Predictors and Mediators of Long-term Functional Limitations in the Older Adult Population

With nearly 40 million Americans being treated for nonfatal injuries in emergency departments annually, the burden of nonfatal injury in the United States is extensive. The longterm functional consequences of these injuries can be enduring and far-reaching, especially for older adults. Although studies have reported that persistent functional deficits exist after injury, less information is known about long-term recovery patterns and the factors that influence functional outcomes. The primary aims of this study are to (1) classify differences in long-term, longitudinal changes in functional limitations within the injured population, (2) identify individual characteristics that predict recovery after injury and (3) assess whether medical care use mediates the relationship between long-term changes in functional limitations and significant predictors of outcomes after injury, specifically insurance status. Longitudinal survey data from the Health and Retirement Study (HRS) was analyzed using group-based trajectory modeling and mediation analysis. The trajectory analysis identified five distinct functional trajectories with the following characteristics: Trajectory 1- consistently low functional limitations scores (18.9%), Trajectory 2- increase in functional limitations after injury followed by a gradual, but not complete recovery (46.3%), Trajectory 3- increase in functional limitations followed by further decline in functioning over time (10.5%), Trajectory 4- increase in functional limitations after injury followed by a gradual, complete recovery (13.4%), and Trajectory 5- consistently high functional limitations scores (10.8%). Regression analyses showed that women, individuals with multiple health conditions, and individuals with no insurance and public insurance were more likely to belong to trajectories with poorer functional outcomes. The mediation analysis found that public insurance was associated with increased functional limitations relative to private insurance. The total effect of public insurance on functional limitations was partially mediated by medical care use. Doctor visits was the only significant medical care use mediator for individuals with public insurance. The relative total and direct effects of being uninsured on functional limitations were not significant. However, the indirect effect of being uninsured on functional limitations was significant, indicating that medical care use may suppress the effect of being uninsured on functional outcomes. Prescription drug use was the only significant mediator of the effect of not having insurance on functional status. These results illustrate that distinct courses of recovery after injury in the older adult population exist. Furthermore, personal characteristics of individuals can be used to predict functional trajectories. This study also demonstrated that insurance status is a significant predictor of both functional outcomes and medical care use after injury. Insurance status was found to exert its effect on health outcomes both directly and indirectly through medical care. Ultimately, the findings from this study can be used to improve the understanding of how individuals\u27 functional outcomes differ after injury and the causal processes that determine these outcomes. This knowledge may lead to tailored policies and treatments that improve quality of life after injury

Understanding adolescent girls’ vulnerability to the impact of the mass media on body image and restrained eating behaviour: the role of media type, body perfect internalisation and materialism

There is a strong body of psychological research implicating the mass media in the aetiology of adolescent girls’ negative body image and eating behaviours. The present thesis aims to extend this research by examining potential factors – namely, media type, body perfect internalisation and materialism – that make girls more vulnerable to the negative impact of the mass media. An initial meta-analysis (Chapter 3) collated the findings of existing research examining the impact of ‘body perfect’ media on adolescents’ body image; examining gender, age and media type as moderators of this effect. Chapter 4 examined the relative roles of both media type and media model identification (a key dimension of body perfect internalisation), within the mass media and body image relationship. Using both survey and experimental methods (N = 199), it was found that adolescent girls’ habitual tendency to identify with media models, was a more potent vulnerability factor within the mass media and body image relationship, than media type. Due to the limitations associated with existing measures of body perfect internalisation, a new measure of body perfect internalisation was developed in Chapter 5 (N =373), which was subsequently utilised in the final experiments of the thesis. Chapter 6 demonstrated that acute music video exposure had a more potent negative impact on girls’ body image than still media images (N = 142); an effect that was fully mediated by wishful character identification and also moderated by body perfect internalisation. Chapter 7 consists of two studies that demonstrate the important role which materialism plays within the mass media, body image and eating behaviour relationship. In Study 1, structural equation modelling identified a direct pathway between materialism and restrained eating that was independent of body image (N = 199). This finding was further replicated in an exposure experiment, which demonstrated that brief exposure to materialistic media causes acute diet-like behaviours in adolescent girls (N = 180)

