White-tailed deer (Odocoileus virginianus) are important game mammals and potential reservoirs of diseases of domestic livestock, so diseases of deer are of great concern to wildlife managers. In many situations, models can be useful for integrating existing data, understanding disease transmission patterns, and predicting effects on host populations. Individual-based modeling (IBM) has become more commonplace in ecology as a tool to link individual behavior to population dynamics and community interactions, especially for gauging the effects of management actions. Spatially explicit IBMs are especially useful when ecological processes, such as disease transmission, are affected by the spatial composition of the environment. I developed a spatially explicit IBM, DeerLandscapeDisease (DLD), to simulate direct and indirect disease transmission in white-tailed deer. Using data from GPS-collared deer in southern Illinois, I developed methods to identify habitats and times of high contact probability. I parameterized movement models, for use in DLD, using field data from GPS-collared deer in both southern and east-central Illinois. I then used DLD to simulate deer movements and epizootiology in two different landscapes: a predominantly agricultural landscape with fragmented forest patches in east-central Illinois and a landscape dominated by forest in southern Illinois. Behavioral and demographic parameters that could not be estimated from the field data were estimated using published literature of deer ecology. I assumed that bioavailability of infectious pathogens deposited in the environment decreased exponentially. Transmission probabilities were estimated by fitting to published trends in infection prevalence, assuming that infection probability during an encounter was equal for all age classes, so infection prevalence varied with sex- and age-specific behavior. DLD simulations of chronic wasting disease epizootiology demonstrated significant effects of landscape structure, social behavior, and mode of transmission on prevalence, emphasizing the importance of spatial, temporal and behavioral heterogeneity in disease modeling. These results demonstrate the utility of IBMs in incorporating spatio-temporal variables as well as animal behavior when predicting and modeling disease spread.

Purpose: This study explored therapeutic processes associated with developing a course for patients with persistent pain which integrated osteopathic treatment with Acceptance and Commitment Therapy (ACT). This 'third wave’ cognitive behavioural approach is effective for a range of physical and psychological problems, including persistent pain, and congruent with osteopathic principles of holism, function and agency, which provided a theoretical basis for developing an integrated intervention to promote resilience and well-being. A qualitative case study was conducted as part of a developmental research programme to explore how ACT could be integrated with osteopathic treatment for individual patients, and with what effects on processes and outcomes. Method: Linguistic ethnography was used to explore links between pain-related discourses, clinical decisions and responses to pain. Treatments were audio-recorded, transcribed, and coded. Extracts referring to discourses about pain experienced during manual therapy were subjected to micro-level conversation analysis, sociolinguistic analysis of participants’ roles, and macro-level analysis of links to broader healthcare discourses. A reflective diary was used to explore experiential learning and integrate auto-ethnographic information. Results: Two distinctive forms of mechanistic and facilitative pain discourse were identified. In predominantly mechanistic discourses, agency and expertise were located with the osteopath, and intention was focused on fixing ‘broken’ parts and relieving pain using ‘familiar’ osteopathic techniques. In facilitative discourses, the osteopath adopted a more collaborative role, focused on developing the patient's body and self-awareness to promote more flexible, active pain responses. Practitioner challenges included learning how to shift intention between mechanistic and facilitative interventions, a process that was enabled by mindfulness and willingness to tolerate uncertainty. Conclusions: In this study, ACT-informed osteopathy involved facilitative discourses, associated with increased patient agency and flexibility in response to pain. Further research is needed to explore whether this pattern of discourse is robust in other clinical settings; relationships between mechanistic and facilitative discourses and therapeutic outcomes; and effects of ACT training on practitioner mindfulness and attitude towards clinical uncertainty. Findings suggest that this integrated approach could expand the scope of osteopathic care for patients with persistent pain, and is worth further investigation.

