Core Outcome Measures for Adults with Neurologic Conditions: Pilot Implementation in Hospital-Based Outpatient Clinic.

This residency capstone project’s objective was implementation of 3 of the core neuro outcome measures within a small outpatient clinic, as they were being used inconsistently and heterogeneously. The project included 3 phases: preparation/development, education, and implementation, followed by analyzing and reporting on the project’s and resident’s outcomes

Core Outcome Measures for Adults with Neurologic Conditions: Pilot Implementation in Hospital-Based Outpatient Clinic.

Purpose: To describe a pilot implementation project of 3 of the core neuro outcome measures (OMs) within a small outpatient clinic. Description: OMs provide standardized methods to track patient progress and functional status across levels of care. As the PT profession continues implementing standardized and evidence-based clinical practice guidelines (CPGs) to reflect expertise in the movement system, consistent use of OMs is crucial.1-3 A core set of OMs (COMs) CPG was developed for adults with neurologic conditions; tools to facilitate its use are being produced through the Academy of Neurologic PT (ANPT).4-6 PTs from new grads to clinical specialists should have adequate exposure to COMs and be able to administer them competently.7 Components of DPT education should be upheld once in the clinic. This capstone residency project is helping bridge that gap, bringing didactic and skills training into the clinic to refresh PTs’ OM exposure and facilitate standard and consistent use. Summary of Use: Needs assessment identified that the clinic (10-15 therapists) was not equipped to use COMs according to ANPT recommendations, and OMs were being used inconsistently. However, staff expressed willingness to begin adopting the CPG recommendations. Clinicians were provided ANPT administration guides and electronic medical record (EMR) documentation phrases. To introduce the CPG and COMs, an education session was given emphasizing recommended COM use, standardization of methods and interpretations, and group work for clinical decision-making with certain patient presentations. The session concluded with a departmental discussion on barriers to using OMs and a plan to address them, with the goal for intentional and consistent use beginning with 3 of the COMs. The department was equipped with a binder with laminated copies of ANPT guides, and the clinic was set up to standardize COM administration. For lab training, clinicians were provided copies of the 3 ANPT guides and a competency checklist, and each OM was demonstrated by the resident. During the lab, clinicians role-played alternating as therapist, patient, and observer for each OM to complete the checklist. Next steps of roll-out are currently in progress, beginning with a 5-week period to collect data, followed by data analysis. Implementation of the measures will occur during the 5 weeks, tracking frequency of OM use, documentation in the EMR, and incorporation into the plan of care as collected through a chart audit tool and weekly check-ins. It will also include a subjective pre/post survey to assess clinician learning outcomes and perceptions. Importance to Members: Barriers to OM administration are clinic-wide, and changing practice patterns may often be met with resistance.5,6,8-11 This pilot project may reflect a feasible way to standardize implementation of the COMs into hospital-based outpatient clinics in a way that is not overwhelming to clinicians nor overtly costly to management. This type of standardized OM implementation may also be able to aid in nation-wide outcomes tracking

The Relationship of Anti-Mullerian Hormone Levels and Urine Cortisol in Women with Chronic Abdominal Pain

Context: Persistent and intense stress leads to chronic activation of the hypothalamic-pituitary-adrenal (HPA) axis, placing an individual at increased risk for the development of disease. HPA activity inhibits ovarian functioning, and may contribute to female infertility. Objective: The objective of the study was to explore the association of HPA activity with ovarian functioning in female participants with and without chronic abdominal pain (CAP). Design/setting/and subjects: A secondary data analysis was performed using data from female participants in a natural history protocol at the National Institutes of Health. A total of 36 females (19–39 years, mean 27.11) were included in the study. Main outcome measurements: Whole blood was drawn for determination of serum levels of anti-Mullerian hormone (AMH), luteinizing hormone, follicle stimulating hormone, and cortisol. Urine samples were collected over a five hour period for determination of cortisol levels. CAP was defined as presence or absence of chronic abdominal pain for \u3e6 months and was determined via self-report. Results: AMH concentrations declined significantly with age as expected. When AMH levels were dichotomized as normal or abnormal (defined as higher or lower than age-specific normative ranges), there were significant associations between abnormal AMH levels and CAP and urine cortisol levels. Subjects with CAP or low urine cortisol levels were significantly more likely to have abnormal AMH levels. Conclusions: Results suggest that chronic pain and HPA dysregulation may be associated with abnormal AMH levels

