Addressing Patients' Mental Health Needs at a Student-Run Free Clinic.

Student-run free clinics are uniquely positioned to understand the barriers to accessing mental health resources. We abstracted patient demographics and clinical characteristics from 355 patient charts and examined referral patterns for a subset of patients. Seventy-three (21%) of patients were found to have a psychiatric diagnosis and were more likely to have more medical comorbidities (10 versus 6, p < 0.001), total medications (8 versus 6, p < 0.001, and to be English-speaking (odds ratio: 1.97, p < 0.05). Of patients who received a referral, 37 (60%) were referred to specialty treatment, the majority to a single outside agency provider. 15 (25%) of patients were interviewed. Barriers to successful referral included transportation and medical symptoms. A facilitator of successful referral was concern for individual's health. Language, social stigma, and cost were not cited as barriers. This study describes mental health needs at a SRFC and suggests opportunities for improvement.

Reliability and construct validity of 3 psychometric trust scales for women seeking substance abuse treatment in a community setting.

Background: Women with a history of substance use disorder (SUD) constitute a unique population with gender-specific needs in treatment. Most notable is high rates of prior trauma and the need for a trauma-informed care framework. Given theoretical links between trauma and interpersonal trust, understanding quantitatively how trust may impact outcomes for women in this population requires confirmation of validity of existing psychometric instruments. Objective: This study sought to confirm reliability and construct validity of the Rotter Interpersonal Trust Scale, Wake Forest Trust in Physician Scale, and the Revised Health Care System Distrust Scale (RHCSDS) for use in women with a history of SUD seeking treatment in a community-based setting. Methods: A total of 301 participants were enrolled between August 2017 and March 2018 at an urban, community-based residential substance abuse treatment program in the mid-South. Participants were given an electronic survey containing questions about demographics/clinical characteristics, the Rotter, Wake Forest, and RHCSDS scales, Socially Desirable Response Five-Item Survey (SDRS-5), and the Adverse Childhood Experiences (ACEs) questionnaire. All participants also completed a modified protocol of the "Trust Game." Statistical analysis was completed for each trust scale in regard to scale means and distribution, internal consistency, interscale correlation, and scale correlation to the ACE score. Results: Results confirm statistically significant (P < .001) differences in global trust and trust of health care providers compared with general population samples in prior studies. Internal consistency of scales is comparable to reliability testing in prior studies (α > .70 for all scales). Interscale correlation between individual scales is statistically significant, with the strongest relationship between the 2 health care-specific scales (r = -.740, P < .001). There was a weak, negative correlation between the ACE score and interpersonal trust (r = -.135, P = .019). Individual scales do not have statistically significant correlation with "Trust Game" scores. Discussion: Findings suggest reliability and construct validity of scales for use in this population.

"A scarlet letter": Stigma and other factors affecting trust in the health care system for women seeking substance abuse treatment in a community setting.

Background: Trust in health care has been shown to influence health care utilization, perceptions of fair treatment, and health outcomes in the general population. The literature on trust in health care in individuals with a history of substance use disorder (SUD) is more limited, primarily examining the patient-provider relationship. Women seeking substance abuse treatment in community-based programs have higher rates of prior trauma and health disparities compared with male counterparts and the general population. With higher rates of prior trauma, this population is theoretically at high risk of decreased interpersonal trust and altered interpersonal relationships. Objective: This study sought to identify factors influencing trust in the health care system for women seeking substance abuse treatment in a community-based residential treatment program. Methods: Six client focus groups (n = 30), 1 provider focus group (n = 7), and 2 individual clinical administrator interviews (n = 2) were conducted between November 2016 and August 2017. Focus groups and interviews were audio recorded and transcribed. Coding and coding reconciliation were conducted by 2 independent coders. Themes were extracted and analyzed from sorted and coded quotes. Results: Six themes emerged. Factors that influence trust in the health care system in this population include (1) prior experiences with diagnosis, treatment, and outcomes; (2) stigma of addiction; (3) payment and reimbursement structure; (4) patient rights and protections; (5) efficiency-driven care; and (6) the health care system's role in causing and/or enabling addiction. Conclusions: These themes demonstrate a general distrust of the health care system by women in this population. Distrust is influenced by a perception of a health care system providing care that is variable in quality, often stigmatizing, unaffordable, efficiency driven, and often influencing individuals' SUD. This aligns with and extends prior literature around trust of health care in individuals with SUD. Future directions in research include formally assessing the impact of trust on health outcomes such as treatment entry and retention.

