human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Summary A multidisciplinary cognitive behavioral program might have beneficial effects on people with chronic neuropathic spinal cord injury pain . ABSTRACT Many people with spinal cord injury ( SCI ) rate chronic neuropathic pain as one of the most difficult problems to manage . The aim of the CONECSI ( COping with NEuropathiC Spinal cord Injury pain ) trial was to evaluate a multidisciplinary cognitive behavioral treatment program for persons with chronic neuropathic pain after SCI . The intervention consisted of educational , cognitive , and behavioral elements .  A total of 61 people were r and omized to either the intervention group or the waiting list control group in 4 Dutch rehabilitation centers . Primary outcomes were pain intensity and pain‐related disability ( Chronic Pain Grade question naire ) , and secondary outcomes were mood ( Hospital Anxiety and Depression Scale ) , participation in activities ( Utrecht Activities List ) , and life satisfaction ( Life Satisfaction Question naire ) . Measurements were performed at baseline , and at 3 , and 6 months follow‐up . The primary statistical technique was r and om coefficient analysis . The analyses showed significant changes over time on both primary ( t1–t2 ) , and 2 out of 4 secondary outcomes ( both t1–t2 and t1–t3 ) . Significant intervention effects ( Time * Group interactions ) were found for anxiety and participation in activities , but not for the primary outcomes . Subsequent paired t tests showed significant changes in the intervention group that were not seen in the control group : decrease of pain intensity , pain‐related disability , anxiety , and increase of participation in activities . This study implies that a multidisciplinary cognitive behavioral program might have beneficial effects on people with chronic neuropathic SCI pain Study design : A repeated measures , non-r and omised controlled trial . Objective : To examine the effectiveness of individualised cognitive behaviour therapy ( CBT ) on the psychological adjustment of patients undergoing rehabilitation for newly acquired spinal cord injury . Setting : South Australian Spinal Cord Injury Service , Hampstead Rehabilitation Centre , South Australia , Australia . Methods : Eleven participants received individual CBT as part of their spinal rehabilitation .  Self-reported levels of depression , anxiety and stress were assessed before the intervention , at week 12 of rehabilitation and at 3 months post-discharge , using the depression , anxiety and stress scales ( DASS-21 ) . Functional independence was also assessed , using the Functional Independence Measure ( FIM ) . Responses were compared with 13 participants , closely matched on demographic and injury variables , who received  st and ard psychological care ( that is , assessment and monitoring only ) . Results : Depression scores for treatment participants showed a significant time effect , with worsening symptoms reported at three-month follow-up , after CBT was discontinued . In contrast , the DASS-21 scores of st and ard care participants remained at sub clinical levels throughout the study . Clinical improvements in symptoms of anxiety and stress were also reported by the treatment group as inpatient therapy progressed . Conclusion : Targeted , individualised psychological treatment contributed to short-term , meaningful improvements in emotional outcomes for individuals reporting psychological morbidity after recent spinal injury . The results also highlight the need for ongoing access to specialised , psychological services post-discharge . Replication of these results with a larger sample is required before definitive conclusions can be drawn OBJECTIVE To assess whether a comprehensive multidisciplinary pain management programme could contribute to improvement regarding sleep quality , mood , life satisfaction , health-related quality of life , sense of coherence and pain for patients with a spinal cord injury and neuropathic pain . DESIGN A prospect i ve intervention study . PATIENTS Twenty-seven patients with spinal cord injury and neuropathic pain participated in a pain management programme  in parallel with 11 patients in a control group . METHODS A comprehensive pain management programme comprising educational , cognitive , and behavioural interventions was created for patients with spinal cord injury and neuropathic pain . The pain management programme consisted of 20 sessions over a 10-week period and included educational sessions , behavioural therapy , relaxation , stretching , light exercise and body awareness training . All patients were followed-up 3 , 6 and 12 months after completion of the programme . RESULTS At the 12-month follow-up , levels of anxiety and depression in the treatment group decreased compared with baseline values , and a tendency towards better quality of sleep was seen . In comparison with the control group , patients in the treatment group improved regarding sense of coherence and depression . CONCLUSION This study implies that a multidimensional