archives@tulane.edu / Research has shown that populations with mental illness tend to have higher rates of obesity, diabetes, and other chronic conditions. This can be due in part to the medication treatment as anti-psychotic and anti-depressant medications have been shown to be major contributors to elevated rates of obesity, diabetes, dyslipidemia, and metabolic disorders that have the potential to lead to cardiovascular disease. Existing literature has identified many barriers that contribute to low preventive care utilization and screenings for metabolic risk factors. Consequently, national policy initiatives, such as the 2010 Affordable Care Act’s (ACA) Medicaid expansion, have aimed to improve access to care impacting adults with mental illness and expand coverage for more preventive and mental health services. Thus, this project: (1) examined longitudinal trends in diabetes preventive screenings and healthcare utilization associated with the 2016 Louisiana Medicaid expansion for a traditionally enrolled Severe Mentally Ill (SMI) Medicaid insured population, (2) assessed differences in racial and other socio-demographic characteristics associated with receiving diabetes preventive care and utilizing health care services amongst a traditionally enrolled SMI Medicaid insured population, and (3) assessed if Medicaid expansion was associated with better access to care and increased utilization of preventive care for diabetes-related complications in adults with diabetes and depression. To address these aims, adults ages 18 to 64 were analyzed through two data sources. The first is Louisiana Medicaid claims data; a longitudinal assessment of screening rates over a five-year period was used in an interrupted time series analysis to look at the change in screening rates for preventive care services and health care utilization before and after expansion for adults with SMI. Next, we used multivariable logit regression modeling, to examine the likelihood of receiving preventive care and utilizing health care services based on sociodemographic characteristics. Results from these analyses showed there was a total of 53,926 adults with a diagnosed SMI who had continuous enrollment in Medicaid between January 1st, 2014 – December 31st, 2018. Medicaid expansion was associated with significant increases in ED utilization and average inpatient length of stay for traditionally enrolled SMI adults. Racial differences in the likelihood of going to the ED were also apparent as blacks were more likely to go to the ED and for reasons that could have been prevented. For the third aim, data were extracted from the Behavioral Risk Factor Surveillance System survey for the years 2010 to 2017 for all adults with a self-reported diagnoses of depression and diabetes by a health professional. A retrospective cross-sectional study design using difference-in-differences analysis assessed relationship between Medicaid expansion and access to care and preventive care utilization for Medicaid eligible respondents in expansion states, compared to Medicaid eligible respondents in non-expansion states. Medicaid expansion significantly increased insurance coverage and the likelihood of having a personal doctor for eligible respondents in expansion states. / 1 / Alisha Monnette

Severe congenital neutropenia (SCN) is a rare blood disorder characterized by abnormally low levels of circulating neutrophils. Mutations in multiple genes like neutrophil elastase gene (ELANE) and granulocyte colony stimulating factor receptor (CSF3R) may cause SCN. The treatment of choice for SCN is the administration of granulocyte-colony stimulating factor (G-CSF) which elevates the neutrophil count and hence improves the survival and quality of life. Long term survivorship on G-CSF is however linked to development of MDS (myelodysplastic syndrome)/AML (acute myeloid leukemia). About 70% of MDS/AML patients acquire nonsense mutations affecting the cytoplasmic domain of CSF3R. In this project, we hypothesized that this coding region of CSF3R constitutes a hotspot, vulnerable to mutations resulting from excessive oxidative stress or endoplasmic reticulum (ER) stress. We used the murine Ba/F3 cell line to study the effect of induced oxidative or ER stress on the mutation rate in our hypothesized hotspot of the exogenous human CSF3R, the corresponding region in the endogenous Csf3r, and a leukemia-associated gene Runx1. Ba/F3 cells transduced with the cDNA for partial C-terminal of CSF3R fused in-frame with a Green Fluorescent Protein (GFP) tag was subjected to cellular stress inducing mutagen treatment for a prolonged period of time (30 days). The amplicon based targeted deep sequencing data for days 15 and 30 samples show that although there was increased mutagenesis observed in all genes, there were more mutations in the GFP region as compared to the GC-rich partial CSF3R region. Our findings also indicate that there is no correlation between the stress-inducing chemical treatments and mutagenesis in Ba/F3 cells. Thus, we conclude that there are other mechanisms to acquired mutations of CSF3R that help drive the evolution of SCN to MDS/AML. To test this hypothesis, further experiments using unique barcoding system are in progress to characterize the clonal competition between different mutant CSF3R and ELANE expressing cell lines. This study will shed further light on the selection advantage that is provided to cells because cooperativity between mutations in different genes.

