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The purpose of this study was to assess the effect of Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) on student self-perceived competencies and perceptions of interprofessional (IP) communication and teamwork in a clinical case review activity. TeamSTEPPS is an evidence-based curriculum that is used to enhance and support IP healthcare communication.A repeated-measures, pretest/posttest study evaluated physician assistant students' and student pharmacists' perceptions of TeamSTEPPS. Students completed Performance Assessment for Communication and Teamwork (PACT) surveys, evaluating teamwork, knowledge, attitudes, and skills perceptions before and after a TeamSTEPPS lecture and associated activity with peer feedback.Overall, 87.4% (n = 429) completed pre- and post-PACT surveys. Apart from the Mutual Support domain (p = .898), all changes were significantly positive (p.004), with the greatest improvements occurring in the Attitudes and Perceived Skills domains.TeamSTEPPS IP education, application, and peer feedback improved students' perceptions of multiple domains, including effective communication. Using TeamSTEPPS tools in IP formats enabled the students to safely practice and collaborate in preparation for clinical practice.

To determine whether cognitive and psychological symptom profiles differentiate clinical diagnostic classifications (eg, history of mild traumatic brain injury [mTBI] and posttraumatic stress disorder [PTSD]) in military personnel.US Active-Duty Service Members ( N = 209, 89% male) with a history of mTBI ( n = 56), current PTSD ( n = 23), combined mTBI + PTSD ( n = 70), or orthopedic injury controls ( n = 60) completed a neuropsychological battery assessing cognitive and psychological functioning. Latent profile analysis was performed to determine how neuropsychological outcomes of individuals clustered together. Diagnostic classifications (ie, mTBI, PTSD, mTBI + PTSD, and orthopedic injury controls) within each symptom profile were examined.A 5-profile model had the best fit. The profiles differentiated subgroups with high (34.0%) or normal (21.5%) cognitive and psychological functioning, cognitive symptoms (19.1%), psychological symptoms (15.3%), and combined cognitive and psychological symptoms (10.0%). The symptom profiles differentiated participants as would generally be expected. Participants with PTSD were mainly represented in the psychological symptom subgroup, while orthopedic injury controls were mainly represented in the high-functioning subgroup. Further, approximately 79% of participants with comorbid mTBI and PTSD were represented in a symptomatic group (∼24% = cognitive symptoms, ∼29% = psychological symptoms, and 26% = combined cognitive/psychological symptoms). Our results also showed that approximately 70% of military personnel with a history of mTBI were represented in the high- and normal-functioning groups.These results demonstrate both overlapping and heterogeneous symptom and performance profiles in military personnel with a history of mTBI, PTSD, and/or mTBI + PTSD. The overlapping profiles may underscore why these diagnoses are often difficult to diagnose and treat, but suggest that advanced statistical models may aid in identifying profiles representing symptom and cognitive performance impairments within patient groups and enable identification of more effective treatment targets.

Mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) commonly occur among military Service Members and Veterans and have heterogenous, but also overlapping symptom presentations, which often complicate the diagnoses of underlying impairments and development of effective treatment plans. Thus, we sought to examine whether the combination of whole brain gray matter (GM) and white matter (WM) structural measures with neuropsychological performance can aid in the classification of military personnel with mTBI and PTSD.Active-Duty US Service Members (n = 156; 87.8% male) with a history of mTBI, PTSD, combined mTBI+PTSD, or orthopedic injury completed a neuropsychological battery and T1- and diffusion-weighted structural neuroimaging. Cortical, subcortical, ventricular, and WM volumes and whole brain fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), and axial diffusivity (AD) were calculated. Latent profile analyses were performed to determine how the GM and WM indicators, together with neuropsychological indicators, classified individuals.For both GM and WM, respectively, a 4-profile model was the best fit. The GM model identified greater ventricular volumes in Service Members with cognitive symptoms, including those with a diagnosis of mTBI, either alone or with PTSD. The WM model identified reduced FA and elevated RD in those with psychological symptoms, including those with PTSD or mTBI and comorbid PTSD. However, contrary to expectation, a global neural signature unique to those with comorbid mTBI and PTSD was not identified.The findings demonstrate that neuropsychological performance alone is more robust in differentiating Active-Duty Service Members with mTBI and PTSD, whereas global neuroimaging measures do not reliably differentiate between these groups.

Background Laboratory and other healthcare professionals participate in developing clinical practice guidelines through systematic review of the evidence. A significant challenge is the identification of areas for analytic focus when the evidence consists of several categories of interventions and outcomes that span both laboratory and clinical processes. The challenge increases when these interventions present as sets of combined interventions. A scoping review may provide a transparent and defensible analytic route forward for systematic reviews challenged in this manner. Content A scoping review was carried out to characterize the evidence on rapid identification of bloodstream infections. Fifty-five studies previously identified by the supported systematic review were charted in duplicate. Charted records were analyzed using descriptive content analysis and evidence mapping with a 5-step process. Summary The 5-step analysis culminated in the characterization of 9 different intervention chain configurations that will facilitate the comparison of complex intervention practices across studies. Furthermore, our evidence map indicates that the current evidence base is strongly centered on 3 specific clinical outcomes, and it links these outcomes to the most represented intervention chain configurations. The scoping review effort generated a route forward for the supported systematic review and meta-analysis.

