Using a Polygraph System for Evaluation of the Social Desirability Response Bias in Self-Report Measures of Aggression.

Empirical evidence suggests that respondents systematically overreport socially desirable behaviors and systematically underreport socially undesirable behaviors. This "social desirability response bias (SDRB)" presents significant challenges for research that relies on self-report measures to assess behaviors that adhere to or violate social norms. The present study used a state-of-the-art polygraph system to examine SDRB in widely used aggression questionnaires, including the Buss-Perry Aggression Questionnaire-Short Form, the Indirect Aggression subscale of the Aggression Questionnaire by Western Psychological Services, and the Reactive-Proactive Questionnaire. Sixteen college students with no criminal record, no known prior history of aggressive behavior, and no reported drug abuse, responded to verbally administered forms of the instruments. Indirect aggression items produced the largest, statistically significant physiological response across the sampled channels. The magnitude of this response was negatively and significantly correlated with the self-report ratings of the frequency of such behaviors. The mean separation between physiological (skin conductance) and self-report responses for indirect aggression remained significant and consistent with correlational analyses when both types of responses were converted to the same scale and compared directly. Finally, the relative magnitude of skin conductance response for items assessing indirect aggression was significantly greater than the relative magnitude of skin conductance response for direct aggression. Overall, the study suggests that the use of automated state-of-the art polygraph systems may potentially identify sensitive items on self-report instruments where social responsibility response bias is possible. Implications for the use of this procedure with such instruments are discussed.

Visually Evoked Potential Markers of Concussion History in Patients with Convergence Insufficiency.

PURPOSE: We investigated whether differences in the pattern visual evoked potentials exist between patients with convergence insufficiency and those with convergence insufficiency and a history of concussion using stimuli designed to differentiate between magnocellular (transient) and parvocellular (sustained) neural pathways. METHODS: Sustained stimuli included 2-rev/s, 85% contrast checkerboard patterns of 1- and 2-degree check sizes, whereas transient stimuli comprised 4-rev/s, 10% contrast vertical sinusoidal gratings with column width of 0.25 and 0.50 cycles/degree. We tested two models: an a priori clinical model based on an assumption of at least a minimal (beyond instrumentation's margin of error) 2-millisecond lag of transient response latencies behind sustained response latencies in concussed patients and a statistical model derived from the sample data. RESULTS: Both models discriminated between concussed and nonconcussed groups significantly above chance (with 76% and 86% accuracy, respectively). In the statistical model, patients with mean vertical sinusoidal grating response latencies greater than 119 milliseconds to 0.25-cycle/degree stimuli (or mean vertical sinusoidal latencies >113 milliseconds to 0.50-cycle/degree stimuli) and mean vertical sinusoidal grating amplitudes of less than 14.75 mV to 0.50-cycle/degree stimuli were classified as having had a history of concussion. The resultant receiver operating characteristic curve for this model had excellent discrimination between the concussed and nonconcussed (area under the curve = 0.857; P < .01) groups with sensitivity of 0.92 and specificity of 0.80. CONCLUSIONS: The results suggest a promising electrophysiological approach to identifying individuals with convergence insufficiency and a history of concussion.

The role of visual perception measures used in sports vision programmes in predicting actual game performance in Division I collegiate hockey players.

Abstract In the growing field of sports vision little is still known about unique attributes of visual processing in ice hockey and what role visual processing plays in the overall athlete's performance. In the present study we evaluated whether visual, perceptual and cognitive/motor variables collected using the Nike SPARQ Sensory Training Station have significant relevance to the real game statistics of 38 Division I collegiate male and female hockey players. The results demonstrated that 69% of variance in the goals made by forwards in 2011-2013 could be predicted by their faster reaction time to a visual stimulus, better visual memory, better visual discrimination and a faster ability to shift focus between near and far objects. Approximately 33% of variance in game points was significantly related to better discrimination among competing visual stimuli. In addition, reaction time to a visual stimulus as well as stereoptic quickness significantly accounted for 24% of variance in the mean duration of the player's penalty time. This is one of the first studies to show that some of the visual skills that state-of-the-art generalised sports vision programmes are purported to target may indeed be important for hockey players' actual performance on the ice.

Screening for lifetime concussion in athletes: importance of oculomotor measures.

