Dissertations / Theses on the topic 'Ambulatory assessment'

The purpose of this study was twofold: to test the Competence Model for Normal Aging and to generate valid and reliable indices of mental health outcomes in elderly clients. A correlational descriptive design accommodated the psychometric assessment of the instruments with a causal modeling methodology. The relationship between competence and self-esteem was the primary focus. Theoretical model testing was used to test the causal relationships between competence and three estimates of cognition: causal attributions, self-efficacy, and value. Associated demographic variables, age, and gender, were included in the model. Well elders (n = 137) living independently in Tucson participated in the study by completing 9 instruments within a 40-minute testing period. The mean age of the group was 73 (sd = 7.9). A quarter of the sample was at least 80 years old. All participants were caucasian, with more than twice the number of females than males. Most participants were married or widowed. The instruments met validity and reliability criteria in varying degrees. Hypothesis 1 was supported in both the separate success and failure models and the total sample theoretical model. Self-efficacy (β = .48) and value (β = .27) predicted competence (R² = .42). The social subscale of competence was strongly predicted by the same variables (β = .53, β = .26; R² = .39). The same predictors were evident in the total sample theoretical model (β = .52; β = .25; R² = .38). Hypothesis 2 was partially supported. Self-efficacy predicted total competence (β = .49; R² = .30) and the social dimension of competence (β = .59; R² = .32). Hypothesis 2 was minimally supported in the total sample theoretical model by self-efficacy (β = .29) predicting the social component of competence (R² = .44). Hypothesis 3 was most strongly supported. Competence predicted self-esteem under multiple conditions (βs averaged .43). The associated demographic and gender variables made minimal contributions to the model, except under failure conditions. Not being married and being a male negatively impacted upon competence (β = -.21; β = -.39; R² = .31). Both theoretical and empirical model results have similar explained variances. The theoretical model provided key information regarding the process of self-esteem, and the empirical model provided a guide for clinicians to measure mental health outcomes.

Class of 2014 Abstract
Specific Aims: The purpose of this study is to compare frequency of pharmacy services available in ambulatory care practice between adult and pediatric populations and to identify factors that affect the availability of such practice settings between the two populations in the United States. Methods: This study was a descriptive survey study that was distributed nationally. Participants were recruited using two electronic listservs registered with the American College of Clinical Pharmacy (ACCP), the Pediatric PRN listserv and Ambulatory Care PRN listserv. A total of 126 participants completed and submitted the electronic questionnaire. This descriptive survey study collected data through an online questionnaire distributed to adult and pediatric ambulatory care pharmacists. Descriptive variables, demographic variables, categorical variables, and ordinal data were analyzed by calculating frequencies, percentages, and averages. Main Results: The majority of participants specialize in diabetes (n = 51, 40.5%), anticoagulation (n=42, 33.3%), hypertension (n=42, 33.3%), hyperlipidemia (n=40, 31.8%), and asthma (n=32, 25.4%). Adult care was greater than pediatric care in diabetes (Adult: n=54, 42.83%; Ped: n=14, 9.53%), anticoagulation (Adult: n=46, 43.66%; Ped: n=6, 4.76%), hypertension (Adult: n=44, 34.94%; Ped: n=8, 6.34%), hyperlipidemia (Adult: n=42, 33.34%; Ped: n=3, 2.39%), and asthma (Adult: n=35, 27.78%; Ped: n=28, 22.23%). Averages of 4.88 hours of hours per week and 5.21 years of experience were obtained for provision of pediatric care in the ambulatory care setting. Conclusion: In conclusion, availability of ambulatory care services for pediatric patients is dramatically less than those available for adults. Generalized structure for location of clinics, billing for services, and funding for positions may increase the opportunity for provision of adult and pediatric ambulatory care services.

OBJETIVOS Esta tesis pretende desarrollar una herramienta de fácil aplicación, fiable, consistente y no invasiva que sea capaz de evaluar el estatus del sistema circadiano. Para conseguir este objetivo, se plantearon los siguientes objetivos específicos: 1. Crear un algoritmo para la evaluación ambulatoria y no invasiva del sistema circadiano mediante la integración de los ritmos de temperatura periférica, actividad motora y posición corporal en la variable compuesta TAP. 2. Validar la variable integrada TAP para la detección de sueño y vigilia en comparación con el gold standard para este propósito, la polisomnografía. Además, se pretende comprobar si TAP mejora la detección de sueño con respecto a las estimaciones obtenidas mediante la actigrafía convencional. 3. Transferir la utilidad de TAP, implementada en un dispositivo de registro ambulatorio en una patente internacional. 4. Evaluar la validez de la variable TAP para la detección de alteraciones circadianas en condiciones patológicas: 4.1. Revisar los conocimientos previos sobre cáncer y ritmos circadianos, prestando especial atención a los tratamientos que tienen en cuenta el sistema circadiano. 4.2. Estudiar las diferencias interindividuales del ritmo de actividad-reposo que podrían potencialmente afectar el resultado del tratamiento en pacientes de cáncer. 4.3. Evaluar cómo los tratamientos cronomodulados afectan la sincronización interna de diferentes ritmos circadianos en pacientes de cáncer. 4.4. Evaluar las perturbaciones circadianas de sujetos con deterioro cognitivo leve con el fin de establecer la utilidad de la variable TAP para evaluar objetivamente la progresión de la enfermedad. METODOLOGÍA En esta tesis, se evaluaron tres ritmos y procesaron con el fin de obtener la variable TAP que después se aplicó en varias condiciones de salud y enfermedad. Ritmo de temperatura Este ritmo se evaluó mediante un sensor de temperatura (Thermochron iButton DS1921H, Dallas, Maxim) cosido a una muñequera de modo que la superficie del sensor quedara en contacto con la arteria radial de la muñeca de la mano no dominante. Ritmo de actividad motora y posición corporal Estos ritmos se evaluaron gracias a un actímetro (Hobo Pendant G Acceleration Data Logger, Massachusetts, USA) colocado en el brazo no dominante mediante un brazalete deportivo. De la información proporcionada por el actímetro, se definieron 2 variables: actividad motora, expresada como grados de cambio de posición y posición corporal, definida como el ángulo entre el eje X y el plano horizontal. Procesamiento de los datos Cada variable se normalizó entre 0 y 1 después de haber eliminado los artefactos mediante inspección visual de los datos. Además, los datos de temperatura se invirtieron de modo que los valores máximos de todas las variables coincidieran en el mismo momento. Después, calculamos la media de las variables normalizadas para cada sujeto obteniendo la variable TAP cuyos valores varían entre 0 (para periodos de reposo) y 1 (para periodos activos). CONCLUSIÓN GENERAL La monitorización circadiana ambulatoria, no invasiva y fiable del estado funcional del sistema circadiano humano es un procedimiento muy útil para la prognosis de ciertas enfermedades como cáncer, deterioro cognitivo leve y perturbaciones del sueño. La monitorización conjunta y la integración de varias salidas del reloj biológico mejora la consistencia de los resultados y facilita la evaluación de la desincronización interna entre diferentes variables rítmicas. De este modo, la variable TAP, basada en la integración de los ritmos de Temperatura periférica, Actividad motora y Posición corporal, ha superado las premisas de alta fiabilidad, aceptación y versatilidad para el estudio ambulatorio y prolongado del estado del sistema circadiano humano en muy distintas situaciones de salud y enfermedad. Además, ha sido posible implementar este algoritmo en un dispositivo bajo patente internacional.
OBJECTIVES This thesis aims to develop a reliable, consistent, non-invasive and easily applied tool based on multivariable recordings, able to depict circadian system status and circadian rhythmic synchrony in humans. In order to pursue this final goal, the following specific objectives were determined: 1. To create a multivariable tool able to reliably and non-invasively ambulatory assess the circadian system status by integrating wrist temperature, motor activity and body position rhythms into the composite TAP variable. 2. To validate this integrated variable for sleep and wake detection against the gold standard for this purpose, the polysomnography and test if TAP improves the detection from that obtained with actigraphy alone. 3. To test the validity of TAP variable in specific pathological conditions with known circadian impairments: 3.1. To review, the previous knowledge on cancer and circadian rhythms, as well as circadian-based treatments for this disease. 3.2. To study the inter-individual differences in rest-activity rhythm, that could potentially affect treatment outcome, in colorectal cancer patients. 3.3. To assess how chronomodulated treatment affects internal synchronization on cancer patients by multivariable recordings. 3.4. To evaluate circadian disturbances in mild cognitively impaired subjects, a previous condition to Alzheimer’s Disease, in order to establish its potential usefulness to objectively assess the disease progression. 4. To transfer the usefulness of TAP implemented in an ambulatory monitoring device for its clinical application and its potential commercialization by an international patent. METHODOLOGY In these PhD, three rhythms were recorded and processed as to obtain an integrated variable TAP in several conditions of health and disease. Temperature rhythm The wrist temperature rhythm was assessed using a temperature sensor (Thermochron iButton DS1921H, Dallas, Maxim) attached to a double-sided cotton sport wrist band, and the sensor surface was placed over the inside of the wrist on the radial artery of the non-dominant hand. Body position and rest-activity rhythm The body position and rest-activity rhythm was assessed using an actimeter (Hobo Pendant G Acceleration Data Logger, Massachusetts, USA) placed on the non-dominant arm by means of a sports band, with its X-axis parallel to the humerus bone. From the information provided by the actimeter, we defined 2 variables: motor activity (A) and body position (P). Motor activity was expressed as degrees of change in position. Body position was calculated as the angle between the X-axis of the actimeter and a horizontal plane. Thus, P oscillated between 0º for maximum horizontality and 90º for maximum verticality. Data processing Each variable was normalized between 0 and 1, after removing artifacts identified by visual inspection of the data. In addition, wrist temperature data were inverted in such a way that maximum values for all variables occurred at the same time. We then calculated the mean of the normalized variables for each subject, obtaining TAP values which range between 0 (for rest periods) and 1 (for active periods). GENERAL CONCLUSION The reliable ambulatory monitoring of circadian system in humans has proven very relevant for disease prognosis in such conditions as cancer, mild cognitive impairments and sleep disturbances. The joint recording and following integration of several clock outputs increase results’ consistency as isolated variable artifacts are minimized by the integration of several variables and enables the calculation of internal desynchronization among different rhythmic variables. TAP, integration of wrist Temperature, motor Activity and body Position rhythms, has supported the premises of high reliability, acceptance and versatility for the long-period ambulatory study of human circadian system status under several conditions of health and disease. Thus, these positive results have facilitated the implementation of TAP’s algorithm in a new device for ambulatory monitoring and registered in an international patent, already in exploitation.

