Key features of a trauma-informed public health emergency approach: A rapid review.

COVID-19 is a major threat to public safety, and emergency public health measures to protect lives (e.g., lockdown, social distancing) have caused widespread disruption. While these measures are necessary to prevent catastrophic trauma and grief, many people are experiencing heightened stress and fear. Public health measures, risks of COVID-19 and stress responses compound existing inequities in our community. First Nations communities are particularly at risk due to historical trauma, ongoing socio-economic deprivation, and lack of trust in government authorities as a result of colonization. The objective of this study was to review evidence for trauma-informed public health emergency responses to inform development of a culturally-responsive trauma-informed public health emergency framework for First Nations communities. We searched relevant databases from 1/1/2000 to 13/11/2020 inclusive, which identified 40 primary studies (and eight associated references) for inclusion in this review. Extracted data were subjected to framework and thematic synthesis. No studies reported evaluations of a trauma-informed public health emergency response. However, included studies highlighted key elements of a "trauma-informed lens," which may help to consider implications, reduce risks and foster a sense of security, wellbeing, self- and collective-efficacy, hope and resilience for First Nations communities during COVID-19. We identified key elements for minimizing the impact of compounding trauma on First Nations communities, including: a commitment to equity and human rights, cultural responsiveness, good communication, and positive leadership. The six principles guiding trauma-informed culturally-responsive public health emergency frameworks included: (i) safety, (ii) empowerment, (iii) holistic support, (iv) connectedness and collaboration, (v) compassion and caring, and (vi) trust and transparency in multi-level responses, well-functioning social systems, and provision of basic services. These findings will be discussed with First Nations public health experts, together with data on the experiences of First Nations families and communities during COVID-19, to develop a trauma-integrated public health emergency response framework or "lens" to minimize compounding trauma for First Nations communities.

A Culturally Responsive Trauma-Informed Public Health Emergency Framework for Aboriginal and Torres Strait Islander Communities in Australia, Developed during COVID-19.

The Coronavirus Disease 2019 (COVID-19) pandemic impacted peoples' livelihoods and mental wellbeing. Aboriginal and Torres Strait Islander peoples in Australia continue to experience intergenerational trauma associated with colonization and may experience trauma-related distress in response to government responses to public health emergencies. We aimed to develop a culturally responsive trauma-informed public health emergency response framework for Aboriginal and Torres Strait Islander peoples. This Aboriginal and Torres Strait Islander-led study involved: (i) a review of trauma-informed public health emergency responses to develop a draft framework (ii) interviews with 110 Aboriginal and Torres Strait Islander parents about how COVID-19 impacted their lives, and (iii) a workshop with 36 stakeholders about pandemic experiences using framework analysis to refine a culturally responsive trauma-informed framework. The framework included: an overarching philosophy (cultural humility, safety and responsiveness); key enablers (local leadership and Eldership); supporting strategies (provision of basic needs and resources, well-functioning social systems, human rights, dignity, choice, justice and ethics, mutuality and collective responsibility, and strengthening of existing systems); interdependent core concepts (safety, transparency, and empowerment, holistic support, connectedness and collaboration, and compassion, protection and caring); and central goals (a sense of security, resilience, wellbeing, self- and collective-efficacy, hope, trust, resilience, and healing from grief and loss).

Learning the subtle dance: The experience of therapists who deliver mentalisation-based therapy for borderline personality disorder.

OBJECTIVES: This study aimed to understand therapists' lived experiences of delivering mentalisation-based therapy (MBT), including their experiences of service user change. METHOD: One-to-one semi-structured interviews or focus groups were conducted with 14 MBT therapists and analysed using interpretative phenomenological analysis (IPA). RESULTS: Four superordinate themes were identified: (1) experiencing the challenges and complexities of being with service users during MBT; (2) being on a journey of discovery and change; (3) being an MBT therapist: a new way of working and developing a new therapeutic identity; and (4) being a therapist in the group: seeing it all come together. CONCLUSION: Our findings highlight the complexity, challenges and individualised experience of working therapeutically with service users with a diagnosis of BPD. The study provides a perspective of service use change that is enriched by idiosyncrasies within the therapeutic encounter. We conclude with a consideration of implications for MBT research and clinical practice.

