How training evaluation can be used to potentiate employee development in an organization

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Management from the NOVA – School of Business and Economics

Key-elements of family interventions for psychosis : a qualitative research

RESUMO:As perturbações psicóticas são doenças mentais complexas sendo influenciadas na sua etiologia e prognóstico por factores biológicos e psicossociais. A interferência do ambiente familiar na evolução da doença espelha bem esta realidade. Quando em 1962 George Brown e colaboradores descobriram que ambientes familiares com elevada Emoção Expressa (EE) contribuíam para um aumento significativo do número de recaídas de pessoas com esquizofrenia (Brown et al., 1962), estava aberto o caminho para o desenvolvimento de novas intervenções familiares. A EE inclui cinco componentes: três componentes negativos, i.e. criticismo, hostilidade e envolvimento emocional excessivo; e dois componentes positivos, i.e. afectividade e apreço (Amaresha & Venkatasubramanian, 2012; Kuipers et al., 2002). No final dos anos 1970 surgiram os primeiros trabalhos na área das intervenções familiares nas psicoses (IFP). Dois grupos em países diferentes, no Reino Unido e nos Estados Unidos da América, desenvolveram quase em simultâneo duas abordagens distintas. Em Londres, a equipa liderada por Julian Leff desenhava uma intervenção combinando sessões unifamiliares em casa, incluindo o paciente, e sessões em grupo, apenas para os familiares (Leff et al., 1982). Por seu turno, em Pittsburgh, Gerard Hogarty e colaboradores desenvolviam uma abordagem que compreendia a dinamização de sessões educativas em grupo (Anderson e tal., 1980). Para designar este trabalho, Hogarty e colaboradores propuseram o termo “psicoeducação”. As IFP começaram a ser conhecidas por esta designação que se generalizou até aos dias de hoje. Neste contexto a educação era vista como a partilha de informação acerca da doença, dos profissionais para os familiares. Nas sessões os profissionais eram informados acerca das manifestações, etiologia, tratamento e evolução das psicoses, bem como de formas para lidar com as situações difíceis geradas pela doença, e.g. risco de recaída. Os trabalhos pioneiros das IFP foram rapidamente sucedidos pelo desenvolvimento de novos modelos e a proliferação de estudos de eficácia. Para além dos modelos de Leff e Hogarty, os modelos IFP que ficaram mais conhecidos foram: (1) a Terapia Familiar-Comportamental, desenvolvida por Ian Falloon e colaboradores (Falloon et al., 1984); e (2) a Terapia Multifamiliar em Grupo, desenvolvida por William McFarlane e colaboradores (McFarlane, 1991). O incremento de estudos de eficácia contribuiu rapidamente para as primeiras meta-análises. Estas, por sua vez, resultaram na inclusão das IFP nas normas de orientação clínica mais relevantes para o tratamento das psicoses, nomeadamente da esquizofrenia (e.g. PORT Recomendations e NICE Guidelines). No geral os estudos apontavam para uma diminuição do risco de recaída na esquizofrenia na ordem dos 20 a 50% em dois anos (Pitschel-Walz et al., 2001). No final dos anos 1990 as IFP atingiam assim o apogeu. Contudo, a sua aplicação prática tem ficado aquém do esperado e as barreiras à implementação das IFP passaram a ser o foco das atenções (Gonçalves-Pereira et al., 2006; Leff, 2000). Simultaneamente, alguns autores começaram a levantar a questão da incerteza sobre quais os elementos-chave da intervenção. O conhecimento sobre o processo das IFP era reduzido e começaram a surgir as primeiras publicações sobre o assunto (Lam, 1991). Em 1997 foi dinamizada uma reunião de consenso entre os três investigadores mais relevantes do momento, Falloon, Leff e McFarlane. Deste encontro promovido pela World Schizophrenia Fellowship for Schizophrenia and Allied Disorders surgiu um documento estabelecendo dois objectivos e quinze princípios para as IFP (WFSAD, 1997). Não obstante os contributos que foram feitos, continua a existir uma grande falta de evidência empírica acerca do processo das IFP e dos seus elementos-chave (Cohen et al., 2008; Dixon et al., 2001; Lam, 1991; Leff, 2000; McFarlane et al., 2003). Também em Portugal, apesar da reflexão teórica nesta área e do registo de ensaios de efectividade de grupos para familiares – estudo FAPS (Gonçalves-Pereira, 2010), os componentes fundamentais das IFP nunca foram analisados directamente. Assim, o projecto de investigação descrito nesta tese teve como objectivo identificar os elementos-chave das IFP com base em investigação qualitativa. Para tal, conduzimos três estudos que nos permitiriam alcançar dados empíricos sobre o tema. O primeiro estudo (descrito no Capítulo 2) consistiu na realização de uma revisão sistemática da literatura científica acerca das variáveis relacionadas com o processo das IFP. A nossa pesquisa esteve focada essencialmente em estudos qualitativos. Contudo, decidimos não restringir demasiado os critérios de inclusão tendo em conta as dificuldades em pesquisar sobre investigação qualitativa nas bases de dados electrónicas e também devido ao facto de ser possível obter informação sobre as variáveis relacionadas com o processo a partir de estudos quantitativos. O método para este estudo foi baseado no PRISMA Statement para revisões sistemáticas da literatura. Depois de definirmos os critérios de inclusão e exclusão, iniciámos várias pesquisas nas bases de dados electrónicas utilizando termos booleanos, truncações e marcadores de campo. Pesquisámos na PubMed/MEDLINE, Web of Science e nas bases de dados incluídas na EBSCO Host (Academic Search Complete; Education Research Complete; Education Source; ERIC; and PsycINFO). As pesquisas geraram 733 resultados. Depois de serem removidos os duplicados, 663 registos foram analisados e foram seleccionados 38 artigos em texto integral. No final, 22 artigos foram incluídos na síntese qualitativa tendo sido agrupados em quatro categorias: (1) estudos examinando de forma abrangente o processo; (2) estudos acerca da opinião dos participantes sobre a intervenção que receberam; (3) estudos comparativos que individualizaram variáveis sobre o processo; e (4) estudos acerca de variáveis mediadoras. Os resultados evidenciaram um considerável hiato na investigação em torno do processo das IFP. Identificámos apenas um estudo que abordava de forma abrangente o processo das IFP (Bloch, et al., 1995). Este artigo descrevia uma análise qualitativa de um estudo experimental de uma IFP. Contudo, as suas conclusões gerais revelaramse pobres e apenas se podia extrair com certeza de que as IFP devem ser baseadas nas necessidades dos participantes e que os terapeutas devem assumir diferentes papéis ao longo da intervenção. Da revisão foi possível perceber que os factores terapêuticos comuns como a aliança terapêutica, empatia, apreço e a “aceitação incondicional”, podiam ser eles próprios um elemento isolado para a eficácia das IFP. Outros estudos enfatizaram a educação como elemento chave da intervenção (e.g. Levy-Frank et al., 2011), ao passo que outros ainda colocavam a ênfase no treino de estratégias para lidar com a doença i.e. coping (e.g. Tarrier et al., 1988). Com base nesta diversidade de resultados e tendo em conta algumas propostas prévias de peritos (McFarlane, 1991; Liberman & Liberman, 2003), desenvolvemos a hipótese de concebermos as IFP como um processo por etapas, de acordo com as necessidades dos familiares. No primeiro nível estariam as estratégias relacionadas