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Premature termination from child and adolescent psychotherapy is a prevalent problem for clients, their families, and mental health services. Rates of premature termination have been estimated at a range of 16-72%. Many variables have been examined as potential predictors of premature termination, yielding inconsistent conclusions. Researchers propose that part of this variability in rates and predictors is due to the inconsistent application of definitions of premature termination. The past literature identifies two main categories of definitions in this line of research: therapist judgment and number of sessions. This study aims to incorporate a relatively new definition, clinically significant change, in the evaluation of premature termination rates and predictor variables in a sample of adolescents receiving treatment in three community mental health clinics. Results showed that 65.7% of the participants were classified as premature terminators under the definition of clinically significant change. Premature termination was significantly correlated with parenting skills and ratings of the therapeutic alliance by both the parent and adolescent. However, the only variable that predicted PT was the therapeutic alliance as rated by the adolescent. It appears that, rather than having a small range of rates and universal predictors of premature termination, it may depend on the definition that is chosen.

The current study sought to examine client outcome data for clients seen for outpatient psychotherapy services by graduate-level student therapists in doctoral psychology training clinics in order to better understand the change process occurring in such settings and to examine whether services being offered are meaningful for clients. One hundred ninety-nine clients seen by graduate-level therapists at a training clinic setting were assessed on a session-by-session basis using the Outcome Questionnaire-45 in order to identify the percentage of clients who met criteria for clinically significant change, reliable improvement, no change, or deterioration in outcomes across the course of treatment. Approximately 28% of clients seen for treatment met criteria for clinically significant change at the termination of treatment and 23% reliably improved. Survival analysis indicated that the median time required to attain clinically significant change was six sessions. Current findings are compared to earlier investigations in both training and nontraining settings. The implications of these findings for education and training, client care and clinical services, and policy are discussed.

Background: Stroke is the leading cause of disability in the United States. Physical therapists treating patients post acute stroke use measurement tools specifically designed to measure gait and balance ability. People with sub-acute stroke typically have rapid and large changes in gait and balance ability while undergoing inpatient physical therapy. There is a lack of information about how much change in gait speed is needed in hospitalized people with sub-acute stroke to be considered an important amount. There is no information regarding the validity, and reliability of the Tinetti Performance Oriented Mobility Assessment (POMA) to measure balance ability in people with stroke or how much change is needed to be important to people in the sub acute phases of stroke. Objective: The purpose of this study was to 1) estimate minimal clinically important difference (MCID) for comfortable gait speed in persons who have experienced stroke and are undergoing inpatient physical therapy using 3 different anchors of change; 2) estimate minimal clinically important difference (MCID) for Tinetti POMA in persons who have experienced stroke and are undergoing inpatient physical therapy using 3 different anchors of change; 3) determine the test retest reliability and minimal detectable change (MDC) for the Tinetti POMA; and 4) explore the construct validity of the Tinetti POMA for use in people with stroke undergoing inpatient physical therapy. Study Design: This study was a prospective, longitudinal study, which followed a cohort of patients who were undergoing inpatient physical therapy post acute stroke. Methods: Participants were recruited if they had a first documented stroke and were receiving physical therapy during inpatient rehabilitation. Participants were excluded from the study if they had a history of a previous stroke, were medically unstable, were non-English speaking or were unable to walk without assistance prior to the current stroke event. Comfortable gait speed measured by a 5-meter walk test, Tinetti POMA scores and motor Functional Independence Measure (FIMTM) scores were collected at admission to and discharge from inpatient rehabilitation. To determine test re-test reliability, two trials of comfortable gait speed were administered during the same treatment session and two trials of Tinetti POMA were performed one day apart. Global Rating of Change (GROC) scores were collected at discharge from inpatient rehabilitation. A score of 6 (¡°a great deal better, an important amount¡±) on a Global Rating of Change scale and achievement of ¡Ý17 point change on the motor FIM was