Anti-Müllerian Hormone Levels and Urinary Cortisol in Women With Chronic Abdominal Pain

AbstractObjectiveTo explore the association of hypothalamic–pituitary–adrenal activity with ovarian functioning in women with and without chronic abdominal pain (CAP).Design and SettingA secondary data analysis was performed with data from female participants in a natural history protocol at the National Institutes of Health.ParticipantsA total of 36 women (age range = 19–39 years, mean = 27.11 years) were included in the study.MethodsThis pilot study was conducted with a subset of participants enrolled in a natural history protocol conducted in the Hatfield Clinical Research Center at the National Institutes of Health. The parent study included participants with and without CAP who provided a 5-hour urine sample for determination of cortisol levels and serum samples for determination of circulating levels of cortisol, luteinizing hormone, and follicle-stimulating hormone. CAP was defined as presence or absence of chronic pain for at least 6 months and was determined via self-report.ResultsAnti-Müllerian hormone (AMH) concentrations declined significantly with age as expected. When AMH levels were dichotomized as normal or abnormal (defined as higher or lower than age-specific normative ranges, respectively), there were significant associations between abnormal AMH levels and CAP and urine cortisol levels. Participants with CAP or low urine cortisol levels were significantly more likely to have abnormal AMH levels.ConclusionResults suggest that chronic abdominal pain and hypothalamic–pituitary–adrenal dysregulation may be associated with abnormal AMH levels

Chronic Stress and Ovarian Function in Female Childhood Cancer Survivors

Objectives: To explore the relationships among perceived stress, biomarkers of hypothalamic–pituitary–adrenal (HPA) activity, gonadotropin levels, and anti-Müllerian hormone (AMH) in female childhood cancer survivors (CCSs). Sample & Setting: 24 female CCSs from the Royal Hospital for Sick Children in Edinburgh, Scotland, were included in the study. Methods & Variables: Perceived stress was measured using the Perceived Stress Scale. HPA activity was measured using salivary cortisol and hair cortisol. Ovarian function was measured using serum gonadotropin levels and serum AMH levels. Latent growth curve modeling was used to determine diurnal cortisol slope and intercept. Bayesian structural equation modeling was used to explore the relationship among perceived stress, biomarkers of HPA activity, and ovarian function. Results: The authors found an inverse association between perceived stress and ovarian function and a positive association between biomarkers of HPA activity and ovarian function. Implications for Nursing: Further research is needed to understand factors contributing to risk for post-treatment reproductive dysfunction in female CCSs

A Comparison of Measured Creatinine Clearance versus Calculated Glomerular Filtration Rate for Assessment of Renal Function before Autologous and Allogeneic BMT