com os factores terapêuticos comuns e o suporte emocional,no segundo nível a educação acerca da doença, e num nível mais avançado, o foco seria o treino de estratégias para lidar com a doença e diminuir a EE. Neste estudo concluímos que nem todas as famílias iriam precisar de IFP complexas e que nesses casos seria possível obter resultados favoráveis com IFP pouco intensas. O Estudo 2 (descrito no Capítulo 3) consistiu numa análise qualitativa dos registos clínicos do primeiro ensaio clínico da IFP de Leff e colaboradores (Leff et al., 1982). Este ensaio clínico culminou numa das evidências mais substanciais alguma vez alcançada com uma IFP (Leff et al., 1982; Leff et al., 1985; Pitschel-Walz et al., 2001). Este estudo teve como objectivo modular a EE recorrendo a um modelo misto com que compreendia sessões familiares em grupo e algumas sessões unifamiliares em casa, incluindo o paciente. Os resultados mostraram uma diminuição das recaídas em nove meses de 50% no grupo de controlo para 8% no grupo experimental. Os registos analisados neste estudo datam do período de 1977 a 1982 e podem ser considerados como material histórico de alto valor, que surpreendentemente nunca tinha sido analisado. Eram compostos por descrições pormenorizadas dos terapeutas, incluindo excertos em discurso directo e estavam descritos segundo uma estrutura, contendo também os comentários dos terapeutas. No total os registos representavam 85 sessões em grupo para familiares durante os cinco anos do ensaio clínico e 25 sessões unifamiliares em casa incluindo o paciente. Para a análise qualitativa decidimos utilizar um método de análise dedutivo, com uma abordagem mecânica de codificação dos registos em categorias previamente definidas. Tomámos esta decisão com base na extensão apreciável dos registos e porque tínhamos disponível informação válida acerca das categorias que iríamos encontrar nos mesmos, nomeadamente a informação contida no manual da intervenção, publicado sob a forma de livro, e nos resultados da 140 nossa revisão sistemática da literatura (Estudo 1). Deste modo, foi construída uma grelha com a estrutura de codificação, que serviu de base para a análise, envolvendo 15 categorias. De modo a cumprir com critérios de validade e fidelidade rigorosos, optámos por executar uma dupla codificação independente. Deste modo dois observadores leram e codificaram independentemente os registos. As discrepâncias na codificação foram revistas até se obter um consenso. No caso de não ser possível chegar a acordo, um terceiro observador, mais experiente nos aspectos técnicos das IFP, tomaria a decisão sobre a codificação. A análise foi executada com recurso ao programa informático NVivo® versão 10 (QSR International). O número de vezes que cada estratégia foi utilizada foi contabilizado, especificando a sessão e o participante. Os dados foram depois exportados para uma base de dados e analisados recorrendo ao programa informático de análise estatística SPSS® versão 20 (IBM Corp.). Foram realizadas explorações estatísticas para descrever os dados e obter informação sobre possíveis relações entre as variáveis. De modo a perceber a significância das observações, recorremos a testes de hipóteses, utilizando as equações de estimação generalizadas. Os resultados da análise revelaram que as estratégias terapêuticas mais utilizadas na intervenção em grupo foram: (1) a criação de momentos para ouvir as necessidades dos participantes e para a partilha de preocupações entre eles – representando 21% de todas as estratégias utilizadas; (2) treino e aconselhamento acerca de formas para lidar com os aspectos mais difíceis da doença – 15%; (3) criar condições para que os participantes recebam suporte emocional – 12%; (4) lidar com o envolvimento emocional excessivo 10%; e (5) o reenquadramento das atribuições dos familiares acerca dos comportamentos dos pacientes – 10%. Nas sessões unifamiliares em casa, as estratégias mais utilizadas foram: (1) lidar com o envolvimento emocional excessivo – representando 33% de todas as estratégias utilizadas nas sessões unifamiliares em casa; (2) treino e aconselhamento acerca de formas para lidar com os aspectos desafiadores da doença – 22%; e (3) o reenquadramento das atribuições dos familiares acerca dos comportamentos dos pacientes, juntamente com o lidar com a zanga, o conflito e a rejeição – ambas com 10%. A análise longitudinal mostrou que a criação de momentos para ouvir as necessidades dos familiares tende a acontecer invariavelmente ao longo do programa. Sempre que isso acontece, são geralmente utilizadas estratégias para ajudar os familiares a lidarem melhor com os aspectos difíceis da doença e estratégias para fomentar o suporte emocional. Por sua vez, foi possível perceber que o trabalho para diminuir o envolvimento emocional excessivo pode acontecer logo nas primeiras sessões. O reenquadramento e o lidar com a zanga/ conflito/ rejeição tendem a acontecer a partir da fase intermédia até às últimas sessões. A análise das diferenças entre os familiares com baixa EE e os de elevada EE, mostrou que os familiares com elevada EE tendem a tornar-se o foco da intervenção grupal. Por sua vez, os familiares com baixa EE recebem mais estratégias relacionadas com aliança terapêutica, comparativamente com os familiares com elevada EE. São de realçar os dados relativamente às estratégias educativas. Foi possível observar que estas tendem a acontecer mais no início dos grupos, não estando associadas a outras estratégias. Contudo é de notar a sua baixa utilização, a rondar apenas os 5%.O Estudo 3 (descrito no Capítulo 4) surgiu como uma forma de completar a análise do Estudo 2, permitindo uma visão mais narrativa do processo e focando, adicionalmente, as mudanças que ocorrem nos participantes. Com base nos mesmos registos utilizados no Estudo 2, codificámos de forma secundária os registos em duas categorias i.e. marcadores de mudança e marcadores emocionais. Os marcadores de mudança foram cotados sempre que um participante exibia comportamentos ou pensamentos diferentes dos anteriores no sentido de uma eventual redução na EE. Os marcadores emocionais correspondiam à expressão intensa de sentimentos por parte dos participantes nas sessões e que estariam relacionados com assuntos-chave para essas pessoas. Os excertos que continham a informação destes marcadores foram posteriormente revistos e articulados com notas e comentários não estruturados que recolhemos durante a codificação do Estudo 2. Com base nesta informação os registos foram revistos e, utilizando um método indutivo, elaborámos uma narrativa acerca da intervenção. Os resultados da narrativa foram discutidos com dados de que dispúnhamos, referentes a reuniões com os terapeutas envolvidos na intervenção em análise (Elizabeth Kuipers, Ruth Berkowitz e Julian Leff; Londres, Novembro de 2011). Reconhecemos que, pela sua natureza não estruturada e indutiva, a avaliação narrativa está mais sujeita ao viés de observador. Não obstante, os resultados deste Estudo 3 parecem revestir uma consistência elevada. O mais relevante foi a evidência de que na intervenção em análise ocorreram mudanças emocionais significativas nos familiares ao longo das sessões em grupo. Numa fase inicial os familiares tenderam a expressar sentimentos de zanga. Seguidamente, os terapeutas iam nterrompendo o discurso de reminiscências, direccionavam o discurso para as suas preocupações actuais e os familiares pareciam ficar mais calmos. Contudo, à medida que os 143 