Clinical case report: yoga for fatigue in five young adult survivors of childhood cancer

PURPOSE: Cancer-related fatigue (CRF) is a distressing consequence of cancer and its treatment. CRF impacts many young adult (YA) survivors of childhood cancer, compromising work, social relationships, and daily activities. No satisfactory treatment exists. This pilot study aimed to assess the feasibility, safety, and preliminary efficacy of an 8-week twice/week Iyengar yoga (IY) intervention for treating persistent fatigue in YA survivors of childhood cancer. 

Is diagnosis enough to guide interventions in mental health? Using case formulation in clinical practice

While diagnosis has traditionally been viewed as an essential concept in medicine, particularly when selecting treatments, we suggest that the use of diagnosis alone may be limited, particularly within mental health. The concept of clinical case formulation advocates for collaboratively working with patients to identify idiosyncratic aspects of their presentation and select interventions on this basis. Identifying individualized contributing factors, and how these could influence the person's presentation, in addition to attending to personal strengths, may allow the clinician a deeper understanding of a patient, result in a more personalized treatment approach, and potentially provide a better clinical outcome.

Studentship and oppositional behaviour within physical education teacher education : a case study ; and, Between the rings and under the gym mat : a narrative

This thesis represents a part of a program of study that is reaching a closure. The broadest brush that could be applied to my work is that it concerns Physical Education Teacher Education (PETE), that it focuses on aspects of professional socialisation, and that it involves various case studies utilising naturalistic inquiry. Whilst it would be impossible and naive to believe that the reading of these texts will produce the meanings that I encourage, or have internalised, nevertheless the order of reading is at least something that I can argue for. Read in the order I suggest throughout the thesis I am hopeful that my subjectivities, and the learning and understandings I have reached may become clear. The purpose of this two part thesis is an exploration of the interplay or dialectic that exists between PETE students, academic staff and the subject matter within PETE. I have had to come to understand the limitations and advantages of insider research as the work has been completed at my University in the School of Human Movement and Sports Science where I have worked for twenty years. This thesis examines the extent to which studentship and oppositional behaviour underlies the dialectic that exists between the students and the various discourses within the program. I have written the study in two very different formats, one, a collection of stories about PETE and the other, an interpretative case study conducted during 1993 and 1994. Within the case study, studentship and oppositional behaviour were viewed as a measure of the extent to which students react and push against the forces of socialisation within their PETE program that is seen to represent dominant discourses, The following broad research questions were considered to enable the above analysis. 1. What is the nature of studentship and oppositional behaviour in a high status subject within PETE compared to a subject that is seen by students to be of little relevance and of low status? 2. How are studentship and oppositional behaviour related to students subjective warrants? 3. How are the studentship and oppositional behaviours exhibited by students related to the pedagogy and discourses reflected in the knowledge, beliefs and practices within the two sites. The starting point for this research was a study conducted as a totally separate research task (Swan, 1992) that investigated the hierarchies of subject knowledge within a PETE site and investigated the influence of such hierarchies upon student intention. A great deal of meta analysis exists about the manner in which a technocratic rationality pervades PETE but very little case study material of what this means to students and academic staff within such institutions is available. The stories in Between The Rings And Under The Gym Mat, which is the second part of this thesis, represent ‘the data’ differently from the case study, but they speak their own truth. At times the nature of the story is indistinguishable from the reality of the case study. Wexler (1992) undertook an ethnographic study about identity formation in three very different high schools, and published the findings in a book entitled Becoming Somebody. His introductory words about the nature of the social story he tells, are significant to this study and story. Social history is recounted by creative intervention that can only be made from culturally accessible materials. Ethnography is neither an objective realist, nor subjective imaginist account. Rather, it is an historical artefact that is mediated by elaborated distancing of culturally embedded and internally contradictory (but seemingly independent and coherent) concepts that take on a life of their own as theory. So, this is not ‘news from nowhere,’ but a theoretically structured story where both the story and its structure are part of my times. (p.6) The case study before you is organised with an analysis of studentship and oppositional behaviour detailed in chapter one. The following chapter conceptualises studentship and oppositional behaviour in relation to particular themes of professional socialisation, resistance to oppression and youth culture. Chapter three locates the case study to the major paradigmatic debates about the value and nature of the subject matter content within PETE, Chapter four outlines the case site, the research process and the research dilemma’s confronted in this study. The remaining three chapters are the case record as I can best understand it. In Between the Rings and under the Gym Mat (part B) the story most directly concerned with studentship and oppositional behaviour, is called Tale of Two Classes’. It takes on a very different reality to the case study (part A) and much can be said about the reality of lived experience which can be portrayed in narrative form as opposed to a clinical case study. Many of the other stories pose similar images that are contradictory and never quite complete. I have written a separate methodological section for the narrative stories. It is my intention that the case study and the series of stories should be viewed as essentially complementary, but also a discrete representation of a part of PETE. As part of the Ed D program I have undertaken four discrete research tasks as the starting point for this research I have referred to the first one (Hierarchies of Subject knowledge within PETE). I also undertook an action research project about ‘Teaching Poorly by Choice.’ A further piece of research was a somewhat reflective effort to draw together what this has all meant to me from a subjective and reflexive perspective. Such efforts are often seen as being self indulgent, as subjectivity in the form of lived experience sits uneasily in academia. A final paper involved an evaluation of Between the Rings and Under the Gym Mat from a pedagogical perspective by PETE professionals around the world. And that's the way things turned out.

