The Feasibility of Using Metacognitive Strategy Training to Improve Performance, Foster Participation, and Reduce Impairment Following Neurological Injury

Executive function is central to our ability to learn and participate in everyday life activities and rehabilitation outcomes for individuals with executive dysfunction after neurological injury are poor. The impairments and performance challenges these individuals experience are typically not identified appropriately so they often do not receive adequate rehabilitation and can have significant challenges returning to complex everyday life activities. The vast majority of rehabilitation efforts to support individuals with neurological injuries with executive dysfunction are based on a restoration model that aims to improve cognitive function with the expectation that these gains will translate to everyday life. The available evidence suggests this translation is not happening as improvement in cognitive performance is often not leading to improvement in everyday life activities. Performance-based interventions that target improved engagement in everyday life activity are being developed with the expectation that this approach will remediate/mitigate impairments; however, these performance-based approaches have not been adequately evaluated. The purpose of this dissertation was to evaluate the feasibility and preliminary efficacy of a performance-based intervention approach, metacognitive-strategy training, on performance and impairment reduction in individuals with central neurological injury

The Impact of Mild Stroke on Participation in Physical Fitness Activities

Objective. To compare participation in moderate to high intensity physical activities in persons before and after a mild stroke. Methods. We used data from the Cognitive Rehabilitation and Research Group to examine changes in moderate to high intensity physical activity participation in persons who had a mild stroke as defined by an NIH Stroke Scale score of less than 6 (). Using the Activity Card Sort, we compared the participants' high-demand leisure activity (leisure activities that are moderate to high intensity physical activities) participation at 6-months after stroke with their prestroke level. Results. We found a significant decrease in numbers of high-demand leisure activities in all participants and in each demographic group after mild stroke. Conclusion. These results suggest that persons after mild stroke are not retaining the high-demand leisure activities they were doing prior to their stroke. Health professionals must promote participation in high-demand leisure activities in patients with mild stroke as a tool to enhance health and fitness

Estimating the risk of HIV transmission from homosexual men receiving treatment to their HIV-uninfected partners

Objective To determine how the risk of HIV transmission from homosexual men receiving antiretroviral treatment is related to patterns of patient monitoring and condom use. Methods A stochastic mathematical simulation model was developed of cohorts of men in the Netherlands who have sex with men (MSM), defining the parameters of the model using observational cohort data. The model incorporates viral load trends during first-line treatment, patient monitoring and different scenarios for the way in which condom use may depend on recent viral load measurements. The model does not include the effect of sexually transmitted infections on HIV transmission. Results For MSM receiving treatment, the risk of transmitting HIV to their long-term partner is 22% (uncertainty interval: 9-37%) if condoms are never used. With incomplete use (in 30% of sex acts) the risk is reduced slightly, to 17% (7-29%). However, the risk is as low as 3% (0.2-8%) when men receiving treatment use condoms only 6 months beyond their last undetectable viral load measurement. The risk is further reduced when 3 months is the time period beyond which condoms are used. Conclusions When condom use by HIV-infected men receiving combination treatment with antiretroviral agents is based on their last viral load measurement, the transmission risk is much lower than with incomplete condom use. The key message for patients is that although always using condoms during treatment is the best way to protect partners from the risk of HIV transmission, when such use cannot be achieved, the second best strategy is to use condoms whenever the last undetectable viral load was measured more than 3 months ag

Predictors of Occupational Competence in People Hospitalized with Chronic Conditions

Background: Chronic diseases limit participation in meaningful daily activities, roles, and routines, which can negatively impact occupational competence, a sense of self, and life satisfaction, especially when hospitalization is required to manage disease symptoms. Standardized measures of occupational competence and related functional, cognitive, and environmental factors may enhance occupational therapists’ ability to identify potential barriers to and make targeted recommendations for self- and health management in the community. Method: This cross-sectional study investigated occupational competence in patients hospitalized with chronic conditions. The participants completed measures of occupational competence, values, self-care function, environmental impact, and functional cognition while hospitalized. Results: The participants (n = 51) reported moderate to high levels of occupational competence. The overall regression model was significant. Values, self-care function, and environmental impact were significant predictors of occupational competence. Conclusion: Values, self-care function, and environmental impact predict occupational competence in people hospitalized with chronic conditions. Occupational therapists should incorporate standardized measures of occupational competence, values, self-care function, and environmental impact into current evaluation practices to support recommendations for follow-up care and community supports. Future research should include a larger sample that is more representative of an occupational therapy caseload and incorporate alternative measures of functional cognition to better measure this construct