HYPOTHESIS/OBJECTIVE: The purpose of the present study was to determine the utility of oculomotor-based evaluation protocols in screening for lifetime concussion incidence in elite hockey players. METHODS: Forty-two Division I collegiate male and female hockey players were evaluated using the guidelines of an overall oculomotor-based diagnostic clinical test protocol for the mTBI population. The sensitivity of the collected measures to lifetime concussion was then compared with the corresponding sensitivity of measures of neuropsychological functioning (ImPACT) often used with athletes for acute concussion diagnosis. RESULTS: This model showed that a hockey player with a Near Point of Fixation Disparity (NPFD) equal to or greater than 15 cm, Visagraph comprehension rate less than 85% and the total score on part A of an ADHD questionnaire equal to or greater than 11 was on average 10.72-times more likely to have previously suffered a concussion than an athlete with lower values on the NPFD and ADHD questionnaire and a higher comprehension rate on the Visagraph. None of the IMPACT baseline assessment measures were significantly predictive of the individual's concussion history. CONCLUSION: The study provides a relatively sensitive screening tool to assess the probability of previous concussion(s) in an athlete. This model may allow athletic personnel to address in a timely manner the risks associated with repeat concussions and to develop individualized concussion management protocols.

The role of fear and disgust in predicting the effectiveness of television advertisements that graphically depict the health harms of smoking.

INTRODUCTION: Antismoking television advertisements that depict the graphic health harms of smoking are increasingly considered best practices, as exemplified by the Centers for Disease Control and Prevention's current national campaign. Evaluation of responses to these widely used advertisements is important to determine advertisements that are most effective and their mechanisms of action. Our study tested the hypothesis that advertisements rated highest in fear- and disgust-eliciting imagery would be rated as the most effective. METHODS: Our laboratory study included 144 women and men aged 18 to 33; 84% were current nonsmokers. All participants viewed 6 antismoking television advertisements that depicted the health harms of smoking; they rated their responses of fear and disgust and the effectiveness of the advertisements. We used multilevel modeling to test the effects of the following in predicting effectiveness: fear, disgust, the fear-disgust interaction, the advertisement, and the participant's sex and smoking status. Follow-up analyses examined differences in ratings of fear, disgust, and effectiveness. RESULTS: Advertisement, fear, disgust, and the fear-disgust interaction were each significant predictors of effectiveness. Smoking status and sex were not significant predictors. The 3 advertisements that elicited the highest ratings of fear and disgust were rated the most effective. CONCLUSION: Our findings support the hypothesis that antismoking advertisements of health harms that elicit the greatest responses of fear or disgust are the most effective. When advertisements elicit high ratings of both fear and disgust, advertisements with graphic imagery are effective, whereas advertisements without graphic imagery are not.

Effectiveness of a Novel Video Game Platform in the Treatment of Pediatric Amblyopia.

PURPOSE: To test the non-inferiority of a novel game platform for the treatment of pediatric amblyopia compared to standard eye patching. METHODS: Forty participants (ages 4 to 18 years) across seven optometric clinics in the United States diagnosed as having amblyopia associated with anisometropia were randomly assigned to either 12 weeks of eye patching therapy (n = 19) or Barron Vision (Barron Associates, Inc) video game treatment (n = 21). Participants in the eye patching group with best corrected visual acuity (BCVA) worse than 20/200 in their amblyopic eye were prescribed 6 hours of patching daily, whereas those whose BCVA was 20/200 (1.00 logarithm of the minimum angle of resolution [logMAR]) or better were instructed to patch for 2 hours daily. Participants in the video game group, irrespective of the severity of their amblyopia, were instructed to play four different 5-minute mini-games five times a week for a total of 20 minutes a day. RESULTS: A mixed linear modeling analysis of before and after BCVA differences after 12 weeks showed the non-inferiority of video game treatment to eye patching using a 0.10 logMAR threshold while adjusting for the participant's age, sex, and baseline BCVA. CONCLUSIONS: The results of the study suggest that a 12-week home-based video game vision therapy intervention can provide equivalent treatment outcomes to eye patching for amblyopia in children ages 5 to 18 years. Video game-based vision therapy may be a more acceptable and time-efficient alternative to existing approaches. By incorporating elements of perceptual learning, approaches such as Barron Vision video game treatment may have additional long-term therapeutic benefits and may improve treatment compliance. [J Pediatr Ophthalmol Strabismus. 2024;61(1):20-29.].