PURPOSE The purpose of this study was to retrospectively compare the exam performance of physician assistant (PA) students given asthma instruction in a flipped classroom with PA students in a traditional lecture setting while controlling for students' previous academic performance and clinical asthma experience. METHODS Three cohorts of PA students (n = 146) from the years 2017 (traditional-lecture setting) and 2018 and 2019 (flipped-classroom setting) were included in the study. Academic performance across cohorts was compared using answers to 11 exam questions reflective of the asthma content. RESULTS Findings demonstrated significantly greater performance in the flipped classroom compared with traditional lecture. The 2018 and 2019 cohorts scored 9.4% and 13.2% higher, respectively, compared with the 2017 cohort. Exam performance of students with a low likelihood of clinical exposure to asthmatic patients before PA school was similar to those with a high likelihood. CONCLUSION This study found improved exam performance with a flipped classroom. The flipped classroom represents a potential opportunity to maximize similar performances by both less experienced students and more experienced students.

INTRODUCTION: Impairments in cognitive performance after sports-related concussion (SRC) typically resolve within weeks of the injury, whereas alterations to white matter (WM) organization have been found to persist longer into the chronic injury stage. However, longer-term associations between cognition and WM organisation following SRC have not been studied. The objective of this study was to compare WM organisation and cognitive performance in collegiate athletes an average of almost 4 years post-SRC to athletes with no history of SRC. METHOD: National Collegiate Athletic Association Division III athletes (n = 71, age = 19.3 +/− 1.2; 14 with self-reported SRC) completed a neurocognitive assessment and diffusion tensor imaging (DTI). WM organisation was assessed by extracting measures of fractional anisotropy (FA), mean diffusivity (MD), and radial diffusivity (RD) from 20 WM regions of interest (ROIs). Multivariate partial least squares analyses were used to compare athletes with and without a history of SRC and assess relationships between DTI-derived metrics of WM organisation and cognitive measures. RESULTS: Cognitive performance and ROI metrics did not differ between athletes with and without prior SRC. However, among athletes with a history of SRC, better executive function, processing speed, and memory but worse choice reaction time were associated with higher FA and lower MD and RD in several WM tracts. CONCLUSION: Athletes with a history of SRC demonstrated greater associations between cognitive performance and WM organization, but also variability in the domains showing associations. Taken together, the findings demonstrate the importance of examining brain-behaviour relationships several years after SRC to better gauge how WM organisation supports cognition.

Individuals diagnosed with serious mental illness (SMI) have greater trauma exposure and are at increased risk for posttraumatic stress disorder (PTSD). However, PTSD is rarely documented in their clinical records. This study investigated the predictors of PTSD documentation among 776 clients with SMI receiving public mental health services, who had probable PTSD as indicated by a PTSD Checklist score of at least 45. Only 5.3% of clients had PTSD listed as a primary diagnosis, and 8.4% had PTSD as a secondary diagnosis, with a total 13.7% documentation rate. PTSD documentation rate was highest for clients with major depression (18.8%) compared to those with schizophrenia (4.1%) or bipolar disorder (6.3%). Factors that predicted a lower likelihood of having a chart diagnosis of PTSD included being diagnosed with schizophrenia/schizoaffective disorder or bipolar disorder. Factors that predicted a higher likelihood of having a chart diagnosis of PTSD included being of non-white race, being female, and experiencing eight or more types of traumatic events. Findings highlight the need for PTSD screening and trauma informed care for clients with SMI receiving public mental health services.

Persons with traumatic spinal cord injury (SCI) have severe bone loss below the level of lesion with the distal femur (DF) and proximal tibia (PT) being the skeletal regions having the highest risk of fracture. While a reference areal bone mineral density (aBMD) database is available at the total hip (TH) using the combined National Health and Nutrition Examination Survey (NHANES) III study and General Electric (GE) combined (GE/NHANES) to calculate T-score (T-score

Background Research contributions by registered dietitian nutritionists (RDNs) are important for enhancing the use of nutrition-related evidence-based guidelines in dietetics practice. Involvement of RDNs in research activities has been studied previously, but little is known about the drivers (motivators) of sustaining research involvement by RDNs who work in clinical practice. Objective To identify key characteristics of established RDN clinician researchers and drivers that contributed to their sustained research involvement. Design We used a convergent parallel mixed methods study design utilizing the clinician career research trajectory as a framework. Research involvement was examined using the Practice-Based Dietitian Research Involvement Survey (PBDRIS). Workplace support was assessed using the Research Capacity and Culture (RCC) survey. Semistructured interviews were used to investigate key themes in established RDN clinician researchers. Participants/setting We identified 450 RDNs involved with research activities in the United States through hand-searching clinically relevant nutrition journals and contacted them to participate in an online survey. A total of 29 RDNs met criteria and completed (6.4%) the quantitative survey, then a subsample (n=10) participated in semistructured interviews to explore drivers for continued research involvement. Results Research involvement scores (n=29) from the PBDRIS ranged from 60.0% to 97.5%, indicating involvement in higher-level research-related tasks by our sample participants. RCC results revealed the importance of workplace support and mentorship. Interviews with established RDN clinician researchers identified exposure, curiosity, and dedication as three overarching themes with eight subthemes driving continued research involvement. Conclusion Based on the experiences of select RDN clinician researchers who have demonstrated success in sustaining their research involvement, we found that having an available mentor, support from their workplace environment, and personal drive were integral to their success.

