Thesis advisor: Stephanie Greene / This paper addresses the recent concerns about concussions in the sport of football and elaborates on the medical findings, litigation, and ethical questions that have surrounded the issue. The goal is to present a compelling case for change in how concussions are viewed and handled in the sport. By using concrete examples to explain the lasting effects concussions have had on players after their careers have ended, I hope to show the need for change. I will explore the most recent developments of chronic traumatic encephalopathy in order to show its harmful reach and will touch upon litigation that has been filed by players who experienced post career problems. In addition, through the insight of current college players as well as referencing my own experience as a Division I College Football player, I wish to establish an emotional connection in the paper and unveil the roots of the problem – the toxic nature of the football culture. I am optimistic that this inquiry will help cultivate a culture change through a variety of approaches. First, I indicate the need for a transformation of the football culture. Second, I suggest a formal, mandatory education to inform players at all levels about concussions, subconcussive hits, and the potential diseases that can stem from. Third, I propose new penalties for players, coaches, support staff, and all involved in player safety in an attempt to further prevent head injuries. This thesis attacks the issue of concussions in football from all angles. It calls for the football community to accept the severity of concussions, educate on concussions, and prevent repeated concussions in order to prompt action. / Thesis (BS) — Boston College, 2016. / Submitted to: Boston College. Carroll School of Management. / Discipline: Departmental Honors. / Discipline: Other.

Introduction: Posttraumatic Stress Disorder (PTSD) affects as many as 30 percent of United States veterans, who are often at greater risk for PTSD, due to adverse military experiences (e.g., combat injury). PTSD occurs when the natural process of recovery is obstructed by the individual’s cognitions and emotions, such as guilt, related to the traumatic event. Guilt has emerged in the literature as a significant contributor to the development and maintenance of PTSD. As such, researchers have sought protective factors that may attenuate the association between guilt and PTSD. One such factor, self-compassion, may facilitate the natural process of recovery, perhaps by promoting the process of posttraumatic growth (PTG) – a process of adaptive growth following a trauma. Our study examined the direct association between guilt and symptoms of PTSD, and the potential mediating role of self-compassion and PTG. At the bivariate level, we hypothesized that guilt will be inversely related to self-compassion and PTG, and positively associated with PTSD symptoms. At the multivariate level, we hypothesized that guilt will be directly related to PTSD symptoms and, further, indirectly related via its serial association with self-compassion and PTG. Methods: Participants (N = 172) in this IRB-approved study were recruited via online invitations distributed to veterans-related social media groups and national organizations (e.g., Veterans of Foreign Wars [VFW] chapters). Participants were included in the study if they reported experiencing injury during combat. Participants completed self-report surveys including the Differential Emotions Scale, the Self-Compassion Scale – Short Form, the Posttraumatic Growth Inventory – Short Form, and the PTSD Checklist for DSM-5 (PCL-5) – Military Version. Results: At the bivariate level, symptoms of PTSD were positively associated with guilt and both were negatively associated with self-compassion and PTG. Self-compassion and PTG were positively associated. At the multivariate level, guilt exhibited a significant total effect on PTSD that, while remaining significant, was significantly reduced when accounting for self-compassion and PTG. Guilt also exhibited a significant total indirect effect, via its deleterious impact on self-compassion. No other indirect pathways were significant. Conclusions: The association between guilt and symptoms of PTSD may be due, in part, to the stifling effect of guilt on self-compassion and post-traumatic growth. Therapeutically reducing guilt, perhaps via cognitive restructuring (e.g., about the nature of, or role in, trauma), or promoting self-compassion (e.g., via self-soothing, guided meditation; blessings journal) may, in turn, reduce symptoms of PTSD.