Five severe convective cells over North Texas from three separate dates were examined to determine what three dimensional, or “total” lightning data can add to the understanding of a convective cell’s intensity, propagation, and severe weather potential. Total lightning data were obtained from Vaisala Inc.’s Dallas/Fort Worth (D/FW) Lightning Detection and Ranging (LDAR) network. Radar data from two Weather Surveillance Radar – 1988 Doppler (WSR-88D) sites were used for position data and information regarding the intensity and kinematic properties of each cell. Total lightning products used by the National Weather Service Forecast Office in Fort Worth, Texas were compared to total lightning flash rate; a quantity that has been shown to be correlated to changes in cell intensity inferred from other sources, such as radar and satellite data. These products, specifically flash extent density (FED) were also compared to CG flash rate and radar derived measures from the WSR-88D sites. The results of this work show that FED and total flash rate are well correlated, with an average Pearson correlation value of 0.73, indicating that previous total flash rate results may also apply to FED. Lightning hooks, holes, and notches in FED displays indicated likely updraft regions, while appendages were observed to develop prior to deviant motion with two supercells. These results, combined with a greater update frequency provided a useful complement to radar data in the warning decision process. FED jumps were observed prior to several severe weather reports, indicating that total lightning activity may be related to updraft strength as found in past studies. However, FED jumps were sometimes observed without any associated severe event. More work is clearly needed to define what FED changes are of most importance in the short-term prediction of storm severity. The usefulness of the total lightning data on these dates was dependant upon LDAR network status and distance of the cell from the network center. The results of this study suggest that combining total flash rate trends with visual displays of FED provides the greatest added benefit to forecasters in maintaining situational awareness during warning operations.

Severe acute respiratory syndrome (SARS) is an emerging infectious disease that first manifested in humans in China in November 2002 and has subsequently spread worldwide. According to the World Health Organization, 8098 cases occurred during the outbreak, and healthcare workers accounted for 1707 (21%) of the cases. To determine the prevalence of SARS infection of healthcare workers in Taiwan, we performed a serosurvey by the recombinant protein-based enzyme-linked immunosorbent assay (ELISA) to test for immunoglobulin (Ig) G antibodies to the SARS coronavirus (SARS-CoV) among 1525 healthcare workers in 26 hospitals that admitted SARS patients in mid-May, 2003. Then, a case-control study was carried out to evaluate the risk factors of SARS infection among the healthcare workers. A total of 52 infected staffs and 78 hospital and age matched non-infected controls were recruited. The seroprevalence rate was 3.68% (58/1525) for healthcare workers. Univariate analysis showed that with the habit of drinking coffee or tea, taking care of fever patients more than 8 days, ever practice of CPR, suction of sputum, taking patient¡¦s temperature, use of P100 mask, use of N95 mask, use of face cover, use of goggles, use of gown, removing gloves after work, working in isolation area or fever screen station were significantly protective factors. In addition, eating jujube was a risk factor for SARS infection. Then, the multivariate analysis showed that use of P100 ¡]OR: 0.056, 95%CI: 0.019-0.162, p value: <0.001¡^and working in isolation area ¡]OR: 0.153, 95%CI: 0.029-0.810, p value: 0.027¡^or fever screen station¡]OR: 0.103, 95%CI: 0.011-0.963, p value: 0.046¡^were the most important protective factors for SARS infection. These findings suggest that nosocomial infection of SARS can be prevented effectively by use of P100 and the triage screening in emergency departments.

