Community narratives on rural homelessness: Tales of terror and tales of compassion.

Homelessness is often assumed to be mostly confined to urban spaces, leaving experiences of homelessness in rural contexts largely unexamined. The present study aims to understand the discursive context, or public understanding, of homelessness in rural communities. We examined community narratives related to the idea of "homelessness" in rural spaces. Semi-structured qualitative interviews were conducted with 70 key stakeholders from four rural communities in the U.S. State of Maine. Participants were asked to give their impressions related to homelessness in their community. We conducted a systematic qualitative analysis of these interviews and our analysis was grounded in a critical discourse analysis perspective. Using Rappaport's framework for understanding helpful and harmful community narratives, we identified three community narratives that harm by stereotyping or erasing homelessness in rural communities: Not Here, That One Guy, and Mainly Outsiders. We also examined counter-narratives that worked against each of the three primary narratives: It Looks Different, It's More Hidden, and Local Struggle and Lack of Resources. The counter-narratives tell a different, more compassionate, story of homelessness in rural spaces. Our main goal was to analyze the "work" that each of these narratives were doing in terms of constructing different understandings of "rural homelessness." The implications for policy and practice are discussed.

Using geographic information systems to assess community-level vulnerability to housing insecurity in rural areas.

Research examining homelessness in rural areas has been sparse. The current study aims to expand conceptions of rural homelessness by mapping community-level risk factors related to housing insecurity. Geographic information systems (GIS) techniques were used to map the distribution of select community-level risk indicators in the State of Maine. Three methodological choices related to this process are demonstrated: (1) selection and distribution of housing insecurity risk indicators; (2) use of location quotients; and (3) use of spatial lags. After examining and mapping selected risk factors against the location of homeless service supports, four areas in Maine were identified as communities of concern for housing insecurity. Better understanding the extent and location of areas of high need that are resource poor can help service and funding agencies to plan for the more efficient and effective distribution of homeless prevention and mitigation services. Implications for research in rural areas are discussed.

A Validated Scale for Assessing the Severity of Acute Infectious Mononucleosis.

OBJECTIVES: To develop a scale for the severity of mononucleosis. STUDY DESIGN: One to 5 percent of college students develop infectious mononucleosis annually, and about 10% meet criteria for chronic fatigue syndrome (CFS) 6 months following infectious mononucleosis. We developed a severity of mononucleosis scale based on a review of the literature. College students were enrolled, generally when they were healthy. When the students developed infectious mononucleosis, an assessment was made as to the severity of their infectious mononucleosis independently by 2 physicians using the severity of mononucleosis scale. This scale was correlated with corticosteroid use and hospitalization. Six months following infectious mononucleosis, an assessment is made for recovery from infectious mononucleosis or meeting 1 or more case definitions of CFS. RESULTS: In total, 126 severity of mononucleosis scales were analyzed. The concordance between the 2 physician reviewers was 95%. All 3 hospitalized subjects had severity of mononucleosis scores ≥2. Subjects with severity of mononucleosis scores of ≥1 were 1.83 times as likely to be given corticosteroids. Students with severity of mononucleosis scores of 0 or 1 were less likely to meet more than 1 case definition of CFS 6 months following infectious mononucleosis. CONCLUSIONS: The severity of mononucleosis scale has interobserver, concurrent and predictive validity for hospitalization, corticosteroid use, and meeting criteria for CFS 6 months following infectious mononucleosis.

Dismissing chronic illness: A qualitative analysis of negative health care experiences.

In the US, medical training is inadequate regarding the symptomatology, prognosis, and treatment for myalgic encephalomyelitis (ME) and chronic fatigue syndrome (CFS). As a result, many physicians lack the appropriate level of knowledge about effective methods for ME and CFS symptom reduction and often suggest inappropriate treatments, such as increased exercise or psychiatric services. The authors' purpose in this study was to analyze negative patient experiences with health care professionals. Patients with ME and CFS who reported experiencing a dismissive physician attitude were asked to detail the encounter via open-ended response on an international, online survey. Participant responses were thematically coded and analyzed using processes outlined by Patton. Emergent themes related to perceived physician attitudes and how they impact patient wellbeing are described and their implications discussed. Additionally, we highlight suggestions for how the health care system can effectively approach this often marginalized patient group.

Operationalizing Substantial Reduction in Functioning Among Young Adults with Chronic Fatigue Syndrome.

