It is likely that a counselor-in-training (CITs) will counsel a lesbian, gay, or bisexual (LGB) client in practice. The American Counseling Association (ACA, 2014) and the Council for Accreditation of Counseling and Related Educational Programs (CACREP, 2009) address ethical and training standards about counseling clients from diverse populations and multicultural counselor competence. The purpose of this dissertation was to examine master's-level CITs' perceived LGB counselor competence and potentially related and predictive factors including age, gender, religiosity, spirituality, personal relationships with LGB individuals, and having an "out" faculty or peer in the training program. This quantitative study included 105 CITs from CACREP accredited counselor education programs, surveyed from a national stratified sample, based on CACREP regions. The survey included the Sexual Orientation Counselor Competence Scale (Bidell, 2005), the Toronto Empathy Questionnaire (Spreng, McKinnon, Mar, & Levine, 2009); a Religiosity Index (Statistics Canada, 2006), Spiritual Transcendence Index-Modified (Seidlitz et al., 2002), the Marlowe-Crowne Social Desirability Scale-Sort Form C (Reynolds, 1982), and additional survey items to collect information on the number of personal relationships with LGB individuals (i.e., family, friends, faculty, and peers), age, gender and demographic information. Results indicated that CITs felt least competent in their skills to work with LGB clients and most competent in their attitudes towards LGB individuals. A regression analysis revealed that religiosity negatively predicts perceived LGB counselor competence and personal relationships with LGB individuals positively predicted LGB competence. Additionally, there was a significant positive relationship between having an "out" LGB peer in the training program and perceived LGB counselor competence. Implications suggest that counselor training programs increase the use of LGB themed case studies, role plays, and other classroom initiatives to help CITs meet the needs of their future LGB clients. An interesting finding in this study was the positive relationship between having an "out" LGB peer in the training program and increased LGB competence. Future research should investigate the dynamics of this relationship.

京都大学 / 0048 / 新制・論文博士 / 博士(医学) / 乙第13063号 / 論医博第2121号 / 新制||医||1018(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 髙橋 良輔, 教授 福原 俊一, 教授 中山 健夫 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

Objetivos: A avaliação da angiogênese no câncerde mama é um importante fator prognóstico e preditivo. A expressão do fator de crescimento vascular endotelial (VEGF) tem sido relatada como metodologia adequada posto sua relação com a densidade microvascular tumoral (MVD), a dosagem de VEGF plasmático assim como com a expressão de outros genes relacionados a angiogênese. Pacientes e Métodos: este estudo avaliou 30 pacientes com diagnóstico de carcinoma de mama localmente avançado tratadas inicialmente pela quimioterapia neoadjuvante e foi correlacionada a expressão da proteína VEGF e outros caracteres clínico-patológicos destas pacientes. Resultados: A expressão da proteína VEGF foi significamente correlacionada com a resposta patológica completa (p= 0,04). Não houve correlação entre expressão de VEGF e tamanho tumoral (p= 0,76), envolvimento axilar (p= 0,70), RP (p= 0,92), RE (p= 0,98), superexpressão de HER-2 (p= 0,79), grau tumoral (p= 0,68) ou menopausa (p= 0,07). Conclusões: A expressão de VEGF foi consistentemente associada a resposta patológica completa e pode ser utilizada como fator preditivo para selecionar pacientes com CMLA para tratamento primário pela quimioterapia. / Purpose: The assessment of angiogenesis in breast canceris a import predictive and prognostic factor. Vascular endothelial growth factor (VEGF) expression has been reported as reliable methodology to evaluate the relationship between microvascular density (MVD). VEGF plasma level and the expression of other angiogenesis related genes. Patients and Methods: This study examined 30 locally advanced breast cancer patients submitted to neoadjuvant chemotherapy. We analyzed the correlation between VEGF protein expression and clinicopathologicalcharacteristics. Results: VEGF expression was significantly correlated to complete pathological response (p= 0,04). There were no correlation between a VEGF expression and tumor size (p= 0,76), axillary involvement (p= 0,70), PR (p= 0,92), ER (p=0,96), HER-2 overexpression (p= 0,79), tumor grade (p=0,68) or menopausal status (p= 0,07). Conclusion: VEGF expression was consistently associated to complete pathological response and may be used as predictive factor to select patients to primary chemotherapy in LABC patients.

