Lower extremity amputation in people with diabetes: Trends and determinants

Introduction: The prevalence of diabetes is rising rapidly. Assessing quality of diabetes care is difficult. Lower Extremity Amputation (LEA) is recognised as a marker of the quality of diabetes care. The focus of this thesis was first to describe the trends in LEA rates in people with and without diabetes in the Republic of Ireland (RoI) in recent years and then, to explore the determinants of LEA in people with diabetes. While clinical and socio-demographic determinants have been well-established, the role of service-related factors has been less well-explored. Methods: Using hospital discharge data, trends in LEA rates in people with and without diabetes were described and compared to other countries. Background work included concordance studies exploring the reliability of hospital discharge data for recording LEA and diabetes and estimation of diabetes prevalence rates in the RoI from a nationally representative study (SLAN 2007). To explore determinants, a systematic review and meta-analysis assessed the effect of contact with a podiatrist on the outcome of LEA in people with diabetes. Finally, a case-control study using hospital discharge data explored determinants of LEA in people with diabetes with a particular focus on the timing of access to secondary healthcare services as a risk factor. Results: There are high levels of agreement between hospital discharge data and medical records for LEA and diabetes. Thus, hospital discharge data was deemed sufficiently reliable for use in this PhD thesis. A decrease in major diabetes-related LEA rates in people with diabetes was observed in the RoI from 2005-2012. In 2012, the relative risk of a person with diabetes undergoing a major LEA was 6.2 times (95% CI 4.8-8.1) that of a person without diabetes. Based on the systematic review and meta-analysis, contact with a podiatrist did not significantly affect the relative risk (RR) of LEA in people with diabetes. Results from the case-control study identified being single, documented CKD and documented hypertension as significant risk factors for LEA in people with diabetes whilst documented retinopathy was protective. Within the seven year time window included in the study, no association was detected between LEA in patients with diabetes and timing of patient access to secondary healthcare for diabetes management. Discussion: Many countries have reported reduced major LEA rates in people with diabetes coinciding with improved organisation of healthcare systems. Reassuringly, these first national estimates in people with diabetes in the RoI from 2005 to 2012 demonstrated reducing trends in major LEA rates. This may be attributable to changes in diabetes care and also, secular trends in smoking, dyslipidaemia and hypertension. Consistent with international practice, LEA trends data in Ireland can be used to monitor quality of care. Quantifying this improvement precisely, though, is problematic without robust denominator data on the prevalence of diabetes. However, a reduction in major diabetes-related LEA rates suggests improved quality of diabetes care. Much controversy exists around the reliability of hospital discharge data in the RoI. This thesis includes the first multi-site study to explore this issue and found hospital discharge data reliable for the reporting of the procedure of LEA and diagnosis of diabetes. This project did not detect protective effects of access to services including podiatry and secondary healthcare for LEA in people with diabetes. A major limitation of the systematic review and meta-analysis was the design and quality of the included studies. The data available in the area of effect of contact with a podiatrist on LEA risk are too sparse to say anything definitive about the efficacy of podiatry on LEA. Limitations of the case-control study include lack of a diabetes register in Ireland, restricted information from secondary healthcare and lack of data available from primary healthcare. Due to these issues, duration of disease could not be accounted for in the study which limits the conclusions that can be drawn from the results. The model of diabetes care in the RoI is currently undergoing a re-configuration with plans to introduce integrated care. In the future, trends in LEA rates should be continuously monitored to evaluate the effectiveness of changes to the healthcare system. Efforts are already underway to improve the availability of routine data from primary healthcare with the recent development of the iPCRN (Irish Primary Care Research Network). Linkage of primary and secondary healthcare records with a unique patient identifier should be the goal for the future.

Between respectability and disgrace: schismogenesis and the regeneration of inequality, stigma and social exclusion in Limerick