Class of 2009 Abstract
OBJECTIVES: To assess patients’ satisfaction with pharmaceutical care services provided in a community health center diabetes management clinic. METHODS: Patients who received diabetes-related pharmaceutical services from the clinical pharmacist at El Rio Health Center in Tucson, Arizona from November 2008 to January 2009 were contacted during a visit to the diabetes clinic and asked to complete the consumer assessment of pharmaceutical services questionnaire. The questionnaire included 14 likert-type items with response options ranging from “Never” to “Always” or “Disagree” to “Agree.” In addition, the patient’s most recent hemoglobin A1C (HgbA1C) was obtained from the electronic medical record. The survey instrument was also translated from English to Spanish to serve the Hispanic participants who could not communicate fluently in English. A descriptive cross-sectional analysis was completed in order to assess patient satisfaction. Dependent variables extracted from the survey were analyzed by Mann-Whitney U test. Interval and ratio data were analyzed by calculating means, standard deviations, and an independent t-test. Nominal data were analyzed using the Chi-Square test. RESULTS: A total of 46 patients completed the questionnaires, including 17 men and 29 women (mean age = 56, SD = 11.3, 80% Hispanic). All patients had seen the clinical pharmacist at least 3 times. Overall, this study showed that majority of the patients were satisfied with the service provided in the clinic. There was no statistically significant difference between English and Spanish patient populations in terms of satisfaction with pharmaceutical services provided about their disease management. CONCLUSIONS: Patients in this clinic were highly satisfied with the pharmaceutical care services provided by the clinical pharmacist.

This article reviews the Electronically Activated Recorder (EAR) as an ambulatory ecological momentary assessment tool for the real-world observation of daily behavior. Technically, the EAR is an audio recorder that intermittently records snippets of ambient sounds while participants go about their lives. Conceptually, it is a naturalistic observation method that yields an acoustic log of a person’s day as it unfolds. The power of the EAR lies in unobtrusively collecting authentic real-life observational data. In preserving a high degree of naturalism at the level of the raw recordings, it resembles ethnographic methods; through its sampling and coding, it enables larger empirical studies. This article provides an overview of the EAR method; reviews its validity, utility, and limitations; and discusses it in the context of current developments in ambulatory assessment, specifically the emerging field of mobile sensing.

Adolescence is a time of increased developmental stress and associated risk for psychopathology. At the same time, today’s adolescent is almost constantly digitally connected, and the online space has been largely overlooked by researchers as a context for youthful coping. As a result, the current thesis includes three empirical studies to address critical gaps in our measurement of adolescent coping (online or off), how adolescents look to the digital arena as they navigate day-to-day life, and the short-term influence of online coping on adolescents’ emotional well-being. First, Study 1 sought to characterize how scholars are using technology to measure adolescent coping via ambulatory assessment (AA), and to delineate associated advantages and challenges of varying approaches. Previous published research has remained challenged by how best to conceptualize, measure, and analyse adolescents’ coping in situ. Thus, drawing from 60 adolescent AA coping studies, Study 1 called for scholars to revisit coping theory in their study designs to ensure they tap their focal aspect of the adolescent coping process. Study 1 also provided key lessons and recommendations for scholars seeking to deploy AA methods in their pursuit of measuring coping. Second, Study 2 sought to establish a foundation for adolescent online coping. This study brought together data from adolescent focus groups (Study 1; n = 16), experience sampling (Study 2; n = 156), and young adult surveys (Supplementary data; n = 213). Study findings validated adolescents’ online coping as a strategy that youth widely endorse in the face of daily stress. Specifically, in line with common coping facets, and drawing on the communications literature, three online coping strategies emerged: online emotional support seeking, information seeking, and self-distraction. Moreover, findings suggest negative linear effects for these online coping strategies; when conceived as an individual difference construct, whereby more online coping was associated with worse emotional reactions to stress in daily life. Third, Study 3 sought to explore the impact of adolescents’ online coping using a more fine-grained approach. Specifically, by tying ambulatory assessments of online coping to momentary stress reports, this study allowed for the analyses of the full coping process—stress, coping, response—within an in-situ framework. Moreover, this study capitalized on momentary coping reports in a subset of youth (n = 115; 1,241 timepoints) to assess both linear and non-linear associations with short-term emotional well-being. Findings indicated a negative linear impact of momentary online coping, such that more emotional support seeking, information seeking, and distraction online were associated with worse emotional responses. However, testing of non-linear associations indicated better fitting models across the board, and a robust pattern of results. Here, moderate levels of online coping had a clear positive impact on adolescents’ emotional recovery from stress. All told, thesis findings point to the important arena of technology to support adolescents' coping and associated well-being. Thesis studies contribute to the literature in several arenas, including a much-needed scoping review of the existing AA coping literature, and a robust validation of the online coping construct. Further and most importantly, studies make clear that online coping has an effect on adolescents’ emotional well-being, and when used in moderation, may be beneficial to their emotional functioning.
Thesis (Professional Doctorate)
Doctor of Philosophy in Clinical Psychology (PhD ClinPsych)
School of Applied Psychology
Griffith Health
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At the Primary Health Care Centre in Vännäs (VPHCC), northern Sweden, a development work was implemented in 1976-1980. The overall purpose was to enhance primary health care planning. In trying to improve health care delivery cooperation with community members was initiated and some organizational changes like a new appointment system, a new medical record and local care programs for some common diseases were introduced. Official statistics were also used for comparative purposes. The aims of the work were postulated (increased accessibility, higher continuity, more equitable distribution and enhanced cooperation) and suitable methods were designed. From postal surveys, chartreviews and administrative data (from hospitals, out-patient clinics and health centres) figures and information were collected. Accessibility was studied by waiting room time which was reduced and continuity, analyzed with a new concept - visit based provider continuity - was improved. The question of equitable distribution was studied by the consultation rates at different out-patient clinics. It seemed as if the local development work changed the patterns of utilization but some important issues were not decisively answered. Repeated postal surveys reflected the question of equitable distribution and the cooperation between the VPHCC and the community members. Positive responses were recorded in aspects like telephone accessibility and health care information. In a tracer study of diabetes the quality of care was studied. The local care program was actually implemented in the daily practice but the question of care quality needs further penetration. Within the frames of the development work new methods in the health care planning were introduced. Our work started from the prerequisits of the VPHCC and other health centres might find other ways of planning for care provision. On a general level, however, the structure of our work - defining aims, means and evaluation methods - can be used by others.