Worldwide there are several million war refugees, many of whom stay in the host countries for years. However, little is known about their long-term mental health. The current thesis examined the prevalence, course, and predictors of mental disorders and subjective quality of life (SQOL) in 854 war refugees from former Yugoslavia who had resettled in Germany, Italy and the United Kingdom 9.3 years previously. 215 interviewees with Posttraumatic Stress Disorder (PTSD) at baseline were reinterviewed one-year later. The participants were additionally assessed for use of social and health care interventions during the one-year follow-up period. Prevalence rates of mental disorders in the war refugees varied substantially across countries, with between 42.1% and 67.8% of refugees having a mental disorder. Warrelated factors explained most variance in rates of PTSD whereas post-migration factors explained most variance in mood, anxiety and substance use disorder rates. Risk factors for each disorder were consistent across host countries. At the end of the one-year follow-up period, a third of the sample no longer met the criteria for PTSD. Recovery was positively associated with employment and negatively associated with severity of war exposure, baseline PTSD symptom severity and use of mental health services. Despite the high rates of mental disorders, refugees felt reasonably satisfied with SQOL. Low SQOL was associated with poor post-migration living conditions and mental illness, but not with war trauma. In conclusion, mental disorders appeared to be highly prevalent in war refugees many years after resettlement. This increased risk may result from exposure not only to wartime trauma but also to post-migration socio-economic adversity. Policies promoting community integration and employment may be more effective than existing psychiatric and psychological interventions in improving mental health and quality of life in war refugees.

Infection after trauma complicates the patients clinical course. Infection leads to longer critical care and hospital stays, has been associated with increased mortality rates and places considerable cost pressures on health economies. The predictors of infection after severe injury are not known, and the effects on outcomes other than mortality are under-reported. The overall objective of this research was to characterise factors predictive of infection in severely injured patients admitted to critical care. A prospective cohort study of 271 patients investigated admission factors predictive of the development of infection. A second study of 280 patients evaluated post-injury immune cell changes and the association with infection. Thirdly the relationship between early coagulopathy and infections was investigated in 158 patients. Finally a study of 385 patients examined the use of Tranexamic Acid (TXA) and its association with infection and other outcomes. Infection was a significant burden for severely injured patients. Admission hypoperfusion was the only early characteristic associated with the development of infection, and a dose dependent relationship was observed between severity of shock and increased percentage of infection (p<0.01). Lymphopenia prolonged to day four post injury was strongly predictive infection (OR 0.10, CI 0.02-0.48, p<0.01). At 24 hours, the anticoagulant Protein C was lower in those with infection (Infection: 70.2 iu/dL vs. No infection: 83.3 iu/dL p=0.02), and increased fibrinolysis was also associated with infectious complications (Infection: 6156 μg/L vs. No infection: 3324 μg/L p=0.03). There was a trend to a beneficial relationship between TXA and infection, and it was independently associated with reduced organ failure (OR 0.27, CI: 0.10 – 0.73, p=0.01) and mortality (OR 0.16 CI 0.03 - 0.86, p=0.03). In severely injured patients, admission shock, prolonged lymphopenia and early coagulation dysfunction post severe injury were independent predictors of infection. Timely modulation of these responses after trauma may help to reduce the burden of infection.

Background: People who experience physical trauma face a range of psychosocial outcomes. These may be overlooked by busy clinicians. While some risk factors are understood, our understanding of the psychological effects of violent injury remains limited. Furthermore, there has been little research on the effect of facial trauma. Although changes to appearance can be distressing, the effects of these have not been studied in traumatic injury patients. Aims: To establish the prevalence and persistence of psychological distress and appearance concerns following injury. To compare the psychological outcomes in i) violent and accidental injury and ii) facial and other injury, and iii) to identify explanatory risk factors for psychological distress. Methods: Participants were adults admitted to the Royal London Hospital with traumatic injuries. Two hundred and twenty five participants (225) completed questionnaires in hospital. Follow up was at three months (N = 100) and six months (N = 112). Standardised measures were used to assess symptoms of post-traumatic stress (PTSS) (Acute Stress Disorder Scale, PTSD Checklist), depression and anxiety (Hospital Anxiety and Depression Scale), and appearance concern (Derriford Appearance Scale). Explanatory measures were collected, including history of mental health. Data were analysed in logistic and linear regressions, using multilevel models. Results: PTSS and depressive symptoms affected 28% and 33% respectively at baseline. At six months, 27% and 31% respectively reported these symptoms. After adjusting for demographic factors, violent injury was associated with increased PTSS (OR 6.44, CI 1.75 to 23.75), depressive symptoms (OR 4.78, CI 1.41 to 16.18) and appearance concern (2.78, CI 0.09 to 5.47). A history of mental health problems increased distress. Conclusions: There were high levels of psychological distress in this sample. Violent injury was associated with a complex interaction of social and psychological factors. People vulnerable to distress may benefit from psychological support. Hospital admission provides a unique opportunity to engage them in interventions.

