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. / Maternal and perinatal mortality remains significantly high in low‐income countries with over 800 deaths per day of women around childbirth. Greater than 90% of such deaths occur in low‐income countries. The concept of maternity waiting homes (MWH) was reintroduced to aid in decreasing maternal and perinatal mortality. Since the previous Cochrane Review in 2012 on maternity waiting homes, there have not been any published randomized controlled studies. Do observational studies on MWHs demonstrate decreased maternal and perinatal mortality in low‐income countries when compared with the standard of care? We searched for primary articles that reported maternal and perinatal deaths as major outcomes in studies who compared MWHs to other methods such as direct hospital admits, we also investigated cesarean delivery rates. Search engines used were: Cochrane Review, Medline and CINAHL. Meta‐analyses and forests plots were formulated using MedCalc Software. Systematic review was drafted using MOOSE guidelines for meta‐analysis and systematic reviews of observation. Seven articles met criteria for this study. The maternal mortality rate for MWH was 105/100,000 and 1,066/100,000 for non‐MWH, Relative Risk (RR) 0.145 (95% Confidence Interval (CI) 0.062 to 0.204). Perinatal mortality rate was 60/1,000 in MWH compared to 65/1,000, RR 0.782 (CI 0.602 to 1.120) in non‐MWH. Stillbirth rate was 18/1,000 in MWH and 184/1,000 in non‐MWH, RR 0.204 (CI 63.88 to 94.08). Neonatal mortality rates were 16/1,000 in MWH and 15/1,000 in non‐MWH, RR 0.862 (CI 0.392 to 1.628). Cesarean deliveries rate was 24/100 for MWH and 18/100 in non‐MWH, RR 1.229 (CI 1.226‐1.555). MHWs statistically decreased maternal death, stillbirths and increased cesarean delivery rates. Overall, the observation nature of the study designs introduces selection biases that may have altered the results of the studies. No randomized trials have been done to date. We suggest cluster‐randomized studies to further evaluate the effect of MWHs.

Superficial venous thrombosis (SVT) is a common inflammatory and thrombotic pathology occurring within a superficial vein. SVT can result in distressing symptoms of redness and pain in the affected area and exposes patients to a risk of developing deep vein thrombosis (DVT) and pulmonary embolism (PE). Various therapeutic options are available to patients including anti-inflammatories, anti-coagulation and surgical procedures, however which of these therapies is the best first line treatment remains unknown. Several randomized controlled trials have been conducted addressing this question, yet methodological and design flaws have limited the translation of their results into a change of clinical practice. The following thesis consists of a multi-step process of reviewing the evidence to date followed by a process of engaging with clinician stakeholders with the goal of designing a randomized control trial that would provide a meaningful answer to patients and their clinicians. In the first step of this process, a systematic review of the literature was performed, including a meta-analysis to estimate pooled risk of developing symptomatic venous thromboembolic (VTE) complications in patients with isolated SVT following various treatments. These results were then presented to expert Canadian clinicians in a series of surveys using a Delphi process to determine the clinical trial design that would have the greatest impact on changing clinical practice. An additional survey of expert clinicians was conducted to determine current practice variation in the diagnosis, management, and follow up of patients with SVT, in order to design a clinical trial that best reflected current standard Canadian clinical practice. Our systematic review identified 15 articles and including 5775 patients. Quality and assessment of risk of bias was moderate for most included studies. The findings of our meta-analysis identified that Fondaparinux, at prophylactic dose, to had the lowest event rate of 2.0 events per 100 patient years of follow-up (95% CI 0.4 to 4.7, I2=33%) for the primary outcome of deep vein thrombosis (DVT) or pulmonary embolism (PE) during follow-up. Pooled event rates ranged from 8.6-16.6 events per 100 patient-years across other treatment categories, including placebo/observation only, with an event rate of 10.5 events per 100-patient years (95% CI 3.0 to 22.0). Heterogeneity was moderate to high for most pooled estimates, limiting the interpretation of these findings. Our survey of practice variation among expert Canadian clinicians revealed wide practice variation in in diagnosis and therapeutic management including sub-groups (e.g. cancer). There was agreement that clinical equipoise exists for the optimal treatment of SVT (77% of respondents), supporting the need for further research. Two rounds of surveys were performed using Delphi process methods, resulting in consensus for the design of a future randomized control trial (RCT). The agreed on design was for a randomized control trial comparing a direct oral anticoagulant (DOAC) such as Rivaroxaban, to Non-Steroidal Anti-Inflammatories (NSAIDs), using a non-inferiority RCT design with a non-inferiority margin of 3%. Future direction of this research will be to continue stakeholder engagement by engaging patients in the clinical trial design, followed by development of a pilot RCT protocol and application for peer-reviewed funding.

