Construct Validity of the SF-12v2 for the Homeless Population with Mental Illness: An Instrument to Measure Self-Reported Mental and Physical Health

Background

Self-reported health measures are important indicators used by clinicians and researchers for the evaluation of health interventions, outcome assessment of clinical studies, and identification of health needs to improve resource allocation. However, the application of self-reported health measures relies on developing reliable and valid instruments that are suitable across diverse populations. The main objective of this study is to evaluate the construct validity of the SF-12v.2, an instrument for measuring self-rated physical and mental health, for homeless adults with mental illness. Various interventions have been aimed at improving the health of homeless people with mental illness, and the development of valid instruments to evaluate these interventions is imperative.

Study Design

We measured self-rated mental and physical health from a quota sample of 575 homeless people with mental illness using the SF-12v2, EQ-5D, Colorado Symptoms Index, and physical/mental health visual analogue scales. We examined the construct validity of the SF-12v2 through confirmatory factor analyses (CFA), and using ANOVA/correlation analyses to compare the SF-12v2 to the other instruments to ascertain discriminant/convergent validity.

Results

Our CFA showed that the measurement properties of the original SF-12v2 model had a mediocre fit with our empirical data (χ² = 193.6, df = 43, p < .0001, CFI = 0.85, NFI = 0.83, RMSEA = 0.08). We demonstrate that changes based on theoretical rationale and previous studies can significantly improve the model, achieving an excellent fit in our final model (χ² = 160.6, df = 48, p < .0001, CFI = 0.95, NFI = 0.95, RMSEA = 0.06). Our CFA results suggest that an alternative scoring method based on the new model may optimize health status measurement of a homeless population. Despite these issues, convergent and discriminant validity of the SF-12v2 (scored based on the original model) was supported through multiple comparisons with other instruments.

Conclusion

Our study demonstrates for the first time that the SF-12v2 is generally appropriate as a measure of physical and mental health status for a homeless population with mental illness.     

Gentamicin-loaded chitosan/folic acid-based carbon quantum dots nanocomposite hydrogel films as potential antimicrobial wound dressing

The potential to directly harness photosynthesis to make actuators, biosensors and bioprocessors has been previously demonstrated in the literature. Herein, this capability has been expanded to more advanced systems — Marimo Actuated Rover Systems (MARS) — which are capable of autonomous, solar powered, movement. We demonstrate this ability is both a practical and viable alternative to conventional mobile platforms for exploration and dynamic environmental monitoring. Prototypes have been successfully tested to measure their speed of travel and ability to automatically bypass obstacles. Further, MARS is electromagnetically silent, thus avoiding the background noise generated by conventional electro/mechanical platforms which reduces instrument sensitivity. The cost of MARS is significantly lower than platforms based on conventional technology. An autonomous, low-cost, lightweight, compact size, photosynthetically powered rover is reported. The potential for further system enhancements are identified and under development.     

Determinants of gait stability while walking on a treadmill: A machine learning approach

Dynamic balance in human locomotion can be assessed through the local dynamic stability (LDS) method. Whereas gait LDS has been used successfully in many settings and applications, little is known about its sensitivity to individual characteristics of healthy adults. Therefore, we reanalyzed a large dataset of accelerometric data measured for 100 healthy adults from 20 to 70 years of age performing 10 min treadmill walking. We sought to assess the extent to which the variations of age, body mass and height, sex, and preferred walking speed (PWS) could influence gait LDS. The random forest (RF) and multiple adaptive regression splines (MARS) algorithms were selected for their good bias-variance tradeoff and their capabilities to handle nonlinear associations. First, through variable importance measure (VIM), we used RF to evaluate which individual characteristics had the highest influence on gait LDS. Second, we used MARS to detect potential interactions among individual characteristics that may influence LDS. The VIM and MARS results indicated that PWS and age correlated with LDS, whereas no associations were found for sex, body height, and body mass. Further, the MARS model detected an age by PWS interaction: on one hand, at high PWS, gait stability is constant across age while, on the other hand, at low PWS, gait instability increases substantially with age. We conclude that it is advisable to consider the participants’ age as well as their PWS to avoid potential biases in evaluating dynamic balance through LDS.     

