The condition of multimorbidity — the presence of two or more medical conditions in an individual — is a growing phenomenon worldwide. In the United States, multimorbid patients represent more than a third of the population and the trend is steadily increasing in an already aging population. There is thus a pressing need to understand the patterns in which multimorbidity occurs, and to better understand the nature of the care that is required to be provided to such patients. In this thesis, we use data from the Medical Expenditure Panel Survey (MEPS) from the years 2011 to 2015 to identify combinations of multiple chronic conditions (MCCs). We first quantify the significant heterogeneity observed in these combinations and how often they are observed across the five years. Next, using two criteria associated with each combination -- (a) the annual prevalence and (b) the annual median expenditure -- along with the concept of non-dominated Pareto fronts, we determine the degree of impact each combination has on the healthcare system. Our analysis reveals that combinations of four or more conditions are often mixtures of diseases that belong to different clinically meaningful groupings such as the metabolic disorders (diabetes, hypertension, hyperlipidemia); musculoskeletal conditions (osteoarthritis, spondylosis, back problems etc.); respiratory disorders (asthma, COPD etc.); heart conditions (atherosclerosis, myocardial infarction); and mental health conditions (anxiety disorders, depression etc.). Next, we use unsupervised learning techniques such as association rule mining and hierarchical clustering to visually explore the strength of the relationships/associations between different conditions and condition groupings. This interactive framework allows epidemiologists and clinicians (in particular primary care physicians) to have a systematic approach to understand the relationships between conditions and build a strategy with regards to screening, diagnosis and treatment over a longer term, especially for individuals at risk for more complications. The findings from this study aim to create a foundation for future work where a more holistic view of multimorbidity is possible.

Aptamers being used as sensors is an emerging field that has capabilities of being tomorrow’s diagnostic tools. As aptameric sensors have become more popular, their visualization systems have been limited. The majority of today’s aptameric sensors require expensive machinery such as a fluorometer in order to visualize results. We propose a system that will cut the need for instrumentation and be detected via the naked eye. With the selection of an aptamer to bind the pH indicating dye bromocresol purple (BCP) this may be achieved. When rendered active, the binding towards BCP will facilitate a color change from yellow to purple or vice versa. Previous studies have shown albumin contains the ability to facilitate this role and we now intend to use a DNA aptamer to achieve this as well. The BCP aptamer has the potential to serve as a signaling domain to any already selected aptamer thus making it a universal tool for both research and diagnostic measures. We have found that an alternative structure-switching systematic evolution of ligands by exponential enrichment (SELEX) method which left the dye unaltered was not sufficient for selecting an aptamer. We believe that a classical SELEX will enable us to select an aptamer that may be used to accomplish this role as a universal visual detector.

Polymerase chain reaction (PCR) is a method used in many research protocols to amplify a small amount of a short segment of DNA to millions of copies. PCR is used for many taxonomic studies, as well as for some medical diagnostic procedures. Through PCR, short DNA primers bind to the template DNA to allow the thermostable DNA polymerase to copy the DNA. Often, researchers create universal primers to target a conserved region of DNA in multiple species, for example, the 16S rRNA gene in bacteria. The problem with these universal primers is that they do not always perfectly match the target DNA. The mismatch primers can still bind to the template, but could affect the efficiency of the PCR amplification. The effect of mismatch primers on the efficiency of the amplification in PCR is the focus of this thesis. Four forward primers with various mismatch overhangs were generated and incorporated into a DNA template through an initial PCR. These primers contained the binding region complementary to the V3/V4 region of the 16S rRNA bacterial gene. Further quantitative PCR (qPCR) reactions were run on these newly-made templates using two sets of primers complementary to the 16S rRNA gene region – one with ambiguous base pairs, one with unambiguous base pairs. The qPCR amplification curves, the Cq values, and the initial concentrations of DNA products (seed values) were analyzed and compared. The results showed differences in the Cq values and seed values between the reactions containing mismatches and those not containing mismatches. Other variables including annealing temperature, addition of Illumina sequencing tails to the primers, and initial primer concentration were also tested to determine if these variables had an effect on the amplification. The results from these reactions using different variables were inconclusive.

The research dealt with the implementation of Gestalt play therapy for the treatment of the sexually abused primary school child who experiences problems to maintain himself. The need for research on the theme originated from the researcher's experience with sexually abused primary school children. The aim of the research was to render therapeutic support to the primary school child through Gestalt play therapy, in order to explore the influence of such support on the child's maintaining behaviour. The applied research design was used for this purpose. For the purpose of the research, one sexually abused child who experienced problems to maintain himself was identified by means of purposeful sampling. During each Gestalt play therapy session the child was brought into contact with his senses. Conclusions as well as recommendations were formulated as a result of the research. / Social Work / M. Diac. (Play Therapy)

Text in Afrikaans / Hierdie studie ondersoek die bantering van seksueel-gemolesteerde kinders. Die kliniese beeld sowel as die fisiese- en gedragsimptome is kriteria by die uitkenning van seksuele molestering. Die bantering van die seksueel-gemolesteerde kind is medebepalend vir die onmiddellike en langtennyn gevolge van seksuele molestering. Seksuele molestering word vanuit 'n sielkundig-opvoedkundige perspektief bespreek. Die studie neem die seksueel-gemolesteerde kind se betekenisgewing, belewing, betrokkenheid, selfaktualisering en selfkonsep in beskouing. Terapeutiese tegnieke, soos toegepas in gevalle van seksuele molestering, word vir gebruik deur professionele persone en instansies, bespreek. Die empiriese ondersoek fokus op die houdinge, hanteringswyses en toepassing van terapeutiese tegnieke deur professionele persone en instansies in die Witbank omgewing. Volgens die navorsingsresultate is daar geen uniforme hanteringswyse of riglyne vir terapie ten opsigte van seksueel-gemolesteerde kinders nie. Die navorsing toon verder swak interinstansie-samewerking wat die voordele van uniforme hanteringswyses en riglyne vir terapie emstig aan bande le / This study investigates the treatment of sexually-abused children. The clinical framework and the physical and behavioural symptoms being some of the criteria utilised to identify such children. The methods used to treat cases co-determine the immediate and long-term effects of sexual abuse. Sexual abuse is discussed from an educational-psychological perspective. The study reflects on the child's meanin& experiencing, involvement, selfactualisation, self-concept and their effects on her life. Professional approaches, therapeutic techniques and treatments are described for use by professionals and agencies, based on an empirical investigation conducted in Witbank. The results of the research indicate a non-uniform approach in guidelines used for therapeutic techniques and the treatment of sexually-abused children. The research shows further that interaction between professional bodies and -individuals in treatment of these cases is poor and the benefits that should result from uniform treatment are therefore severely limited / Psychology of Education / M. Ed. (Spesialisering in Voorligting)

Text in Afrikaans / Summaries in English and Afrikaans / Die dood van 'n ouer he! 'n effek op die totale lewe van die kind en dompel die kind in emosionele nood wat terapeutiese begeleiding noodsaak. Na afloop van die afsterwe van 'n ouer, vind daar fisieke, emosionele, sosiale en kognitiewe veranderinge in die kind se lewe plaas waarop hy nie voorbereid is nie, en wat hy ook nie verstaan nie. Hierdie veranderinge veroorsaak dat die kind se leefwereld in so mate verander dat sy funksionering benadeel word. Daar is met hierdie studie gepoog om vas te stel watter effek die dood van 'n ouer op die kind he! en tot watter mate terapeutiese begeleiding die kind se emosionele nood kan verlig. Daar is in die studie gevind dat rou inderdaad 'n gekompliseerde proses is wat lei tot die ontstaan van talle onbeantwoorde vrae, gevoelens van magteloosheid en emosionele pyn. Kinders wat in rousmart verkeer word dikwels deur die samelewing misgekyk en kry as gevolg hiervan nie voldoende hulp nie. Di! lei tot die ontstaan van persoonlikheidsontwikkelingsprobleme, relasionele probleme en intra-psigiese probleme soos 'n swak selfbeeld, ego-verdedigingsmeganismes, persoonlike kwesbaarheid, ongunstige betekenisgewing en ongunstige belewenisse. Hierdie probleme veroorsaak dat die kind in sy selfaktualisering gerem word en as gevolg hiervan nie sy gegewe moontlikhede verwerklik nie. Die studie het verder bewys dat die kind wat 'n ouer aan die dood afgestaan het, wel deur middel van terapeutiese begeleiding deur 'n sielkundige gehelp kan word om die verlies van 'n ouer in so 'n mate te hanteer dat die faktore wat die kind se selfaktualisering rem, opgehef kan word. Die studie voorsien die sielkundige van riglyne ten opsigte van die proses van terapeutiese begeleiding aan die kind wat 'n ouer aan die dood afgestaan het. Riglyne word gebied ten opsigte van die hantering van die kind se onmiddellike situasie, die evaluasie van die kind-inrousmart, die vasstelling van doelstellings en doelwitte vir terapeutiese begeleiding, die selektering van terapeutiese tegnieke, die terapeutiese hulpverlening aan die kind, die hulpverlening aan die oorblywende ouer en die hulpverlening aan die onderwyser wat gemoeid is met die kind-in-rousmart. Riglyne word ook gebied ten opsigte van die terminering van terapie. / The death if a parent has an influence on the total life of a child and causes emotional trauma that necessitates therapeutic guidance. After the death of a parent, physical, emotional, social and cognitive changes occur in the child's life for which he is not prepared and that he also does not understand. These factors cause such a change in the child's life-world that his functioning is hampered. In this study it was endeavoured to determine what effect the death of a parent has on a child's life and to what extent therapeutic guidance can alleviate the child's emotional trauma. In this study it was found that mourning is indeed a complicated process that gives rise to countless unanswered questions, feelings of helplessness and emotional pain. Children suffering grief in mourning are often ignored by society and as result of this, they do not receive adequate assistance. This leads to problems concerned with the development of the personality, relational problems and intrapsychological problems such as a poor self-concept, ego defence mechanisms, personal vulnerability, negative ways of acquiring meaning and unfavourable ways of experiencing life. These problems give rise to the hampering of the child's selfactualisation and because of this he cannot realise his potential. The study has furthermore proved that the child who has lost a parent through death, can be helped by a psychologist. This can be done by means of therapeutic guidance so that the child can handle the loss of a parent to such an extent that the factors that hamper his self-actualisation can be removed. The study provides guidelines for therapeutic guidance to the child who has Jost a parent through death. Guidelines are given on handling the child's immediate situation, the evaluation of the child in mourning, the determination of aims and objectives for therapeutic guidance, the selection of therapeutic techniques, therapeutic assistance to the child, assistance to the remaining parent and assistance to the educator who is involved with the child in mourning. Guidelines are also given for the termination of therapy. / Educational Studies / D.Ed (Clinical Psychologist)

Glycosaminoglycans are heterogeneous polysaccharides that mediate important biological functions. There has been considerable interest in deciphering the precise GAG sequences that are responsible for protein interactions. In fact, several GAG oligosaccharides have been discovered to date as targeting proteins with higher level of specificity. Yet, it has been difficult to develop GAG oligosaccharides as drugs. One of the key reasons for this state of art is that GAG synthesis is extremely challenging and is highly structure-specific. Thus, much of the biology and pharmacology of GAG remains unknown and unexploited to date. An alternative approach is to prepare GAG oligosaccharides using enzymatic depolymerization of polymeric GAGs. GAG lyases, including heparinases and chondritinases represent powerful tools that can theoretically generate multiple oligosaccharides in parallel. However, it is difficult to implement such procedures with high consistency. Moreover, GAG lyases can digest GAGs down to disaccharides. A priori, non-polymeric GAGs, or alternatively GAG oligosaccharides containing 4 to 10 residues, would be expected to function better as therapeutic agents because they would be more homogeneous and less non-specific than their polymeric precursors. Thus, we reasoned that immobilization of these enzymes may engineer altered biopolymer processing, which may afford longer oligosaccharides in higher proportions and greater consistency. Heparinase-I and chondroitinase ABC were immobilized on CNBr-activated Sepharose and compared with the free form of the enzyme. Immobilized GAG lyases retained high efficiency of depolymerization over a wide range of pH, temperature and reusability. Most importantly, the immobilized enzyme was found to produce larger proportions of oligosaccharides longer than di- and tetra-saccharides as compared to lyases in the free form. A two dimensional separation involves size exclusion chromatography followed by reversed phase ion-pairing ultra performance liquid chromatography coupled to electrospray ionization mass spectrometry was employed to separate and characterize oligosaccharide structures. We have identified 40 heparin oligosaccharides, including regular and rare structures ranging from dp4 to dp10 and 39 chondroitin sulfate oligosaccharides in high homogeneity and significant yields. Overall, this technology is likely to offer a simple and cost effective route to preparation of larger amounts of sequences that can be expected to bind and modulate protein function.