The thesis examines cultural processes underpinning the emergence, institutionalisation and reproduction of class boundaries in Limerick city. The research aims to bring a new understanding to the contemporary context of the city’s urban regeneration programme. Acknowledging and recognising other contemporary studies of division and exclusion, the thesis creates a distinctive approach which focuses on uncovering the cultural roots of inequality, educational disadvantage, stigma and social exclusion and the dynamics of their social reproduction. Using Bateson’s concept of schismogenesis (1953), the thesis looks to the persistent, but fragmented culture of community and develops a heuristic ‘symbolic order of the city’. This is defined as “…a cultural structure, the meaning making aspect of hierarchy, the categorical structures of world understanding, the way Limerick people understand themselves, their local and larger world” (p. 37). This provides a very different departure point for exploring the basis for urban regeneration in Limerick (and everywhere). The central argument is that if we want to understand the present (multiple) crises in Limerick we need to understand the historical, anthropological and recursive processes underpinning ‘generalised patterns of rivalry and conflict’. In addition to exploring the historical roots of status and stigma in Limerick, the thesis explores the mythopoesis of persistent, recurrent narratives and labels that mark the boundaries of the city’s identities. The thesis examines the cultural and social function of ‘slagging’ as a vernacular and highly particularised form of ironic, ritualised and, often, ‘cruel’ medium of communication (often exclusion). This is combined with an etymology of the vocabulary of Limerick slang and its mythological base. By tracing the origins of many normalised patterns of Limerick speech ‘sayings’, which have long since forgotten their roots, the thesis demonstrates how they perform a significant contemporary function in maintaining and reinforcing symbolic mechanisms of inclusion/exclusion. The thesis combines historical and archival data with biographical interviews, ethnographic data married to a deep historical hermeneutic analysis of this political community.

Development and psychometric evaluation of the spirituality instrument (SpI-27) in a sample of people with chronic illness

Background: Spirituality is fundamental to all human beings, existing within a person, and developing until death. This research sought to operationalise spirituality in a sample of individuals with chronic illness. A review of the conceptual literature identified three dimensions of spirituality: connectedness, transcendence, and meaning in life. A review of the empirical literature identified one instrument that measures the three dimensions together. Yet, recent appraisals of this instrument highlighted issues with item formulation and limited evidence of reliability and validity. Aim: The aim of this research was to develop a theoretically-grounded instrument to measure spirituality – the Spirituality Instrument-27 (SpI-27). A secondary aim was to psychometrically evaluate this instrument in a sample of individuals with chronic illness (n=249). Methods: A two-phase design was adopted. Phase one consisted of the development of the SpI-27 based on item generation from a concept analysis, a literature review, and an instrument appraisal. The second phase established the psychometric properties of the instrument and included: a qualitative descriptive design to establish content validity; a pilot study to evaluate the mode of administration; and a descriptive correlational design to assess the instrument’s reliability and validity. Data were analysed using SPSS (Version 18). Results: Results of exploratory factor analysis concluded a final five-factor solution with 27 items. These five factors were labelled: Connectedness with Others, Self-Transcendence, Self-Cognisance, Conservationism, and Connectedness with a Higher Power. Cronbach’s alpha coefficients ranged from 0.823 to 0.911 for the five factors, and 0.904 for the overall scale, indicating high internal consistency. Paired-sample t-tests, intra-class correlations, and weighted kappa values supported the temporal stability of the instrument over 2 weeks. A significant positive correlation was found between the SpI-27 and the Spirituality Index of Well-Being, providing evidence for convergent validity. Conclusion: This research addresses a call for a theoretically-grounded instrument to measure spirituality.

Exploring the relationship between social network sites and the consumption of cultural goods through the lens of affordances

This thesis presents research theorising the use of social network sites (SNS) for the consumption of cultural goods. SNS are Internet-based applications that enable people to connect, interact, discover, and share user-generated content. They have transformed communication practices and are facilitating users to present their identity online through the disclosure of information on a profile. SNS are especially effective for propagating content far and wide within a network of connections. Cultural goods constitute hedonic experiential goods with cultural, artistic, and entertainment value, such as music, books, films, and fashion. Their consumption is culturally dependant and they have unique characteristics that distinguish them from utilitarian products. The way in which users express their identity on SNS is through the sharing of cultural interests and tastes. This makes cultural good consumption vulnerable to the exchange of content and ideas that occurs across an expansive network of connections within these social systems. This study proposes the lens of affordances to theorise the use of social network sites for the consumption of cultural goods. Qualitative case study research using two phases of data collection is proposed in the application of affordances to the research topic. The interaction between task, technology, and user characteristics is investigated by examining each characteristic in detail, before investigating the actual interaction between the user and the artifact for a particular purpose. The study contributes to knowledge by (i) improving our understanding of the affordances of social network sites for the consumption of cultural goods, (ii) demonstrating the role of task, technology and user characteristics in mediating user behaviour for user-artifact interactions, (iii) explaining the technical features and user activities important to the process of consuming cultural goods using social network sites, and (iv) theorising the consumption of cultural goods using SNS by presenting a theoretical research model which identifies empirical indicators of model constructs and maps out affordance dependencies and hierarchies. The study also provides a systematic research process for applying the concept of affordances to the study of system use.

Anti-cholinergic load, health care utilization, and survival in people with advanced cancer: a pilot study.