The purpose of this study is to evaluate the past and recent literature in order to determine the role of pre-operative CT scans in chronic otitis media. We aim to find consensus on the diagnostic ability of CT imaging in various anatomical parts of the middle ear and mastoid, and how this knowledge can affect clinical and surgical management. In context of all literature, there has been mixed results when looking at the sensitivity and specificity of middle ear structures. There was favorable consensus for CT's diagnosis of erosion of the malleus-incus complex, lateral semicircular canal, the facial nerve canal, and presence of soft tissue in the middle ear cavity. There were mixed results with respect to the erosion of tegmen tympani, and sigmoid sinus. Lastly, there was an unfavorable consensus when looking at the erosion of the stapes, oval window, and round window. Various studies conclude that the information gained from CT regarding the condition of the mastoid and middle ear can influence both the type of surgical method used and the success rate by reducing the risk of complications and recurrence of disease. In many studies, the methodology and interpretation of the CT scans are not very well presented. This unfortunately disallows meta-analysis between studies as the number of uncontrolled variables is too large. In the future, we hope that more information is provided as to the method of interpretation as well as the type of CT scanner and dosage. This will allow for a more meaningful result when comparing sensitivities and specificities towards middle ear pathologies, and it will allow for better examination of image quality and usefulness in context of the risk of radiation. Many otologists make routine use pre-operative CT scans in cases of chronic otitis media while others are more selective. In order to reach a consensus, however, more research focused on specific the decision-making process of physicians.

Chronic kidney disease is a substantial health problem effecting a large portion of the US population. Presence of excess protein, particularly albumin, in the urine of patients with chronic kidney disease is an independent risk factor for cardiovascular disease and progression to end stage renal disease. In addition, excess protein reabsorption in the proximal tubule is sufficient to cause damage to the proximal tubule independent of the initial condition that lead to chronic disease. In the last decade, excess protein reabsorption by the proximal tubule as a result of chronic kidney damage has been shown to cause oxidative and ER stress, cell death, as well as tubule inflammation and fibrosis in the proximal tubule cell. Only recently have two studies investigated the role of autophagy in protein-induced tubule damage. Autophagy is a dynamic catabolic mechanism used to degrade cytosolic elements in times of cell starvation and is an important process in the cell's response to stress. The results of the studies by Wei Jin Liu et al. and Yamahara et. al. provide important first steps to determine whether autophagy of excess protein in proteinuric states prevents proximal tubule cell toxicity and potentially slow the progression of chronic kidney disease (CKD). This thesis will explore the results of these two studies in the context of proximal tubule damage in chronic kidney disease, and discuss the potential for protein autophagy to improve our understanding and treatment of chronic kidney disease.

OBJECTIVES: 1) To measure the prevalence of precipitating events in pediatric chronic pain patients and 2) to compare pain and functional disability outcomes at evaluation and 4-month follow-up by presence and type of precipitating event. METHODS: Precipitating events (e.g., injury) were coded from the medical record for 401 youth (6-19) who presented to a tertiary care chronic pain clinic. Four-month follow-up disability and pain were collected for 187 patients. In addition to frequency of events, we examined differences in pain and disability measures by event type at evaluation and follow-up using multiple statistical analysis strategies. RESULTS: Two-thirds of patients had a precipitating event prior to pain onset. Injury was the most common (55%), followed by chronic disease (23%), infection/illness (12.8%), and surgery (7.5%). Patients whose pain was triggered by injury reported the highest average pain levels, F(3, 340)=2.67, p<.05 and functional disability, F(3, 295)=3.54, p<.05. There were multiple cases of event groups that had significantly different baseline and follow-up psychological measures when compared to the rest of the patient population. Trajectories of pain and disability did not differ between patients with and without a precipitating event. Patients with injuries reported greater improvement in functional disability at follow-up (time x injury) F(1, 183)=4.88, p<.05 whereas patients with chronic disease reported less improvement in disability (time x chronic disease), F(1, 183)=5.49, p<.05. No other interactions were significant for disability or pain. CONCLUSIONS: A majority of patients had experienced some form of precipitating event prior to their pain onset, and the presence of a precipitating event had varied effects on the treatment outcomes of patients at four-month follow-up. Although patients with injuries presented with greater disability and pain, they had significantly more improvement, while chronic disease patients were less likely to improve in terms of functional disability. Type of precipitating event appears to be associated with treatment response and can inform clinical prognoses.

Thesis (M.A.)--Boston University / Sports-related concussions are a very large public health concern and have only recently been brought into the national spotlight, thanks largely to the increased media coverage following the deaths of several current and former players of the National Football League (NFL). This problem extends not only to professional athletes, but reaches down through college, high school and to our youth athletes as well. The symptoms resulting from concussion are diverse and include both acute and long-term effects, and could have particularly debilitating effects on the developing brains of young athletes. Various neurocognitive deficits, as well as neurodegenerative diseases such as chronic traumatic encephalopathy (CTE) have been associated with concussions. Research about both the short and long-term effects of concussions has been growing in recent years, and will continue to grow as advanced neuroimaging tools and biomarkers become better developed. This will improve diagnostic capabilities, result in better prognoses, as well as treatments and prevention. This review analyzes current literature in order to evaluate the lasting impacts of sports-related concussions. By showing the effects of sports-related concussions, especially on the developing brain, policy changes aimed at the prevention of concussion in sports will be suggested, specifically in terms of mitigating the adverse effects of concussions on brain development.

