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Characteristics and workload of full-time faculty in baccalaureate dental hygiene programsCollins, Marie Antoinette. January 2006 (has links) (PDF)
Thesis (Ed.D.)--Georgia Southern University, 2006. / "A dissertation submitted to the Graduate Faculty of Georgia Southern University in partial fulfillment of the requirements for the degree Doctor of Education" ETD. Includes bibliographical references (p. 133-138) and appendices.
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Fullness of life an exploration into wellness /Hahn, Judith. January 1982 (has links)
Thesis (M.T.S.)--Catholic Theological Union, 1982. / Includes bibliographical references (leaves 141-144).
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Cancer medicines : clinical impact, economics, and valueSalas-Vega, Sebastian January 2017 (has links)
Background and Importance: There has been much debate recently over rapidly growing drug expenditures. Cancer medicines, in particular, have driven new brand spending over recent years, and US oncological expenditures have risen faster than for many other disease areas, in part because of rapidly growing drug prices, as well as increased rates of use. Objective: In the face of ongoing debates on how to reasonably control growth in pharmaceutical spending, while also providing patients with the best possible care, this thesis sets out to help address the question of whether growing pharmaceutical expenditures are providing value-for-money to patients and society. Novelty and Empirical Contributions: This thesis is based in part on a systematic review with narrative synthesis of English-language HTA appraisals of the comparative clinical risks and benefits of new cancer medicines, as well as on the novel use of methods to generate comparative evidence on their use and cost. Adapting established methods, these data are then used to examine existing questions over whether growing expenditures are worth the cost to patients and society. This thesis makes five major contributions to the literature on value-based spending on cancer medicines: 1) approximately one in three newly licensed cancer medicines provide no known overall survival benefit, while one in five provide no known overall survival, quality of life, or safety benefit; 2) novel use of methodologies to model treatment course and duration reveals that cancer drug use and costs vary greatly between individual medicines, and across Australia, France, the UK, and the US; 3) the monetized value of survival gains attributable to cancer drug innovation, net of growth in cancer drug spending, varies across individual medicines, and, at a country-level, remains unambiguously positive in Australia, France, and the UK, but negative in the US; 4) spending on new cancer medicines is often only weakly associated with their clinical benefits; and 5) the strength of this association nevertheless varies across countries, with the UK demonstrating the strongest evidence of value-based spending on new cancer medicines. Clinical and Policy Implications: Findings from this thesis provide a resource for valuebased clinical decision-making by patients and physicians. Moreover, growing expenditures on cancer medicines may only weakly be associated with meaningful clinical benefits, though the extent to which this is true differs across countries. These findings highlight the important role that health policy can have in encouraging valuebased cancer drug spending. In particular, it is argued that managed access schemes promoting access and evidence development, as well as the use of value-based spending policies, can help expedite access to new treatments, incentivize the development of clinically meaningful medicines, and rationalize growing cancer drug expenditures. Future Research Directions: The comparative clinical risks and benefits from new cancer medicines using real-world data, and how they compare with trial-based results; how evidence on the comparative impact from new treatments is measured, weighted, and rewarded in decision-making by regulators and payers; and how it is effectively linked through policy and regulation to cancer drug spending.
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AIDS denialism in South Africa : a case study in the rationality and ethics of science policyFurman, Katherine January 2016 (has links)
From 28 October 1999 to 26 September 2000 Mbeki publically endorsed the position of ‘denialist’ AIDS scientists – a marginal group who oppose the claim that HIV causes AIDS – and used their views as the basis for a policy of not providing ARVs (antiretrovirals – the treatment that prevents HIV from replicating) via the public health system. This policy persisted until 2004, with severe consequences – best estimates indicate that it resulted in 171,000 avoidable new infections and 343,000 deaths over the 1999 – 2002 period. I use this case to address two questions. First, is it reasonable for policy makers to consult non-mainstream scientists in the process of policy development? Second, can they be held personally morally responsible for the consequences of having done so when things go very badly wrong? I begin by providing a motivation for why philosophers should be interested in real-world cases. Having justified the philosophical “methodology” of this thesis, I move on to describing the specific case of South African AIDS denialism in the early 2000s. I then take a chronological step back in order to assess the rationality of accepting HIV as the sole cause of AIDS in 1984, when the virus was first identified. I argue that it was rational, but that some explanatory power was lost when other competing accounts of the disease’s aetiology were discarded. I argue that this explanatory loss can be accounted for by re-considering the way causation is understood in biomedicine and epidemiology. Having settled the scientific issues of the case, I then move on to the question of moral responsibility. I specifically look at when an agent can be held morally responsible for their ignorance, and the role of suppressed disagreement in the production of that ignorance.