pain management programme can be a valuable complement in the treatment of spinal cord injured patients with neuropathic pain OBJECTIVE To explore the long-term outcomes of CONECSI ( COping with NEuropathiC Spinal cord Injury pain ) , a multidisciplinary cognitive behavioural treatment programme in persons with spinal cord injury . DESIGN Long-term follow-up pre-post-intervention design . SUBJECTS A total of 29 subjects with a spinal cord injury and chronic neuropathic pain from 4 Dutch rehabilitation centres . METHODS Primary outcomes were pain intensity and pain-related disability ( Chronic Pain Grade question naire ) . Secondary outcomes were mood ( Hospital Anxiety and Depression Scale ) , participation in activities ( Utrecht Activities List ) , and life satisfaction ( Life Satisfaction Question naire ) . R and om coefficient analysis was used for the analyses of measurements before ( t1 ) , immediate post-intervention ( t2 ) , and 6 ( t3 ) , 9 ( t4 ) , and 12 ( t5 ) months follow-up . RESULTS The analyses showed significant improvements on pain intensity ( t1-t2 and t1-t5 ) and pain-related disability ( t1-t2 , t1-t4 , and t1-t5 ) , anxiety and participation in activities ( t1-t2 , t1-t3 , and t1-t5 ) . CONCLUSION This exploratory study suggests that a multidisciplinary cognitive behavioural programme might have lasting improvements on pain intensity , pain-related disability , anxiety , and participation in activities in people with chronic neuropathic spinal cord injury pain and highlights the potential of such programmes PURPOSE To examine change in resilience in people with spinal cord injury ( SCI ) when  group cognitive behavior therapy ( GCBT ) was added to routine psychosocial rehabilitation ( RPR ) . RESEARCH METHOD / DESIGN A prospect i ve repeated- measures cohort design was used to determine the efficacy of the addition of  GCBT ( n = 50 ) . The control group consisted of individuals receiving RPR  , which included access to individual CBT ( ICBT ) when required  ( n = 38 ) . Groups were assessed on 3 occasions : soon after admission , within 2 weeks of discharge , and 6-months postdischarge . Measures included sociodemographic , injury , and psychosocial factors . The outcome variable was resilience , considered an important outcome measure for recovery . To adjust for baseline differences in self-efficacy , depressive mood and anxiety between the 2 groups , these factors were entered into a repeated measures multivariate analysis of covariance ( MANCOVA ) as covariates . Latent class analysis was used to determine the best-fitting model of resilience trajectories for both groups . RESULTS The MANCOVA indicated that the addition of GCBT to psychosocial rehabilitation did not result in improved resilience compared with the ICBT group . Trajectory data indicated over 60 % were demonstrating acceptable resilience irrespective of group . CONCLUSION / IMPLICATION S Changes in resilience mean scores suggest the addition of GCBT adds little to resilience outcomes . Latent class modeling indicated both groups experienced similar trajectories of improvement and deterioration . Results highlight the importance of conducting multivariate modeling analysis that isolates subgroups of related cases over time to underst and complex trajectories . Further research is needed to clarify individual differences in CBT intervention preference as well as other factors which impact on resilience This study aim ed to test the effectiveness of a nurse-led structured psychosocial intervention program in Chinese patients with first-onset mental illness . A single-blind , parallel group , r and omized controlled trial design was used . The study involved 180 participants with mild to moderate-severe symptoms of psychotic or mood disorders who were newly referred to two psychiatric outpatient clinics in Hong Kong . Patients were r and omly assigned to either an eight-session nurse-led psychosocial intervention program ( plus usual care ) or usual psychiatric outpatient care ( both n=90 ) . The primary outcome was psychiatric symptoms . Outcomes were measured at recruitment , one week and 12 months post-intervention . Patients in the psychosocial intervention group reported statistically significant improvements in symptoms compared to treatment as usual . There were also significant improvements in illness insight and perceived quality of life and reduction in length of re-hospitalizations over the 12-month follow-up . The findings provide evidence that the nurse-led psychosocial intervention program result ed in improved health outcomes in Chinese patients with first-onset mental illness OBJECTIVE To extend the findings of a pilot study that evaluated a brief group-based psychological intervention aim ed at improving psychological adjustment , self-perception and enhancing adaptive coping following spinal cord injury . The theoretical underpinnings of the Coping Effectiveness Training ( CET ) Programme are Lazarus and Folkman 's ( 1984 ) cognitive theory of stress and coping , and cognitive behavioural therapy techniques . DESIGN A