The southeast United States is prone to severe weather throughout the year. Despite technological advances, some severe weather events occasionally remain unwarned in this part of the country. Past studies examined the relationship between cloud-to-ground (CG) lightning and warm season severe weather episodes. The present study examined the relationship between cool season tornadoes and CG lightning, with a focus over the southeastern United States, where most cool season tornadoes occur. Data from the Storm Prediction Center and National Lightning Detection Network (NLDN) were used to investigate CG lightning properties within 50 km and one hour before tornado touchdown. This was completed over a period of 13 cool seasons from October 1989 through March 2002. Of 3325 tornado events, 2358 contained at least one NLDN-detectable flash. CG lightning attributes of peak current, multiplicity, and flash density compared well with those of prior warm season lightning research. Overall event frequency appeared to be lower than in the warm season. Almost all Central Plains events were accompanied by at least one NLDN-detectable flash. Up to 70% of tornado events near the Gulf of Mexico and Atlantic coasts contained no NLDN-detectable lightning. Although it is not known why this trend was observed, it is speculated that NLDN detection efficiency and/or storm structure differences may play a role in these observations. Warm season studies have correlated tornadoes with predominantly positive (>50% positive CG lightning), or PPCG storms. Gridded maps showed the greatest percentage and highest frequency of cool season PPCG storms across Kansas and Nebraska, with up to 70% of events associated with PPCG lightning. A secondary, albeit lower, frequency maximum extended 1° to 2° inland across Louisiana into North Carolina. This study also subjectively defined a storm with “enhanced” positive cloud-to-ground (EPCG) lightning as one containing >25% positive cloud-to-ground lightning, which corresponds to approximately the 75th percentile of all cool season tornadoes. This has lead to speculation that EPCG criterion may be a better indicator of the possibility of severe weather than the traditional PPCG criterion.

The literature reports controversy among teachers about the value of an alternate assessment for students with significant cognitive disabilities (SCD) (Kampfer, Horvath, Kleinert, & Kearns, 2001).The purpose of this study was to investigate the perceptions of special education teachers about the value and implementation of the Arizona Alternate Assessment (AIMS-A) for instructional planning.Twelve elementary special education teachers from three school districts in Southern Arizona were placed in one of two focus groups. They were asked questions about the value of the alternate assessment, the impact on instructional planning, the allocation of time to complete the assessment, and the usefulness of the data collected for the alternate assessment. Later, in-depth interviews were held with three of the 12 teachers representing each of the districts. The teachers' responses to the questions asked in the focus group and interview sessions were tape-recorded, transcribed, and organized into themes.Results revealed four major themes and 11 sub-themes. Most teachers valued the AIMS-A information in guiding their teaching. Some teachers, however, believed the instrument did not accurately assess students with the most severe disabilities. Teachers reported the assessment helped guide their instructional planning. The limited time allocated during the school day to complete the assessment resulted in an additional burden on teachers' personal time. Teachers found documenting and collection data throughout the school year was necessary to be able to accurately assess students during the spring testing period. Most of the teachers found the progress data useful.Six recommendations for State (SEAs) and Local Education Agencies (LEAs) resulted from the implications. The first recommendation is to acquire positive teacher perceptions and support for the AIMS-A by providing teachers with a thorough understanding of the benefits of the assessment. A second recommendation is for LEA administrators to assist teachers in finding time to administer the AIMS-A. The third recommendation is that the LEA's must provide in-service training. The fourth recommendation requires modification of existing policies when needed. The fifth recommendation is to create a state-wide data base that articulates student progress on the AIMS-A. The final recommendation is to modify existing policies where needed.

This study aims to examine howdifferent forms of social support are perceived to affect the recovery process of people with severe mental health difficulties, and what factors people within this group perceive as being most beneficial for their recovery. This study was conducted in Uganda for eight weeks during November 2013 and December 2013 and is based on semi-structured interviews with people in recovery from severe mental illness such as bi-polar affective disorder and schizophrenia. This study is using Interpretative phenomenological analysis (IPA), which is a qualitative research approach, and the strength of IPA is its commitment to examine lived experience and personal meaning in detail. This study has shown that social support received from service user organisations was perceived to highly affect the recovery process in a most fundamental way. The service user organisations/associations were seen as platforms providing acceptance, understanding and recognition of what one has been or are going through. In terms of social support from family members, this was neither described as particularly helpful or hindering for the recovery process by most of the participants; this finding was somewhat unexpected but could be explained due to the complexity that proved to exist within the relationships between the participants and their family members. Medication was perceived as very important in terms of recovery, however it was strongly pointed out that medication alone was not enough. Despite this a majority of the participants had negative perceptions regarding both the dosage and the prescribed medicine itself particularly the prescription of Chlorpromazine, here feelings of being overmedicated and dealing with severe side effects were expressed, leading to some of the participants changing the prescribed dose on their own, so called manipulative medication.

