Acute myeloid leukemia (AML) and high-risk myelodysplastic syndrome (MDS) are hematologic malignancies that occur most frequently in the sixth and seventh decades of life. Both disorders are associated with a poor prognosis, with median survival of one year or less. An overall five-year survival rate for both disorders, regardless of treatment, is less than 10%. A primary goal of treatment is to improve quality of life (QOL) because cure is improbable. The purpose of this longitudinal cohort study was to compare QOL between groups, intensive, non-intensive therapy, and supportive care. The sample consisted of 85 patients with high risk MDS and AML recruited from Moffitt Cancer Center. Functional Assessment of Cancer Therapy-Leukemia (FACT-Leu) was used to measure QOL. The aims for the study were to: 1) To compare the difference in QOL scores measured by the Functional Assessment of Cancer Therapy –Leukemia version for intensive chemotherapy, non-intensive therapy and supportive care within 7 days of new treatment and one month after initiation of treatment; 2) To determine QOL predictors of AML and high risk MDS from age, comorbidity, fatigue, and diagnosis; 3) To test the moderating effect of treatment with age, comorbidity, and fatigue on QOL. The first aim was analyzed with repeated measures analysis of variance (ANOVA). The supportive care group was not included in the analysis because of low accrual. Results indicated that there was a significant group by time interaction (with p=.040). Follow up tests revealed that the intensive treatment group had a significant improvement in their QOL scores at 1 month post treatment (p=.020). The second aim was conducted using Pearson’s correlations with age, comorbidity, fatigue, and diagnosis with significant correlations found between fatigue and QOL (r=-.693, p< .001). These findings identify an important relationship between fatigue and QOL. This was a negative correlation, showing that as fatigue increases QOL decreases. The third aim was explored using regression with Hayes (2013) application for moderation analysis. Scores for QOL for age, comorbidity, and fatigue were not moderated by treatment. These findings suggest that the most intensive treatment approach improves QOL. In addition, fatigue is a significant predictor of QOL. As fatigue increases, QOL scores decrease. Additional studies with a larger, more diverse sample is needed to explore the relationship between treatment approaches and QOL. In addition, intervention studies can be developed in AML and high risk MDS focused on fatigue management. It is anticipated that the results of this study will be used to inform patients and health care providers when making decisions concerning treatment based on QOL outcomes.

Chronic insomnia is a highly prevalent disorder in general and young adult populations, and contributes a significant economic burden on society. Previous studies have shown healthcare utilization (HCU) is significantly higher for people with insomnia than people without insomnia. One limitation with previous research is accurate measurement of HCU in people with insomnia is difficult due to a high co-morbidity of medical and mental health problems as well as varying operational definitions of insomnia. Assessing HCU in people with insomnia can be improved by applying research diagnostic criteria (RDC) for insomnia, using a population with low rates of co-morbid medical/mental health problems, and measuring HCU with subjective, objective, and predictive methods. The current study found young adults with chronic insomnia had greater HCU than normal sleepers, specifically on number of medications, and chronic disease score (CDS) estimates of total healthcare costs, outpatient costs, and predicted number of primary care visits. The presence of a medical and/or mental health problem acted as a moderating variable between chronic insomnia and HCU. Simple effects testing found young adults with chronic insomnia and a medical/mental health problem had the greatest HCU followed by normal sleepers with a medical/mental health problem, chronic insomnia, and normal sleepers. Exploratory analyses found young adults with chronic insomnia had a greater likelihood of emergency room visits and overnight hospital admissions. More efforts for early identification and intervention of insomnia are necessary to help reduce costs associated with chronic insomnia co-morbid with medical and/or mental health problems.