controlled trial comparing patients that received the CET intervention with matched controls on measures of psychological adjustment and coping . METHOD A total of 45 intervention group participants and 40 matched controls were selected from in patients at a hospital-based spinal cord injury centre . Outcome measures of anxiety and depression , self-perception and coping were collected before , immediately after and 6 weeks following the intervention . RESULTS Intervention group participants showed a significant reduction in depression and anxiety , compared to the matched controls following the intervention . There was no evidence of a significant change in the pattern of coping strategies used by the intervention group compared to controls . The intervention group alone completed measures of self-perception . There was a significant decrease in the discrepancy between participants ' ' ideal ' self and ' as I am ' , and between ' as I would be without the injury ' and ' as I am ' following the intervention and at follow-up . Significant correlations were also found between self-perception , and anxiety and depression over time . CONCLUSIONS These results confirm the findings of the pilot study , that the CET intervention facilitated a significant improvement in psychological adjustment to spinal cord injury . It is proposed that this improvement may be understood in terms of changing participants ' negative appraisal s of the implication s of spinal cord injury with the result of increasing the perceived manageability of its consequences . Such decatastrophizing alters appraisal s which are associated with current mood . Participants found shared discussion and problem-solving to be particularly helpful . Avenues for further research are discussed Though group interventions are widely used in community-based and clinical setting s , there are few brief instruments for assessing the group environment . Two studies on the development of a brief measure to assess intervention group environments are described , and psychometric properties of the new scale are presented . The new measure is based on Moos ' ( 1994 ) Group Environment Scale ( GES ) .  Participants in the studies were from two independent r and omized controlled clinical trials ( RCTs ) of group interventions ( combined N = 334 ) . In Study 1 ( N = 139 ) , the factor content of the original 90-item GES was examined . The scale was shortened , the response format was changed , and items were adapted and added to in an effort to increase applicability to community-based and clinical intervention groups . In Study 2 ( N = 195 ) , the new scale was evaluated , the factor solution obtained in Study 1 was cross-vali date d , and subsequently the length of the scale was shortened again . The final scale contains 25 items with three subscales . Reliability and validity of the new scale was examined . Finally , the research and practice implication s of the scale are discussed PURPOSE To compare coping effectiveness training ( CET ) with supportive group therapy ( SGT ) for  anxiety , depression , and adjustment to injury in an acute spinal cord injury/dysfunction ( SCI/D ) rehabilitation population .  CET was shown to result in decreased anxiety and depression symptoms when compared to historical no-treatment control groups ( Kennedy , Duff , Evans , & Beedie , 2003 ; King & Kennedy , 1999 ) . The present study sought to extend those findings with a comparison of CET to an alternative active therapy condition , SGT . RESEARCH METHOD Participants ( N = 40 ) entering a hospital-based program were assigned to treatment condition using block r and omization . Question naire mood measures were completed at program admission , program discharge , and 3-month postdischarge follow-up . Adjustment to disability was assessed at follow-up only . Analyses of variance tested for group differences in anxiety , depression , and adjustment to injury . RESULTS Both groups reported reductions in mood symptoms with no differences between treatment conditions . However , similar reductions were obtained after fewer sessions of CET .  Symptoms of depression increased in both groups following hospital discharge . CONCLUSIONS Clinical and research implication s , including innovative interventions during the period after discharge , are discussed OBJECTIVES To develop and evaluate a brief group-based psychological intervention for improving psychological adjustment and enhancing adaptive coping following spinal cord injury . The Coping Effectiveness Training ( CET ) programme is grounded on the cognitive theory of stress and coping of Lazarus & Folkman ( 1984 ) , and represents an original adaptation of the theory to the needs of this client group . DESIGN A controlled trial comparing patients receiving the CET intervention  to matched controls in measures of psychological adjustment and coping was used . METHODS Nineteen intervention group participants and 19 matched controls were selected from in- patients at a hospital-based spinal injury rehabilitation centre . Outcome measures 
    Output:
    
