8/31 Mission

Mission
1.key in the data of new cases.
2.go through the latest articles

QUESTION:
1.if the p't retest again in BADL & have new data of IADL, is it can receive and save it to another new detail

8/30 clinical assessment

* stream management server still crashing down,the website show the information just like below :

'/stream' 應用程式中發生伺服器錯誤。
在建立連接至伺服器時發生錯誤。當連接至 SQL Server 2005 時，失敗的原因可能是，在預設設定下，SQL Server 不允許遠端連接。 (provider: 具名的管線提供者, error: 40 - 無法開啟至 SQL Server 的連接) 描述: 在執行目前 Web 要求的過程中發生未處理的例外情形。請檢閱堆疊追蹤以取得錯誤的詳細資訊，以及在程式碼中產生的位置。 例外詳細資訊: System.Data.SqlClient.SqlException: 在建立連接至伺服器時發生錯誤。當連接至 SQL Server 2005 時，失敗的原因可能是，在預設設定下，SQL Server 不允許遠端連接。 (provider: 具名的管線提供者, error: 40 - 無法開啟至 SQL Server 的連接)原始程式錯誤:
在執行目前 Web 要求期間，產生未處理的例外狀況。如需有關例外狀況來源與位置的資訊，可以使用下列的例外狀況堆疊追蹤取得。 堆疊追蹤:
[SqlException (0x80131904): 在建立連接至伺服器時發生錯誤。當連接至 SQL Server 2005 時，失敗的原因可能是，在預設設定下，SQL Server 不允許遠端連接。 (provider: 具名的管線提供者, error: 40 - 無法開啟至 SQL Server 的連接)]
System.Data.SqlClient.SqlInternalConnection.OnError(SqlException exception, Boolean breakConnection) +739123
System.Data.SqlClient.TdsParser.ThrowExceptionAndWarning(TdsParserStateObject stateObj) +188
System.Data.SqlClient.TdsParser.Connect(ServerInfo serverInfo, SqlInternalConnectionTds connHandler, Boolean ignoreSniOpenTimeout, Int64 timerExpire, Boolean encrypt, Boolean trustServerCert, Boolean integratedSecurity, SqlConnection owningObject) +685966
System.Data.SqlClient.SqlInternalConnectionTds.AttemptOneLogin(ServerInfo serverInfo, String newPassword, Boolean ignoreSniOpenTimeout, Int64 timerExpire, SqlConnection owningObject) +109
System.Data.SqlClient.SqlInternalConnectionTds.LoginNoFailover(String host, String newPassword, Boolean redirectedUserInstance, SqlConnection owningObject, SqlConnectionString connectionOptions, Int64 timerStart) +383
System.Data.SqlClient.SqlInternalConnectionTds.OpenLoginEnlist(SqlConnection owningObject, SqlConnectionString connectionOptions, String newPassword, Boolean redirectedUserInstance) +181
System.Data.SqlClient.SqlInternalConnectionTds..ctor(DbConnectionPoolIdentity identity, SqlConnectionString connectionOptions, Object providerInfo, String newPassword, SqlConnection owningObject, Boolean redirectedUserInstance) +170
System.Data.SqlClient.SqlConnectionFactory.CreateConnection(DbConnectionOptions options, Object poolGroupProviderInfo, DbConnectionPool pool, DbConnection owningConnection) +359
System.Data.ProviderBase.DbConnectionFactory.CreatePooledConnection(DbConnection owningConnection, DbConnectionPool pool, DbConnectionOptions options) +28
System.Data.ProviderBase.DbConnectionPool.CreateObject(DbConnection owningObject) +424
System.Data.ProviderBase.DbConnectionPool.UserCreateRequest(DbConnection owningObject) +66
System.Data.ProviderBase.DbConnectionPool.GetConnection(DbConnection owningObject) +496
System.Data.ProviderBase.DbConnectionFactory.GetConnection(DbConnection owningConnection) +82
System.Data.ProviderBase.DbConnectionClosed.OpenConnection(DbConnection outerConnection, DbConnectionFactory connectionFactory) +105
System.Data.SqlClient.SqlConnection.Open() +111
ASP.global_asax.Application_Start(Object sender, EventArgs e) +150
版本資訊: Microsoft .NET Framework 版本:2.0.50727.832; ASP.NET 版本:2.0.50727.832

Mission:
1.connect to Mr周業太 for cencern about the stream management server
2.key in the p't's data
3.tomorrow i will coming whole day!