participantes “mergulhavam” nos problemas com que se confrontavam na altura, os sentimentos de zanga davam lugar a sentimentos de perda e angústia. Nessa altura os terapeutas enfatizavam o suporte emocional e introduziam progressivamente técnicas de reenquadramento para ajudar os participantes a avaliar de forma mais positiva as situações. Este trabalho dava lugar a sentimentos mais positivos, como a aceitação, apreço e a sensação de controlo. O Estudo 3 evidenciou também o que designamos como o “Efeito de Passagem de Testemunho”. Este efeito aconteceu sempre que um membro novo se juntava ao grupo. Os membros antigos, que estavam a ser o alvo das atenções e naturalmente a receber mais intervenção, mudam de papel e passam eles próprios a focar as suas atenções nos membros mais recentes do grupo, contribuindo para a dinâmica do grupo com as mesmas intervenções que os ajudaram previamente. Por exemplo, alguns membros antigos que eram altamente críticos nos grupos em relação aos seus familiares passavam a fazer comentários de reenquadramento dirigidos para os novos membros. Por fim, o Capítulo 5 resume as conclusões gerais deste projecto de investigação. Os estudos apresentados permitiram um incremento no conhecimento acerca do processo das IFP. Anteriormente esta informação era baseada sobretudo na opinião de peritos. Com este projecto aumentámos o nível de evidência ao apresentar estudos com base em dados empíricos. A análise qualitativa do Estudo 2 permitiu pela primeira vez, tanto quanto é do nosso conhecimento, perceber de forma aprofundada o processo subjacente a uma IFP (no contexto de um ensaio clínico que se revelou como um dos mais eficazes de sempre). Identificámos as estratégias mais utilizadas, as relações entre elas e a sua diferente aplicação entre familiares com baixa EE e familiares com alta EE.O Estudo 3 completou a informação incluindo aspectos relacionados com as mudanças individuais durante o programa. No final foi possível perceber que as IFP devem ser um programa por etapas. Nos Estudo 2 e 3, evidenciámos que numa fase inicial, os terapeutas dedicaram especial atenção para que os familiares tivessem espaço para partilharem as suas necessidades, disponibilizando logo de seguida estratégias para promover o suporte emocional e estratégias de coping. Num nível subsequente do programa, o trabalho terapêutico avançou para estratégias mais direccionadas para regular a EE, mantendo sempre as estratégias iniciais ao longo das sessões. Assim apesar de a educação ter sido um componente importante na IFP em análise, houve outras estratégias mais relevantes no processo. A evidência gerada pelos Estudos 2 e 3 baseou-se em registos históricos de elevado valor, sendo que os constructos subjacentes na época, nomeadamente a EE, continuam a ser a base da investigação e prática das IFP a nível mundial em diferentes culturas (Butzlaff & Hooley, 1998). Concluímos que as IFP são um processo complexo com diferentes níveis de intervenção, podendo gerar mudanças emocionais nos participantes durante as sessões. No futuro será importante replicar o nosso trabalho (nomeadamente o Estudo 2) com outras abordagens de IFP, de modo a obter informação acerca do seu processo. Esse conhecimento será fundamental para uma possível evolução do paradigma das IFP. ----------- ABSTRACT: Background: Psychotic-spectrum disorders are complex biopsychosocial conditions and family issues are important determinants of prognosis. The discovery of the influence of expressed emotion on the course of schizophrenia paved the road to the development of family interventions aiming to lower the “emotional temperature” in the family. These treatment approaches became widely recognised. Effectiveness studies showed remarkable and strong results in relapse prevention and these interventions were generalised to other psychotic disorders besides schizophrenia. Family interventions for psychosis (FIP) prospered and were included in the most important treatment guidelines. However, there was little knowledge about the process of FIP. Different FIP approaches all led to similar outcomes. This intriguing fact caught the attention of authors and attempts were made to identify the key-elements of FIP. Notwithstanding, these efforts were mainly based on experts’ opinions and the conclusions were scanty. Therefore, the knowledge about the process of FIP remains unclear. Aims: To find out which are the key-elements of FIP based on empirical data. Methods: Qualitative research. Three studies were conducted to explore the process of FIP and isolate variables that allowed the identification of the key-elements of FIP. Study 1 consisted of a systematic literature review of studies evaluating process-related variables of FIP. Study 2 subjected the intervention records of a formerly conducted effective clinical trial of FIP to a qualitative analysis. Records were analysed into categories and the emerging data were explored using descriptive statistics and generalised estimating equations. Study 3 consisted of a narrative evaluation using an inductive qualitative approach, examining the same data of Study 2. Emotional markers and markers of change were identified in the records and the content of these excerpts was synthesised and discussed. Results: On Study 1, searches revealed 733 results and 22 papers were included in the qualitative synthesis. We found a single study comprehensively exploring the process of FIP. All other studies focused on particular aspects of the process-related variables. The key-elements of FIP seemed to be the so-called “common therapeutic factors”, followed by education about the illness and coping skills training. Other elements were also identified, as the majority of studies evidenced a multiple array of components. Study 2,revealed as the most used strategies in the intervention programme we analysed: the addressing of needs; sharing; coping skills and advice; emotional support; dealing with overinvolvement; and reframing relatives’ views about patients’ behaviours. Patterns of the usefulness of the strategies throughout the intervention programme were identified and differences between high expressed emotion and low expressed emotion relatives were elucidated. Study 3 accumulated evidence that relatives experience different emotions during group sessions, ranging from anger to grief, and later on, to acceptance and positive feelings. Discussion: Study 1 suggested a stepped model of intervention according to the needs of the families. It also revealed a gap in qualitative research of FIP. Study 2 demonstrated that therapists of the trial under analysis often created opportunities for relatives to express and share their concerns throughout the entire treatment programme. The use of this strategy was immediately followed by coping skills enhancement, advice and emotional support. Strategies aiming to deal with overinvolvement may also occur early in the treatment programme. Reframing was the next most used strategy, followed by dealing with anger, conflict and rejection. This middle and later work seems to operate in lowering criticism and hostility, while the former seems to diminish overinvolvement. Single-family sessions may be used to augment the work developed in the relatives groups. Study 3 revealed a missing part of Study 2. It demonstrated that the process of FIP promotes emotional changes in the relatives and therapists must be sensitive to the emotional pathway of each participant in the group.