A Novel Home-Based Medication Management Program and Its Influence on Hospitalization Rates among Home Health Care Recipients.

Patients do not take their medicine as prescribed 50% of the time, and of medication-related hospital admissions in the United States, 33% to 69% are due to poor medication adherence, at a cost of approximately $100 billion a year. Continue CareRx (CCRx) is a novel home-based medication management program that includes adherence packaging alongside medication reconciliation, review, and education by clinicians. We hypothesized that home health patients receiving the CCRx service may have a lower hospitalization rate than control home health patients. Between May 1, 2021, and March 31, 2023, 113 home health patients whose insurance covered the program were enrolled in CCRx. Home health patients not eligible for the program due to a noncovered pharmacy insurance benefit made up the control group (n = 21,304), which was matched with the CCRx group on age range (45-99 years old) and gender (67% women). Hospitalization rate was calculated in both groups and compared using generalized estimating equations analysis. The control group had a total of 7015 hospitalizations during the study period during 2,128,738 total managed days, whereas the CCRx group had 21 hospitalizations during 23,622 total managed days. These translated into rates of 1203 hospitalizations per 1000 per year for the control group, and 324 hospitalizations per 1000 per year for the CCRx group. The results showed that there was a significant main effect of group in predicting individual annual hospitalization rate (Wald χ2 = 56.415, P < .01). Specifically, being in the control group was associated with a 43.42-fold increase in the likelihood of a higher hospitalization rate (95% Wald CI for odds ratios: 7.24-230.44). Home health recipients enrolled in CCRx experienced a 73.1% lower hospitalization rate than controls. Making the program more widely available to patients receiving home health care may present a significant opportunity to reduce hospitalizations in this group.

Delay and probability discounting of multiple commodities in smokers and never-smokers using multiple-choice tasks.

The purpose of the present study was to investigate temporal and probabilistic discounting in smokers and never-smokers, across a number of commodities, using a multiple-choice method. One hundred and eighty-two undergraduate university students, of whom 90 had never smoked, 73 were self-reported light smokers (<10 cigarettes/day), and 17 were heavy smokers (10+cigarettes/day), completed computerized batteries of delay and probability discounting questions pertaining to a total of eight commodities and administered in a multiple-choice format. In addition to cigarettes, monetary rewards, and health outcomes, the tasks included novel commodities such as ideal dating partner and retirement income. The results showed that heavy smokers probability discounted commodities at a significantly shallower rate than never-smokers, suggesting greater risk-taking. No effect of smoking status was observed for delay discounting questions. The only commodity that was probability discounted significantly less than others was 'finding an ideal dating partner'. The results suggest that probability discounting tasks using the multiple-choice format can discriminate between non-abstaining smokers and never-smokers and could be further explored in the context of behavioral and drug addictions.

Functional near-infrared spectroscopy is a sensitive marker of neurophysiological deficits on executive function tasks in young adults with a history of child abuse.

Previous research has shown the utility of imaging measures of neural activity in identifying deficits in cognitive functioning in individuals with a history of child abuse. The purpose of the present study was to measure differences that may exist between individuals who reported physical, emotional, or sexual abuse as children (n = 37) vs. those who did not (n = 47) using Functional Near Infrared Spectroscopy (fNIRS) during the completion of cognitive tasks of executive function. The results showed a significantly higher rate and number of errors of commission on the Conners CPT test in the child abuse group compared to the control group. The analyses also showed a statistically significant decrease in oxyhemoglobin (oxy-Hb) concentration in the left rostral prefrontal cortex in the child abuse group compared to the no-abuse group during the Wisconsin Card Sorting Test (WCST). A similar, albeit non-significant, trend toward decreased oxy-Hb concentration was observed in the child abuse group in the right dorsolateral prefrontal cortex (dlPFC) on the OSPAN and Connors CPT. The results suggest that the latter group may show subtle neurological deficits that persist into adulthood that may not manifest on traditional measures of cognitive function. These findings have implications for the development of remediation and treatment strategies in this population.

Provision of Home-Based Primary Care to Individuals With Intellectual and/or Developmental Disability Is Associated With a Lower Hospitalization Rate Than a Traditional Primary Care Model.