Single nucleotide polymorphism array analysis of bone marrow failure patients reveals characteristic patterns of genetic changes.

The bone marrow failure syndromes (BMFS) are a heterogeneous group of rare blood disorders characterized by inadequate haematopoiesis, clonal evolution, and increased risk of leukaemia. Single nucleotide polymorphism arrays (SNP-A) have been proposed as a tool for surveillance of clonal evolution in BMFS. To better understand the natural history of BMFS and to assess the clinical utility of SNP-A in these disorders, we analysed 124 SNP-A from a comprehensively characterized cohort of 91 patients at our BMFS centre. SNP-A were correlated with medical histories, haematopathology, cytogenetic and molecular data. To assess clonal evolution, longitudinal analysis of SNP-A was performed in 25 patients. We found that acquired copy number-neutral loss of heterozygosity (CN-LOH) was significantly more frequent in acquired aplastic anaemia (aAA) than in other BMFS (odds ratio 12·2, P < 0·01). Homozygosity by descent was most common in congenital BMFS, frequently unmasking autosomal recessive mutations. Copy number variants (CNVs) were frequently polymorphic, and we identified CNVs enriched in neutropenia and aAA. Our results suggest that acquired CN-LOH is a general phenomenon in aAA that is probably mechanistically and prognostically distinct from typical CN-LOH of myeloid malignancies. Our analysis of clinical utility of SNP-A shows the highest yield of detecting new clonal haematopoiesis at diagnosis and at relapse.

Common polymorphic deletion of glutathione S-transferase theta predisposes to acquired aplastic anemia: Independent cohort and meta-analysis of 609 patients.

Acquired aplastic anemia (AA) is a rare life-threatening bone marrow failure syndrome, caused by autoimmune destruction of hematopoietic stem and progenitor cells. Epidemiologic studies suggest that environmental exposures and metabolic gene polymorphisms contribute to disease pathogenesis. Several case-control studies linked homozygous deletion of the glutathione S-transferase theta (GSTT1) gene to AA; however, the role of GSTT1 deletion remains controversial as other studies failed to confirm the association. We asked whether a more precise relationship between the GSTT1 null polymorphism and aplastic anemia could be defined using a meta-analysis of 609 aplastic anemia patients, including an independent cohort of 67 patients from our institution. We searched PubMed, Embase, and the Cochrane Database for studies evaluating the association between GSTT1 null genotype and development of AA. Seven studies, involving a total of 609 patients and 3,914 controls, fulfilled the eligibility criteria. Meta-analysis revealed a significant association of GSTT1 null genotype and AA, with an OR = 1.74 (95% CI 1.31-2.31, P < 0.0001). The effect was not driven by any one individual result, nor was there evidence of significant publication bias. The association between AA and GSTT1 deletion suggests a role of glutathione-conjugation in AA, possibly through protecting the hematopoietic compartment from endogenous metabolites or environmental exposures. We propose a model whereby protein adducts generated by reactive metabolites serve as neo-epitopes to trigger autoimmunity in aplastic anemia.

Psychometric Properties of Scales Measuring Resilience in U.S. Latinx Populations: A Systematic Review.

Objectives: Instruments used to measure resilience have typically been developed in European or Anglosphere countries and emphasize personal factors of resilience. In addition to being a quickly growing ethnic minority group in the United States, Latinx individuals face unique stressors and protective factors that may contribute to resilience. This review sought to determine the extent to which instruments measuring resilience have been validated in U.S. Latinx populations and what domains of resilience those scales capture. Methods: A systematic literature review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards and included studies describing psychometric properties of resilience scales for Latinx individuals living in the United States. Articles were assessed for quality of psychometric validation; scales used in the final studies were assessed for representation of domains of the social ecological resilience model. Results: Nine studies were included in the final review examining eight separate resilience measures. The populations of these studies were heterogeneous geographically and demographically; more than half the studies only included Latinx populations as a subgroup. The breadth and quality of psychometric validation were variable across studies. The domains represented by the scales in the review most heavily assessed individual domains of resilience. Conclusion: The literature to date on psychometric validation of resilience measures in Latinx populations in the United States is limited and does not robustly capture aspects of resilience that may be particularly meaningful for Latinx populations, such as community or cultural factors. Instruments that are developed with and for Latinx populations are necessary to better understand and measure resilience in this population.

Using the project ECHO™ model to teach mental health topics in rural Guatemala: An implementation science-guided evaluation.