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The influence of age, cardiorespiratory fitness, exercise and sedentary behaviours on circulating angiogenic cells and cell surface receptor expressionRoss, Mark D. January 2016 (has links)
Cardiovascular disease (CVD) is the biggest killer of people in western civilisation. Age is a significant risk factor for the development for CVD, and treatments and therapies to address this increased risk are crucial to quality of life and longevity. Exercise is one such intervention which has been shown to reduce CVD risk. Age is also associated with endothelial dysfunction, reduced angiogenic capabilities, and reduced ability to repair the vessel wall. Circulating angiogenic cells (CACs) are a subset of circulating cells which assist in the repair and growth of the vasculature and in the maintenance of endothelial function. Reductions in these cells are observed in those with vascular disease compared to age-matched healthy controls. Exercise may reduce CVD risk by improvements in number and/or function of these CACs. Data was collected from human volunteers of various ages, cardiorespiratory fitness (CRF) levels and latent viral infection history status to investigate the effects of chronological age, CRF, viral serology and other lifestyle factors, such as sedentary behaviours and exercise on CACs. The levels of CACs in these volunteers were measured using four colour flow cytometry using various monoclonal antibodies specific to cell surface markers that are used to identify specific subsets of these CACs. In addition, the response to acute exercise of a specific subset of these CACs, termed ‘angiogenic T-cells' (TANG) were investigated, in a group of well-trained males aged 20-40 years, using a strenuous submaximal exercise bout. Advancing age was associated with a decline in various subsets of CACs, including bone marrow-derived CD34+ progenitors, putative endothelial progenitor cells (EPCs) and also TANG cells. Individuals with a higher CRF were more likely to have higher circulating numbers of TANG cells, particularly in the CD4+ subset. CRF did not appear to modulate CD34+ progenitors or EPC subsets. Increasing sitting time was associated with reduction in TANG cells, but after correcting for the effects of fitness, sitting time no longer negatively affected the circulating number of these cells. Acute exercise was a powerful stimulus for increasing the number of TANG cells (140% increase), potentially through an SDF-1:CXCR4-dependent mechanism, but more studies are required to investigate this. Latent CMV infection was associated with higher number of TANG cells (CD8+), but only in 18-40 year old individuals, and not in an older age group (41-65 year old). The significance of this has yet to be understood. In conclusion, advancing age may contribute to increased CVD risk partly due to the observed reductions in angiogenic cells circulating in the peripheral compartment. Maintaining a high CRF may attenuate this CVD reduction by modulating TANG cell number, but potentially not CD34+ progenitor or EPC subsets. Acute exercise may offer a short window for vascular adaptation through the mobilisation of TANG cells into the circulation.
