How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect? How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect? Drug-related problems identified in post-discharge medication reviews for patients taking warfarin Androgen levels in adult females: changes with age, menopause, and oophorectomy. The state of rehabilitation research: art or science? Rehabilitation in the home versus the hospital: the importance of context. The Psychiatric Emergency Research Collaboration-01: methods and results. Developing and evaluating the implementation of a complex intervention: using mixed methods to inform the design of a randomised controlled trial of an oral healthcare intervention after stroke Comparison of remedial and compensatory interventions for adults with acquired brain injuries. Reports of clinical trials should begin and end with up-to-date systematic reviews of other relevant evidence: a status report. The impact of childhood abuse and neglect on adult mental health: a prospective study. Does treadmill exercise improve performance of cognitive or upper-extremity tasks in people with chronic stroke? A randomized cross-over trial. Towards a programme theory for fidelity in the evaluation of complex interventions. Rehabilitation Regimens Following Surgical Repair of Extensor Tendon Injuries of the Hand—A Systematic Review of Controlled Trials Systematic review of the effectiveness of integrated care pathways: what works, for whom, in which circumstances? Evidence for the Use of Hearing Assistive Technology by Adults: The Role of the FM System FIRE (facilitating implementation of research evidence): a study protocol Translating research into policy: lessons learned from eclampsia treatment and malaria control in three southern African countries Childhood trauma and hallucinations in bipolar affective disorder: preliminary investigation. The use of a simulated environment (easy street) to retrain independent living skills in elderly persons: a randomized controlled trial. Being mindful of mindfulness interventions in cancer: A systematic review of intervention reporting and study methodology Neurocognitive testing and cochlear implantation: insights into performance in older adults Applying the COM-B behaviour model and behaviour change wheel to develop an intervention to improve hearing-aid use in adult auditory rehabilitation
Background Across the developed world , we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision . Integrated care pathways ( ICPs ) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration . ICPs map out a patient 's journey , providing coordination of services for users . They aim to have : ' the right people , doing the right things , in the right order , at the right time , in the right place , with the right outcome ' . The value for ICPs in supporting the delivery of care across organisational boundaries , providing greater consistency in practice , improving service continuity and increasing collaboration has been advocated by many . However , there is little evidence to support their use , and the need for systematic evaluations in order to measure their effectiveness has been widely identified . A recent Cochrane review assessed the effects of ICPs on functional outcome , process of care , quality of life and hospitalisation costs of in patients with acute stroke , but did not specifically focus on service integration or its derivatives . To the best of our knowledge , no such systematic review of the literature exists . Objectives To systematic ally review all high‐ quality studies which have evaluated the impact of care pathway technologies on ' service integration ' and its derivatives in stroke care To examine how elements of service integration are defined in such studies To examine the type of evidence utilised to measure service integration To analyse the weight of evidence used to support cl aims about the effectiveness of ICPs on improving service integration To produce recommendations for ICP developers , users and evaluators . Inclusion criteria Types of participants The review focused on the care of adult patients who had suffered a stroke . It included the full spectrum of services ‐ acute care , rehabilitation and long‐term support ‐ in hospital and community setting s. Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest , defined for the purpose of this review as ' a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and st and ardise the outcome orientated care ' . Here ' multidisciplinary ' is taken to refer to the involvement of two or more disciplines . Types of outcomes Service integration ' was the outcome of interest however , this was defined and measured in the selected studies . Types of studies This review was concerned with how ' service integration ' was defined in evaluations of ICPs ; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on ' service integration ' . Studies that made an explicit link between ICPs and service integration were included in the review . Evidence generated from r and omised controlled trials , quasi‐experimental , qualitative and health economics research was sought . The search was limited to publications after 1980 , coinciding with the emergence of ICPs in the healthcare context . Assessment for inclusion of foreign papers was based on the English‐ language abstract , where available . These were included only if an English translation was available . Exclusion criteria This review excluded studies that : focused only on a single aspect of stroke care ( e.g. dysphasia ) evaluated ICPs as part of a wider program of service development did not make an explicit link between ICPs and service integration did not meet the definition of ICP utilised for the purpose s of the review focused exclusively on the outcomes of variance analysis Search strategy In order to avoid replication , the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Data base and the Cochrane Library were search ed to establish that no systematic review s existed and none were in progress . A three‐stage search strategy was then used to identify both published and unpublished studies ( see Appendix III ) . Data collection Our search strategy located 2123 papers , of which 39 were retrieved for further evaluation . We critically appraised seven papers , representing five studies . These were all evaluation studies and , as is typical in this field , comprised a range of study design s and data collection methods . Owing to the diversity of the study types included in the review , we developed a single‐ appraisal checklist and data ‐ extraction tool which could be applied to all research design s.32 The tool drew on the Joanna Briggs Institute ( JBI ) appraisal checklists for experimental studies and interpretive and critical research , and also incorporated specific information and issues which were relevant for our purpose s ( see Appendix VI ) . This extends the thinking outlined in Lyne et al.31 in which , drawing on Campbell and Stanley 's classic paper , the case is made for developing an appraisal tool which is applicable to all types of evaluation , irrespective of study design . In assessing the quality of the papers , we were sympathetic to the method ological challenges of evaluating complex interventions such as ICPs . We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare context s. In accordance with the aims of this particular review , we have included studies , which are method ologically weaker than is typical of many systematic review s because , in our view , in the absence of stronger evidence , they yield useful information . Data synthesis Given the heterogeneity of the