Healthcare Reforms for the Mentally Ill

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Neuropsychiatric illnesses are some of the most devastating conditions in the world. Despite being non-communicable, mental and neurological conditions are estimated to contribute to approximately 30.8% of all of the years lived in disability1. Furthermore, in developed nations like the United States, mental disorders have been reported to erode around 2.5% of the yearly gross national product, which fails to account for the opportunity cost of families who have to take care of patients long-term.¹ If left untreated, many patients with neuropsychiatric illnesses cannot find gainful employment; their aberrant behavior is stigmatized and prevents forward professional and personal advancement. In fact, about three times as many individuals living with mental illnesses who are in state/local prisons rather than rehabilitative psychiatric institutions.²

Though the Affordable Care Act has substantially decreased the amount of uninsured individuals in the U.S., there are still millions of people who fall into something called the Medicaid gap.³ People in this group make too much money for Medicaid, but too little money to be able to qualify for government tax credits in purchasing an insurance plan. In an attempt to fix this ‘hole,’ the federal government offers aid to states in order to expand their Medicaid programs as needed.⁴ States that have accepted the Medicaid expansion sponsored by the federal government, have seen sudden reductions in their populations of uninsured people, which has directly improved quality of life for the least fortunate people in society. However, in the many states that continue to reject federal aid, the situation is considerably worse--especially for the mentally ill.

Mental health patients are especially vulnerable to falling into the Medicare gap. Many patients suffering from psychiatric conditions often are unable to find serious employment. According to a report by the Department of Health and Human Services in March 2016, there are 1.9 million low-income, uninsured individuals with mental health disorders who cannot access proper healthcare resources.⁵ These impoverished psychiatric patients are originally eligible for Medicare. However, once their treatment takes and they become employed, they might pass the Medicare income threshold. If their private health insurance does not cover the cost of their psychiatric treatments, patients will relapse, creating a vicious cycle that is exceptionally difficult to break out of.⁶

Furthermore, many psychiatric illnesses often initially present during adolescence or early adulthood, which is right around the time students leave home to go to college. So, during initial presentation, many students lack the proper support system necessary to deal with their condition, causing many to drop out of college or receive poor grades. Families often chalk up these conditions to poor adjustments to a brand new college environment at home, preventing psychiatric patients from properly receiving treatment.⁶ Alone, many students with psychiatric conditions delay seeking treatment, fearing being labeled as “crazy” or “insane” by their peers.

Under the status quo, psychiatric patients face significant barriers to care. As the Medicaid gap is unfortunately subject to political maneuverings, it probably will not be fixed immediately. However, the United States could fund the expansion of Assertive Community Treatment programs, which provide medication, therapy, and social support in an outpatient setting.⁸ Such programs dramatically reduce hospitalization times for psychiatric patients, alleviating the costs of medical treatment. Funding these programs would help insurance issues from being a deterrent to treatment.

In the current system, psychiatric patients face numerous deterrents to receiving treatment, from lack of family support to significant social stigma. Having access to health insurance be a further barrier to care is a significant oversight of the current system and ought to be corrected.

References

1. World Health Organization. Chapter 2: Burden of Mental and Behavioural Disorders. 2001. 20 3 2016 <http://www.who.int/whr/2001/chapter2/en/index3.html>.
2. Torrey, E. F.; Kennard, A. D.; Elsinger, D.; Lamb, R.; Pavle, J. More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: A Survey of the States .
3. Kaiser Family Foundation. Key Facts about the Uninsured Population. 5 8 2015. 25 3 2016 <http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/>.
4. Ross, Janell. Obamacare mandated better mental health-care coverage. It hasn't happened. 7 8 2015. 24 3 2016 <https://www.washingtonpost.com/news/the-fix/wp/2015/10/07/obamacare-mandated-better-mental-health-care-coverage-it-hasnt-happened/>.
5. Dey, J.; Rosenoff, E.; West, K. Benefits of Medicaid Expansion for Behavioral Health. 28 3 2016 <https://aspe.hhs.gov/sites/default/files/pdf/190506/BHMedicaidExpansion.pdf>
6. Taskiran, Sarper. Interview. Rishi Suresh. Istanbul, 3 3 2016.
7. Gonen, Oner Gurkan. Interview. Rishi Suresh. Houston, 1 4 2016.
8. Assertive Community Treatment https://www.centerforebp.case.edu/practices/act (accessed Jan 2017).

Modeling Climate Change: A Gift From the Pliocene

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Believe it or not, we are still recovering from the most recent ice age that occurred between 21,000 and 11,500 years ago. And yet, in the past 200 years, the Earth's average global temperature has risen by 0.8 ºC at a rate more than ten times faster than the average ice-age recovery rate.¹ This increase in global temperature, which shows no signs of slowing down, will have tremendous consequences for our planet’s biodiversity and overall ecology.

Climate change is caused by three main factors: changes in the position of the Earth’s continents, variations in the Earth’s orbital positions, and increases in the atmospheric concentration of “greenhouse gases”, such as carbon dioxide.² In the past 200 years, the Earth’s continents have barely moved and its orbit around the sun has not changed.² Therefore, to explain the 0.8 ºC increase in global average temperature that has occurred, the only reasonable conclusion is that there has been a change in the concentration of greenhouse gases.

After decades of research by the Intergovernmental Panel on Climate Change (IPCC), this theory was supported. The IPCC Fourth Assessment Report concluded that the increase in global average temperature is very likely due to the observed increase in anthropogenic greenhouse gas concentrations. Also included in the report is a prediction that global temperatures will increase between 1.1 ºC and 6.4 ºC by the end of the 21st century.²

Though we know what is causing the warming, we are unsure of its effects. The geologists and geophysicists at the US Geological Service (USGS) are attempting to address this uncertainty through the Pliocene Research, Interpretation, and Synoptic Mapping (PRISM) program.³

The middle of the Pliocene Era occurred roughly 3 million years ago-- a relatively short time on the geological time scale. Between the Pliocene era and our current Holocene era, the continents have barely drifted, the planet has maintained a near identical orbit around the sun, and the type of organisms living on earth has remained relatively constant.² Because of these three commonalities , we can draw three conclusions. Because the continents have barely drifted, global heat distribution through oceanic circulation is the same. Additionally, because the planet’s orbit is essentially the same, glacial-interglacial cycles have not been altered. Finally, because the type of organisms has remained relatively constant, the biodiversity of the Pliocene is comparable to our own.