The present study investigates the organization of primary care behavioral health within student health centers and assesses the relationship between organizational structure and practice integration among physical and mental health services.

Objective: To identify T-score values at the total hip (TH) and femoral neck (FN) that correspond to the cutoff value of

[Purpose] This pilot study aims to determine whether improvements in postural sway, particularly among older adults, can be augmented immediately after training participants to activate and isolate the transverse abdominis (TrA) muscle. [Participants and Methods] Fifty six participants (in three age groups) took part in a single session TrA training intervention. Aspects of postural sway, balance and muscle activation patterns were measured before and after training and compared. [Results] There was significant improvement across four of six postural sway variables for the combined sample of all age groups. Older adults improved more than younger and middle-age participants in two important postural sway variables. No marked differences were evident in static reach distance across all age groups. There were no differences between groups with regard to surface electromyography (sEMG) amplitudes despite the emergence of different activation patterns among age groups. [Conclusion] Immediate effects were induced in postural sway measures after the single session training intervention. By improving neuromuscular control of the TrA and maximizing the efficiency of related proximal core muscles center of pressure (COP) sway velocities decreased during single limb standing (SLS).

BACKGROUND Preoperative malnutrition adversely impacts perioperative outcomes among patients with gastrointestinal (GI) cancer. The attributable risk (AR) that nutrition status contributes towards negative outcomes is poorly understood. METHODS Adults undergoing GI cancer surgeries were identified within the American College of Surgeons National Surgical Quality Improvement Program database (2005-2017). Emergency surgeries, outpatients, and cases with an American Society of Anesthesiologists status above III were excluded. Adjusted multivariable models were constructed to determine the associations between markers of nutrition status (body mass index, >10% weight loss in last 6 months, functional status, and serum albumin level) and adverse perioperative outcomes (presence and number of complications, death, 30-day readmission, and length of stay). Predictive accuracy statistics and population AR (PAR) were determined. RESULTS The final sample included 78,662 cases. Patients with >10% weight loss 6 months preceding surgery (compared with those who did not), had a significantly increased risk of complications (Relative Risk = 1.28; 95% CI, 1.20-1.37) and odds of death (odds ratio [OR] = 1.37; 95% CI, 1.18-1.59). A totally dependent functional status (compared with independent status) was associated with a 3.3-times higher odds of death (OR = 3.30; 95% CI, 1.53-7.15). Multivariable models were not predictive of adverse outcomes; PAR from the markers ranged 1%-2%. CONCLUSION Ten percent weight loss in preceding 6 months was associated with increased risk of adverse perioperative outcomes among adults undergoing GI cancer surgery. The contribution of nutrition status markers to surgical outcomes as assessed by PAR was small (1%-2%), a finding not previously reported. Future intervention studies should include validated nutrition risk markers, control for effects of perioperative variables, and evaluate PAR within the immediate/long-term postoperative periods.

No systematic, universally accepted method of diagnosing malnutrition in hospitalized patients exists, which may contribute to underdiagnosis, undertreatment, and poorer patient outcomes. To address this issue, the Academy of Nutrition and Dietetics is conducting a cohort study to: assess the predictive validity of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition indicators for the diagnosis of adult and pediatric malnutrition in hospital settings; assess the interrater reliability of the indicators for the diagnosis of adult and pediatric malnutrition; and quantify the level of registered dietitian nutritionist care needed to improve patient outcomes. Up to 60 adult and 60 pediatric hospital sites will collect data to estimate level of registered dietitian nutritionist care, along with patient medical history and Malnutrition Screening Tool (adult) or STRONGkids (pediatric) results. A subset of 600 adult and 600 pediatric patients (∼1:1 screened as high- or low-risk for malnutrition) will be randomly selected for the indicators for the diagnosis of adult and pediatric malnutrition and Nutrition Focused Physical Exam data collection; 100 adult and 100 pediatric patients in this group will also undergo a bioelectrical impedance analysis measurement. Additional nutrition care and medical outcomes (eg, mortality and length of stay) will be collected for a 3-month period after the initial nutrition encounter. Multilevel linear, logistic, Poisson, or Cox regression models will be used to assess indicators for the diagnosis of adult and pediatric malnutrition validity and registered dietitian nutritionist staffing levels as appropriate for each medical outcome. Validation results will allow US clinicians to standardize the way they diagnose malnutrition in hospitalized patients, and the staffing data will support advocacy for available registered dietitian nutritionist-delivered malnutrition treatment to improve patient outcomes.