INTRODUCTION: Anti-cholinergic medications have been associated with increased risks of cognitive impairment, premature mortality and increased risk of hospitalisation. Anti-cholinergic load associated with medication increases as death approaches in those with advanced cancer, yet little is known about associated adverse outcomes in this setting. METHODS: A substudy of 112 participants in a randomised control trial who had cancer and an Australia modified Karnofsky Performance Scale (AKPS) score (AKPS) of 60 or above, explored survival and health service utilisation; with anti-cholinergic load calculated using the Clinician Rated Anti-cholinergic Scale (modified version) longitudinally to death. A standardised starting point for prospectively calculating survival was an AKPS of 60 or above. RESULTS: Baseline entry to the sub-study was a mean 62 +/- 81 days (median 37, range 1-588) days before death (survival), with mean of 4.8 (median 3, SD 4.18, range 1 - 24) study assessments in this time period. Participants spent 22% of time as an inpatient. There was no significant association between anti-cholinergic score and time spent as an inpatient (adjusted for survival time) (p = 0.94); or survival time. DISCUSSION: No association between anti-cholinergic load and survival or time spent as an inpatient was seen. Future studies need to include cognitively impaired populations where the risks of symptomatic deterioration may be more substantial.

Moral masochism: on the connection between guilt and self-punishment.

Do people sometimes seek to atone for their transgressions by harming themselves physically? The current results suggest that they do. People who wrote about a past guilt-inducing event inflicted more intense electric shocks on themselves than did those who wrote about feeling sad or about a neutral event. Moreover, the stronger the shocks that guilty participants administered to themselves, the more their feelings of guilt were alleviated. We discuss how this method of atonement relates to other methods examined in previous research.

One sound or two? Object-related negativity indexes echo perception.

The ability to isolate a single sound source among concurrent sources and reverberant energy is necessary for understanding the auditory world. The precedence effect describes a related experimental finding, that when presented with identical sounds from two locations with a short onset asynchrony (on the order of milliseconds), listeners report a single source with a location dominated by the lead sound. Single-cell recordings in multiple animal models have indicated that there are low-level mechanisms that may contribute to the precedence effect, yet psychophysical studies in humans have provided evidence that top-down cognitive processes have a great deal of influence on the perception of simulated echoes. In the present study, event-related potentials evoked by click pairs at and around listeners' echo thresholds indicate that perception of the lead and lag sound as individual sources elicits a negativity between 100 and 250 msec, previously termed the object-related negativity (ORN). Even for physically identical stimuli, the ORN is evident when listeners report hearing, as compared with not hearing, a second sound source. These results define a neural mechanism related to the conscious perception of multiple auditory objects.

Chimpanzees and bonobos distinguish between risk and ambiguity.

Although recent research has investigated animal decision-making under risk, little is known about how animals choose under conditions of ambiguity when they lack information about the available alternatives. Many models of choice behaviour assume that ambiguity does not impact decision-makers, but studies of humans suggest that people tend to be more averse to choosing ambiguous options than risky options with known probabilities. To illuminate the evolutionary roots of human economic behaviour, we examined whether our closest living relatives, chimpanzees (Pan troglodytes) and bonobos (Pan paniscus), share this bias against ambiguity. Apes chose between a certain option that reliably provided an intermediately preferred food type, and a variable option that could vary in the probability that it provided a highly preferred food type. To examine the impact of ambiguity on ape decision-making, we interspersed trials in which chimpanzees and bonobos had no knowledge about the probabilities. Both species avoided the ambiguous option compared with their choices for a risky option, indicating that ambiguity aversion is shared by humans, bonobos and chimpanzees.

People who expect to enter psychotherapy are prone to believing that they have forgotten memories of childhood trauma and abuse.

We asked 1004 undergraduates to estimate both the probability that they would enter therapy and the probability that they experienced but could not remember incidents of potentially life-threatening childhood traumas or physical and sexual abuse. We found a linear relation between the expectation of entering therapy and the belief that one had, but cannot now remember, childhood trauma and abuse. Thus individuals who are prone to seek psychotherapy are also prone to accept a suggested memory of childhood trauma or abuse as fitting their expectations. In multiple regressions predicting the probability of forgotten memories of childhood traumas and abuse, the expectation of entering therapy remained as a substantial predictor when self-report measures of mood, anxiety, post-traumatic stress disorder symptom severity, and trauma exposure were included.

People over forty feel 20% younger than their age: subjective age across the lifespan.