While the eras share many similarities, the main difference between them is that the Pliocene was about 4 ºC warmer at the equator and 10 ºC warmer at the poles.⁴ Because the Pliocene had similar conditions to today, but was warmer, it is likely that at the end of the century, our planet’s ecology may begin to look like the Pliocene. This idea has been supported by the research done by the USGS’s PRISM.³

It is a unique and exciting opportunity to be able to study a geological era so similar to our own and apply discoveries we make from that era to our current environment. PRISM is using multiple techniques to extract as much data about the Pliocene as possible. The concentration of magnesium ions, the number of carbon double bonds in organic structures called alkenones, and the concentration and distribution of fossilized pollen all provide a wealth of information that can be used to inform us about climate change. However, the single most useful source of such information comes from planktic foraminifera, or foram.⁵

Foram, abundant during the Pliocene era, are unicellular, ocean-dwelling organisms adorned with calcium shells. Fossilized foram are extracted from deep-sea core drilling. The type and concentration of the extracted foram reveal vital information about the temperature, salinity, and productivity of the oceans during the foram’s lifetime.⁵ By performing factor analysis and other statistical analyses on this information, PRISM has created a model of the Pliocene that covers both oceanic and terrestrial areas, providing a broad view of our planet as it existed 3 million years ago. Using the information provided by this model, scientists can determine where temperatures will increase the most and what impact such a temperature increase will have on life that can exist in those areas.

Since its inception in 1989, PRISM has predicted, with proven accuracy, two main trends.The first is that average temperatures will increase the most at the poles, with areas nearest to the equator experiencing the least amount of temperature increase.⁵ The second is that tropical plants will expand outward from the equator, taking root in the middle and higher latitudes.⁵

There are some uncertainties associated with the research behind PRISM. Several assumptions were made, such as the idea of uniformitarianism, which states that the same natural laws and physical processes that occur now were true in the past. The researchers also assumed that the ecological tolerances of certain key species, such as foram, have not significantly changed in the last 3 million years. Even with these normalizing assumptions, an important discrepancy exists between the Pliocene and our Holocene: the Pliocene achieved its temperature at a normal rate and remained relatively stable throughout its era, while our temperatures are increasing at a much more rapid rate.

The film industry has fetishized climate change, predicting giant hurricanes and an instant ice age, as seen in the films 2012 and The Day After Tomorrow. Fortunately, nothing as cataclysmic will occur. However, a rise in global average temperature and a change in our ecosystems is nothing to be ignored or dismissed as normal. It is only through the research done by the USGS via PRISM and similar systems that our species can be prepared for the coming decades of change.

References

1. Earth Observatory. http://earthobservatory.nasa.gov/Features/GlobalWarming/page3.php (accessed Oct. 1, 2016).
2. Pachauri, R.K., et. al. IPCC 4th Assessment 2007, 104.
3. PRISM4D Collaborating Institutions. Pliocene Research Interpretation and Synoptic Mapping. http://geology.er.usgs.gov/egpsc/prism/ (Oct. 3, 2016).
4. Monroe, R. What Does 400PPM Look Like?. https://scripps.ucsd.edu/programs/keelingcurve/2013/12/03/what-does-400-ppm-look-like/ (accessed Oct. 19, 2016).
5. Robinson, M. M., J. Am. Sci. 2011, 99, 228

Algae: Pond Scum or Energy of the Future?

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In many ways, rising fuel demands indicate positive development--a global increase in energy accessibility. But as the threat of climate change from burning fuel begins to manifest, it spurs the question: How can the planet meet global energy needs while sustaining our environment for years to come? While every person deserves access to energy and the comfort it brings, the population cannot afford to stand by as climate change brings about ecosystem loss, natural disaster, and the submersion of coastal communities. Instead, we need a technological solution which will meet global energy needs while promoting ecological sustainability. When people think of renewable energy, they tend to picture solar panels, wind turbines, and corn-based ethanol. But what our society may need to start picturing is that nondescript, green-brown muck that crowds the surface of ponds: algae.

Conventional fuel sources, such as oil and coal, produce energy when the carbon they contain combusts upon burning. Problematically, these sources have sequestered carbon for millions of years, hence the term fossil fuels. Releasing this carbon now increases atmospheric CO₂ to levels that our planet cannot tolerate without a significant change in climate. Because fossils fuels form directly from the decomposition of plants, live plants also produce the compounds we normally burn to release energy. But, unlike fossil fuels, living biomass photosynthesizes up to the point of harvest, taking CO₂ out of the atmosphere. This coupling between the uptake of CO₂ by photosynthesis and the release of CO₂ by combustion means using biomass for fuel should not add net carbon to the atmosphere.¹ Because biofuel provides the same form of energy through the same processes as fossil fuel, but uses renewable resources and does not increase atmospheric carbon, it can viably support both societal and ecological sustainability.

If biofuel can come from a variety of sources such as corn, soy, and other crops, then why should we consider algae in particular? Algae double every few hours, a high growth rate which will be crucial for meeting current energy demands.² And beyond just their power in numbers, algae provide energy more efficiently than other biomass sources, such as corn.¹ Fat composes up to 50 percent of their body weight, making them the most productive provider of plant oil.^3,2 Compared to traditional vegetable biofuel sources, algae can provide up to 50 times more oil per acre.⁴ Also, unlike other sources of biomass, using algae for fuel will not detract from food production. One of the primary drawbacks of growing biomass for fuel is that it competes with agricultural land and draws from resources that would otherwise be used to feed people.³ Not only does algae avoid this dilemma by either growing on arid, otherwise unusable land or on water, but also it need not compete with overtaxed freshwater resources. Algae proliferates easily on saltwater and even wastewater.⁴ Furthermore, introducing algae biofuel into the energy economy would not require a systemic change in infrastructure because it can be processed in existing oil refineries and sold in existing gas stations.²

However, algae biofuel has yet to make its grand entrance into the energy industry. When oil prices rose in 2007, interest shifted towards alternative energy sources. U.S. energy autonomy and the environmental consequences of carbon emission became key points of discussion. Scientists and policymakers alike were excited by the prospect of algae biofuel, and research on algae drew governmental and industrial support. But as U.S. fossil fuel production increased and oil prices dropped, enthusiasm waned.²