Diss. (sammanfattning) Umeå : Umeå universitet, 1986, härtill 6 uppsatser.

digitalisering@umu

Chronic venous insufficiency is the term used to describe lower limb venous disease causing symptoms in the leg, which include swelling, lipodermatosclerosis and ulceration. The underlying processes for the development of these symptoms are venous reflux, deep venous occlusion or both, which in turn result in venous hypertension. This thesis is focussed on the former process only, as deep venous occlusion is usually managed conservatively at the institutions in which this research took place.

Aim: The aim of this thesis was to investigate the psychophysiological response to the dynamic working environment within a cohort of higher education employees via ambulatory assessment of psychosocial and physiological measures. Methods: Data was collected from two observational studies. Study one employed a cross-sectional design to investigate relationships between work-related psychosocial hazard, work-time heart rate variability, blood pressure, and the cortisol awakening response. Consideration was given to occupation type and acute work-related demand. Study two, a single-subject case study, employed an experience sampling methodology to peform a 24 hour assessment over 21 days. Workload, affect and demand were sampled during working hours, while heart rate variability and physical activity were continually sampled (24 hours), with salivary cortisol, being sampled at 3 time points during the awakening period. This study also investigated some of the methodological issues associated with ambulatory assessment of both heart rate variability and the cortisol awakening response. Findings: Chronic work-related demand was found to be positively associated with sympathetic dominance of the autonomic nervous system. Acute work-related demand was associated with ambulatory heart rate variability during work time and evening time whilst the rise in salivary free cortisol over the immediate post awakening period varies according to acute anticipatory demand and prior day's workload. Substantial intra--individual variation in both the cortisol awakening response and ambulatory heart variability was found to occur across work-days. Work time activity levels accounted for little of the variation in ambulatory heart rate variability and blood pressure. The cortisol awakening response was associated with both heart rate variability and nocturnal movement in the latter stage of sleep. Conclusion: Attending to the psychophysiological response to work at the individual level by means of ambulatory assessment appears to provide a useful means of assessing the balance between employee and environment. This could have significant implications for work design, employee selection and targeting of workplace interventions.

Since the Institute of Medicine highlighted the devastating impact of medical errors in their seminal report, “To Err is Human” (2000), efforts have been underway to improve patient safety. A portion of medical errors are due to medication errors, and a large portion of these can be attributed to inadequate laboratory monitoring. In this thesis, I attempt to address this small but important corner of this patient safety endeavor. Why are patients not getting their laboratory monitoring tests? Do they fail to complete them or do doctors not order the tests in the first place? Which prescribers and which patients are least likely to do what is needed for testing to happen and what interventions would be most promising? To address these questions, I conducted a systematic review of existing interventions. I then proceeded with three aims: 1) To identify reasons that patients give for missing monitoring tests; 2) To identify patient and provider factors associated with monitoring test ordering; and 3) To identify patient and provider factors associated with completion of ordered testing. To achieve these aims, I worked with patients and data at the Fallon Clinic. For aim 1, I conducted a qualitative analysis of their reasons for missing tests as well as reporting completion and ordering rates. For aims 2 and 3, I used electronic medical record data and conducted a regression with patient and provider characteristics as covariates to identify factors contributing to test ordering and completion. Interviews revealed that patients had few barriers to completion, with forgetting being the most common reason for missing a test. The quantitative studies showed that: older patients with more interactions with the health care system were more likely to have tests ordered and were more likely to complete them; providers who more frequently prescribe a drug were more likely to order testing for it; and drug-test combinations that were particularly dangerous, indicated by a black box warning, were more likely to have appropriate ordering, though for these combinations, primary care providers were less likely to order tests appropriately, and patients were less likely to complete tests. Taken together, my work can inform future interventions in laboratory monitoring and patient safety.

Cardiovascular diseases are an increasing source of concern in modern societies due to their increasing prevalence and high impact on the lives of many people. Monitoring cardiovascular parameters in ambulatory scenarios is an emerging approach that can provide better medical access to patients while decreasing the costs associated to the treatment of these diseases. This work analyzes systems and methods to measure time intervals between the electrocardiogram (ECG), impedance plethysmogram (IPG), and the ballistocardiogram (BCG), which can be obtained at the limbs in ambulatory scenarios using simple and cost-effective systems, to assess cardiovascular intervals of interest, such as the pulse arrival time (PAT), pulse transit time (PTT), or the pre-ejection period (PEP). The first section of this thesis analyzes the impact of the signal acquisition system on the uncertainty in timing measurements in order to establish the design specifications for systems intended for that purpose. The minimal requirements found are not very demanding yet some common signal acquisition systems do not fulfill all of them while other capabilities typically found in signal acquisition systems could be downgraded without worsening the timing uncertainty. This section is also devoted to the design of systems intended for timing measurements in ambulatory scenarios according to the specifications previously established. The systems presented have evolved from the current state-of-the-art and are designed for adequate performance in timing measurements with a minimal number of active components. The second section is focused on the measurement of time intervals from the IPG measured from limb to limb, which is a signal that until now has only been used to monitor heart rate. A model to estimate the contributions to the time events in the measured waveform of the different body segments along the current path from geometrical properties of the large arteries is proposed, and the simulation under blood pressure changes suggests that the signal is sensitive to changes in proximal sites of the current path rather than in distal sites. Experimental results show that the PAT to the hand-to-hand IPG, which is obtained from a novel four-electrode handheld system, is correlated to changes in the PEP whereas the PAT to the foot-to-foot IPG shows good performance in assessing changes in the femoral PAT. Therefore, limb-to-limb IPG measurements significantly increase the number of time intervals of interest that can be measured at the limbs since the signals deliver information from proximal sites complementary to that of other measurements typically performed at distal sites. The next section is devoted to the measurement of time intervals that involve different waves of the BCG obtained in a standing platform and whose origin is still under discussion. From the relative timing of other physiological signals, it is hypothesized that the IJ interval of the BCG is sensitive to variations in the PTT. Experimental results show that the BCG I wave is a better surrogate of the cardiac ejection time than the widely-used J wave, which is also supported by the good correlation found between the IJ interval and the aortic PTT. Finally, the novel time interval from the BCG I wave to the foot of the IPG measured between feet, which can be obtained from the same bathroom scale than the BCG, shows good performance in assessing the aortic PAT. The results presented reinforce the role of the BCG as a tool for ambulatory monitoring since the main time intervals targeted in this thesis can be obtained from the timing of its waves. Even though the methods described were tested in a small group of subjects, the results presented in this work show the feasibility and potential of several time interval measurements between the proposed signals that can be performed in ambulatory scenarios, provided the systems intended for that purpose fulfill some minimal design requirements.
Les malalties cardiovasculars són una tema de preocupació creixent en societats modernes, degut a l’augment de la seva prevalença i l'elevat impacte en les vides dels pacients que les sofreixen. La mesura i monitoratge de paràmetres cardiovasculars en entorns ambulatoris és una pràctica emergent que facilita l’accés als serveis mèdics i permet reduir dràsticament els costos associats al tractament d'aquestes malalties. En aquest treball s’analitzen sistemes i mètodes per la mesura d’intervals temporals entre l’electrocardiograma (ECG), el pletismograma d’impedància (IPG) i el balistocardiograma (BCG), que es poden obtenir de les extremitats i en entorns ambulatoris a partir de sistemes de baix cost, per tal d’avaluar intervals cardiovasculars d’interès com el pulse arrival time (PAT), pulse transit time (PTT) o el pre-ejection period (PEP). En la primera secció d'aquesta tesi s’analitza l’impacte del sistema d’adquisició del senyal en la incertesa de mesures temporals, per tal d’establir els requeriments mínims que s’han de complir en entorns ambulatoris. Tot i que els valors obtinguts de l’anàlisi no són especialment exigents, alguns no són assolits en diversos sistemes habitualment utilitzats mentre que altres solen estar sobredimensionats i es podrien degradar sense augmentar la incertesa en mesures temporals. Aquesta secció també inclou el disseny i proposta de sistemes per la mesura d’intervals en entorns ambulatoris d’acord amb les especificacions anteriorment establertes, a partir de l’estat de l’art i amb l’objectiu de garantir un correcte funcionament en entorns ambulatoris amb un nombre mínim d’elements actius per reduir el cost i el consum. La segona secció es centra en la mesura d’intervals temporals a partir de l’IPG mesurat entre extremitats, que fins al moment només s’ha fet servir per mesurar el ritme cardíac. Es proposa un model per estimar la contribució de cada segment arterial per on circula el corrent a la forma d’ona obtinguda a partir de la geometria i propietats físiques de les artèries, i les simulacions suggereixen que la senyal entre extremitats és més sensible a canvis en arteries proximals que en distals. Els resultats experimentals mostren que el PAT al hand-to-hand IPG, obtingut a partir d’un innovador sistema handheld de quatre elèctrodes, està fortament correlacionat amb els canvis de PEP, mentre que el PAT al foot-to-foot IPG està correlat amb els canvis en PAT femoral. Conseqüentment, l’ILG entre extremitats augmenta de manera significativa els intervals d’interès que es poden obtenir en extremitats degut a que proporciona informació complementària a les mesures que habitualment s’hi realitzen. La tercera secció està dedicada a la mesura d’intervals que inclouen les ones del BCG vertical obtingut en plataformes, de les que encara se’n discuteix l’origen. A partir de la posició temporal relativa respecte altres ones fisiològiques, s’hipostatitza que l’interval IJ del BCG es sensible a variacions del PTT. Els resultats experimentals mostren que la ona I del BCG és un millor indicador de l’ejecció cardíaca que el pic J, tot i que aquest és el més utilitzat habitualment, degut a la bona correlació entre l’interval IJ i el PTT aòrtic. Finalment, es presenta un mètode alternatiu per la mesura del PTT aòrtic a partir de l’interval entre el pic I del BCG i el peu del foot-to-foot IPG, que es pot obtenir de la mateixa plataforma que el BCG i incrementa la robustesa de la mesura. Els resultats presentats reforcen el paper del BCG com a en mesures en entorns ambulatoris, ja que els principals intervals objectiu d’aquesta tesi es poden obtenir a partir de les seves ones. Tot i que els mètodes descrits han estat provats en grups petits de subjectes saludables, els resultats mostren la viabilitat i el potencial de diversos intervals temporals entre les senyals proposades que poden ésser realitzats en entorns ambulatoris, sempre que els sistemes emprats compleixin els requisits mínims de disseny.