Cell mass is an important indicator of cell health and status. A diverse set of techniques have been developed to precisely measure the masses of single cells, with varying degrees of technical complexity and throughput. Here, the development of a non-invasive, label-free optical technique, termed Live-Cell Interferometry (LCI), is described. Several applications are presented, including an evaluation of LCI’s utility for assessing drug response heterogeneity in patient-derived melanoma lines and the measurement of CD3+ T cell kinetics during hematopoietic stem cell transplantation. The characterization of mast cells during degranulation, the measurement of viral reactivation kinetics in Kaposi’s Sarcoma, and drug response studies in patient-derived xenograft models of triple-negative breast cancer are also discussed. Taken together, data from these studies highlight LCI’s versatility as a tool for clinical, translational, and basic research applications.

Chemo-radiation therapy is a principal modality for the treatment of head and neck cancers, and its efficacy depends on the interaction of tumor oxygen with free radicals. In this study, we adopted a novel hybrid diffuse optical instrument combining a commercial frequency-domain tissue oximeter (Imagent) and a custom-made diffuse correlation spectroscopy (DCS) flowmeter, which allowed for simultaneous measurements of tumor blood flow and blood oxygenation. Using this hybrid instrument we continually measured tumor hemodynamic responses to chemo-radiation therapy over the treatment period of 7 weeks. We also explored monitoring dynamic tumor hemodynamic changes during radiation delivery. Blood flow data analysis was improved by simultaneously extracting multiple parameters from one single autocorrelation function curve measured by DCS. Patients were classified into two groups based on clinical outcomes: a complete response (CR) group and an incomplete response (IR) group with remote metastasis and/or local recurrence within one year. Interestingly, we found human papilloma virus (HPV-16) status largely affected tumor homodynamic responses to therapy. Significant differences in tumor blood flow index (BFI) and reduced scattering coefficient (μs’) between the IR and CR groups were observed in HPV-16 negative patients at Week 3. Significant differences in oxygenated hemoglobin concentration ([HbO2]) and blood oxygen saturation (StO2) between the two groups were found in HPV-16 positive patients at Week 1 and Week 3, respectively. Receiver operating characteristic curves were constructed and results indicated high sensitivities and specificities of these hemodynamic parameters for early (within the first three weeks of the treatment) prediction of one-year treatment outcomes. Measurement of tumor hemodynamics may serve as a predictive tool allowing treatment selection based on biologic tumor characteristics. Ultimately, reduction of side effects in patients not benefiting from radiation treatment may be feasible.

Socialization of an individual with behavioural disorder {--} programme ,,Borouk University Decree (Diploma) Work Abstract The aim of the thesis is to monitor situations of clients with problems of behavioural disorder, who was allowed from a hospital and protective training in Educational Institution and Canteen {\clqq}Husův dům`` in Dvůr Králové na Labem, and an evaluation of the socializational programme {\clqq}Borouk``. In a practical part of the thesis the author chose a quatitative research, in which she analysed data of clients allowed from 2001 to 2005. The programme {\clqq}Borouk`` is evaluated on the basis of data about resocialization of those clients. There is a case study enclosed in the text. In the closing part of the thesis, the programme {\clqq}Borouk`` is evaluated as a suitable programme, which helps clients with the behavioural disorder to socialize. The results show that a wide range of aspects of lifes of a group of examined clients were improved. In spite of their suitable integration and related elimination of negative social phenomenons, it is necessary to provide the clients with behavioural disorder with lifelong assistance and support. Diploma work supervisor: Author: Jiří Hartl, M. A. Bc. Lenka Nápravníková (Personal signature (Personal signature attached {--} illegible) attached {--} illegible) České Budějovice 2007