BACKGROUND: Mental health (MH) disorders are major causes of disability in Guatemala. Unfortunately, limited academic training and funding resources make MH care inaccessible to most people in rural Guatemala. These disparities leave many indigenous populations without care. Project ECHO™ is an educational model used globally to deliver virtual training for providers in rural/ underserved communities. The aim of this project was to implement and evaluate a Project ECHO™ program bridging MH training gaps for providers who serve rural communities in Guatemala. METHODS: The Project ECHO™ curriculum was implemented through a partnership between educational and nonprofit institutions in Guatemala City and the United States. Participants were primary care physicians and nurses working in rural Guatemala as well as medical/nursing/psychology students. Evaluation of its implementation was guided by a RE-AIM framework. Reach, effectiveness, adoption, fidelity, sustainability, acceptability, feasibility, and appropriateness were evaluated using a mixed-methods approach, using a pre-post survey and semi-structured focus groups. RESULTS: Forty unique participants attended the five sessions. Attitudes about mental health did not change quantitatively but self-efficacy improved in four of five modules. High quality fidelity scores were noted in two of five sessions. Sustainability scores across multiple domains were highly rated. Scores on instruments measuring acceptability, feasibility, and appropriateness were high. Focus groups showed two main themes: the curriculum filled a gap in education and further adaptation of the model might help improve the experience. CONCLUSION: Implementation of the Project ECHO™ educational model appeared to have good reach/adoption, showed improvements in self-efficacy, illuminated facilitators and barriers to sustainability, and was felt to be acceptable, feasible, and appropriate. Qualitative analysis supported these conclusions. Future directions would include ongoing evaluation and monitoring of further Project ECHO™ curricular experiences through this partnership and adaptation of this project to other learners and settings in Latin America.

Implementation and Evaluation of a Dual-Track Research Training Program for Community Members and Community-Based Organizations.

BACKGROUND: It is a public health priority to increase community research participation to improve health outcomes and eliminate health disparities. There is a need for effective research training programs that build community stakeholders' capacity to engage as equitable partners. OBJECTIVES: To describe the collaborative process of implementing and evaluating a dual-track community research training program-Meharry Vanderbilt Community Engaged Research Core-Community Research Training Program (MVC-CRT) Program-and present participant evaluations. METHODS: The MVC-CRT is a six-session community-based organization (CBO) curriculum and a three-session community member (CM) curriculum, based on needs identified by various community stakeholders, that was piloted in 2016. Immediately post-training, an outcome evaluation (surveys) was used to measure trainees' confidence relative to 30 learning objectives for the combined training sessions (e.g., Introduction to research), satisfaction in preparing them for research roles, and impact on research activities (e.g., building sustainable partnerships). 2 and 3 months after training, a process evaluation (focus groups) was used to assess each session's flow, materials, group discussions, and facilitators. RESULTS: Trainees' immediate post-training confidence increased or remained the same across 26 of 30 learning objectives. Two to 3 months after training, trainees reported sustained confidence, perceived increased knowledge, and increased intentions to engage in or improve research activities. All participants were satisfied with the program and felt better prepared for research roles. CONCLUSIONS: Tailored community research training may result in positive outcomes that can ultimately increase community capacity to be equitable partners in research in support of efforts to improve health outcomes and eliminate health disparities.

Emergence of clonal hematopoiesis in the majority of patients with acquired aplastic anemia.

Acquired aplastic anemia (aAA) is a nonmalignant disease caused by autoimmune destruction of early hematopoietic cells. Clonal hematopoiesis is a late complication, seen in 20-25% of older patients. We hypothesized that clonal hematopoiesis in aAA is a more general phenomenon, which can arise early in disease, even in younger patients. To evaluate clonal hematopoiesis in aAA, we used comparative whole exome sequencing of paired bone marrow and skin samples in 22 patients. We found somatic mutations in 16 patients (72.7%) with a median disease duration of 1 year; of these, 12 (66.7%) were patients with pediatric-onset aAA. Fifty-eight mutations in 51 unique genes were found primarily in pathways of immunity and transcriptional regulation. Most frequently mutated was PIGA, with seven mutations. Only two mutations were in genes recurrently mutated in myelodysplastic syndrome. Two patients had oligoclonal loss of the HLA alleles, linking immune escape to clone emergence. Two patients had activating mutations in key signaling pathways (STAT5B (p.N642H) and CAMK2G (p.T306M)). Our results suggest that clonal hematopoiesis in aAA is common, with two mechanisms emerging-immune escape and increased proliferation. Our findings expand conceptual understanding of this nonneoplastic blood disorder. Future prospective studies of clonal hematopoiesis in aAA will be critical for understanding outcomes and for designing personalized treatment strategies.