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Schär S, Mürner-Lavanchy I, Schmidt SJ, Koenig J, Kaess M. Child maltreatment and hypothalamic-pituitary-adrenal axis functioning: A systematic review and meta-analysis. Front Neuroendocrinol 2022; 66:100987. [PMID: 35202606 DOI: 10.1016/j.yfrne.2022.100987] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 02/11/2022] [Accepted: 02/17/2022] [Indexed: 11/04/2022]
Abstract
Alterations in hypothalamic-pituitary-adrenal (HPA) axis and its effector hormone cortisol have been proposed as one possible mechanism linking child maltreatment experiences to health disparities. In this series of meta-analyses, we aimed to quantify the existing evidence on the effect of child maltreatment on various measures of HPA axis activity. The systematic literature search yielded 1,858 records, of which 87 studies (k = 132) were included. Using random-effects models, we found evidence for blunted cortisol stress reactivity in individuals exposed to child maltreatment. In contrast, no overall differences were found in any of the other HPA axis activity measures (including measures of daily activity, cortisol assessed in the context of pharmacological challenges and cumulative measures of cortisol secretion). The impact of several moderators (e.g., sex, psychopathology, study quality), the role of methodological shortcomings of existing studies, as well as potential directions for future research are discussed.
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Affiliation(s)
- Selina Schär
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Ines Mürner-Lavanchy
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Stefanie J Schmidt
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Julian Koenig
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Cologne, Germany; Section for Experimental Child and Adolescent Psychiatry, Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany
| | - Michael Kaess
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland; Clinic for Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany.
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2
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Kakehi R, Hori H, Yoshida F, Itoh M, Lin M, Niwa M, Narita M, Ino K, Imai R, Sasayama D, Kamo T, Kunugi H, Kim Y. Hypothalamic-pituitary-adrenal axis and renin-angiotensin-aldosterone system in adulthood PTSD and childhood maltreatment history. Front Psychiatry 2022; 13:967779. [PMID: 36699501 PMCID: PMC9869036 DOI: 10.3389/fpsyt.2022.967779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 12/16/2022] [Indexed: 01/12/2023] Open
Abstract
Accumulated evidence shows that psychological trauma and posttraumatic stress disorder (PTSD) are associated with dysfunction in the hypothalamic-pituitary-adrenal (HPA) axis. Besides the HPA axis hormones, recent evidence suggests that the renin-angiotensin-aldosterone (RAA) system and genetic factors may be involved in trauma/PTSD as well as in HPA axis regulation. This study attempted to better understand the HPA axis function in relation to PTSD and childhood maltreatment by simultaneously examining RAA system and genetic polymorphisms of candidate genes. Here we studied 69 civilian women with PTSD and 107 healthy control women without DSM-IV-based traumatic experience. Childhood maltreatment history was assessed with the Childhood Trauma Questionnaire. PTSD severity was assessed with the Posttraumatic Diagnostic Scale. Functional disability was assessed with the Sheehan Disability Scale. HPA axis was examined by measuring blood levels of cortisol, adrenocorticotropic hormone, and dehydroepiandrosterone-sulphate (DHEA-S). RAA system was examined by measuring blood renin and aldosterone levels. The FKBP5 rs1360780 and CACNA1C rs1006737 polymorphisms were genotyped. No significant differences were seen between patients and controls in any of the five hormone levels. DHEA-S levels were significantly negatively correlated with overall PTSD severity (p = 0.003) and functional disability (p = 0.008). A two-way analysis of variance with diagnostic groups and genotypes as fixed factors revealed that patients with the rs1006737 A-allele had significantly lower DHEA-S levels than patients with the GG genotype (p = 0.002) and controls with the A-allele (p = 0.006). Childhood maltreatment history was not significantly correlated with any of the five hormone levels. These results were generally unchanged after controlling for the potentially confounding effect of age, depression, and anxiety. Our findings suggest that lower DHEA-S levels could indicate more severe subtype of PTSD, the association of which might be partly modified by the CACNA1C polymorphism.
