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The majority of self-management interventions are designed with a narrow focus on patient skills and fail to consider their potential as “catalysts” for improving care delivery. A project was undertaken to develop a patient self-management resource to support evidence-based, person-centered care for cancer pain and overcome barriers at the levels of the patient, provider, and health system.
The project used a mixed-method design with concurrent triangulation, including the following: a national online survey of current practice; two systematic reviews of cancer pain needs and education; a desktop review of online patient pain diaries and other related resources; consultation with stakeholders; and interviews with patients regarding acceptability and usefulness of a draft resource.
Findings suggested that an optimal self-management resource should encourage pain reporting, build patients’ sense of control, and support communication with providers and coordination between services. Each of these characteristics was identified as important in overcoming established barriers to cancer pain care. A pain self-management resource was developed to include: (1) a template for setting specific, measureable, achievable, relevant and time-bound goals of care, as well as identifying potential obstacles and ways to overcome these; and (2) a pain management plan detailing exacerbating and alleviating factors, current strategies for management, and contacts for support.
Significance of results
Self-management resources have the potential for addressing barriers not only at the patient level, but also at provider and health system levels. A cluster randomized controlled trial is under way to test effectiveness of the resource designed in this project in combination with pain screening, audit and feedback, and provider education. More research of this kind is needed to understand how interventions at different levels can be optimally combined to overcome barriers and improve care.
OBJECTIVES/SPECIFIC AIMS: Using a novel biomechanical-based motor speech assessment alongside commonly used clinically-based motor speech assessments, the goal of this study was to describe longitudinal recovery in speech movements and functional speech in a cohort of 5 patients following facial transplantation. METHODS/STUDY POPULATION: Five participants who had received either full or partial face transplantation were included in this study. Each participant received a unique facial graft from their donor, which included varied amounts of soft tissue, facial musculature, nerve, and bone. Two participants were early in the recovery period and were assessed from zero to 24 months post-transplantation. Three participants were late in the recovery period and were assessed from 36 to 60 months post-transplantation. Each participant completed two data collection sessions and the average time between sessions was 20.4 months. At each session, orofacial movements were recorded using a 3D motion capture system. A 4-sensor head marker was used to subtract head movement (translation and rotation) from the facial markers. The analyses in this study were restricted to two markers: midline lower lip and a virtually calculated midline jaw marker. A marker at the top of the nose bridge was used as the origin point. The following kinematic variables were obtained from each lip-jaw movement time-series: peak movement speed (mm/s), and displacement (mm). Each patient was instructed to perform 10 repetitions of the phrase “buy bobby a puppy” at his or her typical speaking rate and volume. Sentence-level intelligibility was obtained using the Sentence Intelligibility Test (SIT) and word-level intelligibility was obtained using the Word Intelligibility Test, using standard procedures. Intelligibility, measured in percentage of words correctly transcribed, and speaking rate, measured in words per minute (wpm), was derived from the SIT sentences for each patient. Intelligibility, measured in percentage of words correctly chosen via multiple choice was derived from the Word Intelligibility Test. RESULTS/ANTICIPATED RESULTS: Effect sizes (Cohen’s d) across the 10 trials of “buy bobby a puppy” were computed to assess the effects of recovery time on range of motion and speed of the lower lip alone, the jaw alone, and the lower lip and jaw together for both range of motion and for speed. The largest effect sizes were observed for increased range of motion and increased speed of the articulators for participants within 24 months of surgery. Smaller effect sizes were observed for these parameters for the participants in the later stages of recovery, with some participants showing declines in range of motion and speed of some but not all articulators. Descriptive statistics indicate that both speech and word intelligibility improvements are most notable in the first two years following transplantation and appear to plateau during the later stages of recovery. Only two out of five of our participants achieved “normal” speech intelligibility (i.e., >97%) at five years post-transplantation. DISCUSSION/SIGNIFICANCE OF IMPACT: Biomechanical assessment revealed that kinematic recovery of articulator range of motion and speed appears most significant in the first two years following surgery, but that improvement continues to some degree as far as five-years post-transplant. Clinically-based assessments suggest that gains in intelligibility appear to plateau by 3-years post-surgery.
High body mass index (BMI) has been associated with lower risks of suicidal behaviour and being underweight with increased risks. However, evidence is inconsistent and sparse, particularly for women. We aim to study this relationship in a large cohort of UK women.
In total 1.2 million women, mean age 56 (s.d. 5) years, without prior suicide attempts or other major illness, recruited in 1996–2001 were followed by record linkage to national hospital admission and death databases. Cox regression yielded relative risks (RRs) and 95% confidence intervals (CIs) for attempted suicide and suicide by BMI, adjusted for baseline lifestyle factors and self-reported treatment for depression or anxiety.
After 16 (s.d. 3) years of follow-up, 4930 women attempted suicide and 642 died by suicide. The small proportion (4%) with BMI <20 kg/m2 were at clearly greater risk of attempted suicide (RR = 1.38, 95% CI 1.23–1.56) and suicide (RR = 2.10, 1.59–2.78) than women of BMI 20–24.9 kg/m2; p < 0.0001 for both comparisons. Small body size at 10 and 20 years old was also associated with increased risks. Half the cohort had BMIs >25 kg/m2 and, while risks were somewhat lower than for BMI 20–24.9 kg/m2 (attempted suicide RR = 0.91, 0.86–0.96; p = 0.001; suicide RR = 0.79, 0.67–0.93; p = 0.006), the reductions in risk were not strongly related to level of BMI.
Being underweight is associated with a definite increase in the risk of suicidal behaviour, particularly death by suicide. Residual confounding cannot be excluded for the small and inconsistent decreased risk of suicidal behaviour associated with being overweight or obese.
Using decades of public opinion data from the US, UK, Australia, Germany and Canada, and distinguishing between three concepts - issue ownership, performance and generalised competence - Green and Jennings show how political parties come to gain or lose 'ownership' of issues, how they are judged on their performance in government across policy issues and how they develop a reputation for competence (or incompetence) over a period in office. Their analysis tracks the major events causing people to re-evaluate party reputations and the costs of governing which cause electorates to punish parties in power. They reveal why, when and how these movements in public opinion matter to elections. The implications are important for long-standing debates about performance and partisanship, and reveal that public opinion about party and governing competence is, to a great extent, the product of major shocks and predictable dynamics.