used to dichotomize participants into those who had important change in walking and balance ability and those who did not. Receiver operator characteristic (ROC) curves were constructed to estimate important change values for gait speed using the three anchors. Effect Size (ES) index was used to determine the responsiveness of gait speed and the Tinetti POMA, Intraclass Correlation Coefficient (ICC2,1) was used to determine test re-test reliability and MDC values for gait speed and Tinetti POMA and Spearman¡¯s Rho (rs) was used to explore the construct validity of the Tinetti POMA. Results: The participants in this study were 43 people with average age of 76¡À11 years who had experienced first documented stroke, began inpatient physical therapy at a mean of 8¡À5 days post stroke and were discharged from the hospital at an average of 38¡À11 days post stroke. The mean length of stay for all participants was 23¡À11 days. MCID of comfortable gait speed was estimated to be 0.24 m/s (AUC= 0.644 , sn/sp=66%/64%, LR+=1.83, LR-0.54) anchored to motor FIM change scores. Test re-test reliability of gait speed was ICC2,1=0.931 at admission and ICC2,1=0.987 at discharge. MDC of comfortable gait speed was 0.12 m/s at admission and 0.08 m/s at discharge. MCID of the Tinetti POMA was 7 points (AUC=0.743, sn/sp=79%/64%, LR+=2.18, LR-=0.32) anchored to motor FIM change. Test re-test reliability of the Tinetti POMA was ICC2,1 0.859 and MDC was 5 points. Tinetti POMA scores were moderately correlated to motor FIM and gait speed scores at admission (rs=0.74 and 0.67) and discharge (rs=0.60 and 0.76) to gait speed and motor FIM scores. Conclusions: People with stroke who experience a 7 point change on the Tinetti POMA during inpatient rehabilitation are likely to experience an important change in functional mobility. The Tinetti POMA demonstrates validity and reliability to measure balance ability people with stroke. More research is needed to estimate meaningful change people with sub-acute stroke using larger cohorts with similar characteristics.

Prostatacancer är den vanligaste cancerformen hos män. Prostatan tillhör de manliga reproduktionsorganen och producerar bland annat prostataspecifikt antigen (PSA) som kan påvisas i blodet. Förhöjda värden av PSA kan bero på prostatacancer. Transrektalt ultraljuds (TRULS)-ledda systematiska biopsier används i högre frekvens än magnetkamera med riktad biopsi. Röntgensjuksköterskans möte med dessa patienter är före, under och efter bildtagningen med magnetkameran. Syftet var att göra en översikt av den diagnostiska träffsäkerheten för TRULS-ledda systematiska biopsier och magnetresonans (MR)-undersökning med riktade biopsier vid misstanke om prostatacancer. Metoden bestod av en litteraturöversikt med systematisk ansats. Inkluderingskriterier var vetenskapliga artiklar skrivna mellan 2015–2020. Artiklarna skulle vara peer-reviewed och etiskt granskade. Databasen Medline användes till sökningen. Kvalitetsgranskning gjordes med granskningsprotokoll hämtade från Avdelningen för omvårdnad på Hälsohögskolan. I resultatet inkluderades 15 artiklar som visade att skillnaden i den diagnostiska träffsäkerheten för prostatacancer hos män inte var stor mellan metoderna. Däremot hittade MR-undersökning med riktade biopsier större andel kliniskt signifikanta cancrar och mindre del insignifikanta cancrar än vad TRULS-ledda systematiska biopsier gjorde. MR-undersökning med riktad biopsi är en bra metod för att öka träffsäkerheten att hitta kliniskt signifikant cancer. Dock går det inte utesluta TRULS-ledda systematiska biopsier då kontraindikationer och missade cancrar på MR-undersökning med riktade biopsier förkommer. / Prostate cancer is the most common cancer in men. The prostate belongs to the male reproductive organs and produces, among other things, prostate-specific antigen (PSA) that can be detected in the blood. Elevated levels of PSA may be due to prostate cancer. Transrectally ultrasound (TRULS)-guided systemic biopsies are used at higher frequency than magnetic cameras with directed biopsy. The X-ray nurse's meeting with these patients is before, during and after the imaging with the magnetic camera. The aim was to make an overview of the diagnostic accuracy of TRULS guided systematic biopsies and MRI with targeted biopsies on suspicion of prostate cancer. The method consisted of a literature review with systematic approach. Inclusion criteria were scientific articles written between 2015-2020. The articles would be peer-reviewed and ethically approved. The Medline database was used for the search. Quality review was done with review protocols obtained from the Department of Nursing at the School of Health. The result included 15 articles showing that there was no big difference in the diagnostic accuracy of prostate cancer in men between the methods. In contrast, MRI with targeted biopsies found a greater proportion of clinically significant cancers and a smaller proportion of insignificant cancers than TRULS guided systematic biopsies did. MRI with targeted biopsy is a good method for increasing the accuracy of finding clinically significant cancer. However, TRULS guided systematic biopsies cannot be ruled out as contraindications and missed cancers on MRI with targeted biopsies occur.

