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Individual choice of insurance is used in several health systems as a means to empower citizens. This is based on the assumption that the insurers will act strategically on behalf of their clients to meet their needs and preferences and ensure access to high quality services, or else risk losing them to a competing insurer. Competition among insurance funds is expected to lead to improved health system efficiency, higher satisfaction with insurer services for clients (such as timely provision of information, easy administration, low waiting times, waiting list mediation, etc.). There is also an expectation that insurance competition will lead to improved care quality and could stimulate the development of more person-centred services.
The degree of choice and competition between insurers varies between health systems that have introduced this approach, as do the expectations that policy-makers in individual settings associate with choice and competition.
This chapter discusses a range of issues related to good clinical practice in psychopharmacology. It has been written to address the wide readership of care professionals who are involved in prescribing, monitoring and/or advising patients about psychiatric medication, which includes psychiatrists, pharmacists, psychiatric nurses, primary care physicians and hospital doctors.
Movement disorders associated with exposure to antipsychotic drugs are common and stigmatising but underdiagnosed.
To develop and evaluate a new clinical procedure, the ScanMove instrument, for the screening of antipsychotic-associated movement disorders for use by mental health nurses.
Item selection and content validity assessment for the ScanMove instrument were conducted by a panel of neurologists, psychiatrists and a mental health nurse, who operationalised a 31-item screening procedure. Interrater reliability was measured on ratings for 30 patients with psychosis from ten mental health nurses evaluating video recordings of the procedure. Criterion and concurrent validity were tested comparing the ScanMove instrument-based rating of 13 mental health nurses for 635 community patients from mental health services with diagnostic judgement of a movement disorder neurologist based on the ScanMove instrument and a reference procedure comprising a selection of commonly used rating scales.
Interreliability analysis showed no systematic difference between raters in their prediction of any antipsychotic-associated movement disorders category. On criterion validity testing, the ScanMove instrument showed good sensitivity for parkinsonism (90%) and hyperkinesia (89%), but not for akathisia (38%), whereas specificity was low for parkinsonism and hyperkinesia, and moderate for akathisia.
The ScanMove instrument demonstrated good feasibility and interrater reliability, and acceptable sensitivity as a mental health nurse-administered screening tool for parkinsonism and hyperkinesia.
The United States has been a leader in the creation of disability rights law, providing a policy template for other nations. Yet the social model, the animating philosophy behind the disability rights movement, has had little effect on the wide range of welfare programs that serve people with disabilities. These programs, whose creation preceded the modern disability rights movement, reflect a medical model of disability that is at odds with the social model. Analysing the Americans with Disabilities Act (which embodies the social model) and Social Security Disability Insurance (the largest welfare program for people with disabilities), we explore how and why this layering of contradictory disability rights and welfare programs developed and how it has been maintained. We argue that the tension between these policies engendered a series of patches, or ‘kludges’, that allow the policies to coexist without meaningful synthesis. We contend that the United States is particularly prone to this layering of ‘tense policies’, but that it is likely characteristic of disability policy in many nations. Finally we argue that accurate benchmarking of disability rights regimes across nations requires analysts to dig through all the layers of disability policy.