The use of complementary and alternative medicine continues to increase among people with depression. Tai chi, qigong, and yoga are classified as a subset of complementary and alternative medicine, called mind-body movement therapies. Tai chi originated thousands of years ago in China. Traditionally, tai chi is described as a practice that combines intentional breath and conscious movement to realign the opposing forces of yin and yang in the body. Nowadays, there is a diverse array of tai chi styles that may differ in their emphasis of physicality, flexibility, and attention to breath. Common forms include Yang and Sun styles. The current literature has postulated different biological mechanisms by which tai chi improves physical and mental health. Previous studies have found evidence of improved structural connectivity in brain regions involved in emotion regulation and self-awareness after regular tai chi practice. Furthermore, decreases in inflammation and improved balance between parasympathetic and sympathetic nervous systems have been identified as potential biological mechanisms. Promoting systemic changes in biology, tai chi may have great value as a clinical intervention for a range of disease populations with comorbid depression. Indeed, 44 original clinical trials have been identified in patients with depression alone as well as comorbid metabolic and gastrointestinal conditions, cancer, cardiovascular and respiratory diseases, musculoskeletal disorders, cognitive decline, neurodegenerative diseases, and other psychiatric disorders. In sum, the findings of these trials are mixed, with several studies suffering from small sample sizes and a lack of clearly detailed and published trial protocols. Furthermore, differences in intervention format as well as follow up-data duration across studies makes comparison of trials’ results difficult. Future research to assess tai chi’s efficacy would benefit from larger sample sizes, inclusion of more methodologically rigorous control and comparator groups, and a reproducible description of trial protocol. As complementary and alternative medicine becomes more established in traditional health care institutions, greater funding and research into how tai chi specifically impacts depression symptoms in different patient populations would improve the individually tailored nature of health care for people with complex disease profiles.

Background: There is growing evidence of abnormalities in neurocognition, neuroanatomy, and functional connectivity in posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). However, there has been less work on individuals who suffer with comorbid PTSD and MDD. It is important to investigate the neurobiology of this overlap because of its prevalence, its associated morbidity, and the hope that it may shed more light on the mechanisms involved in each disorder, including the role of the prefrontal regions. This dissertation tests the hypothesis that women with PTSD and MDD display distinct patterns of neurocognitive impairment and associated brain dysfunction, relative to healthy controls, and these effects will be amplified in patients with both disorders. Methods: This dissertation was undertaken within the Drakenstein Child Health Study, a study exploring child health determinants in mother-infant dyads from the Drakenstein district, Western Cape. Mothers (between 18 and 50 years) were recruited and divided into 4 groups: PTSD, MDD, PTSD with MDD, and healthy controls. Participants were assessed using the computerised NIH Toolbox, and paper and pencil neurocognitive tests. Domains assessed included memory, learning, and processing speed, and with particular focus on executive function and attention domains. Participants underwent resting-state functional imaging as well as structural brain imaging. Functional connectivity within and between cognitive control networks (salience network, dorsal attention network, and frontoparietal networks) and a default mode network were compared across the 4 groups. Neuroanatomical indices (cortical thickness, volume, and surface area) of 10 frontal cortical regions from the Desikan-Killiany atlas in Freesurfer 6 were analysed across the 4 groups. Results: All three clinical groups demonstrated no group differences on measures of attention and executive function, diagnoses of PTSD and MDD were associated with more intrusive thoughts and delayed recall impairment, respectively. However, neurocognitive findings indicate that PTSD with comorbid MDD is not associated with greater neurocognitive dysfunction relative to mono-diagnostic groups. Abnormal resting-state connectivity was observed for the MDD group in the default mode network, and for both comorbid and MDD patient groups within frontoparietal networks. Abnormal salience network connectivity for the comorbid group was observed when examining performance on the Pattern Comparison Processing Speed test. No between-network connectivity group differences were observed. Surface area and volume reductions of prefrontal regions were evident for PTSD and MDD, however, no volumetric and surface area differences were observed for the comorbid group. Conclusion: In this sample of mothers from a low-middle income region, distinct patterns of neurocognitive dysfunction and impairment in PTSD, MDD, and PTSD with MDD were observed. However, contrary to hypotheses, comorbidity is not associated with greater dysfunction and impairment and the associations of PTSD and comorbid MDD are not amplified in this sample. These findings have implications for the development of treatment plans for patients diagnosed with PTSD, MDD, and PTSD with comorbid MDD, so that interventions are tailored in a way that is responsive to differences between these groups in the presentation of neurocognitive profile, brain function, and structure.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Masters of Medicine. Johannesburg 2019 / Background: The high level of co-morbid TB/HIV cases with severe organ failure on presentation in South Africa, results in an increased number of ICU admissions often with a poor prognosis at presentation. In this study, the aim was to identify patients admitted with HIV/TB co-infection and calculate the APACHE II scores and SOFA scores for each patient. Predicted percentage mortality was compared with actual mortality. Predictors of mortality were further identified, as well as the benefit of initiating ARV treatment in patients who are ARV naive upon admission to ICU. Methods: A retrospective audit of consecutive cases over a 24 month period was completed. Patient demographics; CD 4 count; ARV treatment status; ICU and 30 day mortality; the APACHE II Score; SOFA scores and correlating predicted percentage mortality were documented. The survival of patients was assessed using Kaplan Meier survival curves, and a univariate analysis was performed to identify risk factors for mortality. Calculated predicted mortality was compared with actual mortality to validate each scoring system and infer which was the better tool. Results: Of 75 patients admitted with pulmonary (43 cases) or extra-pulmonary (32 cases) TB, 23 died in the ICU (mortality 30,7%), and a further 10 died in the first 30 days of hospitalisation (30 day mortality 44%). A survival analysis established ARV treatment and CD 4 counts greater than 50 cells/mm3 were associated with a higher survival rate at any point of the analysis. In the entire study period, only 2 patients were initiated on ARV therapy during their ICU stay, 1 survived to discharge and 1 died in ICU. The APACHE II Predicted Mortality was within the 95% Confidence Intervals for all groups while the SOFA score was outside the upper bound limit of the 95% confidence intervals of actual mortality for those patients taking ARV treatment (52%, 95% CI 43,1% - 59,5% vs actual mortality 30%, 95% CI 17,7% - 46,1%), those with a CD 4 count of more than 50 (53,5% 95% CI 45,4% - 60,6% vs actual mortality 34%, 95% CI 22,1% - 48,4%) and female patients (51,2%, 95% CI 41,6% - 58,1% vs actual mortality 35,1%, 95% CI 21,4% - 50,4%). Conclusion: The study found that both the APACHE II and SOFA scoring systems were both statistically significant in prognosticating mortality in the study population. The APACHE II scoring system however showed a slightly improved prognostication in specific cohorts who had improved survival. It was also confirmed that patients with a CD 4 count of more than 50 cells/mm3, and those on ARV therapy had a statistically significant improved mortality. Further studies reviewing survival benefit of ARV initiation in ICU are warranted. ACKNOWLEDGEMENTS Supervisor: Prof GA Richards Co-Supervisor: Dr SHH Mohamadali Statistician: Mr MH Zondi Assistant - Data Collection: Ms S Madanlall / E.K. 2019

