Doctor of Philosophy / Despite the demonstrated efficacy of cognitive-behavioural therapy for chronic pain, recent research has attempted to identify predictors of treatment outcome in order to improve the effectiveness of such treatments. This research has indicated that variables such as the nature of the onset of the pain and psychopathology are associated with poor adjustment to chronic pain. Accordingly, these variables might also be predictive of poor response to treatment. Individuals who experience a sudden onset of pain following an injury or accident, particularly when the instigating event is experienced as psychologically traumatic, may present for treatment with high levels of distress, including symptoms consistent with a posttraumatic stress response. The impact of this type of onset of pain and posttraumatic stress symptoms on adjustment to chronic pain and treatment outcome is the focus of this thesis. Three studies were conducted to clarify and extend earlier research findings in this area. Using 536 patients referred for treatment in a tertiary referral pain management centre, the first study examined the psychometric properties of a widely used self-report measure of posttraumatic stress symptoms (the PTSD Checklist, or PCL), modified for use in a chronic pain sample. This study provided preliminary support for the suitability of the PCL as a self-report measure of Posttraumatic Stress Disorder (PTSD) symptoms in chronic pain patients. However, the study also highlighted a number of issues with the use of self-report measures of posttraumatic stress symptoms in chronic pain patient samples. In particular, PCL items enquiring about symptoms which are a common aspect of the chronic pain experience (e.g. irritability, sleep problems) appeared to contribute to high mean scores on the PCL Avoidance and Arousal subscales. Furthermore, application of diagnostic cut-off scores and an algorithm recommended for the PCL in other trauma groups suggested that a much larger proportion of the sample was identified as potentially meeting diagnostic criteria for PTSD than would have been expected from previous research. The second study utilised the modified PCL to investigate the impact of different types of onset of pain (e.g. traumatic onset) and posttraumatic stress symptoms on adjustment to chronic pain in a sample of 196 chronic pain patients referred to the same centre. For patients who experienced the onset of pain related to a specific event, two independent experts in the field of PTSD determined whether these events satisfied the definition of a traumatic event according to DSM-IV diagnostic criteria. Adjustment was assessed through a number of validated measures of mood, disability, pain experience, and pain-related cognitions. Contrary to expectations, comparisons between patients who had experienced different types of onset of pain revealed few significant differences between them. That is, analyses comparing patients presenting with accident-related pain, or pain related to other specific events, to patients who had experienced spontaneous or insidious onset of pain revealed no significant differences between the groups on measures of pain severity, pain-related disability, and symptoms of affective distress after adjustment for age, pain duration, and compensation status. Similarly, comparisons between patients who had experienced a potentially traumatic onset of pain with those who had experienced a non-traumatic or spontaneous or insidious onset of pain also revealed no significant differences on the aforementioned variables. In contrast, compensation status, age, and a number of cognitive variables were significant predictors of pain severity, pain-related disability, and depression. The final study investigated the impact of type of pain onset and posttraumatic stress symptoms on response to a multidisciplinary cognitive-behavioural pain management program. Unlike the previous study, this treatment outcome study revealed a number of differences between onset groups. Most notably, patients who had experienced an insidious or spontaneous onset of pain reported greater improvements in pain severity and maintained these improvements more effectively over a one month period than patients who had experienced pain in the context of an accident or other specific incident. There was also limited evidence that improvements in depression favoured patients who had experienced an insidious or spontaneous and non-traumatic onset of pain. Consistent with this, posttraumatic stress symptoms were a significant predictor of treatment outcome, with higher levels of symptoms being associated with smaller improvements in pain-related disability and distress. Notably, this study also revealed that certain cognitive variables (i.e. catastrophising, self-efficacy, and fear-avoidance beliefs) were also significant predictors of treatment outcome, consistent with previous findings in the pain literature. This provided some perspective on the relative roles of both PTSD symptoms and cognitive variables in adjustment to persisting pain and treatment response. These findings were all consistent with expectations and with previous research. Implications for future research and for the assessment and treatment of chronic pain patients who present with posttraumatic stress symptoms are discussed.

Diss. (sammanfattning) Stockholm : Karol. inst., 2005. / Härtill 5 uppsatser.