Evaluation of antihypertensive drugs in patients with obstructive sleep apnea and in rats submitted to chronic intermittent hypoxia

RESUMO: A hipertensão arterial (HA) é uma patologia altamente prevalente, embora claramente subdiagnosticada, em doentes com síndrome de apneia obstrutiva do sono (SAOS). Estas duas patologias apresentam uma estreita relação e a monitorização ambulatória da pressão arterial (MAPA), por um período de 24 horas, parece ser o método mais preciso para o diagnóstico de hipertensão em doentes com SAOS. No entanto, esta ferramenta de diagnóstico para além de ser dispendiosa e envolver um número acrescido de meios técnicos e humanos, é mais morosa e, por conseguinte, não é utilizada por rotina no contexto do diagnóstico da SAOS. Por outro lado, apesar da aplicação de pressão positiva contínua nas vias aéreas (CPAP – Continous Positive Airway Pressure) ser considerada a terapêutica de eleição para os doentes com SAOS, o seu efeito no abaixamento da pressão arterial (PA) parece ser modesto, exigindo, por conseguinte, a implementação concomitante de terapêutica anti-hipertensora. Acontece que são escassos os dados relativos aos regimes de fármacos anti-hipertensores utilizados em doentes com SAOS e, acresce ainda que, as guidelines terapêuticas para o tratamento farmacológico da HA, neste grupo particular de doentes, permanecem, até ao momento, inexistentes. A utilização de modelos animais de hipóxia crónica intermitente (CIH), que mimetizam a HA observada em doentes com SAOS, revela-se extremamente importante, uma vez que se torna imperativo identificar fármacos que promovam um controle adequado da PA neste grupo de doentes. No entanto, estudos concebidos com o intuito de investigar o efeito anti-hipertensor dos fármacos neste modelo animal revelam-se insuficientes e, por outro lado, os escassos estudos que testaram fármacos anti-hipertensores neste modelo não foram desenhados para responder a questões de natureza farmacológica. Acresce ainda que se torna imprescindível garantir a escolha de um método para administração destes fármacos que seja não invasivo e que minimize o stress do animal. Embora a gavagem seja uma técnica indiscutivelmente eficaz e amplamente utilizada para a administração diária de fármacos a animais de laboratório, ela compreende uma sequência de procedimentos geradores de stress para os animais e, que podem por conseguinte, constituir um viés na interpretação dos resultados obtidos. O objectivo global da presente investigação translacional foi contribuir para a identificação de fármacos anti-hipertensores mais efectivos para o tratamento da HT nos indivíduos com SAOS e investigar mecanismos subjacentes aos efeitos sistémicos associadas à SAOS bem como a sua modulação por fármacos anti-hipertensores. Os objectivos específicos foram: em primeiro lugar,encontrar novos critérios, baseados nas medidas antropométricas, que permitam a identificação de doentes com suspeita de SAOS, que erroneamente se auto-classifiquem como nãohipertensos, e desta forma promover um uso mais criterioso do MAPA; em segundo lugar, investigar a existência de uma hipotética associação entre os esquemas de fármacos antihipertensores e o controle da PA (antes e após a adaptação de CPAP) em doentes com SAOS em terceiro lugar, avaliar a eficácia do carvedilol (CVD), um fármaco bloqueador β-adrenérgico não selectivo com actividade antagonista α1 intrínseca e propriedades anti-oxidantes num modelo animal de hipertensão induzida pela CIH; em quarto lugar, explorar os efeitos da CIH sobre o perfil farmacocinético do CVD; e, em quinto lugar, investigar um método alternativo à gavagem para a administração crónica de fármacos anti-hipertensores a animais de laboratório. Com este intuito, na primeira fase deste projecto, fizemos uso de uma amostra com um número apreciável de doentes com SAOS (n=369), que acorreram, pela primeira vez, à consulta de Patologia do Sono do CHLN e que foram submetidos a um estudo polissonográfico do sono, à MAPA e que preencheram um questionário que contemplava a obtenção de informação relativa ao perfil da medicação anti-hipertensora em curso. Numa segunda fase, utilizámos um modelo experimental de HT no rato induzida por um paradigma de CIH. Do nosso trabalho resultaram os seguintes resultados principais: em primeiro lugar, o índice de massa corporal (IMC) e o perímetro do pescoço (PP) foram identificados como preditores independentes de “auto-classificação errónea” da HA em doentes com suspeita de SAOS; em segundo lugar, não encontramos qualquer associação com significado estatístico entre os vários esquemas de fármacos anti-hipertensores bem como o número de fármacos incluídos nesse esquemas, e o controle da PA (antes e depois da adaptação do CPAP); em terceiro lugar, apesar das doses de 10, 30 e 50 mg/kg de carvedilol terem promovido uma redução significativa da frequência cardíaca, não foi observado qualquer decréscimo na PA no nosso modelo animal; em quarto lugar, as razões S/(R+S) dos enantiómeros do CVD nos animais expostos à CIH e a condições de normóxia revelaram-se diferentes; e, em quinto lugar, a administração oral voluntária mostrou ser um método eficaz para a administração diária controlada de fármacos anti-hipertensores e que é independente da manipulação e contenção do animal. Em conclusão, os resultados obtidos através do estudo clínico revelaram que o controle da PA, antes e após a adaptação do CPAP, em doentes com SAOS é independente, quer do esquema de fármacos anti-hipertensores, quer do número de fármacos incluídos num determinado esquema. Os nossos resultados salientam ainda a falta de validade da chamada self-reported hypertension e sugerem que em todos os doentes com suspeita de SAOS, com HA não diagnosticada e com um IMC e um PP acima de 27 kg/m2 e 39 cm, respectivamente, a confirmação do diagnóstico de HA deverá ser realizada através da MAPA, ao invés de outros métodos que com maior frequência são utilizados com este propósito. Os resultados obtidos no modelo animal de HA induzida pela CIH sugerem que o bloqueio do sistema nervoso simpático, juntamente com os supostos efeitos pleiotrópicos do CVD, não parece ser a estratégia mais adequada para reverter este tipo particular de hipertensão e indicam que as alterações farmacocinéticas induzidas pela CIH no ratio S/(R+S) não justificam a falta de eficácia anti-hipertensora do CVD observada neste modelo animal. Por último, os resultados do presente trabalho suportam ainda a viabilidade da utilização da administração oral voluntária, em alternativa à gavagem, para a administração crónica de uma dose fixa de fármacos anti-hipertensores.