Case study demonstration of the family context of anxiety disorders across the lifespan and the effectiveness of cognitive-behavioural interventions

This portfolio aims to explore some of the issues related to the treatment of anxiety disorders in clinical practice by reviewing the literature on anxiety disorders across the lifespan and presenting four clinical case studies of individuals with different anxiety disorders.

Responding to self-harm in borderline personality disorder : from clinician frustration to therapeutic enquiry

Pessimistic attitudes and reactive behavioural management strategies act as a major barrier to effective service provision for patients with borderline personality disorder. This paper reviews research on countertransference reactions (negative professional attitudes) towards these patients and the professional response to the common presentation of self harm in this particular client group. The psychotherapeutic treatment of patients with borderline personality disorder is complex and both professionally and personally demanding. A clinical framework is proposed that enables clinicians to develop a more nuanced and empathic understanding of self harm within the context of personality disorder in order to facilitate enhanced therapeutic engagement with these challenging patients. A clinical case study illustrates the use of this framework and the potential for enhanced therapeutic management in conjunction with the recognition and reduction of clinician indifference and rejection, thus improving patient outcomes. (editor abstract)Pessimistic attitudes and reactive behavioural management strategies act as a major barrier to effective service provision for patients with borderline personality disorder. This paper reviews research on countertransference reactions (negative professional attitudes) towards these patients and the professional response to the common presentation of self harm in this particular client group. The psychotherapeutic treatment of patients with borderline personality disorder is complex and both professionally and personally demanding. A clinical framework is proposed that enables clinicians to develop a more nuanced and empathic understanding of self harm within the context of personality disorder in order to facilitate enhanced therapeutic engagement with these challenging patients. A clinical case study illustrates the use of this framework and the potential for enhanced therapeutic management in conjunction with the recognition and reduction of clinician indifference and rejection, thus improving patient outcomes.

A boarding school outbreak of pertussis in adolescents : value of laboratory diagnostic methods

Culture for Bordetella pertussis (B. pertussis) is the traditional gold standard for laboratory diagnosis of pertussis but is insensitive, especially later in the course of illness and in vaccinated persons. Interpretation of serology is limited by the lack of an appropriate reference standard. An outbreak of pertussis in a crowded boarding-school dormitory allowed evaluation of laboratory correlates of infection. Questionnaires, serum samples and throat swabs were collected from members of the exposed group. Serum samples from unexposed controls of a similar age group were used for comparison. B. pertussis PCR was performed on throat swabs, and sera were tested for IgA antibodies against whole-cell (WC) B. pertussis antigen and IgG antibodies to pertussis toxin (PT). The Centers for Disease Control and Prevention definition for pertussis was used to define clinical cases. We evaluated the use of a previously published cut-off for PT IgG of 125 EIA units (EU)/ml. Completed questionnaires were obtained from 115 students, of whom 85 (74%) reported coughing symptoms, including 32 (28%) who met the clinical case definition for pertussis. B. pertussis was detected by PCR in 17 (15%) and WC IgA in 22 (19%) students; neither correlated with symptoms, but dormitory of residence strongly predicted PCR status. The mean PT IgG geometric mean concentration, in this situation of high pertussis exposure, correlated with severity of symptoms and was significantly higher in both symptomatic and asymptomatic children exposed during the outbreak (P<0·001) than in control children. A cut-off for PT IgG of 125 EU/ml was too high in an outbreak situation to be sensitive enough to identify pertussis cases. A case of pertussis in a crowded boarding-school dormitory resulted rapidly in an outbreak. Serology and PCR were useful in identifying the outbreak and commencing disease control measures. The use of serology has mostly been evaluated in community serosurveys, where it is not possible to determine if immunity reflects vaccination, asymptomatic disease or symptomatic disease. This outbreak gave us the opportunity to evaluate the value of serology and PCR in the presence of confirmed exposure to pertussis.

The relationship between stress and the symptomatology of fibromyalgia

Fibromyalgia is an unexplained but often debilitating syndrome, characterised primarily by widespread pain. This thesis provides direct evidence that physical and emotional stress exacerbates pain, fatigue and other symptoms of Fibromyalgia and supports the assertion that symptoms may be related to disordered stress-response mechanisma in the human brain. The professional portfolio presents four clinical case studies that demonstrate the utility of Acceptance and Commitment Therapy (ACT) in the psychotherapeutic treatment of people with chronic illness.