Subjective age--the age people think of themselves asbeing--is measured in a representative Danish sample of 1,470 adults between 20 and 97 years of age through personal, in-home interviews. On the average, adults younger than 25 have older subjective ages, and those older than 25 have younger subjective ages, favoring a lifespan-developmental view over an age-denial view of subjective age. When the discrepancy between subjective and chronological age is calculated as a proportion of chronological age, no increase is seen after age 40; older respondents feel 20% younger than their actual age. Demographic variables (gender, income, and education) account for very little variance in subjective age.

OPERA IN AMERICA: MUSIC OF, BY, AND FOR THE PEOPLE­: A PERFORMANCE DISSERTATION

Opera in America: Music of, by, and for the people is a study of the relationship between American popular culture and opera in the United States. Four performance projects demonstrate the on-going exchange between the operatic community-including its composer, singers, and patrons-and the country's popular entertainment industry with its broad audience base. Numerous examples of artistic cross pollination between lowbrow and highbrow music will illustrate the artistic and social consequences created by this artistic amalgamation. Program #1, By George! By Ira! By Gershwin!, is a retrospective of Gershwin's vocal music representing a blending of popular and serious music in both style and form. The concert includes selections from Porgy and Bess, a work considered by many musicologists as the first American opera. Program #2, Shadowboxer, is a premiere performance of an opera by Frank Proto and John Chenault. For this newly commissioned work, I serve as Assistant Director to Leon Major. Shadowboxer provides a clear example of opera utilizing popular culture both musically and dramatically to tell the true story of American hero and legendary boxer, Joe Louis. Program #3, Just a Song at Twilight, is an original theatrical music piece featuring music, letters, diaries, and journals of the Gilded Age, an era when opera was synonymous with popular entertainment. Special attention is focused on tum-of­ the-century singers who performed in both opera and vaudeville. Program #4 is a presentation of Dominick Argento's Miss Manners on Music and illustrates the strong relationship that can exist between opera and American popular entertainment. Originally conceived as a song cycle, I have staged the work as a one-act opera sung and acted by soprano Carmen Balthrop. This piece is based on the writings of pop icon and newspaper columnist Judith Martin, otherwise known as Miss Manners. All four performances are recorded in audio and video formats.

Improving mental health among people living with HIV: a review of intervention trials in low- and middle-income countries.

People living with HIV (PLWH) experience greater psychological distress than the general population. Evidence from high-incomes countries suggests that psychological interventions for PLWH can improve mental health symptoms, quality of life, and HIV care engagement. However, little is known about the effectiveness of mental health interventions for PLWH in low and middle-income countries (LMICs), where the large majority of PLWH reside. This systematized review aims to synthesize findings from mental health intervention trials with PLWH in LMICs to inform the delivery of mental health services in these settings. A systematic search strategy was undertaken to identify peer-reviewed published papers of intervention trials addressing negative psychological states or disorders (e.g., depression, anxiety) among PLWH in LMIC settings. Search results were assessed against pre-established inclusion and exclusion criteria. Data from papers meeting criteria were extracted for synthesis. Twenty-six papers, published between 2000 and 2014, describing 22 unique interventions were identified. Trials were implemented in sub-Saharan Africa (n=13), Asia (n=7), and the Middle East (n=2), and addressed mental health using a variety of approaches, including cognitive-behavioral (n=18), family-level (n=2), and pharmacological (n=2) treatments. Four randomized controlled trials reported significant intervention effects in mental health outcomes, and eleven preliminary studies demonstrated promising findings. Among the limited mental health intervention trials with PLWH in LMICs, few demonstrated efficacy. Mental health interventions for PLWH in LMICs must be further developed and adapted for resource-limited settings to improve effectiveness.

Employment discrimination against transgender people and self-esteem.

The evocation of gender identity in company anti-discrimination policies is still very rare. This observation is also true forscientific studies. Very few researches have focused exclusively on transgender employees. Transgender are neither sick nor lesscompetent, and yet, the feeling of being strongly discriminated is shared by many transgender people. Such discrimination and thetype of causal attribution do not remain without any effect on the well-being of the concerned individuals. According to Crocker &Quinn (1998), the attribution of the discrimination to the existing prejudices may be a way to protect one-self from the negativeimpact on self-esteem. In this theoretical scope, the "rejection-identification" model (Branscombe, Schmitt & Harvey, 1999) has beenhighly mobilized. It emphasizes the importance of ingroup identification in the causal relationship between perceived discriminationsituation and well-being. Previous studies which did test this model show that the identification to a certain group can counteract thenegative effects on well-being. Following this theoretical frame, the presented study examines the impact of different types of causalattributions on self-esteem: internal causes (e.g. lack of skills), external causes (e.g. economic crisis), and gender identity relatedissues. For that purpose, an online survey has been created and fulfilled by 110 transgender people. Different scales were used to testthe model: the Rosenberg self-esteem scale, a causal attribution scale, the perceived discrimination of the transgender population inthe workplace scale and a group identification scale. The results show that transgender people feel still highly stigmatized today andattribute, significantly, the causes of their situation to the prejudices they are victim of. Also, in accordance with the “rejectionidentification”model, three links are observed: (1) a negative link between perceived discrimination and self-esteem; (2) a positivelink between perceived discrimination and ingroup identification; and (3) a positive link between ingroup identification and selfesteem.This situation reflects a lack in diversity considerations. Nevertheless, the attribution made to group stigmatization seems toplay a protective role towards transgender people self-esteem.

