A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / The purpose of this study was to review and compare a variety of depression inventories in Parkinson’s disease (PD) and normal controls (NC) to look for patterns or trends to help with clinical management of these patients. The study population consisted of subjects enrolled in a brain and body donation program who were receiving annual neurological and neuropsychiatric assessments. Statistical models were applied to the data to compare trends between screening tools, medications, and demographics. The frequency of depression was greater in PD cases than NC across the inventories. The greatest frequency of positive screens came from the Neuropsychiatric Inventory (NPI). Because the NPI requires an informant to administer, and had the highest percent of positive screens in both PD and NC groups, this study suggests that a caregiver or partner may be a helpful addition in clinical practice during depression screening in elderly patients with and without PD.

Typical energy audits are sufficiently expensive and time-consuming that many owners and managers of buildings are not willing to invest the time and money required for a full audit. This dissertation provides a methodology to identify buildings with large potential energy savings using limited information, specifically, utility bills, total area and weather data. The methodology is developed based on the hypothesis: if a commercial building is properly designed, constructed, operated, and maintained, the measured energy consumption should approximately match the simulated value for a typical building of the same size with the most efficient HVAC system; otherwise, there may be potential for energy savings. There are four steps in the methodology: 1) testing to determine whether the utility bills include both weather-dependent and weatherindependent loads; 2) separating weather-dependent and weather-independent loads when both are present in the same data; 3) determining the main type of HVAC system; 4) estimating potential energy savings and recommending an energy audit if appropriate. The Flatness Index is selected to test whether the utility bills include both weatherdependent and weather-independent loads. An approach to separate the utility bills based on thermal balance is developed to separate utility bills into weather-dependent and weather-independent loads for facilities in hot and humid climates. The average relative error in estimated cooling consumption is only 1.1% for 40 buildings in Texas, whereas it is -54.8% using the traditional 3P method. An application of fuzzy logic is used to identify the main type of HVAC system in buildings from their 12-month weatherdependent energy consumption. When 40 buildings were tested, 18 systems were identified correctly, seven were incorrect and the HVAC system type cannot be identified in 15 cases. The estimated potential savings by the screening methodology in eight large commercial buildings were compared with audit estimated savings for the same buildings. The audit estimated savings are between 25% - 150% of the potential energy savings estimated by the screening procedure in seven cases. The other two cases are less accurate, indicating that further refinement of the method would be valuable. The data required are easily obtained; the procedure can be carried out automatically, so no experience is required. If the actual type of HVAC system, measured weather-dependent, and weather-independent energy consumption are known, the methodology should work better.

The American Academy of Pediatrics (AAP) released a statement recommending that primary care providers perform developmental screening with a standardized instrument for all 9-, 18-, 24-, or 30-month well-child visits. Despite evidence-based recommendations by the AAP, numerous pediatric practices do not currently use a standardized instrument for well-child visits. This quality improvement project aimed to determine the feasibility of implementing the Ages and Stages Questionnaire (ASQ), a validated developmental screening tool, at a pediatric primary care practice. In order to accurately assess implementation barriers and benefits, this feasibility study would have determined if the ASQ was the right fit for this pediatric practice. The first phase of implementation would have begun with the 9-month well-child visits and using the same process, later expanded to include the 18- and 24-month visits. The Plan-Do-Study-Act (PDSA) method would have provided the implementation framework for this project and the project would have been written utilizing the SQUIRE (Standards for Quality Improvement Reporting Excellence) guidelines. However, due to unforeseen complications, this project was unable to be completed as planned. Instead, this project discusses outcomes of the DNP project without data, and provides guidance and points of consideration for future implementation in pediatric primary care settings.