OBJECTIVES/SPECIFIC AIMS: The goal of this research is to use circulating tumor cells (CTC) enumeration and characterization to monitor anticancer treatment response. Emerging evidence strongly suggests the implications that epithelial-to-mesenchymal transition may have in cancer metastasis. Consequently, we hope to elucidate the significance of mesenchymal and stem-like CTCs in the peripheral blood of metastatic pancreatic cancer patients by analyzing the prevalence and frequency trends of CD133+ CTCs, as they relate to clinical events. We also hope to determine if there is a correlation between EpCAM+ CTCs and CD133+ CTCs numbers with tumor size, disease stage, and patient clinical outcome. METHODS/STUDY POPULATION: Blood samples of patients with metastatic pancreatic cancer (stage IV) were obtained from the University of Florida Health Cancer Center after informed consent through an IRB-approved protocol. CTC capture, characterization, and enumeration was performed on the blood of these cancer patients during their anticancer treatment. Patients had blood drawn for this purpose at time points aligned with clinical phlebotomy (every 2 weeks). CTC capture was performed by introducing treated patient blood samples into antibody-functionalized microdevices. The PDMS devices were functionalized by immobilizing either anti-EpCAM or anti-CD133, through an avidin-biotin complex. After capture, cells were fixated and permeabilized with 4% paraformaldehyde and 0.2% Triton X-100, respectively. Three-color immunocytochemistry (anti-cytokeratin-FITC, anti-CD45-PE, and DAPI) was performed to identify CTCs from nonspecifically captured blood cells. To be counted as a CTC, based on the FDA-approved technical definition, a cell with the appropriate cell size and morphology must be nucleated (DAPI+), express cytokeratin (CK+), and lack the leukocytic CD45 marker (CD45−). RESULTS/ANTICIPATED RESULTS: We tested the clinical utility of the device for monitoring the response of patients with advanced pancreatic cancer to a chemotherapy treatment consisting of anticancer drugs including 5-fluorouracil, leucovorin, oxaliplatin, and dasatinib. We have detected EpCAM+ CTCs in 47/47 (100%) and CD133+ CTCs in 41/47 (87.2%) of blood samples, coming from a cohort of 16 patients. We studied the correlation between the CTC numbers and the clinical result of patients in the study. We found that the size and changes in the size of the primary tumor (confirmed by CT scans) correlated with the frequency and increase/decrease trends in the number of CTCs detected. We expect to find some relationship between the number of detected CD133+ CTCs, or rather stem-like CTCs, and the clinical outcome of patients (eg, disease progression leading to withdrawal from study). DISCUSSION/SIGNIFICANCE OF IMPACT: Enumeration of patient CTCs and stem-like CTCs at different stages of a patient’s treatment may correlate with disease stage and prognosis, and prove useful in monitoring early recurrence, patient-specific treatment response, and newly acquired resistances; all of which would aid in providing guidance for the next step in clinical intervention. This type of liquid biopsy technology has great potential to make an impact in the future of personalized medicine and point-of-care diagnostics, as well as become a sturdy tool for translational research.
Archaeological tunneling is a standard excavation strategy in Mesoamerica. The ancient Maya built new structures atop older ones that were no longer deemed usable, whether for logistical or ideological reasons. This means that as archaeologists excavate horizontal tunnels into ancient Maya structures, they are essentially moving back in time. As earlier constructions are encountered, these tunnels may deviate in many directions in order to document architectural remains. The resultant excavations often become intricate labyrinths, extending dozens of meters. Traditional forms of archaeological documentation, such as photographs, plan views, and profile drawings, are limited in their ability to convey the complexity of tunnel excavations. Terrestrial Lidar (light detection and ranging) instruments are able to generate precise 3D models of tunnel excavations. This article presents the results of a model created with a Faro™ Focus 3D 120 Scanner of tunneling excavations at the site of El Zotz, Guatemala. The lidar data document the excavations inside a large mortuary pyramid, including intricately decorated architecture from an Early Classic (A.D. 300–600) platform buried within the present form of the structure. Increased collaboration between archaeologists and scholars with technical expertise maximizes the effectiveness of 3D models, as does presenting digital results in tandem with traditional forms of documentation.
Knowledge on the ecology of humpback whales in the eastern North Atlantic is lacking by comparison with most other ocean basins. Humpback whales were historically over-exploited in the region and are still found in low relative abundances. This, coupled with their large range makes them difficult to study. With the aim of informing more effective conservation measures in Ireland, the Irish Whale and Dolphin Group began recording sightings and images suitable for photo-identification of humpback whales from Irish waters in 1999. Validated records submitted by members of the public and data from dedicated surveys were analysed to form a longitudinal study of individually recognizable humpback whales. The distribution, relative abundance and seasonality of humpback whale sighting records are presented, revealing discrete important areas for humpback whales in Irish coastal waters. An annual easterly movement of humpback whales along the southern coast of Ireland is documented, mirroring that of their preferred prey: herring and sprat. Photo-identification images were compared with others collected throughout the North Atlantic (N = 8016), resulting in matches of two individuals between Ireland and Iceland, Norway and the Netherlands but no matches to known breeding grounds (Cape Verde and West Indies). This study demonstrates that combining public records with dedicated survey data is an effective approach to studying low-density, threatened migratory species over temporal and spatial scales that are relevant to conservation and management.