---------------------------- ABSTRACT: Hypertension (HT) is a highly prevalent condition, although under diagnosed, in patients with obstructive sleep apnea (OSA). These conditions are closely related and 24-hour ambulatory blood pressure monitoring (ABPM) seems to be the most accurate measurement for diagnosing hypertension in OSA. However, this diagnostic tool is expensive and time-consuming and, therefore, not routinely used. On the other hand, although continuous positive airway pressure (CPAP) is considered the gold standard treatment for symptomatic OSA, its lowering effect on blood pressure (BP) seems to be modest and, therefore, concomitant antihypertensive therapy is still required. Data on antihypertensive drug regimens in patients with OSA are scarce and specific therapeutic guidelines for the pharmacological treatment of hypertension in these patients remain absent. The use of animal models of CIH, which mimic the HT observed in patients with OSA, is extremely important since it is imperative to identify preferred compounds for an adequate BP control in this group of patients. However, studies aimed at investigating the antihypertensive effect of antihypertensive drugs in this animal model are insufficient, and most reports on CIH animal models in which drugs have been tested were not designed to respond to pharmacological issues. Moreover, when testing antihypertensive drugs (AHDs) it becomes crucial to ensure the selection of a non-invasive and stress-free method for drug delivery. Although gavage is effective and a widely performed technique for daily dosing in laboratory rodents, it comprises a sequence of potentially stressful procedures for laboratory animals that may constitute bias for the experimental results. The overall goal of the present translational research was to contribute to identify more effective AHDs for the treatment of hypertension in patients with OSA and investigate underlying mechanisms of systemic effects associated with OSA, as well as its modulation by AHDs. The specific aims were: first, to find new predictors based on anthropometric measures to identify patients that misclassify themselves as non-hypertensive, and thereby promote the selective use of ABPM; second, to investigate a hypothetical association between ongoing antihypertensive regimens and BP control rates in patients with OSA, before and after CPAP adaptation; third, to determine, in a rat model of CIH-induced hypertension, the efficacy of carvedilol (CVD), a nonselective beta-blocker with intrinsic anti-α1-adrenergic activity and antioxidant properties; fourth, to explore the effects of CIH on the pharmacokinetics profile of CVD and fifth, to investigate an alternative method to gavage, for chronic administration of AHDs to laboratory rats. For that, in the first phase of this project, we used a sizeable sample of patients with OSA (n=369), that attended a first visit at Centro Hospitalar Lisboa Norte, EPE Sleep Unit, and underwent overnight polysomnography, 24-h ABPM and filled a questionnaire that included ongoing antihypertensive medication profile registration. In the second phase, a rat experimental model of HT induced by a paradigm of CIH that simulates OSA was used. The main findings of this work were: first, body mass index (BMI) and neck circumference (NC) were identified as independent predictors of hypertension misclassification in patients suspected of OSA; second, in patients with OSA, BP control is independent of both the antihypertensive regimen and the number of antihypertensive drugs, either before or after CPAP adaptation; third, although the doses of 10, 30 and 50 mg/Kg of CVD promoted a significant reduction in heart rate, no decrease in mean arterial pressure was observed; fourth, the S/(R+S) ratios of CVD enantiomers, between rats exposed to CIH and normoxic conditions, were different and fifth, voluntary ingestion proved to be an effective method for a controlled daily dose administration, with a define timetable, that is independent of handling and restraint procedures. In conclusion, the clinical study showed that BP control in OSA patients is independent of both the antihypertensive regimen and the number of antihypertensive drugs. Additionally, our results highlight the lack of validity of self-reported hypertension and suggest that all patients suspected of OSA with undiagnosed hypertension and with a BMI and NC above 27 Kg/m2 and 39 cm should be screened for hypertension, through ABPM. The results attained in the rat model of HT related to CIH suggest that the blockade of the sympathetic nervous system together with the putative pleiotropic effects of carvedilol is not able to revert hypertension induced by CIH and point out that the pharmacokinetic changes induced by CIH on S/(R+S) ratio are not apparently responsible for the lack of efficacy of carvedilol in reversing this particular type of hypertension. Finally, the results here presented support the use of voluntary oral administration as a viable alternative to gavage for chronic administration of a fixed dose of AHDs.

