An extensive body of literature supports the clinical utility and feasibility of client-centric goal-setting techniques in neurorehabilitation. However, such techniques are seldom used and difficult to adopt in mainstream clinical practice. Two primary barriers that limit uptake and adoption of individualized goal-setting techniques into routine practice include: (1) lack of an operationalized framework susceptible to variations in the characteristics of the user and constraints of a medical setting and (2) limited knowledge on the part of clinicians and clients to confidently engage in goal-setting conversations. The eGAS app was designed to address the need for a semi-structured client-centric goal-setting framework for clinicians engaged in neurorehabilitation. This study used a single-subject design to investigate the effects of using eGAS in an outpatient hospital setting on clinician behavior and client responsiveness. A nonconcurrent, multiple-baseline design was used across three clinicians to determine if use of eGAS would result in functional changes in collaborative interviewing behaviors, validity of generated goal scales, and reliability of the process. Results revealed that using eGAS had strong functional effects on collaborative interviewing behaviors and validity of goal scales, and a weak effect on reliability. Another noteworthy finding was that eGAS could be implemented with relatively high fidelity within the constraints of a clinical context despite variations in the characteristics of the end-user, i.e. clients and clinicians. I discuss support for ecological validity of eGAS in terms of implementation barriers and facilitators that affected outcomes, methodological limitations, and future steps to improve design validity and implementation integrity.

Osteoarthritis (OA) is one of the leading causes of global disability. Surgical intervention in the form of Total Knee Arthroplasty (TKA) has been established as an excellent treatment modality for people with OA who experience joint symptoms that have a substantial impact on their quality of life and are refractory to non-surgical treatment. In the 1970s the concept of implanting TKAs in mechanical alignment (MA) was developed as a compromise to confer mechanical advantage to the prosthesis, ignoring the patient's natural anatomy, to prevent early failure of the implant. Until now, this compromise has not been revisited. Satisfaction following TKA remains inferior to total hip arthroplasty. The cause of this dissatisfaction is not clear. Implant survival is no longer comparable to that of the early designs of TKA, and recent studies have suggested that deviation from neutral alignment does not have the detrimental effect on survivorship as previously thought. In an attempt to improve patient satisfaction following TKA a new technique has been developed whereby the prostheses are implanted in such a way as to recreate the alignment of the knee in the patient's pre-arthritic state. This has been termed natural or kinematic alignment (KA). This thesis examines the impact of KA in TKA with the primary hypothesis that TKA performed utilising KA would lead to improved functional outcome following surgery compared to that of MA. An initial single surgeon proof of concept case series of 25 patients was performed to look at the precision of new patient specific cutting blocks. The results suggested that the cutting blocks were accurate in producing the desired cuts. Following the proof of concept case series, a feasibility study was then performed comparing the new KA technique with the standard MA technique. The feasibility study familiarised the operating surgeons with the new technology in preparation for a Randomised Control Trial (RCT). A prospective blinded RCT was performed to compare the functional outcome of patients implanted with TKA in MA with that of KA. A total of 71 patients undergoing TKA were randomised to either MA (n=35) or KA (n=36). Preand post-operative hip knee ankle (HKA) radiographs were analysed. A number of patient reported outcome measures and functional tests were assessed pre-operatively, 6 weeks, 3 months, 6 months, and at 1 year post-operation. The cutting guides were accurate. There were no statistically significant differences between the MA and KA groups at 1 year. A cohort of post-menopausal women with unilateral osteoarthritis treated with TKA utilising the KA philosophy had dual energy x-ray absorptiometry scans 1.5 years post-operatively using a modified validated densitometric analysis protocol, to assess peri-prosthetic Bone Mineral Density (BMD). The contralateral knee was scanned so that relative bone mineral density could be calculated. Statistical analysis revealed no significant difference in relative peri-prosthetic bone mineral density due to variation in implant position with respect to the Lateral Distal Femoral Angle (LDFA) and the Medial Proximal Tibial Angle (MPTA). There was a significant correlation with overall HKA angle and the relative BMD under the medial side of the tibial tray. KA TKAs appear to have comparable short-term results to MA TKAs with no significant differences in function 1 year post-operatively. Overall HKA angle rather than the individual component position caused change in relative BMD under the tibial tray, therefore aiming for an anatomical joint line may improve kinematics without a detrimental effect on the implant. Further research is required to see if any theoretical long-term functional benefits of KA are realised or if there are any potential effects on implant survival.