Background The detection of early warning signs is essential in the long-term treatment of bipolar disorders. However, in bipolar patients’ daily life and outpatient treatment the assessment of upcoming state changes faces several difficulties. In this trial, we examine the effectiveness of a smartphone based automated feedback about ambulatory assessed early warning signs in prolonging states of euthymia and therefore preventing hospitalization. This study aims to assess, whether patients experience longer episodes of euthymia, when their treating psychiatrists receive automated feedback about changes in communication and activity. With this additional information an intervention at an earlier stage in the development of mania or depression could be facilitated. We expect that the amount of time will be longer between affective episodes in the intervention group. Methods/design The current study is designed as a randomized, multi-center, observer-blind, active-control, parallel group trial within a nationwide research project on the topic of innovative methods for diagnostics, prevention and interventions of bipolar disorders. One hundred and twenty patients with bipolar disorder will be randomly assigned to (1) the experimental group with included automated feedback or (2) the control group without feedback. During the intervention phase, the psychopathologic state of all participants is assessed every four weeks over 18 months. Kaplan-Meier estimators will be used for estimating the survival functions, a Log-Rank test will be used to formally compare time to a new episode across treatment groups. An intention-to-treat analysis will include data from all randomized patients. Discussion This article describes the design of a clinical trial investigating the effectiveness of a smartphone-based feedback loop. This feedback loop is meant to elicit early interventions at the detection of warning signs for the prevention of affective episodes in bipolar patients. This approach will hopefully improve the chances of a timely intervention helping patients to keep a balanced mood for longer periods of time. In detail, if our hypothesis can be confirmed, clinical practice treating psychiatrists will be enabled to react quickly when changes are automatically detected. Therefore, outpatients would receive an even more individually tailored treatment concerning time and frequency of doctor’s appointments. Trial registration: ClinicalTrials.gov: NCT02782910: Title: “Smartphone-based Ambulatory Assessment of Early Warning Signs (BipoLife_A3)”. Registered May 25 2016. Protocol Amendment Number: 03. Issue Date: 26 March 2018. Author(s): ES.

O estudo tem por tema o cuidar paliativo na atenção ambulatorial, em particular as percepções sobre esse cuidado sob o ponto de vista dos usuários do Ambulatório de Cuidados Paliativos em Oncologia, do Hospital do Câncer IV, do Instituto Nacional de Câncer - INCA/MS. O palco do nosso estudo sofreu transformações em sua estrutura física e na forma do atendimento dispensado a partir de março de 2009. Na atualidade, e diferentemente do que é mais comum na maioria dos ambulatórios das demais unidades INCA, os pacientes, quando chamados para consulta, entram para uma sala de atendimento e aguardam os profissionais, ao invés de percorrem as salas de consulta de cada especialidade. Buscamos trazer e compreender a percepção dos sujeitos através de suas falas, bem como as dificuldades por eles vivenciadas na assistência do cuidado, e sua relação com a Integralidade. Esta última foi entendida como tecnologia que permeia as ações, favorecendo e aprimorando o cuidado em saúde. Ao relacionar os pilares da integralidade isto é, o acesso, o acolhimento, o vínculo, a autonomização e a responsabilização procuramos entender os parâmetros desse conceito e sua aplicabilidade no sistema do INCA. Demarcamos como caminhos teóricos desta pesquisa, as questões voltadas à Integralidade e às tecnologias como orientadoras dos processos de trabalho em serviço de saúde. O elemento decisivo e norteador para seguir este caminho foi o conceito de tecnologias leves formulado por Merhy, que guarda em suas definições uma ponte entre as mesmas e a integralidade conceitos estes básicos para a investigação proposta. Optamos pela metodologia qualitativa, com o uso de entrevistas semi-estruturadas que possibilitariam um maior aprofundamento na compreensão das percepções dos sujeitos sobre o atendimento à saúde naquela Unidade Hospitalar. Os relatos dos pacientes e cuidadores entrevistados revelam, sem nenhuma exceção, que eles apreciam bem mais este modo de atendimento do que aquele experimentado em outras unidades hospitalares. Os usuários expressaram, como aspectos positivos, a redução no tempo de espera e a qualidade da atenção dispensada, uma vez que suas necessidades (físicas, psicológicas e emocionais) são mais emergenciais, dada a fragilidade do seu estado bio-psico-socio-espiritual. Em suma, foi possível observar que os principais pilares da Integralidade estão expressos nas percepções dos usuários, mesmo que eles não saibam que o fazem. Ao ressaltar as percepções sobre as práticas que os usuários identificaram como positivas e negativas no sistema de atendimento do ambulatório do HC IV, apontamos para possibilidades de melhoria da qualidade assistencial com base na Integralidade
The present study is about ambulatory attention in palliative care, particularly users perceptions over this care given in the Oncologic Ambulatory for Palliative Care of the Brazilian National Cancer Institute-RJ. From this perspective we brought the users speech, as well as their difficulty, felt and experienced during the assistance, and its relation with the integrality. This one understood as a technology that is all through the actions facilitating and improving health care. When relating some of its pillars as, access, boundary, linkage, self-government and responsiveness, we can better understand the limits of this concepts and its applicability in the INCA system. We delimitate as theoretic path of this study, integrality issues and technologies to orient the work process in health services. The decisive element was the concept of soft technologies formulated by Merhy; within its definition there is a bridge to integrality basic concepts to the investigation proposed. This ambulatory underwent a transformation on its physical structure and on the assistance model offered to its users. The difference between this and the conventional ambulatory model of assistance that takes place on the other INCA ambulatory hospitals, for this one from HC IV, rely on the fact that this one is specific for patients undergoing oncological palliative care, in which the patients has walking difficulties. Because of those, a different model was build. In this new mode, patients are called to a room and wait for the assistance, the professionals alternates themselves between this and the other rooms, where there are other patients. This attitude prevents patients from walking from room to room to be assisted. As a reminder, this new assistance manner began on march 2009, with one year experience. The statement of the interviewed patients and their caretakers revealed, with not even one exception, that they prefer this new way of integrative care instead of the traditional experienced in other INCA hospital units. Patients appreciate the quietness of this process and the certainty of the scheduled appointment. Its impossible to deny that in this manner of assistance, not only the patients but also their caretakers have more privacy. One of its improvements for patients is the end of the walking from room to room to get assisted by all professionals. This new physical structure prevents undesirable walking and stress for patients under oncologic palliative care. And its also clear that users express, as positive aspect, the reduction of time waiting for the appointment in the ambulatory. Taking into consideration the particularity of these users revealed, was the quality of the assistance they acquire: faster, human and multidisciplinary, since their necessities are more urgent because of their bio-psycho-social-spiritual fragility state. Finally, was possible to observe that the main Integrality pillars are expressed in their perceptions, although they dont state this concepts specifically. About responsiveness, we found little evidence, as the users dont have their rights notion and there for they dont criticize the system. Only one of them marked his position, asking about a patients bath adapted for colostomy user`s