xv, 170 p. A print copy of this title is available from the UO Libraries, under the call number: KNIGHT LB1131 .B14 2007 / Many research studies in early childhood assessment have addressed the importance of quality assessment services. Such services involve gathering information on children through direct observation of functional skills in natural settings, which requires considerable time and effort. Due to the unavailability of sufficient resources for the quality assessment services, a new approach needs to be undertaken. Current research has suggested that parent-completed screening utilizing parental knowledge about their child is valid and reliable in appraising current and observable behaviors (Bodnarchuk & Eaton, 2004; O'Neill, 2007). There has been, however, little investigation on in-depth standardized assessments completed by parents for young children aged 18 to 36 months. This study examined validity and reliability of in-depth parental report on child development with the Ages and Stages Questionnaire Inventory for Toddlers (ASQ-IT) for children aged 18-36 moths old. Fifty child-caregiver dyads were divided into two groups, non-risk and risk based on environmental factors including maternal age at the child's birth, family income, and maternal education. In examining psychometric information of the parent-completed measure, acceptable outcomes were found. Accuracy was supported by two examinations for concurrent validity; (1) the Battelle Developmental Inventory, 2nd Edition (BDI-2) administered by professionals and the ASQ-IT completed by parents (r = .63 -.83,p < .01), and (2) the same two measures completed by professionals (r = .72 -.92,p < .01). Findings of both reliability studies, test-retest reliability with the ASQ-IT completed by parents, and inter-observer reliability between parents and professionals, suggested substantial consistency, p = .79 -.93 and p = .65 -.88 respectively. In differential item functioning (DIF) (i.e., 3% of DIF items) and known-group validity analyses (p < .0005 at 36 months), the ability of the ASQ-IT to detect changes in the children's development was confirmed. Results from the social validity examining parent perception of the ASQIT completion identified efficiency of the ASQ-IT (e.g., reasonable time to complete) as well as many benefits. / Adviser: Jane K. Squires

This research represents phase C in the development of Toddler NutriSTEP® (Nutrition Screening Tool for Every Preschooler). NutriSTEP® is a valid and reliable screening tool designed to assess nutritional risk in preschoolers (3-5 years). A draft toddler (18-35 months) version of NutriSTEP® has recently been developed because of an expressed need. Convenience samples of caregivers were recruited across Ontario to assess the test-retest reliability and construct validity of the tool. Test-retest reliability was assessed based on total score and attribute scores using paired sample t-tests and intraclass correlation coefficients; individual questions were assessed using Wilcoxcon signed rank tests and kappa statistics. Construct validity was assessed through comparison of high-risk groups to Toddler NutriSTEP® scores, as well as through exploratory and confirmatory factor analyses. Toddler NutriSTEP® was found to be test-retest reliable and construct valid, and therefore may be used to assess nutritional risk in Canadian toddlers. / Funded by the Canadian Institutes of Health Research

Background: Fear of birth (FOB) is becoming increasingly recognised as a clinical issue that can have profound effects on the mother and her experience of pregnancy and birth. Failure to identify women with FOB could potentially lead to them feeling isolated and unsupported, and impact on their psychological health and the health of their baby. Aim: The main aim of this study was to gain an understanding of FOB and the associated impact on health professional practice, clinical outcomes and women's experiences of birth. The objectives were to: identify the most effective way of measuring FOB in clinical practice; investigate the most appropriate antenatal intervention to support women who fear childbirth; inform the study design for an RCT to assess the effectiveness of the intervention; and assess the most meaningful outcomes to include in future work. Methods: An explanatory mixed-methods study design was used. The first phase was a two-part online survey sent to Heads of Midwifery at 202 maternity units in the UK via Survey Monkey. Respondents were asked to give details of their unit in part 1 and service provision and evaluation for women with FOB in part 2. The second phase was a prospective cohort study of 148 women who had not experienced childbirth who were consecutively attending the Elisabeth Garrett Anderson and Obstetric Hospital, London or St Mary's Hospital, Manchester. Demographic data and details of sources of information on pregnancy were collected from participants in the first trimester along with their score on the tool chosen to measure FOB, the Fear Of Birth Scale (FOBS), and a saliva sample to measure cortisol