Doctor of Philosophy

dissertationThe purpose of this study was to determine the association of each of five cardiometabolic risk factors (diabetes, hypertension, elevated triglycerides, low high density lipoproteins, obesity), and MetS (three or more risk factors present) with the level of physical function 1) prior to surgery in patients with TKA/THA surgery and 2) 6 weeks postsurgery in patients with TKA/THA surgery, controlling for age, sex, physical activity, and comorbidity. Patient physical function data were retrospectively extracted from a clinical orthopedic database between September of 2008 and November of 2010. Comorbidities were obtained by chart abstraction. Patients were ≥40 years old with a primary total hip or knee arthroplasty. Relationships between MetS and its individual components, and physical function were completed using the Lower Extremity Function Scale (LEFS) and SF-36 physical component score (PCS). Covariates were age, sex, comorbidities, and physical activity. Preoperatively, a total of 174 TKA and 112 THA candidates were included. For TKA candidates, mean LEFS scores were significantly (p<0.001) lower for patients with MetS (30.0, SD 14.2) than without MetS (39.9, SD 16.0). In TKA cohort, MetS remained significantly associated with reduced lower-extremity physical function; additionally, female sex, chronic back pain and insomnia significantly reduced preoperative lower-extremity physical function, in the adjusted analysis. For THA iv candidates, adjusted analysis found MetS and being female were significantly (p<0.05) associated with worse lower-extremity physical function. Postoperatively, 170 and 111 patients with a total knee and total hip arthroplasty were included. In the adjusted analysis: Diabetes, chronic back pain and presurgical physical function remained significantly associated with reduced postoperative lowerextremity physical function. For THA, being female, chronic back pain and presurgical physical function were significantly (p<0.05) associated with worse physical health. MetS was not significantly associated with postoperative physical function (PCS or LEFS) in the THA/TKA population. This study provides evidence that MetS, back pain, and insomnia are modifiable conditions that influence preoperative physical function while back pain, diabetes and preoperative physical function are modifiable conditions that influence postoperative physical function. MetS was not associated with postoperative physical function in either the TKA or THA cohort

Clinical Research on Diabetic Complications

Refrigeration, air conditioning, and heat pumps (RACHP) have an important impact on the final energy uses of many sectors of modern society, such as residential, commercial, industrial, transport, and automotive. Moreover, RACHP also have an important environmental impact due to the working fluids that deplete the stratospheric ozone layer, which are being phased out according to the Montreal Protocol (1989). Last, but not least, high global working potential (GWP), working fluids (directly), and energy consumption (indirectly) are responsible for a non-negligible quota of greenhouse gas (GHG) emissions in the atmosphere, thus impacting climate change

Quality of life in intestinal failure

PhDAims/objectives: The objectives of this research were to investigate and compare aspects of Quality of Life (QoL) in adult patients who require HPN, in adult patients who have pseudo-obstruction, and in carers of, and children on, HPN. Methods: Demographic data, clinical parameters and current symptoms were collected and analysed. Generic QoL questionnaires were applied to the above groups. Results: HPN patients have significantly lower QoL than the rest of the UK population, report increased levels of bodily pain, anxiety and depression, a reduction in physical functioning, social functioning, general health, vitality and satisfactory levels of mental health and emotional functioning. Aspects of QoL improve over the first 6 months on HPN. Pseudo-obstruction has a negative impact on all aspects of QoL when compared to a normal population. A previous intestinal resection and opiate use had a negative impact on aspects of QoL. Carers of a child on HPN seek more social support and use more positive reappraisal coping strategies, more planful problem solving and less distancing than the controls and a higher level of psychiatric disorder is also seen. Children on HPN have a poorer functional status than those not on HPN, and there is a correlation between level of child dysfunction and parental general health. Families caring for a child on HPN function within normal and healthy parameters. Conclusions: Our studies indicate that the loss of intestinal function does have a negative impact on aspects of QoL but patients make adjustments to meet everyday requirements, even if it produces limitations with which these persons have to live by

Parental Influence on Children's Chronic Abdominal Pain Experiences: Exploring the Relationship between Parental Protective Behaviors and Child Quality of Life