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The expansion of public health insurance in Mexico : health, financial and distributional effectsSáenz de Miera Juárez, Belén January 2017 (has links)
During the past decade, the Mexican government launched an ambitious expansion of public health insurance through the Seguro Popular programme (SP). As a result, health care access was legislated as citizens’ entitlement, a generous benefit package was offered, and public health expenditure was significantly increased. In 2011, the programme had reached 52 million affiliates. However, there is limited evidence on its effects on a number of outcomes and their distribution. This thesis analyses three aspects that are key to evaluate health system performance. Specifically, using quasi-experimental methods and recent distributional measures of pure health, it examines the effect of universal insurance coverage on infant mortality, non-medical consumption, and health inequalities. Drawing on municipality-level data, the first article finds that the programme led to a 3.9 per cent decrease in infant and neonatal mortality. These reductions were concentrated in more populated, urban, and less marginalised municipalities, however, probably because this type of municipalities have been traditionally better equipped and are thus better prepared to offer all the interventions from the benefit package. Based on data from the Mexican Family Life Survey (MxFLS), the second article shows that unexpected health events such as accidents and deterioration in physical capacity are associated with large declines in non-medical consumption. Social security seems to provide protection against both types of shocks, but endogeneity-corrected estimates show that the SP only protects consumption against accidents. This suggests that income losses associated with disability shocks for which the programme does not offer protection, are likely larger than medical care expenditures, and poses the question of whether other social security benefits, such as disability insurance, should also be extended. Finally, the third article analyses the distribution of health in the context of the SP implementation. Unlike traditional studies, pure health inequality and mobility are analysed using a recently developed class of indices appropriate for categorical data. If a downward-looking definition of status is employed, the distribution of health appears stable, but if an upward-looking definition is adopted, a significant increase in inequality is observed. Evidence of strong persistence in health was also found. This lack of improvement in the health distribution suggests that factors other than health insurance coverage, such as institutional performance, are more important determinants of health inequalities. Overall, this thesis finds important health effects from extending health insurance coverage but limited effects on economic welfare and the distribution of health status across the entire population.
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Multiple criteria decision analysis for assessing the value of new medical technologies : researching, developing and applying a new value framework for the purpose of health technology assessmentAngelis, Aris Nikolaos January 2017 (has links)
Introduction: Current evaluation approaches for new medical technologies are problematic for a plethora of reasons relating to measuring their expected costs and consequences, but also due to hurdles in turning assessed information into coverage decisions. Most adopted methodologies focus on a limited number of value dimensions, despite the fact that the value of new medicines is multi-dimensional in nature. Explicit elicitation of social value tradeoffs is not possible and decision-makers may adopt intuitive or heuristic modes for simplification purposes, based on ad hoc procedures that might lead to arbitrary decisions. Objectives: The objective of the present thesis is to develop and empirically test a methodological framework that can be used to assess the overall value of new medical technologies by explicitly capturing multiple aspects of value while allowing for their tradeoffs, through the incorporation of decision-makers’ preferences in a structured and transparent way. The research hypothesis is that Multiple Criteria Decision Analysis (MCDA) can provide a methodological option for the evaluation of new medicines in the context of Health Technology Assessment (HTA), to support decision-making and contribute to more efficient resource allocation. Methods and Empirical Evidence: The first paper proposes a conceptual methodological process, based on multi-attribute value theory (MAVT) methods comprising five distinct phases, outlining the stages involved in each phase and discusses their relevance in the HTA context. The second paper conducts a systematic literature review and expert consultation in order to investigate the practices, processes and policies of value-assessment for new medicines across eight European countries and identifies the evaluation criteria employed and how these inform coverage recommendations as part of HTA. The third paper develops a MAVT value framework for HTA, incorporating a generic value tree for new medicines composed from different levels of criteria that fall under five value domains (i.e. therapeutic, safety, burden of disease, innovation and socio-economic), together with a selection of scoring, weighting and aggregating techniques. In the fourth and fifth papers, the value framework is tested empirically by conducting two real-world case studies: in the first, the value tree is adapted for the evaluation of second-line biological treatments for metastatic colorectal cancer (mCRC) patients having received prior oxaliplatin-based chemotherapy; in the second, the value tree is conditioned for the evaluation of third-line treatments for metastatic castrate resistant prostate cancer (mCRPC) patients having received prior docetaxel chemotherapy. Both case studies were informed by decision conferences with relevant expert panels. In the mCRC decision conference multiple stakeholders participated reflecting the composition of the English National Institute for Health and Care Excellence (NICE) technology appraisal committees, whereas in the mCRPC decision conference a group of evaluators participated from the Swedish Dental and Pharmaceutical Benefits Agency (TLV), thereby adopting the TLV decision-making perspective. Policy Implications: The value scores produced from the MCDA process reflect a more comprehensive benefit metric that embeds the preferences of stakeholders and decisionsmakers across a number of explicit evaluation criteria. The incorporation of alternative treatments’ purchasing costs can then be used to derive incremental cost value ratios based on which the treatments can be ranked on ‘value-for-money’ grounds, reflecting their incremental cost relative to incremental value. Conclusion: The MCDA value framework developed can aid HTA decision-makers by allowing them to explicitly consider multiple criteria and their relative importance, enabling them to understand and incorporate their own preferences and value trade-offs in a constructed and transparent way. It can be turned into a flexible decision tool for resource allocation purposes in the coverage of new medicines by payers but could also be adapted for other decision-making contexts along their development, regulation and use.