Enhancing juror decision-making through provision of transcripts

This thesis explored how much evidence jurors remember when instructed to reach a verdict. Results indicated that jurors required to rely on memory recalled significantly less evidence than jurors provided with access to the court transcript and were less confident than aided jurors that they had returned the 'right' verdict. The portfolio explored a possible association between chronic childhood challenging behaviours and later offending behaviour in individuals with intellectual disability. Includes four clinical case studies. The importance of early intervention is illustrated.

Basic symptoms in young people at ultra high-risk of psychosis

Basic Symptoms are cognitive and emotional disturbances characteristic of the early stage of psychosis. This study established the utility of an instrument to identify Basic Symptoms amongst young people at high-risk for developing psychosis, thereby facilitating the pathway to treatment for these individuals. The portfolio focuses on how having an unwell parent contributes to and influences the development of psychopathology in offspring. The four clinical case studies are presented in detail, and the intervention strategies for each individual are evaluated.

Cruelty to animals and psychosocial adjustment among Chinese children

Childhood cruelty to animals is associated with interpersonal violence in later life. The study for this thesis investigated risk factors for childhood cruelty to animals in China. For both boys and girls externalising problems, poor communication within families, and harsh parental discipline predicted animal cruelty, providing targets for intervention to prevent later violence. The portfolio presents four clinical case studies which demonstrate the complex and varied impact that intimate partner violence has on women, and the importance of psychological intervention in assisting women to manage their physical and mental health and well-being.

A touch of sugar : a multimedia case study to facilitate student dietitians learning about the clinical management of diabetes

This paper describes the development, implementation and evaluation of a multimedia case study on dietetic case management of diabetes. A multimedia web-based program was developed to use the interactive capacity of the web-based environment to enable student dietitians to develop the skills of clinical reasoning and to trigger their learning about the nutritional management of diabetes. A case study of a person with diabetes was developed using a simulated medical history, video clips and sound clips. The students were asked to manage the patient online by responding to the patient's questions, attending a team meeting and outpatient clinic, attending to food service tasks and responding to visual cues. Tutors were able to access the student's responses to submissions online. Evaluation of the program was by questionnaire, which gathered quantitative and qualitative data on the student's perceptions of their experiences in using the web-based case. The students rated the content and the interactive parts of the case highly but experienced technical difficulties and found the case took too much time to complete.

Evidence-based clinical policy: case report of a reproducible process to encourage understanding and evaluation of evidence

We report within a case study a reproducible process to facilitate the explicit incorporation of evidence by a multidisciplinary group into clinical policy development. To support the decision-making of a multidisciplinary Intersectoral Advisory Group (IAG) convened by the Royal Australasian College of Physicians Health Policy Unit, a systematic review of randomized controlled trials about environmental tobacco smoke and smoking cessation interventions in paediatric settings was first undertaken. As reported in detail here, IAG members were then formally engaged in a transparent and replicable process to understand and interpret the synthesized evidence and to proffer their independent reactions regarding policy, practice and research. Our intention was to ensure that all IAG members were democratically engaged and made aware of the available evidence. As clinical policy must engage stakeholder representatives from diverse backgrounds, a process to equalize understanding of the evidence and 'democratize' judgment about its implications is needed. Future research must then examine the benefits of such explicit steps when guidelines, in turn, are implemented. We hypothesize that changes to future practice will be more likely if processes undertaken to develop guidelines are transparent to clinicians and other target groups.

Collaboration : integrating education and clinical practice : The Case of La Trobe University/The Alfred Clinical School of Nursing

A Clinical School of Nursing combines resources, opportunities and benefits for hospital and university staff as well as students. Collaboration is essential in the partnership between the two institutions and aspects will be explored in this paper, including antecedent conditions of organisational commitment, cooperation and trust, identification of costs, and a formal agreement. Collaboration itself is built on cooperative endeavour, willing participation, shared planning and decision making, a team approach, and shared responsibility and power. These attributes are readily identifiable in this exciting initiative.

Integrating data to facilitate clinical research : a case study

The integration of routine clinical administrative activities into ongoing rigorous clinical research poses challenges for both clinicians and researchers. This case study describes the development of a responsive database system used to facilitate comprehensive longitudinal research into the outcomes of patients waiting for hip and knee replacement surgery in a large public teaching hospital. The initial research procedure was paper-based, with manual patient matching and data entry. This process was time-consuming and associated with substantial risk of error and omissions, necessitating the design of a better system. An integrated database system was designed to receive daily electronic updates of the orthopaedic waiting-list and scheduled clinic and surgery dates. Using readily available software (Microsoft Access), new patients were identified through specifying inclusion and exclusion criteria which allowed rapid and complete recruitment at time of entry to the waiting-list. The integrated system specified the appropriate timing of multiple follow-up assessments, provided prompt information on recruitment for reporting purposes and integrated multiple linked research projects within one database. Seamless exporting of data to statistical programs for analysis was also enabled. This simple integrated approach facilitated efficient execution of a longitudinal study from recruitment to statistical analysis while maximising confidentiality and minimising resources required. This case study describes the development and design of a simple system which could be easily adapted for database management in hospital or clinic-based settings according to local requirements.