agent
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Summary A multidisciplinary cognitive behavioral program might have beneficial effects on people with chronic neuropathic spinal cord injury pain . ABSTRACT Many people with spinal cord injury ( SCI ) rate chronic neuropathic pain as one of the most difficult problems to manage . The aim of the CONECSI ( COping with NEuropathiC Spinal cord Injury pain ) trial was to evaluate a multidisciplinary cognitive behavioral treatment program for persons with chronic neuropathic pain after SCI . The intervention consisted of educational , cognitive , and behavioral elements .  A total of 61 people were r and omized to either the intervention group or the waiting list control group in 4 Dutch rehabilitation centers . Primary outcomes were pain intensity and pain‐related disability ( Chronic Pain Grade question naire ) , and secondary outcomes were mood ( Hospital Anxiety and Depression Scale ) , participation in activities ( Utrecht Activities List ) , and life satisfaction ( Life Satisfaction Question naire ) . Measurements were performed at baseline , and at 3 , and 6 months follow‐up . The primary statistical technique was r and om coefficient analysis . The analyses showed significant changes over time on both primary ( t1–t2 ) , and 2 out of 4 secondary outcomes ( both t1–t2 and t1–t3 ) . Significant intervention effects ( Time * Group interactions ) were found for anxiety and participation in activities , but not for the primary outcomes . Subsequent paired t tests showed significant changes in the intervention group that were not seen in the control group : decrease of pain intensity , pain‐related disability , anxiety , and increase of participation in activities . This study implies that a multidisciplinary cognitive behavioral program might have beneficial effects on people with chronic neuropathic SCI pain Study design : A repeated measures , non-r and omised controlled trial . Objective : To examine the effectiveness of individualised cognitive behaviour therapy ( CBT ) on the psychological adjustment of patients undergoing rehabilitation for newly acquired spinal cord injury . Setting : South Australian Spinal Cord Injury Service , Hampstead Rehabilitation Centre , South Australia , Australia . Methods : Eleven participants received individual CBT as part of their spinal rehabilitation .  Self-reported levels of depression , anxiety and stress were assessed before the intervention , at week 12 of rehabilitation and at 3 months post-discharge , using the depression , anxiety and stress scales ( DASS-21 ) . Functional independence was also assessed , using the Functional Independence Measure ( FIM ) . Responses were compared with 13 participants , closely matched on demographic and injury variables , who received  st and ard psychological care ( that is , assessment and monitoring only ) . Results : Depression scores for treatment participants showed a significant time effect , with worsening symptoms reported at three-month follow-up , after CBT was discontinued . In contrast , the DASS-21 scores of st and ard care participants remained at sub clinical levels throughout the study . Clinical improvements in symptoms of anxiety and stress were also reported by the treatment group as inpatient therapy progressed . Conclusion : Targeted , individualised psychological treatment contributed to short-term , meaningful improvements in emotional outcomes for individuals reporting psychological morbidity after recent spinal injury . The results also highlight the need for ongoing access to specialised , psychological services post-discharge . Replication of these results with a larger sample is required before definitive conclusions can be drawn OBJECTIVE To assess whether a comprehensive multidisciplinary pain management programme could contribute to improvement regarding sleep quality , mood , life satisfaction , health-related quality of life , sense of coherence and pain for patients with a spinal cord injury and neuropathic pain . DESIGN A prospect i ve intervention study . PATIENTS Twenty-seven patients with spinal cord injury and neuropathic pain participated in a pain management programme  in parallel with 11 patients in a control group . METHODS A comprehensive pain management programme comprising educational , cognitive , and behavioural interventions was created for patients with spinal cord injury and neuropathic pain . The pain management programme consisted of 20 sessions over a 10-week period and included educational sessions , behavioural therapy , relaxation , stretching , light exercise and body awareness training . All patients were followed-up 3 , 6 and 12 months after completion of the programme . RESULTS At the 12-month follow-up , levels of anxiety and depression in the treatment group decreased compared with baseline values , and a tendency towards better quality of sleep was seen . In comparison with the control group , patients in the treatment group improved regarding sense of coherence and depression . CONCLUSION This study implies that a multidimensional