Research has examined the effects of micronutrients on mood in both healthy and psychiatric populations. EMPowerplus (EMP+) is a formula containing a wide range of vitamins and minerals. It has been examined for the treatment of mood instability, anxiety, Attention Deficit Hyperactivity Disorder (ADHD) and autism. The present study trialled EMP+ with five adolescents, aged 16-21, all with Severe Mood Dysregulation (SMD) as well as co-occuring psychiatric diagnoses i.e. ADHD, anxiety and substance abuse. The sample reflects a group of adolescents with complex psychiatric presentations and therefore difficult to treat. An ABAB (off-on-off-on) research design was employed. An open-label trial (8 weeks) of the micronutrients was followed by a withdrawal phase (8 weeks) and then a reinstatement of the micronutrients for a longer period of time (up to 24 weeks). There were in-depth pre and post assessments and on-going monitoring of the participants for the duration of the study. Clinically significant improvements in symptoms and functioning were demonstrated in three/four participants. Two participants demonstrated on-off control of psychiatric symptoms, with a reversal and replication of treatment effect. Further, one participant demonstrated clinically significant improvements in mood and functioning while on the micronutrients; however, he was lost to follow up following the 7.1 earthquake, and a reversal was not obtained. One participant demonstrated a trend toward improvements in mood while on the micronutrients and subsequent deterioration during the wash-out phase. However, she decided to withdraw from the study at four weeks off to go on psychiatric medication. Further, one participant demonstrated a variable response. This study provides some further evidence that micronutrients may be an effective treatment for psychiatric symptoms, consistent with other reports. Further research, such as randomised clinical trials and studies investigating the mechanisms of action, appears warranted.

Asthma is a heterogeneity disease that is mostly managed successfully using bronchodilators and anti-inflammatory drugs. Around 10%-15% of asthmatics however have difficult or severe asthma which is less responsive to treatments. Asthma and in particular severe asthma are now thought of a description of symptoms which may contain possible sub-groups with possible different pathologies which could be useful for targeting different drugs for different sub-groups. However little statistical work has been carried out to determine these sub-phenotypes. Studies have been carried out to partition severe asthma variables in to a number of sub-groups but the algorithms used in these studies are not based on statistical inference and it is difficult to select the number of best fitting sub-groups using such methods. It is also unclear where the clusters or sub-groups returned are actual sub-groups or reflect a bigger non-normal distribution. In the thesis we have developed a statistical model that combines factor analysis, a method used to obtain independent factors to describe processes allowing for variation over variables, and infinite mixture modelling, a process that involves determining the most probable number of mixtures or clusters thus allowing for variation over individuals. This model created is a Dirichlet process normal mixture latent variable model DPNMLVN and it is capable of determining the correct number of mixtures over each factor. The model was tested with simulations and used to analysis two severe asthma datasets and a cancer clinical trial. Sub-groups were found that reflect a high Eosinophilic group and an average eosinophilic group, a late onset older non atopic group and a highly atopic younger early onset group. In the clinical trial data 3 distinct mixtures were found relating to existing biomarkers not used in the mixture analysis.

The aim of this thesis is to analyse and examine the debate on prenatal testing in Western countries, with a special focus on my own country, Sweden. In the near future it might be possible for a pregnant woman to profile the DNA of her foetus with a simple blood test early in pregnancy. This method of prenatal testing – Non Invasive Prenatal Diagnosis (NIPD) – could potentially detect the genetic causes of almost every disease. I will argue that prenatal testing should be offered by society to all pregnant women, not only to those at highest risk of giving birth to children with severe conditions. I will do that from a perspective of reproductive freedom. Furthermore, I will argue that offering prenatal testing for some conditions (such as Downs’s syndrome) and not for others, is conflicting with the autonomous choice of the pregnant woman.