Persons with neurologically motor‐complete spinal cord injury (SCI) have a marked loss of bone mineral density (BMD) of the long bones of the lower extremities, predisposing them to fragility fractures, especially at the knee. Denosumab, a commercially available human monoclonal IgG antibody to receptor activator of nuclear factor‐κB ligand (RANKL), may provide an immunopharmacological solution to the rapid progressive deterioration of sublesional bone after SCI. Twenty‐six SCI participants with subacute motor‐complete SCI were randomized to receive either denosumab (60 mg) or placebo at baseline (BL), 6, and 12 months. Areal bone mineral density (aBMD) by dual energy x‐ray absorptiometry (DXA) at 18 months at the distal femur was the primary outcome and aBMD of the proximal tibia and hip were the secondary outcomes analyzed in 18 of the 26 participants (denosumab, n = 10 and placebo, n = 8). The metrics of peripheral QCT (pQCT) were the exploratory outcomes analyzed in a subsample of the cohort (denosumab, n = 7 and placebo n = 7). The mean aBMD (±95% CI) for the denosumab versus the placebo groups demonstrated a significant group × time interactions for the following regions of interest at BL and 18 months: distal femoral metaphysis = mean aBMD 1.187; 95% CI, 1.074 to 1.300 and mean aBMD 1.202; 95% CI, 1.074 to 1.329 versus mean aBMD 1.162; 95% CI, 0.962 to 1.362 and mean aBMD 0.961; 95% CI, 0.763 to 1.159, respectively (p

BACKGROUND We assessed the differences in postoperative feeding outcomes when comparing early and traditional diet advancement in patients who had an ostomy creation. METHODS At a U.S. tertiary care hospital, data from patients who underwent an ileostomy or colostomy creation from June 1, 2013, to April 30, 2017 were extracted from an institutional database. Patients who received early diet advancement (postoperative days 0 and 1) were compared with traditional diet advancement (postoperative day 2 and later) for demographics, preoperative risk factors, and operative features. The postoperative feeding outcomes included time to first flatus and ostomy output. Mann-Whitney U tests determined bivariate differences in postoperative feeding outcomes between groups. Poisson regression was used to adjust for unequal baseline characteristics. RESULTS Data from 255 patients were included; 204 (80.0%) received early diet advancement, and 51 (20.0%) had traditional diet advancement. Time to first flatus and time to first ostomy output were significantly shorter in the early compared with traditional diet advancement group (median difference of 1 day for both flatus and ostomy output, P < 0.001). Adjusting for baseline group differences (American Society for Anesthesiology Physical Status Classification System, surgical approach, resection and ostomy type) maintained the significant findings for both time to first flatus (β = 1.32, P = 0.01) and time to first ostomy output (β = 1.41, P < 0.001). CONCLUSIONS Early diet advancement is associated with earlier return of flatus and first ostomy output compared with traditional diet advancement after the creation of an ileostomy or colostomy.

BackgroundDiagnostic test accuracy (DTA) systematic reviews (SRs) characterize a test’s potential for diagnostic quality and safety. However, interpreting DTA measures in the context of SRs is challenging. Further, some evidence grading methods (e.g. Centers for Disease Control and Prevention, Division of Laboratory Systems Laboratory Medicine Best Practices method) require determination of qualitative effect size ratings as a contributor to practice recommendations. This paper describes a recently developed effect size rating approach for assessing a DTA evidence base.MethodsA likelihood ratio scatter matrix will plot positive and negative likelihood ratio pairings for DTA studies. Pairings are graphed as single point estimates with confidence intervals, positioned in one of four quadrants derived from established thresholds for test clinical validity. These quadrants support defensible judgments on “substantial”, “moderate”, or “minimal” effect size ratings for each plotted study. The approach is flexible in relation to a priori determinations of the relative clinical importance of false positive and false negative test results.Results and conclusionsThis qualitative effect size rating approach was operationalized in a recent SR that assessed effectiveness of test practices for the diagnosis ofClostridium difficile. Relevance of this approach to other methods of grading evidence, and efforts to measure diagnostic quality and safety are described. Limitations of the approach arise from understanding that a diagnostic test is not an isolated element in the diagnostic process, but provides information in clinical context towards diagnostic quality and safety.

Objective The study purpose was to explore the relationship between nutritional status, as measured by Subjective Global Assessment (SGA), and Health Related Quality of Life measured using the Nutrition Specific Quality of Life (NS-QoL), tool among participants on maintenance hemodialysis (MHD). The study aim was to determine if NS-QoL may be an adjuvant tool for detecting changes in nutritional status among patients on MHD. Design, Setting, and Subjects This is a cross-sectional, secondary analysis of data from a multi-center study. Participants were adult (>18) men and women on MHD (n = 145) recruited from 3 institutions in the Northeastern United States. Methods Statistical tests were conducted to determine the relationship between key demographic characteristics (age, sex, dialysis vintage, gender, and ethnicity) and SGA and NS-QoL. Spearman's correlation examined the relationship between the independent variable, SGA and the dependent variable, NS-QoL. A univariate general linear model was conducted to adjust for confounding variables. Main Outcome Measure The relationship between overall SGA score and composite NS-QoL score. Results The sample consisted of 85 men (58.6%), with a mean age of 55.3 ± 11.9 years, who were largely African–American (84.1%) and non-Hispanic (77.2%). Mean SGA score was 5.5 ± 1.0, and the mean NS-QoL composite score was 9.51 ± 3.77. No key demographic characteristics had a statistically significant relationship with SGA, whereas sex ( P P = .015) both had statistically significant relationships with NSQoL. After adjusting for the variables of race and sex, NS-QoL score was positively correlated with SGA composite score ( P = .042); as NS-QoL score increased so did the SGA score. Conclusion The present study found a positive linear correlation between NS-QoL composite score and SGA, as well as 5 SGA subcomponent scores and NS-QoL. These findings indicate that NS-QoL can complement the SGA to provide information about a patient's nutritional status.