Faculty of health sciences School of Public Health 0204521g dgresie@yahoo.co.uk;dgresie@hotmail.com / Ethylene oxide is used widely in hospitals as a gaseous sterilant for heat-sensitive medical items, surgical instruments and other objects and fluids that come into contact with biological tissues. Although ethylene oxide is recognised as a reproductive toxicant in humans, so far few studies have been carried out to investigate the association between exposure to ethylene oxide and the occurrence of adverse reproductive outcomes (Hemminki et al 1982 and 1983; Rowland et al, 1996; Yakubova et al, 1976). The results of these studies suggested that ethylene oxide is capable of causing reproductive dysfunction and that further research is needed in order to understand its effects on reproductive health. This study investigated the association between exposure to ethylene oxide during pregnancy and adverse reproductive outcome in women sterilising staff working in sterilising units using ethylene oxide in Gauteng province, South Africa. The study had the following objectives: 1) to describe the extent and nature of ethylene oxide use in sterilising units operational in medical facilities in Gauteng; 2) to assess the current exposure to ethylene oxide in sterilising units in Gauteng; 3) to collect information on the last recognised pregnancy using a questionnaire; 4) to assess the validity of the information on the evolution and outcome of the last recognised pregnancy collected by the means of the questionnaire; 5) to assess the association between occupational exposure to ethylene oxide during pregnancy and adverse reproductive outcome. The study population was represented by singleton pregnancies that: 1) occurred in women currently working in sterilising units using ethylene oxide in Gauteng province, South Africa; 2) were the last recognised pregnancy occurring in these women after the 1st January 1992; 3) occurred while the mother was employed. The adverse reproductive outcome was defined as the occurrence of any the following: spontaneous abortion, still birth, pregnancy loss (spontaneous abortion or still birth), low birth weight and combined adverse reproductive outcome (spontaneous abortion, still birth or low birth weight). The study enrolled 68.8% of the medical facilities in Gauteng that were using ethylene oxide to sterilise medical equipment. The majority of the employees working in the sterilising units included in the study were women (96.6%) and they were employed in one of the following jobs: technician (operator), instrument packer and cleaner. xiii Most of the sterilising units participating in the study used ethylene oxide sterilisation daily and only 15.4% of them reported that the employees operating the ethylene oxide steriliser used protective clothing. Recorded levels of ethylene oxide were provided by 46.2% of the sterilising units; they were all bellow 0.25 ppm (the South African long-term exposure limit for occupational exposure to ethylene oxide is 5 ppm). Changes in ethylene oxide sterilisation equipment and or technology were reported by 42.3% of the sterilising units and they were all engineering control measures aimed at reducing exposure to ethylene oxide. Measurements of the current levels of ethylene oxide were performed at the time of the study by the National Institute for Occupational Health using hydrobromic acid-coated petroleum charcoal tubes connected to calibrated Gilian pumps through which air containing ethylene oxide was drawn. The samples were analysed by the Analytical Services of the National Institute for Occupational Health. A total of 418 samples were collected (100 blank samples, 97 personal samples and 221 static samples). Quality control was ensured by the following methods: 1) verification by an Approved Inspection Authority; 2) collection of duplicate samples; 3) collection of blank samples. These measurements showed that exposure to ethylene oxide still occurred in sterilising units (ethylene oxide was detected in 9 out of the 10 public hospitals) and that the employees most exposed are the ones working with the ethylene oxide steriliser (technician or operator). There were 113 women working in the sterilising units enrolled in the study who had been pregnant after the 1st January 1992; 109 of them agreed to participate in the study and to complete the questionnaire. Information on exposure to ethylene oxide during pregnancy was obtained from three sources: walk-through survey, questionnaire-collected data and measurements of the levels of ethylene oxide in sterilising units at the time of the study. Information on the evolution and outcome of these pregnancies was gathered from the mother using a questionnaire. The questionnaire collected demographic data, reproductive history, medical data, risk factors for the adverse reproductive outcome (environmental and occupational exposures, lifestyle), and data regarding the evolution and outcome of the last recognised pregnancy. The questionnaire also collected detailed information on the job held at the time of the last recognised pregnancy (if the woman was working with ethylene oxide, she was asked to provide a complete list of daily tasks she was performing). Prior to administration, the questionnaire was tested on a small sample of working women. xiv The validity of the questionnaire-collected information on the evolution and outcome of the last recognised pregnancy was assessed by comparing this information against medical records (considered the “gold standard”). The assessment showed that mothers’ recall was accurate for the following variables: medical facility were the pregnancy was recorded, date of the reproductive event, gestation length, vital status of the newborn, number of foetuses, child gender, disease/medical problems during pregnancy and treatment received during pregnancy. There was an error in the mothers’ reporting of the birth weight of their babies. The possible misclassification of outcome resulting from this error was shown to be nondifferential (the proportion of subjects misclassified on outcome did not depend on exposure). Therefore, this misclassification could bias the effect estimate towards the null value or it could not produce any bias at all. The analysis carried out to detect possible associations between exposure to ethylene oxide and adverse reproductive outcomes included 98 of the initial 109 pregnancies on which information had been collected (11 pregnancies were excluded from the analysis for the following reasons: 2 were multiple pregnancies, 4 were conceived before 1st January 1992 and 5 were conceived while the mother was not employed). Amongst the 98 singleton pregnancies included in the analysis, 19 were classified as exposed and 79 as unexposed to ethylene oxide. The relative risk for spontaneous abortion was RR=16.63 (95%CI=1.97-140.42; p=0.004), for stillbirths RR=3.47 (95%CI=0.63-19.01; p=0.18), for pregnancy loss RR=6.24 (95%CI=1.95- 19.93; p=0.003), for low birth weight RR=0.61 (95%CI=0.09-4.30; p=0.51) and for combined adverse reproductive outcome RR=2.09 (95%CI=1.00-4.36; p=0.06). No confounders were detected for any of the associations between exposure to ethylene oxide and the adverse reproductive outcomes under study. For the association between exposure to ethylene oxide and combined adverse reproductive outcome the analysis detected three effect modifiers: paternal age (father aged 40 or older at conception), passive smoking and maternal age (mother aged 35 or older at conception). In conclusion, this study, the first in South Africa on ethylene oxide exposure and adverse reproductive outcomes, confirmed the widespread use of ethylene oxide, exposure to this agent in public sector hospitals and associations between exposure to ethylene oxide and spontaneous abortion and between exposure to ethylene oxide and pregnancy loss (either spontaneous abortion or stillbirth). xv Moreover, the study provided data on reproductive outcomes in employed women (on which scant data are available in South Africa) and added information on the validity of selfreported pregnancy data relative to medical records. The findings of the study support the conclusions of the previous studies that had suggested that exposure to ethylene oxide during pregnancy could lead to adverse reproductive outcomes. The study detected no associations between exposure to ethylene oxide and stillbirth, low birth weight or between exposure to ethylene oxide and combined adverse reproductive outcome.