included studies , meta‐ analysis and /or qualitative synthesis was not possible . A narrative summary of the study findings is presented . Results ICPs can be effective in ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner , although these improvements may reflect better documentation rather than actual changes in practice . ICPs can be effective in improving the documentation of rehabilitation goals , documentation of communication with patients , carers ( diagnosis , prognosis and follow‐up arrangements ) and documentation of notification of primary care physicians of discharge . However , this can create additional burdens of work for staff . Early studies of  ICP‐managed care in the acute stroke context have demonstrated reduced length of stay without any associated adverse effects on discharge destination , morbidity or mortality . These effects do not reach statistical significance , however , and may reflect wider changes in service provision and a general trend towards reduced length of hospital stay . While later studies in the acute and rehabilitation context s do not reveal any significant reduction in length of stay , they do report greater documented use of certain clinical interventions and assessment s , suggesting that ICPs can be effective in mobilising hospital re sources around the patient . ICPs implemented in the context of acute stroke care can be effective in reducing the occurrence of urinary tract infections , although we do not know whether this can be attributed to improved service integration . ICP management in stroke rehabilitation may not be flexible enough to meet diverse patient needs and can result in insufficient attention to higher‐level functioning and carer needs influencing perceptions of quality of life . ICP management may assist in clarifying role boundaries and a shared underst and ing of the work , but this can result in some members of the disciplinary team perceiving that their contribution is not appropriately reflected in the documentation . There is some evidence that ICPs may be effective in changing professional behaviours in the desired direction where there is scope for improvement , but in situations in which multidisciplinary working is effective , their positive effects may be limited . Furthermore , it is far from clear what the active ingredients of ICPs actually are . Kwan et al. suggest that it was the process of ICP development that had most impact on behaviours rather than the use of the artefact per se.20 None of the studies assessed the balance of costs and benefits of ICP use . Therefore , we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits . Conclusions Implication s for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care . This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of re sources around the patient without incurring additional increases in length of stay . ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable . Their value in the context of rehabilitation setting s in which recovery pathways are more variable is less clear . There is some evidence that ICPs may be effective in bringing about behavioural changes in context s where deficiencies in service provision have been identified . Their value in context s where inter‐professional working is well established is less clear . While earlier before and after studies show a reduction in length of stay in ICP‐managed care , this may reflect wider healthcare trends , and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced . There is some evidence to suggest that ICPs bring about improvements in documentation , but we do not know how far documented practice reflects actual practice . It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use . As none of the studies review ed included an economic evaluation , moreover , it remains unclear whether the benefits of ICPs UNLABELLED EXECUTIVE SUMMARY : BACKGROUND Across the developed world , we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision . Integrated care pathways ( ICPs ) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration . ICPs map out a patient 's journey , providing coordination of services for users . They aim to have : ' the right people , doing the right things , in the right order , at the right time , in the right place , with the right outcome ' . The value for ICPs in supporting the delivery of care across organisational boundaries , providing greater consistency in practice , improving service continuity and increasing collaboration has been advocated by many . However , there is little evidence to support their use , and the need for systematic evaluations in order to measure their effectiveness has been widely identified . A recent Cochrane review assessed the effects of ICPs on functional outcome , process of care , quality of life and hospitalisation costs of in patients with acute stroke , but did not specifically focus on service integration or its derivatives . To the best of our knowledge , no such systematic review of the literature exists . OBJECTIVES • To systematic ally review all high- quality studies which have evaluated the impact of care pathway technologies on ' service integration ' and its derivatives in stroke care • To examine how elements of service integration are defined in such studies • To examine the type of evidence utilised to measure service integration • To analyse the weight of evidence used to support cl aims about the effectiveness of ICPs on improving service integration • To produce recommendations for ICP developers , users and evaluators . INCLUSION CRITERIA Types of participants The review focused on the care of adult patients who had suffered a stroke . It included the full spectrum of services - acute care , rehabilitation and long-term support - in hospital and community setting s. Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest , defined for the purpose of this review as ' a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and st and ardise the outcome orientated care ' Here ' multidisciplinary ' is taken to refer to the involvement of two or more disciplines . Types of outcomes ' Service integration ' was the outcome of interest however , this was defined and measured in the selected studies . Types of studies This review was concerned with how ' service integration ' was defined in evaluations of ICPs ; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on ' service integration ' . Studies that made an explicit link between ICPs and service integration were included in the review . Evidence generated from r and omised controlled trials , quasi-experimental , qualitative and health economics research was sought . The search was limited to publications after 1980 , coinciding with the emergence of ICPs in the healthcare context . Assessment for inclusion of foreign papers was based on the English- language abstract , where available . These were included only if an English translation was available . EXCLUSION CRITERIA This review excluded studies that : • focused only on a single aspect of stroke care ( e.g. dysphasia ) • evaluated ICPs as part of a wider program of service development • did not make an explicit link between ICPs and service integration • did not meet the definition of ICP utilised for the purpose s of the review • focused exclusively on the outcomes of variance analysis SEARCH STRATEGY In order to avoid replication , the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Data base and the Cochrane Library were search ed to establish that no systematic review s existed and none were in progress . A three-stage search strategy was then used to identify both published and unpublished studies ( see Appendix III ) . DATA COLLECTION Our search strategy located 2123 papers , of which 39 were retrieved for further evaluation . We critically appraised seven papers , representing five studies . These were all evaluation studies and , as is typical in this field , comprised a range of study design s and data collection methods . Owing to the diversity of the study types included in the review , we developed a single- appraisal checklist and data - extraction tool which could be applied to all research design s.