Background and Purpose: Little is known about the process of engaging key stakeholders to select and design a knowledge translation (KT) intervention to increase the use of an outcome measure using...

Objective To compare the 7-point subjective global assessment (SGA) and the protein energy wasting (PEW) score with nutrition evaluations conducted by registered dietitian nutritionists in identifying PEW risk in stage 5 chronic kidney disease patients on maintenance hemodialysis. Design and Methods This study is a secondary analysis of a cross-sectional study entitled "Development and Validation of a Predictive energy Equation in Hemodialysis". PEW risk identified by the 7-point SGA and the PEW score was compared against the nutrition evaluations conducted by registered dietitian nutritionists through data examination from the original study (reference standard). Subjects A total of 133 patients were included for the analysis. Main Outcome Measures The sensitivity, specificity, positive and negative predictive value (PPV and NPV), positive and negative likelihood ratio (PLR and NLR) of both scoring tools were calculated when compared against the reference standard. Results The patients were predominately African American (n = 112, 84.2%), non-Hispanic (n = 101, 75.9%), and male (n = 80, 60.2%). Both the 7-point SGA (sensitivity = 78.6%, specificity = 59.1%, PPV = 33.9%, NPV = 91.2%, PLR = 1.9, and NLR = 0.4) and the PEW score (sensitivity = 100%, specificity = 28.6%, PPV = 27.2%, NPV = 100%, PLR = 1.4, and NLR = 0) were more sensitive than specific in identifying PEW risk. The 7-point SGA may miss 21.4% patients having PEW and falsely identify 40.9% of patients who do not have PEW. The PEW score can identify PEW risk in all patients, but 71.4% of patients identified may not have PEW risk. Conclusions Both the 7-point SGA and the PEW score could identify PEW risk. The 7-point SGA was more specific, and the PEW score was more sensitive. Both scoring tools were found to be clinically confident in identifying patients who were actually not at PEW risk.

As the Cytotechnology Program Review Committee (CPRC) shared its intent to transition all undergraduate and certificate training programs to a Master's degree curriculum by 2022, mixed opinions have been expressed by various stakeholders from the larger pathology and allied health communities. In order to build a consensus path forward, a framework entitled "Walk in the Woods," an international diplomacy approach, is described. Unlike many problem-solving approaches which directly identify a problem and potential solutions, this approach is a four-step process which includes: (1) self-interest, (2) enlarged interest, (3) enlightened interest, and (4) aligning interest; each step builds on the preceding step. While four steps may take longer than the traditional "problem to solution" paradigm, the purpose of each step is to increase transparency and clarity in a complex multiparty negotiation, such as the path forward for cytotechnology. This commentary demonstrates, in a step-by-step manner, how a "Walk in the Woods" can aid in the facilitation of the transition of the cytology degree to an entry-level Master's degree curriculum and evidence- and interest-based negotiation approach.

This article seeks to outline the implementation of a longitudinal interprofessional education (IPE) program in the predoctoral curriculum at a U.S. dental school. The challenges of implementing the curriculum in a complex environment are reviewed, and an overview of the 4-year curriculum is offered, including exposure, immersion, and clinical readiness components. Results of developmental evaluations are reviewed. Respondents to surveys regarding the capstone case conference experiences overwhelmingly suggest the conferences were educationally rewarding as well as enriching for each of the health professions represented. While response was limited, alumni surveys also indicate satisfaction with the IPE experience. A discussion of challenges and suggestions regarding successful implementation and expansion of IPE programs from didactic to clinical settings are also included.

Objective: To identify T-score values at the total hip (TH) and femoral neck (FN) that correspond to the cutoff value of

The evidence base for the optimal laboratory diagnosis of Clostridioides (Clostridium) difficile in adults is currently unresolved due to the uncertain performance characteristics and various combinations of tests. This systematic review evaluates the diagnostic accuracy of laboratory testing algorithms that include nucleic acid amplification tests (NAATs) to detect the presence of C. difficile., SUMMARY The evidence base for the optimal laboratory diagnosis of Clostridioides (Clostridium) difficile in adults is currently unresolved due to the uncertain performance characteristics and various combinations of tests. This systematic review evaluates the diagnostic accuracy of laboratory testing algorithms that include nucleic acid amplification tests (NAATs) to detect the presence of C. difficile. The systematic review and meta-analysis included eligible studies (those that had PICO [population, intervention, comparison, outcome] elements) that assessed the diagnostic accuracy of NAAT alone or following glutamate dehydrogenase (GDH) enzyme immunoassays (EIAs) or GDH EIAs plus C. difficile toxin EIAs (toxin). The diagnostic yield of NAAT for repeat testing after an initial negative result was also assessed. Two hundred thirty-eight studies met inclusion criteria. Seventy-two of these studies had sufficient data for meta-analysis. The strength of evidence ranged from high to insufficient. The uses of NAAT only, GDH-positive EIA followed by NAAT, and GDH-positive/toxin-negative EIA followed by NAAT are all recommended as American Society for Microbiology (ASM) best practices for the detection of the C. difficile toxin gene or organism. Meta-analysis of published evidence supports the use of testing algorithms that use NAAT alone or in combination with GDH or GDH plus toxin EIA to detect the presence of C. difficile in adults. There is insufficient evidence to recommend against repeat testing of the sample using NAAT after an initial negative result due to a lack of evidence of harm (i.e., financial, length of stay, or delay of treatment) as specified by the Laboratory Medicine Best Practices (LMBP) systematic review method in making such an assessment. Findings from this systematic review provide clarity to diagnostic testing strategies and highlight gaps, such as low numbers of GDH/toxin/PCR studies, in existing evidence on diagnostic performance, which can be used to guide future clinical research studies.