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Affiliation(s)
- Ryoko Kakehi
- Department of Behavioral Medicine, National Center of Neurology and Psychiatry, National Institute of Mental Health, Tokyo, Japan.,Department of Medical Science, Tohoku University Graduate School of Medicine, Sendai, Japan.,Department of Nursing, Wayō Women's University, Chiba, Japan
| | - Hiroaki Hori
- Department of Behavioral Medicine, National Center of Neurology and Psychiatry, National Institute of Mental Health, Tokyo, Japan
| | - Fuyuko Yoshida
- Department of Behavioral Medicine, National Center of Neurology and Psychiatry, National Institute of Mental Health, Tokyo, Japan.,Department of Mental Disorder Research, National Center of Neurology and Psychiatry, National Institute of Neuroscience, Tokyo, Japan
| | - Mariko Itoh
- Department of Behavioral Medicine, National Center of Neurology and Psychiatry, National Institute of Mental Health, Tokyo, Japan.,Center for Environmental and Health Sciences, Hokkaido University, Sapporo, Japan
| | - Mingming Lin
- Department of Behavioral Medicine, National Center of Neurology and Psychiatry, National Institute of Mental Health, Tokyo, Japan
| | - Madoka Niwa
- Department of Behavioral Medicine, National Center of Neurology and Psychiatry, National Institute of Mental Health, Tokyo, Japan
| | - Megumi Narita
- Department of Behavioral Medicine, National Center of Neurology and Psychiatry, National Institute of Mental Health, Tokyo, Japan
| | - Keiko Ino
- Department of Behavioral Medicine, National Center of Neurology and Psychiatry, National Institute of Mental Health, Tokyo, Japan.,Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Risa Imai
- Risa Irinaka Mental Clinic, Nagoya, Japan
| | - Daimei Sasayama
- Department of Psychiatry, Shinshu University School of Medicine, Nagano, Japan
| | - Toshiko Kamo
- Wakamatsu-cho Mental and Skin Clinic, Tokyo, Japan
| | - Hiroshi Kunugi
- Department of Mental Disorder Research, National Center of Neurology and Psychiatry, National Institute of Neuroscience, Tokyo, Japan.,Department of Psychiatry, Teikyo University School of Medicine, Tokyo, Japan
| | - Yoshiharu Kim
- Department of Behavioral Medicine, National Center of Neurology and Psychiatry, National Institute of Mental Health, Tokyo, Japan
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3
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Cahill S, Chandola T, Hager R. Genetic Variants Associated With Resilience in Human and Animal Studies. Front Psychiatry 2022; 13:840120. [PMID: 35669264 PMCID: PMC9163442 DOI: 10.3389/fpsyt.2022.840120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/19/2022] [Indexed: 11/15/2022] Open
Abstract
Resilience is broadly defined as the ability to maintain or regain functioning in the face of adversity and is influenced by both environmental and genetic factors. The identification of specific genetic factors and their biological pathways underpinning resilient functioning can help in the identification of common key factors, but heterogeneities in the operationalisation of resilience have hampered advances. We conducted a systematic review of genetic variants associated with resilience to enable the identification of general resilience mechanisms. We adopted broad inclusion criteria for the definition of resilience to capture both human and animal model studies, which use a wide range of resilience definitions and measure very different outcomes. Analyzing 158 studies, we found 71 candidate genes associated with resilience. OPRM1 (Opioid receptor mu 1), NPY (neuropeptide Y), CACNA1C (calcium voltage-gated channel subunit alpha1 C), DCC (deleted in colorectal carcinoma), and FKBP5 (FKBP prolyl isomerase 5) had both animal and human variants associated with resilience, supporting the idea of shared biological pathways. Further, for OPRM1, OXTR (oxytocin receptor), CRHR1 (corticotropin-releasing hormone receptor 1), COMT (catechol-O-methyltransferase), BDNF (brain-derived neurotrophic factor), APOE (apolipoprotein E), and SLC6A4 (solute carrier family 6 member 4), the same allele was associated with resilience across divergent resilience definitions, which suggests these genes may therefore provide a starting point for further research examining commonality in resilience pathways.