(32 ) The tool drew on the Joanna Briggs Institute ( JBI ) appraisal checklists for experimental studies and interpretive and critical research , and also incorporated specific information and issues which were relevant for our purpose s ( see Appendix VI ) . This extends the thinking outlined in Lyne et al.(31 ) in which , drawing on Campbell and Stanley 's classic paper , the case is made for developing an appraisal tool which is applicable to all types of evaluation , irrespective of study design . In assessing the quality of the papers , we were sympathetic to the method ological challenges of evaluating complex interventions such as ICPs . We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare context s. In accordance with the aims of this particular review , we have included studies , which are method ologically weaker than is typical of many systematic review s because , in our view , in the absence of stronger evidence , they yield useful information . DATA SYNTHESIS Given the heterogeneity of the included studies , meta- analysis and /or qualitative synthesis was not possible . A narrative summary of the study findings is presented . RESULTS 1 ICPs can be effective in ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner , although these improvements may reflect better documentation rather than actual changes in practice . 2 ICPs can be effective in improving the documentation of rehabilitation goals , documentation of communication with patients , carers ( diagnosis , prognosis and follow-up arrangements ) and documentation of notification of primary care physicians of discharge . However , this can create additional burdens of work for staff . 3 Early studies of ICP-managed care in the acute stroke context have demonstrated reduced length of stay without any associated adverse effects on discharge destination , morbidity or mortality . These effects do not reach statistical significance , however , and may reflect wider changes in service provision and a general trend towards reduced length of hospital stay . While later studies in the acute and rehabilitation context s do not reveal any significant reduction in length of stay , they do report greater documented use of certain clinical interventions and assessment s , suggesting that ICPs can be effective in mobilising hospital re sources around the patient . 4 ICPs implemented in the context of acute stroke care can be effective in reducing the occurrence of urinary tract infections , although we do not know whether this can be attributed to improved service integration . 5 ICP management in stroke rehabilitation may not be flexible enough to meet diverse patient needs and can result in insufficient attention to higher-level functioning and carer needs influencing perceptions of quality of life . 6 ICP management may assist in clarifying role boundaries and a shared underst and ing of the work , but this can result in some members of the disciplinary team perceiving that their contribution is not appropriately reflected in the documentation . 7 There is some evidence that ICPs may be effective in changing professional behaviours in the desired direction where there is scope for improvement , but in situations in which multidisciplinary working is effective , their positive effects may be limited . Furthermore , it is far from clear what the active ingredients of ICPs actually are . Kwan et al. suggest that it was the process of ICP development that had most impact on behaviours rather than the use of the artefact per se.(20 ) 8 None of the studies assessed the balance of costs and benefits of ICP  use . Therefore , we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits . CONCLUSIONS Implication s for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care . This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of re sources around the patient without incurring additional increases in length of stay .  ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable . Their value in the context of rehabilitation setting s in which recovery pathways are more variable is less clear . There is some evidence that ICPs may be effective in bringing about behavioural changes in context s where deficiencies in service provision have been identified . Their value in context s where inter-professional working is well established is less clear . While earlier before and after studies show a reduction in length of stay in ICP-managed care , this may reflect wider healthcare trends , and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced . There is some evidence to suggest that ICPs bring about improvements in documentation , but we do not know how far documented practice reflects actual practice . It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use . ( ABSTRACT TRUNCATED Objective To characterise the nature of the drug-related problems with warfarin therapy identified in  pharmacist-conducted medication review s during a collaborative post-discharge warfarin management service , with a focus on potentially serious drug interactions . Setting Australian community pharmacy practice . Method Medication review reports su bmi tted by pharmacists to patients ’ general practitioners as part of the service were review ed and the type and clinical significance of the warfarin-associated drug-related problems , and the pharmacists ’ recommendations were classified . The prevalence of prescribing of ‘ potentially hazardous ’ warfarin drug interactions was investigated and compared with the frequency of documentation of these interactions in the medication review reports . Main outcome measure The number and nature of warfarin-associated drug-related problems identified and the rate of documentation of ‘ potentially hazardous ’ warfarin drug interactions in the reports from pharmacist-conducted medication review s. Results A total of 157 warfarin-associated drug-related problems were documented in 109 medication review reports ( mean 1.4 per patient , 95 % CI 1.3–1.6 , range 0–5 ) . Drug selection and Education or information were the most commonly identified warfarin-associated drug-related problems ; most drug-related problems were of moderate clinical significance . Eight of 23 potentially serious warfarin drug interactions ( 34.8 % ) were identified in the medication review reports . Conclusion Pharmacists addressing drug selection and warfarin education drug-related problems during medication review s may have contributed to the positive outcomes of the post-discharge service .  