Thesis advisor: Marilyn Cochran-Smith / The clinical experience of future urban teachers is increasingly regarded as one of the most important aspects of teacher preparation (NCATE, 2010; NRC, 2010). However, there is widespread agreement that further knowledge must be acquired on what constitutes rich clinical experience, and on the influence of such learning opportunities especially in urban, high-needs contexts (Anderson & Stillman, 2013; Levine, 2006; Picus, Monk, & Knight, 2012). This dissertation aims to increase our understanding of clinical experience. Based on sociocultural and socio-constructivist perspectives, and drawing on Lave and Wenger’s (1991) theories of learning within communities of practice, this dissertation employed qualitative research methods to examine the phenomenon of content coaching during an urban teacher residency program. This dissertation argues that residency content coaching provided a context within which residents could integrate what they were learning about “ambitious teaching” (Lampert & Graziani, 2009; Newmann & Wehlage, 1993) into their own practice through ongoing negotiations with their coaches. Coaching interactions were by and large responsive to individual resident’s learning needs, and guided residents to begin to place their students’ learning at the center of decision-making when planning, teaching, and assessing. The dissertation further investigates the actual and aspirational characteristics of coaching in this context. Overall findings suggest that content coaching addresses several persistent problems of traditional pre-service fieldwork supervision (Darling-Hammond, 2010; Featherstone, 2007), and offers a more coherent approach. Consequently, this dissertation contributes to our collective understanding of clinical experience in preparing teachers to teach ambitiously in urban classrooms. / Thesis (PhD) — Boston College, 2016. / Submitted to: Boston College. Lynch School of Education. / Discipline: Teacher Education, Special Education, Curriculum and Instruction.

People diagnosed with cancer or undergoing cancer treatment experience a wide range of symptoms. One of the most common symptoms experienced by cancer patients today is cancer-related fatigue. Cancer-related fatigue is a complex condition, recognised as a multidimensional construct and thought to be associated with a cluster of symptoms rather than occurring in isolation. Cancer-related fatigue is distressing and can persist beyond the treatment phase or the disease itself. Current understanding of cancer-related fatigue and its management is limited. Further developing our knowledge of cancer-related fatigue may lead to innovative means of improving the identification, prediction and management of this troublesome symptom. To this end, this thesis aims to: I) identify factors reported to have a relationship with cancer-related fatigue; II) examine the course of cancer-related fatigue during and after radiotherapy; III) determine a method of detecting clinically meaningful change in fatigue; IV) examine whether correlates of fatigue are consistent across all fatigue dimensions or whether each dimension has its own unique pattern of correlates; and, V) develop and trial a group-based educational intervention to target cancer-related fatigue. To address Aim I in this thesis, relevant literature was reviewed to identify factors which potentially influence cancer-related fatigue. Factors identified include underlying medical factors (biomedical mechanisms, disease-related factors, treatment-related factors and comorbid conditions); physical or behavioural factors (poor nutrition, decreased activity, sleep disturbance, pain); psychological factors (anxiety and depression); and sociodemographic factors (social support, employment and education). The range of inter-related factors identified makes cancer-related fatigue a challenging condition to manage. The factors associated with cancer-related fatigue were synthesized into the Fatigue Framework to provide a clinically useful format for health professionals working with people with cancer. The Fatigue Framework was used to guide the remainder of the research into cancer-related fatigue presented in this thesis. This research consists of two main studies; a prospective longitudinal cohort study (to address Aims II, III, IV) and a randomised controlled trial (to address Aim V). The first study in this research examined the factors and effects associated with cancer-related fatigue in a radiotherapy population (n=210). Patients undergoing radiotherapy were recruited for a single-centre prospective longitudinal cohort study. Participants were assessed using a battery of assessments at three time points, at the start of radiotherapy, the end of radiotherapy and six weeks after radiotherapy completion. The results of this study were used to address Aim II, to identify the pattern of fatigue over the course of radiotherapy. The level of fatigue reported was shown to significantly increase from start to the end of radiotherapy and then