Purpose To develop a transparent and reproducible method of evaluating communication within interprofessional educational (IPE) sessions that differentiates talk that is conversational, collaborative, and interprofessional from other types of dialogue, and to statistically model predictors of collaboration. The method and programmatic utility of this approach are detailed. Method Eight 2-h case review sessions (n = 125 participants: 7560 speech turns) were videoed and double coded for speaker, target, speech act, type of collaboration, professions of interlocutors, topic and sex. Length of speech acts were measured to 0.1 second. Data were statistically analyzed using multilevel models to identify predictors of time-in-collaboration. Instances of collaboration were then further analyzed using descriptive statistics. Results Four types of collaborative communication were identified. Subjective assessments overestimated the extent of collaboration. Direct, student-to-student collaboration comprised approximately 5.1% of the total time-in-talk. Using a reproducible, transparent method of assessing student collaboration provided the basis for evidence-directed program enhancements.

Background: This pilot study determined the feasibility of a specifically designed 8-week yoga program for people with moderate multiple sclerosis (MS)–related disability. We explored the program's effect on quality of life (QOL) and physical and mental performance. Methods: We used a single-group design with repeated measurements at baseline, postintervention, and 8-week follow-up. Feasibility was examined through cost, recruitment, retention, attendance, and safety. Outcomes included the Multiple Sclerosis Quality of Life Inventory (MSQLI), 12-item Multiple Sclerosis Walking Scale (MSWS-12), Timed 25-Foot Walk test (T25FW), 6-Minute Walk Test (6MWT), Nine-Hole Peg Test (NHPT), Five-Times Sit-to-Stand Test (FTSTS), Multidirectional Reach Test (MDRT), maximum expiratory pressure, and Paced Auditory Serial Addition Test-3″ (PASAT-3″). Results: Fourteen participants completed the study. The program was feasible. There were significant main effects on the 36-item Short Form Health Status Survey Mental Component Summary (SF-36 MCS), Modified Fatigue Impact Scale (MFIS), Bladder Control Scale (BLCS), Perceived Deficits Questionnaire (PDQ), Mental Health Inventory (MHI), MSWS-12, T25FW, NHPT, PASAT-3″, 6MWT, FTSTS, and MDRT-Back. Improvements were found on the SF-36 MCS, MFIS, BLCS, PDQ, MHI, and MSWS-12 between baseline and postintervention. The effect on PDQ persisted at follow-up. Improvements were found on the T25FW, NHPT, 6MWT, FTSTS, and MDRT-Back between baseline and postintervention that persisted at follow-up. The PASAT-3″ did not change between baseline and postintervention but did between postintervention and follow-up. Conclusions: The yoga program was safe and feasible. Improvements in certain measures of QOL and performance were seen at postintervention and follow-up.

INTRODUCTIONThe number of students applying to physical therapist education programs has been dramatically rising. In 2008, the mean number of applicants applying to physical therapist education programs was 92; in 2011, this number was 357.1 As the number of applicants to physical therapist education programs escalates, the importance of criteria that can help determine who should be admitted to the programs and who has the best chance at success, as measured by the ability to pass the National Physical Therapy Examination (NPTE), increases. Several measures predicting students' success are currently in use. Both academic (Graduate Record Examination [GRE], grade point average [GPA], and standardized tests) and nonacademic (volunteer clinic hours, demographic information, scores on admission rubrics, interview scores, writing sample scores, stress inventory, coping inventory, and program characteristics) variables have been studied in attempts to predict success on the NPTE.2-9 It has been reported that GRE scores and the GPA correlate with success in passing the NPTE.10 The GRE measures students' ability to analyze written material, problem solving in mathematics and data analysis, critical thinking, and analytical writing skills,11 and the GPA is widely accepted as being representative of students' academic success. Although the GRE and the GPA have been reported to predict outcomes on the NPTE, they account for less than 50% of the variance in performance on the NPTE.3-5 These data prompt the following question: What is missing?A portion of the GRE assesses students' ability to think critically and general problem solving, but it is not designed to assess the complex problem solving required of entry-level clinicians. The NPTE assesses basic entry-level competence, including the ability to solve complex clinical problems. However, the GRE may not capture the full range of cognitive skills required for addressing complex clinical questions. Complex clinical problems are contextually dependent because they involve the integration of multiple aspects of the patient's situation (eg, physiological, cognitive/emotional, and social setting), the therapeutic task, and the setting in which the problem occurs. It is possible that additional measures can improve the ability to predict success on the NPTE because students' ability to evaluate contextual dependency in the use of problem-solving skills is not assessed by the GRE or the GPA. The Health Sciences Reasoning Test (HSRT; Insight Assessment, Millbrae, California), a standardized test of clinical reasoning skills, is a measure customized for students in the health care professions. Questions are situated within contextual clinical scenarios. Therefore, the HSRT may prove to be an additional measure that can help predict success on the NPTE12 and aid in the admissions decision-making process.Physical therapist educators have actively pursued the identification of characteristics that can help determine who should be admitted to a physical therapist education program and who is likely to pass the NPTE. Three domains have been examined in relation to NPTE performance: cognitive measures (GRE, GPA, and standardized tests), noncognitive characteristics (volunteer clinic hours, demographic information, scores on admission rubrics, interview scores, writing sample scores, stress inventory, coping inventory, and program characteristics), and academic program characteristics. Although studies have reported inconsistent results on the associations between NPTE performance and noncognitive8-13-14 and program6-7 characteristics, models that combine measures of students' academic performance typically perform better3-8-10-14 Previous research reported relationships of the undergraduate GPA (uGPA),4-10-14 the GPA at the end of the first year in a Doctor of Physical Therapy program (fGPA),3 and GRE scores7-10 with success on the NPTE. However, these variables failed to explain most of the variance in NPTE performance. …