Class of 2013 Abstract / Specific Aims: This study assessed the extent to which American Indians were involved in the research process (i.e. design, implementation, analysis, and dissemination) in relationship to funding sources and reported limitations in research interventions that addressed diabetes, as well as research method or design. Methods: Systematic searches of The Cochrane Library, PubMed, CINAHL, International Pharmaceutical Abstracts (IPA), Web of Science, ERIC, and PsychINFO identified studies focused on type 2 diabetes in American Indians published between October 5, 2010 and April 30, 2012. Studies selected for inclusion were those that were interventional or programmatic in nature, used a comparison group for statistical analysis and reported patient level or patient related outcomes. Data were extracted and analyzed for study characteristics, reported limitations, funding sources, and extent to which the community was involved in the research process.       Main Results: A total of 6 studies were included. There was no difference between American Indian involvement in the research process with respect to funding sources and reported limitations (p = 0.17 and p = 0.23, respectively). The majority of studies were conducted in a clinic setting (33.3%) on tribal/sovereign land (66.7%). Study design was evenly split between randomized controlled trials and observational studies (50% for both). The most frequently reported intervention was combination/multimodal (50%).       Conclusion: American Indian involvement in the research process was not impacted by either funding sources or reported limitations.

Class of 2013 Abstract / Specific Aims: Conduct a comprehensive and systematic review to identify and describe studies from October 2010 to May 2012 that have addressed diabetes interventions in American Indian populations and assess the impact those interventions had on improving humanistic and therapeutic outcomes in preventing or treating diabetes in American Indians. Methods: Studies published between 5 October 2010 and 30 May 2012 that described diabetes interventions or programs in American Indian populations were identified via electronic searches of PubMed, CINAHL, IPA, Cochrane, PsychINFO, Web of Science, and ERIC using key search terms related to (and MeSH terms where applicable) diabetes, interventions, medication adherence, diet, exercise, blood glucose, cholesterol, blood pressure, North American Indians, American Indians, Native Americans, and Alaska Natives. Articles were reviewed and were excluded if the study had no comparison group, was not interventional or programmatic in nature, took place outside the US, study population was < 50% American Indian, or did not report on patient-related outcomes. Data on study characteristics, patient characteristics, and study outcomes were extracted. Main Results: A total of five studies were included. Positive, significant effects were reported on A1c in 40% (n=2), cholesterol in 40% (n=2), blood pressure in 40% (n=2), weight/BMI in 20% (n=1), blood glucose monitoring in 20% (n=1), diet in 20% (n=1), and diabetes knowledge and health literacy in 20% (n=1). Conclusion: The literature review had minimal results. Of those included, the majority of diabetes interventions were educational-related, observational in design, assessed only adults, and study populations were primarily female. Few of the included studies interventions demonstrated significant improvements in diabetic outcomes. Continued research and efforts to further improve diabetes management within the American Indian community is needed.