Este estudo avaliou o potencial da Telemedicina como suporte complementar a assistência ambulatorial na monitoração de sintomas em pacientes com câncer avançado. Foram acompanhados 12 pacientes do ambulatório do Núcleo de Cuidados Paliativos do Hospital Universitário Pedro Ernesto (NCP-HUPE) de janeiro de 2011 a agosto de 2013. Mensalmente foram feitas consultas ambulatoriais pela médica e equipe multidisciplinar. Neste intervalo, os pacientes do domicilio, através de seus computadores pessoais se conectaram ao Laboratório de TeleSSaúde UERJ pelo serviço de webconferências interagindo com a mesma médica assistente do ambulatório. Os pacientes também tiveram acesso à médica por celular e email. A cada entrevista (presencial e remota) foi aplicada a Escala de Avaliação de Sintomas de Edmonton [Edmonton Symptom Assessment System (ESAS)], e coletado outros dados quanto a outras queixas biopsicossociais e espirituais, agravos à saúde, qualidade de áudio e vídeo da conexão, avaliação dos familiares com a Telemedicina e interferência da Telemedicina quanto ao local do óbito do paciente. Houve dificuldade na seleção dos pacientes, pois o HUPE é um hospital público cuja população assistida tem, caracteristicamente, baixa escolaridade, nível socioeconômico restrito e pouca habilidade com informática. O tempo médio de acompanhamento foi de 195 dias (DP 175,11; range: 11-553 dias). Todos receberam diagnóstico de câncer avançado e tinham dificuldades com locomoção. Sem dúvidas, a ESAS favoreceu a comunicação dos sintomas com os profissionais de saúde; porém, condições clínicas e controle dos sintomas singulares, avaliados em momentos distintos e sujeitos a influências diversas, impedem conclusões em relação às pretensas vantagens. Acompanhamento clínico, detecção de agravos à saúde e de sintomas físicos, psicossociais e espirituais foram possíveis de ser observados pela Telemedicina, confirmados e medicados nas consultas presenciais. A conexão para webconferência foi estabelecida por familiares, pois nenhum paciente operava computadores. O óbito domiciliar ocorreu em 41,67% e todos, mesmo os óbitos hospitalares, receberam suporte à distância do NCP. Durante o estudo foram feitos 305 contatos: 110 consultas presenciais a pacientes e familiares e 195 por Telemedicina (77 webconferências, 38 telefonemas e 80 emails). Todos os familiares referiram satisfação com o suporte oferecido. A Telemedicina permitiu maior acesso ao sistema de saúde (maior número de contatos), reduziu a busca por serviços de emergência, ajudou o controle dos sintomas e proporcionou orientações e segurança aos familiares. Este suporte favoreceu intervenções precoces e proativas e assistência continuada até o óbito. A Telemedicina demonstrou ser um bom adjuvante na monitoração e gerenciamento de sintomas de pacientes em cuidados paliativos em domicílio, não substituindo, mas complementando a assistência presencial.
This study assessed telemedicine potential as a complementary support to ambulatory care in monitoring symptoms in patients with advanced cancer. Twelve patients were followed up at the Palliative Care Nucleus ambulatory of the Pedro Ernesto University Hospital (NCP-HUPE) from January 2011 to August 2013. Monthly, assistance were made by physician and multidisciplinary team. Meanwhile, patients at home, with their personal computer connected to UERJ Telehealth Laboratory webconference service, interacting with the same ambulatory physician. Patients also had access to doctors cellphone and e-mail. At each interview (personal and remote) was applied the Edmonton Symptom Assessment System (ESAS), collected data on other biopsychosocial and spiritual complaints, health problems, audio and video quality connection, family's evaluation about Telemedicine and Telemedicine interference on patient's place of death. There was difficulty to select patients because HUPE is a public hospital whose population assisted has typically low educational and socioeconomic status, and restricted ability to deal with computers. The mean follow-up time was 195 days (SD 175.11; range: 11-553 days). All were diagnosed with advanced cancer and had transportation difficulties. There is no doubt that ESAS favored symptoms communication with health professionals; however, singular clinical conditions and symptom control assessed at different moments and subjected to many factors, preclude conclusions regarding alleged advantages. Clinical monitoring, detection of health problems and physical, psychosocial and spiritual symptoms were possible to be observed by Telemedicine, and were confirmed and treated at face-to-face consultations. Webconference connection was made by family members, because no patient operated computers. Death at home occurred in 41.67% and everyone, even the hospital deaths, received NCP support at distance. During the study was made 305 contacts; 110 face-to-face consultations to patients and families and 195 by Telemedicine (77 webconference, 38 telephone calls and 80 emails). Telemedicine allowed better access to health system (greater number of contacts), reduced search for emergency services, helped symptom control and provided orientations and reassurance to family members. This support favored early and proactive interventions and continuing assistance till death. Telemedicine has proved to be a good adjuvant in home monitoring and managing symptoms in palliative care patients, complementing face-to-face assistance, but not substituting it.