To determine the influence of admission anthropometry on clinical outcomes in mechanically ventilated children in the PICU.Data from two multicenter cohort studies were compiled to examine the unique contribution of nutritional status, defined by body mass index z score, to 60-day mortality, hospital-acquired infections, length of hospital stay, and ventilator-free days, using multivariate analysis.Ninety PICUs from 16 countries with eight or more beds.Children aged 1 month to 18 years, admitted to each participating PICU and requiring mechanical ventilation for more than 48 hours.Data from 1,622 eligible patients, 54.8% men and mean (SD) age 4.5 years (5.1), were analyzed. Subjects were classified as underweight (17.9%), normal weight (54.2%), overweight (14.5%), and obese (13.4%) based on body mass index z score at admission. After adjusting for severity of illness and site, the odds of 60-day mortality were higher in underweight (odds ratio, 1.53; p0.001) children. The odds of hospital-acquired infections were higher in underweight (odds ratio, 1.88; p = 0.008) and obese (odds ratio, 1.64; p0.001) children. Hazard ratios for hospital discharge were lower among underweight (hazard ratio, 0.71; p0.001) and obese (hazard ratio, 0.82; p = 0.04) children. Underweight was associated with 1.3 (p = 0.001) and 1.6 (p0.001) fewer ventilator-free days than normal weight and overweight, respectively.Malnutrition is prevalent in mechanically ventilated children on admission to PICUs worldwide. Classification as underweight or obese was associated with higher risk of hospital-acquired infections and lower likelihood of hospital discharge. Underweight children had a higher risk of mortality and fewer ventilator-free days.

Chimeric antigen receptor (CAR) T-cell therapy has shown promise for relapsed/refractory malignancies. Many patients have undergone prior hematopoietic stem cell transplant (HSCT), yet effects of transplant status on CAR T-cell therapy efficacy and safety have not been reported. The purpose of the study is to systematically evaluate the likelihood of achieving optimum response, severe cytokine release syndrome (sCRS), and neurotoxicity in the context of CAR T-cell therapy for HSCT-naïve patients versus those with prior HSCT. Trials were identified in ClinicalTrials.gov, Cochrane Library, and PubMed, and through reference pearl growing. Included studies used CD19-directed CAR T-cells for relapsed/refractory B-lineage Acute Lymphoblastic Leukemia and B cell Chronic Lymphocytic Leukemia, enrolled both HSCT-naïve and prior-HSCT patients, and denoted transplant status with outcomes. Six studies were included for optimum response, five for sCRS incidence, and four for neurotoxicity incidence. The pooled odds ratio for optimum response was 1.57 favoring HSCT-naïve patients (95% CI 0.54-4.61), whereas the pooled odds ratios for sCRS and neurotoxicity were 1.41 (95% CI 0.51-3.94) and 1.37 (95% CI 0.28-6.77), respectively, toward HSCT-naïve patients. Odds ratios were non-statistically significant. Overall risk of bias was moderate. While pooled estimates showed an advantage among HSCT-naïve patients for achieving optimum response and increased likelihood for sCRS and neurotoxicity, findings were not statistically significant. Any differences in efficacy and safety of CAR T-cell therapy cannot be verifiably attributed to transplant status, and additional controlled trials with increased sample sizes are needed to determine whether suggestive patterns favoring HSCT-naïve patients are validated.

Due to heterogeneity in pulmonary disease, current literature may misrepresent inspiratory muscle involvement in cystic fibrosis (CF). This study investigated inspiratory muscle strength (IMS) relative to disease severity in adults with CF.Maximal inspiratory pressure (MIP) was assessed in 58 adults with stable CF grouped by disease severity (20 mild, 20 moderate, 18 severe) and compared to 20 controls. Relationships between MIP, lung function, dyspnea and anthropometrics were evaluated using multivariable linear models.MIP in cmH2O and %-predicted was decreased in advanced CF lung disease as compared to mild disease and healthy controls (p0.05). Disease severity accounted for 24% of the variance in IMS after controlling for confounding variables (p0.001).IMS is decreased in some adults with stable CF with moderate and severe pulmonary disease, and is related to dyspnea. Future studies should determine if decreased IMS contributes inefficient breathing patterns, respiratory pump dysfunction, and/or exercise intolerance in advanced CF.

to guide the development of nutrition education programs, or to evaluate program plans or proposals. GENIE has been validated across a wide range of nutrition education program proposals, 12 giving this tool the unique ability to compare disparate programs. This article describes a literature review in which GENIE was used to assess and compare published program descriptions and to: 1) identify qualities of nutrition education programs commonly present or absent in both high-scoring and lower-scoring interventions when assessed with GENIE; 2) provide examples of high-scoring programs in each category; and 3) determine the relationship between GENIE score and program outcomes.