Warfarin drug interactions were frequently identified ; however , well-recognised potentially hazardous interactions were under-reported . Improved communication along the continuum of care would permit improved targeting of drug-related problem reporting , especially in relation to preventable drug interactions CONTEXT Changes in and rogen levels across the adult female life span and the effects of natural menopause and oophorectomy have not been clearly established . OBJECTIVE The objective of this study was to document the effects of age on and rogen levels in healthy women and to explore the effects of natural and surgical menopause . DESIGN , SETTING , AND PARTICIPANTS A cross-sectional study was conducted of 1423 non-healthcare-seeking women , aged 18 - 75 yr , r and omly recruited from the community over 15 months . MAIN OUTCOME MEASURES Serum levels by age of total testosterone ( T ) , calculated free T , dehydroepi and rosterone sulfate , and and rostenedione in a reference group of women free of confounding factors . Women in the reference group had no usage of exogenous steroid therapy ; no history of tubal ligation , hysterectomy , or bilateral oophorectomy ; and no hyperprolactinemia or polycystic ovarian syndrome . The effects of natural and surgical menopause on sex steroid levels were also examined . RESULTS In the reference population ( n = 595 ) , total T , calculated free T , dehydroepi and rosterone sulfate , and and rostenedione declined steeply with age ( P < 0.001 ) , with the decline of each being greater in the earlier than the later decades . Examination of serum and rogen levels by year in women aged 45 - 54 yr showed no independent effect of menopausal status on and rogen levels . In women aged 55 yr or older , those who reported bilateral oophorectomy and were not on exogenous steroids had significantly lower total T and free T levels than women 55 yr or older in the reference group . CONCLUSIONS We report that serum and rogen levels decline steeply in the early reproductive years and do not vary because a consequence of natural menopause and that the postmenopausal ovary appears to be an ongoing site of testosterone production . These significant variations in and rogens with age must be taken into account when normal ranges are reported and in studies of the role of and rogens in women Rehabilitation research has been criticized as not st and ing up enough to the rigors of scientific method to be called " science . " The field has been portrayed as slow to promote its scientific achievements and to include them under the rubric of evidence -based rehabilitation . Following in the footsteps of psychology , rehabilitation as a broad-based discipline has faced many similar obstacles in achieving scientific status . Controversy exists about what exactly constitutes rehabilitation science versus its art and its respective multidisciplinary domains . The conception of these domains is directly related to current methods available to assess the state of the discipline and its research accomplishments . I used quantitative methods , such as r and omized clinical and /or controlled trials ( RCTs ) and systematic review s  , to assess the status of rehabilitation research . Findings suggest that , as a field , rehabilitation makes significant contributions to science , measurable by the number and quality of RCTs and systematic review s conducted so far on topics of critical importance for clinical care . In " artful " complement , qualitative approaches can be used as research tools to aid investigators in seeking knowledge beyond that obtained by quantitative methods , assessing many complexities associated with the various context s of rehabilitation research . Other requirements to develop a common vision of rehabilitation science are also discussed PURPOSE Stroke rehabilitation has received increased attention in the past decade . Recent trials with new alternatives such as home-based rehabilitation services are being conducted . The purpose of the study was to explore differences between a therapy session with a stroke patient in two different context s , i.e. in the patient 's home and in the hospital . METHODS The research design was a qualitative case study . Three data collection methods were used ; participant observations of therapy sessions in two different context s , semi-structured interviews and documents . RESULTS The data were examined and coded for common categories . Analysis of the data looking for similarities and differences in behaviour of two therapists and their patients during therapy sessions in the hospital and in the home was performed . The observations revealed that there was clearly a difference in behaviour ; a different role-set used by the two therapists when working in the patient 's home versus in the hospital . The major difference in patient behaviour was that the patient , observed in his home , took the initiative and expressed his goals , which was not the case with the patients observed in the hospital . The findings were confirmed in the interviews and the documents . CONCLUSION It is suggested that the context is a key component to be considered in the rehabilitation process of stroke patients OBJECTIVE To describe the Psychiatric Emergency Research Collaboration ( PERC ) , the methods used to create a structured chart review tool and the results of our multicenter study . METHOD Members of the PERC Steering Committee created a structured chart review tool design ed to provide a comprehensive picture of the assessment and management of psychiatric emergency patients . Ten primary indicators were chosen based on the Steering Committee 's professional experience , the published literature and existing consensus panel guidelines . Eight emergency departments completed data abstract ion of 50 r and omly selected emergency psychiatric patients , with seven providing data from two independent raters . Inter-rater reliability ( Kappas ) and descriptive statistics were computed . RESULTS Four hundred patient charts were abstract ed . Initial concordance between raters was variable , with some sites achieving high agreement and others not . Reconciliation of discordant ratings through re- review of the original source documentation was necessary for four of the sites . Two hundred eighty-five ( 71 % ) subjects had some form of laboratory test performed , including 212 ( 53 % ) who had urine toxicology screening and 163 ( 41 % ) who had blood alcohol levels drawn . Agitation was present in 220 ( 52 % ) , with 98 ( 25 % ) receiving a medication to reduce agitation and 22 ( 6 % ) being physically restrained . Self-harm ideation was present in 226 ( 55 % ) , while other-harm ideation was present in 82 ( 20 % ) . One hundred seventy-nine ( 45 % ) were admitted to an inpatient or observation unit . CONCLUSION Creating a common st and ard for documenting , abstract ing and reporting on the nature and management of psychiatric emergencies is feasible across a wide range of health care institutions Background Many interventions delivered within the stroke rehabilitation setting could be considered complex , though some are more complex than others . The degree of complexity might be based on the number of and interactions between levels , components and actions targeted within the intervention . The number of ( and variation within ) participant groups and the context s in which it is delivered might also reflect the extent of complexity . Similarly , design ing the evaluation of a complex intervention can be challenging . Considerations include the necessity for intervention st and ardisation , the multiplicity of outcome measures employed to capture the impact of a multifaceted intervention and the delivery of the intervention across different clinical setting s operating within varying healthcare context s. Our aim was to develop and evaluate the implementation of a complex , multidimensional oral health care ( OHC ) intervention for people in stroke rehabilitation setting s which would inform the development of a r and omised controlled trial . Methods After review ing the evidence for the provision of OHC following stroke , multi-disciplinary experts informed the development of our intervention . Using both quantitative and qualitative methods we evaluated the implementation of the complex OHC intervention across patients , staff and service levels of care . We also adopted a pragmatic approach to patient recruitment , the completion of assessment tools and delivery of OHC , alongside an attention to the context in which it was delivered . Results We demonstrated the feasibility of implementing a  complex OHC intervention  across three levels of care . The complementary nature of the mixed methods approach to data gathering provided a complete picture of the implementation of the intervention and a detailed underst and ing of the variations within and interactions between the components of the intervention . Information on the feasibility of the outcome measures used to capture impact across a range of components was also collected , though some process orientated uncertainties including eligibility and recruitment rates remain to be further explored within a Phase II exploratory trial . Conclusions Complex interventions can be captured and described in a manner which facilitates evaluation in the form of exploratory and subsequently definitive clinical trials . If effective , the evidence captured relating to the intervention context will facilitate translation into clinical practice OBJECTIVE To examine the effects of a compensatory intervention versus a remedial intervention for deficits in visual processing of adults with acquired brain injuries ( ABI ) . SETTING A cognitive rehabilitation program at a large comprehensive rehabilitation hospital in the New York City metropolitan area . PATIENTS Thirty adults with ABI were matched according to severity of injury , gender , age , and time post-injury , and r and omly assigned to the remedial or compensatory group . INTERVENTIONS The remedial intervention consisted of four 45-minute sessions ( once weekly ) of participation in computer tasks without instruction in compensatory strategies . The compensatory intervention consisted of four 45-minute sessions of instruction in the use of three internal compensatory strategies , including verbalization , chunking , and pacing . MAIN OUTCOME MEASURES Pretest/posttest measures included three functional computer tasks . Weekly measures included a computerized version of the Paced Auditory Serial Addition Task ( PASAT ) and two computerized matching tasks . RESULTS Both groups exhibited statistically significant improvement of comparable degree on posttests and weekly measures . Further analysis revealed that 80 % of both groups used compensatory strategies , regardless of intervention method . Those who used strategies demonstrated better performance than those who did not . CONCLUSION The ability to use internal compensatory strategies may be a significant confound in research examining the effects of the various cognitive rehabilitation intervention methods OBJECTIVE Scientific and ethical justification for new clinical trials requires them to have been design ed in the light of scientifically defensible assessment s of relevant previous research . Reliable interpretation of the results of new clinical trials entails setting them in the context of up date s of the review s upon which they were deemed scientifically and ethically justifiable . We have shown previously that most reports of r and omized trials published in five general medical journals in May 1997 and in May 2001 failed to set their results in the context of the findings from similar research . In the current study , we assess whether there had been progress in this respect in 2005 and also investigate the extent to which reports begin by referring to systematic review s providing the justification for the new research reported . DESIGN Assessment of the Introduction and Discussion sections in all reports of r and omized trials published during May 2005 in five general medical journals . SETTING Reports of r and omized trials in five general medical journals . PARTICIPANTS Annals of Internal Medicine , BMJ , JAMA , Lancet and New Engl and Journal of Medicine . INTERVENTIONS None . MAIN OUTCOME MEASURES The inclusion or mention of one or more systematic review s in the Introduction or Discussion section of each report assessed . RESULTS We found 18 reports of r and omized trials . The Introduction sections referred to systematic review s in five ( 27 % ) of these reports . None of the discussion sections of the 15 reports of trials that were not the first published trials to address the question studied placed the results of the new trial in the context of an up date d systematic review of other research . Although reference was made to relevant systematic review s in five of these 15 reports , there was no integration - quantitative or qualitative - of the results of the new trials in an up date of these review s. In the remaining ten reports there was no evidence that any systematic attempt had been made to set the new results in the context of previous trials . CONCLUSIONS There is no evidence of progress between 1997 and 2005 in the proportion of reports of trials published in general medical journals which discussed new results within the context of up-to- date systematic review s of relevant evidence from other controlled trials . Although the proportion of trials referring to systematic review s in Discussion sections has increased , the majority of reports continued to fail even to do this . Similarly , most research ers appear not to have considered a systematic review when design ing their trial . Research ers and journal editors do a disservice to the interests of the public and others involved in healthcare decision-making by acquiescing in this situation This paper examines the impact of three types of victimization in childhood --  sexual abuse , physical abuse , and neglect -- on lifetime measures of mental health among adults . In contrast to research that relies on retrospective recall of childhood victimization , this work uses a prospect i ve sample gathered from records of documented court cases of childhood abuse and neglect in a midwestern city around 1970 . These subjects were interviewed about twenty years later . In addition , this research compares outcomes of the 641 members of the abuse and neglect group with a matched control group of 510 persons who did not have documented cases of abuse or neglect .  The results indicate that men who were abused and neglected as children have more dysthymia and antisocial personality disorder as adults than matched controls , but they did not have more alcohol problems . Abused and neglected women report more symptoms of dysthymia , antisocial personality disorder , and alcohol problems than controls . After controlling for stressful life events , however , childhood victimization had little direct impact on any lifetime mental health outcome . This research indicates the importance of adopting an approach that places childhood victimization in the context of other life stressors and of prospect i ve changes over the life course OBJECTIVE To determine whether acute exercise , using a body-weight-supported treadmill , improves performance on subsequent cognitive tests or an upper-extremity task in people with stroke . DESIGN The study was a within-subject , cross-over design in which 21 subjects received , r and omly , 2 different testing sequences separated by an interval of 7 to 10 days . SETTING Outpatient department of a rehabilitation hospital . PARTICIPANTS Of 72 potential participants in the convenience sample , 21 people with chronic stroke completed the study . They were 0.5 to 5 years after only 1 documented stroke , were able