OBJECTIVES: This study aims to explore the relationships between preoperative psychosocial factors in relation to postoperative chronic pelvic pain (CPP) in adolescents and young women with endometriosis, which is a significant public health concern. As a pilot sample, there is large need to present preliminary data exploring the biopsychosocial correlates and possible predictors of central sensitization and CPP, which remains non-existent in the realm of adolescents and young adults with CPP secondary to endometriosis. METHODS: Eligible candidates included patients 12-22 years old who were diagnosed with CPP after laparoscopic confirmation of endometriosis. 25 successfully enrolled subjects had pre-surgical information obtained from baseline surveys and underwent a postoperative sensory protocol to assess mechanical allodynia, pressure pain sensitivity, central sensitization, and a self-report measure of pain sensitivity. Correlation calculations were conducted between pre-surgical factors (pain intensity, pain catastrophizing (PCS), and quality-of-life (from SF-36)) and post-surgical factors (pain and sensitivity thresholds as measured by QST and the PSQ) in the subject population as a whole, and in two population subgroups: those exhibiting central sensitization and those who are not. One-way ANOVA calculations and one sample t-tests were conducted to compare differences between cohorts and between abdominal and control sites for various study parameters. RESULTS: 6 of 25 (24%) subjects experienced a wind-up phenomenon during the temporal summation for pain test, serving as a surrogate for central sensitization. The differences in study parameters that this group (+CS) exhibited in comparison to the –CS group, failed to reach significance in all study parameters. Both cohorts exhibited positive correlations between pre-operative disability due to bodily pain (SF-36) and sensitivity of the abdomen, as well as negative correlations between disability due to bodily pain and pressure pain thresholds of the abdomen. The +CS cohort also exhibited a negative correlation between disability due to bodily pain and pinprick pain scores, a positive correlation between role limitations due to physical health (SF-36) and sensitivity of the abdomen, and a positive correlation between pain catastrophizing and sensitivity of the abdomen. As a whole, the subject population had significantly higher levels of catastrophizing than published means. In all cohorts, pressure pain thresholds of the abdomen were significantly lower than the control values, and PSQ-minor scores were significantly higher than published means. CONCLUSIONS: Results suggest the importance of pre-operative pain and psychosocial functioning on pain outcomes, particularly when considering subjects presenting with central sensitization, in young women with CPP secondary to endometriosis. The results indicate the need for a larger sample as well as established control values to further explore the relationships between these variables.

OBJECTIVES: This study aims to better understand the relationship between psychosocial factors and the development of chronic pelvic pain (CPP) in cases of adolescent endometriosis, specifically mood disorders, pain catastrophizing and quality of life, and to detect the development of central sensitization within this population. METHODS: Eligible candidates were patients between 14 and 22 years old with confirmed diagnosis of endometriosis and chronic pelvic pain who were enrolled in the Women’s Health Study: From Adolescence to Adulthood through the Boston Center for Endometriosis (BCE) and Boston Children’s Hospital. The administration of quantitative sensory testing (QST) to assess mechanical touch perception, pressure pain sensitivity and temporal summation was performed on 48 subjects. Pre-surgical baseline surveys, which included pain catastrophizing and quality of life measures, were obtained from the BCE. Record of diagnosed mood disorder (anxiety/depression) was obtained through medical chart review. Pearson correlations between QST measures, pain catastrophizing, presence of mood disorders or central sensitization and pre-surgical pain scores were conducted. One-way ANOVA calculations, and one sample and paired t-tests were conducted to gain further understanding of these variables as they relate to groups within the cohort. RESULTS: Regarding QST measures, 23 subjects (47.9%) produced a wind-up phenomenon from temporal summation during QST administration, which serves as a surrogate for the presence of central sensitization (+CS). Pressure sensation and pain scores correlated at all test sites (lower and upper abdomen, as well as finger control site) and wind-up phenomenon correlated in the lower and upper abdomen throughout the cohort. For the presence of mood disorders, anxiety and depression were equally distributed across the +CS and –CS groups. Review of pre-surgical pain scores and pain catastrophizing (PCS) within the cohort had significant correlations between pre-surgical pain and PCS subsets of rumination and magnification. PCS total and subset scores also correlated to +CS. One-way ANOVA calculations showed the cohort as a whole presented with clinically significant helplessness. CONCLUSIONS: Results encourage further investigation of the relationship between endometriosis, comorbid conditions, environmental factors and the development of CPP within the adolescent population. More detailed data regarding mental health and documentation of condition progression, as well as establishment of health control values and sample growth are encouraged for the continued progress of this project. / 2020-07-03T00:00:00Z