Objetivos: A avaliação da angiogênese no câncerde mama é um importante fator prognóstico e preditivo. A expressão do fator de crescimento vascular endotelial (VEGF) tem sido relatada como metodologia adequada posto sua relação com a densidade microvascular tumoral (MVD), a dosagem de VEGF plasmático assim como com a expressão de outros genes relacionados a angiogênese. Pacientes e Métodos: este estudo avaliou 30 pacientes com diagnóstico de carcinoma de mama localmente avançado tratadas inicialmente pela quimioterapia neoadjuvante e foi correlacionada a expressão da proteína VEGF e outros caracteres clínico-patológicos destas pacientes. Resultados: A expressão da proteína VEGF foi significamente correlacionada com a resposta patológica completa (p= 0,04). Não houve correlação entre expressão de VEGF e tamanho tumoral (p= 0,76), envolvimento axilar (p= 0,70), RP (p= 0,92), RE (p= 0,98), superexpressão de HER-2 (p= 0,79), grau tumoral (p= 0,68) ou menopausa (p= 0,07). Conclusões: A expressão de VEGF foi consistentemente associada a resposta patológica completa e pode ser utilizada como fator preditivo para selecionar pacientes com CMLA para tratamento primário pela quimioterapia. / Purpose: The assessment of angiogenesis in breast canceris a import predictive and prognostic factor. Vascular endothelial growth factor (VEGF) expression has been reported as reliable methodology to evaluate the relationship between microvascular density (MVD). VEGF plasma level and the expression of other angiogenesis related genes. Patients and Methods: This study examined 30 locally advanced breast cancer patients submitted to neoadjuvant chemotherapy. We analyzed the correlation between VEGF protein expression and clinicopathologicalcharacteristics. Results: VEGF expression was significantly correlated to complete pathological response (p= 0,04). There were no correlation between a VEGF expression and tumor size (p= 0,76), axillary involvement (p= 0,70), PR (p= 0,92), ER (p=0,96), HER-2 overexpression (p= 0,79), tumor grade (p=0,68) or menopausal status (p= 0,07). Conclusion: VEGF expression was consistently associated to complete pathological response and may be used as predictive factor to select patients to primary chemotherapy in LABC patients.

Aim: To assess the ability of critical flicker frequency (CFF) and optimal reading speed (ORS) to predict the potential vision in patients with cataract with and without ocular comorbidity. Methods: The two novel tests were compared with two well established potential vision tests (PVTs), the potential acuity meter (PAM) and the laser interferometer (LI). Measurements were made preoperatively in 1 eye of 88 subjects using the battery of 4 PVTs. Postoperative measurements were made with the CFF and the ORS. The subjects studied were consecutive cases over a 12-month period who fulfilled the inclusion and exclusion criteria, and agreed to participate in this study. Results: CFF was the PVT most resistant to the presence of cataract. Both CFF and ORS give a similar predictive precision in the presence of cataract and ocular comorbidity, although CFF seems more precise when the cataract is dense. Conclusions: The PAM and the LI showed a limited clinical capability in predicting postoperative visual acuity, particularly with dense opacities. The CFF shows the most promise as a PVT, particularly with dense cataract. Further evaluation is required for both CFF and ORS.

La maladie d’Alzheimer (MA) se caractérise par une détérioration progressive et continue des fonctions cognitives. Un des objectifs de la prise en charge d’un patient atteint de MA est le maintien d’une bonne qualité de vie liée à la santé (QDVLS) pour lui et son entourage. Les objectifs de l’étude étaient de rechercher les facteurs associés à la QDVLS des patients atteints de MA et d’identifier les facteurs associés au déclin cognitif rapide (DCR) des patients atteints de MA. Le Dementia Quality of Life (DQoL) et le Quality of life in Alzheimer Disease (QoL-AD) ont été administrés à 123 patients atteints de MA de stade léger à modéré. Des données sociodémographiques et cliniques (notamment les capacités cognitives, les troubles du comportement, les capacités fonctionnelles, la thymie, l’état nutritionnel et les comorbidités) ont été recueillies. La dépression et la polymédication étaient des facteurs influençant la QDVLS du patient, qu’elle soit évaluée par le DQoL ou par le QoL-AD. Concernant le questionnaire « aidant » du QoL-AD, le fardeau de l’aidant influençait l’évaluation de la QDVLS du patient faite par l’aidant. Le type de relation entre le patient et son aidant principal, la polymédication et l’existence d’un fardeau de l’aidant étaient des facteurs associés au DCR. L’importance de l’évaluation de la QDVLS chez les patients atteints de MA n’est plus à démontrer. Cette étude montre la nécessité de prendre en compte le couple patient/aidant pour définir au mieux les stratégies à mettre en place. Un suivi médical et psychologique régulier est nécessaire pour les aidants de patients atteints de MA, en plus d’une formation spécifique à ce rôle. / Alzheimer’s disease (AD) is characterised by progressive cognitive decline. Management of patients with AD is based on a multidisciplinary approach (medical, cognitive, psychological, social and functional), with the primary aim of maintaining the health related quality of life (HRQoL) of patient and his/her familyStudy’s aims were to identify factors associated with HRQoL in patients with AD and to determine predictive factors associated with rapid cognitive decline (RCD) in patients with AD.HRQoL was evaluated using Dementia Quality of Life (DQoL) and using Quality of life in Alzheimer Disease (QoL-AD) for 123 patients with AD. Sociodemographic and clinical (notably cognitive functions, behavioural troubles, level of patient dependence, depression, nutritional status and comorbidities) were recorded.Depression and polymedication were associated with HRQoL, whether assessed by DQoL or QoL-AD. Regarding to the QoL-AD caregiver score, presence of caregiver burden was factor associated with HRQoL. Type of relationship between the patient and the primary caregiver, polymedication and existence of a caregiver burden were factors associated with the RCD.The importance of HRQoL’s evaluation in patients with AD is no longer to be demonstrated. This study showed the need to take into account the couple patient/caregiver to define the strategies to be put in place. Regular medical and psychological follow-up is required for caregivers of patients with AD, in addition to training specific to this role.

