Newspaper Coverage of Adverse Childhood Experiences and Toxic Stress in the United States, 2014-2020: Consequences, Causes, and Solutions

News media can shape public opinion about child adversity and influence the translation of research into public policy. Research about adverse childhood experiences (ACEs) and toxic stress has increased dramatically in recent years, but little is known about how these concepts are covered in news media. We reviewed how newspapers in the United States have portrayed the consequences of, causes of, and solutions to address ACEs and toxic stress, examined trends in newspaper coverage, and assessed differences in coverage of ACEs versus toxic stress. Quantitative content analysis was conducted of 746 newspaper articles mentioning "adverse childhood experience(s)" and/or "toxic stress" published in 25 U.S. newspapers between January 1, 2014, and May 30, 2020. κ statistics of interrater reliability were calculated, and variables with κ ≥ .60 were retained for quantitative analysis. We found that newspaper coverage of ACEs and toxic stress increased dramatically between 2014 and 2018 and then sharply declined. Only 13.3% of articles mentioned both ACEs and toxic stress. There were many statistically significant (p < .05) differences in the causes, consequences, and solutions identified in articles focused on ACEs versus toxic stress. Coverage of both concepts predominantly focused on consequences for individuals, not society. However, 54.6% of articles identified a structural cause of ACEs and/or toxic stress. Increased volume in newspaper coverage about ACEs and toxic stress could increase public awareness about the relationship between childhood adversity and adult outcomes. There is a need to portray ACEs and toxic stress as complementary concepts more coherently in news media.

Unintended consequences of disseminating behavioral health evidence to policymakers: Results from a survey-based experiment

Background

Communication research demonstrates that messages often have unintended consequences, but this work has received limited attention in implementation science. This dissemination experiment sought to determine whether state-tailored policy briefs about the behavioral health consequences of adverse childhood experiences (ACEs), compared to national policy briefs on the topic, increased state legislators'/staffers' perceptions of the policy brief relevance and parental blame for the consequences of ACEs, and whether effects differed between Democrats and Republicans.

Method

A preregistered, web-based survey experiment with U.S. state legislators/staffers was conducted in 2021 (n  =  133). Respondents were randomized to view a policy brief about the behavioral health consequences of ACEs that included state-tailored data (intervention condition) or national data (control condition) and then answered survey questions. Dependent variables were perceived policy brief relevance and parental blame for the consequences of ACEs.

Results

The mean policy brief relevance score was 4.1% higher in the intervention than in the control condition (p  =  .24), but the mean parental blame score was 16.5% higher (p  =  .02). When outcomes were dichotomized, 61.2% of respondents in the intervention condition rated parents as "very much to blame" for the consequences of ACEs compared to 37.1% in the control condition (p  =  .01). When the sample was stratified by political affiliation, the effect of the state-tailored policy brief on parental blame was larger in magnitude among Democrats and not significant among Republicans. The intervention policy brief increased the mean parental blame score by 22.8% among Democrats relative to the control policy brief (p  =  .007) and doubled the proportion rating parents as "very much to blame" (52.2% vs. 26.1%, p  =  .03).

Conclusions

Despite limited statistical power, state-tailored policy briefs significantly increased state legislators'/staffers' perceptions of parental blame for the behavioral health consequences of ACEs, relative to a policy brief with national data. Unintended messaging effects warrant greater attention in dissemination research and practice.

State Policies that Impact the Design of Children's Mental Health Services: A Modified Delphi Study

To identify the state-level policies and policy domains that state policymakers and advocates perceive as most important for positively impacting the use of children's mental health services (CMHS). We used a modified Delphi technique (i.e., two rounds of questionnaires and an interview) during Spring 2021 to elicit perceptions among state mental health agency officials and advocates (n = 28) from twelve states on state policies that impact the use of CMHS. Participants rated a list of pre-specified policies on a 7-point Likert scale (1 = not important, 7 = extremely important) in the following policy domains: insurance coverage and limits, mental health services, school and social. Participants added nine policies to the initial list of 24 policies. The "school" policy domain was perceived as the most important, while the "social" policy domain was perceived as the least important after the first questionnaire and the second most important policy domain after the second questionnaire. The individual policies perceived as most important were school-based mental health services, state mental health parity, and Medicaid reimbursement rates. Key stakeholders in CMHS should leverage this group of policies to understand the current policy landscape in their state and to identify gaps in policy domains and potential policy opportunities to create a more comprehensive system to address children's mental health from a holistic, evidence-based policymaking perspective.

Review: Structural Racism, Children's Mental Health Service Systems, and Recommendations for Policy and Practice Change

OBJECTIVE

Racism is a public health crisis that impacts on children's mental health, yet mental health service systems are insufficiently focused on addressing racism. Moreover, a focus on interpersonal racism and on individual coping with the impacts of racism has been prioritized over addressing structural racism at the level of the service system and associated institutions. In this paper, we examine strategies to address structural racism via policies affecting children's mental health services.

METHOD

First, we identify and analyze federal and state policies focused on racism and mental health equity. Second, we evaluate areas of focus in these policies and discuss the evidence base informing their implementation. Finally, we provide recommendations for what states, counties, cities, and mental health systems can do to promote antiracist evidence-based practices in children's mental health.

RESULTS

Our analysis highlights gaps and opportunities in the evidence base for policy implementation strategies, including the following: mental health services for youth of color, interventions addressing interpersonal racism and bias in the mental health service system, interventions addressing structural racism, changes to provider licensure and license renewal, and development of the community health workforce.

CONCLUSION

Recommendations are provided both within and across systems to catalyze broader systems transformation.

Inter-agency collaboration is associated with increased frequency of research use in children's mental health policy making

OBJECTIVE

To determine whether the self-report frequency of inter-agency collaboration about children's mental health issues is associated with the self-report frequency of using research evidence in children's mental health policy and program decision making in mental health agencies (MHAs).

DATA SOURCES

Primary data were collected through web-based surveys of state (N = 221) and county (N = 117) MHA officials.

DESIGN

The primary independent variable was a composite score quantifying the frequency of collaboration about children's mental health issues between officials in MHAs and six other state agencies. The dependent variables were composite scores quantifying the frequency of research use in children's mental health policy and program decision making in general and for specific purposes (i.e., conceptual, instrumental, tactical, imposed). Covariates were composite scores quantifying well-established determinants of research use (e.g., agency leadership, research use skills) in agency policy and program decision making.

DATA METHODS

Separate multiple linear regression models estimated associations between frequency of inter-agency collaboration and research use scores, adjusting for other determinants of research use, respondent state, and other covariates. Data from state and county officials were analyzed separately.

PRINCIPAL FINDINGS

The frequency of inter-agency collaboration was positively and independently associated with the frequency of research use in children's mental health policy making among state (β = 0.22, p = 0.004) and county (β = 0.39, p < 0.0001) MHA officials. Inter-agency collaboration was also the only variable significantly associated with the frequency of research use for all four specific purposes among state MHA officials, and similar findings we observed among county MHA officials. The magnitudes of associations between inter-agency collaboration and frequency of research use were generally stronger than for more well-established determinants of research use in policy making.

CONCLUSIONS

Strategies that promote collaboration between MHA officials and external agencies could increase the use of research evidence in children's mental health policy and program decision making in MHAs.