Farmworkers play an integral role in the production and availability of tomato fruit for consumption. Yet the work activities of farmworkers present risk factors for musculoskeletal disorders. Tasks involving stake pounding, picking, bucket toss, and trellising entail risk factors such as repetitive motions, lifting/carrying of heavy loads, and working in flexed trunk postures. These physically demanding activities are typically associated with musculoskeletal disorders (MSDs). Presently, quantitative assessments of these jobs and health risks to the workers are rare. Access to the workers who are often migrant and seasonal can pose an impediment to such investigations. This research examines three tasks performed by tomato farmworkers using objective quantitative tools such as electromyography and physical activity monitoring. It also studies the relationship between self-reported and/or clinically diagnosed chronic health conditions among tomato farmworkers in the region, and risks for developing musculoskeletal disorders in the workplace. Finally, it provides models for studying risk factors of migrant farmworkers via cooperation with a migrant health center and the construction of a tomato test plot. The results of the test plot study show that the anterior deltoid and upper trapezius muscles are disproportionately impacted by tomato farm work activity, even though the three tasks studied are of moderate physical intensity. A high prevalence of musculoskeletal pain was found to exist among tomato farmworkers with the age of the worker influencing the presence or absence of chronic and comorbid conditions. Diabetes, obesity and hypertension were studied in relation to musculoskeletal disorders. The studies described in this dissertation lay the groundwork for future studies and may also encourage policy makers to support programs and collaborative partnerships that address the needs of migrant agricultural workers. We recommend longitudinal studies to research the interplay between comorbidities, jobs performed, and musculoskeletal conditions. We also recommend the use of test plots and full-shift evaluations to better characterize the degree of overexertion in tomato industry tasks.