level. In the third trimester, a second FOBS score and saliva sample were collected, and the Personal Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) were administered to measure depression and anxiety respectively. Birth outcomes for the participants were collected from clinical records. In the third phase, 15 women participating in the second phase were purposively selected to reflect a range of FOBS scores and interviewed by telephone using a semi-structured interview to find out their experiences of pregnancy, being part of the study and service provision. Results: Response rates for the online survey were 63% for part 1 and 54% for part 2. Consultant obstetricians 25% had the most involvement in the care of women with FOB, followed by consultant midwives 21% and 30% had a designated midwife for dealing with FOB and only 32% provided specialist midwifery-led services for women with FOB, with 16% referring to a consultant obstetrician and 47% providing no specialist provision. No unit provided an evaluation of their services, although 19% had undertaken local audits. In the cohort study, using a cut-off of 54 for the FOBS, 30/148 (20%) had a FOB in the first trimester while 21/80 (26%) had a FOB in the third trimester. Compared with the first trimester, 51/80 women showed an increase in FOBS score, with 14 gaining and 7 losing a FOB. FOBS scores were not correlated with salivary cortisol in either trimester but they were correlated with PQH-9 and GAD-7 scores in the third trimester. They were also associated with a previous history of depression but only in the first trimester (p=0.011). FOBS scores showed considerable variability and a high measurement error, indicating a need for further refinement and psychometric testing. The qualitative interviews identified three themes underlying FOB: fearing the worst (pain, fear for the baby and fear of the unknown and complications), pathways to fear (friend-induced fear, mother-induced fear or reassurance and media-induced fear) and igniting or reducing fear (sources of information, support and communication). Conclusions: The FOBS is a potentially effective way of measuring FOB in clinical practice and research, but it requires enhancement informed by the themes identified by this study and psychometric testing in all three trimesters. An enhanced version of the FOBS could be used as the primary outcome to measure FOB during pregnancy in an RCT assessing the effectiveness of a suitable intervention, with the PHQ-9 and GAD-7 as secondary outcomes to measure depression and anxiety during pregnancy. An intervention to support primiparous women with FOB should be developed informed by the findings of this study, including components such as psychological education, relaxation, social support, reliable information sources and continuity of carer.

Having a child who is suffering with chronic pain can profoundly impact a parent’s life. Reciprocally, parent cognitive, emotional, and behavioral responses to their child’s chronic pain can influence the child pain experience. We developed the Parent Risk and Impact Screening Measure (PRISM) to assess parent physical and emotional functioning, behavioral responses to child pain, and impact on daily life due to their child’s chronic pain. In an effort to validate this screening tool, we examined the PRISM in relation to existing measures of parent distress, parent behavior, and child functioning. The 30-item PRISM was administered via RedCAP survey to 112 parents of children with persistent pain presenting to a multidisciplinary pain clinic at Boston Children’s Hospital. Parents also completed the Patient Reported Outcomes Measurement Information System (PROMIS-29), Bath Adolescent Pain Questionnaire-Parental Impact Questionnaire (BAQ-PIQ), Adult Responses to Children’s Symptoms (ARCS), and Pain Catastrophizing Scale (PCS). Children completed the Functional Disability Inventory (FDI), Fear of Pain Questionnaire (FOPQ), and Pediatric Quality of Life Inventory (PedsQL). Parents were predominantly mothers (84%), married (74%), and college- educated (70%). Their children (ages 8-18) were predominantly female (88%) and endorsed daily pain (84%; Mean=6/10). PRISM total scores were strongly correlated with parent general symptoms of depression, anxiety, fatigue, social restrictions, and pain interference (PROMIS-29; r=0.47, 0.54, 0.59, 0.57, 0.38). PRISM total scores were also highly associated with parent pain-specific domains including self-blame and helplessness (BAP-PIQ; r=0.62), parent behavior (BAP-PIQ; r=0.54), and protective responses (ARCS; r=0.59). For child outcomes, higher PRISM scores correlated with more disability (FDI; r=0.49), higher fear of pain (FOPQ; r=0.53), and lower functioning within emotional, social, and psychosocial domains (PedsQL; r=0.36, 0.34, 0.48). Altogether the PRISM tool appears to be a brief and clinically important means of screening parent distress and behaviors associated with child pain-related dysfunction. Future work will include item level analysis with the goal of reducing the length of this screening tool.