Public Opinion About Adverse Childhood Experiences: Social Stigma, Attribution of Blame, and Government Intervention

Adverse childhood experiences (ACEs) are receiving increasing attention in academic, policy, and media discourses. However, no public opinion research has focused on ACEs. We conducted a nationally representative survey of U.S. adults to address this knowledge gap. A web-based survey was conducted using the Ipsos KnowledgePanel (N = 503, completion rate = 60.5%) in fall 2019. We found that inter-personal stigma and parental blame related to ACEs were prevalent, with 25.0% of respondents unwilling to have a person with "a lot of ACEs" as a close co-worker and 65.2% believing that parents were very much to blame for the consequences of ACEs. Fifty percent of respondents believed that government intervention to prevent ACEs was very important. After adjustment for demographic characteristics, inter-personal stigma toward people with ACEs and conservative ideology were significantly associated with lower perceived importance of government intervention to prevent ACEs. Black race, Hispanic ethnicity, and female gender were significantly associated with higher perceived importance of government intervention. These findings provide an empirical foundation to inform strategies to communicate ACE science to public and policymaker audiences.

Partisan differences in the effects of economic evidence and local data on legislator engagement with dissemination materials about behavioral health: a dissemination trial

BACKGROUND

State legislators make policy decisions that influence children's exposure to adverse childhood experiences (ACEs), such as child maltreatment, and their effects on behavioral health. Effective dissemination of scientific research can increase the likelihood that legislators' decisions are aligned with evidence to prevent ACEs and their consequences, and effective dissemination requires legislators to engage with dissemination materials. Informed by the elaboration likelihood model of persuasive communication and Brownson's Model of Dissemination Research, we tested the hypothesis that inclusion of economic evidence and local data would increase legislator engagement with dissemination materials about evidence-supported policies related to ACEs and behavioral health.

METHODS

A three-arm randomized dissemination trial was conducted. A university researcher e-mailed dissemination materials which contained evidence about ACEs and behavioral health problems to state legislators (two e-mails sent 2 weeks apart, 12,662 e-mails delivered to 6509 legislators). The e-mail subject lines, text, and policy brief content were manipulated across the study arms. The intervention condition received state-tailored data about rates of ACEs and state-tailored economic evidence about the costs of ACEs for public systems, the enhanced control condition received state-tailored data and not economic evidence, and the control condition received national data and not economic evidence. Outcomes were rates of e-mail views, policy brief link clicks, requests for researcher consultation, and mentions of child maltreatment terms in legislators' social media posts.

RESULTS

For the first e-mail, the e-mail view rate was 42.6% higher in the intervention than in the enhanced control condition (22.8% vs. 14.8%) and 20.8% higher than in the control condition (22.8% vs. 18.5%) (both p < .0001). Similar results were observed for the second e-mail. These differences remained significant after adjustment for demographic differences across study conditions in individual-level models, but not multilevel models. There was a significant interaction between the experimental condition and political party (p < .0001) in which the intervention increased e-mail view rates among Democrats but not Republicans. The intervention had no effect on policy brief link clicks or requests for consultation and a mixed effect on social media posts.

CONCLUSIONS

Inclusion of state-tailored economic evidence in dissemination materials can increase engagement with research evidence among Democrat, but not Republican, legislators. Dissemination strategies tailored for legislators' political party affiliation may be needed.

Policy Makers' Priorities for Addressing Youth Substance Use and Factors That Influence Priorities

OBJECTIVE

Understanding public policy makers' priorities for addressing youth substance use and the factors that influence these priorities can inform the dissemination and implementation of strategies that promote evidence-based decision making. This study characterized the priorities of policy makers in substance use agencies of U.S. states and counties for addressing youth substance use, the factors that influenced these priorities, and the differences in priorities and influences between state and county policy makers.

METHODS

In 2020, a total of 122 substance use agency policy makers from 35 states completed a Web-based survey (response rate=22%). Respondents rated the priority of 14 issues related to youth substance use and the extent to which nine factors influenced these priorities. Data were analyzed as dichotomous and continuous variables and for state and county policy makers together and separately.

RESULTS

The highest priorities for youth substance use were social determinants of substance use (87%), adverse childhood experiences and childhood trauma (85%), and increasing access to school-based substance use programs (82%). The lowest priorities were increasing access to naloxone for youths (49%), increasing access to medications for opioid use disorder among youths (49%), and deimplementing non-evidence-based youth substance use programs (41%). The factors that most influenced priorities were budget issues (80%) and state legislature (69%), federal (67%), and governor priorities (65%). Issues related to program implementation and deimplementation were significantly higher priorities for state than for county policy makers.

CONCLUSIONS

These findings can inform the tailoring of dissemination and implementation strategies to account for the inner- and outer-setting contexts of substance use agencies.

Impacts of COVID-19 on Mental Health Safety Net Services for Youths: A National Survey of Agency Officials

OBJECTIVE

Mental health agencies provide critical safety net services for youths. No research has assessed impacts of the COVID-19 pandemic on services these agencies provide or youths they serve. This study sought to characterize agency officials' perceptions of the pandemic's impacts on youths and challenges to providing youth services during the pandemic and to examine associations between these challenges and impacts.

METHODS

Surveys were completed in September-October 2020 by 159 state or county mental health agency officials from 46 states. Respondents used 7-point scales (higher rating indicated more severe impact or challenge) to rate the pandemic's impact on youth mental health issues, general service challenges, and telepsychiatry service challenges across patient, provider, and financing domains. Multiple linear regression models estimated associations between service challenges (independent variables) and pandemic impacts (dependent variables).

RESULTS

Most agency officials perceived the pandemic as having disproportionately negative mental health impacts on socially disadvantaged youths (serious impact, 72%; mean rating=5.85). Only 15% (mean=4.29) perceived the pandemic as having a seriously negative impact on receipt of needed youth services. Serious service challenges were related to youths' lack of reliable equipment or Internet access for telepsychiatry services (serious challenge, 59%; mean=5.47) and the inability to provide some services remotely (serious challenge, 42%, mean=4.72). In regression models, the inability to provide some services remotely was significantly (p≤0.01) associated with three of five pandemic impacts.

CONCLUSIONS

Officials perceived the COVID-19 pandemic as exacerbating youth mental health disparities but as not having a dramatic impact on receipt of needed services.

Simulating the role of knowledge brokers in policy making in state agencies: An agent-based model

OBJECTIVE

To model children's mental health policy making dynamics and simulate the impacts of knowledge broker interventions.

DATA SOURCES

Primary data from surveys (n = 221) and interviews (n = 64) conducted in 2019-2021 with mental health agency (MHA) officials in state agencies.

STUDY DESIGN

A prototype agent-based model (ABM) was developed using the PARTE (Properties, Actions, Rules, Time, Environment) framework and informed through primary data collection. In each simulation, a policy is randomly generated (salience weights: cost, contextual alignment, and strength of evidence) and discussed among agents. Agents are MHA officials and heterogenous in their properties (policy making power and network influence) and policy preferences (based on salience weights). Knowledge broker interventions add agents to the MHA social network who primarily focus on the policy's research evidence.