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Affiliation(s)
- Stephanie Cahill
- Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, United Kingdom.,Faculty of Humanities, Cathie Marsh Institute for Social Research, The University of Manchester, Manchester, United Kingdom
| | - Tarani Chandola
- Faculty of Humanities, Cathie Marsh Institute for Social Research, The University of Manchester, Manchester, United Kingdom.,Methods Hub, Department of Sociology, Faculty of Social Sciences, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Reinmar Hager
- Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, United Kingdom
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Pennington K, Klaus K, Fachim HA, Butler K, Trischel K, Dalton CF, Heald A, Reynolds GP. CACNA1C methylation: association with cortisol, perceived stress, rs1006737 and childhood trauma in males. Epigenomics 2020; 12:1739-1749. [PMID: 33169621 DOI: 10.2217/epi-2020-0034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: We investigated morning cortisol, stress, rs1006737 and childhood trauma relationship with CACNA1C methylation. Materials & methods: Morning cortisol release, childhood trauma and perceived stress were collected and genotyping for rs1006737 conducted in 103 adult males. Genomic DNA extracted from saliva was bisulphite converted and using pyrosequencing methylation determined at 11 CpG sites within intron 3 of CACNA1C. Results: A significant negative correlation between waking cortisol and overall mean methylation was found and a positive correlation between CpG5 methylation and perceived stress. Conclusion: CACNA1C methylation levels may be related to cortisol release and stress perception. Future work should evaluate the influence of altered CACNA1C methylation on stress reactivity to investigate this as a potential mechanism for mental health vulnerability.
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Affiliation(s)
| | - Kristel Klaus
- School of Psychology, University of Lincoln, Lincoln, UK.,Medical Research Council Cognition & Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Helene A Fachim
- Department of Diabetes & Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Kevin Butler
- School of Psychology, University of Lincoln, Lincoln, UK.,Translational Addiction Research Laboratory, Centre for Addiction & Mental Health, Toronto, ON, Canada
| | | | - Caroline F Dalton
- Biomolecular Sciences Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Adrian Heald
- Department of Diabetes & Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK.,The School of Medicine & Manchester Health Sciences Centre, University of Manchester, Manchester, UK
| | - Gavin P Reynolds
- Biomolecular Sciences Research Centre, Sheffield Hallam University, Sheffield, UK
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5
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Salomon RE, Tan KR, Vaughan A, Adynski H, Muscatell KA. Minimally-invasive methods for examining biological changes in response to chronic stress: A scoping review. Int J Nurs Stud 2020; 103:103419. [PMID: 31945603 DOI: 10.1016/j.ijnurstu.2019.103419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 09/05/2019] [Accepted: 09/06/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Nurse researchers are increasingly interested in incorporating biological indicators related to chronic stress, or repeated or constant exposure to psychological stressors. Minimally invasive collection methods may improve access to vulnerable populations. OBJECTIVE To map biological indicators measured through minimally invasive methods investigating biological changes in response to chronic stress. DESIGN, DATA SOURCES, AND METHODS The paper seeks to answer two questions: What are the characteristics of the minimally-invasive methods used to measure the biological correlates of chronic stress? What are the limitations regarding the use of the minimally-invasive methods and/or biological indicators identified above? Authors completed a scoping review following guidelines from the Joanna Briggs Institute Manual and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews. A literature search was completed in PubMed, PsycINFO, and Scopus. 2518 articles were screened and 145 studies were included. Data were extracted using a standardized extraction tool, compiled, and coded. RESULTS Studies included minimally-invasive methods to measure the hypothalamic-adrenal-pituitary axis (N = 173), immune and inflammatory markers (N = 118), and adult neurogenesis (N = 6). Cortisol was most frequently measured (N = 136), usually in saliva (N = 86). Studies included a variety of limitations for the methods and indicators, including concerns about timing and accuracy of collection, frequency of sampling, and controlling for acute stressors. CONCLUSIONS Nurse researchers have access to many minimally-invasive methods to measure altered biological processes related to chronic stress. A gap identified by this review is the paucity of minimally-invasive methods for investigating neurogenesis; the measurement of brain derived neurotrophic factor in plasma is a distal proxy and further research is needed to test the response of peripheral levels to psychosocial stress interventions. Additionally, while this scoping review allows nurse researchers to consider possible biological indicators to include in their research, future research is still needed on some of the basic premises of stress research, including agreement on the conceptualization of chronic stress.