A qualidade dos serviços de saúde que assistem pessoas que vivem com HIV é um dos fatores determinantes do desfecho clínico e do impacto do tratamento na transmissão do HIV. No Brasil, desde a instituição do acesso universal à assistência e tratamento da aids em 1996, houve grande expansão do número de serviços de assistência em HIV, inseridos em estruturas do Sistema Único de Saúde (SUS) de diferentes tipos: unidades básicas de saúde, ambulatórios de especialidade vinculados a hospitais e serviços especializados em DST/Aids. Estes serviços atendem hoje cerca de 830 mil pessoas vivendo com HIV. Exceto pelos insumos específicos (antirretrovirais, carga viral, contagem de linfócitos CD4 e genotipagem) providos pelo nível federal, todos os demais recursos são dependentes da configuração local do SUS. Estas condições conformaram um conjunto bastante heterogêneo de serviços. O objetivo deste estudo foi avaliar os serviços do SUS de assistência ambulatorial a adultos vivendo com HIV. Os dados são provenientes da base de dados de 419 serviços que participaram das duas aplicações nacionais do Questionário Qualiaids de avaliação da qualidade organizacional em 2007 e 2010. O questionário, validado em 2001, é respondido online pelo responsável técnico pelo serviço de assistência em HIV. Contém 107 questões, das quais 97 são indicadores da qualidade, classificadas em três dimensões teóricas: organização do processo de assistência (07 domínios: 42 indicadores), gerenciamento técnico do trabalho (05 domínios: 31 indicadores), e disponibilidade de recursos (04 domínios: 24 indicadores). As respostas às questões indicadoras de qualidade são pontuadas em escala de 0 (padrão insuficiente), 1 (aceitável) a 2 (esperado) produzindo médias gerais de desempenho dos serviços. Não houve diferença entre a média geral obtida pelos 419 serviços que responderam o questionário em 2007 (1,27) e 2010 (1,28). Mostraram diferença as médias da dimensão de organização do processo de assistência (2007: 1,26; 2010: 1,29) e de disponibilidade de recursos (2007: 1,28; 2019:1,34). O aporte de recursos de provisão federal manteve-se alto para a grande maioria dos serviços, enquanto recursos humanos de provisão local, com destaque para o acesso às especialidades médicas, permanecem incipientes e menos disponíveis que em 2007. O gerenciamento técnico dos serviços manteve a proporção alta de serviços que realiza atendimento a pacientes com dificuldade de adesão ao tratamento em consultas médicas de retorno em intervalos menores, ou que reforçam a adesão para todos os pacientes durante a consulta médica e em consultas com outros profissionais. No entanto, permanece pequena a proporção de serviços que convoca os pacientes faltosos (~30%), assim como a proporção que conduz reuniões para discussão de casos. Entre os componentes do fluxograma geral da assistência, a proporção de serviços em que o monitoramento da adesão ao tratamento é realizado durante a consulta médica se manteve alta, semelhante à proporção de serviços que atendem os pacientes faltosos/em abandono no mesmo dia em que procuram o serviço. Contudo, continua baixo o número de serviços que realizam o agendamento de consultas médicas com hora marcada. O agrupamento dos serviços segundo kmédias produziu 4 grupos de qualidade em 2007, com 27,7% (116) dos serviços estudados no melhor grupo; em 2010, o agrupamento produziu 5 grupos, com 28,9%(121) dos serviços no melhor grupo. Analisou-se as chances de pertencer ao melhor grupo de qualidade em ambos os anos segundo características dos serviços não consideradas na pontuação de qualidade (instituição gestora, tipo de unidade, porte do serviço e número de habitantes). Associaram-se independentemente à maior chance de pertencer ao grupo de melhor qualidade, em 2007 e 2010, serviços com mais de 500 pacientes e do tipo especializados. Houve 58 serviços (13,8%) que se mantiveram no grupo de melhor qualidade em 2007 e 2010. Além de apresentarem altas médias nas dimensões de organização do processo de assistência e disponibilidade de recursos, este grupo distingue-se pelo desempenho do gerenciamento técnico especialmente na condução de atividades de planejamento, avaliação e coordenação do trabalho assistencial. A qualidade em serviços de saúde deve ser pensada sempre de modo incremental. Sistemas como o Qualiaids fornecem à gestão dos programas e dos serviços a possibilidade de monitorar o incremento da qualidade organizacional ao longo do tempo. Em que pese a relevância do sistema para a identificação de monitoramento de processos que necessitam atenção, seu papel no alcance de melhores resultados para o bem-estar dos pacientes depende da integração em políticas de qualidade e do aporte de recursos que sustentem uma vigorosa resposta assistencial, essencial para o programa como um todo
The quality of healthcare services for people living with HIV is one of the factors determining the clinical outcome and impact of treatment in HIV transmission. In Brazil, since the introduction of universal access for AIDs care and treatment in 1996, there has been a major increase in the number of HIV care services within the framework of the Brazilian National Health Service (SUS) of different types: basic healthcare units, specialist out-patient clinics affiliated to hospitals and specialized services for STD/AIDS. These services currently provide care for around 830,000 people living with HIV. Apart from specific inputs (antiretroviral drugs, viral load, CD4 lymphocyte counts and genotyping) provided at a Federal level, all other resources are dependent on the local structure of the SUS. These conditions give rise to a highly heterogeneous group of services. The objective of this study was to assess the SUS out-patient care services for adults living with HIV. The data were drawn from a database on 419 services involved in two nationwide applications of the Qualiaids Questionnaire assessing organizational quality in 2007 and 2010. The questionnaire, validated in 2001, is answered online by the technician in charge of each HIV care service. The survey comprised 107 questions, 97 of which relate to quality indicators, classified under three theoretical dimensions: Organization of the care process (07 domains: 42 indicators), Technical management of the service (05 domains: 31 indicators), and Availability of resources (04 domains: 24 indicators). The responses to the quality indicator questions are scored on a scale of 0 (insufficient level), 1 (acceptable) or 2 (expected), yielding overall mean performance scores for the services. There were no differences for overall means attained by the 419 services that answered the questionnaire in 2007 (1.27) and 2010 (1.28). However, differences in means for the dimensions \"organization of the care process\" (2007: 1.26; 2010: 1.29) and \"availability of resources\" (2007: 1.28; 2019:1.34) were evident. The level of resources provided Federally remained high for the vast majority of the services, whereas the locally provided human resources, particularly for access to medical specialties, remained underdeveloped and with lower availability in 2010 compared to 2007. The technical management of the services maintained a high proportion of services for patients having difficulties adhering to treatment involving return medical visits at shorter time intervals, or that focused on adherence for all patients during medical visits and in consultations with other professionals. However, the proportion of services that actively called in non-attenders (~30%), and also the proportion that ran meetings to discuss cases, remained low. Among the components of the general flow-diagram of care, the proportion of services in which monitoring of treatment adherence was performed during the medical consultation remained high, and was similar to the proportion of services that saw patients who had missed appointments or dropped out of treatment on the same day that they sought the service. However, the number of services that scheduled individual medical appointments remained low. K-means clustering of services produced 4 quality groups in 2007, with 27.7% (116) of services classified into the best group; in 2010, this clustering produced 5 groups, with 28.9%(121) of services in the best group. The likelihood of belonging to the best quality group on both years for the characteristics of the services not included in the quality scoring (managing institution, type of unit, size of service and population) was also analyzed. Services with over 500 patients or of the specialized type were independently associated with greater likelihood of belonging to the best quality group in both 2007 and 2010. Fifty-eight (13.8%) services remained in the best quality group in 2007 and 2010. Besides having high means for the dimensions \"organization of the care process\" and \"availability of resources\", this group stood out for performance of technical management, particularly for the activities of planning, assessment and coordination of care. The health service quality should always be considered in terms of progressive improvement. Systems such as Qualiaids allow managers of programs and services to monitor improvements in organizational quality over time. With regards to the relevance of the system for identifying and monitoring processes that require attention, its role in attaining better results for the well-being of patients depends on integration into quality policies and on level of resources which promote a strong care response, essential for the program as a whole

This study addressed gaps in the literature regarding the lack of information about the degree and extent of the relationships among symptom burden, specific symptoms, and health-related quality of life (HRQL). The sample included 89 adults receiving care for colorectal cancer in an outpatient setting. Data for this cross-sectional study were collected over a four month period using the Modified Ambulatory Care Flow Sheet (MACFS), the Rotterdam Symptom Checklist- Modified, numerical rating scales for pain and coping, and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Cancer 30. Results showed that the MACFS was reasonably valid and internally consistent and that symptom burden and number of symptoms were significantly abut weakly correlated with HRQL. Specific symptoms most significantly correlated with HRQL were insomnia, fatigue, pain, nausea and vomiting. Findings support the use of the MACFS to assess symptoms and HRQL in the study population.

Thesis (M.N.)--University of Alberta, 2009.
A thesis submitted to the Faculty of Graduate Studies and Research in partial fulfillment of the requirements for the degree of Master of Nursing, Faculty of Nursing. Title from pdf file main screen (viewed on September 20, 2009). Includes bibliographical references.

碩士
長庚大學
機械工程學系
100
Cerebrovascular disease, commonly known as stroke, has been ranked the third of the leading cause of death in recent year in Taiwan, and the stroke patients often cause unilateral paralysis of upper limb or lower limb muscle, commonly known as hemiplegia. Stroke patients, who are hemiplegic, often have reduction in thigh muscle strength and asymmetry in gait pattern. These abnormalities will affect patients’ activities of daily living, even prone to fall. However, the goals of this study were to integrate a commercial treadmill device and body weight support system, to develop the exoskeleton mechanism with magneto-rheological fluid damper, and to develop the rehabilitation training software. Moreover, the hardware and software parts were integrated as one system and further applied to verification experiments for functional assessments of this system. There are three parts in this study. The first part was to develop the system’s hardware. Solidworks was used to design the magneto-rheological fluid damper, exoskeleton mechanism and its supported equipment. Besides, the kinematic simulation module of Solidworks software was use to simulate the kinematics of exoskeleton mechanism. The result of simulation showed that the linear displacement of magneto-rheological fluid damper was 69.61 mm while knee angle of exoskeleton mechanism was 63°. In addition, material testing system (MTS) was used to evaluate the correlation between input electric currents and output resistances of magneto-rheological fluid dampers, which were installed on exoskeleton mechanism. However, the result of the intraclass correlation coefficient (ICC) was close to 1.0. In the second part, LabVIEW programming language was utilized to develop software modules of this system. These software modules were combined with data acquisition card (NI USB-6009) to control resistance of magneto-rheological fluid damper, velocity and slope of the commercial treadmill, and to acquire the hip and knee angle from changes of exoskeleton mechanism. Besides, the resistance-type rehabilitation training software with visual feedback was also developed in this study. In addition, Zebris system was used to evaluate the correlation between angles of in-house made angle sensor unit and Zebris system. The result of the ICC was close to 1.0. The third part of this study was to evaluate the system functions by experiments with unilateral knee load-bearing, to verify the gait symmetrical training effects with visual feedback on treadmill, and to assess the promotion of tight muscles’ (vastus lateralis, rectus femoris and vastus medialis) strength after gait training on treadmill. A total of fourteen healthy subjects (age: 24.2±1.10 years; height: 169.9±6.29 cm; weight: 69.2±3.90 kg) with no known neurological injuries or gait disorders were randomly distributed into the control group and the experimental group, who participated in experiments of unilateral knee load-bearing and gait symmetrical training with visual feedback on treadmill. The results of unilateral knee load-bearing experiments showed that there was significant difference with the different index of knee flexion maximum angle between unloading and loading leg (p < 0.05). Besides, seven healthy subjects (age: 24.0±1.73 years; height: 169.8±5.21 cm; weight: 68.1±6.43 kg) with no known neurological injuries or gait disorders participated in the evaluating experiments of tight muscles strength after gait training on treadmill. The results of the evaluating experiments showed that the pre-test F/S ratios were all greater than post-test F/S ratios, and strength of patients’ vastus lateralis, rectus femoris and vastus medialis muscles had an incremental tendency after gait training in five days. In this study, the "Exoskeleton Magneto-rheological Damper Controlled Lower Limb Ambulatory Rehabilitation System" has been developed. Besides, the resistance-type rehabilitation training software with visual feedback was also developed, and the experiment of lower limb training for gait symmetry adaption with visual feedback was designed. The results of experiments showed that this system can reduce different index with unloading and loading knee flexion maximum angle of the subjects to improve the symmetry of gait pattern for stroke patients. In addition, the results of the evaluating experiments of tight muscle strength after gait training on treadmill showed that this system could be useful to improve the patients' thigh muscle strength.

Dissertation in fufillment of the degree of MSc(Med), Faculty of Health Sciences, University of the Witwatersrand
Introduction: Measurement of small solute clearance is the objective means of quantifying dose of peritoneal dialysis (PD) and various organisations have issued guidelines on target values. Assessment of PD adequacy involves other factors such as blood pressure control, anaemia management, mineral metabolism, nutritional status and ultrafiltration. Membrane transport characteristic is important for PD prescription on an individual patient basis and is related to patient outcome. In this study the adequacy of PD, using small solute clearance measurement as well as other factors, and membrane characteristics have been assessed and classification of patients using our own reference values is reported for the first time. Nutritional status has been studied and the use of simple tools such as the subjective global assessment has been validated for use in our patients. Materials and Methods: A cross sectional study involving 80 adult continuous ambulatory peritoneal dialysis (CAPD) patients. Peritoneal equilibration test (PET) was performed to assess the membrane characteristics; 24 hour dialysate fluid and urine samples were collected and used for the measurement of solute clearance, while nutritional status was assessed using the subjective global assessment (SGA) instrument, anthropometric measurements and serum albumin estimation. Results: The mean age was 38 ± 12.43 years, 42.3% were females and 86% were blacks. Mean duration on CAPD was 19.8 ± 20.67 months. The mean of 4 hour D/P creatinine was 0.74 ± 0.13 and based on this, 18% were high transporters, 33.8% high average, 36.9% low average and 12% low transporters. Mean kt/v urea was 1.72± 0.32, and the recommended level of 1.7 was achieved by 62.8% of the patients. Mean haemoglobin was 10.99 ± 2.14 g/dl and the recommended target value of 11-12g/dl was reached by 55.8% of the patients. The mean BMI vi was 24.76 ± 3.50, mean Mid Upper Arm Circumference (MUAC) was 28.53±3.89 cm and mean serum albumin was 37.10 ± 7.6 g/l. Based on SGA scores, 42% of our patients were well nourished, 50% moderately undernourished while 8% were severely malnourished. We noted significant correlations between SGA score and BMI and MUAC while there was none with serum albumin level. The mean serum calcium and phosphate levels were within normal though the mean PTH level was higher. Conclusion: The D/P creatinine at 4 hours was higher than those reported in the literature, though the distribution of the transport types was similar. The recommended targets of kt/v and haemoglobin were achieved by the majority of our patients. Mineral metabolism parameters were within normal range. Malnutrition is common and SGA is a reliable method for nutritional assessment in our patients.

碩士
國立成功大學
臨床藥學與藥物科技研究所
101
Background: Because some antiepileptic drugs (AEDs) have great involvements of hepatic enzymes and can affect metabolic processes of drugs, potiential drug-drug interaction (DDI) is one of the main concerns in epileptic treatment. Elderly patients who often take concomitant medications were especially at high risk of drug interactions. However, limited information was available from previous studies about AED-DDIs in this group. Factors associated with higher risk of AED-DDIs have not been identified. Purpose: The study aimed to evaluate the degree and associated risk factors of drug–drug interactions with antiepileptic drugs ( AED-DDIs) in elderly patients with epilepsy in Taiwan. Method: A retrospective cohort study was conducted by using Taiwan’s National Health Insurance Research Database (NHIRD). Patients aged 65 or older with epilepsy defined by ICD-9 code 345 from 2005 to 2009 were included. From the date of AEDs initiation, patients were followed until the end of one year, discontinuation, switch/add-on, or disenrollment. Medications with AED-DDIs were defined by Drug Interaction Facts 2013, Lexi-Comp OnlineTM, and Micromedex. DDI score were calculated as primary indicator of AED-DDIs degree, defining as days of medication with AED-DDIs supplied divided by follow-up days. Multivariate linear regression models were used to identify risk factors associated with AED-DDIs. Result: A total of 5,785 elderly patients with epilepsy were identified with mean age was 76.61 (±7.15) years and 55.9% were male. The mean DDI score of all patients was 0.68 (±0.80), and the highest score were found in patient receiving phenytoin (0.94) and carbamazepine (0.99). Individuals receiving traditional AEDs [β=0.72; 95% CI: 0.65, 0.78], being cared by specialist other than neurologist [β=0.07; 95% CI: 0.03, 0.12], receiving more than 6 drugs for chronic conditions [β=0.20 (95% CI: 0.15, 0.25)], and comorbid condition of stroke [β=0.08 (95% CI: 0.04, 0.13)], hypertension [β=0.22 (95% CI: 0.18, 0.26)], ischemic heart disease [β=0.10 (95% CI: 0.06, 0.15)] and chronic obstructive pulmonary disease [β=0.05 (95% CI: 0.01, 0.10)] were associated with higher DDI score. Conclusion: A high degree of AED-DDIs in elderly patients with epilepsy warrants clinical attentions. Numbers of risk factors were identified and can be strong grounds for future investigations and policy decisions.

Thesis (M.Tech.: Emergency Medical Care)- Dept. of Emergency Medical Care and Rescue, Durban University of Technology, 2008. xvii, 198 leaves.
The purpose of the study was to assess ambulance infection control in an emergency medical service in the Ilembe District of KwaZulu-Natal, by determining the prevalence of bacteria and fungi in ambulances, including those that are potentially pathogenic, and evaluating the knowledge and practices of staff in infection control.

