The use of Complementary and Alternative Medicine (CAM) is now widespread and endeavours are increasingly being made to incorporate CAM into conventional healthcare and move towards Integrative Medicine (IM). To date research has primarily focused on the prevalence of use, and safety and efficacy of CAM; less is known about patients' experiences of and reasons for using specific therapies. While therapeutically diverse, it has been suggested that many CAM modalities share mutually referential ideologies and that people who use them may be motivated to do so by specific health beliefs. This study focuses on traditional acupuncture in a New Zealand context and investigates users' experiences and perceptions of the therapy, and discusses how personal health beliefs influence usage. A systematic review of relevant international qualitative research informed the main study, which was carried out using an interpretive phenomenological methodology (Heidegger's approach). Data was gathered from interviews with 12 participants who had recently received treatment from traditionally trained (non-biomedical) acupuncturists. Thematic analysis suggested that acupuncture was often sought for health conditions (typically of a chronic and benign nature) that are difficult to treat conventionally. Whereas initial access was primarily motivated by ineffective biomedical treatment, personal health beliefs-particularly subscription to holistic and vitalistic ideologies-often inspired more extensive and ongoing use. The therapeutic encounter was interpreted to contain many elements-other than needling-integral to treatment. Outcomes were perceived to be wide ranging, personal and necessarily subjective, and included the relief of symptoms, increased well-being, and changes to understandings and health behaviours. It is concluded that the attraction of acupuncture for patients and many of its perceived benefits lie in therapeutic components that are ultimately embedded in Chinese medicine (holistic) theories of health. A more pluralistic schema for assessing evidence may be necessary to acknowledge treatment outcomes that are meaningful to patients, and to accommodate the divergent ontologies and practice models of acupuncture, other CAMs and biomedicine. Increased interdisciplinary cooperation and communication is suggested as a means to improve patient safety and satisfaction and as a scenario for moving forward with IM.

The research literature reveals a widespread reluctance on the part of therapists to work with older people therapeutically as it is believed to be an unrewarding experience and of little benefit for this cohort. This is in contrast to empirical research which shows that therapeutic interventions can be effective and beneficial for older people. There is little literature that looks at the lived experience of therapists who work with older people and none from a counselling psychology perspective. It is therefore hoped that gaining a phenomenological understanding of the experience will provide insight and understanding into the lived experience of therapists who work with older adults. The research question was: 'What is the experience of working therapeutically with the older client?' A qualitative methodology, Interpretative Phenomenological Analysis (IPA) (Smith and Osborn, 2003) was employed for both the conduct and the analysis of the research. Purposive sampling enabled the selection of seven participants for whom the research question was relevant. Semi-structured interview were carried out with three counselling psychologists and four therapists. The age range of the participants was 31-68 years; there were two males and five females. Three master themes emerged: (1) in respect of age - doing therapy differently; (2) the impact of the older client on the therapist; and (3) the reluctant therapist. A description of the master themes, and related constituent themes, is presented and discussed. Although these findings are consonant with the relevant research literature, the research is unique in capturing not only the therapist's lived experience but that of the counselling psychologist as well. It is therefore an important and significant contribution to the field of therapeutic work with older people and a vital addition to the counselling psychology literature. The results of the analysis and implications for counselling psychology are discussed.

Class of 2016 Abstract / Objectives: To compare the SVR12 rates of newer hepatitis C therapies, approved between November 2013 and December 2014, in patients at Avella Specialty Pharmacy to SVR12 rates from published literature. Insurance coverage rates will be compared to determine a difference among insurances. Methods: Data were collected electronically from patient charts utilizing the existing computer system and manually through chart review. A complete data collection form in excel compiled the collected data and included the SVR12 rates by therapy, and sub-analysis data such as demographic and descriptive variables. Therapies included Harvoni, Olysio + Sovaldi ± Ribavirin (RBV), Viekira Pak ± RBV, or Sovaldi + RBV. Demographic and descriptive variables included gender, medical insurance, hepatitis C genotype, fibrosis score, treatment-experienced, treatment-naïve, and adverse effects. Insurance coverage rates were also collected through a separate electronic report. Results: A total of 578 patients were included in the analysis of SVR12 (mean age = 59, 60% male). There were 50% of patients with genotype 1a, 18% had cirrhosis, and 60% were treatment-naïve. The overall SVR12 rate achieved by patients at Avella was not significantly different from published clinical trials (91% vs 91%, p = 0.75). Data for coverage rates included a total of 6,284 patients and revealed that Medicare had the highest coverage rate (85%) while Medicaid had the lowest (30%). Conclusions: Newer hepatitis C therapies used in a real world setting had similar SVR12 rates to published literature. Medicaid had a lower coverage rate compared to Medicare and commercial insurances while Medicare had the highest coverage rate.