AbstractCommon blood and marrow transplantation (BMT) eligibility criteria include a minimum glomerular filtration rate (GFR) that may vary by regimen intensity. GFR is often estimated by measurement of creatinine clearance in a 24-hour urine collection (24-hr CrCl), an inconvenient and error-prone method that overestimates GFR. The study objectives were to determine which of 6 GFR calculations: Cockroft-Gault (CG), modified CG (mCG), Modification of Diet in Renal Disease 1 (MDRD1), MDRD2, Jelliffe, and Wright, consistently underestimated measured 24-hr CrCl pre-BMT. We retrospectively analyzed 98 consecutive allogeneic (n = 48) or autologous (n = 50) adult BMT patients from January 2006 to April 2007. All 6 formulas were significantly (P < .001) correlated with 24-hr CrCl with R = 0.64 (Wright), 0.63 (CG), 0.61 (mCG), 0.61 (Jelliffe), 0.54 (MDRD2), and 0.50 (MDRD1). When compared to the measured 24-hr CrCl, MDRD2 consistently underestimated it in the highest proportion of patients (66%, P < .001), compared with MDRD1 (65%, P < .001), Jelliffe (61%, P = NS), mCG (55%, P = NS), Wright (34%, P < .001), and CG (34%, P = .001). Measured 24-hr CrCl, pre-BMT serum Cr, and all 6 equations were not predictive of renal regimen-related toxicity (RRT) post-BMT. The Wright and CG formulas are closest to, but overestimate 24-hr CrCl in 66% of patients. In comparison, MDRD2 consistently underestimates 24-hr CrCl in 66%. Although MDRD2 is the most conservative formula, all 6 formulas gave reasonable estimates of GFR and any of the 6 equations can replace the measured 24-hr CrCl. Larger analyses and transplantation of patients with GFR <50 mL/min may better define subgroups at risk for renal RRT

Hematocrit Self-Testing in Patients with Polycythemia Vera and Other Hematological Conditions: Assessing the Accuracy of the StatStrip Xpress® 2 LAC/Hb/Hct Device and User Opinion about the Device in Real-World Clinical Practice.

Maintaining hematocrit (Hct) levels below 45% can reduce morbidity and mortality in patients with polycythemia vera (PV). A device that patients can use to self-monitor Hct levels could enable timely interventions if Hct levels increase above 45%, and could improve quality of life (QoL). This study evaluated the accuracy of the StatStrip Xpress® 2 LAC/Hb/Hct meter (Hb/Hct meter) when used by healthcare professionals (HCPs) or patients in clinical practice. Blood samples from 68 visits for 60 patients with PV or other hematological conditions were collected and analyzed by HCPs using a laboratory hematological analyzer, and by patients (self-test) and HCPs (professional test) using the Hb/Hct meter at two Swiss centers. Accuracy was assessed as the mean difference in readings between two users/methods (mdiff, 90% confidence interval; Spearman correlation [r]). The Hct values were similar between the professional test and analyzer (n = 66 comparisons, mdiff = 0.1% [-0.5 to 0.8]; r = 0.95, p &lt; 0.001), the self-test and professional test (n = 62 comparisons, mdiff = -0.2% [-1.1 to 0.7]; r = 0.93, p &lt; 0.001), and the self-test and analyzer (n = 63 comparisons, mdiff = 0.0% [-0.8 to 0.7]; r = 0.94, p &lt; 0.001). The hemoglobin values across users/methods were also similar. Reporting their opinion on the Hb/Hct meter at visit 1, 100% of the patients found it easy to use, and 97% were willing to use it at home. Of the patients with PV, approximately 71% and 56%, respectively, stated that they would feel safer using a self-testing device, and that it would improve their QoL. These findings demonstrate the potential of the Hb/Hct meter for HCP and patient use in real-world settings

Mental/Behavioural Health and Educational Outcomes of Grandchildren Raised by Custodial Grandparents: A Mixed Methods Systematic Review

Grandparents caring for grandchildren has increased globally in the past two decades, but we have a limited understanding of its effects on custodial grandchildren\u27s mental/behavioural health and educational outcomes. This mixed methods systematic review aims to synthesise mental/behavioural health and educational outcomes of custodial grandchildren within custodial grandparent-headed families and with comparison to other types of household structure and further examine factors associated with these outcomes. A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. We searched ERIC, Family Studies Abstracts, PsycINFO, PubMed, Scopus, Social Work Abstract and SocINDEX in March 2021 and screened 14,515 articles, which resulted in the inclusion of 42 studies, including 33 quantitative, seven qualitative and two mixed methods studies. The quality of included studies was assessed. This review covered 10 countries, yet most studies revealed that grandchildren raised by grandparents had adverse mental/behavioural health and educational outcomes compared to their peers raised by biological parents. This review further identified multi-level factors contributing to custodial grandchildren\u27s adverse outcomes. Methodological limitations and implications for future practice and research were discussed