DATA COLLECTION/EXTRACTION METHODS

A sequential explanatory mixed method approach was used. Descriptive and regression analyses were used for the survey data and directed content analysis was used to code interview data. Triangulated results informed ABM development. In the ABM, policy makers with various degrees of decision influence interact in a scale-free network before and after knowledge broker interventions. Over time, each decides to support or oppose a policy proposal based on policy salience weights and their own properties and interactions. The main outcome is an agency-level decision based on policy maker support. Each intervention and baseline simulation runs 250 times across 50 timesteps.

PRINCIPAL FINDINGS

Surveys and interviews revealed that barriers to research use could be addressed by knowledge brokers. Simulations indicated that policy decision outcomes varied by policy making context within agencies.

CONCLUSIONS

This is the first application of ABM to evidence-informed mental health policy making focusing. Results suggest that the presence of knowledge brokers can: (1) influence consensus formation in MHAs, (2) accelerate policy decisions, and (3) increase the likelihood of evidence-informed policy adoption.

Selecting evidence to frame the consequences of adverse childhood experiences: testing effects on public support for policy action, multi-sector responsibility, and stigma

While clinical and public health researchers have produced a high volume of research evidence about the consequences of ACEs, there is limited research on public understanding of ACEs or how to most effectively communicate about this body of science. The objective of this study was to determine which messages describing evidence about the consequences of adverse childhood experiences (ACEs) affect public perceptions. We conducted an online experiment with a nationally-representative sample of U.S. adults in July-August 2020. Participants were randomized to control groups receiving messages describing ACE prevalence or resilience, or treatment groups receiving messages describing consequences of ACEs on mental health and substance use, economics, racial equity, or biology. We compared respondents' perceptions of prevention policies and likelihood of policy engagement, attributions of multi-sector responsibility, and blame and stigma across experimental groups. Messages about economic consequences increased respondents' support for policy and attributions of multi-sector responsibility relative to control groups, while also increasing parental blame. The message describing racial equity lowered respondents' perceptions of importance of state policy action and attributions of responsibility to health care. None of the messages affected stigmatizing attitudes. Describing the economic consequences of ACEs on public systems boosts public support for policy action. More research is needed on how the public responds to messaging connecting systemic racism with childhood adversity and health.

Academic-Policy Partnerships in Evidence-Based Practice Implementation and Policy Maker Use of Child Mental Health Research

OBJECTIVE

Strategies are needed to improve policy makers' evidence-informed decision making and the availability of evidence-based, state-supported services. This study examined whether academic-policy partnerships could promote these outcomes.

METHODS

Data from two national surveys of state mental health agency representatives were used to compare barriers to implementation of evidence-based practices (EBPs) and policy makers' use of child mental health research in states with strong academic-policy partnerships in workforce training or in program implementation/evaluation (IE) with barriers in states with no or limited partnerships in these areas.

RESULTS

Strong IE partnerships were associated with more confidence in research use and fewer issues with provider readiness and capacity but with more issues with EBP fidelity. Strong training partnerships were associated with fewer endorsements of lack of time as a barrier to research use.

CONCLUSIONS

Academic-policy partnerships had some benefit for states' research use and EBP implementation. Because these partnerships may reduce barriers, further research should explore characteristics of effective collaborations.

Dissemination Strategies to Accelerate the Policy Impact of Children's Mental Health Services Research

The United States is in the midst of a children's mental health crisis, with rates of depression, anxiety, and suicide increasing precipitously. Evidence produced by children's mental health services research can help address this crisis by informing public policy decisions about service delivery, system design, and investments in the social determinants of mental health. Unfortunately, the policy impact of children's mental health services research is limited because evidence often fails to reach policy makers, be responsive to their needs, resonate with their worldview, or reflect the contexts in which they make decisions. Dissemination strategies-defined as the development and targeted distribution of messages and materials about research evidence pertaining to a specific issue or intervention-can help address these challenges. Yet, limited integrated guidance exists to inform the design of such strategies. This article addresses this need by synthesizing the results of empirical studies to provide guidance about how to enhance the dissemination of children's mental health services research to policy makers. The article provides four recommendations about the content of policy maker-focused dissemination materials, discusses how strategic framing and message tailoring can increase the chances that evidence is persuasive to policy makers, and highlights strategies to ensure that evidence reaches policy makers.

Trends Over a Decade in NIH Funding for Autism Spectrum Disorder Services Research

Investments in autism spectrum disorder (ASD) research, guided by the Interagency Autism Coordinating Committee (IACC), have focused disproportionately on etiology over a well-established stakeholder priority area: research to improve accessibility and quality of community-based services. This study analyzed National Institutes of Health ASD services research funding from 2008 to 2018 to examine funding patterns, evaluate the impact of IACC objectives, and identify future directions. Approximately 9% of total funds were allocated to services research. This investment remained relatively stable across time and lacked diversity across domains (e.g., area of focus, ages sampled, implementation strategies used). While advancements were observed, including increased prevalence of projects focused on adult samples and on dissemination/implementation and prevention areas, greater investment in service research is critically needed.

Associations Between Cross-Sector Partnerships and Local Health Department Participation in Population-Based Activities to Prevent Mental Health Conditions

Objectives. To describe partnerships between US local health departments (LHDs) and community organizations and assess the relationship between the types of activities performed in these partnerships and LHD engagement in population-based activities to prevent mental health conditions.Methods. Data were derived from 457 LHDs that responded to module 1 of the 2016 Profile Study conducted by the National Association of County and City Health Officials. These data were used to assess the presence of partnerships with community organizations and examine associations between the types of activities performed in such partnerships and LHDs' participation in population-based activities to prevent mental health conditions.Results. LHDs had higher odds of participating in population-based activities to prevent mental health conditions if they shared personnel or resources or had written agreements with mental health or substance use disorder providers, held regularly scheduled meetings with hospitals, or shared personnel or resources with community health centers. Odds were reduced if they exchanged information with community health centers or shared personnel or resources with faith-based organizations.Conclusions. This study offers an improved understanding of how the types of activities performed in cross-sector partnerships affect LHDs' participation in population-based activities to prevent mental health conditions, which is important as public policies, programs, and funding initiatives continue to encourage cross-sector partnership building.

Factors associated with state legislators' support for opioid use disorder parity laws

BACKGROUND

In the United States, state behavioral health parity laws play a crucial role in ensuring equitable insurance coverage and access to substance use disorder treatment and services for people that need them. State legislators have the exclusive authority to adopt these laws. The purpose of this study was to identify legislator beliefs independently associated with "strong support" for opioid use disorder (OUD) parity.

METHODS

Data were from a 2017 cross-sectional, state-stratified, multi-modal survey of state legislators (N = 475). The dependent variable was "strong support" for OUD parity. Primary independent variables were beliefs about state parity laws. Bivariate analyses and mixed effects logistic regression were conducted.

RESULTS

Legislators who "strongly supported" OUD parity were significantly more likely than legislators who did not "strongly support" OUD parity to be female (64.1% vs. 46.5%, p<.001) , Democrat (76.2% vs. 29.3%, p<.001), and have liberal, compared to conservative, ideology (85.6% vs. 27.1%, p<.001). After adjusting for legislator demographics and state-level covariates, beliefs such as agreeing that state parity laws do not increase health insurance premium costs (aOR=6.77, p<.01) and that substance use disorder treatments can be effective (aOR=5.00, p<.001) remained associated with "strong support" for OUD parity. These state legislators' beliefs were more strongly associated with "strong support" for OUD parity than political party, ideology, and other demographic and state-level characteristics.

