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The case studies presented in this chapter provide evidence of varied experience with private health insurance in three middle-income country settings – Brazil, Egypt and India – where there are large and persisting socioeconomic differentials and where private spending accounts for more than half of health care financing. Brazil is a very large private health insurance market with a recently introduced system of regulation whereas Egypt and India are very small markets with minimal regulation. In all three countries private health insurance plays a supplementary role and overwhelmingly covers richer people employed in the formal sector. All three countries are struggling with regulation of the market to enhance transparency, protect consumers and minimize negative effects on the publicly financed part of the health system.
Evacuees’ quality of life can be improved by investigating both their health problems and the conditions of evacuation centers during natural disasters.
This study aims to develop new evacuee and evacuation center information sheets that focus on infection control, oral health and dentures, mental health, and rehabilitation during natural disasters.
The analysis was conducted with the Delphi method by questioning doctors from various fields (infectious disease, psychiatry, rehabilitation, and dentistry) about the information that may be needed for evacuees and in the evacuation center environment.
Two information sheets were created in this study. One is an evacuation center environmental health assessment sheet that includes information about the overview of evacuees’ health and the evacuation center environment. The other is an evacuee registration sheet that would be completed by the evacuees themselves.
The information sheets developed in this study will be useful in times of disaster because they have the potential to improve evacuee health conditions, as well as evacuation center environments.
Depression is a major cause of disability in adolescents. Higher dietary fibre intake has been associated with lower depressive symptoms in adults, but there is a lack of research in adolescents. We examined the association between dietary fibre intake (Commonwealth Scientific and Industrial Research Organisation (CSIRO) FFQ) and depressive symptoms (Beck Depression Inventory for Youth) in adolescents with prospective data from the Raine Study Gen2 14- and 17-year follow-ups (n 1260 and 653). Odds of moderate/extreme (clinically relevant) depressive symptoms by quartile of fibre intake were calculated using mixed-effects logistic regression for all participants, in a paired sample without moderate/extreme depressive symptoms at 14 years and in a sub-sample of participants with available inflammatory data at the ages of 14 and 17 years (n 718 and 547). Odds of moderate/extreme depressive symptoms were lower in the fourth (highest) quartile of overall fibre intake (OR 0·273, 95 % CI 0·09, 0·81) compared with the first (lowest) quartile, adjusting for sex, age, energy intake, adiposity, and family and lifestyle factors. However, further adjustment for dietary patterns attenuated the results. Associations of depressive symptoms with cereal or fruit and vegetable fibre intake were not significant in the final model. Adjustment for inflammation had no effect on OR. The association between a higher dietary fibre intake and lower odds of clinically relevant depressive symptoms may be more reflective of a high-fibre diet with all its accompanying nutrients than of an independent effect of fibre.
This article updates the trends and developments of Japanese as a second language (JSL) research since Mori and Mori (2011) by reviewing nearly 200 selected empirical studies published in English or Japanese between 2010 and early 2019. The first section of this review examines the cognitive aspects of second language (L2) Japanese development, focusing on vocabulary and kanji (i.e., Chinese characters transferred into Japanese) learning, syntactic development, and the issues surrounding reading and writing. The second part investigates sociocultural issues in L2 Japanese development and use, including pragmatic development, multilingual/translingual perspectives, and multilingual youth. The third section explores the role of affective variables (primarily learner motivation) in L2 Japanese development. The last section considers various pedagogical issues, including corpus-based studies and the development of materials and resources, instructional designs and classroom studies, technology-enhanced language learning and new instructional models, critical approaches to teaching Japanese and content-based instruction. The review of these themes illuminates trends and emerging areas of interest in post-2010 L2 Japanese research inspired by current developments in applied linguistics and second language acquisition (SLA) research, as well as unique features of Japanese language and sociocultural contexts.
To analyse the cost-effectiveness of Baby-Friendly Hospital Initiative (BFHI) in promoting breast-feeding during the first hour of life (BFFHL) and reducing late neonatal mortality.
Cost-effectiveness economic assessment from the health system perspective, preceded by a prospective cohort of mother–baby followed from birth to 6 months of life. The direct costs associated with two health outcomes were analysed: intermediate end point (BFFHL) and final end point (reduction in late neonatal mortality).
Study was carried out in six hospitals in the city of São Paulo (Brazil), three being Baby-Friendly Hospitals (BFH) and three non-BFH.
Mothers with 24 h postpartum, over 18 years old, single fetus and breast-feeding at the time of the interview were included. Poisson regressions adjusted for maternal age and level of education were estimated to identify factors related to BFFHL and late neonatal mortality. Sensitivity analysis was performed to ensure robustness of the economic assessment.