Many technical barriers must be overcome to achieve widespread use of algae, and progress has been slow. For example, algae’s rapid growth rate is both its asset and its Achilles’ heel. Areas colonized by algae can easily become overcrowded, which blocks access to sunlight and causes large amounts of algae to die off. Therefore, in order to farm algae as a fuel source, technology must be developed to regulate its growth.³ Unfortunately, the question of how to sustainably grow algae has proved troublesome to solve. Typically, algae for biofuel use is grown in reactors in order to control growth rate. But the ideal reactor design has yet to be developed, and in fact, some current designs use more energy than the algae yield produces.⁵

Although algae biofuel faces technological obstacles and dwindling government interest, many scientists today still see algae as a viable and crucial solution for future energy sustainability. UC San Diego houses the California Center for Algal Biotechnology, and Dr. Stephen Mayfield, a molecular biologist at the center, has worked with algae for over 30 years. In this time he has helped start four companies, including Sapphire Energy, founded in 2007, which focuses on developing algae biofuels. After receiving $100 million from venture capitalists in 2009, Sapphire Energy built a 70,000-square-foot lab in San Diego and a 220-acre farm in New Mexico. They successfully powered cars and jets with algae biofuel, drawing attention and $600 million in further funding from ExxonMobil. Although diminished interest then stalled production, algal researchers today believe people will come to understand the potential of using algae.² The Mayfield Lab currently works on developing genetic and molecular tools to make algae fuel a viable means of energy production.⁴ They grow algae, extract its lipids, and convert them to gasoline, jet, and diesel fuel. Mayfield believes his lab will reach a low price of 80 or 85 dollars per barrel as they continue researching with large-scale biofuel production.¹

The advantage of growing algae for energy production lies not only in its renewability and carbon neutrality, but also its potential for other uses. In addition to just growing on wastewater, algae can treat the water by removing nitrates.⁵ Algae farms could also provide a means of carbon sequestration. If placed near sources of industrial pollution, they could remove harmful CO₂ emissions from the atmosphere through photosynthesis.⁴ Additionally, algae by-products are high in protein and could serve as fish and animal feed.⁵

At this time of increased energy demand and dwindling fossil fuel reserves, climate change concerns caused by increased atmospheric carbon, and an interest in U.S. energy independence, we need economically viable but also renewable, carbon neutral energy sources.⁴ Algae holds the potential to address these needs. Its rapid growth and photosynthetic ability mean its use as biofuel will be a sustainable process that does not increase net atmospheric carbon. The auxiliary benefits of using algae, such as wastewater treatment and carbon sequestration, increase the economic feasibility of adapting algae biofuel. While technological barriers must be overcome before algae biofuel can be implemented on a large scale, demographic and environmental conditions today indicate that continued research will be a smart investment for future sustainability.

References

1. Deaver, Benjamin. Is Algae Our Last Chance to Fuel the World? Inside Science, Sep. 8, 2016.
2. Dineen, Jessica. How Scientists Are Engineering Algae To Fuel Your Car and Cure Cancer. Forbes UCVoice, Mar. 30, 2015.
3. Top 10 Sources for Biofuel. Seeker, Jan. 19, 2015.
4. California Center for Algae Biotechnology. http://algae.ucsd.edu/. (accessed Oct. 16, 2016).
5. Is Algae the Next Sustainable Biofuel? Forbes StatoilVoice, Feb. 27, 2015. (republished from Dec. 2013)

First World Health Problems

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I am a first generation American, as both of my parents immigrated here from Myanmar, a third world country. There had been no occurrence of any Inflammatory Bowel Disease (IBD) in my family, yet I was diagnosed with Ulcerative Colitis at the beginning of my sophomore year of high school. Since IBD is known to be caused by a mix of genetic and environmental factors,^1,2 what specifically triggered me to develop Ulcerative Colitis? Was it the food in America, the air I was exposed to, a combination of the two, or neither of them at all? Did the “environment” of the first world in the United States cause me to develop Ulcerative Colitis?

IBD is a chronic autoimmune disease, characterized by persistent inflammation of the digestive tract and classified into two separate categories: Ulcerative Colitis and Crohn’s Disease.³ Currently, there is no known cure for IBD, as its pathogenesis (i.e. the manner in which it develops) is not fully understood.¹ Interestingly, the incidence of IBD has increased dramatically over the past century.¹ A systematic review by Molodecky et al. showed that the incidence rate of IBD was significantly higher in Western nations. This may be due to better diagnostic techniques or the growth of environmental factors that promote its development. This could also suggest that there may be certain stimuli in first world countries that can trigger pathogenesis in individuals with a genetic predisposition to IBD.

Environmental factors that are believed to affect IBD include smoking, diet, geographic location, social status, stress, and microbes.¹ Smoking has had varying effects on the development of IBD depending on the form; smoking is a key risk factor for Crohn’s Disease, while non-smokers and ex-smokers are usually diagnosed with Ulcerative Colitis.⁴ There have not been many studies investigating the causal relationship between diet and IBD due to the diversity in diet composition.¹ However, since IBD affects the digestive system, diet has long been thought to have some impact on the pathogenesis of the disease.¹ In first world countries, there is access to a larger variety of food, which may impact the prevalence of IBD. People susceptible to the disease in developing countries may have a smaller chance of being exposed to “trigger” foods. In addition, IBD has been found in higher rates in urban areas versus rural areas.^1,4,5 This makes sense, as cities have a multitude of potential disease-inducing environmental factors including pollution, poor sanitation, and microbial exposure. Higher socioeconomic status has also been linked to higher rates of IBD.⁴ This may be partly due to the sedentary nature of white collar work, which has also been linked to increased rates of IBD.¹ Stress used to be viewed as a possible factor in the pathogenesis of IBD, but recent evidence has indicated that it only exacerbates the disease.³ Recent research has focused on the microorganisms in the gut, called gut flora, as they seem to have a vital role in the instigation of IBD.¹ In animal models, it has even been observed that pathogenesis of IBD is not possible in a germ-free environment.¹ The idea of the importance of microorganisms in human health is also linked to the Hygiene Hypothesis.