Background: Non-specific low back pain is a growing problem in society. No treatment have shown satisfying results to reduce pain or disability for patients with non-specific low back pain, and 1-18% of these patients develop chronic low back pain. STarT Back Screening Tool (SBST) is an instrument for sub grouping patients with non-specific low back pain into low, medium or high risk of developing chronic low back pain and then modifying the treatment after the different needs of every patient. The purpose of this study was to do a systematic review, investigating validation of the SBST to evaluate the justification of its use by clinicians. Method: Pubmed, Cinahl and Medline was searched in February 2017 for studies investigating criterion validity, construct validity and content validity of the SBST. The author (JG) assessed risk of bias and extracted relevant data following the procedures of PRISMA-statement. Result: 15 articles were identified for inclusion in the review. 8 articles investigated criterion validity, 11 articles investigated construct validity and 1 article investigated content validity. Predictive validity showed heterogeneous statistical analysis and varying results, a narrative result was presented that showed marginal benefits for the use of SBST for prediction of future outcome. Concurrent validity was measured with Spearman’s rank correlation coefficient in all investigated articles, showing results between 0.34-0.802. Discriminant validity was measured with Area under the curve analysis in all articles, scoring between 0.69-0.92. Convergent validity showed a Pearson’s correlation between 0.708-0.811 and a Spearman’s rank correlation between 0.35-0.74. Conclusion: Because of heterogeneity of the results it is not possible to draw conclusive conclusions. However, results tend to show limited evidence for the use of SBST as a predictive instrument for patients with non-specific low back pain.

Fatores psicossociais não são rotineiramente identificados na avaliação fisioterapêutica e podem influenciar no prognóstico de pacientes com dor lombar. O questionário STarT Back Screening Tool (SBST) foi criado para distinguir subgrupos dentre pacientes com dor lombar em relação ao prognóstico no tratamento considerando fatores físicos e psicossociais, classificando-os em baixo, médio e alto risco de mau prognóstico. Objetivo: Traduzir e adaptar transculturalmente o SBST para Língua Portuguesa do Brasil, testar a confiabilidade e validade de construto. Métodos: A primeira etapa consistiu na tradução, síntese, retro-tradução, revisão pelo grupo de tradução, pré-teste e avaliação dos documentos pelo Comitê. A versão pré-final foi aplicada em duas amostras de 52 pacientes cada, com dor lombar, ambos os sexos, idade acima de 18 anos e níveis educacionais variados. Para verificação da confiabilidade intra-avaliador, foram realizadas duas entrevistas em outra amostra de 50 pacientes, e os resultados analisados pelo Kappa ponderado quadrado. Também foram calculados a consistência interna usando de Cronbach (n=105), o erro padrão da medida (n=50) e a validade de construto (n=151), correlacionando o SBST-Brasil com as versões brasileiras do Oswestry Disability Index (ODI), Rolland Morris (Brasil- RM) e Fear Avoidance Beliefs Questionnaire para trabalho (FABQ-Work) e atividade física (FABQ-Phys). Resultados: O consenso foi atingido nas etapas de tradução e retrotradução, apenas o item 6 não foi compreendido e depois de reformulado foi reaplicado em outros 52 pacientes