With the increased use of performance funding in Tennessee and many other states, it is imperative that administrators strategically budget to meet performance outcome goals. The purpose of this research was to determine the relationship between the budget function allocations of Instruction, Academic Support, and Student Services and performance outcome measures involving student success factors defined as completion of credit hours, awards of technical certificates, and awards of undergraduate degrees through the academic years of 2006-07 and 2013-14. The population included the 13 public community colleges and 9 public universities in Tennessee within the Tennessee Board of Regents and the University of Tennessee systems. Statistical procedures included bivariate correlations and multiple regressions of the predictor variables of budget function allocations and the criterion variables of performance outcomes. Descriptive data indicated an increase in the majority of the budget function area means and decreases in the majority of performance outcomes over the timeframe of the study. Correlation analysis of community college predictor and criterion variables revealed significant positive relationships existed between the following: (a) salary allocations for Student Services and awards of technical certificates; and (b) allocations for salaries for Instruction and completion of credit hours and number of associate degrees awarded. Multiple regression analysis of community college variables indicated salaries of Instruction were the most useful predictor of performance outcomes. Correlation analysis of university predictor and criterion variables revealed significant negative relationships existed between the following: (a) operations for Student Services and completion of 24, 48, and 72 credit hours; (b) salaries for Student Services and completion of 24, 48, and 72 credit hours and number of bachelor degrees awarded; (c) salaries of Academic Support and completion of 24 and 48 credit hours; (d) operations budgets for Instruction and completion of 24, 48, and 72 credit hours; (e) budget allocations for salaries for Instruction and completion of 24 credit hours; and (f) combined budget allocations and completion of 24 and 48 credit hours. Correlation analysis of university predictor and criterion variables revealed significant positive relationships existed between operations budgets for Academic Support and completion of 72 credit hours and number of bachelor degrees awarded

In this case study, we present a patient with preexistent posttraumatic stress disorder and psychosis who has been recently diagnosed with Dementia with Lewy Bodies. He is experiencing vivid hallucinations. What went wrong between him and his wife as a result of these hallucinations is presented. Alternative actions that could have been used are suggested.