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The prevalence and severity of periodontal disease in Type II diabeticsHyslop, James R. January 2011 (has links)
Magister Scientiae Dentium - MSc(Dent) / Introduction: The relationship between Periodontal Disease and Type II diabetes has been reported in recent literature. More recent studies suggest that further research is required into the relationship of glycaemic control on Periodontitis. The main aetiological factor in Periodontal Disease is plaque; however other secondary factors such as Diabetes Mellitus, neutrophil abnormalities, smoking, socio-economic status, age, stress, Human Immunodeficiency Virus (HIV) infections, pregnancy, sex hormones, osteoporosis and several other conditions play an important causative role (Genco, 1993). Aim: The purpose of this study is to test the hypothesis that the prevalence and severity of periodontal disease is greater for patients with poorly controlled Type II Diabetes Mellitus (DM-2) compared to those with better controlled Type II Diabetes Mellitus. Methods: 'Coloured female patients', who were diagnosed with Type II diabetes were included in the study. Demographic information, medical history and HbA1c levels were recorded by the attending physician in the diabetes unit. Periodontal examination was carried out by a single examiner. This included a plaque index (PI), a gingival index (GI), bleeding on probing (BoP), probing depths (PD) and clinical attachment loss (CAL). These measurements were recorded on Ramfjord teeth. The presence of any one sextant showing PD of ≥ 4 mm or clinical loss of attachment of ≥ 3 mm was diagnosed as periodontitis. Results: Poor glycaemic control was associated with more severe periodontitis. Conclusion: The results of the study showed that it could be justified that the regression approach (correlation) be applied to the complete sample of 63 individuals. Most of these correlation coefficients were positive and significantly different from zero, indicating that 'HbA1c' had a detrimental influence on the periodontal measurements; within the limitations of the study. This link could be indirect in that some other properties of diabetes, and not necessarily 'HbA1c', affected the dental health of diabetics adversely.
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Association between active smoking, secondhand smoke and peripheral arterial diseaseLu, Liya January 2017 (has links)
Worldwide, cardiovascular disease (CVD) is the leading cause of death. It is widely accepted that both active smoking and exposure to secondhand smoke (SHS) are associated with CVD. About 20% of the global population smoke tobacco or tobacco-related products. The global prevalence of smoking is increasing, although it is decreasing in some high-income and upper middle-income countries. Globally, about a third of adults and 40% children are regularly exposed to SHS. According to the World Health Organisation (WHO), only 16% of the global population is protected by a comprehensive smoke-free legislation. Coronary heart disease (CHD), stroke and peripheral arterial disease (PAD) are all types of atherosclerosis and often co-exist in the same patients. Therefore, they share many common risk factors including cigarette smoking. However, previous epidemiological studies on CVD including those on cigarette smoking mainly focused on CHD and stroke and pay little attention to PAD. Evidence is increasing in support of the association between exposure to SHS and both CHD and stroke. In contrast, there is a paucity of studies on SHS and the risk of PAD. The overarching aim of this thesis was to collate the published evidence on the association between active cigarette smoking and PAD, and examine the association between exposure to SHS and PAD in the general population. This thesis starts with a systematic review on the association between active cigarette smoking, SHS and PAD undertaken using four databases: Medline, Embase, PubMed and Web of Science to identify existing published evidence up to 30 April 2012 (Chapter 2). Prior to the published studies contained in this thesis, there had been no meta-analyses on the association between active cigarette smoking and PAD and only two studies published on the association between SHS and PAD. Therefore, this systematic review was followed by a meta-analysis on the association between active cigarette smoking and PAD. This meta-analysis identified 55 studies: 43 cross-sectional, 10 cohort and 2 case-control. Of the 68 results for current smokers, 59 (86.8%) were statistically significant and the pooled odds ratio (OR) was 2.72 (95% confidence interval [CI] 2.28-3.21). Of the 40 results for ex-smokers, 29 (72.5%) were statistically significant and the pooled OR was 1.67 (95% CI 1.54-1.81). Active cigarette smoking significantly increases the risk of PAD, compared with never smokers. The magnitude of association between active cigarette smoking