CONCLUSIONS

Dissemination materials and communication strategies to cultivate support for OUD parity laws among state legislators should focus on the fiscal impacts of parity laws and the effectiveness of substance use disorder treatments.

Public transit and depression among older adults: using agent-based models to examine plausible impacts of a free bus policy

BACKGROUND

Daily transport is associated with mental health. A free bus policy (FBP) may be effective in promoting the use of public transit in older adults and be associated with reductions in depressive symptoms.

METHODS

We developed an agent-based model and grounded it using empirical data from England to examine the impact of an FBP on public transit use and depression among older adults. We also used the model to explore whether the impact of the FBP bus use and depression is modified by the type of income segregation or by simultaneous efforts to improve attitudes towards the bus, to reduce waiting times or to increase the cost of driving via parking fees or fuel price.

RESULTS

Our model suggests that improving attitudes towards the bus (eg, campaigns that promote bus use) could enhance the effect of the FBP, especially for those in proximity to public transit. Reducing wait times could also significantly magnify FPB impacts, especially in those who live in proximity to public transit. Contrary to expectation, neither fuel costs nor parking fees significantly enhanced the impact of the FBP. The impact of improving attitudes towards the bus and increasing bus frequency was more pronounced in the lower-income groups in an income segregation scenario in which destination and public transit are denser in the city centre.

CONCLUSION

Our results suggest that the beneficial mental health effects of an FBP for older adults can be magnified when combined with initiatives that reduce bus waiting times and increased spatial access to transit.

A road map for the future: An exploration of attitudes, perceptions, and beliefs among African Americans to tailor health promotion of cancer-related genetic counseling and testing

African Americans (AA), the second largest racial/ethnic minority group in the United States (US), carry the largest mortality burden of cancer compared with other racial/ethnic groups (Cancer Facts & Figures for African Americans, 2019-2021, American Cancer Society).One solution to address this disparity is through cancer-related genetic counseling and testing (CGT). Although CGT is utilized among the general population, it remains underutilized among AA populations. Community-engaged and community-driven health promotion programs within faith-based organizations (FBOs) have been successfully implemented and delivered among AA populations (Israel et al., American Journal of Public Health, 100, 2010, 2094). FBOs are well positioned for cancer-related health promotion and equipped as conduits of health education and information distribution for cancer prevention. In the present pilot study, a community-based participatory approach (CBPR) was used to collect exploratory data on attitudes, perceptions, and beliefs toward CGT and uptake among an AA sample in the Midwest. Focus groups were conducted in two churches where respondents (N=34) answered a pre-focus group survey prior to a discussion. Respondents were largely unaware of CGT and thought of testing as primarily for ancestral discovery and not for an inheritable disease. Themes identified through qualitative analysis included emotional experiences with cancer; perception of cancer risk; different pictures of genetic testing; other things to worry about; trust in the healthcare system/faith in God and the healthcare system; and ideas and insights regarding promotion of CGT. These primary themes showed participants' perceptions of CGT were shaped by their experiences with cancer, faith, faith communities/FBOs, and cost and access to CGT. Overall, participants within these organizations had positive perceptions about the church as a conduit of genetic testing information but had mixed opinions about the rationale for completing CGT. These findings have implications for genetic counselors, medical providers, and health promotion personnel as to how AA faith populations view CGT and the utility of FBOs as promoters of CGT information.

Population-Based Approaches to Mental Health: History, Strategies, and Evidence

There is growing recognition in the fields of public health and mental health services research that the provision of clinical services to individuals is not a viable approach to meeting the mental health needs of a population. Despite enthusiasm for the notion of population-based approaches to mental health, concrete guidance about what such approaches entail is lacking, and evidence of their effectiveness has not been integrated. Drawing from research and scholarship across multiple disciplines, this review provides a concrete definition of population-based approaches to mental health, situates these approaches within their historical context in the United States, and summarizes the nature of these approaches and their evidence. These approaches span three domains: (a) social, economic, and environmental policy interventions that can be implemented by legislators and public agency directors, (b) public health practice interventions that can be implemented by public health department officials, and (c) health care system interventions that can be implemented by hospital and health care system leaders.

State mental health agency officials' preferences for and sources of behavioral health research

State mental health agencies (SMHAs) are integral to public behavioral health service systems. As such, senior-level officials within SMHAs are important targets for advocacy and dissemination of behavioral health research findings. Evidence-informed decision making in SMHAs can potentially be enhanced by developing summaries of behavioral health research (e.g., policy briefs) that reflect SMHA officials' information preferences, but knowledge about these preferences is lacking. An exploratory study was conducted with the aims of characterizing senior-level SMHA officials' preferences for behavioral health research and describing where they turn for this research when making policy decisions. A cross-sectional, web-based survey of senior-level SMHA officials (1 per state) was conducted in March-May 2017 (n = 43, response rate = 84%). The features of behavioral health research that SMHA officials identified as "very important" most frequently were research being relevant to state residents (93.0%), providing data on cost-effectiveness (86.0%) and budget impact (81.4%), and being presented concisely (81.0%). The primary sources that SMHA officials turned to for behavioral research when making policy decisions were professional organizations (79.1%), SMHA agency staff (60.5%), and university researchers (55.8%). Compared with state legislators' responses to the same survey questions, results suggest that senior-level SMHA officials and legislators have similar preferences for behavioral health research but turn to different sources for this research. Advocates and researchers who seek to promote evidence-informed decision making in SMHAs should consider developing policy briefs that are concise, provide state-level prevalence data about behavioral conditions, and contain economic evaluation data, and they should disseminate these materials to multiple sources. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Examining the possible impact of daily transport on depression among older adults using an agent-based model

OBJECTIVES

Daily transport may impact depression risk among older adults through several pathways including facilitating the ability to meet basic needs, enabling and promoting contact with other people and nature, and promoting physical activity (e.g. through active transportation such as walking or walking to public transit). Both daily transport and depression are influenced by the neighborhood environment. To provide insights into how transport interventions may affect depression in older adults, we developed a pilot agent-based model to explore the contribution of daily transport and neighborhood environment to older adults' depression in urban areas.

METHOD

The model includes about 18,500 older adults (i.e. agents) between the ages of 65 and 85 years old, living in a hypothetical city. The city has a grid space with a number of neighborhoods and locations. Key dynamic processes in the model include aging, daily transport use and feedbacks, and the development of depression. Key parameters were derived from US data sources. The model was validated using empirical studies.

RESULTS

An intervention that combines a decrease in bus fares, shorter bus waiting times, and more bus lines and stations is most effective at reducing depression. Lower income groups are likely to be more sensitive to the public transit-oriented intervention.

CONCLUSION

Preliminary results suggest that promoting public transit use may be a promising strategy to increase daily transport and decrease depression. Our results may have implications for transportation policies and interventions to prevent depression in older adults.

Perceptions of patient-provider communication and receipt of mental health treatment among older adults with depressive symptoms

OBJECTIVES

This study aimed to: (1) determine if and how perceptions towards healthcare providers differ between older adults with and without clinically signifcant depressive symptoms (CSDS), and (2) assess whether perceptions towards providers are associated with receipt of mental health treatment among older adults with CSDS.