The Hygiene Hypothesis states that the lack of infections in western countries is the reason for an increasing amount of autoimmune and allergic diseases.⁶ The idea behind the theory is that some infectious agents guard against a wide variety of immune-related disorders.⁶ Animal models and clinical trials have provided some evidence backing the Hygiene Hypothesis, but it is hard to causally attribute the pathogenesis of autoimmune and allergic diseases to a decrease in infections, since first world countries have very different environmental factors than third world countries.⁶

The increasing incidence of IBD in developed countries is not yet fully understood, but recent research points towards a complex combination of environmental and genetic factors. The rise of autoimmune disease diagnoses may also be attributed to better medical equipment and facilities and the tendency of people in more developed countries to regularly get checked by a doctor. There are many difficulties in researching the pathogenesis of IBD including isolating certain environmental factors and obtaining tissue and data from third world countries. However, there is much promising research and it might not be long until we discover a cure for IBD.

References

1. Danese, S. et al. Autoimm Rev 2004, 3.5, 394-400.
2. Podolsky, Daniel K. N Engl J Med 2002,  347.6, 417-29.
3. Mayo Clinic. "Inflammatory Bowel Disease (IBD)." http://www.mayoclinic.org/diseases-conditions/inflammatory-bowel-disease/basics/definition/con-20034908 (accessed Sep. 30, 2016).
4. CDC. "Epidemiology of the IBD." https://www.cdc.gov/ibd/ibd-epidemiology.htm (accessed Oct.17, 2016).
5. Molodecky, N. et al. Gastroenterol 2012, 142.1, n. pag.
6. Okada, H. et. al. Clin Exp Immuno 2010, 160, 1–9.

Corals in Hot Water, Literally

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Coral reefs support more species per unit area than any other marine environment, provide over half a billion people worldwide with socio-economic benefits, and produce an estimated USD $30 billion annually.¹ Many people do not realize that these diverse ecosystems are at risk of extinction as a result of human activity--the Caribbean has already lost 80% of its coral cover in the past few decades² and some estimates report that at least 60% of all coral will be lost by 2030.¹ One of the most predominant and direct threats to the health of these fragile ecosystems is the enormous amount of carbon dioxide and methane that have spilled into the atmosphere, warming the planet and its oceans on unprecedented levels.

Corals are Cnidarians, the phylum characterized by simple symmetrical structural anatomy. Corals reproduce either asexually or sexually and create stationary colonies made up of hundreds of genetically identical polyps.³ The major reef-building corals belong to a sub-order of corals, called Scleractinia. These corals contribute substantially to the reef. framework and are key species in building and maintaining the structural complexity of the reef.³ The survival of this group is of particular concern, since mass die- offs of these corals affect the integrity of the reef. Corals form a symbiosis with tiny single-celled algae of the genus Symbiodinium. This symbiotic relationship supports incredible levels of biodiversity and is a beautifully intricate relationship that is quite fragile to sudden environmental change.³

The oceans absorb nearly half of the carbon dioxide in the atmosphere through chemical processes that occur at its surface.⁴ Carbon dioxide combines with water molecules to create a mixture of bicarbonate, calcium carbonate, and carbonic acid. Calcium carbonate is an important molecule used by many marine organisms to secrete their calcareous shells or skeletons. The increase of carbon dioxide in the atmosphere shifts this chemical equilibrium, creating higher levels of carbonic acid and less calcium carbonate.⁴ Carbonic acid increases the acidity of the ocean and this phenomenon has been shown to affect the skeletal formation of juvenile corals.⁵ Acidification weakens the structural integrity of coral skeletons and contributes to heightened dissolution of carbonate reef structure.³

The massive influx of greenhouse gases into our atmosphere has also caused the planet to warm very quickly. Corals are in hot water, literally. Warmer ocean temperatures have deadly effects on corals and stress the symbiosis that corals have with the algae that live in their tissues. Though coral can procure food by snatching plankton and other organisms with protruding tentacles, they rely heavily on the photosynthesizing organism Symbiodinium for most of their energy supply.³ Symbiodinium provides fixed carbon compounds and sugars necessary for coral skeletal growth. The coral provides the algae with a fixed position in the water column, protection from predators, and supplementary carbon dioxide.³ Symbiodinium live under conditions that are 1 to 2° C below their maximum upper thermal limit. Under warmer conditions due to climate change, sea surface temperatures can rise a few degrees above their maximum thermal limit. This means that a sudden rise in sea temperatures can stress Symbiodinium by causing photosynthetic breakdown and the formation of reactive oxygen species that are toxic to corals.³ The algae leave or are expelled from the coral tissues as a mechanism for short-term survival in what is known as bleaching. Coral will die from starvation unless the stressor dissipates and the algae return to the coral’s tissues.³

Undoubtedly, the warming of the seas is one of the most widespread threats to coral reef ecosystems. However, other threats combined with global warming may have synergistic effects that heighten the vulnerability of coral to higher temperatures. These threats include coastal development that either destroys local reefs or displaces sediment to nearby reefs, smothering them. Large human populations near coasts expel high amounts of nitrogen and phosphorous into the ecosystem, which can increase the abundance of macroalgae and reduce hard coral cover. Increased nutrient loading has been shown to be a factor contributing to a higher prevalence of coral disease and coral bleaching.⁶ Recreational fishing and other activities can cause physical injury to coral making them more susceptible to disease. Additionally, fishing heavily reduces population numbers of many species of fish that keep the ecosystem in balance.

The first documented global bleaching event in 1998 killed off an estimated 16% of the world’s reefs; the world experienced the destruction of the third global bleaching event occurred only last year.¹ Starting in mid-2015, an El Niño Southern Oscillation (ENSO) weather event spurred hot sea surface temperatures that decimated coral reefs across the Pacific, starting with Hawaii, then hitting places like American Samoa, Australia, and reefs in the Indian Ocean.⁷ The aftermath in the Great Barrier Reef is stunning; the north portion of the reef experienced an average of 67% mortality.⁸ Some of these reefs, such as the ones surrounding Lizard Island, have been reduced to coral skeletons draped in macroalgae. With climate change, it is expected that the occurrence of ENSO events will become more frequent, and reefs around the world will be exposed to greater thermal stress.¹

Some scientists are hopeful that corals may be able to acclimatize in the short term and adapt in the long term to warming ocean temperatures. The key to this process lies in the genetic type of Symbiodinium that reside in the coral tissues. There are over 250 identified types of Symbiodinium, and genetically similar types are grouped into clades A-I. The different clades of these algae have the potential to affect the physiological performance of their coral host, including responses to thermotolerance, growth, and survival under more extreme light conditions.³ Clade D symbiont types are generally more thermotolerant than those in other clades. Studies have shown a low abundance of Clade D organisms living in healthy corals before a bleaching event, but after bleaching and subsequently recovering, the coral has a greater abundance of Clade D within its tissues.^9,10 Many corals are generalists and have the ability to shuffle their symbiont type in response to stress.¹¹