Implementing shared decision making in routine mental health care

Shared decision making (SDM) in mental health care involves clinicians and patients working together to make decisions. The key elements of SDM have been identified, decision support tools have been developed, and SDM has been recommended in mental health at policy level. Yet implementation remains limited. Two justifications are typically advanced in support of SDM. The clinical justification is that SDM leads to improved outcome, yet the available empirical evidence base is inconclusive. The ethical justification is that SDM is a right, but clinicians need to balance the biomedical ethical principles of autonomy and justice with beneficence and non‐maleficence. It is argued that SDM is “polyvalent”, a sociological concept which describes an idea commanding superficial but not deep agreement between disparate stakeholders. Implementing SDM in routine mental health services is as much a cultural as a technical problem. Three challenges are identified: creating widespread access to high‐quality decision support tools; integrating SDM with other recovery‐supporting interventions; and responding to cultural changes as patients develop the normal expectations of citizenship. Two approaches which may inform responses in the mental health system to these cultural changes – social marketing and the hospitality industry – are identified.     

Treatment engagement of individuals experiencing mental illness: review and update

Individuals living with serious mental illness are often difficult to engage in ongoing treatment, with high dropout rates. Poor engagement may lead to worse clinical outcomes, with symptom relapse and rehospitalization. Numerous variables may affect level of treatment engagement, including therapeutic alliance, accessibility of care, and a client's trust that the treatment will address his/her own unique goals. As such, we have found that the concept of recovery‐oriented care, which prioritizes autonomy, empowerment and respect for the person receiving services, is a helpful framework in which to view tools and techniques to enhance treatment engagement. Specifically, person‐centered care, including shared decision making, is a treatment approach that focuses on an individual's unique goals and life circumstances. Use of person‐centered care in mental health treatment models has promising outcomes for engagement. Particular populations of people have historically been difficult to engage, such as young adults experiencing a first episode of psychosis, individuals with coexisting psychotic and substance use disorders, and those who are homeless. We review these populations and outline how various evidence‐based, recovery‐oriented treatment techniques have been shown to enhance engagement. Our review then turns to emerging treatment strategies that may improve engagement. We focus on use of electronics and Internet, involvement of peer providers in mental health treatment, and incorporation of the Cultural Formulation Interview to provide culturally competent, person‐centered care. Treatment engagement is complex and multifaceted, but optimizing recovery‐oriented skills and attitudes is essential in delivery of services to those with serious mental illness.     

Uses and abuses of recovery: implementing recovery‐oriented practices in mental health systems

An understanding of recovery as a personal and subjective experience has emerged within mental health systems. This meaning of recovery now underpins mental health policy in many countries. Developing a focus on this type of recovery will involve transformation within mental health systems. Human systems do not easily transform. In this paper, we identify seven mis‐uses (“abuses”) of the concept of recovery: recovery is the latest model; recovery does not apply to “my” patients; services can make people recover through effective treatment; compulsory detention and treatment aid recovery; a recovery orientation means closing services; recovery is about making people independent and normal; and contributing to society happens only after the person is recovered. We then identify ten empirically‐validated interventions which support recovery, by targeting key recovery processes of connectedness, hope, identity, meaning and empowerment (the CHIME framework). The ten interventions are peer support workers, advance directives, wellness recovery action planning, illness management and recovery, REFOCUS, strengths model, recovery colleges or recovery education programs, individual placement and support, supported housing, and mental health trialogues. Finally, three scientific challenges are identified: broadening cultural understandings of recovery, implementing organizational transformation, and promoting citizenship.     

Spider silk constructs enhance axonal regeneration and remyelination in long nerve defects in sheep

Background

Surgical reapposition of peripheral nerve results in some axonal regeneration and functional recovery, but the clinical outcome in long distance nerve defects is disappointing and research continues to utilize further interventional approaches to optimize functional recovery. We describe the use of nerve constructs consisting of decellularized vein grafts filled with spider silk fibers as a guiding material to bridge a 6.0 cm tibial nerve defect in adult sheep.

Methodology/Principal Findings

The nerve constructs were compared to autologous nerve grafts. Regeneration was evaluated for clinical, electrophysiological and histological outcome. Electrophysiological recordings were obtained at 6 months and 10 months post surgery in each group. Ten months later, the nerves were removed and prepared for immunostaining, electrophysiological and electron microscopy. Immunostaining for sodium channel (NaV 1.6) was used to define nodes of Ranvier on regenerated axons in combination with anti-S100 and neurofilament. Anti-S100 was used to identify Schwann cells. Axons regenerated through the constructs and were myelinated indicating migration of Schwann cells into the constructs. Nodes of Ranvier between myelin segments were observed and identified by intense sodium channel (NaV 1.6) staining on the regenerated axons. There was no significant difference in electrophysiological results between control autologous experimental and construct implantation indicating that our construct are an effective alternative to autologous nerve transplantation.

Conclusions/Significance

This study demonstrates that spider silk enhances Schwann cell migration, axonal regrowth and remyelination including electrophysiological recovery in a long-distance peripheral nerve gap model resulting in functional recovery. This improvement in nerve regeneration could have significant clinical implications for reconstructive nerve surgery.     