and PAD was greater in current smokers than ex-smokers. In contrast, prior to my studies in this thesis, only two studies on SHS were identified. Only one showed an overall association between self-report SHS and PAD in Chinese never smokers, with a clear dose-response relationship. The other study used serum cotinine as measure for SHS exposure and found neither an overall association nor a dose-response relationship but suggested a very high cotinine concentration as threshold. Chapter 3 examines the association between SHS exposure and PAD in adult non-smokers in Scotland. This chapter includes two cross-sectional studies using the Generation Scotland: Scottish Family Health Study (GS: SFHS) and the Scottish Health Survey (SHeS), and one retrospective cohort study using the record linkage of the SHeS. In the cross-sectional study using SFHS, PAD was measured using ankle brachial pressure index (ABPI) but SHS exposure was self-report. Of the 5,686 never smokers, 134 (2.4%) had PAD (defined as an ABPI < 0.9). Participants who reported overall high level of SHS exposure (exposed to ≥40 hours per week) were more likely to have PAD, compared with those who reported no exposure to SHS. After adjustment for potential confounders, the association between SHS and PAD persisted (adjusted OR 4.53, 95% CI 1.51-13.56, p=0.007), with suggestion of a dose-response relationship. In the other cross-sectional study using SHeS, SHS exposure was measured objectively using cotinine concentration but PAD was based on self-report symptoms of intermittent claudication (IC) using the Edinburgh Claudication Questionnaire. Of the 4,231 non-smokers (defined as self-reported non-smokers with a salivary cotinine concentration <15 ng/mL), 134 (3.2%) had IC. Participants with high exposure to SHS (cotinine ≥2.7 ng/mL) were at significantly higher risk of IC, after adjustment for potential confounders (adjusted OR 1.76, 95% CI 1.04-3.00, p=0.036). A dose-response relationship was suggested, whereby the risk of IC increased with increasing cotinine concentration. However, the association varied by age category. Participants aged <60 were more strongly associated with PAD. This may be explained by survival bias. For the third, retrospective cohort study in Chapter 3, I used record linkage of SHeS to Scottish Morbidity Record 01 (SMR01) records and death certificates to identify the first hospital admission/death following the SHeS in which PAD was recorded as the primary or secondary cause. Of the 4,045 confirmed non-smokers who were free of baseline IC were included. Over the follow-up period (mean follow-up 9 years), there were 568 deaths, none of which were coded as due to PAD, and 64 participants were hospitalised for PAD. High exposure to SHS was associated with increased risk of all-cause mortality (adjusted hazard ratio [HR] 1.42, 95% CI 1.09- 1.86, p=0.011) among all non-smokers and increased risk of incident PAD (adjusted HR 2.82, 95% CI 1.14-6.96, p=0.024) among male non-smokers. Increased cotinine concentrations at baseline were associated with increased risk of all-cause mortality, with a dose-response relationship. SHS contains both sidestream smoke, from burning cigarette tips, and exhaled mainstream smoke. Shortened telomere length is broadly viewed as a biomarker for biological ageing including atherosclerosis phenotypes such as PAD. Evidence is strong that active smoking increases telomere length attrition but whether such association occurs between SHS and telomere length is unknown. Therefore, Chapter 4 aimed to add to growing evidence that exposure to SHS is associated with disproportionately higher biomarkers of cardiovascular risk compared with active smoking and may accelerate normal biological ageing. This chapter includes two cross-sectional studies. The first study investigated the relationship between salivary cotinine and several preclinical cardiovascular biomarkers: C-reactive protein (CRP), high-density lipoprotein (HDL) cholesterol, TC/HDL cholesterol ratio and fibrinogen in 10,081 adults from the SHeS. CRP concentration and the TC/HDL cholesterol ratio increased, and HDL cholesterol concentration decreased with increasing cotinine concentration among both non-smokers and active smokers. There were step changes in the relationship between tobacco exposure and cardiovascular biomarkers at the interface of non-smokers exposed to SHS and active smokers. Non-smokers with high exposure to SHS had lower cotinine concentrations than light active smokers but comparable concentrations of CRP (p=0.709), HDL cholesterol (p=0.931) and the TC/HDL cholesterol ratio (p=0.405). Fibrinogen concentration was less clear-cut and only increased in moderate and heavy active smokers. The second study in this chapter explored the association between self-reported levels of SHS exposure and telomere shortening per annum using a subgroup of participants from the SFHS. Of the 1,303 non-smokers, telomere length