = 9). We designed a custom multi-access puzzle box (MAB) to present a simple and effective behavioral test for the cats to explore. We measured Repeated Innovation, Persistence, Success, Contact Latency, and the Exploration Diversity of individuals interacting with the MAB. Of the six African lions, three (50%) solved one door to the box, one solved two doors (16.67%), and one solved three doors (16.67%). Of the nine snow leopards, one solved one door (11.11%), three solved two doors (33.33%), and none solved all three doors (0%). Persistence was a significant predictor of Success in African lions and snow leopards; more Persistent individuals were more likely to open a door. We also observed significant individual variation in Persistence for both species, but only snow leopards also exhibited differences in Contact Latency and Exploration Diversity. These results suggest individuals vary in their problem-solving approaches. Our findings support both species as successful, repeated innovators. Carnivores face ecological and social challenges and, presumably, benefit from cognitive abilities facilitating the successful navigation of these challenges in captivity and the wild.

Peritoneal Lavage Cytology Following Neoadjuvant Chemotherapy for Gastric Adenocarcinoma: Low Yield in Detecting Peritoneal Metastases.

BACKGROUND: Peritoneal lavage cytology (PLC) can detect advanced disease in gastric adenocarcinoma (GC); however, routine practice remains controversial. Furthermore, the effect of neoadjuvant chemotherapy (NAC) on cytological detection of carcinomatosis is unknown. METHODS: Using a 2012-2020 prospective database, we retrospectively reviewed patients with GC who underwent NAC followed by a staging laparoscopic peritoneal lavage with or without biopsy of suspicious peritoneal nodules. PLC results were considered discordant if they did not align with the peritoneal biopsy results. Patients with benign peritoneal cytology (Cyt-) or biopsy results who had postoperative time to carcinomatosis of <6 months were considered to have diagnostic failure of peritoneal lavage. RESULTS: Fifty-five patients with GC who underwent NAC followed by staging diagnostic laparoscopy with peritoneal lavage were identified. The majority of the patients in the cohort had Cyt- lavage (89.1%). Of the patients who underwent resection, 76.1% had T3 or greater disease on final pathology and 66% had nodal metastases. In 23 patients (41.8%) who had both peritoneal lavage and biopsy, four cases (17.4%) had discordant results. Diagnostic failure rate was 20% at 6 months and 42.2% at 12 months. The median time to carcinomatosis in patients who were Cyt- or biopsy negative was 7.9 months. CONCLUSION: PLC after NAC has a high diagnostic failure rate and inaccurately predicts carcinomatosis in 20% of patients with GC. Novel methods for identifying cytology positive GC after NAC should also be developed and evaluated, since the risk of peritoneal dissemination is high.

A Multicenter, 10-Year Experience With Hepatocellular Adenoma: Risk Factors and Disease Course.

BACKGROUND: Management of hepatocellular adenoma (HA) is marked by a paucity of recent studies. Long-term follow-up data from an equal access health care system may facilitate our understanding of the natural disease course of HA and identify modifiable risk factors. METHODS: A multi-institutional, retrospective review of patients with HA from 2008-2017 was performed. Patient demographics, disease characteristics, and clinical outcomes were analyzed. RESULTS: Of 124 patients identified, 94% were women with a mean age at diagnosis of 39.5 years (range 20-82). Median follow-up was 22.5 months (range 0-114) with thirty-four (27.4%) patients eventually undergoing hepatectomy. Mean BMI of the study population was 30.5 kg/m2 (range 16-72). Stratified by size, average BMI for adenomas ≥5 cm was 34 kg/m2 compared to 28 kg/m2 for those <5 cm (P < .05). The predominant symptom at presentation was abdominal pain (41.1%), while just 4% presented with acute rupture. Overall incidence of the malignancy was 2.5%. Among all patients, oral contraceptive use was documented in 74 (59.7%) patients, of whom 36 (29.0%) discontinued OC for at least six months. Regression after OC cessation occurred in seven patients (19.4%) while the majority (77.8%) remained stable. DISCUSSION: This decade-long review analyzing the impact of modifiable risk factors identifies a direct correlation between BMI and hepatocellular adenoma size. Rupture and malignant transformation are rare entities. Cessation of OC appears to be an effective strategy in the management of hepatic adenoma. Further investigations are warranted to determine if addressing modifiable risk factors such as BMI might induce further HA regression.