Design This is a cross-sectional study involving quantitative measures and qualitative interviews. Participants Sixteen brain injured men and four brain injured women participated. Eighteen of these had a close relative who also took part. Measures In addition to being interviewed, brain injured participants completed questionnaires on mood symptoms and fatigue, and a speed of information processing task. Relatives of brain injured people were interviewed and completed the symptom checklist. Correlational analysis was applied to the quantitative measures and- qualitative analysis was informed by the grounded theory approach. Results Quantitative measures suggest significant association of subjective perception of fatigue severity with mood and brain injury related symptoms. Relatives' objective perceptions of brain injured relatives' symptoms correlated significantly with subjective views. Subjective perception of fatigue did not correlate significantly with severity of brain injury or information processing speed. Qualitative analysis identified fatigue as a major problem for some people. Descriptions noting the impact of fatigue following injury included increased slowness, decreased energy, and lack of control. Fatigue was commonly considered to be more mental than physical, and was often linked with short temper. Conclusions Findings suggest that fatigue was related less to severity of injury than to psychological and emotional factors. The multidimensional nature of fatigue was confirmed. Links were made with low-mood, anxiety, lack of motivation, boredom, and having to cope with 'normal life' following brain injury. The possibility that 'fatigue' is an umbrella term used by some to describe a range of symptoms following brain injury was considered.

Traumatic brain injury (TBI) is a serious public health concern. Although moderate and severe forms of TBI receive considerable attention, mild TBI accounts for the majority of all injuries. The first two aims of this work used a rodent model of mild blast to simulate primary injury (damage from the blast wave only). The first aim evaluated potential changes in interneurons containing the calcium-binding proteins calretinin or parvalbumin. In addition, morphological changes in astrocytes and microglia were assessed. Brains were analyzed 48 hours and one month following exposure to single or repeated blasts, with a focus on the hippocampus due to its integral role in learning and memory. Results showed significant region-specific alterations in microglia morphology 48 hours following blast. The absence of structural alterations in microglia one month following blast indicated that the regional hippocampal vulnerability may be transient. The second aim compared glial morphologies in the retina and brain (the lateral geniculate nucleus, superior colliculus, and visual cortex) 48 hours or one month following multiple blasts. Fiber degeneration has received considerable attention, however, less is known about the status of glia throughout the visual pathway following mild blasts. Although no structural alterations were detected, it is possible that alterations in glia occurred at a more acute time scale as changes in glia can be rapid and reversible. The final aim of this work focused on the immunocytochemical characterization of tau pathology in the visual cortices of human postmortem brains with advanced chronic traumatic encephalopathy (CTE). CTE is a devastating tauopathy associated with mild, repetitive TBIs. Although visual deficits are reported in CTE, the primary visual cortex is often spared. The main hypothesis under investigation was whether visual association areas would have tau pathology, despite sparing of primary visual cortex. In addition, a sub-class of interneurons containing parvalbumin was used to evaluate a potential cell-specific vulnerability. Results showed increased tau pathology in visual association areas in advanced CTE, that was largely absent from the primary visual cortex. There was no effect on parvalbumin positive interneurons. The results of this work provides valuable insight regarding potential cell-specific resistance to CTE pathology. / 2018-11-03T00:00:00Z