However, there is a catch. Though some algal members of Clade D are highly thermotolerant, they are also known as selfish opportunists. The reason healthy, stress-free corals generally do not have a symbiosis with this clade is that it tends to hoard the energy and organic compounds it creates from photosynthesis and shares fewer products with its coral host.³

Approaches that seemed too radical a decade ago are now widely considered as the only means to save coral reefs from the looming threat of extinction. Ruth Gates, a researcher at the Hawaii Institute of Marine Biology is exploring the idea of assisted evolution in corals. Her experiments include breeding individual corals in the lab, exposing them to an array of stressors, such as higher temperatures and lower pH, and picking the hardiest survivors to transplant to reefs.¹² In other areas of the globe, scientists are breeding coral larvae in labs and then releasing them onto degraded reefs where they will hopefully settle and form colonies.

Governments and policy makers can create policies that have significant impact on the health of reefs. The creation of marine protected areas that heavily regulates or outlaws harvesting of marine species offers sanctuary to a stressed and threatened ecosystem.³ There is still a long way to go, and the discoveries being made so far about coral physiology and resilience are proving that the coral organism is incredibly complex.

The outlook on the future of healthy reefs is bleak; rising fossil fuel consumption rates mock the global goal of keeping rising temperatures below two degrees Celsius. Local stressors such as overfishing, pollution, and coastal development cause degradation of reefs worldwide. Direct human interference in the acclimatization and adaptation of corals may be instrumental to their survival. Rapid transitions to cleaner sources of energy, the creation of more marine protection areas, and rigid management of reef fish stocks may ensure coral reef survival. If humans fail in this endeavor, one of the most biodiverse and productive ecosystems on earth that has persisted for millions of years may come crashing to an end within our lifetime.

References

1. Cesar, H., L. Burke, and L. Pet-Soede. 2003. "The Economics of Worldwide Coral Reef Degradation." Arnhem, The Netherlands: Cesar Environmental Economics Consulting. http://pdf.wri.org/cesardegradationreport100203.pdf (accessed Dec 14, 2016)
2. Gardner, T.A. et al. Science 2003, 301:958–960.
3. Sheppard C., Davy S., Piling G., The Biology of Coral Reefs; Biology of Habitats Series; Oxford University Press; 1st Edition, 2009
4. Branch, T.A.et al. Trends in Ecology and Evolution 2013, 28:178-185
5. Foster, T. et al. Science Advances 2016, 2(2) e1501130
6. Vega Thurber, R.L. et al. Glob Change Biol 2013, 20:544-554
7. NOAA Coral Watch, NOAA declares third ever global coral bleaching event. Oct 8, 2015. http://www.noaanews.noaa.gov/stories2015/100815-noaa-declares-third-ever-global-coral-bleaching-event.html (accessed Dec 15, 2016)
8. ARC Centre of Excellence for Coral Reef Studies, Life and Death after the Great Barrier Reef Bleaching. Nov 29, 2016 https://www.coralcoe.org.au/media-releases/life-and-death-after-great-barrier-reef-bleaching (accessed Dec 13, 2016)
9. Jones A.M. et al. Proc. R. Soc. B 2008, 275:1359-1365
10. Silverstein, R. et al. Glob Change Biology 2014, 1:236-249
11. Correa, A.S.; Baker, A.C. Glob Change Biology 2010, 17:68-75
12. Mascarelli, M. Nature 2014, 508:444-446

Green Sea Turtles: A Shell of What They Once Were

Catalyst Volume 10

Sea turtles appear in many cultures and myths, and are often beloved symbols of longevity and wisdom. However, in spite of the cultural respect shown towards them, green sea turtles have gradually become endangered due to factors such as nesting habitat loss, pollution, egg harvesting, climate change, and boat strikes. Now, there’s a new, even more dangerous threat on the block: herpes. And no, it’s not the herpes you’re thinking of - this kind, known as fibropapillomatosis (FP), is much, much worse.

FP has been observed across all species of sea turtles for years, but it has recently become especially widespread among green sea turtles (Chelonia mydas). The alarming incidence of FP is exacerbating the decline of this already vulnerable population. Among green sea turtles, the number of cases of FP increased 6000% from the 1980s to the mid-1990s, with FP becoming so globally pervasive that the outbreak has been classified as “panzootic,” the animal equivalent of “pandemic.” Now, you might think, “That sounds bad, but why are these turtles dying?” In humans, herpes is unpleasant, but it is seldom life-threatening. Unfortunately, in green sea turtles, the outlook isn’t nearly as optimistic. FP causes the development of tumors on the soft tissues, the shells, and even the eyes of infected turtles. When these growths are left untreated, they can grow to immense sizes, impairing the animal's vital activities, such as breathing and swallowing. So, while the tumors aren’t directly lethal, they invite hordes of secondary infections and pathogens that ultimately result in death.

To make matters worse, treatment for FP is still in development. A landmark study identified the specific pathogen responsible for FP as Chelonid herpesvirus 5 (ChHV5), a close relative of human genital herpes.¹ This discovery was the first step to a cure, but it raised an important question - how had this variant of herpesvirus become so prevalent? Until recently, the answer to that question was elusive.

Fortunately, several recent discoveries offered new explanations for FP’s rise. One study reported a significant positive correlation between serum concentrations of heavy metals and the severity of FP, as well as a significant negative correlation between serum cholesterol concentrations and FP.² In a related find, a team at the University of São Paulo discovered that many green sea turtles have been exposed to organochlorine compounds, which are known to have carcinogenic effects.³ Further research could potentially determine a direct causal relationship between the development of FP and exposure to heavy metals or organochlorine compounds. If such a relationship were found, projects that strive to decrease the prevalence of said compounds in the turtles’ habitats could prove effective in mitigating the spread of FP.