Abstract Breast carcinoma is the most common malignancy in females in western countries. Classical prognostic factors such as the size of a primary tumor and the presence or absence of axillary lymph node metastases, malignancy grade and hormone receptor status reflect the subsequent risk of disease recurrence after primary therapy and the need for adjuvant therapies. However, most breast carcinomas are detected in the early stage of the disease and the value of these classical prognostic factors is limited. There is also a great need to find new factors predicting the clinical efficacy of the anticancer drugs available. In this thesis tumor suppressor gene p53, oncogene c-erbB-2 and matrix metalloproteinase-9 were evaluated for their prognostic relevance in breast carcinoma patients treated in Oulu University Hospital, and matrix metalloproteinase-9 was also analyzed in women with premalignant lesions in the breast tissue in order to examine its role in breast carcinogenesis. Histological analyses were carried out from formalin-fixed, paraffin-embedded primary tumor specimens and p53, c-erbB-2 and matrix metalloproteinase-9 (MMP-9) statuses were systematically analyzed by immunohistochemistry. P53 expression correlated with disease-free survival and overall survival in patients with early-stage breast carcinoma, regardless of adjuvant antiestrogen therapy. The co-expression of p53 and c-erbB-2 characterizes a tumor type with a clinically aggressive course of breast carcinoma. The clinical efficacy of anthracyline-based chemotherapy in metastatic carcinoma might be limited in patients with p53 expression in a primary tumor. When postmenopausal patients with lymph node metastases and receiving adjuvant antiestrogen therapy were examined, MMP-9 expression indicated a slightly greater risk of breast carcinoma recurrence in patients with estrogen receptor negative tumors. Hyperplastic breast tissue and invasive breast carcinoma lesions expressed some MMP-9 immunopositivity. However, the strongest positivity was seen in ductal carcinoma in situ samples, suggesting that MMP-9 participates in breast carcinogenesis in the preinvasive phase.

Le traitement du VHC connaît une évolution rapide avec le développement d'antiviraux à action directe plus efficaces et mieux tolérés qui vont modifier les stratégies thérapeutiques, les facteurs prédictifs de réponse et les modalités de suivi des patients. Notre travail s'intéresse aux paramètres de suivi du traitement que sont les dosages pharmacologiques de ribavirine et le suivi des cinétiques virales lors d'une trithérapie. L'étude d'une cohorte prospective incluant 186 patients sous trithérapie par IP montre que 60% d'entre-eux présentent une SVR12 et que les facteurs prédictifs sont le génotype de l'IL28B et la réponse au précédent traitement. Une diminution de la filtration glomérulaire réversible est également observée. La mesure du taux résiduel de ribavirine permet de réduire les risques hématologiques chez des patients insuffisants rénaux, la réalisation de l'ASC témoigne d'une moins bonne exposition à la ribavirine chez des patients co-infectés par le VIH/VHC et la biodisponibilité de la ribavirine et la sévérité des anémies augmentent chez des patients traités par télaprévir. Au sein de la cohorte CUPIC, la négativation ou la diminution >50-70% de la charge virale initiale à S2 de trithérapie sont fortement prédictives de la SVR12. Cette mesure à S2 permet aussi de dépister les échappements viraux précoces. La place de la ribavirine est importante dans les associations thérapeutiques actuelles et futures. Sa surveillance pharmacologique peut avoir un intérêt au cours de futures multi-thérapies exposant à d'éventuelles interactions médicamenteuses / The rapid development of new direct antiviral agents (DAA) against HCV gives hope of more potent and well tolerated treatments. These new compounds will deeply modify therapeutic schedules, virological response prognostic factors and patients’ monitoring. The aim of our work was to define the relevance of ribavirin plasma concentration and viral kinetics monitoring during triple therapy. The study of a prospective cohort including 186 patients under triple therapy showed an SVR12 rate of 60%. Associated predictive factors were IL-28B genotype and previous treatment response. A reversible decrease of glomerular filtration rate was also observed. Ribavirin plasma concentration monitoring reduced hematological risks among patients with renal insufficiency. Early ribavirin plasma exposure showed an underexposure among HIV/HCV patients and ribavirin biodisponibility with severe anemia increased among telaprevir-treated patients. Within the CUPIC cohort, the initial viral load undetectability or decrease up to 50% or 70% at week 2 of triple therapy were predictive of SVR12. Moreover, this week 2 viral load assessment allowed the detection of early viral breakthrough. Ribavirin still plays a major role in current and future therapeutic strategies. Ribavirin monitoring could also be important during future multi-drug therapy that could be associated with drug interactions