pain management programme can be a valuable complement in the treatment of spinal cord injured patients with neuropathic pain OBJECTIVE To explore the long-term outcomes of CONECSI ( COping with NEuropathiC Spinal cord Injury pain ) , a multidisciplinary cognitive behavioural treatment programme in persons with spinal cord injury . DESIGN Long-term follow-up pre-post-intervention design . SUBJECTS A total of 29 subjects with a spinal cord injury and chronic neuropathic pain from 4 Dutch rehabilitation centres . METHODS Primary outcomes were pain intensity and pain-related disability ( Chronic Pain Grade question naire ) . Secondary outcomes were mood ( Hospital Anxiety and Depression Scale ) , participation in activities ( Utrecht Activities List ) , and life satisfaction ( Life Satisfaction Question naire ) . R and om coefficient analysis was used for the analyses of measurements before ( t1 ) , immediate post-intervention ( t2 ) , and 6 ( t3 ) , 9 ( t4 ) , and 12 ( t5 ) months follow-up . RESULTS The analyses showed significant improvements on pain intensity ( t1-t2 and t1-t5 ) and pain-related disability ( t1-t2 , t1-t4 , and t1-t5 ) , anxiety and participation in activities ( t1-t2 , t1-t3 , and t1-t5 ) . CONCLUSION This exploratory study suggests that a multidisciplinary cognitive behavioural programme might have lasting improvements on pain intensity , pain-related disability , anxiety , and participation in activities in people with chronic neuropathic spinal cord injury pain and highlights the potential of such programmes PURPOSE To examine change in resilience in people with spinal cord injury ( SCI ) when  group cognitive behavior therapy ( GCBT ) was added to routine psychosocial rehabilitation ( RPR ) . RESEARCH METHOD / DESIGN A prospect i ve repeated- measures cohort design was used to determine the efficacy of the addition of  GCBT ( n = 50 ) . The control group consisted of individuals receiving RPR  , which included access to individual CBT ( ICBT ) when required  ( n = 38 ) . Groups were assessed on 3 occasions : soon after admission , within 2 weeks of discharge , and 6-months postdischarge . Measures included sociodemographic , injury , and psychosocial factors . The outcome variable was resilience , considered an important outcome measure for recovery . To adjust for baseline differences in self-efficacy , depressive mood and anxiety between the 2 groups , these factors were entered into a repeated measures multivariate analysis of covariance ( MANCOVA ) as covariates . Latent class analysis was used to determine the best-fitting model of resilience trajectories for both groups . RESULTS The MANCOVA indicated that the addition of GCBT to psychosocial rehabilitation did not result in improved resilience compared with the ICBT group . Trajectory data indicated over 60 % were demonstrating acceptable resilience irrespective of group . CONCLUSION / IMPLICATION S Changes in resilience mean scores suggest the addition of GCBT adds little to resilience outcomes . Latent class modeling indicated both groups experienced similar trajectories of improvement and deterioration . Results highlight the importance of conducting multivariate modeling analysis that isolates subgroups of related cases over time to underst and complex trajectories . Further research is needed to clarify individual differences in CBT intervention preference as well as other factors which impact on resilience This study aim ed to test the effectiveness of a nurse-led structured psychosocial intervention program in Chinese patients with first-onset mental illness . A single-blind , parallel group , r and omized controlled trial design was used . The study involved 180 participants with mild to moderate-severe symptoms of psychotic or mood disorders who were newly referred to two psychiatric outpatient clinics in Hong Kong . Patients were r and omly assigned to either an eight-session nurse-led psychosocial intervention program ( plus usual care ) or usual psychiatric outpatient care ( both n=90 ) . The primary outcome was psychiatric symptoms . Outcomes were measured at recruitment , one week and 12 months post-intervention . Patients in the psychosocial intervention group reported statistically significant improvements in symptoms compared to treatment as usual . There were also significant improvements in illness insight and perceived quality of life and reduction in length of re-hospitalizations over the 12-month follow-up . The findings provide evidence that the nurse-led psychosocial intervention program result ed in improved health outcomes in Chinese patients with first-onset mental illness OBJECTIVE To extend the findings of a pilot study that evaluated a brief group-based psychological intervention aim ed at improving psychological adjustment , self-perception and enhancing adaptive coping following spinal cord injury . The theoretical underpinnings of the Coping Effectiveness Training ( CET ) Programme are Lazarus and Folkman 's ( 1984 ) cognitive theory of stress and coping , and cognitive behavioural therapy techniques . DESIGN A