High reliability is important for optimising quality and safety in healthcare organisations. Reliability efforts include interprofessional collaborative practice (IPCP) and Lean quality/process improvement strategies, which require skilful facilitation. Currently, no validated Lean facilitator assessment tool for interprofessional collaboration exists. This article describes the development and pilot evaluation of such a tool; the Interprofessional Lean Facilitator Assessment Scale (ILFAS), which measures both technical and 'soft' skills, which have not been measured in other instruments. The ILFAS was developed using methodologies and principles from Lean/Shingo, IPCP, metacognition research and Bloom's Taxonomy of Learning Domains. A panel of experts confirmed the initial face validity of the instrument. Researchers independently assessed five facilitators, during six Lean sessions. Analysis included quantitative evaluation of rater agreement. Overall inter-rater agreement of the assessment of facilitator performance was high (92%), and discrepancies in the agreement statistics were analysed. Face and content validity were further established, and usability was evaluated, through primary stakeholder post-pilot feedback, uncovering minor concerns, leading to tool revision. The ILFAS appears comprehensive in the assessment of facilitator knowledge, skills, abilities, and may be useful in the discrimination between facilitators of different skill levels. Further study is needed to explore instrument performance and validity.

The US health care system has been undergoing substantial changes in reimbursement for medical and nutrition services. These changes have offered opportunities and challenges for registered dietitian nutritionists (RDNs) to bill for medical nutrition therapy and other nutrition-related services. During the past 10 years, the Academy of Nutrition and Dietetics has periodically surveyed RDNs providing medical nutrition therapy in ambulatory care settings to learn about their knowledge and patterns of coding, billing, and payment for their services. In 2018, the Academy of Nutrition and Dietetics conducted the latest iteration of this survey. This article compares the results of the 2008, 2013, and 2018 surveys to examine changes in RDNs' knowledge of billing code use and reimbursement patterns over time; understand the potential influences on coding and billing practices in a changing health care environment; and understand the effects of newer practice settings and care delivery models on billing and reimbursement for medical nutrition therapy services. Results from these surveys demonstrate that during the past 10 years RDNs' knowledge of billing and coding has been stable and very low for RDNs not in supervisory roles or private practice. RDNs reported an increase in providing medical nutrition therapy services to patients with multiple conditions. Since 2013, a dramatic increase was noted in the reported proportion of reimbursement from private/commercial health insurance plans. Results also indicate that most RDNs are not aware of changes in health care payment. Individual RDNs need to understand and be held accountable for the business side of practice and their value proposition in today's health care environment.

Nutrition specialists are considered key members of multicomponent pediatric weight management intervention teams, but to date, their contribution has not been quantified.The purpose of this systematic review was to estimate the effectiveness of interventions provided by treatment teams that include a nutrition specialist on pediatric weight management outcomes, including body mass index (BMI), BMI z score, and waist circumference when compared with treatment teams that do not include a nutrition specialist.The results of a comprehensive literature search and a systematic and more targeted update of that search were included in the meta-analyses: a search of controlled trials published between July 2005 and April 2012, conducted during the 2015 Pediatric Weight Management Update Project of the Academy of Nutrition and Dietetics Evidence Analysis Library, and an update search of controlled trials published between May 2012 and December 2015 focusing on a more specific topic within the previous search. Studies included overweight and/or obese patients aged 6 to 18 years receiving outpatient weight management treatment. Data extraction of all studies identified was performed using a standardized tool. The resulting data from the search and the systematic update were merged. Ninety-nine studies and 209 study arms were included in the analysis. An exploratory meta-analysis using alternative meta-analytic methods designed for complex, heterogenous interventions was conducted to identify relative contributions by intervention provider category at selected time points. Meta-regression analyses were used to evaluate significant differences from the reference category for each provider category.The nutrition specialist-only condition resulted in increased reductions in BMI z score compared with behavioralist-only, combined nutrition specialist and behavioralist, and neither nutrition specialist or behavioralist category (reference) throughout the analysis. Meta-regression analysis indicated that the difference in BMI z score between the nutrition specialist-only category and the reference category was significant at 3 to6 months, 6 months to1 year, and 1-year to 2-year time points (P=0.01, P=0.05, and P=0.01, respectively). There were smaller increases in BMI over time for the nutrition specialist-only provider category compared with reference categories, and this difference was significant at the 3 to6 months and 1-year to 2-years time points (P=0.001 and P=0.05, respectively). There were no significant differences among provider categories for waist circumference at any time point.Indirect evidence indicated that pediatric weight management outcomes for BMI z score and BMI at selected time points appeared to be better when a nutrition specialist was involved in delivering care.