to walk with or without a cane , were able to grasp with the affected h and , and scored more than 24 on the Mini-Mental State Examination . INTERVENTIONS One session of body-weight-supported treadmill walking for 20 minutes at 70 % of estimated heart rate reserve or level 13 on the Borg rating of perceived exertion scale . The control condition consisted of a 20-minute review of a home exercise program with a physiotherapist . MAIN OUTCOME MEASURES Cognitive tests included Trail Making Tests Parts A and B , Symbol Digit Substitution Test , and Paced Auditory Serial Addition Test . The Action Research Arm Test ( ARAT ) measured hemiplegic upper-extremity motor skill . RESULTS Treadmill exercise  improved movement of the hemiplegic upper extremity ( P=.04 ) but not cognitive performance . The improvement in the ARAT occurred without a change in strength ( measured by grip strength ) and was negatively correlated with maximum treadmill speed ( R(2)=.20 ; P=.04 ) . CONCLUSIONS These findings suggest that acute treadmill exercise improves subsequent skilled movement of the hemiplegic upper extremity that seems unrelated to attention , visuomotor processing , or strength . The etiology and duration of this enhancing effect are worth further study . The existence of an exercise-cognition relationship in people with stroke is an intriguing area of future research RATIONALE , AIMS AND OBJECTIVES This paper addresses the challenge of investigating fidelity in the implementation of a complex rehabilitation intervention design ed to increase the level of independence in personal activities of daily living of stroke patients living in UK care homes . A programme theory of intervention fidelity was constructed to underpin a process evaluation running alongside a cluster r and omized trial of the rehabilitation intervention . METHODS The programme theory has been constructed drawing on principles of realist evaluation . Using data from in-depth semi-structured interviews ( n = 17 ) with all occupational therapists ( OTs ) and critical incident reports from the trial ( n = 20 ) , and drawing from frameworks for implementation , the programme theory was developed . RESULTS The programme theory incorporates four potential mechanisms through which fidelity within the trial can be investigated . These four programme theory areas are ( 1 ) the balancing of research and professional requirements that therapists performed in a number of areas while delivering the study interventions ; ( 2 ) the OTs rapport building with care home staff ; ( 3 ) the work focused on re-engineering the personal environments of care home patients ; and ( 4 ) the learning about the intervention within the context of the trial and its impacts over time . CONCLUSIONS These findings characterize the real-world nature of fidelity within intervention research , and specifically the negotiated nature of implementation within clinical setting s , including individual patients ' needs . This research adds to the evidence base because current frameworks for fidelity neglect the importance of learning over time of individuals and across the time span of a trial There is no consensus on the most effective rehabilitation regimen following extensor tendon repair of the h and . This systematic review evaluates the outcomes of the various regimens . The Cochrane , MEDLINE , EMBASE , CINAHL , AMED , PEDro , OTseeker data bases were search ed for any prospect i ve r and omised clinical trials comparing rehabilitation regimens for acute extensor tendon injuries in adults . Five papers met the inclusion criteria . The regimens were static immobilisation , dynamic splinting and early active motion ( EAM ) . There was no st and ard format of reporting . The sample size ranged from 27 to 100 patients . The duration of follow-up ranged from 8 to 24 weeks . Overall , patients ’ total active motion improved with time . Early mobilisation regimens ( active and passive ) achieve quicker recovery of motion than static immobilisation but the long-term outcome appears similar . Given the comparable outcomes between dynamic splinting and EAM , we therefore favour EAM which is simpler and more convenient UNLABELLED Aim Integrated care pathways ( ICP ) are management technologies which formalise multidisciplinary team-working and enable professionals to examine their roles and responsibilities . ICPs are now being implemented across international healthcare arena , but evidence to support their use is equivocal . The aim of this study was to identify the circumstances in which ICPs are effective , for whom and in what context s. Methods A systematic review of high- quality r and omised controlled trials published between 1980 and 2008 ( March ) evaluating  ICP use in child and adult population s in the full range of healthcare setting s. RESULTS 1 For relatively predictable trajectories of care ICPs can be effective in supporting proactive care management and ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner . This can lead to improvements in service quality and service efficiency without adverse consequences for patients . 2 ICPs are an effective mechanism for promoting adherence to guidelines or treatment protocol s thereby reducing variation in practice . 3 ICPs can be effective in improving documentation of treatment goals , documentation of communication with patients , carers and health professionals . 4 ICPs can be effective in improving physician agreement about treatment options . 5 ICPs can be effective in supporting decision-making when they incorporate a decision-aide . 6 The evidence considered in this review indicates that ICPs may be particularly effective in changing professional behaviours in the desired direction , where there is scope for improvement or where roles are new . 7 Even in context s in which health professionals are already experienced with a particular pathway , ICP use brings additional beneficial effects in directing professional practice in the desired direction . 8 ICPs may be less effective in bringing about service quality and efficiency gains in variable patient trajectories . 9 ICPs may be less effective in bringing about quality improvements in circumstances in which services are already based on best evidence and multidisciplinary working is well established . 10 Depending on their purpose , the benefits of ICPs may be greater for certain patient subgroups than others . 11 We do not know whether the costs of ICP development and implementation are justified by any of their reported benefits . 12 ICPs may need supporting mechanisms to underpin their implementation and ensure their adoption in practice , particularly in circumstances in which ICP use is a significant change in organisational culture . 