This study aimed to describe the prognostic and predictive factors of breast cancer and the correlation between them with the clinical outcomes observed in patients surgically treated at the University Hospital of Santa Maria, from 1999 to 2009. The study was retrospective, observational , transversal and analytical. The data was obtained by reviewing the medical records of patients with the Medical Records and Statistics Service sector (SAME). Female patients with malignant pathology of the breast, without distant metastases at diagnosis, and treated surgically in HUSM were included in the sample. Patients with a diagnosis of carcinoma in situ of the breast, male patients, patients with metastases at the time of surgery, patients with other concomitant cancer, patients who had surgical treatment before 1999, patients less than 60 months of follow-up, patients transferred after treatment and patients diagnosed with malignant phyllodes tumor. In the period, 411 cases were identified, 136 of them being excluded. In total, 275 cases were included in the study, and the classification of molecular subtypes was performed in 185 cases. The results were: mean age at diagnosis of 53.13 years; average tumor size in pathology assessment of 2.91 cm; 86.18% type invasive ductal carcinoma; 57.45% histologic grade 2; 60 cases of pure luminal tumors and 196 patients in stages I and II (pathological staging); 205 patients presented with disease without activity; It was reported 45 deaths, and in 33 of them the cause was breast cancer. It was not possible to compare the most variables between the groups. Difference was observed between the groups in histological grade and KI-67. The development of a prospective study is suggested, with its own protocol, for proper description of these factors, which will analyze them and compare them among subgroups of patients. The effort to acknowledge the profile and development of malignant neoplasm of the breast can help individualize treatment, adjusting it for each case. / O presente estudo teve como objetivo descrever os fatores prognósticos e preditivos do câncer mama e a correlação destes com os desfechos clínicos observados, em pacientes tratadas cirurgicamente, no Hospital Universitário de Santa Maria, no período de 1999 a 2009. O estudo foi retrospectivo, observacional, transversal e analítico. Os dados foram obtidos por meio da revisão dos prontuários das pacientes junto ao setor de Serviço de Arquivo Médico e Estatística (SAME). Foram incluídas na amostra pacientes com diagnóstico de patologia maligna da mama, do sexo feminino, sem metástases à distância no momento do diagnóstico e tratadas cirurgicamente no HUSM. Foram excluídos pacientes com diagnóstico de carcinoma in situ da mama, pacientes do sexo masculino, pacientes com metástases no momento da cirurgia, pacientes com outro câncer concomitante, pacientes com tratamento cirúrgico antes de 1999, pacientes com menos de 60 meses de seguimento, pacientes transferidos após o tratamento e pacientes com diagnóstico de tumor phyllodes maligno. No período, identificaram-se 411 casos, sendo 136 deles excluídos. No total, 275 casos foram incluídos no estudo, sendo que a classificação em subtipos moleculares foi possível em 185 casos. Os resultados encontrados foram: média de idade ao diagnóstico de 53,13 anos; média de tamanho tumoral na avaliação da patologia de 2,91 cm; 86,18% do tipo carcinoma ductal invasivo; 57,45% grau histológico 2; 60 casos de tumores luminais puros e 196 pacientes nos estádios I e II (estadiamento patológico); 205 pacientes apresentavam-se com doença sem atividade; foram relatados 45 óbitos, sendo que em 33 deles a causa foi o câncer de mama. Não foi possível a comparação da maioria das variáveis entre os grupos. Foi observada diferença entre os grupos no grau histológico e no KI-67. Sugere-se a elaboração de estudo prospectivo, com protocolo próprio, para adequada descrição destes fatores, o que permitirá analisálos e compará-los entre os subgrupos de pacientes. O esforço para o conhecimento do perfil e da evolução da neoplasia maligna da mama pode auxiliar na individualização do tratamento, ajustando-o para cada caso.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23081号 / 医博第4708号 / 新制||医||1049(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 中本 裕士, 教授 小川 誠司, 教授 武田 俊一 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM