Background: Self-harm is important considering the demand it places on health services and its strong association as a risk factor for suicide. Research regarding protective factors for self-harm is limited, protective factors can be personal or social resources that reduce the impact of negative consequences, in the face of stressors. Identifying protective factors is important, provided they can be enhanced and utilised to inform intervention. Aims: This thesis had two aims; to systematically review the literature investigating the relationship between social support and suicidality, and to use Interpretative Phenomenological Analysis to explore the factors that support desistance from self-harm. Methods: Quantitative studies, exploring the relationship between social support and suicidality were reviewed systematically. The empirical study employed Interpretative Phenomenological Analysis to investigate self-harm behaviour in context, identify potential protective factors and explore what participants have found to be helpful to desist from selfharm behaviour. Semi structured interviews were conducted with nine participants (18- 61years) recruited from the Adult Community Mental Health Team. Results: Findings of the systematic review indicate that there is an association between poor social support and increased suicidality in adulthood. In the empirical study four main themes emerged from the data: Self-harm provided Relief from Psychological Distress, Difficulties Communicating, Social support and Gradual desistance. Conclusions: Social support may be an important factor that protects against suicidality; however further research is required to investigate this association. Findings from the empirical study suggest that treatment providers must be sensitive to the context and function of self-harm behaviour for the individual, and be willing to work to reduce the self-harm behaviour, while being cognisant that self-harm may be protective for the individual and prevent more severe self-harm or even suicide.

Background: Alcohol misuse and dependency are major health problems worldwide. Despite the availability of a number of evidence-based treatments for alcohol-dependency, a large proportion of people relapse following detoxification. The costs to society and the individual are vast, not only economically but in terms of social and interpersonal functioning also. There is a recognised need to understand the factors that contribute to poorer outcomes in this population. Cognitive impairment is one factor that has demonstrated considerable associations with poor outcomes in the wider substance-misuse population. Aims: This thesis has two sections. The first comprises a systematic review which aimed to present the objective evidence for emotional decision-making deficits in the alcohol dependent population. The second is an empirical study which aimed to establish whether or not relapse can be predicted in a severely alcohol dependent population in the early stages following inpatient detoxification. In addition, a normative dataset for this clinical population using the ACE-III is presented. Methods: For the systematic review, a structured search of the literature relating to emotional decision-making in alcohol dependent samples was conducted. Iterative application of pre-defined inclusion and exclusion criteria identified eighteen studies for critical review. Quality assessment of these studies was undertaken and validated by means of calculating inter-rater reliability. For the empirical study, two sub-samples of a cross-sectional group of patients being treated for severe alcohol-dependence were examined; one to collate normative data for the ACE-III (N=73) and one to investigate associations between the ACE-III and relapse (N=20), including covariates of age, mood, anxiety and motivation. Results: The systematic review demonstrated substantial support for a deficit in emotional decision-making ability in alcohol-dependence. Methodological quality of the reviewed papers was moderate to high. Deficits in performance on a task of emotional decision-making compared to healthy controls indicated a reduced learning curve in alcohol dependent samples. Limitations of the studies included failure to report power analyses and effect sizes, insufficient detail regarding methodology and exclusion of common comorbidities in alcohol-dependence. The empirical study demonstrated clinically significant cognitive impairment in a sample of severely alcohol dependent individuals in the early stages following detoxification. In a smaller sample, cognitive functioning was not found to be predictive of relapse at one-month post-detoxification. Associations were identified between age and ACE-III score and between age and relapse status. Age was not predictive of outcome. Conclusions: The available evidence points towards the existence of emotional decision-making deficits in alcohol dependent individuals. These are likely to impact on the ability of individuals make the health behaviour changes required to recover from alcohol dependence. Further research may be helpful in identifying factors associated with increased decision-making deficit in this specific population and investigating the processes underlying such difficulties. The clinical normative dataset presented in the empirical study points towards generalised cognitive impairment during the early stages of abstinence which may negatively impact on ability to engage meaningfully with psychosocial interventions. Performance on the ACE-III was not found to predict relapse in the current sample. Previous research would suggest that the links between cognitive functioning and relapse are less well defined in alcohol-misusing samples than in the wider substance-misuse population. Therefore future research may help to clarify this association in alcohol dependent samples. It is acknowledged that the ACE-III is yet to be validated for use in the alcohol dependent population and is limited in its ability to assess executive functions. Given the high prevalence of executive functioning deficits in the alcohol dependent population, it seems of importance to use cognitive screening tools which place appropriate emphasis on these abilities. Service providers are encouraged to incorporate routine cognitive screening into clinical practice and consider the implications of cognitive impairment at both individual and service delivery levels.

Nonmalignant respiratory diseases (NMRD), such as Chronic Obstructive Pulmonary Disease (COPD), are a leading cause of morbidity worldwide. Research has shown that patients with NMRD in the UK, Canada and the US have less access to palliative care services than patients with other respiratory diseases such as lung cancer. Discussing preferences for end-of-life care in NMRD can be difficult for patients, carers and health professionals, however it is essential to ensure that the patient’s wishes are met, particularly when resources are scarce. Despite similar nationalised health care systems in the UK and Canada, a recent report by the Economist Intelligence Unit ranked overall quality of end-of- life care in the UK first out of forty, while Canada was ranked ninth out of forty. Therefore, it was deemed useful to investigate how end-of-life for people with NMRD is discussed between health professionals and patients in the UK and Canada and to develop an instrument allowing health professionals to determine constraints and opportunities for facilitating such discussions in each country as comparing care between countries is helpful to determine the best solutions for individuals and families with complex needs. This study was guided by the Medical Research Council guidelines for developing and implementing complex interventions, and the research process followed the requirements for the development phase of these guidelines. First, two systematic reviews were carried out to establish the evidence base regarding of end-of-life discussions. The first focused on how end-of-life is discussed in NMRD, while the second focused exclusively on end-of-life discussions in a single NMRD (COPD) in the UK and Canada only. The findings of the systematic reviews pointed toward the need for further training of health professionals to iii discuss end-of-life with this patient group, as well as the lack indicators that this patient group is ready or willing to discuss end-of-life. Then, a Delphi study was conducted with specialist respiratory nurses in the UK to determine expert opinion on how health professionals know a patient with NMRD is ready to discuss end-of-life, and to establish the key considerations and topics in such discussions. This study was replicated in Canada with health professionals working with patients with NMRD. Each Delphi study resulted in a country specific tool to assist less experienced health professionals discuss end-of-life with this patient group. Finally, the findings of these Delphi studies were compared to determine what health professionals in each country could learn from each other, as well as specific considerations in each country, and areas for future research. The findings from the comparison process demonstrated that the emotional intelligence of health professionals, the patient education context and the recognition of cultural issues were all important factors when approaching end-of-life discussions. Findings from each phase of the intervention development process resulted in a theoretical model of how end-of-life is discussed in the UK and Canada. This model identifies constraints and opportunities for such discussions from a systems level perspective including: end-of-life policies, prognosis in non-malignant respiratory disease, time, clinical indicators, initiation responsibility, the educational role of health professionals, emotional intelligence, cultural competence and readiness versus willingness to discuss end-of-life. Recommendations are made from the findings of this study for research, clinical practice, education and policy. A detailed plan for the next stage of the development of the intervention is included.

Public policy analysts are often tasked with reviewing research or other forms of evidence in order to provide advice for policy decisions. Many have argued that systematic reviews that include meta-analyses (SRMAs) are the most rigorous forms of evidence, and thus, when possible, should form the basis of policy decisions. However, it is not yet clear to what extent policy analysts are aware of systematic reviews and meta-analyses, or to what extend they use them to inform policy work. Moreover, given the importance of evaluating the quality of research before using it for policy, it is not clear to what extent policy analysts feel able to judge the quality of systematic reviews and meta-analyses. An online survey was used to provide initial estimates of the extent to which policy analysts a) are familiar with SRMAs; b) use these reviews to inform their policy work; and c) are able to evaluate them. It further sought to explore other correlates of use, barriers to use, methods to increase use, and knowledge of factors that influence quality. Thirty-nine Ministerial policy analysts responded to the survey, 18 from the Ministry of Health, 9 from the Ministry of Environment, and 12 from other ministries. Policy analysts reported being fairly familiar with both systematic reviews and meta-analyses, although they were more familiar with systematic reviews than with meta-analyses. There were no differences between the Health, Environment, or Other groups with respect to familiarity. Respondents reported moderate scores on most indicators of use, with results suggesting the Health group having the highest rates of use, followed by the Environment group and then the Other group. Finally, there were relatively high self-ratings on ability to judge the quality of SRMAs, with no differences found between groups. The results of other exploratory analyses are also presented, and implications and recommendations are discussed. / Graduate

Magister Curationis - MCur / Literature shows that cataracts are the leading cause of blindness globally and nationally. Retinal detachment has also been a substantial problem both globally and nationally. Both of these conditions are prevalent in patients of 50 years and older. The treatment for both conditions is for surgery to be performed. In the Western Cape the three leading hospitals do not have ophthalmic pre-operative and post-operative protocols.Review question:What are the best practices to manage pre-operative and post-operative nursing care in patients waiting for cataract and retinal detachment surgery? bjectives:1. To determine the best practice in pre-operative and post-operative care in patients who have undergone cataract and/or retinal detachment surgery regarding: health education offered by nurses, counselling to prevent psychological effects, and positioning to prevent physical complications. 2. To develop a framework based on systematic reviews for pre-operative and post-operative ophthalmic nursing care in South Africa. Methodology: A systematic review using the guide by the Centre for Reviews and Dissemination was done, and studies were identified by searching various electronic databases and visually scanning reference lists from the relevant studies. Studies that were included were evidence-based. All study types were considered and the studies were selected based on the title and, where available, the abstract. These were then assessed against the inclusion criteria. A narrative synthesis was used. Finally the evidence was summarised and a framework was drawn up, focusing on pre-operative and post-operative nursing care for cataract and retinal detachment surgery

Master of Science / Department of Diagnostic Medicine/Pathobiology / Natalia Cernicchiaro / Japanese encephalitis virus (JEV) is a virus of the Flavivirus genus that may result in encephalitis in vertebrate hosts. This vector-borne zoonosis occurs in Eastern and Southeastern Asia and an intentional or inadvertent introduction into the United States (US) would lead to important public health and economic consequences. The objective of this study was to gather, appraise, and synthesize primary research literature to identify and quantify vector and host competence for JEV, using a systematic review-metaanalysis (SR-MA) approach. After defining the research question, we performed a search in selected electronic databases. The title and abstract of the identified articles were screened for relevance using a defined set of exclusion and inclusion criteria, and relevant articles were subjected to a risk of bias assessment followed by data extraction. Random-effects subgroup meta-analysis models were fitted by species (mosquito or vertebrate host species) to estimate pooled summary measures as well as to compute the variance between studies. Meta-regression models were fitted to assess the association between different predictors and the outcomes of interest and to identify sources of heterogeneity among studies. Data were extracted from 171 peer-reviewed articles. Most studies were observational (59.06%) and reported vector competence (60.2%). The outcome measures reported pertained to transmission efficiency, host preference, and vector susceptibility to infection within vector competence; and susceptibility to infection within host competence. All outcome measures (JEV proportion of infection in vectors and hosts from observational studies; and JEV infection, dissemination, and transmission rates in vectors from experimental studies) had high heterogeneity. Mosquito species, diagnostic method, country, and capture method represented important sources of heterogeneity associated with the proportion of JEV infection in vectors; host species and region were considered sources of heterogeneity associated with the proportion of JEV infection in hosts; and diagnostic and mosquito capture methods were deemed important contributors of heterogeneity for the minimum infection rate (MIR) outcome. Mosquito species and administration route represented the main sources of heterogeneity associated with JEV infection rate in vectors. Quantitative estimates resulting from this SR-MA will be inputted into risk assessment models to evaluate risks associated with the introduction of JEV in the US.

No description available.

For decades, sexual expression in older adulthood was a taboo topic in the public discourse and ignored in the empirical literature. As a result of several significant sociocultural changes and medical developments as well as an increasingly older population, however, perspectives are shifting and acceptance and interest in the sexual lives of older adults is growing. The purpose of this dissertation was to investigate sexual well-being in older adulthood and explore its diversity. Study 1 involved a systematic review of the literature on factors associated with the maintenance and cessation of sexual activity in adults 60 years of age and older. Data were extracted from a total of 57 studies and each was assessed for methodological quality. Surprisingly, only four factors (i.e., partner’s interest in sexual activity, past frequency of sexual activity, presence of erectile dysfunction, and partner-related illness) were consistently related, in more than one study, to whether or not older adults were sexually active. Significant variability in study results highlighted methodological caveats of the body of literature, but also the heterogeneity of older adults’ sexuality. Study 2 built upon the findings and recommendations of Study 1 and further examined diversity in sexual well-being. Sexual function and satisfaction, the absence of sexuality-related distress, breadth of sexual experience, and overall frequency of sexual activity were considered as indicators of sexual well-being. The Dual Control Model of Sexual Response (DCM) was used as the theoretical framework in this study of women 50 years of age and older. The DCM posits that sexual response depends on the relative activation of sexual excitatory and sexual inhibitory processes, two separate and independent systems. Study 2 results indicated that, independently, women’s propensities for sexual excitation and sexual inhibition were significantly associated with the majority of the indicators of sexual well-being and the directions of associations were consistent with the tenets of the DCM. The only association that proved not statistically significant was the relationship between sexual excitation and sexual distress. When examined together, sexual excitation and sexual inhibition factors significantly predicted sexual function, satisfaction, and frequency. Sexual distress was predicted more strongly by sexual inhibition factors and sexual breadth by sexual excitation factors. Partner physical and mental health and participant mental health were further identified as moderating variables of these associations. The results of Study 2 expand current knowledge regarding the DCM and its relevance to older women; sexual excitation and sexual inhibition appear to have heuristic value to better understand the variability in sexual activity and well-being in women aged 50 years and older. The results of this dissertation have important implications for the study of sexuality and ageing, perhaps most prominently in terms of highlighting the inter-individual variation in older adulthood and the conclusion that generalizations about “older adults” as a group may not be appropriate.

There is little head-to-head evidence comparing interventions available for juvenile idiopathic arthritis (JIA). This review involved a series of systematic reviews and network meta-analyses (NMAs) to evaluate the comparative efficacy and safety of pharmacological and non-pharmacological interventions among patients with JIA. Outcomes were the American College of Rheumatology Pediatric 30 (ACR Pedi 30) (disease response), its six composite outcomes, pain relief, health-related quality of life, and physical and emotional functioning. There was some evidence that etanercept had greater reduction in the number of joints with active arthritis compared to abatacept for polyarticular-course JIA and that canakinumab had improved ACR Pedi 30 over rilonacept. Non-pharmacological interventions showed no significant results for efficacy but were safe overall. Most included studies were low-quality and many were excluded from analysis because of unclear reporting or no results for outcomes of interest. As more studies are conducted this will improve the estimates from the NMAs.

Pancreatic cancer is the fourth leading cause of cancer death in Canada. Significant advancements in chemotherapy for advanced pancreatic cancer have resulted in the need for a quantitative comparison between these treatments on a relative scale. Therefore, a systematic review and Bayesian network meta-analysis of randomized clinical trials was conducted using gemcitabine, the standard treatment, as the reference comparator. Based on results from the network meta-analysis, in which optimal treatments were identified and side effects of each treatment evaluated, an Internet-based patient decision aid was developed in order to present the benefits and risks of each therapy option: (1) Best supportive care (2) gemcitabine (3) FOLFIRINOX. The objective of the decision aid was to guide patients through the decision-making process based on their individual preferences and values. The decision aid was deemed to be acceptable and feasible based on results from a pilot study conducted at The Ottawa Hospital Cancer Centre.