decreased more rapidly with increasing age among participants with high level of SHS exposure, compared with both those with no exposure (adjusted coefficient -0.006, 95% CI -0.008- -0.004) (high vs no SHS: p=0.010) or low exposure (adjusted coefficient -0.005, 95% CI -0.007- -0.003) (high vs low SHS: p=0.005). In summary, there is now substantial evidence of an association between active cigarette smoking and PAD. / This thesis adds to the limited existing evidence on SHS as an independent risk factor for PAD. There was an overall association between exposure to SHS and PAD, with suggestion of a dose-response relationship. However, the association varied by age category. Individuals aged <60 were more strongly associated with the prevalence of IC. SHS was significantly associated with incident PAD only in men. This thesis further demonstrates that exposure to SHS carries a disproportionately higher cardiovascular risk than active smoking for a given level of smoke exposure. Telomere shortening per year of age may be an intermediate step between SHS and CVD including PAD. This also supports the association between SHS exposure and the atherosclerosis-related biomarkers, which play an important role in the pathophysiology of PAD. Further research is needed in the future to better understand the association between SHS and PAD, and the underlying mechanisms. The research in this thesis supports the need to protect the general public from exposure to SHS.
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Ageing with HIV : an investigation of the health and well-being of older people in a rural South African population with a severe HIV epidemicNyirenda, Makandwe January 2014 (has links)
This study aims to describe the living and informal care circumstances of older people in an area of rural South Africa severely affected by HIV, and examine how those circumstances may influence the physical health, emotional well-being and survival of older people. Using longitudinal surveillance and cross-sectional survey data this thesis is built around four separate but related papers. Specific study objectives were to: 1) investigate household living arrangements and informal care (financial, physical or emotional assistance) by or towards older people in rural South Africa; 2) describe the self-reported health and emotional well-being status of older people by HIV status; and 3) examine the association between self-reported health, emotional well-being and informal care and mortality in older people. Surveillance data for 2005-2010 showed living arrangements remained stable, with over 85% of older people aged 60 years and above living in multi-generational households; over this period employment rates in both older and young people declined, but government grants receipt increased. Being co-resident with own children, household structure and size were important determinants of whether financial support flowed downward (from older to younger) or upward (from young to older person); while peer support (from one older person to another) was rare. Adjusting for age, marital status, education, place of residency and household socio-economic status, exchanges of financial resources in the study population are most likely to be downward or at best reciprocal (bidirectional with young people). Of the cross-sectional study participants (n=422) aged 50+, over 60% were care-givers (provided help with activities of daily living) to at least one adult (18-49 years) or child (below 18 years); around 84% (n=356) of older people were care-receivers; of whom over 92% (n=329) were receiving assistance with fetching water. Spouse, adult child, and grandchildren were the main sources of physical or emotional care for care-recipients. As expected health deteriorated with advancing age and women were less likely to be in good health. Further, care-giving was associated with improved functional ability but decreased emotional well-being. HIV-infected older participants reported better functional ability, quality of life and overall health state than HIV-affected (had an HIV-infected or HIV-related death of adult child) study participants. These differentials in health and well-being were also evident in mortality patterns over three years of follow-up. Mortality was higher among non-care-givers than in care-givers, in older people with poor self-rated health and in participants who had experienced a major depressive episode. Findings suggest there is an intricate relationship between living arrangements, informal care and health, emotional well-being and survival of older people in severely HIV-affected settings. More crucially, with the considerable resources devoted to HIV Care and Treatment programmes, uninfected older persons may be highly vulnerable to poor health. A multifaceted intervention to improving older people’s health and well-being is urgently required.
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