Initial studies examining relationships between parent behaviors and child functioning in chronic pain populations have documented positive associations between parental protective behaviors and child somatic complaints, emotional difficulties (e.g., anxiety, depression), and functional disability. The current study attempts fills existing gaps in this literature by examining the relationship between two specific types of parental protective behaviors (i.e., provision of attention and activity restriction) and Quality of Life (QoL) in a clinical population of children with chronic abdominal pain, while including age and gender as potential moderators. Medical records from initial evaluation at a tertiary pain clinic were reviewed for 430 child and adolescent chronic abdominal pain patients. Parent-reported protective behaviors were assessed via the Illness Behavior Encouragement Scale (IBES; Walker & Zeman, 1992) and QoL was assessed using the Pediatric Quality of Life Inventory, Version 4.0 (PedsQL 4.0; Varni, Seid, & Kurtin, 2001). Simple and hierarchical regression analyses were conducted to examine relationships among variables of interest. Results support previous findings that indicate the importance of parental protective behavior in predicting child functioning and extend previous findings to include multiple types of protective behavior and domains of child functioning. Age and gender differences in these relationships are noted. By identifying specific parental behaviors associated with particularly negative child QoL, the reported results provide information relevant to the development of targeted and effective parent education programs for families coping with a child with chronic pain and directions for future research within the field

Assessment of chronic pain in companion animals : development and concurrent validation of neurophysiological methods

La douleur est une expérience complexe impliquant des composantes sensorielles et de perception (émotionnelle, affective, cognitive). Elle est associée au stress, de la souffrance et une dégradation de la qualité de la vie. Les affections douloureuses chroniques telles que l'arthrose et le cancer des os touchent les chats et les chiens. La douleur dans ces conditions implique de nombreux mécanismes affectant les systèmes nerveux périphérique et central, qui génèrent et entretiennent une douleur pathologique. Les tests sensoriels quantitatifs (TSQ) sont des outils pour quantifier la composante sensorielle de la douleur, qui peuvent aussi être utilisés pour éluder les mécanismes de la douleur impliquée. Les travaux initiaux sur les chats et les chiens souffrant d'arthrose ont permis de développer et de valider certaines méthodes de TSQ; cependant, quelques questions sont restées sans réponse chez les chats souffrant de l'arthrose, et cette méthodologie n'a pas été encore explorée chez les chiens atteints d’ostéosarcome. Nos hypothèses de recherche étaient: 1) les chats arthrosiques sont affectés par des modifications neurophysiologiques caractéristiques de la sensibilisation centrale, pouvant être détectées par les TSQ et répondant à l'administration d'analgésiques à action centrale; et 2) l’ostéosarcome provoque une sensibilisation périphérique et centrale avec des mécanismes descendants d’inhibition de la douleur déficients chez le chien. Nos objectifs étaient : 1) chez les chats souffrant d'arthrose, de fournir des évidences sur la thérapie basée sur les mécanismes neurophysiologiques à l'aide de TSQ; et 2) de tester la capacité d'un protocole TSQ à démontrer la sensibilisation périphérique et centrale chez les chiens atteints de cancer des os, y compris un test de modulation de la douleur conditionnée, et de tester l’efficacité d’un protocole d’analgésique palliatif par paliers chez ces patients. En utilisant les TSQ statiques et dynamiques chez les chats arthrosiques, nous avons démontré que les analgésiques à action centrale tels que le tramadol peuvent renverser la sensibilisation centrale mesurée par la sommation temporelle de la douleur. Cet effet n’a pas été observé après l’administration d’analgésique à action périphérique tel que les antiinflammatoires non stéroïdiens comme le meloxicam. Ces résultats 3 soulignent l’importance d’une approche de traitement fondée sur les mécanismes de la douleur chronique. Le protocole TSQ développé pour les chiens a révélé que ceux atteints de cancer des os manifestaient de l'hyperalgésie primaire et secondaire et de l’allodynie dynamique au brossage par rapport aux chiens en bonne santé. Un test de modulation de la douleur conditionnée pouvant être facilement appliqué a été mis au point et a démontré la capacité de différencier les chiens sains des chiens cancéreux. En utilisant cette méthodologie, il s’est avéré que cette dernière population démontrait un système descendant d’inhibition de la douleur déficient. Ces études ont fourni des preuves des similitudes dans le profil sensoriel entre les malades humains et les animaux de compagnie affectés par l'arthrose, ainsi que les ostéosarcomiques. Les TSQ sont utiles dans la recherche vétérinaire sur la douleur et doivent être accompagnés des normes les plus strictes en matière de soins des animaux et de conception, de conduite et de compte-rendu des études.Pain is a complex experience involving sensory and perceptual components. It causes stress, suffering and decreased quality of life. Chronic painful conditions such as osteoarthritis (OA) and bone cancer affect cats and dogs. Pain in these conditions results from numerous mechanisms affecting the peripheral and central nervous systems which generate and maintain pathological pain in affected individuals. Quantitative sensory testing (QST) are means to quantify the sensory component of pain. In combination with observed analgesic efficacy, they can be used to study mechanisms of pain. Initial work on cats and dogs with OA has helped to develop and validate some QST methods; however, questions remained unanswered in cats with OA, and this methodology was not yet explored in dogs with bone cancer. Our main hypotheses were: 1) osteoarthritic cats are affected by neurophysiological changes characteristic of central sensitization which can be detected by QST and the concomitant administration of centrally-acting analgesics; and 2) bone cancer in dogs causes peripheral and central sensitization with deficient descending modulating mechanisms. Our main objectives were: 1) to provide evidence of mechanism-based therapy in cats with OA using QST; and 2) to test the ability of a QST protocol to provide evidence of peripheral and central sensitization in dogs with bone cancer including the development and validation of a conditioned pain modulation test, and to test the efficacy of a step-wise palliative analgesic protocol in these patients. Using static and dynamic QST in osteoarthritic cats, we demonstrated that centrally-acting analgesics such as tramadol can reverse central sensitization as measured by facilitated temporal summation of pain, while the same is not observed when a peripherally-acting analgesic such as non-steroidal anti-inflammatory drug, meloxicam, is administered. These findings highlight the importance of mechanism-based approach for the treatment of chronic pain. The QST protocol developed for use in dogs revealed that dogs with bone cancer are affected by primary and secondary hyperalgesia and brush allodynia when compared 5 with healthy dogs. A conditioned pain modulation test which can be easily applied into clinical practice was developed and demonstrated ability to differentiate between healthy and cancerous dogs. Using this methodology, the latter population was found to be affected by deficient descending modulating systems. These studies provided evidence of the similarities in sensory profile between people and companion animals affected by OA- and bone cancer-related pain. The use of QST is valuable in veterinary pain research and should be accompanied by the highest standards of animal care and study design, conduct and reporting

