Background: Treatment-resistant depression (TRD) encompasses a segment of individuals with major depressive disorder who are severely ill in terms of chronicity, comorbidity, and prognosis. Although functional impairment is a prominent and costly feature of treatment-resistance, very little is known about the factors that contribute to and maintain functional impairment in TRD. Purpose: This study examined the relationships among neurocognition, symptoms, and functional impairment in TRD. Specifically, I examined the neurocognitive impairments that relate to different symptom domains and to level of symptom severity, as well as the predictors of functional outcomes and real-world behaviour in TRD. Method: Patients (N = 29) with a diagnosis of major depressive disorder were recruited from the Mood Disorders Treatment and Research Service at Providence Care Mental Health Services in Kingston, Ontario. Data were collected during a baseline assessment for a neurocognitive enhancement therapy program. Results: Individuals with TRD show mild to moderate impairments across all neurocognitive domains, with a superimposed severe impairment in verbal working memory. Verbal working memory significantly correlated with depressive symptoms and anxiety, such that increased verbal working memory capacity was related to more severe clinical symptoms. Greater response inhibition significantly correlated with less anxiety. Interpersonal competence was predicted by sustained attention and severity of depressive symptoms. Adaptive competence was significantly predicted by age at baseline and set shifting. Real-world work behaviour, interpersonal relations, and general satisfaction were predicted by the severity of depressive symptoms, whereas observed mood and anxiety predicted real-world recreational activity. Conclusions: The current study pioneered some of the first data regarding the relationships among neurocognition, symptoms, and functional outcomes in treatment-resistant depression. Verbal working memory appears to play an important role in the symptomatology of TRD. Neurocognitive variables and depressive symptoms are important in predicting functional competence (what one can do) but only depressive symptoms predict functional performance (what one actually does in the real world). There may be additional intrinsic or extrinsic factors that mediate the relationships among neurocognition, symptoms, and functioning in TRD. / Thesis (Master, Psychology) -- Queen's University, 2011-09-07 11:55:40.708

This study is a prospective longitudinal outcome study investigating the presence of response shift in disease and generic functional outcome measures in 105 patients undergoing spinal surgery. The then-test method which compares pre-test scores to retrospective pre-test scores was used to quantitate response shift. There was a statistically significant response shift for the Oswestry Disability Index (ODI) (p=0.001) and the Short Form-36-PCS (p=0.078). At three months, seventy-two percent of patients exhibited a response shift with the ODI. Fifty-six and 21 percent of patients exhibited a response shift with the SF-36 physical and mental component scores respectively. When accounting for response shift and using the minimal clinically important difference, the success rate of the surgery at 3 months increased by 20 percent. The presence of response shift has implications for the measurement properties of standard spinal surgery outcome measures including the effect size of treatment and the number of responders to treatment.

This study is a prospective longitudinal outcome study investigating the presence of response shift in disease and generic functional outcome measures in 105 patients undergoing spinal surgery. The then-test method which compares pre-test scores to retrospective pre-test scores was used to quantitate response shift. There was a statistically significant response shift for the Oswestry Disability Index (ODI) (p=0.001) and the Short Form-36-PCS (p=0.078). At three months, seventy-two percent of patients exhibited a response shift with the ODI. Fifty-six and 21 percent of patients exhibited a response shift with the SF-36 physical and mental component scores respectively. When accounting for response shift and using the minimal clinically important difference, the success rate of the surgery at 3 months increased by 20 percent. The presence of response shift has implications for the measurement properties of standard spinal surgery outcome measures including the effect size of treatment and the number of responders to treatment.

No description available.