OBJECTIVES: The objective of this study was to determine if providing home-based primary care (HBPC) to individuals with intellectual and/or developmental disabilities (IDD) was associated with a lower hospitalization rate than a control group receiving traditional primary care. DESIGN AND INTERVENTION: Individuals with IDD living in supported residential settings in Ohio were offered HBPC. Individuals electing HBPC made up the intervention group. Those who did not opt for HBPC continued to receive traditional primary care services and made up the control group. Hospitalizations were tracked in both groups. SETTING AND PARTICIPANTS: The 757 study participants had IDD diagnoses and received residential support services throughout the study period. METHODS: Annualized hospitalization rate was determined in both groups and was compared using generalized estimating equations while controlling for patients' age and hospitalization rate in the year prior to the study. RESULTS: The results showed that group membership had a significant effect on the hospitalization rate (Wald χ2 = 20.71, P < .01). Being in the control group was associated with a 2.12-fold increase in annual hospitalization rate for a given patient. The overall population hospitalization rate was 329 hospitalizations per 1000 per year in the HBPC-receiving individuals and 619 hospitalizations per 1000 per year in the control group. CONCLUSIONS AND IMPLICATIONS: We found that individuals with IDD receiving HBPC were hospitalized at a lower rate than a control group receiving traditional primary care. Expanding access to HBPC may be a worthwhile priority for organizations that support individuals with IDD.

Symptoms of convergence and accommodative insufficiency predict engagement and cognitive fatigue during complex task performance with and without automation.

Deficits in the accommodative and/or vergence responses have been linked with inattentive behavioral symptoms. While using automated systems (e.g., self-driving cars, autopilot), operators (e.g., drivers, pilots, soldiers) visually monitor displays for critical changes, making deficits in the accommodative and/or vergence responses potentially hazardous for individuals remaining actively engaged in the task at hand. The purpose of this study was to determine if symptoms of accommodative-vergence deficits predict an individual's level of task engagement and cognitive fatigue while performing a flight simulation task with or without automation. Eighty-four participants performed a flight simulation task with or without automation. Prior to task completion, self-report accommodative-convergence deficit symptoms were assessed with the Convergence Insufficiency Symptom Survey (CISS). Before and after the flight simulation task participants rated their task engagement and cognitive fatigue. Electroencephalographic activity (EEG) was recorded concurrently during task performance. Results showed that higher scores on the CISS were related to increased feelings of fatigue and decreased ratings of task engagement. The CISS was also positively related to parietal-occipital fast alpha power during the last 10 min of the task for participants using automation, suggesting increased cortical idling. CISS scores did not predict performance. Results have implications for optimizing operator cognitive states over extended task performance.

Which Comes First in Sports Vision Training: The Software or the Hardware Update? Utility of Electrophysiological Measures in Monitoring Specialized Visual Training in Youth Athletes.

In the present study we combined popular methods of sports vision training (SVT) with traditional oculomotor protocols of Optometric Vision Therapy (OVT) and electrophysiological indexes of EEG and VEP activity to monitor training progress and changes in performance of youth ice hockey players without the history of concussion. We hypothesized that administration of OVT protocols before SVT training may result in larger performance improvements compared to the reverse order due to the initial strengthening of visual hardware capable of handling greater demands during training of visuomotor integration and information processing skills (visual software). In a cross-over design 53 youth ice hockey players (ages 13-18) were randomly assigned to one of the two training groups. Group one (hardware-software group) completed 5 weeks of oculomotor training first followed by 5 weeks of software training. For group 2 (software-hardware) the order of procedures were reversed. After 10 weeks of training both groups significantly improved their performance on all but one measure of the Nike/Senaptec Sensory station measures. Additionally, the software-hardware training order resulted in significantly lower frontal theta-to-gamma amplitude ratios on the Nike/Senaptec test of Near-Far Quickness as well as in faster P100 latencies. Both training orders also resulted in significant decreases in post-treatment P100 amplitude to transient VEP stimuli as well as decreased theta-gamma ratios for perception span, Go/No-Go and Hand Reaction time. The observed changes in the electrophysiological indexes in the present study are thought to reflect greater efficiency in visual information processing and cognitive resource allocation following 10 weeks of visual training. There is also some evidence of the greater effectiveness of the software-hardware training order possibly due to the improved preparedness of the oculomotor system in the youth athletes for administration of targeted protocols of the Optometric Vision Therapy.