“Tea and Hot Water Provided”: Conviviality, Commensality, and Hospitality in the Rambling Notes of W.E. Hopkin 1930-1940

The relationship between rambling and food in Britain in the 1930s is explored through the weekly newspaper column Rambling Notes by W. E. Hopkin, head of a ramblers group based around Ripley, Nottinghamshire. Hopkin describes the previous Sunday’s day-hike, and the shared meals with 15-25 other ramblers. British ramblers carried minimal food in their knapsacks, preferring to eat in pubs, and tearooms with signs that read: “Tea and Hot Water Provided.” ‘Tea’ refers both to the meal – sandwiches and cakes – and also the drink. The huge influx of ramblers into the countryside in the 1930s triggered a growth in tearooms, often improvised in farmhouses and private homes. Hopkin’s descriptions of communal meals locate tearooms as sites for creating and maintaining social relations and identities. The symbolic role of food in rambling is examined through the notions of conviviality, commensality, and hospitality. The tea experience was central to the conviviality of the ramble, creating social bonds between diverse rambling group members, reinforced by the commensality of eating and talking together, and the imagined traditional values of the English countryside embodied in the tearoom hostess, welcoming travelers back to an idealized rural past of abundant authentic food and farmhouse comforts

An Assessment of the Academic Impact of Shock Society Members

Professional society membership enhances career development and productivity by offering opportunities for networking and learning about recent advances in the field. The quality and contribution of such societies can be measured in part through the academic productivity, career status, and funding success rates of their members. Here, using Scopus, NIH RePORTER, and departmental websites, we compare characteristics of the Shock Society membership to those of the top 55 NIH-funded American university and hospital-based departments of surgery. Shock Society members' mean number of publications, citations and H-indices were all significantly higher than those of non-members in surgery departments (P < 0.001). A higher percentage of members also have received funding from the NIH (42.5% vs. 18.5%, P < 0.001). Regression analysis indicated that members were more likely to have NIH funding compared with non-members (OR 1.46, 95% CI 1.12-1.916). Trauma surgeons belonging to the Shock Society had a higher number of publications and greater NIH funding than those who did not (130.4 vs. 42.7, P < 0.001; 40.4% vs. 8.5%, P < 0.001). Aggregate academic metrics from the Shock Society were superior to those of the Association for Academic Surgery and generally for the Society of University Surgeons as well. These data indicate that the Shock Society represents a highly academic and productive group of investigators. For surgery faculty, membership is associated with greater academic productivity and career advancement. While it is difficult to ascribe causation, certainly the Shock Society might positively influence careers for its members

Trajectory subtypes after injury and patient-centered outcomes

BACKGROUND: The recent focus on patient-centered outcomes highlights the need to better describe recovery trajectories after injury. The purpose of this study was to characterize recovery trajectory subtypes that exist after non-neurologic injury. MATERIALS AND METHODS: A prospective, observational cohort of 500 adults with an Injury Severity Score > 10 but without traumatic brain or spinal cord injury from 2009 to 2011 was formed. The Short Form-36 was administered at admission and repeated at 1, 2, 4, and 12 mo after injury. Group-based trajectory modeling was used to determine the number and shape of physical composite score (PCS) and mental composite score (MCS) trajectories. RESULTS: Three PCS trajectories and five MCS trajectories were identified. For PCS, trajectory 1 (10.4%) has low baseline scores, followed by no improvement over time. Trajectory 2 (65.6%) declines 1 mo after injury then improves over time. Trajectory 3 (24.1%) has a sharp decline followed by rapid recovery. For MCS, trajectory 1 (9.4%) is low at baseline and remains low. Trajectory 2 (14.4%) has a large decrease after injury and does not recover over the next 12 mo. Trajectory 3 (22.7%) has an initial decrease in MCS early, followed by continuous recovery. Trajectory 4 (19.1%) has a steady decline over the study period. Trajectory 5 (34.3%) stays consistently high at all time points. CONCLUSIONS: Recovery after injury is complex and results in multiple recovery trajectories. This has implications for patient-centered clinical trial design and in development of patient-specific interventions to improve outcomes