Targeting complexity of geriatric emergency department visitors: Comprehensiveness in a high-paced and efficiency-focused medical setting

The emergency department (ED) is one of the most important access points to medical care worldwide and a central link between out- and inpatient care. The demographic development is predicted to change the age distribution of patients in the German health system over the next few decades which could strongly affect the ED as a multidisciplinary centre of the health system. Many EDs in Germany have already observed an increase in the number of older and clinically complex patients that bind more resources and personnel capacities. Geriatric patients in the ED are a particularly vulnerable group with an increased risk of clinical complications compared to younger age groups. The higher prevalence of frailty, atypical symptoms, multimorbidity, polypharmacy, neuropsychiatric and cognitive impairments impede fast diagnosis and therapy. The integration of an elaborate and time-consuming assessment of older patients in an otherwise fast-paced and efficiency-driven environment is a major challenge of present-day and future EDs. Therefore, an effective screening for older patients who would benefit from further evaluation will be paramount. Common standardized triage systems of EDs or existing screening instruments like the Identification of Seniors at Risk (ISAR) score show major difficulties in effectively identifying vulnerable older patients. The Multidimensional Prognostic Index (MPI), which is based on a comprehensive geriatric assessment (CGA), has already been tested in numerous settings and might be an alternative to grasp the complexity of older ED patients. An important but rarely evaluated clinical outcome parameter is health-related quality of life (HRQOL). It is a central component of patient-related treatment concepts and plays a crucial role in the care for geriatric patients. Existing literature shows a strong influence of the health status on HRQOL of older people. The results of the study by Rarek et al., on which this thesis is based upon, were able to show that the HRQOL of geriatric ED patients is significantly associated with clinical prognosis at ED admission and up to 6 months after. Attention to the association between patient-related outcome factors such as HRQOL and objective clinical prognosis can improve a holistic approach for allocation decisions in future concepts of geriatric ED care. Various innovative concepts for the improvement of detection and management of geriatric and patients in the ED have been tested and evaluated in the USA in recent years. The initial experience about advantages and disadvantages of approaches that were tested can help to create adapted concepts for the German health care system. First responses to the increasing number of geriatric patients already exist in Germany and range from new screening tools to specialized ED units and an improved linking of different health care providers. Adapting EDs to the complexities and needs of geriatric patients will be a major challenge in an aging society. The global outbreak of the Coronavirus Disease 2019 (COVID-19) pandemic has threatened the health systems of numerous nations and at the time of this publication, the end is still unforeseeable. Many aspects and challenges of the complexity in geriatric patients in clinical practice have been illustrated by the impact of the pandemic on geriatric care. Older, multimorbid and frail patients are particularly affected by this disease due to an increased risk of a severe course of disease and higher mortality. The need to effectively identify vulnerable patients in the ED with a poor clinical prognosis has become more important due to the pandemic-related scarcity of resources. In addition, it has been observed that the COVID-19 pandemic had a negative impact on HRQOL of older people and the treatment of chronic illnesses. Given that geriatric patients have a higher risk for the development of chronic remnants of COVID-19, the pandemic could have unforeseeable influence on future health of the aging society. In the face of demographic changes, present and future challenges for health systems, effective identification and management of frail and vulnerable patients in the ED and structural changes to obtain geriatric-friendly EDs are important steps to guarantee adequate geriatric care and improve the clinical outcome as well as HRQOL