METHODS

Data from the 2013 and 2014 Medical Expenditure Panel Survey were used to examine CSDS prevalence, receipt of mental health treatment, and perceptions of provider communication among community-dwelling adults ≥ age 65 (N = 6,936) using four of the 'How Well Doctors Communicate' composite items from the Consumer Assessment of Healthcare Providers and Systems(CAHPS). Multivariate logistic regression was used.

RESULTS

CSDS are associated with greater odds of having 'poor' perceptions of provider communication on all four CAHPS communication measures. Perceptions of provider communication are similar among older adults with CSDS who received and did not receive mental health treatment, except on an item measuring a provider's ability to explain information in ways patients understand.

CONCLUSION

Older adults with CSDS have more negative perceptions of the quality of their communication with healthcare providers than their peers. Healthcare systems should consider how to accommodate these patients' unique needs and communication preferences to ensure receipt of quality care.

Urban-Rural Differences in Older Adult Depression: A Systematic Review and Meta-analysis of Comparative Studies

CONTEXT

Depression among older adults (aged 60 years or older) is a problem that could be exacerbated by global trends in urbanization and population aging. The study purpose was to assess whether urban, relative to rural, residence is associated with depression among older adults and whether associations differ in countries with developed versus developing economies.

EVIDENCE ACQUISITION

In 2017, the authors identified and extracted information from comparative studies of urban-rural depression prevalence among older adults. Studies were identified in PubMed, PsychINFO, and Web of Science and limited to English language articles published after 1985. Eighteen studies met inclusion criteria. Random effects meta-analysis was conducted to produce weighted pooled ORs estimating the association between urban-rural residence and depression for all study participants (N=31,598) and sub-analyses were conducted for developed (n=12,728) and developing (n=18,870) countries.

EVIDENCE SYNTHESIS

Depression prevalence was significantly higher among urban residents in ten studies and significantly higher among rural residents in three studies (all three conducted in China). Associations between urban-rural residence and depression generally remained significant after adjusting for covariates. In developed countries, the odds of depression were significantly higher among urban than rural residents (pooled OR=1.44, 95% CI=1.10, 1.88). However, in developing countries, this association was not observed (pooled OR=0.91, 95% CI=0.46, 1.77).

CONCLUSIONS

Converging trends of urbanization and population aging could increase the global burden of depression among older adults. The pathways through which urban-rural residence influences depression risk among older adults might differ by country context. Future research should focus on measuring variation in these contexts.

Hereditary cancer screening: Case reports and review of literature on ten Ashkenazi Jewish founder mutations

BACKGROUND

Historically, three founder mutations in the BRCA1/2 (OMIM 113705; OMIM 600185) genes have been the focus of cancer risks within the Ashkenazi Jewish (AJ) population. However, there are several additional mutations associated with increased susceptibility to cancer in individuals of AJ ancestry.

METHODS

We report three patients who exemplify the need to keep these additional founder mutations in mind when pursuing hereditary cancer genetic testing of individuals in this population. All gene sequences in this paper were aligned to reference sequences based on human genome build GRCh37/UCSC hg19.

RESULTS

review of the literature discusses that the combined risk is 12.36%-20.83% forhaving 1 of the 10 hereditary cancer AJ founder mutations in the BRCA1, BRCA2, CHEK2 (OMIM 604373), APC (OMIM 611731), MSH2 (OMIM 609309), MSH6 (OMIM 600678), and GREM1 (OMIM 603054) genes for individuals of AJ ancestry.

CONCLUSION

We recommend testing for all 10 of these AJ founder cancer susceptibility mutations for individuals within this population as standard screening in order to ensure appropriate cancer risk management and cascade testing.

Examining EMTALA in the era of the patient protection and Affordable Care Act

Background

Little is known regarding the characteristics of hospitals that violate the Emergency Medical Treatment and Labor Act (EMTALA). This study addresses this gap by examining EMTALA settlements from violating hospitals and places these descriptive results within the current debate surrounding the Patient Protection and Affordable Care Act (ACA).

Methods

We conducted a content analysis of all EMTALA Violations that resulted in civil monetary penalty settlements from 2002–2015 and created a dataset describing the nature of each settlement. These data were then matched with Thomson Healthcare hospital data. We then present descriptive statistics of each settlement over time, plot settlements by type of violation, and provide the geographic distribution of settlements.

Results

Settlements resulting from EMTALA violations decreased from a high of 46 in 2002 to a low of 6 in 2015, a decline of 87%. Settlements resulting from violations most commonly occurred for failure to screen and failure to stabilize patients in need of emergency care. Settlements were most common in hospitals in the South (48%) and in urban areas (74%). Among Disproportionate Share Hospitals (DSH) with a violation, the majority (62%) were located in the South or in urban areas (65%). Violating hospitals incurred annual settlements of $31,734 on average, for a total $5,299,500 over the study period.

Conclusions

EMTALA settlements declined prior to and after the implementation of the ACA and were most common in the South and in urban areas. EMTALA's status as an unfunded mandate, scheduled cuts to DSH payments and efforts to repeal the ACA threaten the financial viability of safety-net hospitals and could result in an increase of EMTALA violations. Policymakers should be cognizant of the interplay between the ACA and complementary laws, such as EMTALA, when considering changes to the law.

Modeling the inactivation of ascaris eggs as a function of ammonia concentration and temperature

Ammonia sanitization is a promising technology for sanitizing human excreta intended for use as a fertilizer in agriculture. Ascaris eggs are the most persistent pathogens regarding ammonia inactivation and are commonly present in fecal sludge in low- and middle-income countries. In this study, a model for predicting ammonia inactivation of ascaris eggs was developed. Data from four previous studies were compiled and analyzed statistically, and a mathematical model for the treatment time required for inactivation was created. The inactivation rate increased with NH3 activity to the power of 0.7. The required treatment time was found to decrease 10-fold for each 16 °C temperature increase. Dry matter (DM) content and pH had no direct effect on inactivation, but had an indirect effect due to their impact on NH3 activity, which was estimated using the Pitzer approach. An additional model giving an approximation of Pitzer NH3 activity but based on the Emerson approach, DM content and total ammonia (NHTot) was also developed. The treatment time required for different log10 reductions of ascaris egg viability can thus easily be estimated by the model as a function of NH3 activity and temperature. The impact on treatment time by different treatment options can then be theoretically evaluated, promoting improvements of the treatment e.g. by adding urea or alkaline agents, or increasing the temperature by solar heating.

An innovative sustainability assessment for urban wastewater infrastructure and its application in Chengdu, China

Sustainability assessments are an increasingly common tool for measuring progress towards sustainable development. Despite their popularity, sustainability assessments and the indicators that compose them are said to have had little impact on the policy arena. In this paper we discuss four attributes that we contend will improve the use of sustainability assessments to guide decision making: non-compartmentalization, site specificity, built-in guidance for target setting, and ability to measure active sustainability. We present a novel assessment tool for wastewater treatment infrastructure that illustrates these attributes. The assessment is composed of two-dimensional indicators we call "burden to capacity" ratios, that reveal and quantify the local value of resources embodied in wastewater and treatment byproducts, and the tradeoffs between designing systems for disposal versus reuse. We apply the sustainability assessment framework to an existing treatment plant in Chengdu, China and discuss the results.