An acoustic glucose sensor

In vivo glucose monitoring is required for tighter glycaemic control. This report describes a new approach to construct a miniature implantable device based on a magnetic acoustic resonance sensor (MARS). A ≈ 600-800 nm thick glucose-responsive poly(acrylamide-co-3-acrylamidophenylboronic acid) (poly(acrylamide-co-3-APB)) film was polymerised on the quartz disc (12 mm in diameter and 0.25 mm thick) of the MARS. The swelling/shrinking of the polymer film induced by the glucose binding to the phenylboronate caused changes in the resonance amplitude of the quartz disc in the MARS. A linear relationship between the response of the MARS and the glucose concentration in the range ≈ 0-15 mM was observed, with the optimum response of the MARS sensor being obtained when the polymer films contained ≈ 20 mol% 3-APB. The MARS glucose sensor also functioned under flow conditions (9 μl/min) with a response almost identical to the sensor under static or non-flow conditions. The results suggest that the MARS could offer a promising strategy for developing a small subcutaneously implanted continuous glucose monitor.     

Structure-based protein NMR assignments using native structural ensembles

An important step in NMR protein structure determination is the assignment of resonances and NOEs to corresponding nuclei. Structure-based assignment (SBA) uses a model structure ("template") for the target protein to expedite this process. Nuclear vector replacement (NVR) is an SBA framework that combines multiple sources of NMR data (chemical shifts, RDCs, sparse NOEs, amide exchange rates, TOCSY) and has high accuracy when the template is close to the target protein's structure (less than 2 A backbone RMSD). However, a close template may not always be available. We extend the circle of convergence of NVR for distant templates by using an ensemble of structures. This ensemble corresponds to the low-frequency perturbations of the given template and is obtained using normal mode analysis (NMA). Our algorithm assigns resonances and sparse NOEs using each of the structures in the ensemble separately, and aggregates the results using a voting scheme based on maximum bipartite matching. Experimental results on human ubiquitin, using four distant template structures show an increase in the assignment accuracy. Our algorithm also improves the robustness of NVR with respect to structural noise. We provide a confidence measure for each assignment using the percentage of the structures that agree on that assignment. We use this measure to assign a subset of the peaks with even higher accuracy. We further validate our algorithm on data for two additional proteins with NVR. We then show the general applicability of our approach by applying our NMA ensemble-based voting scheme to another SBA tool, MARS. For three test proteins with corresponding templates, including the 370-residue maltose binding protein, we increase the number of reliable assignments made by MARS. Finally, we show that our voting scheme is sound and optimal, by proving that it is a maximum likelihood estimator of the correct assignments.     

Caenorhabditis elegans evolves a new architecture for the multi-aminoacyl-tRNA synthetase complex

MARS is an evolutionary conserved supramolecular assembly of aminoacyl-tRNA synthetases found in eukaryotes. This complex was thought to be ubiquitous in the deuterostome and protostome clades of bilaterians because similar complexes were isolated from arthropods and vertebrates. However, several features of the component enzymes suggested that in the nematode Caenorhabditis elegans, a species grouped with arthropods in modern phylogeny, this complex might not exist, or should display a significantly different structural organization. C. elegans was also taken as a model system to study in a multicellular organism amenable to experimental approaches, the reason for existence of these supramolecular entities. Here, using a proteomic approach, we have characterized the components of MARS in C. elegans. We show that this organism evolved a specific structural organization of this complex, which contains several bona fide components of the MARS complexes known so far, but also displays significant variations. These data highlight molecular evolution events that took place after radiation of bilaterians. Remarkably, it shows that expansion of MARS assembly in metazoans is not linear, but is the result of additions but also of subtractions along evolution. We then undertook an experimental approach, using inactivation of the endogenous copy of methionyl-tRNA synthetase by RNAi and expression of transgenic variants, to understand the role in complex assembly and the in vivo functionality, of the eukaryotic-specific domains appended to aminoacyl-tRNA synthetases. We show that rescue of the worms and assembly of transgenic variants into MARS rest on the presence of these appended domains.     

The vision of recovery today: what it is and what it means for services

In the past, practice in mental health was guided by the belief that individuals with serious mental illnesses do not recover. The course of their illness was either seen pessimistically, as deteriorative, or optimistically, as a maintenance course. Research over the past thirty to forty years has indicted that belief and shown that a vision of recovery can be achieved for many individuals. People with serious mental illnesses have themselves published accounts of their own recovery as well as advocated for the development of recovery promoting services. In North America and other regions, policies have been developed to make recovery the guiding vision of services. Today, particularly in the United States, much effort is going into the transformation of services and systems to achieve recovery outcomes. Despite these trends, the idea of recovery remains controversial and, some say, even illusory. This article clarifies the meaning of the term "recovery", reviews the research and first person accounts providing a rationale for recovery, and sets out implications for developing recovery oriented services.     