Thesis (M.N.)--Memorial University of Newfoundland, 2004. / Bibliography: leaves 188-195.

abstract: The prevalence of chronic illness among children in the United States is on the rise (CDC, 2014). Having a child with a chronic illness can be a substantial source of stress for a couple, including physical, emotional, and financial demands of caregiving as well as difficult decision-making regarding the child’s health (Mayo Clinic, 2015). Coping with such stressors can have a negative effect on the couple’s well-being, and, if not managed within the relationship, can lead to increased negative outcomes for both partners. Partners can, however, learn to cope with stress by engaging in the coping process together with dyadic coping (DC). Couples can engage in positive (i.e., supportive emotion-focused, supportive problem-focused, and delegated) or negative forms of DC. DC has been shown to mitigate stress for couples, while increasing reports of individual well-being (IWB) and relational well-being (RWB), but it has not been examined in the context of couples with a child with a chronic illness. To bridge this gap, the present study examined how couples cope with general stress as well as stress associated with their child’s diagnosis of a chronic illness (CI-related stress) and whether positive DC and negative DC moderate association between stress (general stress and CI-related stress) and well-being (IWB and RWB). Consistent with hypotheses, there were significant main effects of both types of stress (general and CI-related stress) on both types of well-being (IWB and RWB). Contrary to the hypotheses that DC (positive DC and negative DC) would moderate the associations between both types of stress and both types of well-being, only one significant interaction was found between CI-related stress and negative DC on IWB. Implications of these findings are discussed. / Dissertation/Thesis / Masters Thesis Counseling 2016

No description available.

Accurate assessment is the foundation on which effective nursing interventions rest. However, it is not known how accurately nurses identify and prioritize the needs of parents whose children have chronic conditions. When nurses proceed with interventions based on inaccurate assessments, the results can be unsuccessful interventions that neither meet parental needs nor provide optimal health care for this population of children. This descriptive comparative study was conducted to 1) examine parental needs identified and prioritized by parents of children with chronic conditions and their respective nurse care-givers, and 2) identify similarities and differences between the two groups. Patterns that evolved from these similarities and differences provide us with information related to where nurses have expertise or difficulty identifying and prioritizing the needs of parents. Kleinman's (1978) health care systems theory, which supports the premise that health care professionals and clients perceive health care episodes differently, provided the conceptual framework for this study. Study participants included 38 parents and 13 nurses who were affiliated with ten ambulatory programs in a Western Canadian pediatric hospital. Both groups completed the modified Family Needs Survey (Bailey & Simeonsson, 1988b) and socio-demographic tool developed by this investigator. Responses to the 35-item scale of the Family Needs Survey were described and ranked, in addition to being analyzed using inferential parametric statistics to determine differences between parents' and nurses' identification of parental needs. Responses to the open-ended question on the Survey were described and ranked. Research findings revealed some similarities and a number of striking differences between the responses of parents and nurses. On the 35-item scale, parents and nurses agreed that five parental needs were 1) information about current research, future services and treatments, 2) help locating competent regular or respite care providers, 3) reading material about other parents with a similar child, 4) opportunity to meet and talk with other parents, with a similar child, and 5) more time for self, spouse and other children. Both groups were consistent in their ranking of the first two needs as the most important needs in the information and community services subscales, respectively. However, nurses had generally higher responses on all subscales and identified eight more parental needs than did parents which were related to information, support, and family functioning. Parents and nurses repeated most of the above needs on the open-ended question, although nurses indicated that parents also had a number of needs related to psychosocial issues and family functioning. Nurses ranked counselling (child's condition, treatment, stress management) as the primary support need. Further, both groups differed in their prioritization of parental needs on the open-ended question. Where parents ranked information, community services, and support needs as the most important, nurses ranked support, information, and community services. The implications of these research findings for nursing practice and education are discussed and recommendations for future research are presented. / Applied Science, Faculty of / Nursing, School of / Graduate