PURPOSE: Chronic fatigue syndrome and myalgic encephalomyelitis are fatiguing illnesses that often result in long-term impairment in daily functioning. In reviewing case definitions, Thrope et al. (Fatigue 4(3):175-188, 2016) noted that the vast majority of case definitions used to describe these illnesses list a "substantial reduction" in activities as a required feature for diagnosis. However, there is no consensus on how to best operationalize the criterion of substantial reduction. METHOD: The present study used a series of receiver operating curve (ROC) analyses to explore the use of the Medical Outcomes Study Short-Form-36 Health Survey (SF-36), designed by Ware and Shelbourne for operationalizing the substantial reduction criterion in a young adult population (18-29 years old). We compared the sensitivity and specificity of various cutoff scores for the SF-36 subscales and assessed their usefulness in discriminating between a group of young adults with a known diagnosis of chronic fatigue syndrome or myalgic encephalomyelitis (n = 98) versus those without that diagnosis (n = 272). RESULTS: The four top performing subscales and their associated cutoffs were determined: Physical Functioning ≤ 80, General Health ≤ 47, Role Physical ≤ 25, and Social Functioning ≤ 50. Used in combination, these four cutoff scores were shown to reliably discriminate between the patients and controls in our sample of young adults. CONCLUSION: The implications of these findings for employing the substantial reduction criterion in both clinical and research settings are discussed.

Subtyping Patients with Myalgic Encephalomyelitis (ME) and Chronic Fatigue Syndrome (CFS) By Course of Illness.

Past research has subtyped patients with Myalgic Encephalomyelitis (ME) and Chronic Fatigue Syndrome (CFS) according to factors related to illness onset, illness duration, and age. However, no classification system fully accounts for the wide range of symptom severity, functional disability, progression, and prognosis seen among patients. This study examined whether illness trajectories among individuals with CFS were predictive of different levels of symptomology, functional disability, and energy expenditure. Of the participants (N=541), the majority described their illness as Fluctuating (59.7%), with 15.9% Constantly Getting Worse, 14.1% Persisting, 8.5% Relapsing and Remitting, and 1.9% Constantly Getting Better. The illness courses were associated with significant differences in symptomology on select domains of the DSQ, functioning on select subscales of the SF-36, and on overall levels of energy expenditure. The significant symptomatic and functional differences between groups suggest that subtyping patients with CFS according to illness course is a promising method for creating more homogeneous groups of patients.

A Prospective Study of Infectious Mononucleosis in College Students.

BACKGROUND: The present study aims to prospectively investigate possible biological and psychological factors present in college students who will go on to develop chronic fatigue syndrome (CFS) following Infectious Mononucleosis (IM). Identification of risk factors predisposing patients towards developing CFS may help to understand the underlying mechanisms and ultimately prevent its occurrence. Our study is enrolling healthy college students over the age of 18. Enrollment began in March of 2013 and is ongoing. METHODS: Biological and psychological data are collected when students are well (Stage 1), when they develop IM (Stage 2), and approximately 6 months after IM diagnosis (Stage 3). RESULTS: Two case studies demonstrate the progression of student symptomology across all three stages. CONCLUSION: The Case Studies presented illustrate the usefulness of a prospective research design that tracks healthy students, following their trajectory of IM illness to either a) full recovery or b) diagnosis with CFS.

Describing Trajectories of Homeless Service Use in Hawai'i Using Latent Class Growth Analysis.

The State of Hawai'i, like many other areas across the United States, has large numbers of individuals and families experiencing homelessness, many of whom seek support through statewide shelters and services. This study explored the diversity of ways in which individuals and families moved through Hawai'i's homeless service system. Using administrative data, a cohort of new service users was tracked across time to trace the developmental trajectories of their homeless service use. The sample consisted of adults who had entered the service system for the first time in the fiscal year (FY) of 2010 (N = 4655). These individuals were then tracked through the end of FY 2014, as they used emergency shelter, transitional shelter, and outreach services. A latent class growth analysis was conducted and identified four distinct patterns of service use: low service use (n = 3966, 85.2%); typical transitional shelter use (n = 452, 9.7%); atypical transitional use (n = 127, 2.7%), and potential chronic service use (n = 110, 2.4%). Multinomial logistic regression models were then used to determine if select demographic, family, background experience (e.g., education, employment), or health variables were associated with class membership. The distinct profiles for class membership are discussed.

Assessing current functioning as a measure of significant reduction in activity level.