Examining Perioperative Risk Associated with Simultaneous Resection of Primary Neuroendocrine Tumors and Synchronous Hepatic Metastases.

BACKGROUND: Surgical debulking of primary neuroendocrine tumors (NETs) and hepatic resection of metastatic NET disease may each independently improve overall survival. However, evidence for combined primary site debulking and metastasectomy on survival and impact on short-term perioperative outcomes is limited. METHODS: The 2014-2016 ACS-NSQIP targeted hepatectomy database was queried for all patients undergoing liver resection for metastatic NET. Secondary procedure codes were evaluated for major concurrent operations. Multivariable analysis was performed to determine risk factors for 30-day morbidity and mortality. RESULTS: A total of 472 patients were identified, of whom 153 (32.4%) underwent ≥1 additional concurrent major operation. The most common concurrent procedures were small bowel resection (14.6%), partial colectomy (8.9%), and radical lymphadenectomy (7.4%). Among all patients, overall 30-day mortality and morbidity were 1.5% and 25.6%, respectively. Modifiable and treatment-related factors associated with increased major postoperative morbidity risk included >10% weight loss within six months of surgery (p = 0.05), increasing number of hepatic lesions treated (p = 0.05), and biliary reconstruction (p = 0.001). No major concurrent procedure was associated with increased 30-day morbidity (all p > 0.05). CONCLUSIONS: Approximately one-third of patients with stage IV NET underwent combined hepatic and multi-organ resection. Although modifiable and treatment-related factors predictive of perioperative morbidity were identified, performance of concurrent major procedures did not increase perioperative morbidity. These results support consideration of multi-organ resection in carefully selected patients with metastatic NET.

Outcomes of neoadjuvant therapy for cholangiocarcinoma: A review of existing evidence assessing treatment response and R0 resection rate.

Adjuvant chemotherapy for cholangiocarcinoma (CCA) has not been shown to gain significant improvements in survival. Factors contributing to suboptimal treatment response include aggressive disease biology and late clinical presentation. When feasible, surgical resection is the first line of treatment. Yet, recurrence remains high and long-term survival is rare. Neoadjuvant therapy is an appealing approach, with oncologic advantages in allowing the treatment of occult systemic disease and selection of patients most likely to benefit from radical surgery. However, given the surgery-first treatment paradigm for CCA, there is a paucity of data supporting neoadjuvant therapy. This review summarizes the current evidence on treatment response and margin-negative (R0) resection rate associated with neoadjuvant therapy for CCA.

Predictors of Progression of Appendiceal Mucinous Neoplasm to Pseudomyxoma Peritonei.

Appendiceal mucinous neoplasm (AMN) can present with a spectrum of disease. Predicting factors in development of pseudomyxoma peritonei (PMP) from AMN could aid in management and treatment. The aim of this study was to determine factors predictive of PMP from AMN. This was a retrospective multicenter study of all patients diagnosed with AMN from 2006-2017. Diagnosis of PMP was compared by (1) patient demographics, (2) tumor characteristics, and (3) surgery. Secondary end points were disease-specific survival (DSS) and overall survival (OS).One-hundred thirty-eight patients with AMN were identified. Thirty-six patients (26.1%) had a ruptured appendix at presentation, and 12 patients (8.7%) were diagnosed with PMP during the study period. Eight patients presented with PMP at the time of surgery. No demographic factors were predictive of PMP. Operative approach and extent of initial resection did not correlate with PMP. Tumor rupture at presentation was the only factor associated with PMP, though only 14% of patients who presented with simple rupture eventually progressed to PMP.OS was not different between those who were diagnosed with PMP and those who were not. DSS was significantly lower for the group diagnosed with PMP (P = .007). Tumor rupture at presentation did not influence OS or DSS. The only factor found to be significantly associated with PMP was tumor rupture at presentation. Diagnosis of PMP did not affect OS but did lead to decreased DSS.In conclusion, though a majority of patients who presented with rupture did not go on to develop PMP, tumor rupture at presentation was the only factor significantly associated with PMP. Diagnosis of PMP did not affect OS at 5 years. In patients with AMN who present with a ruptured appendix on final pathology, we recommended continued surveillance, though overall risk of PMP is relatively low.