The use of treatment support tools to enhance client outcomes is not well understood in the youth treatment literature. Adult outcome researchers have found that the use of Clinical Support Tools (CST) leads to improved outcomes with clients identified as at risk for treatment failure. However, the American Psychological Association (APA) has noted that understanding important client factors that influence treatment is critical during the clinical formulation and treatment planning phase of therapy. No studies to date have evaluated the effectiveness of utilizing a CST as a treatment planning tool with youth clients. The purpose of this study was to evaluate the effectiveness of the Treatment Support Measure, a CST, for the purpose of treatment planning rather than as a reaction to clients who became at-risk for treatment failure. Two hundred and eight youth participants and their caregivers from three outpatient community mental health clinics were randomly assigned to a feedback (TSM-FB) or Non-FB condition. All participants completed the Youth Outcome Questionnaire (Y-OQ) at each session. The TSM was administered to clients in the TSM-FB condition during the intake session. Only therapists whose clients were in the TSM-FB condition received TSM and Y-OQ data. A multilevel model was created to evaluate for differences between conditions on the dependent variable. The initial randomization failed to create similar groups at intake and a statistically and clinically significant difference was detected on the Y-OQ at intake. As such, no conclusions can be drawn for hypotheses tied to the primary dependent variable. Premature termination (PT) rates were significantly lower for the TSM-FB condition when defined as attending more than one session. Contrastingly, there was no difference between conditions on PT when defining PT based on the therapist's opinion. A significant minority of therapists (40%) found that the TSM was useful for treatment planning compared to 10% which did not.

No description available.

Inhalation exposure to semi-volatile polychlorobiphenyls (PCBs) that ubiquitously exist in the environment has the potential to cause adverse health effects. Recently identified sources of airborne PCBs, especially non-legacy sources, stress the importance of risk assessment for inhalation exposure. However, the fate of inhaled airborne PCBs in biological systems and the resultant toxicity remain unexplored. The objective of this thesis research was to investigate the distribution and elimination of semi-volatile PCBs in biological systems after inhalation exposure and evaluate the biologic and toxicologic consequences. This objective was achieved by conducting the following inhalation studies in rats: a short-term exposure study of the body burden and elimination; a subchronic exposure toxicity study; an acute exposure study of PCB11 metabolism; and a mass balance study of [14C]PCB11 following lung exposure. PCBs found in technical Aroclor mixtures and PCB11 were readily absorbed and distributed following nose-only inhalation exposure. PCBs accumulated in adipose tissue, but decayed in other tissues with biological half-lives of several hours. Their elimination was dependent on the structure of the PCB congeners and the metabolic nature of the organ. Lower-chlorinated PCBs exhibited more rapid clearance than higher-chlorinated congeners yet differential rates of elimination were also seen within the homologue. A distinct congener pattern was found in tissues, ranging from tri- to pentachorobiphenyls after subacute and subchronic exposure. Rapid elimination of PCB11 and its metabolite, 4-OH-CB11, were detected in liver following nose-only inhalation exposure by our established methodology. Further investigation revealed that [14C]PCB11 was 99.8% absorbed in lung. Elimination of the [14C]PCB11 and products consisted of an initial fast phase followed by a slow clearance phase. [14C]PCB11 underwent rapid and extensive metabolism in liver. The major products were phase II metabolites which dominated in the non-adipose tissues and were eliminated via the large intestine and urine. Overall, differential congener elimination was found after inhalation of airborne PCBs, with minimal toxicity. Lower-chlorinated congeners were rapidly and extensively metabolized to phase II products and eliminated within hours.

Concerns about the value and quality of higher education have led to increased scrutiny of the U.S. system of peer accreditation. Public policy-makers have begun to question the extent to which accrediting agencies achieve their quality assurance and quality improvement objectives in the colleges and universities they accredit. Some have begun to call for an expanded federal role in assuring quality at the nation's colleges and universities. Only a few studies exist that examine accreditation processes and outcomes in any higher education context. This qualitative, multi-case study utilizes in-depth interview data to explore perceived outcomes, specific changes attributable to the accreditation process, and perceived effects, the long-term or unintended results of accreditation, at four institutions recently accredited by the Association for Biblical Higher Education (ABHE) for the purpose of evaluating the value of peer accreditation to assure or advance quality. Content analysis of within-case and across-case data support the finding that accreditation processes do exert a positive influence on institutions pursuing accredited status. All four case institutions perceived mission refinement, formalization of processes and structures, role differentiation and clarification, resource development, program development, and evaluation as they engaged in the accreditation process. These efforts resulted in enhanced mission achievement, increased institutional or sector credibility, increased institutional resources, and increased organizational effectiveness.

I use 2000-2017 American Community Survey data to study the impact of source county conflict on the earnings of US immigrants from Syria and Lebanon. My data initially presented large wealth disparities between men and women, from both countries. Thus, they were analyzed separately. I conducted a standard Ordinary Least Squares regression using Earnings as my DV and Conflict as my IV and control for personal characteristics as well as time spent working. Overall, my findings proved to be far more nuanced than expected. A negative statistically significant relationship between conflict and earnings was presented for Lebanese men, while a small but positive significant relationship was presented for Syrian men. The results for conflict for women were insignificant for both countries.