Progressive Neurochemical Abnormalities in Cognitive and Motor Subgroups of Amyotrophic Lateral Sclerosis: A Prospective Multicenter Study.

OBJECTIVE: To evaluate progressive cerebral degeneration in amyotrophic lateral sclerosis (ALS) by assessing alterations in N-acetylaspartate (NAA) ratios in the motor and prefrontal cortex within clinical subgroups of ALS. METHODS: Seventy-six patients with ALS and 59 healthy controls were enrolled in a prospective, longitudinal, multicenter study in the Canadian ALS Neuroimaging Consortium. Participants underwent serial clinical evaluations and magnetic resonance spectroscopy at baseline and 4 and 8 months using a harmonized protocol across 5 centers. NAA ratios were quantified in the motor cortex and prefrontal cortex. Patients were stratified into subgroups based on disease progression rate, upper motor neuron (UMN) signs, and cognitive status. Linear mixed models were used for baseline and longitudinal comparisons of NAA metabolite ratios. RESULTS: Patients with ALS had reduced NAA ratios in the motor cortex at baseline (p < 0.001). Ratios were lower in those with more rapid disease progression and greater UMN signs (p < 0.05). A longitudinal decline in NAA ratios was observed in the motor cortex in the rapidly progressing (p < 0.01) and high UMN burden (p < 0.01) cohorts. The severity of UMN signs did not change significantly over time. NAA ratios were reduced in the prefrontal cortex only in cognitively impaired patients (p < 0.05); prefrontal cortex metabolites did not change over time. CONCLUSIONS: Progressive degeneration of the motor cortex in ALS is associated with more aggressive clinical presentations. These findings provide biological evidence of variable spatial and temporal cerebral degeneration linked to the disease heterogeneity of ALS. The use of standardized imaging protocols may have a role in clinical trials for patient selection or subgrouping. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that MRS NAA metabolite ratios of the motor cortex are associated with more rapid disease progression and greater UMN signs in patients with ALS. TRIAL REGISTRATION INFORMATION: ClinicalTrials.gov Identifier: NCT02405182.

The weirdness of having a bunch of other minds like yours in the room: The lived experiences of mentalization-based therapy for borderline personality disorder.

OBJECTIVES: Studies of lived experiences are important for improving treatment effectiveness, but most studies of mentalization-based therapy (MBT) are quantitative. This qualitative study aimed to better understand service users' lived experiences of MBT, including their experiences of change. DESIGN: This is a qualitative study that used one-to-one semi-structured interviews. METHOD: Semi-structured interviews were conducted with eight MBT service users recruited via four NHS trusts. Interviews were analysed using interpretative phenomenological analysis (IPA). FINDINGS: Three superordinate themes were identified: being borderline, being in the group, and being on a journey. 'Experiences of diagnosis' and 'the group' are salient topics in the lived experiences of service users' during the MBT journey, as is the nature/type of 'change' that can create symptom reduction albeit alongside a negative felt experience. CONCLUSION: Our research aligns with current thought regarding the complexity and challenges of treating BPD via psychotherapy and adds a further dimension, that of experiencing MBT and changes during therapy. The participants' experiences of BPD and of experiencing MBT are discussed. PRACTITIONER POINTS: Therapists are observant of how each client gives meaning to their experience of diagnosis, the group, and change, particularly since the experience of recovery is not all positive. Service users' emerging and ongoing construction of their experience of diagnosis is closely monitored and additional appropriate strategies implemented where necessary. The impact of joining MBT, especially the group, becomes a process for formal regular review. Therapists undertake an in-depth exploration of service users' felt experiences to capture less quantifiable dimensions of change.

The management gram-negative bacterial haematogenous vertebral osteomyelitis: a case series of diagnosis, treatment and therapeutic outcomes.