This is a foundational study that applies Receiver Operating Characteristic (ROC) analysis to the evaluation of a chronic disease model that utilizes Remote Monitoring (RM) devices to identify clinical deterioration in a Chronic Obstructive Pulmonary Disease (COPD) population. Background: RM programmes in Disease Management (DM) are proliferating as one strategy to address management of chronic disease. The need to validate and quantify evidence-based value is acute. There is a need to apply new methods to better evaluate automated RM systems. ROC analysis is an engineering approach that has been widely applied to medical programmes but has not been applied to RM systems. Evaluation of classifiers, determination of thresholds and predictive accuracy for RM systems have not been evaluated using ROC analysis. Objectives: (1) apply ROC analysis to evaluation of a RM system; (2) analyse the performance of the model when applied to patient outcomes for a COPD population; (3) identify predictive classifier(s); (4) identify optimal threshold(s) and the predictive capacity of the classifiers. Methods: Parametric and non-parametric methods are utilized to determine accuracy, sensitivity, specificity and predictive capacity of classifiers Saturated Peripheral Oxygen (SpO2), Blood Pressure (BP), Pulse Rate (PR) based on event-based patient outcomes that include hospitalisation (IP), accident & emergency (A&E) and home visits (HH). Population: Patients identified with a primary diagnosis of COPD, monitored for a minimum of 183 days with at least one episode of in-patient (IP) hospitalisation for COPD in the 12 months preceding the monitoring period. Data Source: A subset of retrospective de-identified patient data from an NHS Direct evaluation of a COPD RM programme. Subsets utilized include classifiers, biometric readings, alerts generated by the system and resource utilisation. Contribution: Validates ROC methodology, identifies classifier performance and optimal threshold settings for the classifier, while making design recommendations and putting forth the next steps for research. The question answered by this research is that ROC analysis can provide additional information on the predictive capacity of RM systems. Justification of benefit: The results can be applied when evaluating health services and planning decisions on the costs and benefits. Methods can be applied to system design, protocol development, work flows and commissioning decisions based on value and benefit. Conclusion: Results validate the use of ROC analysis as a robust methodology for DM programmes that use RM devices to evaluate classifiers, thresholds and identification of the predictive capacity as well as identify areas where additional design may improve the predictive capacity of the model.

Chronic respiratory diseases (CRDs) include chronic diseases involving the airways and other structures of the lung. In the current circumstance of Vietnam, people are exposed to numerous risk factors of CRD, such as heavy smoking, high frequency of pulmonary tuberculosis, chronic helminthiasis, allergic factors, migration and urbanization (the last associated with traffic-related pollution). The phenotype diagnoses should take into account the risk factors of each individual besides the clinical features, while the differential diagnoses mostly depend on the available techniques in each healthcare center. Our aim was to improve the differential diagnoses of the 3 most frequent CRDs: chronic obstructive pulmonary disease (COPD), asthma and COPD – asthma overlap syndrome (ACOS), in Vietnam. In the first part, we evaluated the prevalence of the allergen sensitization among patients with CRD, in regard to the urban and rural area in the South of Vietnam. House dust mites and cockroach droppings were the most frequent sensitizer. Compared with participants born in the urban setting, those born in the rural environment were less frequently sensitized and this protective effect disappeared in the case of migration from rural to urban areas. In the second part, we evaluated skin prick test as a method to screen dust mite sensitization in CRD in southern Vietnam. The data suggested that, in the present circumstance, skin prick test can be used to screen mite sensitization. In the third part, we evaluated the risk of mite sensitization in the native and migrant population, in regard to several environmental factors. Consistently with the hygiene hypothesis, compared to urban, exposure to high endotoxin concentration in rural was a protective factor against allergic sensitization. We reported for the first time that this effect was reversible among the migrants from rural to urban setting in association with lower endotoxin exposure. In the fourth part, we have defined asthma, COPD and ACOS based on clinical symptoms, cumulative smoking and airway expiratory flow with reversibility, on one side, and the age-related of the different phenotypes, on the other side. We hypothesized that the cumulative exposure to noxious particles should increase the age-related prevalence of COPD, while due to the immunosenescence process, the prevalence of IgE-mediated asthma should decrease with age, and ACOS prevalence being not related to age due to the combined mechanisms.  In conclusion, we showed in the South of Vietnam that:1) mites and cockroach allergens were the most frequent sensitizer in chronic respiratory diseases;2) the skin prick test to mite has been validated to screen mite sensitization;3) associated with a reduced level of endotoxin level, migration from rural to the urban setting was a risk factor of mite sensitization in chronic respiratory diseases;4) based on the clinical symptoms, spirometric values, and cumulative smoking, the diagnosis of asthma, COPD and ACOS have been made and their prevalence were 25, 42 and 33%, respectively. / Doctorat en Sciences biomédicales et pharmaceutiques (Médecine) / info:eu-repo/semantics/nonPublished

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2005. / Härtill 4 uppsatser.