It is important to note that many substances detected in the plant samples were not detected in the blood or urine samples. Some examples include 5-Fluoro-NNEI 2’-naphthyl isomer, 5-fluoropentylindole, NM-2201 and NPB-22. There are multiple explanations for these findings. The patient may have used SC products that were not included in our plant samples and therefore would not be associated with the urine and blood samples. It is also possible that the metabolites of the compound were not in the database or that the level was below the LC TOF detection limits. Furthermore, the metabolite may have been metabolized to a common XLR metabolite that was detected, or the drug had already been eliminated from the body.However, the study has a number of important limitations. First, the selection of patients was based on the judgment of our ED team and toxicologists based on abnormal vital signs, subjective history from the patient, presentation of decreased mental status and clinical judgment. Many intoxicated patients may have been evaluated and treated without being included in the study. In addition, patients may have had altered mental status for reasons other than SC intoxication and may have been erroneously included in the study because their ED arrival was associated with other patients with SC intoxication. Although there were 141 visits, several patients with recurrent intoxications were included as multiple visits in the study. The SC samples were provided by patients, but it should not be assumed that the specific sample was necessarily the cause of their intoxication. Furthermore, the samples were collected anonymously,curing cannabis without designation to a specific patient, and therefore we were unable to identify which of the patients presenting with bradycardia tested positive for certain compounds.
This significantly diminished our ability to conclude that certain types of SC are associated with more profound presentations of bradycardia and psychomotor depression. Lastly, the majority of the patients presented from a large, nearby psychiatric center. The patients often presented as groups, possibly due to simultaneous drug use with the same sample. This patient population tends to have multiple comorbidities, and members may be taking neuroleptic medications that may increase the opportunity for interactions with the cannabinoids. This is a population with an increased risk of substance use, and therefore the results of our case series cannot necessarily be extrapolated to other populations.More than one-quarter of a million women in the United States are currently living with HIV , and many women living with HIV fare poorly on the HIV Care Continuum . In 2015, only 50% of WLHIV were retained in care and 48% achieved HIV viral suppression . Despite the broad availability of effective antiretroviral medications, WLHIV also experience high rates of morbidity and mortality compared to the general population . Trauma is increasingly recognized as a near-universal experience among WLHIV and as a key contributor to HIV acquisition, morbidity, and mortality. Defined as “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects” , trauma can include childhood and/or adult physical, sexual, or emotional abuse or neglect, as well as sociostructural violence such as racism, sexism, homophobia, transphobia, xenophobia, or living in a community where violence is common. People living with HIV experience disproportionately high rates of trauma , including rates of childhood sexual abuse that are more than twice the rates among the general population. Trauma exposure in PLHIV is associated with nonAIDS related deaths , and is predictive of experiencing later violence . It is also closely associated with mental health disorders including depression, PTSD, and anxiety , as well as with increased HIV-risk behavior, including substance use disorders . HIV diagnosis is itself often highly traumatic . Among PLHIV, trauma and substance use often function syndemically, as “epidemics interacting synergistically and contributing, as a result of their interaction, to excess burden of disease in a population” . The syndemic of violence/trauma, substance use, and HIV has been identified as one of the main drivers of HIV infection and of poor health outcomes among women living with HIV . Research has consistently shown high rates of substance use among people living with HIV, and rates that are higher than among the general population . Substance use has also been shown to have a negative impact on HIV treatment adherence and virologic suppression .
The link between trauma and health outcomes has led to calls for increased attention to trauma in health care by advocates and government leaders, including the U.S. Preventive Services Health Task Force, the Institute of Medicine, and the Agency for Healthcare Research and Quality . While an emerging literature describes interventions to address trauma and PTSD among PLHIV , no prospective study has evaluated the impact of a comprehensive model of trauma-informed health care delivery on health outcomes. To address this gap, we initiated implementation of a model of traumainformed health care in one clinic serving WLHIV in the San Francisco Bay Area. As part of this effort, we are conducting a broad evaluation of the impact of TIHC on patient health outcomes. Here we report results of baseline data analyses, examining the association of trauma with physical, behavioral, and social health indicators, with particular attention to quality of life and undetectable viral load. We then consider how the results of the investigation serve to inform efforts within health care settings to improve outcomes. Women were recruited from the waiting room during regular clinic hours on two half-days each week. Researchers approached patients in the waiting room, briefly explained the purpose of the study and, if a patient was interested, met with her in a private room. At that time, the researchers reviewed consent documents, explained the study procedures including data abstraction from the electronic health record , and answered any questions. Individuals were eligible to participate if they self-identified as cisgender or transgender women who were 18 years of age or older, were currently receiving primary HIV care at the clinic,cannabis dryer and were English-speaking and cognitively able to complete the interview. If the patient was eligible and willing, she signed a general consent form and an EHR data abstraction consent form. Following consent, the researcher conducted the interview by reading each question aloud and marking responses in a survey booklet. At the end of the interview, the participant received a $25 gift card in appreciation of her time. Most interviews took 30-45 minutes to complete. After the interview, researchers abstracted relevant data from the participant’s EHR. This study was designed as a broad evaluation and, as such, was exploratory in nature. Thus, data were collected on a wide variety of constructs. Two women living with HIV who were not clinic patients or study participants reviewed and provided input on the measures used in the interview. Demographics. We asked participants for general demographic information. Based on observed distributions, we dichotomized race into white women and women of color; and dichotomized education into more than a high school education or not. We dichotomized housing into stable or not; individuals who self-identified as being homeless, living in a car or vehicle, or having lived in a location for fewer than 6 months were characterized as unstably housed.