PURPOSE: The incidence of gram-negative bacterial haematogenous vertebral osteomyelitis (GNB HVO) is increasing. We performed a retrospective cohort study of patients with this type of infection in an effort to gain an improved understanding of the current clinical presentation, management and outcome. METHODS: Between May 2007 and May 2010, all patients, over the age of 18 years, suffering from GNB HVO were identified and their microbiological diagnoses were evaluated. RESULTS: This study identified seventy-nine patients with haematogenous vertebral osteomyelitis (HVO). Of these seventy-nine patients, 10 patients (12.66%) had Gram-negative organisms isolated. These organisms included Escherichia coli (4), Pseudomonas aeruginosa (3), Klebsiella pneumonia (1), Haemophilus influenza (1) and Enterobacter cloacae (1). Eight patients were successfully treated with antibiotics and/or surgery. Of the eight patients whose HVO was cured, five had Ciprofloxacin as part of their definitive antibiotic regime. CONCLUSION: The treatment of GNB HVO is often challenging because of unpredictable resistance patterns and limited published data on effective treatment regimens. Our study has highlighted the need for prompt microbiological sampling and initiation of early appropriate antibiotic regime. The most effective treatment for GNB HVO was with oral Ciprofloxacin over a period of 6-8 weeks.

Investigation of fMRI neurofeedback of differential primary motor cortex activity using kinesthetic motor imagery.

Functional MRI neurofeedback (fMRI NF) is an emerging technique that trains subjects to regulate their brain activity while they manipulate sensory stimulus representations of fMRI signals in "real-time". Here we report an fMRI NF study of brain activity associated with kinesthetic motor imagery (kMI), analyzed using partial least squares (PLS), a multivariate analysis technique. Thirteen healthy young adult subjects performed kMI involving each hand separately, with NF training targeting regions of interest (ROIs) in the left and right primary motor cortex (M1). Throughout, subjects attempted to maximize a laterality index (LI) of brain activity-the difference in activity between the contralateral ROI (relative to the hand involved in kMI) and the ipsilateral M1 ROI-while receiving real-time updates on a visual display. Six of 13 subjects were successful in increasing the LI value, whereas the other 7 were not successful and performed similarly to 5 control subjects who received sham NF training. Ability to suppress activity in the ipsilateral M1 ROI was the primary driver of successful NF performance. Multiple PLS analyses depicted activated networks of brain regions involved with imagery, self-awareness, and feedback processing, and additionally showed that activation of the task positive network was correlated with task performance. These results indicate that fMRI NF of kMI is capable of modulating brain activity in primary motor regions in a subset of the population. In the future, such methods may be useful in the development of NF training methods for enhancing motor rehabilitation following stroke.

Multiecho coarse voxel acquisition for neurofeedback fMRI.

"Real-time" functional magnetic resonance imaging is starting to be used in neurofeedback applications, enabling individuals to regulate their brain activity for therapeutic purposes. These applications use two-dimensional multislice echo planar or spiral readouts to image the entire brain volume, often with a much smaller region of interest within the brain monitored for feedback purposes. Given that such brain activity should be sampled rapidly, it is worthwhile considering alternative functional magnetic resonance imaging pulse sequences that trade spatial resolution for temporal resolution. We developed a prototype sequence localizing a column of magnetization by outer volume saturation, from which densely sampled transverse relaxation time decays are obtained at coarse voxel locations using an asymmetric gradient echo train. For 5×20×20 mm3 voxels, 256 echoes are sampled at ∼1 msec and then combined in weighted summation to increase functional magnetic resonance imaging signal contrast. This multiecho coarse voxel pulse sequence is shown experimentally at 1.5 T to provide the same signal contrast to noise ratio as obtained by spiral imaging for a primary motor cortex region of interest, but with potential for enhanced temporal resolution. A neurofeedback experiment also illustrates measurement and calculation of functional magnetic resonance imaging signals within 1 sec, emphasizing the future potential of the approach.

Investigating the role of PDGF as a potential drug therapy in bone formation and fracture healing.