Cost-effectiveness analysis showed that BFHI was highly cost-effective in raising BFFHL by 32·0 % at lower cost in comparison with non-BFHI. In addition, BFHI was cost-effective in reducing late neonatal mortality rate by 13·0 % from all causes and by 13·1 % of infant mortality rate from infections.
The cost-effectiveness of the BFHI in promoting breast-feeding and reducing neonatal mortality rates justifies the investments required for its expansion within the Brazilian health system.
A high dietary fibre intake has been associated with improvements in inflammatory conditions in adults. However, little is known on whether associations between dietary fibre and inflammation are evident during adolescence. We examined the relationship between dietary fibre intake measured by FFQ and the inflammatory marker high-sensitivity C-reactive protein (hs-CRP) and the adipokines leptin and adiponectin cross-sectionally in 17-year-olds participating in the Raine Study (n 621). In weighted analysis using tobit and linear regression, and after excluding participants with hs-CRP > 10 mg/l, higher total dietary fibre intake (per 5 g/d) was significantly associated with lower leptin (β = –0·13, 95 % CI –0·17, –0·09) and adiponectin (β = –0·28, 95 % CI –0·49, –0·07), but not hs-CRP, in unadjusted analyses. These associations were no longer significant after adjustment for sex, anthropometry and a number of lifestyle factors. However, higher cereal and grain fibre intake was significantly associated with lower leptin (β = –0·06, 95 % CI –0·10, –0·01) in fully adjusted analysis. Our findings suggest that a higher intake of cereal and grain fibre may contribute to lower leptin in adolescents. This may contribute to reductions in low-grade chronic inflammation and improved health outcomes.
Schizophrenia is associated with a high familiar, social and economic burden. During the recent years early and specific intervention for first psychotic episodes has been suggested to improve the long term outcome of the disease. Despite the promising results obtained so far, early intervention is still scarcely applied. One major problem arises from the translation of research findings into stakeholder policies. In fact very few analyses of cost reductions obtained with early intervention have been reported. In the present paper we present a simulation of direct cost reduction that can be obtained with early intervention programmes. We based our analysis on available data about schizophrenia care costs in Italy and the expected cost reduction with the use of early intervention. We observed that the increase in costs due to the more intensive early intervention is largely compensated by the reduction of inpatient admissions with a reduction of direct costs of 6.01%. Despite the apparently small economic gain, early intervention offers more clinical and social benefits as it seems to be effective also in decreasing relapse rates, in improving the patients' quality of life and disability associated with psychosis and in increasing employment rates. Those indirect costs however are difficult to estimate and were not included in our model.
In conclusion, our study supports the use of early intervention in schizophrenia, which could allow an outcome improvement with lower direct and indirect costs.
The use of standardized tools for assessment and monitoring of a rehabilitation program is strongly recommended, though not so often accomplished in clinical practice.
To describe the development and feasibility of a computerised method of assessment of rehabilitation activities based on psychometrics.
The software “SVAROSKI” was implemented by means of a relational ER (Entity-Relationship) model with a user interface managed by MS-Access. The rehabilitation activities were: Physical therapy; Locomotion, Occupational Therapy and Reality-Orientation Therapy. Patients were administered at the beginning and at the end of admission the following tests: MMSE, MODA, Barthel Index, Tinetti.
The software enables processing of test data with those obtained from rating scales at each session.
For each patient, two graphical reports are made available:
Punctual performance of each item divided by subject areas;
Overall pace of the three scales assessing rehabilitation (physical therapy was maintained for an evaluation board, partly qualitative, for the sake of the physiotherapist of the structure).
The software allows:
1) the rapid storage of the scores obtained from patients during the course of rehabilitation activities,
2) the real-time consultation of the development of therapeutic and rehabilitation,
3) the comparison of the iteration of several rehabilitation interventions on the patient.
SVAROSKY is a useful tool for analysis and monitoring of developments in the rehabilitation of the patient as a valid tool for the development of a synthesis report of the rehabilitation process.
There is an increasing awareness that pathological gambling can occur as an adverse effect of some dopamine agonist, specially pramipexole, used in the treatment of Parkinson disease. The aim of this study is: 1) to make a review of the literature concerning to this issue; 2) to describe a case that developed pathological gambling after increasing dopamine agonist dose in clinical practice.
We systematically searched PubMed database using the following combinations of variables: “compulsive gambling”, “Parkinson disease”, “dopamine agonist” and “gambling”. We also review the clinical record of the patient we identified.