Cultural Consonance and Psychological Well-Being. Estimates Using Longitudinal Data from an Amazonian Society

Researchers have hypothesized that the degree to which an individual’s actual behavior approximates the culturally valued lifestyle encoded in the dominant cultural model has consequences for physical and mental health. We contribute to this line of research by analyzing data from a longitudinal study composed of five annual surveys (2002–2006 inclusive) of 791 adults in one society of foragers-farmers in the Bolivian Amazon, the Tsimane’. We estimate the association between a standard measure of individual achievement of the cultural model and (a) four indicators of psychological well-being (sadness, anger, fear and happiness) and (b) consumption of four potentially addictive substances (alcohol, cigarette, coca leaves and home-brewed beer) as indicators of stress behavior. After controlling for individual fixed effects, we found a negative association between individual achievement of the cultural model and psychological distress and a positive association between individual achievement of the cultural model and psychological well-being. Only the consumption of commercial alcohol bears the expected negative association with cultural consonance in material lifestyle, probably because the other substances analyzed have cultural values attached. Our work contributes to research on psychological health disparities by showing that a locally defined and culturally specific measure of lifestyle success is associated with psychological health.     

Comparison of statistical methods commonly used in predictive modelling

Logistic Multiple Regression, Principal Component Regression and Classification and Regression Tree Analysis (CART), commonly used in ecological modelling using GIS, are compared with a relatively new statistical technique, Multivariate Adaptive Regression Splines (MARS), to test their accuracy, reliability, implementation within GIS and ease of use. All were applied to the same two data sets, covering a wide range of conditions common in predictive modelling, namely geographical range, scale, nature of the predictors and sampling method. We ran two series of analyses to verify if model validation by an independent data set was required or cross‐validation on a learning data set sufficed. Results show that validation by independent data sets is needed. Model accuracy was evaluated using the area under Receiver Operating Characteristics curve (AUC). This measure was used because it summarizes performance across all possible thresholds, and is independent of balance between classes. MARS and Regression Tree Analysis achieved the best prediction success, although the CART model was difficult to use for cartographic purposes due to the high model complexity.     

Social capital and mental health in Japan: a multilevel analysis

Background

A national cross-sectional survey was conducted in Japan. This is because the growing recognition of the social determinants of health has stimulated research on social capital and mental health. In recent years, systematic reviews have found that social capital may be a useful factor in the prevention of mental illness. Despite these studies, evidence on the association between social capital and mental health is limited as there have been few empirical discussions that adopt a multilevel framework to assess whether social capital at the ecological level is associated with individual mental health. The aim of this study was to use the multilevel approach to investigate the association between neighborhood social capital and mental health after taking into account potential individual confounders.

Methodology/Principal Findings

We conducted a multilevel analysis on 5,956 individuals nested within 199 neighborhoods. The outcome variable of self-reported mental health was measured by the one dimension of SF-36 and was summed to calculate a score ranging from 0 to 100. This study showed that high levels of cognitive social capital, measured by trust (regression coefficient = 9.56), and high levels of structural social capital, measured by membership in sports, recreation, hobby, or cultural groups (regression coefficient = 8.72), were associated with better mental health after adjusting for age, sex, household income, and educational attainment. Furthermore, after adjusting for social capital perceptions at the individual level, we found that the association between social capital and mental health also remained.

Conclusions/Significance

Our findings suggest that both cognitive and structural social capital at the ecological level may influence mental health, even after adjusting for individual potential confounders including social capital perceptions. Promoting social capital may contribute to enhancing the mental health of the Japanese.     

Personalized treatment plans with multivariate outcomes

In this work, we propose a novel method for individualized treatment selection when the treatment response is multivariate. Our method covers any number of treatments and it can be applied for a broad set of models. The proposed method uses a Mahalanobis-type distance measure to establish an ordering of treatments based on treatment performance measures. Our investigation in this work deals with means of responses conditional on lower dimensional composite scores based on covariates where these scores are built using single index models to approximate mean responses against patient covariates. Smoothed estimates of such conditional means are combined to construct an estimate of the aforementioned distance measure, which is then used to estimate the optimal treatment. An empirical study demonstrates the performance of the proposed method in finite samples. We also present a data analysis using an HIV clinical trial data to show the applicability of the proposed procedure for real data.     

