Shoulder dysfunction is frequently treated and persistent symptoms are common. Differential diagnosis of shoulder injuries can be challenging and knowledge of a diagnosis alone does not appear to be enough information to predict outcomes. Determination of a set of factors that predict outcome would assist clinicians in making the most effective treatment decision for patients with shoulder pain. The purposes of this dissertation were to investigate patient-clinician agreement in an orthopedic population of patients with shoulder pain and to determine what combination of factors best predicts positive patient-reported outcome following standardized rehabilitation in patients with shoulder pain. In the first study, it was determined that patient-clinician agreement was moderate to good. This further supports the use of patient reported outcomes as an appropriate approximation of “true” outcome. In the second study, patient-nominated functional limitations were reduced to 14 categories for inclusion as candidate predictors in the prediction model. In the third study, we observed that the combination of absence of neck pain, shorter duration of symptoms and report of exercise as a functional limitation were associated with greater odds of positive clinical outcome following 6 weeks of standardized rehabilitation. Due to limited sample size, generalizations cannot yet be made to other samples. Future investigation of this model in a larger sample and subsequent external validation in a separate sample are necessary to further develop the model for clinical use.

京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第20624号 / 社医博第82号 / 社新制||医||9(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 木原 正博, 教授 古川 壽亮, 教授 柳田 素子 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

Prior research in individual therapy has provided evidence that therapists are poor predictors of client outcome without the aid of objective measures and often misjudge clients' perceptions of the therapeutic relationship. The focus of the current research was to conduct a similar study in a group setting. Therapists from a university counseling center and a state psychiatric hospital were recruited to test their accuracy in predicting client outcome, quality of therapeutic relationship and their own use of empirically supported group interventions. Results indicated that therapists are poor predictors of all three, providing support for the implementation of measure-based feedback systems to inform therapists about key information that may affect the effectiveness of group psychotherapy.

Background - Current guidelines suggest that all cancer patients with venous thrombosis be treated with long-term low molecular weight heparin. Whether treatment strategies should vary according to clinical characteristics remains unknown. // Systematic review - A systematic review was performed to determine current understanding of the association between malignancy characteristics in patients with cancer-associated VTE and the risk of VTE recurrence. Four retrospective and 6 prospective studies were included. They suggest that lung cancer, metastases, and adenocarcinomas confer an increased the risk of recurrence and breast cancer a low risk. // Survey - I performed survey to evaluate thrombosis experts’ opinion about the low risk of VTE recurrence they would consider acceptable for patients with cancer- associated thrombosis 103 specialists participated. 80% of respondents agreed that a risk of recurrent VTE during anticoagulation below 7% is low enough. 92% agreed that a CPR that categorizes risk of recurrence is relevant. // Retrospective Study - I performed a single retrospective cohort study to assess the feasibility of derivation of a CPR that stratifies VTE recurrence risk in patients with cancer–associated thrombosis. The study included 543 patients. A multivariate analysis selected female, lung cancer and prior history of VTE as high risk predictors and breast cancer and stage I disease as low risk. // Conclusion - Patients with cancer-associated thrombosis do have varying risks of recurrent VTE depending on clinical characteristics.

Background - Current guidelines suggest that all cancer patients with venous thrombosis be treated with long-term low molecular weight heparin. Whether treatment strategies should vary according to clinical characteristics remains unknown. // Systematic review - A systematic review was performed to determine current understanding of the association between malignancy characteristics in patients with cancer-associated VTE and the risk of VTE recurrence. Four retrospective and 6 prospective studies were included. They suggest that lung cancer, metastases, and adenocarcinomas confer an increased the risk of recurrence and breast cancer a low risk. // Survey - I performed survey to evaluate thrombosis experts’ opinion about the low risk of VTE recurrence they would consider acceptable for patients with cancer- associated thrombosis 103 specialists participated. 80% of respondents agreed that a risk of recurrent VTE during anticoagulation below 7% is low enough. 92% agreed that a CPR that categorizes risk of recurrence is relevant. // Retrospective Study - I performed a single retrospective cohort study to assess the feasibility of derivation of a CPR that stratifies VTE recurrence risk in patients with cancer–associated thrombosis. The study included 543 patients. A multivariate analysis selected female, lung cancer and prior history of VTE as high risk predictors and breast cancer and stage I disease as low risk. // Conclusion - Patients with cancer-associated thrombosis do have varying risks of recurrent VTE depending on clinical characteristics.

Background - Current guidelines suggest that all cancer patients with venous thrombosis be treated with long-term low molecular weight heparin. Whether treatment strategies should vary according to clinical characteristics remains unknown. // Systematic review - A systematic review was performed to determine current understanding of the association between malignancy characteristics in patients with cancer-associated VTE and the risk of VTE recurrence. Four retrospective and 6 prospective studies were included. They suggest that lung cancer, metastases, and adenocarcinomas confer an increased the risk of recurrence and breast cancer a low risk. // Survey - I performed survey to evaluate thrombosis experts’ opinion about the low risk of VTE recurrence they would consider acceptable for patients with cancer- associated thrombosis 103 specialists participated. 80% of respondents agreed that a risk of recurrent VTE during anticoagulation below 7% is low enough. 92% agreed that a CPR that categorizes risk of recurrence is relevant. // Retrospective Study - I performed a single retrospective cohort study to assess the feasibility of derivation of a CPR that stratifies VTE recurrence risk in patients with cancer–associated thrombosis. The study included 543 patients. A multivariate analysis selected female, lung cancer and prior history of VTE as high risk predictors and breast cancer and stage I disease as low risk. // Conclusion - Patients with cancer-associated thrombosis do have varying risks of recurrent VTE depending on clinical characteristics.