So what’s the prognosis for the green sea turtle? Unfortunately, even knowing what we now know, it may not be good. A study by Jones et. al. found almost all of the infected turtles are juveniles, potentially creating a big problem for the population.⁴ Jones believes the most optimistic explanation for this trend is that current adults and hatchlings have never been exposed to the disease, so only one generation (the juveniles) has been infected. Another optimistic possibility is that once infected turtles recover from the disease, they will simply acquire immunity as adults. However, there is another, devastating possibility: all of the affected juveniles will perish before they reach adulthood, leaving only the unaffected alive and dooming the species. In a heartbreaking aside, Jones reported that FP “grows on their [the turtles’] eyes, they can't see predators, they can't catch food, so sometimes they slowly starve to death — it's not a nice thing for the turtles to experience. Severely affected turtles are quite skinny and have other pathogens affecting them – that’s why they die.”

Eradicating such a devastating disease will no doubt take many more years of specialized research, and significant efforts are needed immediately to rehabilitate the green sea turtle population. Luckily, conservation groups such as The Turtle Hospital, located in the Florida Keys, are making an active effort to save infected sea turtles. They perform surgeries that remove FP tumors, rehabilitate the turtles, and then release them back into the wild. In addition, they collaborate with universities to study the virus and educate the public on sea turtle conservation. To date, the Turtle Hospital has successfully treated and released over 1,500 sea turtles. Through the hard work of conservation organizations and researchers across the globe, we may still be able to save the green sea turtle.

References

1. Jacobson, E. R. et al. Dis. Aquat. Organ. 1991, 12.
2. Carneiro da Silva, C., et al. Aquat. Toxicol. 2016, 170, 42-51.
3. Sánchez-Sarmiento, A. M. et al. J. Mar. Biol. Assoc. U. K. 2016, 1-9.
4. Jones, K., et al. Vet. J. 2016, 212, 48-57.
5. Borrowman, K. Electronic Theses and Dissertations. 2008
6. Monezi, T. A. et al. Vet. Microbiol. 2016, 186, 150-156.
7. Herbst, L. H. et al. Dis. Aquat. Organ. 1995, 22.
8. The Turtle Hospital. Rescue, Rehab, Release. http://www.turtlehospital.org/about-us/ (accessed Oct. 4, 2016).

Visualizing the Future of Medicine

Catalyst Volume 10

What do you do when you get sick? Most likely you schedule a doctor’s appointment, show up, and spend ten to fifteen minutes with the doctor. The physician quickly scans your chart, combines your narrative of your illness with your medical history and his or her observations so that you can leave with diagnosis and prescription in hand. While few give the seemingly routine process a second thought, the very way in which healthcare providers approach the doctor-patient experience is evolving. There is a growing interest in the medical humanities, a more interdisciplinary study of illness. According to Baylor College of Medicine, the aim of the medical humanities is “understanding the profound effects of illness and disease on patients, health professionals, and the social worlds in which they live and work.”¹ Yet medical humanities is somewhat of a catch all term. It encompasses disciplines including literature, anthropology, sociology, philosophy, the fine arts and even “science and technology studies.”¹ This nuanced approach to medicine is exactly what Dr. Kirsten Ostherr, one of the developers of Rice University’s medical humanities program, promotes.

Dr. Ostherr uses this interdisciplinary approach to study the intersection of technology and medicine. She has conducted research on historical medical visualizations through media such as art and film and its application to medicine today. Originally a PhD recipient of American Studies and Media Studies at Brown University, Dr. Ostherr’s interest in medicine and media was sparked while working at the Department of Public Health at Oregon Health Sciences University, where researchers were using the humanities as a lens through which they could analyze health data. “I noticed that the epidemiologists there used narrative to make sense of data, and that intrigued me,” she said. This inspired Dr. Ostherr to use her background in media and public health to explore how film and media in general have affected medicine and to predict where the future of medical media lies.

While the integration of medicine and media may seem revolutionary, it is not a new concept. In her book, Medical Visions, Dr. Ostherr says that “We know we have become a patient when we are subjected to a doctor’s clinical gaze,” a gaze that is powerfully humanizing and can “transform subjects into patients.”² With the integration of technology and medicine, this “gaze” has extended to include the visualizations vital to understanding the patient and decoding disease. Visualizations have been a part of the doctor-patient experience for longer than one might think, from X-rays in 1912 to the electronic medical records used by physicians today.³

In her book, Dr. Ostherr traces and analyzes a series of different types of medical visualizations throughout history. Her research begins with the study of scientific films of the early twentieth century, and their attempt to bridge the gap between scientific knowledge and the general public.² The use of film in medical education was also significant in the 20th century. These technical films helped facilitate the globalization of health and media in the postwar era. Another form of medical visualizations that emerged with the advent of medicine on television. At the intersection of entertainment and education, medical documentary evolved into “health information programming” in the 1980’s which in turn transitioned into the rise of medical reality television.² The history of this diverse and expanding media, she says, proves that the use of visualizations in healthcare and our daily lives has made medicine “a visual science.”

One of the main takeaways from Dr. Ostherr’s historical analysis of medical visualizations was the deep-rooted relationship between visualizations and their role in spreading medical knowledge to the average person. While skeptics may argue against this characterization, “this is a broad social change that is taking place,” Dr. Ostherr said, citing new scientific research emerging on human centered design and the use of visual arts in medical training. “It’s the future of medicine,” she said. There is already evidence that such a change is taking place: the method of recording patient information using health records has begun to change. In recent years there has been a movement to adopt electronic health records due to their potential to save the healthcare industry millions of dollars and improve efficiency.⁴ Yet recent studies show that the current systems in place are not as effective as predicted.⁵ Online patient portals allow patients to keep up with their health information, view test results and even communicate with their health care providers, but while these portals can involve patients as active participants in their care, they can also be quite technical.⁶ As a result, there is a push to develop electronic health records with more readily understandable language.

In order to conduct further research in the field including projects such as the development of better, easier to understand electronic health records, Dr. Ostherr co-founded and is the director of the Medical Futures Lab. The lab draws resources from Baylor College of Medicine, University of Texas Health Science Center, and Rice University and its diverse team ranges from humanist scholars to doctors to computer scientists.⁷ The use of technology in medicine has continued to develop rapidly alongside the increasing demand for personalized, humanizing care. While it seems like there is an inherent conflict between the two, Dr. Ostherr believes medicine needs the “right balance of high tech and high touch” which is what her team at the Medical Futures Lab (MFL) works to find. The MFL team works on projects heavily focused on deconstructing and reconstructing the role of the patient in education and diagnosis.⁷

The increasingly integrated humanistic and scientific approach to medicine is revolutionizing healthcare. As the Medical Futures Lab explores the relationship between personal care and technology, the world of healthcare is undergoing a broad cultural shift. Early on in their medical education, physicians are being taught the value of incorporating the humanities and social sciences into their training, and that science can only teach one so much about the doctor-patient relationship. For Dr. Ostherr, the question moving forward will be “what is it that is uniquely human about healing?” What are the limitations of technology in healing and what about healing process can be done exclusively by the human body? According to Dr. Ostherr, the histories of visualizations in medicine can serve as a roadmap and an inspiration for the evolution and implementation of new media and technology in transforming the medical subject into the patient.