Risikowahrnehmung und psychologische Reaktionen in öffentlichen Krisensituationen am Beispiel von Terrorattentaten / Risk perception and psychological reactions in public crisis situations using the example of terror attacks

The reactions to the 9/11 terror attacks were immense in the western population. In the current review, the impact of terror attacks is presented with surveys, clinical interviews, and scientific polls, which were identified in a comprehensive literature search. Results show that the fear of further terror attacks is comparatively overestimated in the population and is associated with numerous psychological consequences and reactions. The overestimation of the probability of further terror attacks is related among other reasons to its unique features and its strong representation in the media. Several independent studies proved that the number of stress symptoms and psychiatric diagnoses is associated with a high risk perception in relation to terror attacks. This was not only the case for victims of terror attacks, but also for people indirectly exposed to the terror attacks. In addition, there is evidence that the number of the stress symptoms correlate with the duration of TV consumption of new findings about terror attempts. Methodologically, there is a critical lack of more in-depth analyses to explain the development of risk perceptions and its influence on mental and physical health. Because of the international importance and cross-cultural differences, an international standardization of research is desirable. [In German] Die Reaktionen auf die Terrorattentate vom 9. September 2001 in New York waren in der westlichen Bevölkerung immens. In der vorliegenden Übersichtsarbeit werden die Auswirkungen von Terrorattentaten durch Einbeziehung bevölkerungsrepräsentativer Untersuchungen, Surveys, klinischer Interviews und Einstellungsbefragungen dargestellt, die über eine deskriptive Literaturrecherche ermittelt wurden. Als Ergebnis des Reviews zeigt sich, dass die Angst vor weiteren Terrorattentaten in der Bevölkerung vergleichsweise hoch und mit zahlreichen psychologischen Folgen und Reaktionen assoziiert ist. Die Einschätzung der Auftretenswahrscheinlichkeit eines Terrorattentats hängt unter anderem mit den besonderen Charakteristika und der hohen medialen Präsenz des Themas zusammen. Die Anzahl der Stresssymptome bis hin zu psychiatrischen Diagnosen erwies sich in mehreren unabhängigen Untersuchungen mit einer hohen Risikowahrnehmung assoziiert. Dies ließ sich nicht nur bei den Opfern von Terrorattentaten, sondern auch bei indirekt Betroffenen zeigen. Darüber hinaus gibt es mehrfache Belege dafür, dass die Anzahl der Stresssymptome mit der Dauer des TV-Konsums über Neuigkeiten zu Terrorattentaten zusammenhing. Als methodische Kritik ist an den gegenwärtigen Untersuchungsszenarien einzuwenden, dass es derzeit keine tiefer gehenden Analysen zur Entwicklung der Risikowahrnehmung und zu ihrem Einfluss auf die Gesundheit gibt. Aufgrund der internationalen Bedeutung des Themas und der interkulturellen Unterschiede im Umgang mit Krisensituationen ist eine internationale Standardisierung von Untersuchungszugängen wünschenswert.

Practitioners’ perception of the impact of the vision of policy-makers on practice: The example of the recommendations of the Moser Commission

This paper presents the perception of practitioners of the impact of the Moser Committee recommendations and the Skills for Life agenda it generated. The paper further explores areas of convergence and divergence between practitioners’ perceptions and the underpinning values of the Moser Committee recommendations. The study utilised a range of research tools including an online questionnaire, documentary analysis and elements of discourse analysis in the collection and analysis of data. It found that there is substantial divergence between the perception of practitioners and the values underpinning policy. It concludes by suggesting that a varying perception of what constitutes sustainable education and the lack of input from practitioners into policy might be responsible for this significant divergence of opinion and also raised a question on the perceived role of practitioners in the policy‐making process.