13 ICP documentation can introduce scope for new kinds of error . Conclusions ICPs are most effective in context s where patient care trajectories are predictable . Their value in setting s in which recovery pathways are more variable is less clear . ICPs are most effective in bringing about behavioural changes where there are identified deficiencies in services ; their value in context s where inter-professional working is well established is less certain . None of the studies review ed included an economic evaluation and thus it is not known whether their benefits justify the costs of their implementation Hearing assistive technologies include listening , alerting , and /or signaling devices that use auditory , visual , and /or tactile modalities to augment communication and /or facilitate awareness of environmental sounds . The importance of hearing assistive technologies in the management of adults with hearing loss was recently acknowledged in an evidence -based clinical practice guideline developed by the American Academy of Audiology . Most currently available evidence for hearing assistive technology use by adults focuses on frequency-modulated ( FM ) technology . Previous research is review ed that demonstrates the efficacy of FM devices for adults in terms of laboratory measures of speech underst and ing in noise . Also review ed are the outcomes from field trials of FM use by community-dwelling adults , which , to date , have been disappointing . Few to no individuals , in previous studies , elected to use FM devices at the end of the trial periods . Data are presented from a 1-group pretest-posttest study examining the role of extensive counseling , coaching , and instruction on FM use by adults . In addition , the potential influence of the cost of devices to the individual was eliminated by conducting the study with veterans who were eligible to receive FM systems through the Veterans Affairs National Hearing Aid Program . Positive outcomes were obtained at the end of a 6-week trial period and were found to remain 1 year after study completion . Implication s for increasing the evidence base for the use of FM devices by adults are discussed Background Research evidence underpins best practice , but is not always used in healthcare . The Promoting Action on Research Implementation in Health Services ( PARIHS ) framework suggests that the nature of evidence , the context in which it is used , and whether those trying to use evidence are helped ( or facilitated ) affect the use of evidence . Urinary incontinence has a major effect on quality of life of older people , has a high prevalence , and is a key priority within European health and social care policy . Improving continence care has the potential to improve the quality of life for older people and reduce the costs associated with providing incontinence aids . Objectives This study aims to advance underst and ing about the contribution facilitation can make to implementing research findings into practice via : extending current knowledge of facilitation as a process for translating research evidence into practice ; evaluating the feasibility , effectiveness , and cost-effectiveness of two different models of facilitation in promoting the uptake of research evidence on continence management ; assessing the impact of context ual factors on the processes and outcomes of implementation ; and implementing a pro-active knowledge transfer and dissemination strategy to diffuse study findings to a wide policy and practice community . Setting and sample Four European countries , each with six long-term nursing care sites ( total 24 sites ) for people aged 60 years and over with documented urinary incontinence Methods and design Pragmatic r and omised controlled trial with three arms ( st and ard dissemination and two different programmes of facilitation ) , with embedded process and economic evaluation . The primary outcome is compliance with the continence recommendations . Secondary outcomes include proportion of residents with incontinence , incidence of incontinence-related dermatitis , urinary tract infections , and quality of life . Outcomes are assessed at baseline , then at 6 , 12 , 18 , and 24 months after the start of the facilitation interventions . Detailed context ual and process data are collected throughout , using interviews with staff , residents and next of kin , observations , assessment of context using the Alberta Context Tool , and documentary evidence . A realistic evaluation framework is used to develop explanatory theory about what works for whom in what circumstances . Trial registration Current Controlled Trials IS RCT N11598502 Background Little is known about the process of knowledge translation in low- and middle-income countries . We studied policymaking processes in Mozambique , South Africa and Zimbabwe to underst and the factors affecting the use of research evidence in national policy development , with a particular focus on the findings from r and omized control trials ( RCTs ) . We examined two cases : the use of magnesium sulphate ( MgSO4 ) in the treatment of eclampsia in pregnancy ( a clinical case ) ; and the use of insecticide treated bed nets and indoor residual household spraying for malaria vector control ( a public health case ) . Methods We used a qualitative case- study methodology to explore the policy making process . We carried out key informants interviews with a range of research and policy stakeholders in each country , review ed documents and developed timelines of key events . Using an iterative approach , we undertook a thematic analysis of the data . Findings Prior experience of particular interventions , local champions , stakeholders and international networks , and the involvement of research ers in policy development were important in knowledge translation for both case studies . Key differences across the two case studies included the nature of the evidence , with clear evidence of efficacy for MgSO4 and ongoing debate regarding the efficacy of bed nets compared with spraying ; local research er involvement in international evidence production , which was stronger for MgSO4 than for malaria vector control ; and a long-st and ing culture of evidence -based health care within obstetrics . Other differences were the importance of bureaucratic processes for clinical regulatory approval of MgSO4 , and regional networks and political interests for malaria control . In contrast to treatment policies for eclampsia , a diverse group of stakeholders with varied interests , differing in their use and interpretation of evidence , was involved in malaria policy decisions in the three countries . Conclusion Translating research knowledge into policy is a complex and context sensitive process . Research ers aim ing to enhance knowledge translation need to be aware of factors influencing the dem and for different types of research ; interact and work closely with key policy stakeholders , networks and local champions ; and acknowledge the roles of important interest groups BACKGROUND Strong evidence exists for an association between childhood trauma , particularly childhood sexual abuse , and hallucinations in schizophrenia . Hallucinations are also well-documented symptoms in people with bipolar affective disorder . AIMS To investigate the relationship between childhood sexual abuse and other childhood traumas and hallucinations in people with bipolar affective disorder . METHOD A sample of 96 participants was drawn from the Medical Research Council multi-centre trial of cognitive-behavioural therapy for bipolar affective disorder . The trial therapists recorded spontaneous reports of childhood sexual abuse made during the course of therapy . Symptom data were collected by trained research assistants masked to the hypothesis . RESULTS A significant association was found between those reporting general trauma ( n=38 ) and auditory hallucinations . A highly significant association was found between those reporting childhood sexual abuse ( n=15 ) and auditory hallucinations . CONCLUSIONS The relationship between childhood sexual abuse and hallucinations in bipolar disorder warrants further investigation BACKGROUND Older adults who receive training for functional skills in context ually appropriate environments may show greater functional improvement than persons trained in a traditional environment . Functionally limited older adults receiving training in context ually appropriate environments ( simulated home and community setting s ) may show greater improvement