BACKGROUND: Platelet-derived growth factor (PDGF) has been shown in vivo to increase bone formation and supplement fracture healing, and may have a role as a therapeutic agent in the treatment of bone loss and fracture healing in humans. OBJECTIVE: A comprehensive review of the recent literature on the effect of PDGF on bone mineral density and fracture healing. METHODS: In vitro and in vivo evidence was systematically collected using medical search engines MEDLINE/OVID (1950 to March 2008) and EMBASE (1980 to March 2008) databases. RESULTS/CONCLUSION: Evidence to date suggests that PDGF-BB, and to a lesser extent PDGF-AA, may have potential therapeutic use in the treatment of osteoporosis and bone healing in humans. Additionally, by targeting alpha-receptors on osteoblasts, a potential anabolic effect on bone metabolism in humans can be anticipated; however, more research needs to be done to assess the role of beta-receptors in human bone.

The effect of beta-blockers on bone metabolism as potential drugs under investigation for osteoporosis and fracture healing.

BACKGROUND: beta-Adrenergic receptor antagonists (beta-blockers) have a well-recognised antihypertensive action that is mediated through a reduction in cardiac output and in the release of renin from the kidneys and inhibition of the action of endogenous catecholamines on beta-adrenergic receptors. This class of drugs has been shown to reduce the incidence of cardiovascular disease. Recent evidence suggests that beta-blockers may also have an effect on bone structure, metabolism and fracture healing. OBJECTIVE: This paper reviews in vitro and in vivo data that suggest beta-blockers have primarily an anabolic effect on bone metabolism. RESULTS: The sympathetic nervous system has a catabolic effect on bone, and in vitro studies have shown that adrenergic agonists stimulate bone resorption. The beta-blocker propranolol has been shown to increase bone formation in ovariectomised female rats. Also, recent observational clinical studies provide evidence to show that beta-blockers are associated with reduction in fracture risk in both men and women. CONCLUSION: Although there are some controversial studies, most research concludes that beta-blockers show promise in the treatment of osteoporosis and fracture healing.

Clustered functional MRI of overt speech production.

To investigate the neural network of overt speech production, event-related fMRI was performed in 9 young healthy adult volunteers. A clustered image acquisition technique was chosen to minimize speech-related movement artifacts. Functional images were acquired during the production of oral movements and of speech of increasing complexity (isolated vowel as well as monosyllabic and trisyllabic utterances). This imaging technique and behavioral task enabled depiction of the articulo-phonologic network of speech production from the supplementary motor area at the cranial end to the red nucleus at the caudal end. Speaking a single vowel and performing simple oral movements involved very similar activation of the cortical and subcortical motor systems. More complex, polysyllabic utterances were associated with additional activation in the bilateral cerebellum, reflecting increased demand on speech motor control, and additional activation in the bilateral temporal cortex, reflecting the stronger involvement of phonologic processing.

Left thalamo-cortical network implicated in successful speech separation and identification.

The separation of concurrent sounds is paramount to human communication in everyday settings. The primary auditory cortex and the planum temporale are thought to be essential for both the separation of physical sound sources into perceptual objects and the comparison of those representations with previously learned acoustic events. To examine the role of these areas in speech separation, we measured brain activity using event-related functional Magnetic Resonance Imaging (fMRI) while participants were asked to identify two phonetically different vowels presented simultaneously. The processing of brief speech sounds (200 ms in duration) activated the thalamus and superior temporal gyrus bilaterally, left anterior temporal lobe, and left inferior temporal gyrus. A comparison of fMRI signals between trials in which participants successfully identified both vowels as opposed to when only one of the two vowels was recognized revealed enhanced activity in left thalamus, Heschl's gyrus, superior temporal gyrus, and the planum temporale. Because participants successfully identified at least one of the two vowels on each trial, the difference in fMRI signal indexes the extra computational work needed to segregate and identify successfully the other concurrently presented vowel. The results support the view that auditory cortex in or near Heschl's gyrus as well as in the planum temporale are involved in sound segregation and reveal a link between left thalamo-cortical activation and the successful separation and identification of simultaneous speech sounds.

Optimizing the experimental design for ankle dorsiflexion fMRI.