que não tiveram mais dúvida. A confiabilidade foi considerada substancial (0,79 - 95% IC 0,63 0,95), a consistência interna aceitável (0,74 pontuação total e 0,72 da subescala psicossocial), e o valor do erro de padrão da medida muito bom (1,9%). Em relação à validação, a pontuação total do SBST- Brasil mostrou alta correlação com o Brasil-RM (r=0,61), moderada correlação com o ODI (r = 0,56) e FABQ-Work (r=0,3) e fraca correlação com o FABQ-Phys (r = 0,18). Já a subescala psicossocial mostrou correlação moderada com o Brasil-RM (r =0,49) e ODI (r =0,47) e fraca correlação com o FABQ-Work (r =0,24) e FABQ-Phys (r =0,21). Além disso, a estratificação dos grupos de risco do SBST-Brasil foi compatível com os valores de classificação do ODI, Brasil-RM e FABQ-Phys para risco de mau prognóstico. Conclusão: O SBST-Brasil mostrou-se confiável e válido para avaliar a influência de fatores psicossociais em pacientes com dor lombar. / Psychosocial factors are not usually identified on physiotherapy assessment, what influences on low back pain prognosis. The questionnaire STarT Back Screening Tool\" (SBST) was created to identify patients with potentially treatment modifiable prognostic influenced by physical and psychosocial indicators which are relevant to initial decision making, classifying them into low, medium and high risk categories. Aim: Translation and cross-culturally adaptation of the SBST into Brazilian-Portuguese, assess its reliability and construct validity. Methods: The translation and cross-cultural adaptation process involved the steps of Translation, Synthesis, Back-translation, Committee Revision, Pretesting and Submission the documents to the Committee. The pre-final version was applied to two samples of 52 patients each, with low back pain, both sexes, aged over 18 years, from different education levels. After that, two interviews assessed intra-rater reliability on a different sample of 50 patients, and the quadratic weighted Kappa was used for statistical analysis. The Cronbach´s alpha was also calculated for internal consistency (n=105), standard error measurement (n=50) and construct validity (n=151) analyzing the correlation between the SBST-Brasil and the Brazilian version of Oswestry Disability Index (ODI), Rolland Morris (Brasil- RM) and Fear Avoidance Beliefs Questionnaire for work (FABQ-Work) and physical activity (FABQ-Phys). Results: Consensus was found on translations and back-translations processes, and only the item 6, which patients had some difficulty in understanding, was reviewed and re-applied to 52 additional subjects with no difficulties being reported. The reliability was classified as substantial (0.79 - 95% CI 0.63 0.95), the internal consistency acceptable (0.74 for total score and 0.72 for psychosocial subscale score) and a very good standard measurement error (1.9%). The correlation between the SBST-Brasil total score and Brasil- RM was high (r =0.61), moderate with ODI (r = 0.56) and with FABQ-Work (r = 0.3), and low correlation with FABQ-Phys (r = 0,18). Moderate correlation was found with SBST psychosocial subscale score and Brasil-RM (r = 0.49), also with ODI (r = 0.47), and low correlation with FABQ-Work (r = 0.24) and FABQ-Phys (r = 0.21). After that, the stratification of SBST-Brasil risk groups was compatible with ODI, Brasil-RM and FABQPhys classification for risk of poor prognosis. Conclusion: The SBST-Brasil has shown a reliable and valid tool to screen and identify low back pain patients influenced by psychosocial factors.