References

1. Baylor University Medical Humanities. http://www.baylor.edu/medical_humanities/ (accessed Nov. 27, 2017).
2. Ostherr, K. Medical visions: producing the patient through film, television, and imaging technologies; Oxford University Press: Oxford, 2013.
3. History of Radiography. https://www.nde-ed.org/EducationResources/CommunityCollege/Radiography/Introduction/history.htm (accessed Jan. 2017).
4. Abelson, R.; Creswell, J. In Second Look, Few Savings From Digital Health Records. New York Times [Online], January 11, 2013. http://www.nytimes.com/2013/01/11/business/electronic-records-systems-have-not-reduced-health-costs-report-says.html (accessed Jan 2017).
5. Abrams, L. The Future of Medical Records. The Atlantic [Online], January 17, 2013 http://www.theatlantic.com/health/archive/2013/01/the-future-of-medical-records/267202/ (accessed Jan. 25, 2017).
6. Rosen, M. D. L. High Tech, High Touch: Why Technology Enhances Patient-Centered Care. Huffington Post [Online], December 13, 2012. http://www.huffingtonpost.com/lawrence-rosen-md/health-care-technology_b_2285712.html (accessed Jan 2017).
7. Medical Futures Lab. http://www.medicalfutureslab.org/ (accessed Dec 2017).

Tactile Literacy: The Lasting Importance of Braille

Catalyst Volume 10

On June 27th, 1880, a baby girl was born. At nineteen months old, the little girl contracted a severe fever, and once the fever dissipated, she woke up to a world of darkness and silence. This little girl was Helen Keller. By the age of two, Helen Keller had completely lost her sense of sight and hearing.

Over a century later, it is estimated that 285 million people are visually impaired worldwide, of which 39 million are blind.¹ Blindness is defined as the complete inability to see with a corrected vision of 20/200 or worse.² For Keller to absorb the information around her, she relied on the sensation of touch. The invention of the braille alphabet by Frenchman Louis Braille in the early 1800s allowed Keller to learn about the world and to communicate with others. Like Keller, the majority of the visually impaired today rely on braille as their main method of reading.

The technological advances of smartphones, artificial intelligence, and synthetic speech dictations have opened a whole new world for blind readers. With the advent of the electronic information age, it’s easy to think that blind people don’t need to rely on braille anymore to access information. In fact, braille literacy rates for school-age blind children have already declined from 50 percent 40 years ago to only 12 percent today.³ While current low literacy rates may be in part due to the inclusion of students with multiple disabilities that inhibit language acquisition, these statistics still reveal a major concern about literacy amongst the visually impaired. To substitute synthetic speech for reading and writing devalues the importance of learning braille.

“There are many misunderstandings and stereotypes of braille readers,” says Dr. Robert Englebretson, Professor of Linguistics at Rice University. “When a person reads, they learn about spelling and punctuation, and it’s the exact same for tactile readers. Humans better process information when they actively process it through reading instead of passively listening.”

Dr. Englebretson is also blind, and one part of his research agenda is a collaborative project with Dr. Simon Fischer-Baum in Psychology and pertains to understanding the cognitive and linguistic importance of braille to braille readers. He explores the questions surrounding the nature of perception and reading and explores the ways the mind groups the input of touch into larger pieces to form words.

In order to understand how written language is processed by tactile readers compared to visual readers, Dr. Englebretson conducted experiments to find out if braille readers exhibit an understanding of sublexical structures, or parts of words, similar to that of visual readers. An understanding of sublexical structures is crucial in recognizing letter groupings and acquiring reading fluency. Visual readers recognize sublexical structures automatically as the eye scans over words, whereas tactile readers rely on serially scanning fingers across a line of text.

To explore whether the blind have an understanding of sublexical structures, Dr. Englebretson studied the reaction time of braille readers in order to judge their understanding of word structures. The subjects were given tasks to determine whether the words were real or pseudowords, and the time taken to determine the real words from the pseudowords were recorded. The first experiment tested the ability for braille readers to identify diagraphs or parts of words, and the second experiment test the ability for braille readers to identify morphemes, or the smallest unit of meaning or grammatical function of a word. For braille readers, Dr. Englebretson and his team developed a foot pedal system that enabled braille readers to indicate their answer without pausing to click a screen as the visual readers did. This enabled the braille readers to continuously use their hands while reading. From the reaction times of the braille readers when presented with a morphologically complex word, the findings show evidence of braille readers processing the meaning of words and recognizing these diagraphs and morphemes.⁴

“What we discovered was that tactile readers do rely on sublexical structures and have similar cognitive processes to print readers,” says Dr. Englebretson. “The belief that braille is old-fashioned and not needed anymore is far from the truth. Tactile reading provides an advantage in learning just as visual reading does.”

Dr. Englebretson also gathered a large sample of braille readers and videotaped them reading using a finger tracking system. Similar to an eye tracking system that follows eye movements, the finger tracking system used LED lights on the backs of fingernails to track the LED movements over time using a camera. The movements of the LED lights on the x-y coordinates are then plotted on a graph. This system can track where each finger is, how fast they are moving, and the movements that are made during regressions, or the right-to-left re-reading movement of the finger.⁵ While this test was independent from the experiment about understanding sublexical structures, the data collected offers a paradigm for researchers about braille reading.

The outcome of these studies has not only scientific and academic implications, but also important social implications. “At the scientific level, we now better understand how perception [of written language] works, how the brain organizes and processes written language, and how reading works for tactile and visual readers,” says Dr. Englebretson. “Through understanding how tactile readers read, we will hopefully be able to implement policy on how teachers of blind and visually impaired students teach, and on how to guide the people who are working on updating and maintaining braille.”

With decreasing literacy rates among braille readers, an evidence-base approach to the teaching of braille is as critical as continuing to implement braille literacy programs. With an understanding of braille, someone who is blind can not only access almost infinite pages of literature, but also make better sense of their language and world.