Background An increasing body of research is suggesting that childhood trauma and adversity may be associated with various adverse mental health outcomes, including psychosis. Cognitive functioning is often compromised in psychosis, and research has shown that there may be a link between early trauma and cognitive impairment in people with psychosis. No systematic review of the literature of this link has been undertaken, and very few studies have examined samples of individuals at high clinical risk for psychosis, to assess whether the potential link between adversity and cognitive functioning exists, without the confounding factors of length of illness, antipsychotic medication and chronicity of symptoms. Method The systematic review of all relevant electronic databases investigates the research to date on the association between childhood adverse experiences and cognitive ability in psychosis, and the conclusions that can be drawn from the existing literature, taking into account relevant considerations regarding sample, methodology and statistical analysis. The subsequent empirical study utilizes a sample at clinical high risk of developing psychosis, and a healthy control group to investigate whether any putative association in specific domains of cognitive functioning, or global cognitive ability and childhood adversity exist in those at clinical high risk, compared to controls. Results The systematic review indicated that at present, the literature looking into childhood adversity and cognitive ability in relation to psychosis is heterogeneous, with some studies finding that this association only occurs in patients, whilst others suggest it only occurs in the control groups. Some studies found it to be specific to certain cognitive domains, whilst others suggest it was a more global impairment. Methodology, samples and analysis differed considerably across studies, and likely contribute to the heterogeneity of the literature. The empirical paper showed a significant interaction effect between group (high risk versus controls) in the high childhood adversity group, in relation to global cognitive ability. Interestingly, this was not related to psychotic symptom severity or distress. Conclusion Several limitations of the existing studies limit the conclusions that can be drawn from the existing evidence regarding the link between childhood adversity and cognitive ability, and future research in prodromal samples is essential. The empirical study showed that there is a link between childhood adversity and cognitive ability in those at clinical high risk of developing psychosis, before disorder onset, that is not present in controls. This suggests that this may form a vulnerability in those at high risk for psychosis, rather than a more general mechanism present in the typical population.

54 225: crimes against children reported in 2010/2011  28 128: sexual offences  30% of the sexual offences occurred in children younger than ten years. These figures are a stark reminder of the growing number of children who experience deprivation, abuse and maltreatment in South Africa (Unicef, 2013). Although controversy exists with the reporting methods and the accuracy of recall in adult patients, it remains evident that a significant number of female children are sexually abused. Associations between early life stress and later life dysregulation of the hypothalamic-pituitary-adrenal axis hormone, cortisol, and the immune system cytokine, interleukin 6, have been found in adult patients and in animal studies. Importantly, although there is also evidence that early life stress results in later life neurobiological changes, we have to date, no identifiable biological markers to assist with diagnosis or to inform treatment strategies in young children who present with early life stress such as sexual abuse or maternal neglect. Thus, there is a growing imperative to establish whether the potential precursor biomarkers are evident in early in development following adverse life conditions. Therefore the research focus of the thesis was to investigate (1) whether dysregulation of the HPA axis is evident in young children who are exposed to the traumatic stress of abuse, (2) whether there is evidence that inadequate maternal care, during the neonatal stage of development, has an impact of HPA and immune function and consequently on

Our murine model of mild traumatic brain injury (mTBI) has shown improved survival after Pseudomonas aeruginosa (Psd) challenge as compared to controls (tail trauma or sham injury). Previous work suggests an mTBI-specific involvement of the neuro-immune axis which augments the innate immune response, increasing survival. Additional factors for the enhanced mTBI survival were explored via microarray analysis of lungs harvested 48 hours post-trauma, the point prior to Psd challenge in our model. At 48 hours post-trauma, mTBI lungs have a number of upregulated ATP synthesis and mitochondrial gene sets. Increased available energy could prime the mTBI lungs, allowing an earlier and more robust response to Psd infection, possibly contributing to the increased mTBI survival. This is supported by increased neutrophil recruitment in the bronchoalveolar lavage of mTBI mice four hours after Psd instillation. Downregulated gene sets related to cellular connections suggest that neutrophils recruited to the lung have an easier extravasation pathway into the air space of mTBI lungs compared to control. Based on genetic and neutrophil recruitment data, it is possible that mTBI creates an energetically prepared and easily accessible lung better tailored for recruiting and allowing entry of neutrophils in response to an infection compared to control.