This paper examines the role and significance of kinesthetic empathy through a framework modeled in Dance/Movement Therapy. With the innate capacity to connect with others, understand ourselves in greater depth, and learn about the world around us, this paper argues for the human importance of creating empathy in intersubjective dynamics and relations, for the betterment of all parties involved. A system of phases is proposed which includes biological and psychological factors to create a model for intentional kinesthetic empathy. The model looks at empathy through the lens of kinesthesia, as the most authentic way to create this empathic potential to be used as a learning tool.

No description available.

Class of 2012 Abstract / Specific Aims: The incidence of non-response, recurrence, relapse, and rate of complications of Clostridium difficile infections treated with combination of metronidazole and vancomycin versus vancomycin or metronidazole alone over a one-year period by treatment and strain type (i.e. NAP1/BI/027) were evaluated. The incidence of mortality in patients with moderate to severe Clostridium difficile associated diarrhea prescribed metronidazole, vancomycin, or combination metronidazole plus vancomycin as initial therapy was also determined. Additionally, significant factors associated with the use of combination vancomycin-metronidazole as initial therapy for moderate to severe CDAD were characterized. Methods: T This retrospective medical record review has been approved by the Institutional Review Board. Adult patients with stool specimens tested for detection of Clostridium difficile toxin B by PCR between April 2010 and March 2011 at a tertiary care, academic medical center were evaluated. Patients were included in the study if diagnosed with moderate to severe disease and received either monotherapy with metronidazole, monotherapy with oral vancomycin, or combination therapy with metronidazole and oral vancomycin for at least 80% of the first 10 days of treatment. Patients who are discharged alive within 72 hours of admission or who received therapy for less than 48 hours were excluded. Main Results: All patients (N=411) with laboratory evidence of Clostridium difficile during the study time period were evaluated. A total of 26 subjects who received oral vancomycin monotherapy and 56 subjects who received oral vancomycin along with metronidazole for at least 80% of the first 10 days of treatment were identified. Of the subjects who received oral vancomycin monotherapy during the first ten days of therapy, 5 (19%) were classified has a treatment failure or died within the first 21 days of therapy and 5 (19%) had either a recurrence or reappearance of Clostridium difficile associated diarrhea between 22 and 65 days post start of therapy. Of the subjects who received a combination of oral vancomycin and metronidazole during the first 10 days of therapy, 14 (25%) were classified has a treatment failure or died within the first 21 days of therapy and 22 (39%) had either a recurrence or reappearance of Clostridium difficile associated diarrhea between 22 and 65 days post start of therapy. In the combination therapy group, 5 (9%) were reported to have an ileus, toxic megacolon, or necrotic bowel during the first 10 days of therapy. Conclusions: In this study, the subjects who received a combination of oral vancomycin and metronidazole had higher rates of clinical failure, death, and recurrence than subjects who received monotherapy. Current guideline statements recommend combination therapy only in patients with an ileus with Clostridium difficile-associated diarrhea.