Predictors of Hospital Readmissions for People with Chronic Conditions

Background: Hospital readmissions remain prominent in health care. Functional, cognitive, and environmental factors predict hospital readmissions but may not be thoroughly measured or addressed prior to discharge. Method: In this cross-sectional study, people hospitalized with chronic conditions completed measures of self-care function, functional cognition, occupational competence, and environmental impact. They also participated in a phone call or medical records review to identify hospital readmissions within 30 days of discharge. In a group session, occupational therapists who work in acute care completed acceptability, appropriateness, and feasibility measures for the standardized assessments administered to hospital participants. Results: Occupational competence and functional cognition were significant predictors of hospital readmissions. Therapists rated the Activity Measure of Post-Acute Care (AM-PAC) as the most acceptable, appropriate, and feasible measure for acute care. Conclusions: Occupational competence and functional cognition are predictors of hospital readmissions in people with chronic conditions. Occupational therapists in acute care should consider supplementing current evaluation practices with standardized measures of functional cognition and occupational competence to identify client needs objectively and initiate post-acute referrals that help clients discharge home successfully. Standardized measures, such as the AM-PAC may be feasible in acute care. Further research on the efficacy of standardized measures in this setting is needed

Late Entry to HIV Care Limits the Impact of Anti-Retroviral Therapy in the Netherlands

To explain differences in survival in the first three years of combination anti-retroviral therapy (cART) between HIV treatment centres in The Netherlands.We developed a mathematical simulation model, parameterised using data from the ATHENA cohort that describes patients entering care, being monitored and starting cART. Three scenarios were used to represent three treatment centres with widely varying mortality rates on cART that were differentiated by: (i) the distribution of CD4 counts of patients entering care; (ii) the age distribution of patients entering care; (iii) the average rate of monitoring the patients not on cART. At the level of the treatment centre, the fraction of Dutch MSM dying in the first three years of treatment ranged from 0% to 8%. The mathematical model captured the large variation in observed mortality between the three treatment centres. Manipulating the age-distribution of patients or the frequency of monitoring did not affect the model predictions. In contrast, when the same national average distribution of CD4 count at entry was used in all the scenarios, the variation in predicted mortality between all centres was diminished.Patients entering care with low CD4 counts appears to be the main source of variation in the mortality rates between Dutch treatment centres. Recruiting HIV-infected individuals to care earlier could lead to substantial improvements in cART outcomes. For example, if patients were to present with at least 400 CD4 cells/mm(3), as they do already in some centres, then our model predicts that the mortality in the first three years of cART could be reduced by approximately 20%

Discerning Exoplanet Migration Models Using Spin-Orbit Measurements

We investigate the current sample of exoplanet spin-orbit measurements to determine whether a dominant planet migration channel can be identified, and at what confidence. We use the predictions of Kozai migration plus tidal friction (Fabrycky and Tremaine 2007) and planet-planet scattering (Nagasawa et al. 2008) as our misalignment models, and we allow for a fraction of intrinsically aligned systems, explainable by disk migration. Bayesian model comparison demonstrates that the current sample of 32 spin-orbit measurements strongly favors a two-mode migration scenario combining planet-planet scattering and disk migration over a single-mode Kozai migration scenario. Our analysis indicates that between 34% and 76% of close-in planets (95% confidence) migrated via planet-planet scattering. Separately analyzing the subsample of 12 stars with T_eff > 6250 K---which Winn et al. (2010) predict to be the only type of stars to maintain their primordial misalignments---we find that the data favor a single-mode scattering model over Kozai with 81% confidence. We also assess the number of additional hot star spin-orbit measurements that will likely be necessary to provide a more confident model selection, finding that an additional 20-30 measurements has a >50% chance of resulting in a 95%-confident model selection, if the current model selection is correct. While we test only the predictions of particular Kozai and scattering migration models in this work, our methods may be used to test the predictions of any other spin-orbit misaligning mechanism.Comment: 9 pages, 8 figures, ApJ responded to refere