Recognition and initial management of cardiac emergencies in children

One may have only minutes to change the trajectory of a child who is deteriorating from either congenital or acquired cardiac disease. However, these children may present with rather cryptic patterns of symptoms (e.g. failure to thrive, lethargy, colic, neonatal shock, respiratory distress, wheezing and syncope with exercise). Thus, it is essential that any health care practitioner who cares for children be familiar with key clinical presentations that require consideration of underlying cardiac disease and time sensitive diagnoses that require rapid recognition and therapy in order to optimize the chances of saving the child's life. The objectives of this manuscript are: 1) to review the initial identification and management of cardiac emergencies in children; and 2) to present a brief summary of key cardiac diagnoses that may need to be considered when caring for children in an acute care setting.

Nutritional management of PKU with glycomacropeptide from cheese whey

Individuals with phenylketonuria (PKU) must follow a lifelong low-phenylalanine (Phe) diet to prevent neurological impairment. Compliance with the low-Phe diet is often poor owing to restriction in natural foods and the requirement for consumption of a Phe-free amino acid formula or medical food. Glycomacropeptide (GMP), a natural protein produced during cheese-making, is uniquely suited to a low-Phe diet because when isolated from cheese whey it contains minimal Phe (2.5-5 mg Phe/g protein). This paper reviews progress in evaluating the safety, acceptability and efficacy of GMP in the nutritional management of PKU. A variety of foods and beverages can be made with GMP to improve the taste, variety and convenience of the PKU diet. Sensory studies in individuals with PKU demonstrate that GMP foods are acceptable alternatives to amino acid medical foods. Studies in the PKU mouse model demonstrate that GMP supplemented with limiting indispensable amino acids provides a nutritionally adequate source of protein and improves the metabolic phenotype by reducing concentrations of Phe in plasma and brain. A case report in an adult with classical PKU who followed the GMP diet for 10 weeks at home indicates safety, acceptability of GMP food products, a 13-14% reduction in blood Phe levels (p<0.05) and improved distribution of dietary protein throughout the day compared with the amino acid diet. In summary, food products made with GMP that is supplemented with limiting indispensable amino acids provide a palatable alternative source of protein that may improve dietary compliance and metabolic control of PKU.

Concentrations and inactivation of Ascaris eggs and pathogen indicator organisms in wastewater stabilization pond sludge

During treatment in wastewater stabilization ponds (WSPs) many pathogens, in particular helminth eggs, are concentrated in the sludge layer. Because periodic removal of the sludge is often required, information is needed on the concentrations and inactivation of pathogens in the sludge layer to evaluate the public health risk they pose upon removal of the sludge. In this paper, previous reports on the sludge concentrations of various pathogen indicator organisms and helminth eggs are reviewed and results from our own recent experiments are reported. The advantages and disadvantages of several methods for studying inactivation in the sludge layer are discussed, as well as implications for the management of WSP sludge. In our recent experiments, which were conducted at three WSPs in central Mexico, sludge cores, dialysis chambers, and batch experiments were used to measure the inactivation rates of fecal coliform bacteria, fecal enterococci, F+ coliphage, somatic coliphage, and Ascaris eggs. The first-order inactivation rate constants were found to be approximately 0.1, 0.1, 0.01, 0.001, and 0.001 d(-1), respectively. The concentrations of all the organisms were found to vary both vertically and horizontally in the sludge layer; therefore, to determine the maximum and average concentration of organisms in the sludge layer of a WSP, complete sludge cores must be collected from representative locations throughout the pond.

Inactivation of viable Ascaris eggs by reagents during enumeration

Various reagents commonly used to enumerate viable helminth eggs from wastewater and sludge were evaluated for their potential to inactivate Ascaris eggs under typical laboratory conditions. Two methods were used to enumerate indigenous Ascaris eggs from sludge samples. All steps in the methods were the same except that in method I a phase extraction step with acid-alcohol (35% ethanol in 0.1 N H(2)SO(4)) and diethyl ether was used whereas in method II the extraction step was avoided by pouring the sample through a 38-microm-mesh stainless steel sieve that retained the eggs. The concentration of eggs and their viability were lower in the samples processed by method I than in the samples processed by method II by an average of 48 and 70%, respectively. A second set of experiments was performed using pure solutions of Ascaris suum eggs to elucidate the effect of the individual reagents and relevant combination of reagents on the eggs. The percentages of viable eggs in samples treated with acid-alcohol alone and in combination with diethyl ether or ethyl acetate were 52, 27, and 4%, respectively, whereas in the rest of the samples the viability was about 80%. Neither the acid nor the diethyl ether alone caused any decrease in egg viability. Thus, the observed inactivation was attributed primarily to the 35% ethanol content of the acid-alcohol solution. Inactivation of the eggs was prevented by limiting the direct exposure to the extraction reagents to 30 min and diluting the residual concentration of acid-alcohol in the sample by a factor of 100 before incubation. Also, the viability of the eggs was maintained if the acid-alcohol solution was replaced with an acetoacetic buffer. None of the reagents used for the flotation step of the sample cleaning procedure (ZnSO(4), MgSO(4), and NaCl) or during incubation (0.1 N H(2)SO(4) and 0.5% formalin) inactivated the Ascaris eggs under the conditions studied.

Chyloabdomen in a mature cat

A mature, castrated male cat presented with progressive lethargy and a severely distended abdomen. Abdominal radiographs, abdominocentesis, and evaluation of the fluid obtained led to a diagnosis of chyloabdomen. The underlying pathology, etiology, diagnosis, and treatment associated with this disease are discussed.

Linguistic analysis to assess medically related posttraumatic stress symptoms

The authors examined the presence of posttraumatic stress symptoms (PTSS) in 20 patients requiring ventilation after acute respiratory distress. The subjects completed a semistructured interview about their ventilation experience that was subject to content and linguistic analysis. Subjects also completed two self-report measures to assess PTSS and socioemotional adjustment. Subjects who endorsed PTSS were more likely to use a narrative style suggesting emotional involvement in their recall of the stressful event. The authors indicate that the presence of PTSS is a common consequence of traumatic medical experiences and that denial of distress may be an adaptive short-term coping strategy.

Improved detection and characterization of paroxysmal nocturnal hemoglobinuria using fluorescent aerolysin

Paroxysmal nocturnal hemoglobinuria (PNH) is caused by a somatic mutation in the gene PIGA, which encodes an enzyme essential for the synthesis of glycosylphosphatidylinositol (GPI) anchors. The PIGA mutation results in absence or marked deficiency of more than a dozen proteins on PNH blood cells. Current flow cytometric assays for PNH rely on the use of labeled antibodies to detect deficiencies of specific GPI anchor proteins, such as CD59. However, because no single GPI anchor protein is always expressed in all cell lineages, no one monoclonal antibody can be used with confidence to diagnose PNH. We describe a new diagnostic test for PNH, based on the ability of a fluorescently labeled inactive variant of the protein aerolysin (FLAER) to bind selectively to GPI anchors. We compared GPI anchor protein expression in 8 patients with PNH using FLAER and anti-CD59. In all cases, FLAER detected similar or higher proportions of PNH monocytes and granulocytes compared with anti-CD59. Because of the increased sensitivity of detection, FLAER could detect small abnormal granulocyte populations in patients to a level of about 0.5%; samples from healthy control subjects contained substantially fewer FLAER-negative cells. FLAER gives a more accurate assessment of the GPI anchor deficit in PNH.