Compared to motor studies of the upper limb, few experiments have sought a relationship between blood oxygen level-dependent (BOLD) functional magnetic resonance imaging (fMRI) sensorimotor signals and the resulting lower limb output. In Experiment 1, using an fMRI simulator system, we determined the optimized experimental protocol based on two design types and four behavioral movement types during ankle dorsiflexion. Experiment 2 involved testing the BOLD sensitivity at 1.5 T during ankle movements. Subjects performed large- and small-amplitude dorsiflexion movement types using an event-related design, with the intent of contrasting spatial and temporal features of the BOLD signal. In both experiments, the subject's behavior was guided by visual biofeedback of their ankle flexion angle, using an MR-compatible fiberoptic tape. From Experiment 1, we found electromyography (EMG) difference voltage ratio of approximately 2:1 for large (40 degrees ) and small (15 degrees ) dorsiflexion, 0.13 mV and 0.07 mV, respectively. In Experimental 2, we found the peak BOLD % signal changes of 1.04% and 0.89%, for large (40 degrees ) and small (15 degrees ) dorsiflexion, respectively. In addition, graded dorsiflexion produced graded BOLD signals in the primary sensorimotor and supplementary motor areas in 10 of 12 healthy young subjects, attesting to the feasibility of lower-limb fMRI at 1.5 T. This study provides insight into the cortical network involved in dorsiflexion using an experimental paradigm that is likely to translate effectively to hemiparetic stroke subjects.

fMRI differences in encoding and retrieval of pictures due to encoding strategy in the elderly.

Functional MRI (fMRI) was used to examine the neural correlates of depth of processing during encoding and retrieval of photographs in older normal volunteers (n = 12). Separate scans were run during deep (natural vs. man-made decision) and shallow (color vs. black-and-white decision) encoding and during old/new recognition of pictures initially presented in one of the two encoding conditions. A baseline condition consisting of a scrambled, color photograph was used as a contrast in each scan. Recognition accuracy was greater for the pictures on which semantic decisions were made at encoding, consistent with the expected levels of processing effect. A mixed-effects model was used to compare fMRI differences between conditions (deep-baseline vs. shallow-baseline) in both encoding and retrieval. For encoding, this contrast revealed greater activation associated with deep encoding in several areas, including the left parahippocampal gyrus (PHG), left middle temporal gyrus, and left anterior thalamus. Increased left hippocampal, right dorsolateral, and inferior frontal activations were found for recognition of items that had been presented in the deep relative to the shallow encoding condition. We speculate that the modulation of activity in these regions by the depth of processing manipulation shows that these regions support effective encoding and successful retrieval. A direct comparison between encoding and retrieval revealed greater activation during retrieval in the medial temporal (right hippocampus and bilateral PHG), anterior cingulate, and bilateral prefrontal (inferior and dorsolateral). Most notably, greater right posterior PHG was found during encoding compared to recognition. Focusing on the medial temporal lobe (MTL) region, our results suggest a greater involvement of both anterior MTL and prefrontal regions in retrieval compared to encoding.

Somatosensory gating and recovery from stroke involving the thalamus.

BACKGROUND AND PURPOSE: In the undamaged brain, sensory input to the cortex is intricately controlled via sensory gating mechanisms. Given the role of corticothalamic pathways in this control, it was hypothesized that in patients recovering from thalamic stroke there would be evidence of disrupted sensory gating and that efficient control of cortical sensory inputs would emerge during recovery. METHODS: Four patients were tested serially after stroke from 1 to 24 weeks after injury. Perceptual thresholds, somatosensory evoked potential amplitudes, and functional MRI activations under specific somatosensory stimulation conditions were measured. RESULTS: All patients demonstrated comparable results, revealing disrupted threshold detection to vibrotactile stimuli in the presence of a concurrent competing, contralateral input. In contrast, threshold detection was comparable between the affected and unaffected sides when there were no competing stimuli. This compromised capacity to inhibit competing sensory inputs was paralleled by a reduction in the measured activation of cortical representation in the stroke-affected hemisphere (functional MRI and somatosensory evoked potential) during bilateral stimulation. After recovery, perceptual detection improvements during bilateral stimulation were paralleled by enhancements of primary somatosensory cortical activation in the stroke-affected hemisphere. CONCLUSIONS: These results provide insight into potential mechanisms that contribute to sensory gating and suggest that the ability to control sensory input through effective gating mechanisms, in addition to primary somatosensory representation, may be important for poststroke sensory recovery.