Sarcoma cancer of the proximal femur is a bone tumor that develops near the hip joint. The most common method of treatment is limb salvage surgery (LLS), a highly invasive surgery that often leads to impaired movement including walking due to soft tissue resection. The current thesis focuses on 1) systematically reviewing current literature of functional outcomes after proximal femur LSS to determine if specific methods of muscle reattachment lead to better limb function, and 2) objectively analysing how reducing hip muscle strength impacts one’s ability to achieve healthy gait. Findings from the systematic review suggest using artificial mesh or ligaments for LLS may be a good alternative to allograft prosthesis composites and trochanter osteotomy, producing good functional outcomes with low rates of complications. It was also determined current literature is lacking objective quantitative analysis of patients’ limb function after surgery. Objective 2 was executed using instrumented gait analysis to record the gait kinematics, kinetics and EMG patterns of a patient who received LSS for proximal femur sarcoma. Data from the gait analysis was used to create a patient-specific musculoskeletal model. Healthy gait kinematics were applied to the model and specific hip muscle strengths were systematically reduced to simulate different surgical interventions. After an 85% reduction in gluteus medius and minimus muscle strength, healthy gait kinematics were not achieved. Reducing muscle strength of the gluteus medius and minimus together had a greater impact on the model’s ability to achieve healthy gait kinematics then when reduced individually. An understanding of how patient’s limb function is impacted after surgery can inform surgical technique, implant design and physiotherapy programs leading to better quality of life for patients after surgery. / Thesis / Master of Applied Science (MASc) / Hip reconstructive surgery as treatment for bone cancer is a highly invasive surgery that negatively impacts patients walking patterns and ultimately quality of life. The current thesis investigates existing literature to determine if specific, innovative surgical techniques lead to better functional results for patients after surgery. A three-dimensional model of a patient who had hip reconstruction surgery for bone cancer was created using quantitative analysis of their walking patterns. The model was manipulated to simulate surgical intervention for hip cancer treatment. The model findings suggest when specific hip muscles are substantially affected by surgery, patients walking patterns are negatively impacted. Understanding how surgical intervention impacts walking patterns can inform surgical technique, implant design and physiotherapy programs leading to better quality of life for patients after surgery.

No description available.

Objective: To examine the impact of treatment outcome and treatment condition (Cognitive-behavioral therapy, CBT; Sertraline, SRT; COMB, CBT and SRT; Placebo) for youth treated for anxiety disorders on global and domain-specific functioning across a 3 to 12 year, naturalistic follow-up. Method: A subset (319) of 488 families from the Child/Adolescent Anxiety Multimodal Study (CAMS; Walkup et al., 2008) participated in an average of 3.38 assessments during the follow-up period. All youth met criteria for a principal anxiety disorder pretreatment. Growth curve modeling examined the impact of treatment outcomes (response/remission) and treatment condition on global functioning, global and domain- specific impairment, and life satisfaction across the follow-up period. Logistic regression explored the impact of treatment response and condition on low frequency events (arrests/convictions) and educational achievement (high school graduation/college enrollment). Results: Growth curve analyses revealed that treatment responders/remitters demonstrated better global functioning, increased life satisfaction, and decreased overall impairment at their first follow-up assessment (growth curve mean intercept). The positive effect of treatment response on life satisfaction, but not global functioning or overall impairment, attenuated across the follow-up period. Treatment response also predicted decreased academic impairment at first follow-up. Participants in the COMB condition demonstrated improved functional trajectories with regards to family life and academic grade-point average. CBT participants demonstrated a greater decline in overall impairment and problems with self-care/independence across the follow-up. Treatment response and condition did not predict legal outcomes, school attendance, high school graduation, college attendance, occupational outcomes, or social/peer relationships. Conclusion: Response to early intervention is associated with improved overall functioning, as well as functioning within specific domains (academics) 3 to 12 years posttreatment. Treatment type differentially predicted functional trajectories. Findings support the positive impact of pediatric anxiety treatment on functioning during adolescence and emerging adulthood. / Psychology

This thesis sought to explore the phenomenon of discontinuing neuroleptic medication for psychosis. It comprises three standalone papers. Papers one and two have been prepared for submission to journals and in accordance with the journal guidelines. Paper one is a systematic literature review synthesising studies investigating the association between neuroleptic discontinuation and functional outcomes. Databases were systematically searched and thirteen studies were included in the review. Evidence regarding the association between discontinuation from neuroleptic medication and functional outcomes was mixed. Findings are limited by the scarcity of evidence, diversity in the study methods and designs used, and methodological and design quality issues. Paper two is a qualitative study exploring personal accounts of making choices about neuroleptic medication, specifically considering decisions to discontinue. Twelve participants were interviewed and a constructivist grounded theory approach was used to analyse transcripts. The findings suggest that making sense of choices relates to a continuation-discontinuation spectrum and involves three interrelated tasks. The tasks are: forming a personal theory of the need for, and acceptability of, neuroleptic medication; negotiating the challenges of forming alliances with others; and weaving a safety net to safeguard wellbeing. A theoretical model explaining the processes involved in the tasks and the mediating factors is presented and discussed. The clinical implications of the findings are discussed with reference to existing literature. Paper three is not intended for publication and is a critical review of the research process, in which the strengths and weaknesses of the systematic review and empirical study are evaluated. Personal and professional reflections on the experience of conducting a systematic review and an empirical qualitative study are discussed and the implications of the research for future clinical practice and research are considered.