We also used the Household Food Security Survey , a validated two-item instrument that measures experiences of food insecurity in the past year . Trauma was measured in three ways. First, we measured childhood trauma using the Adverse Childhood Experiences instrument, which counts 10 types of abuse, neglect, and household dysfunction experienced before the age of 18 . A cut-off of 4 is commonly used, and prior research has shown that individuals who experienced 4 or more ACEs have significantly greater risk for later poor health outcomes. We also measured lifetime trauma using the validated checklist from the Trauma History Screen to measure exposure to 14 potentially traumatic events from childhood to the present time . Finally, we asked whether participants had experienced recent trauma based on two questions about sexual coercion and abuse, threats, and victimization in the past 30 days. In our analysis, we found both ACEs and recent trauma to be highly correlated with the Trauma History Screen. For this reason, and because the THS covers both childhood and recent trauma, we use the THS for our analysis. Empowerment was measured using the Empowerment Scale, a 28-item scale developed with members of self-help communities . Social Support was measured using the 4-item Social Support Survey , a shortened version of the original Medical Outcomes Study Social Support Survey . Participants self-reported whether they were currently on HIV antiretroviral medications. Thirty-day HIV medication adherence was self-reported, based on a validated six-point scale , dichotomized into good 30- day adherence or not . We asked participants whether they had disclosed their HIV status to anyone. Of those who had disclosed, we asked, “On a scale of 1-10, how open or ‘out’ are you about your HIV status?” Those who said that they had not disclosed to anyone were given a score of 0. HIV Stigma was measured using the Sayles Stigma Scale , a 28-item instrument that measures internalized stigma through questions about how often certain items happen or are true because of their HIV. PTSD symptoms were measured using the PTSD Checklist for DSM-5 , a 20-item instrument to assess symptom criteria for PTSD . A score of 33 or above indicates a provisional diagnosis of PTSD. Depression symptoms were assessed using the Patient Health Questionnaire- 9, a validated nine-item patient-reported measure of depression symptoms that maps to DSM diagnostic criteria . A score of 10 or above is considered to be indicative of at least moderate depression. Anxiety symptoms were assessed using the Generalized Anxiety Disorder scale , a 7-item self-report scale to measure symptom severity. A score of 10 or above indicates at least moderate anxiety. Substance use was measured in three ways. Alcohol use was assessed using the short Alcohol Use Disorders Identification Test , a 3-item screen to identify individuals who may be hazardous drinkers or who have alcohol use disorders . The instrument provides a raw numerical score ; an indicator of binge drinking; and a diagnostic of AUD . Drug use was measured using one question from the Alcohol, Smoking and Substance Involvement Screening Test asking about substance use in the past three months. We dichotomized this into any non-prescribed drug use in the past 3 months, and a similar variable of “hard” drug use that excludes marijuana. Drug abuse was measured using the Drug Abuse Screening Test 10 , which yields a score range of 0-10. A score of 3 or greater indicates at least a moderate level of drug abuse. Quality of Life was measured using the five-item WHO-Five, developed cross culturally by the World Health Organization . The instrument measures self-reported quality of life over the past two weeks in the areas of mood, physical vitality, and interest in life. A score below 13 indicates poor quality of life . Mental well-being was measured using the seven-item Short Warwick Edinburgh Mental Well being Scale, which focuses on emotions and mental functioning , and yields a score of 7-35. Undetectable viral load. For participants who consented to having data abstracted from their electronic health record , we abstracted HIV viral load and CD4 counts. Data were abstracted only if the person had had a test within the past year, and the most recent test result was used.For the analysis, we focused on undetectable viral load as the outcome of interest. Patient-Provider relationship was measured using the Engagement with Health Care Provider scale , a 13-item instrument in which clients rate their interactions with their providers on a scale of 1 “always” to 4 “never”. Responses are summed to get a total score of 1-52, with lower scores indicated greater engagement. Appointment Adherence. We abstracted EHR data to examine appointment adherence as a proxy for engagement in care. Appointment adherence is the percentage of scheduled clinical appointments that were actually attended in the six months prior to the study visit. First, we generated descriptive statistics to summarize the baseline data. Second, we used bivariate linear and logistic regression analysis to examine relationships between trauma and various indicators of health. Third, we used bivariate linear and logistic regression analysis to examine factors that are associated with the two outcomes of interest: quality of life and undetectable viral load.