Antiretroviral therapy has given hope and expectations for a better life to HIV positive individuals, however, HIV medication cannot be effective without HIV positive individuals’ compliance to it. This study investigated the ways in which living with HIV and taking medication is located within the psychological, social and cultural context of everyday life and relationships in Greece. It also examined gender and identity issues, which make compliance/non-compliance understandable from the HIV positive peoples’ perspective. In addition, emphasis was given to locating compliance to medical regimes in which the perspectives of HIV positive persons were prioritised and understood in relation to relationships with health care professionals. A mixed methods approach was undertaken to provide understanding of compliance and non-compliance factors to HIV medication in a holistic way. A self-completed questionnaire was used to examine the psychosocial factors underpinning compliance to medication. Face-to-face semi-structured interviews were used to explore issues of identity, gender, relationship between doctors and patients and social understandings of HIV. Finally, self-completed weekly diaries were used to document compliance actions, thoughts and feelings in order to reveal the ways medical regimes fit into everyday life. The study was conducted in three Public Hospitals, one Governmental Hospice and one Non-governmental Organization. Eighty (63 males and 17 females) Greek HIV positive patients completed the questionnaire. Interview sample consisted of 7 and 3 males and females respectively. Finally, 6 Greek HIV positive males and 3 females completed the diaries of the research. The questionnaire data was analysed using descriptive statistics via SPSS 11. In addition, a range of non-parametric tests (Mann Whitney and Kruskal Wallis) were used in order to check if ordinal variables influence compliance with HIV medication. Finally linear regression analysis was used in order to establish the influence of factors on compliance with HIV medication. Interviews and the diaries data were analysed though thematic analysis, focusing on identification of patterns and behaviours which were then interpreted in terms of themes. The findings of the study indicated that, when support was given from life partners compliance with HV medication was increased. However, when support was given from family members, compliance with HIV medication was decreased. According to the findings, family dynamics have changed in several cultures over recent decades, partner roles have changed especially in the west and in Mediterranean societies. In regards to 6 medicalization in everyday life, the study showed that when individuals were experiencing side effects, or had fears of future side effects, religious issues (punishment for homosexuality), loss of one’s freedom due to medication, non-compliant behaviours could occur. Finally, the study indicated that some HIV positive individuals perceived their health levels as good and believed that not taking medication once or twice a week was a compliant behaviour. Hence, false perceptions regarding health levels and compliance issues could lead to non-compliant behaviours. A further examination on the communication patterns of the family system and its impact on HIV positive individuals is recommended as it is clearly not very helpful any more. Further exploration of the general socio-cultural positioning of Greece is recommended as certain HIV positive individuals coped with HIV diagnosis and taking medication, by rejecting it. Finally, the need for psychological support is recommended as it is very rarely provided within the Greek health care system.