BACKGROUND: Many different ocular diseases produce a common symptom of macular edema - a leakage of fluid into the retina. In addition to the presence of this structural aberration, functionally, the retina’s capacity to effectively conduct electrochemical signals will be impaired. The impediment can be demonstrated by a decreased electrical response measured via electroretinography (ERG) and visualized as a waveform with quantifiable amplitude. Macular edema and its associated effects on retinal structure and function are resultant of abnormal blood vessel growth, or angiogenesis. The process of angiogenesis involves a pathway of multiple growth factors and signaling molecules, including vascular endothelial growth factor (VEGF). Modern day treatments to help resolve macular edema target VEGF in order to inhibit pathological angiogenesis; two such anti-VEGF medications are aflibercept, or Eylea, and bevacizumab, also known as Avastin. This retrospective cohort study aims to compare the outcomes of patients treated with either Avastin or Eylea, and to observe what structural or functional changes occur in each sample. METHODS: This study included twelve eyes of 8 eligible patients that were injected with intravitreal Avastin for diabetic macular edema (DME), clinically significant macular edema (CSME), proliferative diabetic retinopathy, or non-proliferative diabetic retinopathy (NPDR), and had resolved macular edema. Five eyes of 6 eligible patients that were injected with intravitreal Eylea for NPDR, neovascular age-related macular degeneration (AMD), cystoid macular edema (CME), central retinal vein occlusion (CRVO), or DME, and had resolved edema were also included in the study. Patient data was randomly screened and collected via the MDIntelleSys (MDI) electronic medical record system at Fromer Eye Centers, New York. No personally identifiable information was collected in this study. The parameters used for comparison of the two anti-VEGF medications were the length of treatment, frequency of injection, change in ERG magnitude between subsequent scans, and net change in ERG magnitude between the baseline scan and the most recent scan obtained during the period of the study. The means of each parameter were determined to be the best measure of central tendency to summarize the data. Welch’s t-tests were conducted at a significance level of α= 0.05 between the parameters of each group to determine the significance of the differences in the means obtained. RESULTS: There was no significant difference found between the mean number of injections, time until recovery, change in magnitude, and net change in magnitude for both Avastin-treated patients and those treated with Eylea. CONCLUSION: The results of this study support the conclusion that both aflibercept and bevacizumab are comparably effective anti-VEGF treatments, in both relieving macular edema and restoring function in retinal cells. The similar outcomes observed in each treatment group offer insight into the versatility of anti-VEGF treatment and provide physicians with the flexibility of pursuing alternative medication options for their patients. Further study into the structural and functional effects of various anti-VEGF medications is needed to account for variables such as age, sex, race, or other possibly confounding factors. An inclusion of other quantifiable data such as visual acuity would also benefit this investigation. Furthermore, this study is limited by its focus solely on anti-VEGF medication; this subject of discussion would benefit from an experimental comparison between anti-VEGF treatments and other allopathic interventions. Recent studies have suggested alternatives to anti-VEGF altogether such as intravitreal triamcinolone acetonide and intravitreal steroids like dexamethasone, marketed as Ozurdex.

The purpose of this narrative review is to describe the different nerve-sparing techniques applied during radical prostatectomy and document their functional impact on postoperative outcomes. We performed a PubMed search of the literature using the keywords “nerve-sparing”, “techniques”, “prostatectomy” and “outcomes”. Other potentially eligible studies were retrieved using the reference list of the included studies. Nerve-sparing techniques can be distinguished based on the fascial planes of dissection (intrafascial, interfascial or extrafascial), the direction of dissection (retrograde or antegrade), the timing of the neurovascular bundle dissection off the prostate (early vs. late release), the use of cautery, the application of traction and the number of the neurovascular bundles which are preserved. Despite this rough categorisation, many techniques have been developed which cannot be integrated in one of the categories described above. Moreover, emerging technologies have entered the nerve-sparing field, making its future even more promising. Bilateral nerve-sparing of maximal extent, athermal dissection of the neurovascular bundles with avoidance of traction and utilization of the correct planes remain the basic principles for achieving optimum functional outcomes. Given that potency and continence outcomes after radical prostatectomy are multifactorial endpoints in addition to the difficulty in their postoperative assessment and the well-documented discrepancy existing in their definition, safe conclusions about the superiority of one technique over the other cannot be easily drawn. Further studies, comparing the different nerve-sparing techniques, are necessary.