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Affiliation(s)
- Rebecca E Salomon
- School of Nursing, University of California San Francisco, 2 Koret Way, UCSF Box 0608, San Francisco, CA 94143-0608, USA.
| | - Kelly R Tan
- School of Nursing, University of California San Francisco, 2 Koret Way, UCSF Box 0608, San Francisco, CA 94143-0608, USA.
| | - Ashley Vaughan
- School of Nursing, University of California San Francisco, 2 Koret Way, UCSF Box 0608, San Francisco, CA 94143-0608, USA.
| | - Harry Adynski
- School of Nursing, University of California San Francisco, 2 Koret Way, UCSF Box 0608, San Francisco, CA 94143-0608, USA.
| | - Keely A Muscatell
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Campus Box #3270, 235 E. Cameron Avenue, Chapel Hill, NC 27599-3270, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Campus Box #7295, 450 West Drive, Chapel Hill, NC 27599-7295, USA.
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6
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Cold parenting is associated with cellular aging in offspring: A retrospective study. Biol Psychol 2019; 145:142-149. [PMID: 31014776 DOI: 10.1016/j.biopsycho.2019.03.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 01/30/2019] [Accepted: 03/22/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Early life stress is a known risk factor for diseases and premature death. We tested whether parenting style impacts telomere length (TL), a cellular aging biomarker. METHODS Information on parents' style of parenting was obtained from 199 participants in the Adventist Health Study-1 (AHS-1) who 27+ years later also enrolled in the AHS-2 where blood was collected for relative TL (rTL) assessment. RESULTS Subjects describing their mothers' parenting style as cold had on average 25% smaller rTL compared to subjects not reporting a cold mother (1.89 vs 2.53). This association was greatest among those with less education, and those who stayed overweight/obese or put on weight during follow-up. CONCLUSIONS These results support previous findings that early life stress may have health implications by promoting cellular aging, and expands these stressors to include cold parenting during an individuals' formative years. Higher education and normal weight seem to provide some resilience.
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7
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Sharma S, Ressler KJ. Genomic updates in understanding PTSD. Prog Neuropsychopharmacol Biol Psychiatry 2019; 90:197-203. [PMID: 30452941 PMCID: PMC6431237 DOI: 10.1016/j.pnpbp.2018.11.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 11/07/2018] [Accepted: 11/16/2018] [Indexed: 12/14/2022]
Abstract
Twin studies as well as more recent genetics-based heritability analyses demonstrate that up to 40 to 50% of the variance in predicting PTSD following trauma is heritable. However, most of the specific gene pathways and mechanism that mediate risk vs. resilience for PTSD following trauma exposure have yet to be elucidated. This review will examine the latest results from large scale Genome-wide association studies as well as other approaches aimed at understanding mechanisms of development of and recovery from PTSD.
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Affiliation(s)
- Sumeet Sharma
- Neuroscience Program, Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, United States; McLean Hospital, Division of Depression and Anxiety, Belmont, MA, United States
| | - Kerry J Ressler
- McLean Hospital, Division of Depression and Anxiety, Belmont, MA, United States; Harvard Medical School, Boston, MA, United States; Neuroscience Program, Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, United States.