8/29 mission

Mission
1.the server of stream management still can;t function, they also couldn't find out the problem is!
2.remind sir about the 主持人.
3.not yet key in the data of 3 new p't

8/28 mission

mission:
1.arrange the time table of going to NTUH ,my plan may be will arrange monday and friday morning will go , and Tuesday to Thusday is afternoon only go there!
#NTUH(half day): --Monday and friday morning
--Tuesday to Thusday is afternoon
2.try out the main point of the new article
3.人體試驗送審資料及排列清單裡面:need to phone there and find out what is the meaning !
4.The MMH just need :審核表,申請表,中英文計畫書摘要,詳細計畫書以及受試者同意書(自己設計)
5.need to confirm some detail with sir Tomorrow(8/29):
-->主持人是謝老師或馬偕PT 老師(歐育志),協同主持人
-->詳細計畫書的設計
-->同意書裡面的主持人資料
-->英文計畫書摘要

8/24 clinical & mission

1.look through國立臺灣大學醫學院附設醫院臨床試驗計畫書,get attention on what will need to approach to MMH,and compare to the component of MMH proposal
the component of NTUH proposal include臨床試驗計劃書,申請書,受試者型態概述,快速審查範圍評檢表,受試者說明及同意書,參考文獻.There are six subtitle. Monday(8/27) will disscuss with sir.
2.2 p't are take in assessment(BI,BADL,BIB) ,not yet key in the data,not yet write down the data of the p't!
3. i sent an email to Mr.周業太 on wednesday(8/22)to tell him about stream management server was crashing down,and phone to him again today morning to concern the situation about the server.He will let me now about the situation on today works. But he didn't call me at last.
4.Monday i have arrange 2 P't to accept the asessement about BIB,BADL ,may be have Stream -cat .
5.go through the article!

8/23 clinical

1.2p't have take in the assessment,both of them have a same problem is the function just has a little bit different between affected side and unaffected side,but still can consider to accept them
2. NOT yet key in the data!!
3.look through MMH 研究相關流程
來院收病患的公文。要含以下資料
> 1. 要由系上或是醫學院發文
> 2. 附上研究計畫
> 3. 研究計畫的主旨
> 4. 病患類別與收取哪些類的資料
> 5. 收案時間可以盡量寫寬一點
> 6. 院內所需要附上的資料和流程，如下
http://www.mmh.org.tw/taitam/irb/
看看能不能進去下載
find out what and how the process go through with?
4.continue yesterday articles
5.tomorrow morning go to the clinical !

8/22 reading & mission

1.Arrange 1-2 p't to take in the assessment of stream-cat within a week---check is it the server is still function or not?
2.find out the main point of the latest article
3. find out the future challenges of the first article
4.think out how to arrange the time table(when i suppose go to Mackay Memorial Hospital or NTUH? )

8/21 reading & misison

Mission:
1.arrange p't to take in assessment(BI,BIB,BADL or stream-cat)
2.consider about the arrangement of the schedule that when will go to NTUH or other hospitals
3.Find out the mainpoint of another article!

8/20 reading & discussion

In the first article, how CAT combined IRT method to improve the functional outcome become more precision and effecience!
First step,we need to choose a specified item pool(specified outcome domain).
2nd step , item selection: use IRT to select an initial item to provide good discrimination over a wide range that all p't answer as the first question.
3rd step, patient respone:according to p't respone, we can have an initial score estimate and the score of confidence interval.
-IRT have 2 methods (Rasch modeling & CI).
These two methods can help the CAT to improve the functional outcome become more precision and effecience!
-->got three parameter:1,2,3-parameter;1-parameter is for difficult,2-parameter is for discrimination,3-parameter is for guessing.Now,it has assumption that item have equal dicrimination parameter and that guessing not a factor in the date.
-->Rash modeling :it can provide an index of each item's difficult-easy level, that will let us to determine if this items of the measurement need to modify or make shorten to become more comprehensive measurement or not.Besides,it also can make the item and p't's ability on the same metric. It can provide information about p't's abilities are fit with the specific component outcome domain.

-->confidence interval: it relative to the probabilities of patients, it can determine the suitable place of individual along functional dimension.
IRT can develop measure scale that are comprised of items with a known relationshipbetween item responses and position on an underlying functional domain.,called item characteristic curve. Using this approach,probabilities of patients scoring a particular response on an item at various funtional ability levels can be modeled.These probability can used to determine the individual's most like ly position along the functional dimension.