Fatores psicossociais não são rotineiramente identificados na avaliação fisioterapêutica e podem influenciar no prognóstico de pacientes com dor lombar. O questionário STarT Back Screening Tool (SBST) foi criado para distinguir subgrupos dentre pacientes com dor lombar em relação ao prognóstico no tratamento considerando fatores físicos e psicossociais, classificando-os em baixo, médio e alto risco de mau prognóstico. Objetivo: Traduzir e adaptar transculturalmente o SBST para Língua Portuguesa do Brasil, testar a confiabilidade e validade de construto. Métodos: A primeira etapa consistiu na tradução, síntese, retro-tradução, revisão pelo grupo de tradução, pré-teste e avaliação dos documentos pelo Comitê. A versão pré-final foi aplicada em duas amostras de 52 pacientes cada, com dor lombar, ambos os sexos, idade acima de 18 anos e níveis educacionais variados. Para verificação da confiabilidade intra-avaliador, foram realizadas duas entrevistas em outra amostra de 50 pacientes, e os resultados analisados pelo Kappa ponderado quadrado. Também foram calculados a consistência interna usando de Cronbach (n=105), o erro padrão da medida (n=50) e a validade de construto (n=151), correlacionando o SBST-Brasil com as versões brasileiras do Oswestry Disability Index (ODI), Rolland Morris (Brasil- RM) e Fear Avoidance Beliefs Questionnaire para trabalho (FABQ-Work) e atividade física (FABQ-Phys). Resultados: O consenso foi atingido nas etapas de tradução e retrotradução, apenas o item 6 não foi compreendido e depois de reformulado foi reaplicado em outros 52 pacientes que não tiveram mais dúvida. A confiabilidade foi considerada substancial (0,79 - 95% IC 0,63 0,95), a consistência interna aceitável (0,74 pontuação total e 0,72 da subescala psicossocial), e o valor do erro de padrão da medida muito bom (1,9%). Em relação à validação, a pontuação total do SBST- Brasil mostrou alta correlação com o Brasil-RM (r=0,61), moderada correlação com o ODI (r = 0,56) e FABQ-Work (r=0,3) e fraca correlação com o FABQ-Phys (r = 0,18). Já a subescala psicossocial mostrou correlação moderada com o Brasil-RM (r =0,49) e ODI (r =0,47) e fraca correlação com o FABQ-Work (r =0,24) e FABQ-Phys (r =0,21). Além disso, a estratificação dos grupos de risco do SBST-Brasil foi compatível com os valores de classificação do ODI, Brasil-RM e FABQ-Phys para risco de mau prognóstico. Conclusão: O SBST-Brasil mostrou-se confiável e válido para avaliar a influência de fatores psicossociais em pacientes com dor lombar. / Psychosocial factors are not usually identified on physiotherapy assessment, what influences on low back pain prognosis. The questionnaire STarT Back Screening Tool\" (SBST) was created to identify patients with potentially treatment modifiable prognostic influenced by physical and psychosocial indicators which are relevant to initial decision making, classifying them into low, medium and high risk categories. Aim: Translation and cross-culturally adaptation of the SBST into Brazilian-Portuguese, assess its reliability and construct validity. Methods: The translation and cross-cultural adaptation process involved the steps of Translation, Synthesis, Back-translation, Committee Revision, Pretesting and Submission the documents to the Committee. The pre-final version was applied to two samples of 52 patients each, with low back pain, both sexes, aged over 18 years, from different education levels. After that, two interviews assessed intra-rater reliability on a different sample of 50 patients, and the quadratic weighted Kappa was used for statistical analysis. The Cronbach´s alpha was also calculated for internal consistency (n=105), standard error measurement (n=50) and construct validity (n=151) analyzing the correlation between the SBST-Brasil and the Brazilian version of Oswestry Disability Index (ODI), Rolland Morris (Brasil- RM) and Fear Avoidance Beliefs Questionnaire for work (FABQ-Work) and physical activity (FABQ-Phys). Results: Consensus was found on translations and back-translations processes, and only the item 6, which patients had some difficulty in understanding, was reviewed and re-applied to 52 additional subjects with no difficulties being reported. The reliability was classified as substantial (0.79 - 95% CI 0.63 0.95), the internal consistency acceptable (0.74 for total score and 0.72 for psychosocial subscale score) and a very good standard measurement error (1.9%). The correlation between the SBST-Brasil total score and Brasil- RM was high (r =0.61), moderate with ODI (r = 0.56) and with FABQ-Work (r = 0.3), and low correlation with FABQ-Phys (r = 0,18). Moderate correlation was found with SBST psychosocial subscale score and Brasil-RM (r = 0.49), also with ODI (r = 0.47), and low correlation with FABQ-Work (r = 0.24) and FABQ-Phys (r = 0.21). After that, the stratification of SBST-Brasil risk groups was compatible with ODI, Brasil-RM and FABQPhys classification for risk of poor prognosis. Conclusion: The SBST-Brasil has shown a reliable and valid tool to screen and identify low back pain patients influenced by psychosocial factors.