Safety and Efficacy of an Enhanced Recovery Protocol After Hepatic Resection.

Enhanced recovery protocols (ERPs) have shown to improve outcomes in multiple specialties and were recently applied to hepatic resections. The objective of this study was to determine the safety and efficacy of ERP in hepatic resection. Between 2013-2017, 208 patients underwent hepatectomy. The ERP included early ambulation, early oral intake, and multimodal analgesia. Primary study end points were hospital length of stay (LOS) and overall morbidity; secondary end points were return of bowel function (ROBF), 30-day readmission, and 90-day mortality. Major hepatectomies were selected for separate analysis. Overall, pre-ERP (N = 99) and ERP (N = 109) were similar in demographics. ERP patients had earlier oral intake and ROBF with similar overall morbidity. Although median LOS was 5 days, 43% of ERP patients had LOS ≤4 days vs. 27% in the pre-ERP cohort (P = .02). 30-day readmission was similar (12%), and 90-day mortality was 2.8% vs. 3.0% (pre-ERP vs. ERP, P = .90). In major hepatectomies, pre-ERP (N = 41) and ERP (N = 33) demographics and operative characteristics were similar. ERP patients had earlier oral intake and ROBF with similar morbidity and mortality. There was no significant difference in median LOS; however, 36% of the major hepatectomy ERP patients had LOS ≤4 days vs. 17% of pre-ERP patients, P = .06. In conclusion, ERP can be safely implemented in hepatectomy, with earlier oral intake and ROBF, shorter LOS in some patients, and no increase in morbidity or mortality.

Pancreatectomy in Stage I pancreas cancer: national underutilization of surgery persists.

BACKGROUND: Pancreatectomy in early pancreas adenocarcinoma has been historically underutilized. This retrospective study examines recent trends in the use of pancreatectomy in clinical Stage I (T1-2N0M0) pancreas cancer. METHODS: Using the 2004-2014 National Cancer Database, patients with clinical Stage I pancreas cancer were identified. Patients who underwent surgery or failed to undergo surgery with no identifiable reason were included in analysis. Chi-square, binary logistic regression, and Kaplan Meier estimate were used to identify risk factors for failure to undergo surgery. RESULTS: 23,365 patients were identified. Pancreatectomy increased from 38.4% in 2004 to 52.3% in 2014 (p < 0.001). 50% (n = 11,922) of patients underwent surgery and 48.0% (n = 11,433) did not, of whom 6.8% had a prohibitive co-morbidity, and 36.1% (n = 8594) had no identifiable reason for the lack of operation. Failure to operate was associated with older age, African American race, residence in lower income and less educated areas, lack of insurance, and treatment at community hospitals (all p < 0.001). 5-year survival was maximized in patients who underwent surgery and chemotherapy at 28.1%. CONCLUSION: While utilization of surgery increased overtime, 36% of patients fail to undergo surgery without an identifiable reason. Future investigation is warranted to explain continuing underuse of surgery in early pancreas cancer.

Community-based wildlife management area supports similar mammal species richness and densities compared to a national park.