Channel formation by the glycosylphosphatidylinositol-anchored protein binding toxin aerolysin is not promoted by lipid rafts

Glycosylphosphatidylinositol-anchored proteins may be concentrated in membrane microdomains (lipid rafts) that are also enriched in cholesterol and sphingolipids. The glycosyl anchor of these proteins is a specific, high affinity receptor for the channel-forming protein aerolysin. We wished to determine if the presence of rafts promotes the activity of aerolysin. Treatment of T lymphocytes with methyl-beta-cyclodextrin, which destroys lipid rafts by sequestering cholesterol, had no measurable effect on the sensitivity of the cells to aerolysin; nor did similar treatment of erythrocytes decrease the rate at which they were lysed by the toxin. We also studied the rate of aerolysin-induced channel formation in liposomes containing glycosylphosphatidylinositol-anchored placental alkaline phosphatase, which we show is a receptor for aerolysin. In liposomes containing sphingolipids as well as glycerophospholipids and cholesterol, most of the enzyme was Triton X-100-insoluble, indicating that it was localized in rafts, whereas in liposomes prepared without sphingolipids, all of the enzyme was soluble. Aerolysin was no more active against liposomes containing rafts than against those that did not. We conclude that lipid rafts do not promote channel formation by aerolysin.

Clostridium septicum alpha toxin uses glycosylphosphatidylinositol-anchored protein receptors

The alpha toxin produced by Clostridium septicum is a channel-forming protein that is an important contributor to the virulence of the organism. Chinese hamster ovary (CHO) cells are sensitive to low concentrations of the toxin, indicating that they contain toxin receptors. Using retroviral mutagenesis, a mutant CHO line (BAG15) was generated that is resistant to alpha toxin. FACS analysis showed that the mutant cells have lost the ability to bind the toxin, indicating that they lack an alpha toxin receptor. The mutant cells are also resistant to aerolysin, a channel-forming protein secreted by Aeromonas spp., which is structurally and functionally related to alpha toxin and which is known to bind to glycosylphosphatidylinositol (GPI)-anchored proteins, such as Thy-1. We obtained evidence that the BAG15 cells lack N-acetylglucosaminyl-phosphatidylinositol deacetylase-L, needed for the second step in GPI anchor biosynthesis. Several lymphocyte cell lines lacking GPI-anchored proteins were also shown to be less sensitive to alpha toxin. On the other hand, the sensitivity of CHO cells to alpha toxin was increased when the cells were transfected with the GPI-anchored folate receptor. We conclude that alpha toxin, like aerolysin, binds to GPI-anchored protein receptors. Evidence is also presented that the two toxins bind to different subsets of GPI-anchored proteins.

Channels formed by subnanomolar concentrations of the toxin aerolysin trigger apoptosis of T lymphomas

Aerolysin is a channel-forming toxin that binds to glycosylphosphatidylinositol (GPI)-anchored proteins, such as Thy-1, on target cells. Here, we show that subnanomolar concentrations of aerolysin trigger apoptosis of T lymphomas. Using inactive aerolysin variants, we determined that apoptosis was not directly triggered by binding to GPI-anchored receptors, nor was it caused by receptor clustering induced by toxin oligomerization. Apoptosis was caused by the production of a small number of channels in the cell membrane. Channel formation resulted in a rapid increase in intracellular calcium, which may have been the signal for apoptosis. Overexpression of the antiapoptotic protein bcl-2 blocked aerolysin-induced apoptosis, although this effect was overcome at higher toxin concentrations.

Resistance of paroxysmal nocturnal hemoglobinuria cells to the glycosylphosphatidylinositol-binding toxin aerolysin

Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal stem cell disorder caused by a somatic mutation of the PIGA gene. The product of this gene is required for the biosynthesis of glycosylphosphatidylinositol (GPI) anchors; therefore, the phenotypic hallmark of PNH cells is an absence or marked deficiency of all GPI-anchored proteins. Aerolysin is a toxin secreted by the bacterial pathogen Aeromonas hydrophila and is capable of killing target cells by forming channels in their membranes after binding to GPI-anchored receptors. We found that PNH blood cells (erythrocytes, lymphocytes, and granulocytes), but not blood cells from normals or other hematologic disorders, are resistant to the cytotoxic effects of aerolysin. The percentage of lysis of PNH cells after aerolysin exposure paralleled the percentage of CD59(+) cells in the samples measured by flow cytometry. The kinetics of red blood cell lysis correlated with the type of PNH erythrocytes. PNH type III cells were completely resistant to aerolysin, whereas PNH type II cells displayed intermediate sensitivity. Importantly, the use of aerolysin allowed us to detect PNH populations that could not be detected by standard flow cytometry. Resistance of PNH cells to aerolysin allows for a simple, inexpensive assay for PNH that is sensitive and specific. Aerolysin should also be useful in studying PNH biology.

Expression and properties of an aerolysin--Clostridium septicum alpha toxin hybrid protein

Aerolysin is a bilobal channel-forming toxin secreted by Aeromonas hydrophila. The alpha toxin produced by Clostridium septicum is homologous to the large lobe of aerolysin. However, it does not contain a region corresponding to the small lobe of the Aeromonas toxin, leading us to ask what the function of the small lobe is. We fused the small lobe of aerolysin to alpha toxin, producing a hybrid protein that should structurally resemble aerolysin. Unlike aerolysin, the hybrid was not secreted when expressed in Aeromonas salmonicida. The purified hybrid was activated by proteolytic processing in the same way as both parent proteins and, after activation, it formed oligomers that corresponded to the aerolysin heptamer. Like aerolysin, the hybrid was far more active than alpha toxin against human erythrocytes and mouse T lymphocytes. Both aerolysin and the hybrid bound to human glycophorin, and both were inhibited by preincubation with this erythrocyte glycoprotein, whereas alpha toxin was unaffected. We conclude that aerolysin contains two receptor binding sites, one for glycosyl-phosphatidylinositol-anchored proteins that is located in the large lobe and is also found in alpha toxin, and a second site, located in the small lobe, that binds a surface carbohydrate determinant.

Activation of STAT3 by the c-Fes protein-tyrosine kinase

STATs (signal transducers and activators of transcription) are transcription factors that contain SH2 domains and are activated by tyrosine phosphorylation, often in response to cytokine stimulation. Recent evidence indicates that the transforming tyrosine kinases encoded by the v-Src, v-Abl, and v-Fps oncogenes can induce STAT activation, suggesting that their normal cellular homologs may contribute to STAT activation under physiological conditions. In this report, we provide direct evidence that c-Fes, the normal human homolog of v-Fps, potently activates STAT3. Transient transfection of human 293T cells with STAT3 and Fes resulted in strong stimulation of STAT3 DNA binding activity. In contrast, only modest activation of STAT5 by Fes was observed in this system, indicative of possible selectivity. To determine whether Fes-induced STAT3 activation is dependent upon endogenous mammalian kinases, co-expression studies were also performed in Sf-9 insect cells. Fes also induced a dramatic increase in STAT3 DNA binding activity in this system, whereas no activation of STAT5 was observed. As a positive control, both STAT3 and STAT5 were shown to be activated by the Bcr-Abl tyrosine kinase in Sf-9 cells. Fes induced strong tyrosine phosphorylation of STAT3 in both expression systems, consistent with the gel-shift results. Fes and STAT3 have been independently linked to myeloid differentiation. Results presented here suggest that these proteins may cooperate to promote differentiation signaling in response to hematopoietic cytokines.