碩士
長庚大學
機械工程研究所
91
After surgery for the replacement of hip and knee joints, patients often experience lower limb dysfunction due to pain in the operated area. Abnormalities are seen in the inability of the patient to properly balance his weight on both legs. Surgeons usually suggest that patients should use accessory equipment to improve the weight-bearing balance of both legs in order to accelerate their return to normal function. It is thus important to establish a system for quantitative evaluation of both the weight-bearing balance of the legs during walking and the therapeutic effect of the accessory equipment. A tilting table is a rehabilitation equipment for gravity adaptation but it can neither be used in lower joint exercises, weight-bearing feedback at standing posture, nor in balance training. We also cannot quantitatively evaluate the effect of sole pressure feedback because this measurement needs to be taken simultaneously during training for integrated gravity adaptation and stepping balance. Balance shafts which are commonly used in walking training of patients with lower limb dysfunction cannot sufficiently support the patient’s body-weight and their use will ultimately result in poor recovery of muscle strength. It is interesting to know that during the act of balancing posture, the correct order of muscle activation and the balance of lower limbs can be induced and improved, respectively, in walking training by certain combinations of sole pressure data and electrical stimuli. The goals of the present study can be divided into three major items: quantitative evaluation of walking balance in patients with artificial hip or knee joints, development of a walking training system using sole pressure feedback gravity adaptation, and development of a walking-training system using sole pressure feedback electrostimuli. The first part of this study was done in cooperation with Professor Ming-Yih Lee, who developed the sole pressure detection system, and the Department of Orthopedics at Chang Gung Memorial Hospital. This aimed to analyze and compare the weight-bearing balance during walking between normal individuals and patients with artificial hip or knee joints. In addition, we also evaluated post-stroke patients and compared the efficacy of three different sole pressure detection systems. Our study is the first one to use three balance indicators in the clinical assessment of walking in orthopedic patients. We analyzed the walking balance conditions among ten normal individuals, nine patients with artificial hip joint replacement and 26 patients with artificial knee joints. The subjects were made to walk independently and then walk while using three different kinds of accessory equipment with different heights of armrests. The three different armrest heights include 1) up to the level of the greater trochanter of the standing patient (condition A), 2) midway between the height of the greater trochanter and the palm (condition B) and 3) up to the level of the distal wrist crease (condition C). Our results demonstrated that 40% of knee joint replacement patients who used condition B or C had the best balance indicators, and 56% of hip joint replacement patients who used condition C had the best balance indicators. As for the comparison of the three sole pressure detection systems, our study used a sole pressure detection system developed by ourselves and two commercially available devices, the Pedar and GaitMatII, to clinically evaluate post-stroke patients. Our results showed that in the walking cycles, the single foot standing time ratios between the affected and unaffected legs measured by the GaitMatII pressure pad and our systems were 0.6 and 0.625, respectively. The single foot standing peak force ratio between the affected and unaffected legs measured by Pedar was 0.86 while the single foot standing total pressure ratio between the affected and unaffected leg measured by our system was 0.46. The second part of the study was the improvement of our newly developed gravity adaptation stepping machine. We attached sole pressure detection and feedback equipment and suspended weight supporting gear to the machine and developed a computer-based interface Window program with use of visual basic software. We used a touch-control monitor for better manipulation. The pattern of pressure distribution in 24 sensors in both legs could be monitored simultaneously when the patients stand on the paddle by transducing signals from the monitor to the Programming Logic Controller (PLC) and the sole pressure detection feedback equipment. The system also provided adjustment parameters such as paddle velocity, right and left foot alternation transfer time, and paddle amplitude. As for the suspended weight-supporting gear, our system could not only provide the patients with protection while using this rehabilitation equipment but also provide the accessory tool of body-weight support for handicapped patients. The third part of our study consisted of making some additions to the sole pressure detection system developed by Professor Lee, to lessen the power requirement, miniaturize the hardware design and systemically improve the design elements such as the M30620ECGP single chip microprocessor, quick-flashing memory card, alternative switch, membrane volt-resistance sensory element, signal amplification and transfer circuit, power circuit, liquid crystal display monitor, and amplifier. We also integrated a custom-made double-channel electrostimulator into the sole pressure feedback walking training system. The power circuit was modified to be able to simultaneously provide 3V and 9V of power to achieve a stimulatory effect. We performed function tests of the electrical stimuli by using different frequencies (100 Hz and 5 Hz). The output currents were 2.2mA and 0.6mA respectively, and the output voltage was 90V. We noted no interferences when the two channels were simultaneously tested. In the quantitative analysis of walking weight-bearing balance, our balance indicators could prove to be a useful basis in the clinical evaluation of a patient’ ability to control his posture. The results can provide surgeons and therapists with an objective reference in analyzing the outcomes of surgery and therapy. In the development of the sole pressure feedback gravity adaptation stepping training system, our study demonstrated that patients can use one single equipment for training in balance, stepping, and gravity adaptation simultaneously. This can not only shorten the rehabilitation time but also simultaneously provide the surgeons and therapists with the control parameters through the computer, and thus adjust to a more appropriate rehabilitation regimen for the individual patient. In terms of the custom-built sole pressure feedback electrostimulatory walking system, we have shown that our equipment can not only expand the storage capacity of testing data but also achieve the effect of sole pressure walking training through double stimulatory pulses generated by the pads that are attached to the patients’ lower limbs.

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2021
Introdução: A aplicação do Experience Sampling Method (ESM) tem vindo a aumentar no contexto de perturbações psiquiátricas. Apesar das múltiplas vantagens, este método pode causar um fardo (burden) demasiado alto. Assim, é importante o estudo do fardo em estudos utilizando o ESM em pessoas com primeiro episódio psicótico. O objetivo deste estudo é avaliar o fardo momentâneo através de informação obtida pelo ESM e a sua relação com 1) fardo avaliado retrospetivamente, 2) crítica para a sua perturbação, 3) adesão à metodologia. Métodos: Realizou-se um estudo em indivíduos com primeiro episódio psicótico (n=28) utilizando o ESM através de smartphone durante 10 dias, com 8 questionários por dia. O fardo avaliado retrospetivamente, a adesão e o nível de crítica foram avaliados, assim como a sua relação com o fardo ao longo do estudo. Resultados: O uso de ESM no contexto de primeiro episódio psicótico não foi percecionado pelos indivíduos como oneroso e o fardo não foi considerado preditor de abandono do estudo. Conclusão: Este estudo demonstra que o ESM parece ser bem tolerado por indivíduos com diagnóstico recente de psicose, embora a existência de heterogeneidade inter-indivíduos aconselhe ainda alguma precaução.
Background: The use of smartphone-based Experience Sampling Method (ESM) in the context of psychiatric disorders has been increasing. A more exhaustive understanding of perceived momentary burden in patients with a first episode of psychosis in ESM studies is crucial. The objective of this study was to investigate patient-perceived momentary burden through ESM and clinician assessment ratings. Methods: Patients with a first episode of psychosis (n = 28) participated in a smartphone-based ESM 10-day monitoring period, signaled eight times per day. Our primary outcome was the momentary perceived burden. Results: The findings suggest that the use of ESM in the context of first episode of psychosis was not, on average, perceived by patients as burdensome and the momentary burden was not found to be a predictor of the drop-out status. Conclusion: This study demonstrates that ESM is overall well tolerated by patients with a first episode of psychosis, however, inter-individual heterogeneity warrants some caution.

The purpose of this study was to explore and describe the perceptions of registered nurses about patient-friendly health services rendered within an ambulatory care setting in the King Abdulaziz Medical City, Riyadh (KAMC-R), Kingdom of Saudi Arabia. A qualitative, explorative, descriptive and contextual design was used. Fifteen registered nurses (one male and 14 female) voluntarily participated in this study. The data collection process comprised of semi-structured individual interviews with the participants to explore what they perceived to be patient-friendly health services. The obtained data were analysed using Van Mannen’s thematic analysis method. The emerging empirical data identified four themes, three categories and nine subcategories; a literature control was incorporated to validate the findings. The study findings revealed that the participants identified cultural differences as a quintessential obstacle in rendering patient-friendly health services in the study context. Professional yet patient-friendly communication proved to be a challenge as did ambulatory care flow. This had the potential to compromise patient-friendly health services. Meeting the patients’ needs was acknowledged. However, the needs, goals and values of patientfriendly healthcare services were perceived differently by the patients on the one hand and the registered nurses on the other and this affected the process of interaction and delivery of patient-friendly care. Despite the fact that the registered nurses daily experienced ongoing challenges which compromised patient-friendly health services, they were aware and committed to deliver patient-friendly health services. The process of scientific inquiry concluded with the limitations of the study and recommendations were made based on the findings.
Health Studies
M.A. (Heath Studies)