Community-based conservation models have been widely implemented across Africa to improve wildlife conservation and livelihoods of rural communities. In Tanzania, communities can set aside land and formally register it as Wildlife Management Area (WMA), which allows them to generate revenue via consumptive or nonconsumptive utilization of wildlife. The key, yet often untested, assumption of this model is that economic benefits accrued from wildlife motivate sustainable management of wildlife. To test the ecological effectiveness (here defined as persistence of wildlife populations) of Burunge Wildlife Management Area (BWMA), we employed a participatory monitoring approach involving WMA personnel. At intermittent intervals between 2011 and 2018, we estimated mammal species richness and population densities of ten mammal species (African elephant, giraffe, buffalo, zebra, wildebeest, waterbuck, warthog, impala, Kirk's dik-dik, and vervet monkey) along line transects. We compared mammal species accumulation curves and density estimates with those of time-matched road transect surveys conducted in adjacent Tarangire National Park (TNP). Mammal species richness estimates were similar in both areas, yet observed species richness per transect was greater in TNP compared to BWMA. Species-specific density estimates of time-matched surveys were mostly not significantly different between BWMA and TNP, but elephants occasionally reached greater densities in TNP compared to BWMA. In BWMA, elephant, wildebeest, and impala populations showed significant increases from 2011 to 2018. These results suggest that community-based conservation models can support mammal communities and densities that are similar to national park baselines. In light of the ecological success of this case study, we emphasize the need for continued efforts to ensure that the BWMA is effective. This will require adaptive management to counteract potential negative repercussions of wildlife populations on peoples' livelihoods. This study can be used as a model to evaluate the effectiveness of wildlife management areas across Tanzania.

Implications of Prolonged Time to Pancreaticoduodenectomy After Neoadjuvant Chemoradiation.

BACKGROUND: For patients with pancreatic adenocarcinoma (PA), the optimal time interval between neoadjuvant chemoradiation (CR) to surgical resection has not been well established. METHODS: The National Cancer Database from 2006 to 2014 was queried for patients ≥18 y old diagnosed with PA who received neoadjuvant CR. Survival and short-term outcomes were compared between patients who had pancreaticoduodenectomy ≤12 wk and >12 wk after completion of CR. RESULTS: 1610 patients met selection criteria. Average radiation to surgery (RS) interval was 58.2 ± 39.5 d. 1419 patients had RS interval ≤12 wk (mean 47.4 d) and 191 had RS interval >12 wk (mean 138.8 d). Demographics, CA 19-9 levels, types of chemotherapy and radiation dosage were similar between the two groups. There were more patients with clinical stage III cancers in the >12 wk group than in the ≤12 wk group (33.5% versus 14%). Short-term outcomes were similar between the two groups. However, a long-term survival benefit was observed in the >12 wk group (median 25.8 versus 30.2 mo P = 0.049). An interval >12 wk was associated with significantly prolonged survival on multivariate analysis (HR: 0.80, 95% CI: 0.65-0.99; P = 0.042). Higher clinical stage and positive surgical margins were independently associated with worse survival. CONCLUSIONS: Surgical resection beyond 12 wk after CR for PA did not worsen short-term outcomes. Waiting may contribute to better patient selection, especially those with locally advanced tumors. In the absence of progressive disease, patients need to be continuously evaluated for surgical resection after CR.

Post-traumatic stress and psychological health following infidelity in unmarried young adults.

Infidelity is often conceptualized as a traumatic event; however, little research has explored this topic empirically, particularly in unmarried adults. We determined the prevalence of infidelity-related post-traumatic stress disorder (PTSD) symptoms among unmarried adults who experienced a partner's infidelity and whether probable infidelity-related PTSD was associated with additional psychological health outcomes (i.e., depressive symptoms, perceived stress, and anxiety symptoms). We also investigated whether negative post-traumatic cognitions mediated the associations between infidelity-related PTSD symptoms and psychological health. This study included 73 adults (M age = 19.42, SE = 0.19 years) who experienced infidelity within a committed nonmarital relationship within the last 5 years. Controlling for gender, race, and exposure to Diagnostic and Statistical Manual of Psychiatric Disorders Criterion A traumas, 45.2% of our sample reported symptoms suggesting probable infidelity-related PTSD. Whether used as continuous or categorical predictor, infidelity-related PTSD symptoms were significantly associated with depressive symptoms, although results for perceived stress and anxiety symptoms were mixed. Post-traumatic cognitions acted as a partial mediator for depressive symptoms and full mediator for perceived stress and anxiety symptoms. This empirical evidence suggests that infidelity may produce PTSD symptoms at a relatively high rate, even in unmarried young adults, and may put individuals at risk for poorer psychological health, partially through post-traumatic cognitions.