Both methods will develop the measurement become more precise and faster with effeicient!Because they make the possible area/range/distribution of p't abilities will become more smaller and that will faster let we determine where the p't abilities is!

4th step, score calculation: after the 3rd steo-the basis of the patient's response,then can estimate initial score and confidence interval.
5th step, stop rules or recontinue to step 2: that are based either the size of the pre-programmed confidence Interval are satisfied or the maximum number of items that used to test.
6th step,functional outcome: If there are not satisfied,a new item from the item pool is continued to administer, untilthe stop rule is satisfied.


Question:future challenges
1.why difficult to construct item bank? is the items too much? or other else?
2.why so few expert use CAT instrument
3.advertisement?!

8/17 reading & dicussion

1. what is the logic of the CAT assessment ?how can it possible reach precision and faster?
2. Find out the meaning of confidence interval ?
3. breadth(兩個極端,例如一端為簡單,另一端為困難) vs. depth (解析度)
4. Find out the main point of the new article?(Improving patient reported outcomes using item response theory and computerized adaptive testing)
5. what is the limitation of CAT in the future?

8/16 BADL & mission

Tomorrow mission: photostep the assessment of BADL,BI, agreement of stream-cat and BADL. Second, look through the flims of BIB (part one & two), if get some problem from there , write it down and ask angie about the solvent! Third, need to prepare the assessement for next week!

IRT & CAT

why we use IRT & CAT in this moment? It is because we didnt have clear definition of functional outcome or delineation between intrusments that assess functional outcomes. In the field of rehabilitation have many,different types of intrusments are overlapping with same function. So ,the contemporary measurement techniques have some functions better than traditional measurement such as it can unity,completeness and consistency issues.Following the last discription, it also can saves time in busy clinical settings. Question :how to achieve the functions that mention in the above sentences. Or how to prove that the CAT &IRThave such function?

8/15 BADL & BIB

BIB: when p't failed approaching one or two of the items like item 26 & 24(both feet beat time by turns &墊腳尖 ), but he can succed on item28 & 29(維持跨步). On the item of standing to squat, p't couldn't maintain his stability when he squated in the end of the motion. So, the mark will give is 0. if he can maintain,but he will backwards, the mark will give is 1.

8/14 practice BI , BIB &paper sheet of Stream-cat

BI: the p't felt boring about asking him same question as other assisstant or student had done it before. but we still need to explain to him about we have different item we have to comfortable ,then only let you continue . BIB: Need to pay attention on the safety of p't,for example mobility of item 23-25 . STREAM-CAT: the item of lying on bed knee flexion,when the affected limb knee flexion,the foot need to get close to the bed surface.item of 23(L8),p't usually can't have full range of it or eversion when abduction.

8/13practice Stream-CAT &PDA

Stream-CAT &PDA :safety ;the motion of p't is it completed in the UE/LE extremities' item ? For example, 17(L4)knee flexion :when pts' knee flexion ,but his ankle will slightly eversion about 10 degree , will give him 1 mark. No matter the motion is , if the p't couldn't reach the normal motion, then we will give him 1 mark in the UE/LE extremities' item or 2 mark in the mobility item . I have arrange some p't this few days ,tommorow (Tuesday,8/14) have two (inpatient ward) p't can have assessment about stream-CAT and BIB or ADL on 2.40pm and 4pm. Wednesday 8/15 one OPD p't about 2.30pm can take part in Stream-CAT and IADL . Thusday also have 1 inpatient ward p't (aging women) can have a BI asseseement to her caregiver.

8/10 practice Stream-CAT &BIB

Stream-CAT: Mobility can't have any assissstant for example quatrican,walker and etc. then others subject can use the assisstant to support p't ,prevent fallen. 3 mark is mean all independent. BIB :If pt's easily fatigue,can let him rest first and he /she need more times to finish his motion. Appointment : Monday 8/13 from 2.30pm to 3.30 pm,i have arrange 2 OPD p't to assess Stream-CAT(include PDA) ,BADL or IADL and BIB. Tuesday8/14 4pm, inpatient.