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8
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Linnstaedt SD, Pan Y, Mauck MC, Sullivan J, Zhou CY, Jung L, Rueckeis CA, Blount JD, Carson MS, Tungate AS, Kurz MC, Hendry PL, Lewandowski C, D'Anza T, Datner E, Bell K, Lechner M, Shupp JW, Cairns BA, McLean SA. Evaluation of the Association Between Genetic Variants in Circadian Rhythm Genes and Posttraumatic Stress Symptoms Identifies a Potential Functional Allele in the Transcription Factor TEF. Front Psychiatry 2018; 9:597. [PMID: 30498461 PMCID: PMC6249322 DOI: 10.3389/fpsyt.2018.00597] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/26/2018] [Indexed: 12/13/2022] Open
Abstract
Previous studies suggest that genetic variants within genes affecting the circadian rhythm influence the development of posttraumatic stress symptoms (PTSS). In the present study, we used data from three emergency care-based cohorts to search genetic variants in circadian pathway genes previously associated with neuropsychiatric disorders for variants that influence PTSS severity. The three cohorts used included a discovery cohort of African American men and women enrolled following motor vehicle collision (n = 907) and two replication cohorts: one of multi-ethnic women enrolled following sexual assault (n = 274) and one of multi-ethnic men and women enrolled following major thermal burn injury (n = 68). DNA and RNA were collected from trauma survivors at the time of initial assessment. Validated questionnaires were used to assess peritraumatic distress severity and to assess PTSS severity 6 weeks, 6 months, and 1 year following trauma exposure. Thirty-one genetic variants from circadian rhythm genes were selected for analyses, and main effect and potential gene*stress and gene*sex interactions were evaluated. Secondary analyses assessed whether associated genetic variants affected mRNA expression levels. We found that six genetic variants across five circadian rhythm-associated genes predicted PTSS outcomes following motor vehicle collision (p < 0.05), but only two of these variants survived adjustment for multiple comparisons (False Discovery Rate < 5%). The strongest of these associations, an interaction between the PAR-zip transcription factor, thyrotroph embryonic factor (TEF) variant rs5758324 and peritraumatic distress, predicted PTSS development in all three cohorts. Further analysis of genetic variants in the genetic region surrounding TEFrs5758324 (±125,000 nucleotides) indicated that this allele showed the strongest association. Further, TEF RNA expression levels (determined via RNA-seq) were positively associated with PTSS severity in distressed individuals with at least one copy of the TEFrs5758324 minor allele. These results suggest that rs5758324 genetic variant in TEF, a regulator of clock-controlled genes and key mediator of the core circadian rhythm, influence PTSS severity in a stress-dependent manner.
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Affiliation(s)
- Sarah D Linnstaedt
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States.,Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, United States
| | - Yue Pan
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States.,Department of Biostatistics, University of North Carolina, Chapel Hill, NC, United States
| | - Matthew C Mauck
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States.,Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, United States
| | - Jenyth Sullivan
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States
| | - Christine Y Zhou
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States
| | - Lindsey Jung
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States.,Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | - Cathleen A Rueckeis
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States
| | - Jameson D Blount
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States
| | - Matthew S Carson
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States
| | - Andrew S Tungate
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States
| | - Michael C Kurz
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, AL, United States
| | - Phyllis L Hendry
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, FL, United States
| | | | - Teresa D'Anza
- Albuquerque Sexual Assault Nurse Examiner Collaborative, Albuquerque, NM, United States
| | - Elizabeth Datner
- Department of Emergency Medicine, Albert Einstein Medical Center, Philadelphia, PA, United States
| | - Kathy Bell
- Forensic Nursing Program, Tulsa Police Department, Tulsa, OK, United States
| | - Megan Lechner
- Forensic Nursing Program, Memorial Health System, Colorado Springs, CO, United States
| | - Jeffrey W Shupp
- Department of Surgery, The Burn Center, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC, United States
| | - Bruce A Cairns
- Jaycee Burn Center, University of North Carolina, Chapel Hill, NC, United States
| | - Samuel A McLean
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States.,Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, United States.,Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC, United States
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