significantly decrease from the end of radiotherapy to six weeks post-treatment for each subscale of the MFI. The results of this study were also used to address Aim III, to determine a method of detecting clinically meaningful change in fatigue. Whilst there are many tools used to assess cancer-related fatigue, the Multidimensional Fatigue Inventory (MFI) was the assessment chosen for use in this research study and throughout this thesis. The MFI is one of the few fatigue assessments that takes the various clinical dimensions of fatigue into account and has established reliability and validity. However, unlike other fatigue assessments, there were no published minimal clinically important difference (MCID) criteria for its use in cancer populations. MCID criteria determine the smallest change in scores that can be regarded as important, allowing clinicians and researchers to interpret the meaning of changes in patients’ fatigue scores. Determination of the MCID was based on the relationship of MFI scores to four clinically relevant constructs: (1) treatment impact on fatigue, (2) health-related quality of life, (3) performance status and (4) occupational productivity. These constructs were used as external or anchor-based measures to determine a MCID for each sub-scale of the MFI. Multiple MCID criteria were identified through the first study, each from a different perspective based on the anchor-based construct used. However, a two-point reference for each MFI sub-scale was suggested as a generic MCID as it was most consistent across the anchors examined. The MCID criteria validated in this study allow better interpretation of changes in MFI sub-scale scores and allow effect size calculations for determining sample size in future studies. The MFI allows assessment of multiple dimensions of fatigue (general fatigue, physical fatigue, reduced activity, reduced motivation and mental fatigue). Minimal previous research had considered the differential effect of symptom correlates on individual dimensions of fatigue. The data of the prospective cohort study were further utilised to address Aim IV, to determine whether correlates of fatigue were consistent across all dimensions or whether each fatigue dimension had its own unique pattern of correlates. Results indicated that each dimension of fatigue was associated with a different pattern of correlates supporting the concept of multiple dimensions of fatigue. This enhanced understanding of fatigue could be used to guide the development of individually tailored interventions to target specific correlates of fatigue in affected domains, or group interventions to address all relevant fatigue correlates. Because fatigue is associated with multiple symptom correlates, it requires multi-focused symptom management. Education is a commonly recommended fatigue management strategy which can be used to target multiple symptoms simultaneously. There is a lack of information about the content and format used in education programs and the effectiveness of education in managing fatigue. The second study in this thesis addressed Aim V, to develop and trial a group-based educational intervention to target cancer-related fatigue. The study examined a group-based educational intervention (CAN-FIT) targeting cancer-related fatigue in radiotherapy patients. A pilot study of the intervention’s feasibility and acceptability indicated the intervention was acceptable to participants and its operation was feasible. Small modifications to program components were made based on participant feedback. A randomised controlled trial was then conducted to examine effectiveness of the CAN-FIT program and to ascertain the most effective timing for such an educational intervention. The study employed a factorial design and recruited 110 participants. Assessments were conducted at three time points, the start of radiotherapy, the end of radiotherapy and six weeks after the completion of radiotherapy. Results of the randomised controlled trial of CAN-FIT did not show a significant effect of the program on cancer-related fatigue levels, however the pre-radiotherapy education sessions were associated with significant increases in physical activity participation. Furthermore, the study demonstrated the delivery of education prior to radiotherapy was more effective than delivery after radiotherapy. This thesis successfully addresses its stated aims and provides a greater understanding of the concept of cancer-related fatigue. The results more clearly describe the course and correlates of fatigue and their relationship with the dimensions of fatigue. The MCID criteria for the MFI can be used in future research to evaluate outcomes and determine sample size in power calculations. The intervention trialled can be used in clinical practice to provide a low-resource intervention to improve activity levels without any subsequent change in fatigue in radiotherapy patients. Together these studies build upon current knowledge and provide directions for future research to address this difficult symptom.