Ph.D., Faculty of Health Sciences, University of the Witwatersrand, 2011 / The HIV-­‐1 pandemic continues unabated. Although treatments exist that can substantially alleviate the morbidity and mortality associated with HIV, there is still a need for improved anti-­‐HIV treatments that reduce toxicities and administration frequency and mediate sustained inhibition of viral replication. Given the high mutability and variability of the virus, a strategy that is garnering increasing focus is the targeting of host factors that the virus requires to replicate, so-­‐called HIV-­‐dependency factors (HDFs). It is hoped this will reduce the emergence of viral drug resistance. A number of genome-­‐wide screens have been performed to identify HDFs, although many remain to be validated, particularly in relevant cells lines. An objective of this thesis was to validate three host factors as HDFs, in both TZM-­‐bl reporter and T cell-­‐derived cell lines, and to examine their potential as anti-­‐HIV-­‐1 therapeutic targets through exploitation of the cellular gene silencing pathway, RNA interference (RNAi). These were HIV-­‐1 Tat specific factor 1 (HTATSF1), DEAD (Asp-­‐Glu-­‐Ala-­‐Asp) box polypeptide 3, X-­‐ linked (DDX3X) and SWI/SNF related, matrix associated, actin dependent regulator of chromatin, subfamily b, member 1 (SMARCB1), selected because they had been previously implicated in HIV-­‐ 1 pathogenesis. The well-­‐characterised HDF, PC4 and SFRS1 interacting protein 1 (PSIP1)/lens epithelium-­‐derived growth factor (LEDGF)/p75, was included in the study as a positive control. Cassettes expressing short hairpin RNAs (shRNAs) targeting the four host proteins were generated, although shRNAs did not suppress endogenous ddx3x mRNA levels. The ability of shRNAs to inhibit HIV-­‐1 replication in the reporter cell line, TZM-­‐bl, was examined. These HeLa-­‐ derived cells are permissive for R5-­‐tropic HIV-­‐1 infection and contain an integrated luciferase gene driven by the viral promoter. shRNAs mediated a dose-­‐dependent inhibition of luciferase activity in cells infected with a HIV-­‐1 subtype B molecular clone and, although production of the viral protein p24 was unaltered, infectious particle production was decreased in cells treated with a shRNA suppressing HTATSF1. Little effect was observed with a shRNA targeting SMARCB1, suggesting that this may not function as an HDF under these conditions. No effect on infectious particle production was seen with the shRNA targeting PSIP1, which was a result of the long half-­‐ life of this protein, highlighting a limitation of using such reporter systems for HDF validation. Importantly, shRNAs were not associated with any cytotoxic effects in TZM-­‐bl cells. Whether HTATSF1 is a potential therapeutic target was interrogated further in the more relevant T cell-­‐derived SupT1 cell line. Lentiviruses were used to generate populations where >90% had one copy of the integrated shRNA expression cassette. Replication of the subtype B molecular clone p81A-­‐4 was significantly inhibited in the shH1-­‐expressing SupT1 cell line, which targets HTATSF1, for over 14 days post-­‐infection, although inhibition was not as pronounced asthat observed in the shP1-­‐expressing SupT1 cell line, which targets PSIP1. In contrast to a previous report, no change in the ratio of unspliced to singly-­‐ or multiply-­‐spliced HIV-­‐1 transcripts were detected in shH1-­‐expressing SupT1 cells, suggesting that HTATSF1 does not function as a splicing cofactor in this system. A slight rebound in p24 levels at 14 days post-­‐infection was accompanied by increased HTATSF1 expression and a decrease in the percentage of cells with transgene expression in the population. In addition, there was a slight decrease in shH1-­‐derived guide strand expression, but no change in transcription rates of the htatsf1 gene, suggesting that cells within the population with shH1 expression and HTATSF1 suppression may have a growth disadvantage. Thus, although this work demonstrates for the first time that HTATSF1 functions as an HDF in T cell-­‐derived SupT1 cells, it may not constitute a viable therapeutic target. A second objective of this thesis was to examine the feasibility of transcriptional gene silencing (TGS) of HDFs as an anti-­‐HIV strategy. TGS is a small RNA-­‐induced gene silencing pathway that operates through chromatin remodelling with the potential to mediate long-­‐term silencing of gene expression. Thus, its application may reduce the frequency of drug administration and associated toxicities. Short interfering RNAs (siRNAs) targeting the htatsf1 promoter were able to reduce target mRNA expression, which was accompanied by decreased htatsf1 transcription rates in HEK293T cells, suggesting silencing via a TGS mechanism. The htatsf1 silencing inhibited infectious HIV-­‐1 particle production from TZM-­‐bl cells. This work provides proof of principle that TGS induction at a HDF may inhibit HIV-­‐1 replication. siRNAs targeting the ddx3x promoter did not induce TGS. To examine whether gene susceptibility to TGS may be influenced by promoter architectures, 49 promoter features were examined for enrichment in genes at which small RNA-­‐induced TGS has been reported. Initially, the TGS group was compared to a random set of 2,000 promoters and then all other promoters in the genome. To control for gene activation, two further analyses were performed comparing the TGS group features to those from promoters active in the THP-­‐1 cell line and housekeeping genes. Whilst difficult to ascribe differences between the TGS group and the control groups to anything beyond a variation in the proportion of active genes within each group, there was enrichment for certain promoter features that are independent of activity; the TGS group was characterised by broad transcription start regions, high CpG content and a single expression profile. Moreover, the fraction of promoters with reported non-­‐coding RNA overlap was greater in the TGS group than the control groups. Thus, there is some evidence that a number of promoter features are associated with TGS susceptibility. It is hoped this novel analysis will facilitate selection of future TGS targets, including HDFs. In summary, the work presented in this thesis paves the way for development of improved anti-­‐HIV therapies involving HDF-­‐targeted TGS-­‐based gene therapies that mediate sustained inhibition of the virus.