No / It has long been appreciated in science that correlation does not imply causation. However, with any logical fallacy, simply spotting that the reasoning behind an argument is faulty does not imply that the resulting conclusion is false. Thus, I begin the tricky business of exploring the basis upon which researchers and clinicians are often tempted to conclude that two medical conditions (here alopecia areata and vitiligo), with some striking resemblances, are in fact related. This is relevant, particularly if assumptions of shared aetiology (and to some extent shared pathomechanism) encourage a common strategy to finding a treatment or cure.

Family caregivers of older persons with dementia (PWD) and multiple chronic conditions (MCC) provide high levels of in-home care. Caregiving is complicated by transitions such as changes to one's environment, roles, relationships, and overall health. Although PWD often have MCC, few studies have focused on the influence of MCC on dementia caregiving and transitions. The purpose of this study was to explore the transition experiences of caregivers of PWD and MCC. This study is a sub-study of a larger pragmatic mixed methods randomized controlled trial called MyTools4Care (MT4C). Using interpretive description methodology, semi-structured interviews were conducted across Ontario with a subset of caregivers (n=19) and clinicians working with dementia caregivers (n=7). Purposive theoretical sampling and concurrent data collection and analysis were used. Participants described their transition experiences, factors that influenced these experiences, potential outcomes of transitions, and the influence of MCC on dementia caregiving. Participants identified five key transitions which included: (a) There's no turning off (progressive increase in responsibilities); (b) I'm filling in many roles (changes in roles and relationships); (c) I'm sick, too (changes in overall health and well-being); (d) Dementia defines my social life (changes in social boundaries), and; (e) I know that day will come (changes in preparing for the future). Study findings emphasized how the co-existence of dementia and MCC resulted in added complexity and burden to care management and decision-making for caregivers. Findings suggest that health care professionals (HCP) are an important extension of caregivers' support networks. Thus, HCP need to be comfortable, trained, and knowledgeable in diagnosing and managing dementia and MCCs in order to support caregivers in their transitions. Future research should explore the experience of dementia within the broad context of MCC in order to understand the impact on the dementia caregiving experience. / Thesis / Master of Science (MSc)

No description available.

O trabalho apresenta o risco de óbito, baseado no estudo da comorbidade, nos pacientes internados nos hospitais gerais que oferecem assistência hospitalar na região de Ribeirão Preto adstrita ao Departamento Regional de Saúde XIII - DRS XIII. O risco de óbito foi estimado por meio do cálculo do Índice de Comorbidade de Charlson (ICC). O ICC emprega pesos de 0 a 6 a comorbidades selecionadas, ponderando o risco de morrer. Quanto maior for a pontuação do estrato do paciente, maior a chance de morrer. Para análise, foi desenvolvida uma ferramenta computacional que automatiza o cálculo do índice a fim de auxiliar os gestores na tomada de decisão. Assim, obtivemos a distribuição dos casos estudados por estrato ICC e ICCI - outra abordagem do índice ICC, quando a idade é considerada junto ao vetor de comorbidades - para o ano de 2011. Notamos que para o cálculo do ICC, a curva de risco de óbito não seguiu o previsto por Charlson, cuja mortalidade deveria aumentar à medida que a pontuação do estrato aumenta, porém, a distribuição de casos por ICCI seguiu esse conceito. Por fim, estudamos a distribuição espacial dos casos de alta gravidade que nos mostrou as cidades pólos e subpólos da região em assistência hospitalar. O indicador e a automatização de seu cálculo apresentou-se um bom auxílio na tomada de decisão nas questões de saúde. / The work presents the risk of death, based on the study of comorbidity in hospitalized patients in general hospitals that offer hospital care in the region of Ribeirao Preto enrolled in Regional Department of Health 13th - DRS XII. The risk of death was estimated by means of the calculation of the Index of Charlson Comorbidity (ICC). The ICC employs weights from 0 to 6 the comorbidities selected, considering the risk of dying. The higher the score on the stratum of the patient, the greater the chance of dying. For analysis, a computational tool that automates the calculation of the index was developed, in order to assist managers in decision making. Thus, we obtained the distribution of cases studied by stratum ICC and ICCI - another approach to the ICC index, when the age is considered along the vector of comorbidities - for the year 2011. We note that for the calculation of the ICC, the curve of risk of death did not follow the prescribed by the Charlson index, whose mortality should increase as the score of the stratum increases, however, the distribution of cases by ICCI followed this concept. The indicator and the automation of its calculation proved to be a good aid in decision-making on health issues.