controlled trial comparing patients that received the CET intervention with matched controls on measures of psychological adjustment and coping . METHOD A total of 45 intervention group participants and 40 matched controls were selected from in patients at a hospital-based spinal cord injury centre . Outcome measures of anxiety and depression , self-perception and coping were collected before , immediately after and 6 weeks following the intervention . RESULTS Intervention group participants showed a significant reduction in depression and anxiety , compared to the matched controls following the intervention . There was no evidence of a significant change in the pattern of coping strategies used by the intervention group compared to controls . The intervention group alone completed measures of self-perception . There was a significant decrease in the discrepancy between participants ' ' ideal ' self and ' as I am ' , and between ' as I would be without the injury ' and ' as I am ' following the intervention and at follow-up . Significant correlations were also found between self-perception , and anxiety and depression over time . CONCLUSIONS These results confirm the findings of the pilot study , that the CET intervention facilitated a significant improvement in psychological adjustment to spinal cord injury . It is proposed that this improvement may be understood in terms of changing participants ' negative appraisal s of the implication s of spinal cord injury with the result of increasing the perceived manageability of its consequences . Such decatastrophizing alters appraisal s which are associated with current mood . Participants found shared discussion and problem-solving to be particularly helpful . Avenues for further research are discussed Though group interventions are widely used in community-based and clinical setting s , there are few brief instruments for assessing the group environment . Two studies on the development of a brief measure to assess intervention group environments are described , and psychometric properties of the new scale are presented . The new measure is based on Moos ' ( 1994 ) Group Environment Scale ( GES ) .  Participants in the studies were from two independent r and omized controlled clinical trials ( RCTs ) of group interventions ( combined N = 334 ) . In Study 1 ( N = 139 ) , the factor content of the original 90-item GES was examined . The scale was shortened , the response format was changed , and items were adapted and added to in an effort to increase applicability to community-based and clinical intervention groups . In Study 2 ( N = 195 ) , the new scale was evaluated , the factor solution obtained in Study 1 was cross-vali date d , and subsequently the length of the scale was shortened again . The final scale contains 25 items with three subscales . Reliability and validity of the new scale was examined . Finally , the research and practice implication s of the scale are discussed PURPOSE To compare coping effectiveness training ( CET ) with supportive group therapy ( SGT ) for  anxiety , depression , and adjustment to injury in an acute spinal cord injury/dysfunction ( SCI/D ) rehabilitation population .  CET was shown to result in decreased anxiety and depression symptoms when compared to historical no-treatment control groups ( Kennedy , Duff , Evans , & Beedie , 2003 ; King & Kennedy , 1999 ) . The present study sought to extend those findings with a comparison of CET to an alternative active therapy condition , SGT . RESEARCH METHOD Participants ( N = 40 ) entering a hospital-based program were assigned to treatment condition using block r and omization . Question naire mood measures were completed at program admission , program discharge , and 3-month postdischarge follow-up . Adjustment to disability was assessed at follow-up only . Analyses of variance tested for group differences in anxiety , depression , and adjustment to injury . RESULTS Both groups reported reductions in mood symptoms with no differences between treatment conditions . However , similar reductions were obtained after fewer sessions of CET .  Symptoms of depression increased in both groups following hospital discharge . CONCLUSIONS Clinical and research implication s , including innovative interventions during the period after discharge , are discussed OBJECTIVES To develop and evaluate a brief group-based psychological intervention for improving psychological adjustment and enhancing adaptive coping following spinal cord injury . The Coping Effectiveness Training ( CET ) programme is grounded on the cognitive theory of stress and coping of Lazarus & Folkman ( 1984 ) , and represents an original adaptation of the theory to the needs of this client group . DESIGN A controlled trial comparing patients receiving the CET intervention  to matched controls in measures of psychological adjustment and coping was used . METHODS Nineteen intervention group participants and 19 matched controls were selected from in- patients at a hospital-based spinal injury rehabilitation centre . Outcome measures 
    Output:
    