8/9 pratice BI & BIB

BI : need to remind the p't or caregiver the item of activities in BI are relevant to the ability of p't do in this two days!they will always mention about other days or other function. And they also mention about his Affected Limb that couldn't do the examination ,therefore we need to make a clarify with them .
BIB : pay attention on p't position ,for example when p't sit to stand, we need to make sure his leg didnt lean against the bedside,and make sure he is safety and comfortable. Angie and i have two items to debate about sit to lying and stand to sit.Angie give them zero, and i give them one.Why suppose this will happen ,because of the environment and the diffirent role (audience and tester,what we recept are different.).tomorrow afternoon 230pm also had one to two p't can test about STREAM-CAT&PDA ,BI

8/8 pratice strean-cat & BI

STREAM-CAT
1.item 5(M2 raise up hip) :p't just can raise up alittle bit range(about 20), it makes me difficult to determine is it full range or not!And the marks i need to give hime is 1 or 2. Answer is 1 .
2.item 15(L2 hip flexion in sitting): p't need to use both hand to support the bedside, only can hip flexion like his right leg. Because this item not include in mobility, means no matter what situation also can use any assisstant to support p't to do the motion.
3. if p't just had a little movement on his motion, how we determine it if his movement are different direction ,answer give him zero mark, or not (right direction) will give him 1 mark. for example,standing position then flexion knee ,if he doing the knee flexion are direct the leg behind(knee flexion), g ive it 1 marks. Just a little bit of range or leg is direct to front will give zero.
BI
1. item 3( personal hygiene) : if p't can't do all of items(include comb hair, brush teeth,wash face and shave)or 2 items of all, just can include to zero.


Apointment: tomorrow thusday (8/9)3 pm to 4pm: have 2 p't can have assessment for BADL,BI,STREAM-CAT PDA and BIB.

8/6 practice BIB

if i know the p't abilities of sitting balance with observation, then can skip the item of sitting balance ,go through to the item of position change or standing balance.

• the item of 19,20&21, when p't flexion his waist to get up a pen, make sure his buttock mustn't have touched the bed, means that knee mustn't flexion too much,but need to use trunk flexion more than knee flexion.
• the item of 26,27 the p't can flexion or extension his ankle, if the angle of ankle as same as his another foot
• iteme of th30,31 need to cautions:

1 the heel of front leg need to go close to the tiptoe

2. two legs must be a line(sometimes p't will deviate out of midline to compensate his balance ,mark will be zero.)

Stream-CAT
the items of mobility can't have any assisstant when p't have assessment.

8/3 pratice BIB

one patient that have intention tremor, without consider the expand of time, just determine if he could do it and we will give him 1 mark. Because his tremor make him couldn't take up or touch the pen precisely,need to give him chances, is it wouldn't influence this or others assessment like STREAM-CAT & PDA.

reference from: http://www.merck.com/mmhe/sec06/ch091/ch091c.html
Intention (Cerebellar) Tremor: This relatively slow, broad tremor occurs at the end of a purposeful movement, such as trying to press a button. Intention tremor may result from a damage to the cerebellum or its connections. Multiple sclerosis and stroke are common causes. Wilson's disease, alcoholism, and overuse of sedatives or anticonvulsants can cause the cerebellum to malfunction, resulting in intention tremor.

practice BIB,BI,BADL,IADL,Stream-CAT

Today PDA was crash down,had fixed it ,just need press the button below the PDA, it means reset the network card's detail,but it didnt influence our detail.
BADL(BIB) : need to ask more precise ,for example one item about personal hygiene include bruhes teeth,bathing used and others.
If some patientjust finished one activity , just give 0 mark. Another 1 mark is means that p't need to finish three four of the activites.

8/1 practice IADL &Stream-CAT

IADL
-before disease still have the limitation of time?
if yes,how long before disease?
because this p't have two part of his life, one was stayed at Thailand alone ,another is come back staying here!
Stream-CAT
-item5 :
p't no need to help for stable him legs buthis hips has alittle bit unsymmetric
-item23:
how broad of the range of motion that p't need abduction his leg?

Conclusion :
The assessment need to exam :
Outpatient:
-BADL & IADL
-BIB (over standing item ,like squat more difficult)
-Stream-cat & PDA (Safety & fatigue)

Inpatient:
-BADL
-BIB
-Stream-CAT &PDA (depend to p't)
(fatigue or not enough endurance)

Tomorrow(8/2,Thusday)
Mr.江(OPD) 3:00pm --BIB (BADL) have OT treatment after 3pm
Mr.游(OPD) 2:00pm --Stream-CAT& PDA have OT treatment on 2:30pm
Mr.黃1(Inpatient) 3:30pm -- BADL & BIB have OT treatment on 4pm
subtitution :Mr.黃2(OPD ,W1,2,4) have OT treatment on 2.30, he can accept after treatment