Improving Cardiometabolic Health in Individuals Taking Antipsychotic Drugs at Burnaby Primary Care Clinic

Abstract Metabolic syndrome is a common health issue in individuals with mental health diagnoses and taking antipsychotic drugs. In this Doctor of Nursing Practice (DNP) pilot project, a nurse practitioner (NP) at mental health specialty primary care clinic in British Columbia, Canada, implemented an eight-week evidence-based program to motivate clients to initiate healthy behaviors. The project set the PICO question as Do individuals with mental health illness being treated with antipsychotic drugs (and receiving treatment via telehealth visits) (P) who perform regular self-abdominal circumferences measurement and receive patient education about risks for metabolic syndrome (I) initiate more lifestyle-changing behaviors (O) than prior to these interventions? (C) . The project recruited five mentally and physically stable participants receiving antipsychotic drugs associated with metabolic syndrome from the clinic. All the participants received education on the risks of metabolic syndrome and healthy behaviors from the NP via telephone. The participants were also encouraged to measure their abdominal girth and followed up every two weeks, up to eight weeks. Additionally, health-related quality of questionnaires (HRQOL) were administered at weeks one and eight to see if their health perception improved. Although HRQOL scores and abdominal circumference measurements did not change with statistical significance, the mean of abdominal circumference measurements declined at week eight. Furthermore, the participants who completed the program, initiated and maintained healthy behaviors in week eight. Although the results were limited to this clinic, this project suggests a potential for the future application of such a cardiometabolic program in the clinics in a similar setting in the region. Keywords: DNP Project, Cardiometanolic, Metabolic Syndrome, Mental Health, Primary Car

Racial Differences in Social Support and the Quality of Life Among Individuals with Chronic Illnesses

Previous studies have indicated that the association between social support and quality of life (QOL) among individuals with chronic illnesses differs by race, yet the specifics of these association are uncertain. The purpose of this dissertation was to examine racial differences in associations between factors of social support (i.e. sources of informal social support and positive/negative social support) and four QOL domains (i.e., physical well-being, psychological well-being, social well-being, and spiritual well-being) among individuals previously diagnosed with a chronic illness. The study was guided by three aims: 1) to examine common intrapersonal-level (e.g., stress, coping, and self-esteem) and interpersonal-level constructs (e.g., major discrimination, everyday discrimination, frequency of contact, social network ties, and social network size) as mediators and moderators, 2) to examine associations between sources of informal social support and QOL domains among individuals with chronic illnesses, and 3) to examine associations between sources of positive and negative social support and QOL domains among individuals with chronic illnesses. It is hypothesized the pattern of the associations between factors of social support and the four QOL domains will differ between individuals of African descent (i.e., African Americans and Caribbean Blacks) and non-Hispanic whites. Secondary data analyses of the National Survey of American Life (NSAL) were conducted. The sample was comprised of 3,285 African Americans, Caribbean Blacks, and non-Hispanic whites. Moderation was evaluated through interaction terms. Mediation was assessed through bootstrapping procedures. Multiple imputation analyses primarily assessed the racial differences between factors of social support and QOL domains. Stress and social ties consistently moderated and mediated the relationship between factors of social support and QOL domains. A total of 10 of the 40 associations between factors of social support and QOL domains were moderated by race. In addition, the direction of 16 of the 40 associations between factors of social support and QOL domains indicated differences between individuals of African descent compared to non-Hispanic whites after stratifying the study sample by race. Future prospective longitudinal studies are needed to further assess the influence of social support and QOL domains among individuals of African descent and non-Hispanic whites with chronic illnesses