Estimating marginal and incremental effects on health outcomes using flexible link and variance function models

We propose an extension to the estimating equations in generalized linear models to estimate parameters in the link function and variance structure simultaneously with regression coefficients. Rather than focusing on the regression coefficients, the purpose of these models is inference about the mean of the outcome as a function of a set of covariates, and various functionals of the mean function used to measure the effects of the covariates. A commonly used functional in econometrics, referred to as the marginal effect, is the partial derivative of the mean function with respect to any covariate, averaged over the empirical distribution of covariates in the model. We define an analogous parameter for discrete covariates. The proposed estimation method not only helps to identify an appropriate link function and to suggest an underlying distribution for a specific application but also serves as a robust estimator when no specific distribution for the outcome measure can be identified. Using Monte Carlo simulations, we show that the resulting parameter estimators are consistent. The method is illustrated with an analysis of inpatient expenditure data from a study of hospitalists.     

Proteomic analysis of polypeptides captured from blood during extracorporeal albumin dialysis in patients with cholestasis and resistant pruritus

Albumin dialysis using the molecular adsorbent recirculating system (MARS) is a new therapeutic approach for liver diseases. To gain insight into the mechanisms involved in albumin dialysis, we analyzed the peptides and proteins absorbed into the MARS strong anion exchange (SAX) cartridges as a result of the treatment of patients with cholestasis and resistant pruritus. Proteins extracted from the SAX MARS cartridges after patient treatment were digested with two enzymes. The resulting peptides were analyzed by multidimensional liquid chromatography coupled to tandem mass spectrometry. We identified over 1,500 peptide sequences corresponding to 144 proteins. In addition to the proteins that are present in control albumin-derived samples, this collection includes 60 proteins that were specific to samples obtained after patient treatment. Five of these proteins (neutrophil defensin 1 [HNP-1], secreted Ly-6/uPAR-related protein 1 [SLURP1], serum amyloid A, fibrinogen alpha chain and pancreatic prohormone) were confirmed to be removed by the dialysis procedure using targeted selected-reaction monitoring MS/MS. Furthermore, capture of HNP-1 and SLURP1 was also validated by Western blot. Interestingly, further analyses of SLURP1 in serum indicated that this protein was 3-fold higher in cholestatic patients than in controls. Proteins captured by MARS share certain structural and biological characteristics, and some of them have important biological functions. Therefore, their removal could be related either to therapeutic or possible adverse effects associated with albumin dialysis.     

Estimating treatment effects with partially observed covariates using outcome regression with missing indicators

Missing data is a common issue in research using observational studies to investigate the effect of treatments on health outcomes. When missingness occurs only in the covariates, a simple approach is to use missing indicators to handle the partially observed covariates. The missing indicator approach has been criticized for giving biased results in outcome regression. However, recent papers have suggested that the missing indicator approach can provide unbiased results in propensity score analysis under certain assumptions. We consider assumptions under which the missing indicator approach can provide valid inferences, namely, (1) no unmeasured confounding within missingness patterns; either (2a) covariate values of patients with missing data were conditionally independent of treatment or (2b) these values were conditionally independent of outcome; and (3) the outcome model is correctly specified: specifically, the true outcome model does not include interactions between missing indicators and fully observed covariates. We prove that, under the assumptions above, the missing indicator approach with outcome regression can provide unbiased estimates of the average treatment effect. We use a simulation study to investigate the extent of bias in estimates of the treatment effect when the assumptions are violated and we illustrate our findings using data from electronic health records. In conclusion, the missing indicator approach can provide valid inferences for outcome regression, but the plausibility of its assumptions must first be considered carefully.     

Apparent competition and recovery from infection

We use mathematical models to analyse how the recovery rate from infection influences the fitness of a host in a setting of interspecific competition. We show that sub-optimal immunity against pathogens can be advantageous for the host in the presence of cross-species infection. Weaker immunity allows the parasite to be used as a biological weapon, and this increases the fitness of the host relative to a competitor. A parameter region is observed in which the outcome of competition depends on the initial conditions. We extend this model and consider the dynamics in a spatial setting and find that the outcome depends on the migration rate of the host species. At low migration rates, coexistence of the host species is possible across space. For higher migration rates, the host species characterized by a lower recovery rate can invade the territory of its competitor. Finally, we study these dynamics in an evolutionary setting. Although a lower recovery rate from infection can increase the competitive ability of a species, we find that evolution maximizes the recovery rate and minimizes parasite burden. The models presented are related to the concept of apparent competition, and our results are discussed in relation to both theoretical and empirical studies.