Glycosylphosphatidylinositol anchors of membrane glycoproteins are binding determinants for the channel-forming toxin aerolysin

Cells that are sensitive to the channel-forming toxin aerolysin contain surface glycoproteins that bind the toxin with high affinity. Here we show that a common feature of aerolysin receptors is the presence of a glycosylphosphatidylinositol anchor, and we present evidence that the anchor itself is an essential part of the toxin binding determinant. The glycosylphosphatidylinositol (GPI)-anchored T-lymphocyte protein Thy-1 is an example of a protein that acts as an aerolysin receptor. This protein retained its ability to bind aerolysin when it was expressed in Chinese hamster ovary cells, but could not bind the toxin when expressed in Escherichia coli, where the GPI anchor is absent. An unrelated GPI-anchored protein, the variant surface glycoprotein of trypanosomes, was shown to bind aerolysin with similar affinity to Thy-1, and this binding ability was significantly reduced when the anchor was removed chemically. Cathepsin D, a protein with no affinity for aerolysin, was converted to an aerolysin binding form when it was expressed as a GPI-anchored hybrid in COS cells. Not all GPI-anchored proteins bind aerolysin. In some cases this may be due to differences in the structure of the anchor itself. Thus the GPI-anchored proteins procyclin of Trypanosoma congolense and gp63 of Leishmania major did not bind aerolysin, but when gp63 was expressed with a mammalian GPI anchor in Chinese hamster ovary cells, it bound the toxin.

Movement of a loop in domain 3 of aerolysin is required for channel formation

Aerolysin is a channel-forming toxin that must oligomerize in order to become insertion-competent. Modeling based on the crystal structure of the proaerolysin dimer and electron microscopic images of the oligomer indicated that a loop in domain 3 must move away from the beta-sheet that forms the main body of the protein before oligomerization can proceed. In order to determine if movement actually occurs, strategically located amino acids in the loop and in the sheet were replaced with cysteines by site-directed mutagenesis. A double mutant was produced in which the new cysteines, at position 253 on the loop and position 300 in the sheet, were close enough together to allow formation of a disulfide bridge. The double mutant was unable to oligomerize, and it was completely inactive, showing not only that the bridge had formed but also that movement of the loop was essential for formation of the oligomer. The existence of the bridge was confirmed by X-ray crystallography. The reduced form of the protein and the single mutants T253C and A300C were as active as wild type, indicating that the amino acid replacements themselves had no functional consequences. Labeling studies using an environment-sensitive fluorescent sulfhydryl-reactive probe confirmed that the structure of the protein changes in the loop region as a consequence of proteolytic activation of proaerolysin, a step which also must precede oligomerization.

Constitutive activation of Stat3 in fibroblasts transformed by diverse oncoproteins and in breast carcinoma cells

Signal transducers and activators of transcription (STATs) were originally identified as key components of signaling pathways involved in mediating responses to IFNs. Previous studies showed that the Src oncoprotein constitutively activates one STAT family member, Stat3. In this study, we investigated STAT activation in a panel of rodent fibroblast cell lines stably transformed by diverse viral oncoproteins. Using a temperature-sensitive mutant of v-Src, we determined that Stat3 is activated within 15 min of shift from nonpermissive to permissive temperature for cell transformation. This finding indicates that v-Src tyrosine kinase activity is required for Stat3 activation and suggests that Stat3 is proximal to signaling initiated by Src. In addition, Stat3 activation is induced by another nonreceptor tyrosine kinase, v-Fps; by polyoma virus middle T antigen, which activates Src family kinases; and by v-Sis, which acts as a ligand for the platelet-derived growth factor receptor. In contrast SV40 large T antigen, which transforms cells through different mechanisms, and the v-Ras and v-Raf oncoproteins, which lie in signaling pathways downstream of tyrosine kinases, do not activate Stat3. We did not detect significant activation of Stat1, Stat5, or Stat6 in fibroblasts transformed by the viral oncoproteins investigated. Moreover, Stat3 is activated in response to epidermal growth factor (EGF) but not heregulins in immortalized normal human breast epithelial cells. Because constitutive activation of c-Src and EGF receptor kinases is associated with the progression of breast cancer, we examined activation of STATs in human cell lines derived from breast carcinomas. We detected constitutive activation of Stat3 in five of nine breast carcinoma cell lines but not in normal breast epithelial cells. Furthermore, experiments with an EGF receptor-specific inhibitor indicated that the constitutive activation of Stat3 in these breast carcinoma cell lines is not necessarily dependent on signaling through the EGF receptor, although EGF stimulation further increases Stat3 activation. Taken together, our results demonstrate that selective activation of Stat3 is a common event during oncogenic transformation that directly or indirectly involves activation of specific tyrosine kinase signaling pathways.

The erythrocyte receptor for the channel-forming toxin aerolysin is a novel glycosylphosphatidylinositol-anchored protein

The plasma membrane of rat erythrocytes contains a 47-kDa glycoprotein that binds the channel-forming toxin aerolysin with high affinity and accounts for the sensitivity of these cells to the toxin. The receptor was purified so that its N-terminal sequence could be determined after Western blotting. The sequence did not match any sequences in the databases, indicating that the receptor is a novel erythrocyte surface protein. However, it exhibited considerable homology to the N-termini of a group of membrane proteins that are thought to be involved in ADP-ribosyl transfer reactions. A common property of these proteins is that they are attached to plasma membranes by C-terminal glycosylphosphatidylinositol (GPI) anchors. The aerolysin receptor was shown to be anchored in the same way by treating rat erythrocytes with phosphatidylinositol-specific phospholipase C. This caused the selective release of the receptor and a reduction in the rodent cells' sensitivity to aerolysin. Human and bovine erythrocytes were shown to contain an aerolysin-binding protein with similar properties to the rat erythrocyte receptor. Proteins with GPI anchors are thought to have unusually high lateral mobility, and this may be an advantage for a toxin, such as aerolysin, which must oligomerize after binding to become insertion competent.

The glycosylphosphatidylinositol-anchored surface glycoprotein Thy-1 is a receptor for the channel-forming toxin aerolysin

Aerolysin is a channel-forming protein secreted by virulent Aeromonas spp. Some eucaryotic cells, including T-lymphocytes, are sensitive to very low concentrations of the toxin (<10(-9) M). Here we show that aerolysin binds selectively and with high affinity to the glycosylphosphatidylinositol (GPI)-anchored surface protein Thy-1, which is found on T-lymphocyte populations as well as in brain. Less than 1 ng of purified Thy-1 could be detected by probing Western blots with the toxin. Mutant T-cell lines that lack the ability to add GPI anchors to Thy-1 and other surface proteins were much less sensitive to aerolysin, as were wild-type cells that were pretreated with phosphatidylinositol-specific phospholipase C to remove GPI-anchored proteins. Phosphatidylcholine/cholesterol liposomes containing purified Thy-1 in their membranes were much more sensitive to aerolysin than protein-free liposomes.