We found 36 articles. 4 of them were excluded because they were not strictly about pathological gambling. They describe an association between treatment with dopamine agonists and reversible impulse control disorders (ICD) such as hypersexuality, addictions, compulsive eating and pathological gambling. Daily doses of dopamine agonists were significantly higher in patients who developed an ICD. Pramipexol was the predominantly reported medication. Our case is about a 46 year old married man with Parkinson disease. After increasing the dose of pramipexole in order to achieve a greater efficacy he gradually developed ICD, pathological gambling type. This led to a change in his antiparkinsonian medication.
As many cases of ICD after using dopamine agonists are being reported in the literature, doctors should aware patients about this potential adverse effect.
The international literature underlines an high rate of comorbidity between early psychosis and substance abuse associated to poor outcomes.
The aims of the present study are to evaluate the rate of substance abuse among subjects at first contact for psychotic disorder with one of the three Community Mental Health Centers (CMHC) of Bologna Ovest and to consider its influence on the course of the disease.
A retrospective study was conducted on subjects aged between 18-30 years with ICD-10 F2 (schizophrenia, schizotypal disorder and delusional disorder) diagnosis at first contact with a Bologna Ovest CMHC over a five-year period (January 2002- December 2006).
The sample was investigated about the presence of ‘Substance Abuse’ according to ICD-10 criteria. A 1-year follow-up assessment was performed.
Among the 56 patients recruited, 26 (46%) meet the ICD-10 criteria for ‘Substance Abuse’ (Abusers). Cannabis is the most frequently used substance (88%). Psychosis appears 1,1 year before among Abusers compared to Non-Abusers. At 1-year follow-up the 46% of Abusers works or studies compared to 67% among Non-Abusers. Moreover hospital admission concerns the 31% of subjects among Abusers and only the 17% of Non-Abusers group.
This study confirms the high rate of substance abuse among subjects with early psychosis reported in literature and suggests its potential negative influence on the course of psychotic disease. To improve the prognosis of patients with psychotic disorder and concurrent substance abuse it seems necessary promoting an integrated intervention between the CMHCs and the Addiction Services.
Borderline personality disorder (BPD) patients present a diffuse pattern of unstable interpersonal relations, self-image, affection and considerable impulsiveness.
Describe the circumstances related to prolonged hospitalization of a BPD patient; denote doubts, difficulties, polemics and feelings generated in the care team when managing this situation; and seeking scientific literature support on BPD.
Understand the circumstances related to prolonged hospitalization of a BPD patient and the effects of this situation on the care team.
An exploratory and descriptive research was carried out at the Psychiatric Ward at Ribeirão Preto Medical School Hospital of the University of São Paulo, Brazil. Interviews with five professionals were submitted to thematic content analysis and data from the patient's file were presented as a case report.
Two categories emerged from the interviews. “Team management in conducting the case”: divergencees in case conduction, bad feelings and counter-transference; the patient made demands and wanted to break rules. “Family abandonment”: although ready for discharge, the patient remained hospitalized due to lack of family and economic support. The only alternative was her transfer to a psychiatric hospital. Despite the difficulties, the team considered the experience gained in conducting the case was positive.
Investments are needed in programs aimed at better preparing the family to understand and welcome the patient after discharge from hospital. Moreover, greater cooperation is needed among the social structures of health care, patients and family members.
International literature has recently given great attention to risk factors and early detection of psychosis. According to this research line we have investigated the main characteristics of subjects at first contact for psychotic disorder with one of the three Community Mental Health Centers (CMHC) of Bologna Ovest.
A retrospective study was conducted recruiting subjects with ICD-10 F2 diagnosis (schizophrenia, schizotypal disorder and delusional disorder), psychosis onset between 18-30 years and at first contact with a Bologna Ovest CMHC over a five-year period (January 2002-December 2006).
The identified sample was evaluated on socio-demographic characteristics, history of substance abuse, history of hospital admissions and pathways to CMHCs.
The sample consists of 56 subjects. They are predominantly male (70%), unmarried (95%) and the most of them (79%) lives with their parents. Twenty-four patients (43%) have an eight year education, whereas 22 (39%) a thirteen year one. During the assessed period 24 (43%) subjects are unemployed and 15 (27%) are studying.
The median age of psychosis onset is 23,3 years and a concurrent substance abuse concerns 26 subjects (46%). Twenty-one (37,5%) patients present an history of hospital admissions.
Analyzing pathways to CMHCs we find that 16 (29%) subjects have been referred by hospital wards, 11 (20%) by their family, 10 (18%) by the General Practitioner, whereas 5 (9%) by themselves.
Notwithstanding the small size of the identified sample, this study seems to confirm the main characteristics of subjects at first contact for psychotic disorder reported in literature.