Evaluation of outpatient child-adolescent mental health services (CAMHS) in Attica-Greece

ABSTRACT: Background: Childhood is a critical time for social and emotional development, educational progress and mental health prevention. Mental health for children and adolescents is defined by the achievement of expected developmental, cognitive, social and emotional skills. The development of child-adolescent mental health services (CAMHS) is a necessity for each country, not only as a prevention measure for the wellbeing of people, but also as an investment to the future of countries. Qualitative evaluation of services is the only way to ensure whether services function under quality standards and increase the possibility of better outcomes for their patients. This study examines the greek outpatient CAMHS against the British Standards of National Institute of Excellence for community CAMHS. The Standards assessed refer to the areas of Assessment, Care and Intervention. Objectives: The main objectives of the study are 1) to evaluate Greek outpatient CAMHS in the Attica region 2) to promote the evaluation process for mental health services in Greece. Methods: Due to the fact that Greek services are based on the British model, the tool used was the British self-review questionnaire of Quality Network for Community CAMHS(QNCC).The tool was translated, adapted and posted to services. Twelve out of twenty outpatient CAMHS of Attica (including Athens) responded. Data was collected and performed by the Statistical Package for Social Sciences SPSS. Results: The study resulted that the CAMHS examined, meet moderately the British Standards of 1) Referral and Access, 2) Assessment & Care planning, 3) Care & Intervention. Two out of twelve services examined, meet the standards of "Assessment and Care" in a higher percentage between 75% and 100%. Conclusions: The paper describes a satisfactory function of CAMHS in Attica prefecture taking into consideration the extremely difficult political situation of Greece at the time of the research. Strong and weak domains are identified. Also the translation and adaptation of British tools promote the evaluation process and quality assurance of Greek CAMHS.

Development of human central nervous system 3D in vitro models for preclinical research

Neurological disorders are a major concern in modern societies, with increasing prevalence mainly related with the higher life expectancy. Most of the current available therapeutic options can only control and ameliorate the patients’ symptoms, often be-coming refractory over time. Therapeutic breakthroughs and advances have been hampered by the lack of accurate central nervous system (CNS) models. The develop-ment of these models allows the study of the disease onset/progression mechanisms and the preclinical evaluation of novel therapeutics. This has traditionally relied on genetically engineered animal models that often diverge considerably from the human phenotype (developmentally, anatomically and physiologically) and 2D in vitro cell models, which fail to recapitulate the characteristics of the target tissue (cell-cell and cell-matrix interactions, cell polarity). The in vitro recapitulation of CNS phenotypic and functional features requires the implementation of advanced culture strategies that enable to mimic the in vivo struc-tural and molecular complexity. Models based on differentiation of human neural stem cells (hNSC) in 3D cultures have great potential as complementary tools in preclinical research, bridging the gap between human clinical studies and animal models. This thesis aimed at the development of novel human 3D in vitro CNS models by integrat-ing agitation-based culture systems and a wide array of characterization tools. Neural differentiation of hNSC as 3D neurospheres was explored in Chapter 2. Here, it was demonstrated that human midbrain-derived neural progenitor cells from fetal origin (hmNPC) can generate complex tissue-like structures containing functional dopaminergic neurons, as well as astrocytes and oligodendrocytes. Chapter 3 focused on the development of cellular characterization assays for cell aggregates based on light-sheet fluorescence imaging systems, which resulted in increased spatial resolu-tion both for fixed samples or live imaging. The applicability of the developed human 3D cell model for preclinical research was explored in Chapter 4, evaluating the poten-tial of a viral vector candidate for gene therapy. The efficacy and safety of helper-dependent CAV-2 (hd-CAV-2) for gene delivery in human neurons was evaluated, demonstrating increased neuronal tropism, efficient transgene expression and minimal toxicity. The potential of human 3D in vitro CNS models to mimic brain functions was further addressed in Chapter 5. Exploring the use of 13C-labeled substrates and Nucle-ar Magnetic Resonance (NMR) spectroscopy tools, neural metabolic signatures were evaluated showing lineage-specific metabolic specialization and establishment of neu-ron-astrocytic shuttles upon differentiation. Chapter 6 focused on transferring the knowledge and strategies described in the previous chapters for the implementation of a scalable and robust process for the 3D differentiation of hNSC derived from human induced pluripotent stem cells (hiPSC). Here, software-controlled perfusion stirred-tank bioreactors were used as technological system to sustain cell aggregation and dif-ferentiation. The work developed in this thesis provides practical and versatile new in vitro ap-proaches to model the human brain. Furthermore, the culture strategies described herein can be further extended to other sources of neural phenotypes, including pa-tient-derived hiPSC. The combination of this 3D culture strategy with the implemented characterization methods represents a powerful complementary tool applicable in the drug discovery, toxicology and disease modeling.

Evaluation of cumulative PCB exposure estimated by a job exposure matrix versus PCB serum concentrations.

Although polychlorinated biphenyls (PCBs) have been banned in many countries for more than three decades, exposures to PCBs continue to be of concern due to their long half-lives and carcinogenic effects. In National Institute for Occupational Safety and Health studies, we are using semiquantitative plant-specific job exposure matrices (JEMs) to estimate historical PCB exposures for workers (n = 24,865) exposed to PCBs from 1938 to 1978 at three capacitor manufacturing plants. A subcohort of these workers (n = 410) employed in two of these plants had serum PCB concentrations measured at up to four times between 1976 and 1989. Our objectives were to evaluate the strength of association between an individual worker's measured serum PCB levels and the same worker's cumulative exposure estimated through 1977 with the (1) JEM and (2) duration of employment, and to calculate the explained variance the JEM provides for serum PCB levels using (3) simple linear regression. Consistent strong and statistically significant associations were observed between the cumulative exposures estimated with the JEM and serum PCB concentrations for all years. The strength of association between duration of employment and serum PCBs was good for highly chlorinated (Aroclor 1254/HPCB) but not less chlorinated (Aroclor 1242/LPCB) PCBs. In the simple regression models, cumulative occupational exposure estimated using the JEMs explained 14-24% of the variance of the Aroclor 1242/LPCB and 22-39% for Aroclor 1254/HPCB serum concentrations. We regard the cumulative exposure estimated with the JEM as a better estimate of PCB body burdens than serum concentrations quantified as Aroclor 1242/LPCB and Aroclor 1254/HPCB.

Characterization and clinical evaluation of CD10+ stroma cells in the breast cancer microenvironment.