This project set out to derive a prediction rule based on preoperative clinical variables to identify patients with high risk of developing atrial fibrillation following cardiac surgery. Methods: Prospectively collected data from a perioperative database was corroborated with chart review to identify eligible patients who had non-emergent surgery in 2010. Details on 28 preoperative variables were collected and significant predictors (p<0.2) were inserted into multivariable logistic regression and recursive partitioning. Results: 305 (30.5%) of 999 patients developed new onset postoperative atrial fibrillation. Eleven variables were significantly associated with atrial fibrillation, however, both final models included only three: left atrial dilatation, mitral valve disease and age. Bootstrapping with 5000 samples confirmed that both final models provide consistent predictions. Coefficients from the logistic regression model were converted into a simple seven point predictive score. Conclusions: This simple risk score can identify patients at higher risk of developing atrial fibrillation after cardiac surgery.

There is growing interest in using large-scale observational data collected through national disease registries to develop clinical prediction models (CPMs) that use the experiences of past patients to make predictions about risks of outcome in future patients. CPMs are often developed in isolation across different populations, with repetitive de novo development a common modelling strategy. However, this fails to utilise all available information and does not respond to changes in health processes through time/space. Using the UK transcatheter aortic valve implantation (TAVI) registry as motivation, this thesis aimed to develop methods that improve the development of CPMs within local populations. Three research questions (RQs) were considered: (1) what are the challenges of mortality risk prediction in TAVI due to changes in procedure knowledge and the patient population? (2) Can we use a combination of baseline patient characteristics to predict the risk of mortality post TAVI? (3) How can we exploit multi-dimensional information about patients to inform clinical decision-making at a local-level? Chapter 2 demonstrates potential to simplify the procedure by removing pre-dilation of the aortic valve, thereby altering the underlying treatment pathway, and Chapter 3 shows that mortality rates from registries should be reported in the context of the underlying patient population. Despite Chapter 2 and 3 presenting potential challenges to TAVI risk prediction (RQ 1), CPMs are fundamental to support benchmarking/audit analyses. To this end, Chapter 4 found that the performance of existing TAVI CPMs was inadequate for use in UK patients. Through the discovery of new risk factors (e.g. frailty) in Chapter 5, the thesis derived a UK-TAVI CPM for audit analyses within the UK cohort (Chapter 6). While Chapters 4-6 present the classic framework of CPM development (RQ 2), this cannot overcome the challenges of mortality prediction in the TAVI setting (RQ 1) and is not suited to support local healthcare decision-making (RQ 3). Thus, Chapter 7 found that local model development could be supported through aggregating existing models rather than re-development. Existing methods of model aggregation were extended in Chapter 8 to allow prior research and new data to be utilised within the modelling strategy; application of the herein derived method to the UK TAVI registry indicated that it could facilitate the choice between model aggregation and de novo CPM derivation. Generally, this thesis has the potential to improve the implementation of CPMs within local populations by moving away from the iterative process of re-development. Practically, the thesis derived a UK-TAVI CPM for audit analyses, using classic and novel methodology.

Objectives: To develop a clinical prediction rule (CPR) for the diagnosis of pleural tuberculosis (PT) in patients with pleural exudates in Peru. Methods: Clinical and laboratory information was collected from patients with exudative pleural effusion attending two reference hospitals in Lima, Peru. Predictive findings associated with PT in a multiple logistic regression model were used to develop the CPR. A definite diagnosis of PT was based on a composite reference standard including bacteriological and/or histological analysis of pleural fluid and pleural biopsy specimens. Results: A total of 238 patients were included in the analysis, of whom 176 had PT. Age, sex, previous contact with a TB patient, presence of lymphadenopathy, and pleural adenosine deaminase (ADA) levels were found to be independently associated with PT. These predictive findings were used to construct a CPR, for which the area under the receiver operating characteristics curve (AUC) was 0.92. The single best cut-off point was a score of ≥60 points, which had a sensitivity of 88%, specificity of 92%, a positive likelihood ratio of 10.9, and a negative likelihood ratio of 0.13. Conclusions: The CPR is accurate for the diagnosis of PT and could be useful for treatment initiation while avoiding pleural biopsy. A prospective evaluation is needed before its implementation in different settings.

Background - Current guidelines suggest that all cancer patients with venous thrombosis be treated with long-term low molecular weight heparin. Whether treatment strategies should vary according to clinical characteristics remains unknown. // Systematic review - A systematic review was performed to determine current understanding of the association between malignancy characteristics in patients with cancer-associated VTE and the risk of VTE recurrence. Four retrospective and 6 prospective studies were included. They suggest that lung cancer, metastases, and adenocarcinomas confer an increased the risk of recurrence and breast cancer a low risk. // Survey - I performed survey to evaluate thrombosis experts’ opinion about the low risk of VTE recurrence they would consider acceptable for patients with cancer- associated thrombosis 103 specialists participated. 80% of respondents agreed that a risk of recurrent VTE during anticoagulation below 7% is low enough. 92% agreed that a CPR that categorizes risk of recurrence is relevant. // Retrospective Study - I performed a single retrospective cohort study to assess the feasibility of derivation of a CPR that stratifies VTE recurrence risk in patients with cancer–associated thrombosis. The study included 543 patients. A multivariate analysis selected female, lung cancer and prior history of VTE as high risk predictors and breast cancer and stage I disease as low risk. // Conclusion - Patients with cancer-associated thrombosis do have varying risks of recurrent VTE depending on clinical characteristics.