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京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第22883号 / 医博第4677号 / 新制||医||1048(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 平井 豊博, 教授 川上 浩司, 教授 椛島 健治 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Titel: Magnetfältstyrkans betydelse för personer med multipel skleros eller kliniskt isolerat syndrom - en litteraturstudie Bakgrund: Multipel skleros (MS) är en demyeliniserande autoimmun sjukdom i centrala nervsystemet som debuterar främst hos unga vuxna. MS diagnostiseras utifrån kliniska och radiologiska fynd enligt McDonaldkriterierna där inga krav ställs på vilken fältstyrka som bör användas. Magnetkameror med högre fältstyrkor blir dock vanligare. Syfte: Att undersöka om högre fältstyrka (Tesla, T) gav bättre detektion av lesioner vid magnetresonanstomografiundersökningar av personer med multipel skleros eller kliniskt isolerat syndrom. Metod: I denna litteraturstudie gjordes sökningarna i databaserna PubMed, Web of Science och Scopus mellan 8 och 11 mars 2016. Tio kvantitativa artiklar kvalitetsgranskades och analyserades för att slutligen sammanställas i resultatet. Resultat: Resultatet presenteras under fyra huvudrubriker och totalt tolv underrubriker. Huvudrubrikerna är skillnad mellan fältstyrkor, fältstyrkor och anatomiska regioner, fältstyrkor och pulssekvenser samt artefakter och bildkvalitet. Konklusion: 3T och 7T är bättre än 1,5T och att 7T ofta är bättre än 3T på att detektera lesioner. Dock måste andra aspekter tas i beaktning då det är många parametrar som spelar in vid en magnetresonanstomografiundersökning. Ytterligare studier gällande bland annat optimering av pulssekvenser samt patienters upplevelser av ultrahöga fältstyrkor rekommenderas. / Title: The importance of magnetic field strength for people with multiple sclerosis or clinically isolated syndrome - a literature study. Background: Multiple sclerosis (MS) is an autoimmune demyelinating disease of the central nervous system debuting mostly in young adults. MS is diagnosed based on clinical and radiological findings according to the McDonald criteria where no requirements are placed on which field strength that should be used. Magnetic resonance imaging (MRI) scanners with higher field strengths are however becoming more common. Objective: To investigate whether higher field strength (Tesla, T) gave better detection of lesions at MRI examinations of people with MS or clinically isolated syndrome. Methods: In this literature study searches were made in the databases PubMed, Web of Science and Scopus between the 8th and 11th of March 2016. Ten quantitative articles were examined and analyzed to finally be compiled under the results. Results: The results are presented under four main headings and twelve sub- headings. The main headings are the differences between field strengths, field strength and anatomical regions, field strength and pulse sequences and artifacts and image quality. Conclusion: 3T and 7T are better than 1,5T and 7T is usually better than 3T at detecting lesions. However other aspects need to be taken into account because many parameters come into play during MRI examinations. Further studies regarding optimization of pulse sequences and field strength and patients’ experiences of ultrahigh field strength are recommended, among others.