PURPOSE: There is growing evidence that interaction between stromal and tumor cells is pivotal in breast cancer progression and response to therapy. Based on earlier research suggesting that during breast cancer progression, striking changes occur in CD10(+) stromal cells, we aimed to better characterize this cell population and its clinical relevance. EXPERIMENTAL DESIGN: We developed a CD10(+) stroma gene expression signature (using HG U133 Plus 2.0) on the basis of the comparison of CD10 cells isolated from tumoral (n = 28) and normal (n = 3) breast tissue. We further characterized the CD10(+) cells by coculture experiments of representative breast cancer cell lines with the different CD10(+) stromal cell types (fibroblasts, myoepithelial, and mesenchymal stem cells). We then evaluated its clinical relevance in terms of in situ to invasive progression, invasive breast cancer prognosis, and prediction of efficacy of chemotherapy using publicly available data sets. RESULTS: This 12-gene CD10(+) stroma signature includes, among others, genes involved in matrix remodeling (MMP11, MMP13, and COL10A1) and genes related to osteoblast differentiation (periostin). The coculture experiments showed that all 3 CD10(+) cell types contribute to the CD10(+) stroma signature, although mesenchymal stem cells have the highest CD10(+) stroma signature score. Of interest, this signature showed an important role in differentiating in situ from invasive breast cancer, in prognosis of the HER2(+) subpopulation of breast cancer only, and potentially in nonresponse to chemotherapy for those patients. CONCLUSIONS: Our results highlight the importance of CD10(+) cells in breast cancer prognosis and efficacy of chemotherapy, particularly within the HER2(+) breast cancer disease.

Evaluation of Bond Retainage in Portland Cement Concrete Overlays Using Infrared Thermography and Ground Penetrating Radar, HR-537, Final Report, 1989

When concrete deterioration begins to occur in highway pavement, repairs become necessary to assure the rider safety, extend its useful life and restore its riding qualities. One rehabilitation technique used to restore the pavement to acceptable highway standards is to apply a thin portland cement concrete (PCC) overlay to the existing pavement. First, any necessary repairs are made to the existing pavement, the surface is then prepared, and the PCC overlay is applied. Brice Petrides-Donohue, Inc. (Donohue) was retained by the Iowa Department of Transportation (IDOT) to evaluate the present condition with respect to debonding of the PCC overlay at fifteen sites on Interstate 80 and State Highway 141 throughout the State of Iowa. This was accomplished by conducting an infrared thermographic and ground penetrating radar survey of these sites which were selected by the Iowa Department of Transportation. The fifteen selected sites were all two lanes wide and one-tenth of a mile long, for a total of three lane miles or 190,080 square feet. The selected sites are as follows: On Interstate 80 Eastbound, from milepost 35.25 to 35.35, milepost 36.00 to 36.10, milepost 37.00 to 37.10, milepost 38.00 to 38.10 and milepost 39.00 to 39.10, on State Highway 141 from milepost 134.00 to 134.10, milepost 134.90 to milepost 135.00, milepost 135.90 to 136.00, milepost 137.00 to 137.10 and milepost 138.00 to 138.10, and on Interstate 80 Westbound from milepost 184.00 to 184.10, milepost 185.00 to 185.10, milepost 186.00 to 186.10, milepost 187.00 to 187.10, and from milepost 188.00 to 188.10.

Physico-chemical characterization and oxidative reactivity evaluation of aged brake wear particles

Brake wear dust is a significant component of traffic emissions and has been linked to adverse health effects. Previous research found a strong oxidative stress response in cells exposed to freshly generated brake wear dust. We characterized aged dust collected from passenger vehicles, using microscopy and elemental analyses. Reactive oxygen species (ROS) generation was measured with acellular and cellular assays using 2′7-dichlorodihydrofluorescein dye. Microscopy analyses revealed samples to be heterogeneous particle mixtures with few nanoparticles detected. Several metals, primarily iron and copper, were identified. High oxygen concentrations suggested that the elements were oxidized. ROS were detected in the cell-free fluorescent test, while exposed cells were not dramatically activated by the concentrations used. The fact that aged brake wear samples have lower oxidative stress potential than fresh ones may relate to the highly oxidized or aged state of these particles, as well as their larger size and smaller reactive surface area.

Evaluation of Machine Learning Classifiers for Mobile Network Intrusion Detection Systems

Mobile malwares are increasing with the growing number of Mobile users. Mobile malwares can perform several operations which lead to cybersecurity threats such as, stealing financial or personal information, installing malicious applications, sending premium SMS, creating backdoors, keylogging and crypto-ransomware attacks. Knowing the fact that there are many illegitimate Applications available on the App stores, most of the mobile users remain careless about the security of their Mobile devices and become the potential victim of these threats. Previous studies have shown that not every antivirus is capable of detecting all the threats; due to the fact that Mobile malwares use advance techniques to avoid detection. A Network-based IDS at the operator side will bring an extra layer of security to the subscribers and can detect many advanced threats by analyzing their traffic patterns. Machine Learning(ML) will provide the ability to these systems to detect unknown threats for which signatures are not yet known. This research is focused on the evaluation of Machine Learning classifiers in Network-based Intrusion detection systems for Mobile Networks. In this study, different techniques of Network-based intrusion detection with their advantages, disadvantages and state of the art in Hybrid solutions are discussed. Finally, a ML based NIDS is proposed which will work as a subsystem, to Network-based IDS deployed by Mobile Operators, that can help in detecting unknown threats and reducing false positives. In this research, several ML classifiers were implemented and evaluated. This study is focused on Android-based malwares, as Android is the most popular OS among users, hence most targeted by cyber criminals. Supervised ML algorithms based classifiers were built using the dataset which contained the labeled instances of relevant features. These features were extracted from the traffic generated by samples of several malware families and benign applications. These classifiers were able to detect malicious traffic patterns with the TPR upto 99.6% during Cross-validation test. Also, several experiments were conducted to detect unknown malware traffic and to detect false positives. These classifiers were able to detect unknown threats with the Accuracy of 97.5%. These classifiers could be integrated with current NIDS', which use signatures, statistical or knowledge-based techniques to detect malicious traffic. Technique to integrate the output from ML classifier with traditional NIDS is discussed and proposed for future work.