Turning Contention into Collaboration: Engaging Power, Trust, and Learning in Collaborative Networks

Given the complexity and multiplicity of goals in natural resource governance, it is not surprising that policy debates are often characterized by contention and competition. Yet at times adversaries join together to collaborate to find creative solutions not easily achieved in polarizing forums. We employed qualitative interviews and a quantitative network analysis to investigate a collaborative network that formed to develop a resolution to a challenging natural resource management problem, the conservation of vernal pools. We found that power had become distributed among members, trust had formed across core interests, and social learning had resulted in shared understanding and joint solutions. Furthermore, institutions such as who and when new members joined, norms of inclusion and openness, and the use of small working groups helped create the observed patterns of power, trust, and learning

Factors affecting the Affordable Care Act Marketplace stand-alone pediatric dental plan premiums

BACKGROUND: Children from lower income families have inadequate dental insurance coverage and poorer dental health in the United States. The Affordable Care Act (ACA) created Health Insurance Exchange Marketplaces to increase competition among health insurers and to provide low-income families with less costly health plans. The study examined Marketplace pediatric stand-alone dental plans (SADPs) and factors that affect their premiums. METHODS: The data used were 2016 Federal-Facilitated and State-Partnership Marketplace pediatric SADP data. Ordinary least squares regressions were applied to estimate contributing factors' effects on SADP premiums. RESULTS: Great premium variation was found among low and high coverage level SADPs, respectively. Premiums of Health Maintenance Organization (HMO) SADPs were significantly less expensive than Preferred Provider Organization (PPO) SADPs. SADPs charged significantly higher premiums for more types of services covered. SADPs also charged higher premiums in states where there are larger proportions of low-income people who report poor dental health, more dentists per capita, or higher dentists' wages. The number of insurance companies offering pediatric SADPs in a Marketplace was negatively associated with premiums. CONCLUSION: The current Marketplace pediatric SADPs may have limited effects on increasing economically disadvantaged children's access to quality dental care. Marketplaces can promote competition among its pediatric dental insurers on providing lower-cost pediatric SADPs

Shock volume: Patient-specific cumulative hypoperfusion predicts organ dysfunction in a prospective cohort of multiply injured patients

BACKGROUND: Multiply injured patients are at risk of developing hemorrhagic shock and organ dysfunction. We determined how cumulative hypoperfusion predicted organ dysfunction by integrating serial Shock Index measurements. METHODS: In this study, we calculated shock volume (SHVL) which is a patient-specific index that quantifies cumulative hypoperfusion by integrating abnormally elevated Shock Index (heart rate/systolic blood pressure ≥ 0.9) values acutely after injury. Shock volume was calculated at three hours (3 hr), six hours (6 hr), and twenty-four hours (24 hr) after injury. Organ dysfunction was quantified using Marshall Organ Dysfunction Scores averaged from days 2 through 5 after injury (aMODSD2–D5). Logistic regression was used to determine correspondence of 3hrSHVL, 6hrSHVL, and 24hrSHVL to organ dysfunction. We compared correspondence of SHVL to organ dysfunction with traditional indices of shock including the initial base deficit (BD) and the lowest pH measurement made in the first 24 hr after injury (minimum pH). RESULTS: SHVL at all three time intervals demonstrated higher correspondence to organ dysfunction (R2 = 0.48 to 0.52) compared to initial BD (R2 = 0.32) and minimum pH (R2 = 0.32). Additionally, we compared predictive capabilities of SHVL, initial BD and minimum pH to identify patients at risk of developing high-magnitude organ dysfunction by constructing receiver operator characteristic curves. SHVL at six hours and 24 hours had higher area under the curve compared to initial BD and minimum pH. CONCLUSION: SHVL is a non-invasive metric that can predict anticipated organ dysfunction and identify patients at risk for high-magnitude organ dysfunction after injury. LEVEL OF EVIDENCE: Prognostic study, level III