Background and Aims Sacral nerve stimulation (SNS) is an established therapy for faecal incontinence (FI). Percutaneous tibial nerve stimulation (PTNS) is a newer, less-invasive treatment. The effectiveness, cost and acceptability of these treatments have not been systematically compared. Methods A systematic review of neuromodulation interventions for FI and an investigator-blinded, randomised pilot trial of PTNS vs. SNS including parallel quantitative (clinical outcomes and cost) and qualitative studies. Results The systematic review determined on intention-to-treat, the median success rates for SNS were 63% (range 33-66%), 58% (range 52-81%) and 54% (range 50-58%) in the short, medium and long terms respectively. The success rate for PTNS was 59% at 12 months. In the pilot trial: 40 patients (39 female; mean age 59 years) met eligibility criteria. As designed, 23 were randomised to receive SNS and 17 PTNS. 15 patients progressed to permanent SNS implantation and 16 patients received a full course of PTNS. Within group effect sizes were marginally greater for SNS than PTNS on available case analysis. FI episodes per week at baseline, 3 months and 6 months follow-up: SNS median 5.75 (IQR 5.75-15.5 ) [mean 11.4 (SD 12.0)], 2.5 (2-4.5) [4.0 (4.0)], 1.75 (1.5-5) [4.9 (6.9)], vs. PTNS median 6.5 (IQR 2.5- 16.5) [mean 10.6 (SD 11.2)], 3.5 (0.75-7.25) [5.8 (6.9)], 2.5 (0.75-10.75) [6.3 (6.9)]. At least 50% improvement in FI episodes per week at 6 months: SNS 61% vs. PTNS 47%. Effect estimates for SNS with chronic implanted stimulation were larger (67% at 6 months). Clinical FI scores and quality of life improvements complemented these results. Qualitative analysis demonstrated a very high acceptability and safety profile for both treatments. Total costs were £2,906 (SD £122) per patient for PTNS and £12,748 (SD £4,175) for SNS. Conclusions Definitive trial data between SNS or PTNS is lacking. This RCT pilot study determined that in the short-term, SNS confers a small clinical benefit over PTNS for FI but is much more expensive.

Despite wide agreement in the systemic field that therapists should take a non-blaming stance, historically there has been little exploration of how this stance is achieved in practice. The difficulty in knowing how to put ‘non-blaming’ into practice is further heightened by competing models of intervention with families affected by psychosis. This study contributes to a body of literature that is concerned with how complex issues of morality are achieved dialogically by considering how family therapists manage the tension of intervening to promote change whilst maintaining a multi-partial, non-blaming stance. Two therapies carried out with families affected by psychosis are analysed using the methods of Conversation Analysis (CA) and Membership Categorization Analysis (MCA). In both therapies the sequences examined are drawn from the second session of therapy where explicit blaming events occur. By examining blaming events chronologically through the course of a session the study shows how the rules about the way blame is talked about are achieved interactionally. The analysis demonstrates that systemic theory’s emphasis on the importance of being non-blaming is grounded in a sophisticated understanding of the threat blame poses to co-operation and agreement. In both therapies, the delicacy and ambiguity with which blame is treated serves to enable the conversation to continue without withdrawal. However the cost of ambiguity is a possible misunderstanding of the intent of the speaker. The resulting misalignment, where it continues over several turns and sequences, leads to explicit blame becoming relevant as a solution to a redundant pattern of interaction. The findings indicate that the management of blame requires both the exploration of blame and its interruption when emotions and conflict run high. The former enables understanding and movement towards therapeutic goals while the latter is necessary to promote therapeutic and family alliances. An unintended consequence of the injunction to be non- blaming might be the premature closing down of topics, militating against problem resolution. The study concludes that CA and MCA offer a wealth of knowledge about mundane conversational practices that can be applied fruitfully to systemic therapy process research, teaching and supervision.