Evaluation of a treatment program for individuals with an intellectual disability who have high risk behaviours

In the past two decades numerous programs have emerged to treat individuals with developmental disabilities who have sexual offending behaviours. There has, however been very few studies that systematically examine the effectiveness of long term treatment with this population. The present research examines the therapeutic outcomes of a multi-modal behaviour approach with six individuals with intellectual disabilities previously charged with sexual assault. The participants also exhibited severe behavioural challenges that included verbal aggression, physical aggression, destruction and self-injury. These six participants (5 males, 1 female) were admitted to a Long Term Residential Treatment Program (LTRTP), due to the severity of their behaviours and due to their lack of treatment success in other programs. Individualized treatment plans focused on the reduction of maladaptive behaviours and the enhancing of skills such as positive coping strategies, socio-sexual knowledge, life skills, recreation and leisure skills. The treatment program also included psychiatric, psychological, medical, behavioural and educational interventions. The participants remained in the Long Term Residential Treatment Program (LTRTP) program from 181 to 932 days (average of 1.5 years). Pre and post treatment evaluations were conducted using the following tools: frequency of target behaviours, Psychopathology Inventory for Mentally Retarded Adults (PIMRA), Emotional Problems Scale (EPS), Socio-Sexual Knowledge and Attitudes Assessment Tool (SSKAAT-R) and Quality of Life Questionnaire (QOL-Q). Recidivism rates and the need for re-hospitalization were also noted for each participant. By offering high levels of individualized interventions, all six participants showed a 37 % rate of reduction in maladaptive behaviours with zero to low rates of inappropriate sexualbehaviour, there were no psychiatric hospitalizations, and there was no recidivism for 5 of 6 participants. In addition, medication was reduced. Mental health scores on the PIMRA were reduced across all participants by 25 % and scores on the Quality of Life Questionnaire increased for all participants by an average of 72 %. These findings add to and build upon the existing literature on long term treatment benefits for individuals with a intellectual disability who sexually offend. By utilizing an individualized and multimodal treatment approach to reduce severe behavioural challenges, not only can the maladaptive behaviours be reduced, but adaptive behaviours can be increased, mental health concerns can be managed, and overall quality of life can be improved.

An impact evaluation of the Ontario ban on smoking in schools and on school property : does the ban on smoking influence high school students' intentions to smoke cigarettes?

The Ontario Tobacco Control Act of 1994 imposed a total ban on smoking in schools, and on school property for every school in the province. The imposition of this policy created problems for school administrators. For instance, students who were smoking on walkways and properties adjacent to school boundaries, clashed with neighbouring property owners who were angry about the resulting damage and disruption. The enforcement of this policy consumes valuable resources at each school; therefore, knowledge about the impact of the policy is important. If effective, this policy has the potential to improve the health of students over their lifetime, by preventing or delaying smoking behaviour. Alternatively, an ineffective policy will continue to create administrative problems for the school and serve no legitimate purpose. Therefore, knowledge about the impact of the smoking ban policy on students' smoking intentions assists policy makers and school administrators in their understanding of the policy's impact within the schools. This research provided an impact evaluation of the ban on smoking in schools and on school property in Ontario. A total of 2069 students, from five high schools, in the Niagara Region, provided complete responses to a survey, designed to test whether smoking intentions were affected by the imposition of the policy. The study used Ajzen's theory of planned behaviour (Ajzen, 1991), specifically, the perceived behavioural control measure, to gain some understanding of students' perceptions of control over smoking imposed by the ban. The findings indicate the policy has the potential to influence students' overall smoking intentions. The ban on smoking policy was found to be a significant predictor of the smoking intentions of high school students. As well, attitude, social norms, and perceptions of control were significant predictors of smoking intentions. Exploratory findings also indicated differences between the control beliefs of students from different high schools, indicating potential differences in the enforcement of the smoking ban between schools. The findings also support the utility of the theory of planned behaviour as a methodology for evaluating the influence of punitive policies. This research study should be continued by utilizing the full theory of planned behaviour, including two phases of data collection and the measurement of actual smoking behaviour.

The development, assessment, and implementation of an evaluation of the EMPOWER Program at shelters for abused women /

The development, assessment, and implementation of a program evaluation instrument was carried out to evaluate the impact and efficacy of the EMPOWER Program. This intervention was created to educate residents at a shelter for abused women with an anticipated outcome of prevention. Participants included the staff and residents at 2 shelters in Southern Ontario. Client pre, post and follow-up measures were obtained and analyzed statistically and using keyword content analysis. A single staff measure was obtained and summarized using keyword content analysis. Qualitative results were suggestive of important change in participants. All women in the post and follow-up measures believed their participation in the EMPOWER Program provided them with the knowledge, skills, and confidence to avoid abusive relationships in the fliture. This transformational impact was repeatedly expressed in both resident and staff feedback. Limitations of this research, as well as suggestions for future study were discussed.

Course/instructor evaluation : perspectives of part-time graduate students

This study explored 6 part-time graduate students' perspectives on course/instructor evaluation. The purpose was to explore whether a link exists between the evaluation for course and instructors as contained in the Faculty of Education courselinstructor evaluation form and the needs of part-time students enrolled in that program. The literature review provided contextual information concerning the 3 main subject areas based upon which the research questions were designed: learner needs in the context of part-time graduate students, courselinstructor eval~ation, and the potential lack of congruency between the 2. Using a semistructured interview process, participants identified criteria important or relevant to the evaluation process and incongruent with the course/instructor evaluation form. A qualitative research methodology using a grounded theory approach contributed to the theory on the nature of course evaluation instruments in a graduate program and addressed the notion of where power was situated within the evaluation process. Findings suggested that the concepts of relevance and the instructor's role that participants identified as important in their graduate learning experience were congruent with what they considered important components of the course/instructor evaluation form. Participants noted a lack of congruency between their expectations of a quality graduate learning experience and the format, content, intent, and timing of the evaluation process. The study confirmed that students did want a voice in the evaluation of their learning experience at both the course and program levels.

Evaluation of a professional development curriculum in movement education and adapted physical activity for invisible disabilities : a critical cross-case analysis

Movement education and adapted physical activity are content areas not addressed in pre-service education or in-service training for Ontario practitioners working with individuals with disabilities in physical environments. Consequently, physical activity is often overlooked by service providers in programming and intervention for exceptional young learners. A formative evaluation, multiple-case study design was employed in this research in which a purposeful sample of expert practitioners performed a guided, descriptive evaluation of a three-day professional development workshop curriculum designed to supplement these areas lacking in professional preparation within their respective cohorts. Case-by-case and comparative analyses illustrated the inherent assumptions and societal constraints which prioritize the structure of professional development within the education system and other government organizations providing services for school-aged persons with disabilities in Ontario. Findings, discussed from a critical postmodern perspective, illustrate the paradoxical nature of Western values and prevailing mind/body dichotomy that guide professional practice in these fields.