BACKGROUND:Equine-facilitated therapy (EFT) is a relatively new treatment for trauma and PTSD. EFT has been introduced and implemented in mental health treatment for children and adults, though the research in support of these interventions has not kept up with practice. In this poster we review studies of EFT with individuals who have PTSD/trauma symptoms. METHODS: We searched relevant databases: Social Work Abstracts, Scopus, CINAHL, ERIC, Web of Science, PsychArticles, PsychInfo, and Google Scholar. Due to the newness of this field, we did not restrict the search based on years nor type of study design. Inclusion criteria were: 1) the study was published in a peer-reviewed journal; 2) horses were used as the primary treatment or as an adjunct to traditional treatment; and 3) the study sample was assessed for PTSD/trauma, and/or PTSD/trauma was measured as an outcome. The search followed the PRISMA paradigm. Each author read each abstract, then met to discuss articles to include. If a decision could not be made based on the abstract, we read the full article to make a final decision. RESULTS:Nine studies -- involving 97 participants, five adult and four youth studies, and all published since 2008 – met search criteria. Two adult studies addressed combat-related trauma, two focused on interpersonal violence and one focused generally on traumatic events. There was one qualitative design, one case study and three intervention studies. Of the studies with youth, one was a correlational single system study and three were intervention studies. Two studies focused on children who had experienced maltreatment or sexual abuse, one addressed historical trauma with American Indian children, and the other did not specify the trauma though all met the criteria for PTSD based on a standardized scale. Findings showed EFT resulted in significant improvements in trauma symptoms and PTSD as well as other areas of well-being (e.g., anxiety, social support, alcohol use, and mindfulness in adults; internalizing and externalizing behavior, self-perception, self-esteem, social adjustment and anxiety in youth). CONCLUSIONS and IMPLICATIONS: Despite the limitations of our review (we did not search for gray material) and of the studies themselves (small sample sizes, lack of a control group), to our knowledge this is the first review of EFT that focused on trauma/PTSD. A primary strength was including only studies where trauma symptoms were objectively measured as an outcome. Findings suggest that EFT is a promising intervention for trauma/PTSD. Broadly, more studies of increased rigor are recommended as well as qualitative studies to address the acceptability of EFT to clients and providers, and issues of implementation. Specifically, future research should further explore EFT for veterans, reflecting the current national response to their mental health needs. Research is also needed to examine the mechanisms by which EFT leads to improved outcomes, investigate possible contraindications of equine therapy, as well as termination issues. In summary, EFT is a relatively new modality that offers promise for treating trauma/PTSD symptoms and the studies in this review provide a base upon which to build.

This thesis investigates the underlying mechanisms and processes that shape sport sponsorship in Cyprus. A systematic review of the international sport sponsorship literature (1980-2009) is undertaken and used as the guide for the qualitative empirical study concentrating on football sponsorship activity undertaken in Cyprus as a developing sport sponsorship market. The systematic review reveals sponsorship management structures, practices, tendencies, and models adopted at a range of national settings, and discloses contrasts that exist in different contexts. The findings of the systematic review highlight the management practices employed by sponsors, such as their motives, decision-making practices, activation and leveraging initiatives, objectives, and evaluation processes. With regard to the empirical investigation, sponsorship activity is viewed and interpreted within the broader social and cultural context in which it takes place. The analysis of the findings is informed by critical realism paradigm, so that the underlying causal mechanisms and structures shaping (or influencing) sponsorship activity in Cyprus are identified and discussed. Specifically, the findings of study, which focused on the top division of the national professional league, revealed the existence of a sponsorship continuum involving four significantly different sponsorship approaches, ranging from purely philanthropic to heavily rational and commercial. Interestingly, the study revealed the interdependence of global and local processes within the sponsorship-related practices, suggesting that sponsorship arrangements in this specific context are marked culturally by processes of glocalisation. Such processes appeared to be vividly expressed in sponsorship-related projects in Cyprus, and involved an amalgamation of several local and cultural factors such as a strong prevalence of localism, nationalism, political clientelism, and reliance on personal relations. Community pressures seemed to have a central role in sponsorship related decision-making, whilst sponsorship activity appeared also to be influenced by the structure of the sponsors industry, the organisational structure and corporate culture, as well as by the structure and local specificity of the football market in Cyprus. More specifically, competitive imbalance of the national league, politicisation of football, the level of competition within a particular industry, and centrality of authority and control (both organisational and cultural), are additional factors that appeared to impact sponsorship activity in the specific market.