BACKGROUND: Myalgic encephalomyelitis (ME) and chronic fatigue syndrome (CFS) have case definitions with varying criteria, but almost all criteria require an individual to have a substantial reduction in activity level. Unfortunately, a consensus has not been reached regarding what constitutes substantial reductions. One measure that has been used to measure substantial reduction is the Medical Outcomes Study Short Form-36 Health Survey (SF-36).[1]. PURPOSE: The current study examined the relationship between the SF-36, a measure of current functioning, and a self-report measure of the percent reduction in hours spent on activities. RESULTS: Findings indicated that select subscales of the SF-36 accurately measure significant reductions in functioning. Further, this measure significantly differentiates patients from controls. CONCLUSION: Determining what constitutes a significant reduction in activity is difficult because it is subjective to the individual. However, certain subscales of the SF-36 could provide a uniform way to accurately measure and define substantial reductions in functioning.

EF5 binding and clinical outcome in human soft tissue sarcomas.

PURPOSE: To study the 2-nitroimidazole agent EF5 as a surrogate for measuring hypoxia in a series of patients with soft tissue sarcomas, and to determine whether hypoxia measured with this technique was associated with patient outcome. METHODS AND MATERIALS: Patients with soft tissue sarcomas of the head and neck, extremity, trunk, or retroperitoneum for whom surgical excision was the initial treatment of choice, were given 21 mg/kg EF5 24-48 hours before surgery. Biopsy specimens were stained for EF5 binding with fluorescence-labeled monoclonal antibodies, and the images were analyzed quantitatively. Endpoints included the relationship between EF5 binding, clinically important prognostic factors, and patient outcome. RESULTS: Two patients with recurrent and 14 patients with de novo sarcomas were studied. There were seven low-grade, one intermediate-grade, and eight high-grade tumors. No relationship was found between EF5 binding and patient age, sex, hemoglobin level, or tumor size. In de novo tumors, the presence of mitoses and histologic grade were positively correlated with hypoxia. High-grade and -stage de novo tumors had higher levels of EF5 binding compared with low-grade and -stage tumors. Patients with de novo tumors containing moderate to severe hypoxia (> or = 20% EF5 binding), high grade, or > or = 7% mitoses were more likely to develop metastases. CONCLUSIONS: Further studies in a larger cohort of patients are necessary to determine whether hypoxia, as measured by EF5 binding, is an independent prognostic factor for outcome in high-grade sarcomas. Such data should be useful to identify high-risk patients for clinical trials to determine whether early chemotherapy will influence the occurrence of metastasis.

Hypoxia and Photofrin uptake in the intraperitoneal carcinomatosis and sarcomatosis of photodynamic therapy patients.

PURPOSE: Response to photodynamic therapy depends on adequate tumor oxygenation as well as sufficient accumulation of photosensitizer in the tumor. The goal of this study was to investigate the presence of hypoxia and retention of the photosensitizer Photofrin in the tumors of patients with intra-abdominal carcinomatosis or sarcomatosis. EXPERIMENTAL DESIGN: Tumor nodules from 10 patients were studied. In nine of these patients, hypoxia was identified in histological sections of biopsied tumor after administration of the hypoxia marker 2-(2-nitroimidazol-1[H]-yl)-N-(2,2,3,3,3-pentafluoropropyl)acetamide (EF5). In separate tumor nodules from 10 patients, Photofrin uptake was measured by fluorescence after tissue solubilization. RESULTS: Hypoxia existed in the tumors of five patients, with three of these patients demonstrating at least one severely hypoxic nodule. Physiological levels of oxygen were present in the tumors of four patients. An association between tumor size and hypoxia was not evident because some tumor nodules as small as approximately 2 mm in diameter were severely hypoxic. However, even these tumor nodules contained vascular networks. Three patients with severely hypoxic tumor nodules exhibited moderate levels of Photofrin uptake of 3.9 +/- 0.4 to 3.9 +/- 0.5 ng/mg (mean +/- SE). The four patients with tumors of physiological oxygenation did not consistently exhibit high tumor concentrations of Photofrin: mean +/- SE drug uptake among these patients ranged from 0.6 +/- 0.8 to 5.8 +/- 0.5 ng/mg. CONCLUSIONS: Carcinomatosis or sarcomatosis of the i.p. cavity may exhibit severe tumor hypoxia. Photofrin accumulation in tumors varied by a factor of approximately 10x among all patients, and, on average, those with severe hypoxia in at least one nodule did not demonstrate poor Photofrin uptake in separate tumor samples. These data emphasize the need for reconsideration of the generally accepted paradigm of small tumor size, good oxygenation, and good drug delivery because this may vary on an individual tumor basis.