Assessing health status, behavioral risks, and health disparities in American Indians living on the northern plains of the U.S.

OBJECTIVE: We assessed health status and behavioral risks in American Indians (AIs) from rural, northern plains reservation communities. METHODS: AI interviewers from the communities administered the core and optional modules of the Behavioral Risk Factor Surveillance System (BRFSS) to 404 AI adults randomly selected from housing lists from four AI tribal communities located on the northern plains of the U.S. The BRFSS interview assessed several health functioning areas including medical conditions, preventive screenings, and behavioral risks. We measured health disparities by comparing the AI sample data with a northern plains statewide (North Dakota) sample and a U.S. national sample. We compared outcomes with BRFSS statewide (North Dakota) and U.S. national data from telephone-based interviews. RESULTS: AI participants showed a significantly greater prevalence of diabetes, coronary heart disease, myocardial infarction, smoking, obesity, and heavy alcohol use than either the regional or national samples. They also reported being less likely to engage in leisure-time physical activity and to have had age-appropriate preventive screenings for several diseases including colorectal cancer, prostate cancer, breast cancer, and cardiovascular disease. CONCLUSIONS: Face-to-face interviews conducted by AI community members are an effective means of gathering health information about AIs living in rural, reservation communities. AIs living in these communities on the northern plains have a much higher prevalence of many health-risk behaviors and some medical conditions than are found in the general population. Improved health-care access, better preventive screenings, and culturally appropriate community-based health promotion programs and policies should be examined as possible ways to reduce health disparities.

Confirmed recall and perceived effectiveness of tobacco countermarketing media in rural youth.

This study was the first to examine rural youth's responses to ten television and radio tobacco countermarketing ads aired during a 13-week field campaign conducted in a U.S. Northern Plains state. A post-campaign survey of 391 girls and boys aged 12-17 years and including 58 American Indian youth provided information about their confirmed recall (CR) of the ads; and for recalled ads, their ratings of the ads' perceived effectiveness (PE). Results were that controlling for age and smoking risk, both American Indian and white girls and boys had the highest CR for the television ad Artery and for the radio ad ABC. Artery shows fatty deposits being squeezed from a deceased smoker's aorta, and ABC presents a former smoker speaking through his electro-larynx. Among the television ads, PE ratings were highest for the ad Artery in both boys and girls. Among the radio ads, boys rated ABC highest, whereas girls rated Joe DoBoer highest-an ad that discusses mouth lesions that developed from using smokeless tobacco. An analysis of race/ethnicity differences in PE for the ad Artery and ABC indicated American Indian and white youth considered these ads equally effective. These findings indicate certain TV and radio ads depicting graphic health harms from tobacco-especially the TV ad Artery and the radio ad ABC-are highly recalled and perceived as effective by both American Indian and white girls and boys from a rural region. Future research is needed to better understand which individual- and media-level factors increase the likelihood that anti-tobacco ads will be effective in reducing youth tobacco use.

Frontal theta-gamma ratio is a sensitive index of concussion history in athletes on tasks of visuo-motor control.

Patients with mTBI often show deficits in executive function and changes in neural activity. Similar changes in those with a history of mTBI (i.e. concussion), however, have not been consistently reported. Frontal theta-to-gamma frequency ratio has shown promise in EEG research in predicting performance on working memory tasks. In the present study we explored the sensitivity of the frontal theta-to-gamma relative power spectral density (PSD) ratio to the history of concussion in 81 youth athletes (18 with a history of concussion, ages 13-18) during the tests of the Nike Sensory Training Station that vary in working memory and processing speed demands and motor output requirements. The results showed that the theta-to-gamma relative PSD ratio was significantly lower in the concussion history group on the tests of target capture, perception span and hand reaction time. A principle component analysis further indicated that this metric reflects an underlying dimension shared by several visuo-motor control tests of the Nike battery. The results suggested persistent deficits in psychomotor ability in the athletes with a history of concussion that may have implications for diagnosis, rehabilitation and athletic training.

Examining Positivity Effect and Working Memory in Young-Old and Very Old Adults Using EEG-Derived Cognitive State Metrics.