Student Number : 0416598H - MSc research report - School of Public Health - Faculty of Health Sciences / Background Evidence shows that the efficacy of intravenous quinine, which is the mainstay for treating severe malaria in children, is decreasing. Artemisinin derivatives are the potential replacement for quinine. Their efficacy compared to quinine in treating severe malaria in children is not well known. Objective To assess the efficacy of parenteral artemisinin derivatives versus parenteral quinine in treating severe malaria in children. Search strategy The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE (1966 to October 2005), EMBASE (1980 to October 2005), and LILACS (1982 to October 2005) were searched. Malaria researchers and a pharmaceutical company were contacted. In addition, conference proceedings were also searched. Selection criteria Randomised controlled studies comparing parenteral artemisinin derivatives with parenteral quinine in treating severe malaria in children. All trials had to report mortality as an outcome. Data collection After data were extracted, two individuals independently assessed the trial quality. In addition, information on adverse effects from the studies was also collected. Main results Eleven trials were selected (1455 subjects), nine of them from Africa and the rest from Asia. Allocation concealment was adequate in seven trials (1238 subjects). Overall there was no difference in mortality between artemisinin derivatives and quinine (Risk Ratio= 0.89, 95% confidence interval 0.71 to 1.1). There was no difference in mortality between adequately concealed and inadequately concealed /unconcealed trials (Risk Ratio = 0.93, 95% confidence interval 0.74 to 1.16 and Risk Ratio=0.66, 95% confidence interval 0.36 to 1.22). In Parasite Clearance Time (PCT), though there was no statistical difference between the two groups there was a tendency towards favouring the artemisinin derivatives (weighted mean difference among studies which reported PCT as mean was -4.76 with 95% confidence interval -9.68 to 0.17 and all three studies which reported PCT as median showed that artemisinin derivatives cleared parasites faster than quinine, each had p<0.001). However; when only trials with adequate concealment were considered this potential advantage disappeared. In exploring heterogeneity for PCT, it was shown that study settings (Asia versus Africa) might have been a cause for heterogeneity. The artemisinin derivatives resolved coma faster than quinine (weighted mean difference=-5.32, 95%CI: -8.06 to -2.59), but when only trials with adequate concealment were considered this difference disappeared. Other secondary outcomes i.e. Fever clearance time, Incidence of neurological sequelae, and 28th day cure rate showed no significant difference between artemisinin derivatives and quinine. There was no enough data to make meaningful comparison of adverse effects between the two groups. Conclusions The available evidence suggests that parenteral artemisinin derivatives are as efficacious as quinine in preventing mortality from severe malaria in children.

Migraine affects 8 -16% of population in different countries resulting in significant economic and social impacts. Current pharmacological treatment provides symptomatic relief, but not without side effects. Hence, an increasing proportion of patients prefer complementary therapies including acupuncture for migraine relief. Randomised controlled trials (RCTs) of acupuncture treatment for migraine have produced conflicting evidence due to methodological and reporting deficiencies, including small sample sizes and inappropriate outcome measures. Furthermore, systematic reviews on acupuncture for headache failed to adequately represent non-English studies such as those conducted in China. This project aimed to: (1) systematically review studies of acupuncture for migraine; and (2) conduct a RCT addressing key deficiencies identified from the systematic reviews (SRs). Two SRs were conducted based onfollowing Cochrane review protocols. Major English, Chinese, Japanese and Korean databases were searched. The first SR included 15 English studies and the second SR had 17 Chinese studies. No Japanese or Korean RCTs were identified. Overall, those two SRs supported the value of acupuncture in the treatment and prevention of migraine when compared with western medications. However, conflicting results were found when real acupuncture treatments were compared with sham/placebo procedures. When compared with the studies published in English, Chinese studies had a higher frequency of acupuncture treatment, displayed poor methodological quality, and commonly used pharmacotherapy as a comparator. The SRs revealed that there was limited evaluation of acupuncture for frequent migraine. In the RCT, fifty participants with a minimum of eight migraine days per four weeks were randomly allocated to receive real (RA, n = 26) and sham (SA, n = 24) acupuncture for a total of 16 sessions over 20 weeks in a gradually decreasing treatment frequency. Fixed and supplementary acupoints were used. Participants were followed up for further assessment at three months and one year. Results showed that at the end of the treatment period, the mean (SD) migraine attack days per four weeks decreased from 11.81 (5.76) to 5.17 (5.02) in the RA group and from 12.41 (6.4) to 10.08 (7.11) in SA (group difference: p = .008). Intensity of migraine assessed using a Six-point Likert scale was lower in the RA (2.18 ±1.05) than that in the SA group (2.93 ± 0.61, p = 0.004). The percentile changes of pressure pain threshold (PPTs) detected at the bilateral points of TaiYang (Ex-HN5) were significantly higher in the RA group (RA 228.48% vs. SA -0.66 % on the left and 92.69% vs. -2.52% on the right). However, there was no s tatistically significant difference between the two groups with respect to Migraine Specific Quality of Life (MSQOL). At the end of the three-month follow up, medication consumption was less in the RA group, but not at the one-year follow up. In conclusion, this project demonstrates that acupuncture is a potentially effective and safe option for adult patients with frequent migraine headache with the effects lasting up to three months. Further studies are needed to confirm these therapeutic benefits with adequate sample sizes and the potential mechanism for this action.

Thesis (M.Sc. (Nutrition)--North-West University, Potchefstroom Campus, 2008.

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