References

1. World Health Organization. http://www.who.int/mediacentre/factsheets/fs282/en/ (accessed Jan. 9, 2017).
2. National Federation of the Blind. https://nfb.org/blindness-statistics (accessed Jan. 9, 2017).
3. National Braille Press. https://www.nbp.org/ic/nbp/braille/needforbraille.html (accessed Jan. 10, 2017).
4. Fischer-Baum,S.; Englebretson, R. Science Direct. 2016, http://www.sciencedirect.com/science/article/pii/S0010027716300762 (accessed Jan. 10, 2017)
5. Ulusoy, M.; Sipahi, R. PLoS ONE. 2016, 11. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0148356 (accessed Jan. 10, 2017)

The Secret Behind Social Stigma

Catalyst Volume 10

How do you accurately quantify something as subjective and controversial as discrimination? What about stigma - a superficial mark imposed upon a prototypical group of individuals? How do you attempt to validate what is seemingly invisible? Dr. Michelle “Mikki” Hebl and her team in the Industrial/Organizational (I/O) department of social psychology at Rice University attempt to answer these questions.

In the world of social psychology, where human interactions are often unpredictable, researchers must get creative to control variables as much as possible while simultaneously mimicking real-life situations. Dr. Hebl integrates both laboratory procedures and field studies that involve standardized materials. “My research is fairly novel,” she notes. Unlike the majority of existing stigma and discrimination research, which depends on self-reported assessments, her studies examine real, non-simulated social interactions. Although her approach seeks to provide more realistic and unbiased settings, “it’s messier,” she adds, laughing about the many trials discarded due to uncontrollable circumstances. That attitude— optimistic, determined, and creative—is held proudly by Dr. Hebl. It is clear that her lab’s overall mission—to reduce discrimination and increase equity—is worth undertaking.

Dr. Hebl and her team focus on a form of behavior they call “interpersonal discrimination,” a type of discrimination that occurs implicitly while still shaping the impressions we form and the decisions we make.¹ This kind of bias, rooted in stereotypes and negative social stigma, is far more subtle than some of the more well-known, explicit forms of discrimination. For example, in a field study evaluating bias against homosexual applicants in Texas, Dr. Hebl found that the members of both the experimental and control group, who were wearing hats that said “Gay and Proud” and “Texan and Proud” respectively, did not experience formal bias when entering stores to seek employment. For example, none of the subjects were denied job applications. What she did find, however, was a pattern of interpersonal reactions against the experimental group. Discrete recording devices worn by the subjects revealed a pattern of decreased word count per sentence and shorter interactions for the stigmatized group. Their self-reports further indicated on average a higher perceived negativity and lower perceived employer interest.1 In another study evaluating obesity-related stigma, results showed that obese individuals - in this case subjects wearing obese prosthetic suits - experience similarly negative interactions.²

While many of her studies evaluated biases in seeking employment, Dr. Hebl also explored the presence of interpersonal discrimination against lesser-known groups that experience bias. One surprising finding indicated negative stigmatization against cancer survivors.³ In other studies, the team found patterns relating to stereotypicality; this relatively new phenomena explores the lessened interpersonal discrimination against those who deviate from the stereotypical prototype of their minority group, i.e. a more light-skinned Hispanic male.⁴ A holistic review of her research reveals a pattern of discrimination against stigmatized groups on an implicit level. Once researchers like Dr. Hebl find these patterns, they can investigate them in the lab by further isolating variables to develop a more refined and widely-applicable conclusion.

What can make more subtle forms of bias so detrimental is the ambiguity surrounding them. When someone discriminates against another in a clear and explicit form, one can easily attribute the behavior to the person’s biases. On the other hand, when this bias is perceived in the form of qualitative behavior, such as shortened conversations and body language, it raises questions regarding the person’s intentions. In these cases, the victim often internalizes the negative treatment, questioning the effect of traits that they cannot control—be it race, sexual orientation, or physical appearance. This degree of uncertainty raises conflict and tension between differing groups, thus potentially hindering progress in today’s increasingly diverse workplaces, schools, and universities.⁵

Dr. Hebl knew that exploring the presence of this tension between individuals was only the first step. “One of the most exciting aspects of social psychology is that just learning about these things makes you inoculated against them,” she said. Thus emerges the search for practical solutions involving education and reformation of conventional practices in the workplace. Her current work looks at three primary methods: The first is acknowledging biases on an individual level. This strategy involves individuation, or the recognition of one’s own stigma and subsequent compensation for it.⁶ The second involves implementing organizational methods in the workplace, such as providing support for stigmatized groups and awareness training.⁷ The third, which has the most transformative potential, is the use of research to support reformation of policies that could protect these individuals.

“I won't rest…until we have equity,” she affirmed when asked about the future of her work. For Dr. Hebl, the ultimate goal is education and change. Human interactions are incredibly complex, unpredictable, and difficult to quantify. But they influence our daily decisions and actions, ultimately impacting how we view ourselves and others. Social psychology research suggests that biases, whether we realize it or not, are involved in the choices we make every day: from whom we decide to speak to whom we decide to work with. Dr. Hebl saw this and decided to do something about it. Her work brings us to the complex source of these disparities and suggests that understanding their foundations can lead to a real, desirable change.

References

1. Hebl, M. R.; Foster, J. B.; Mannix, L. M.; Dovidio, J. F. Pers. Soc. Psychol. B. 2002, 28 (6), 815–825.
2. Hebl, M. R.; Mannix, L. M. Pers. Soc. Psychol. B. 2003, 29 (1), 28–38.
3. Martinez, L. R.; White, C. D.; Shapiro, J. R.; Hebl, M. R. J. Appl. Psychol. 2016, 101 (1), 122–128.
4. Hebl, M. R.; Williams, M. J.; Sundermann, J. M.; Kell, H. J.; Davies, P. G. J. Exp. Soc. Psychol. 2012, 48 (6), 1329–1335.
5. Szymanski, D. M.; Gupta, A. J. Couns. Psychol. 2009, 56 (2), 300–300.
6. Singletary, S. L.; Hebl, M. R. J. Appl. Psychol. 2009, 94 (3), 797–805.
7. Martinez, L. R.; Ruggs, E. N.; Sabat, I. E.; Hebl, M. R.; Binggeli, S. J. Bus. Psychol. 2013, 28 (4), 455–466.