in activities of daily living ( ADL ) than persons trained in a traditional manner . METHODS Eighty-eight patients from a day hospital , aged 65 years or older , were r and omized to either receive rehabilitation in a simulated environment ( Easy Street ) or in a gymnasium setting . Rehabilitation focused on retraining functional skills in a context ually appropriate environment ( Easy Street ) or in a traditional setting ( gymnasium ) using motor learning principles for a period of 16 weeks . Outcome measures included the Structured Assessment of Instrumental Living Skills ( SAILS ) , a performance measure with criterion and timed components ; a self-report health status question naire , the Short Form-36 ( SF-36 ) ; and the patient-orientated goal -directed Canadian Occupational Performance Measure ( COPM ) . RESULTS There were no group differences on any of the outcome measures : SAILS ( p = .3 ) ; the SF-36 physical ( p = .83 ) and mental ( p = .51 ) ; and the COPM performance scale ( p = .94 ) and satisfaction scale ( p = .40 ) . CONCLUSIONS Although we have not excluded benefits of context ually appropriate rehabilitation environments with different intervention approaches , at different stages of rehabilitation or with patients at higher functional levels , our results suggest the appropriateness of a moratorium on these expensive interventions pending demonstration of clear positive effects determined from further study OBJECTIVES While mindfulness-based stress reduction ( MBSR ) and mindfulness-based cognitive therapy ( MBCT ) have demonstrated efficacy in clinical population s , the potential therapeutic benefit of mindfulness in the context of cancer is less clear . The aim of this review was to critically appraise mindfulness intervention reporting and study methodology . METHODS Studies using r and omized control trial design and /or a control arm were included . PubMed , Medline , PsycINFO , CINAHL , and Embase data bases between January 1999 and April 2017 were search ed . Studies were assessed on ( 1 ) reported theoretical framework , ( 2 ) intervention description , and ( 3 ) justification of modifications to st and ardized MBSR/MBCT . The overall quality of study design and research methodology were also assessed . RESULTS Of 30 studies identified , none adhered to MBSR . Modified versions of MBSR were reported in 19 studies . Five studies reported variants of MBCT , 1 used a combination of MBSR/MBCT , and 5 inadequately documented the intervention/ theoretical framework . Overall , component and timeline modifications were poorly documented and justified . Mean intervention contact time was less than st and ardized MBSR/MBCT protocol s. Target outcomes were poorly justified , and 12 studies failed to identify a primary aim , reporting multiple outcomes . Only 9 of 15 studies recruiting clinical population s included clinical cutoffs , and an active therapeutic control was included in 4 studies . CONCLUSIONS Mindfulness is increasingly considered a st and ard therapy in psycho-oncology . While many studies procl aim benefits , considerable variability , modification to st and ardized protocol s , and cl aims of benefit often reflect decreases in sub- clinical supportive care symptomology rather than therapeutic relief of clinical ly significant psychological disorders Objective The aim of this case series was to assess the impact of auditory rehabilitation with cochlear implantation on the cognitive function of elderly patients over time . Design This is a longitudinal case series of prospect i ve data assessing neurocognitive function and speech perception in an elderly cohort pre- and post-implantation . Setting University cochlear implant center . Participants The patients were post-lingually deafened elderly female ( mean , 73.6 years ; SD , 5.82 ; range , 67–81 years ) cochlear implant recipients ( n=7 ) . Measurements A neurocognitive battery of 20 tests assessing intellectual function , learning , short- and long-term memory , verbal fluency , attention , mental flexibility , and processing speed was performed prior to and 2–4.1 years ( mean , 3.7 ) after cochlear implant ( CI ) .  Speech perception testing using Consonant – Nucleus – Consonant words was performed prior to implantation and at regular intervals postoperatively . Individual and aggregate differences in cognitive function pre- and post-CI were estimated . Logistic regression with cluster adjustment was used to estimate the association ( % improvement or % decline ) between speech underst and ing and years from implantation at 1 year , 2 years , and 3 years post-CI . Results Improvements after CI were observed in 14 ( 70 % ) of all subtests administered . Declines occurred in five ( 25 % ) subtests . In 55 individual tests ( 43 % ) , post-CI performance improved compared to a patient ’s own performance before implantation . Of these , nine ( 45 % ) showed moderate or pronounced improvement . Overall , improvements were largest in the verbal and memory domains . Logistic regression demonstrated a significant relationship between speech perception and cognitive function over time . Five neurocognitive tests were predictive of improved speech perception following implantation . Conclusion Comprehensive neurocognitive testing of elderly women demonstrated areas of improvement in cognitive function and auditory perception following cochlear implantation . Multiple neurocognitive tests were strongly associated with current speech perception measures . While these data shed light on the complex relationship between hearing and cognition by showing that CI may slow the expected age-related cognitive decline , further research is needed to examine the impact of hearing rehabilitation on cognitive decline Abstract Objectives : To introduce a psychological model of behaviour ; the COM-B model and describe how this has been used in combination with the behaviour change wheel ( BCW ) in developing an intervention which aims to promote regular , long-term use of hearing aids by adults with acquired hearing loss . Design : Qualitative structured interview study using the COM-B model to identify the determinants of behavioural planning on the part of audiologists ; a potentially important factor in encouraging long-term hearing-aid use . Study sample : Ten audiologists drawn from a r and om sample of five English audiology departments . Results : The analysis suggests that behavioural planning might be more likely to occur if audiologists ’ psychological capability , physical and social opportunity , and reflective and automatic motivation were addressed . This analysis forms the basis of an intervention design , using the BCW , to encourage behavioural planning by audiologists and subsequent hearing-aid use by people with hearing loss . Conclusions : The COM-B model and BCW can be applied successfully in the context of audiology to analyse the behaviour of both people with hearing loss and professionals working with them , supplying information that is being used in intervention design . The effectiveness of the intervention will be tested in a clinical trial
Satisfaction and speech perception were frequent secondary outcomes .
There was diversity in measures used to report patient outcomes .
Outcome categories other than patient health status and behavior were rarely reported .
This review has highlighted considerable diversity in patient-reported outcome measurements in r and omized control trials in the context of adult auditory rehabilitation .
OBJECTIVES This review documented the range and nature of reported outcome measures in the context of adult auditory rehabilitative research .