Background The number of people in Sub-Saharan Africa dying of heart failure is increasing. However, little is known about their experiences and needs. In Kenya, palliative care services are available for some people with cancer and HIV/AIDS, but these services may not be configured to meet the needs of patients dying with heart failure. Aims and objectives This study aimed to explore the experiences of patients living and dying with heart failure in Kenya. Specifically, it sought to understand how patients describe their illness experience, their experience of receiving treatment and care, and their perspectives on how their care could be improved. Methods Twenty patients admitted and diagnosed with advanced heart failure were purposively recruited from a rural district hospital. Serial in-depth interviews were conducted with patients at 0, 3 and 6 months after recruitment. Bereavement interviews were carried out with carers. All interviews were conducted and recorded in the local language of Kiswahili, transcribed into English and analysed thematically with the assistance of Nvivo software. Results Forty-four interviews were conducted. Three significant phases were identified in patients’ experience (i) coming to a diagnosis, (ii) living with heart failure and (iii) dying with heart failure. Before receiving the diagnosis of heart failure, many patients were mistakenly misdiagnosed with common serious infectious conditions such as pneumonia, tuberculosis, and malaria. Once treatment commenced and physical symptoms abated, many patients were hopeful of a full recovery, unaware that there would be a progressive deterioration in their health. Social relationships were a source of encouragement but were strained by the accumulating cost of care. Patients particularly those who were younger, felt anxious or depressed when symptoms failed to improve with treatment. Uncertainty was prevalent and underlay patients’ experiences from the time of diagnosis to the end of life. Very few patients spoke about the possibility of death believing that life and death are in the hand of God. Majority of patients had poor understanding of their illness and expressed a need for more information and better communication with health professionals. Conclusion Patients with advanced heart failure in Kenya have significant unmet physical, psychological, social, spiritual, financial, and information needs. Patients’ narratives pointed to how they could benefit from a holistic approach aimed at catering for their multidimensional wellbeing. There is need to improve patients access to information and support better communication with health professionals. Chronic disease management aimed at (i) early identification of patients (ii) improving treatment and care guidelines and (iii) promoting primary and secondary prevention to identify, treat and control common risk factors for heart failure is needed.

It can be useful to discover a person’s chronic drinking consumption in child custody cases and to aid in the diagnosis of diseases like fetal alcohol spectrum disorder. When one alcohol marker in hair is analysed to indicate chronic use false negatives and false positives can occur. When two (ethyl glucuronide (EtG) and fatty acid ethyl esters (FAEEs)) are analysed false negatives and false positives can be recognized and provide stronger evidence as is underlined statistically in this work. For a combined method, the sample preparation and analytical procedures were optimized. The effect of the decontamination step was difficult to interpret, which shows that addressing issues with external contamination is challenging. Analytes may be extracted from the hair matrix during decontamination and analytes can diffuse into the hair shaft from external contamination. The last is illustrated by the incorporation via excretions of endogenous EtG and FAEEs. A novel and sensitive analytical procedure was developed and validated which saves time and possibly money compared to analysing of both markers separately. The best overall method had a linear calibration curve (r2 > 0:99) and an intra-day (n=3) and inter-day (n=9) accuracy for the quality control samples at three concentration levels between 84–118% with a coefficient of variation of 3–30% for both EtG and the FAEEs. The Bayesian approach was suggested as a new interpretation framework for hair tests, to account for the uncertainties in these tests in a transparent manner. In this work databases were constructed with EtG and FAEEs hair concentrations linked to the subject’s chronic alcohol use, the likelihood ratios were calculated and working examples were provided. This showed that a positive hair test for either EtG or FAEEs may very well be only ’limited’ evidence and therefore should only be used with a high prior odds. This means that a hair test result should not be used in isolation. The large confidence interval in this study also underlines the need for more control data.