The positivity effect among older adults is a tendency to process more positive and/or less negative emotional stimuli compared to younger adults, with unknown upper age boundaries. Cognitive and emotional working memory were assessed in young-old adults (60-75) and very old adults (VOAs; 80+) to determine whether emotional working memory declines similar to the age-related decline of cognitive working memory. The moderating role of valence on the link between age and emotional working memory was examined to identify change in positivity effect with advanced age. Electroencephalography (EEG) markers of cognitive workload and engagement were obtained to test the theory of cognitive resource allocation in older adults' emotional stimuli processing. EEG recordings were collected during cognitive memory task and emotional working memory tasks that required rating emotional intensity of images pairs. Results indicate a positivity effect among VOAs that does not require additional cognitive effort and is not likely to diminish with age.

Differential executive functioning in young adulthood as a function of experienced child abuse.

INTRODUCTION: Previous research has shown cognitive dysfunction in adults with a history of child abuse. The purpose of the present study was to measure differences that exist in executive functioning skills between individuals who have been abused as children versus those without the history of childhood abuse. METHODS: The present study recruited 43 students from the University of North Dakota (33 women) between ages 18 and 23 years of age. The participants were administered several prescreening measures, including a measure of physical child abuse, emotional child abuse, and sexual child abuse. Based on responses to these measures, participants were grouped into a no-child-abuse group, a mild-child-abuse group, or a moderate-to-severe child abuse group. All participants were administered measures of executive functioning that included the Wisconsin Card Sorting Task, the Operation Span Task, and the Connors Continuous Performance Task with a simultaneous recording of electroencephalographic activity using a wireless 9 channel EEG system. RESULTS: There was a statistically significant main effect of child abuse group (no child abuse vs. moderate-to-high child abuse) for the EEG-derived probability of cognitive workload during the OSPAN. Beta bandwidths for individuals in the drug abuse group, which served as a covariate, were also found to be significantly attenuated during the Connors CPT. CONCLUSION: Individuals that have been abused as children must use significantly more mental effort to complete executive functioning tasks as compared to their non-abused counterparts. Increased neurological effort could be used to explain poor decision-making skills that are common within the population.

The effects of dynamic workload and experience on commercially available EEG cognitive state metrics in a high-fidelity air traffic control environment.

The current study evaluated the validity of commercially available electroencephalography (EEG) cognitive state metrics of workload and engagement in differentially experienced air traffic control (ATC) students. EEG and pupil diameter recordings were collected from 47 ATC students (27 more experienced and 20 less experienced) during a high-fidelity, variable workload approach-control scenario. Scenario workload was manipulated by increasing the number of aircraft released and the presence of a divided attention task. Results showed that scenario performance significantly degraded with increased aircraft and the presence of the divided attention task. No scenario performance differences were found between experience groups. The EEG engagement metric significantly differed between experience groups, with less experienced controllers exhibiting higher engagement than more experienced controllers. The EEG workload metric and pupil diameter were sensitive to workload manipulations but did not differentiate experience groups. Commercially available EEG cognitive state metrics may be a viable tool for enhancing ATC training.

Factors associated with incidence of "inappropriate" ambulance transport in rural areas in cases of moderate to severe head injury in children.

CONTEXT: Ambulance transport of pediatric trauma patients to designated trauma centers in cases of moderate and severe injury is not always performed, which has been shown to result in poor treatment outcomes. Determination of factors involved in inappropriate patient transport, especially in rural areas, remains an important avenue of research. PURPOSE: To identify factors involved in ambulance transport of pediatric patients sustaining moderate-to-severe head injury to nondesignated trauma centers in rural North Dakota. METHOD: Emergency medical service ambulance records for North Dakota from 1995 to 2000 were used. One hundred fifty-six cases of pediatric head injuries with Glasgow Coma Scale scores < or =12 and transported by rural ambulance squads were selected. A logistic regression analysis was conducted to identify a set of significant predictors of cases of inappropriate deliveries to acute care facilities with no trauma-center designation of any level (II-V). RESULTS: Greater distance (mean = 19.96 miles) to the nearest trauma center and shorter distance traveled by the ambulance squad to the receiving facility (mean = 19.07 miles) corresponded to higher probabilities of mistriage, especially when a child was Native American (16 times more likely) and the transportation was conducted in the winter (9 times more likely). CONCLUSIONS: Timely delivery of pediatric trauma patients to designated trauma centers is encumbered in the winter, particularly in Native American communities, because of the greater traveling distances, which could be counteracted by better mobilization of available resources aimed at administration of optimal trauma care.