Audit is an important tool for quality improvement. The collection of data on clinical performance against evidence-based and clinically relevant standards, which are considered by clinicians to be realistic in routine practice, can usefully prompt reflective practice and the implementation of change. Evidence of participation in clinical audit is required to achieve intended learning outcomes for trainees in psychiatry and revalidation for those who are members of the Royal College of Psychiatrists. This article addresses some of the practical steps involved in conducting an audit project, and, to illustrate key points, draws on lessons learnt from a national, audit-based, quality improvement programme of lithium prescribing and monitoring conducted through the Prescribing Observatory for Mental Health.
It is uncertain whether antipsychotic long-acting injection (LAI) medication in schizophrenia is associated with better clinical outcomes than oral preparations.
To examine the impact of prior treatment delivery route on treatment outcomes and whether any differences are moderated by adherence.
Analysis of data from two pragmatic 1-year clinical trials in which patients with schizophrenia were randomised to either an oral first-generation antipsychotic (FGA), or a non-clozapine second-generation antipsychotic (SGA, CUtLASS 1 study), or a non-clozapine SGA or clozapine (CUtLASS 2 study).
Across both trials, 43% (n = 155) of participants were prescribed an FGA-LAI before randomisation. At 1-year follow-up they showed less improvement in quality of life, symptoms and global functioning than those randomised from oral medication. This difference was confined to patients rated as less than consistently adherent pre-randomisation. The relatively poor improvement in the patients prescribed an LAI pre-randomisation was ameliorated if they had been randomised to clozapine rather than another SGA. There was no advantage to being randomly assigned from an LAI at baseline to a non-clozapine oral SGA rather than an oral FGA.
A switch at randomisation from an LAI to an oral antipsychotic was associated with poorer clinical and functional outcomes at 1-year follow-up compared with switching from one oral antipsychotic to another. This effect appears to be moderated by adherence, and may not extend to switching to clozapine. This has implications for clinical trial design: the drug from which a participant is randomised may have a greater effect than the drug to which they are randomised.
Four years into the Kepler mission, an updated review on the results for RR Lyrae stars is in order. More than 50 RR Lyrae stars in the Kepler field are observed with Kepler and each one of them can provide us with new insight into this class of pulsating stars. Ground-based spectroscopy of the Kepler targets allows us to narrow down their physical parameters. Previously, we already reported a 50% occurrence rate of modulation in the RRab stars, a large variety of modulation behavior, period doubling in several Blazhko stars, the detection of higher- overtone radial modes, probable non-radial modes and new types of multiple-mode RR Lyrae pulsators, among both the RRab and the RRc stars. In addition, the quasi-continuous photometry obtained over several years with Kepler allows one to observe changes in Blazhko behavior and additional longer cycles. These observations have sparked new theoretical modelling efforts. In this short paper we showcase RR Lyr itself. The star has been observed with Kepler in short cadence, and some remarkable features of its pulsation behavior are unveiled in this long-studied prototype, through the Kepler photometry and additional spectroscopic data.
Positive change in prescribing practice in psychiatric services can be achieved with participation in the UK Prescribing Observatory for Mental Health (POMH-UK) quality improvement programmes. Key elements are feedback of benchmarked performance for local clinical reflection and customised change interventions informed by the national audit findings and parallel qualitative work. However, progress is gradual and gains generally modest.
Up to a quarter of people in the UK with a diagnosis of dementia are
prescribed an antipsychotic in any year. The potential risks of such
treatment are becoming clearer, but the benefits remain uncertain.
Concern about the frequency and quality of such prescribing was expressed
in the National Dementia Strategy for England in 2009.
To provide an estimate of the prevalence of antipsychotic use for
dementia in secondary mental health services in the UK and to collect
data relevant to quality improvement initiatives for such prescribing
In the context of a UK quality improvement programme, relevant clinical
audit data were collected for patients with dementia under the care of
specialist older people's mental health services.
Fifty-four mental health National Health Service (NHS) trusts submitted
data on 10 199 patients. Of those patients without comorbid psychotic
illness, 1620 (16%) were prescribed an antipsychotic; the common clinical
indications for such medication were agitation, psychotic symptoms,
aggression and distress. Multivariable regression found younger age, care
home or in-patient setting, vascular or Parkinson's disease dementia and
greater severity of dementia to be all significantly associated with
being prescribed antipsychotic medication. Of the 1001 (62%) patients
prescribed treatment for more than 6 months, only three-quarters had a
documented review of therapeutic response in the previous 6 months.
The data reveal areas of relatively good current practice, including
consideration of alternatives to antipsychotic medication and clear
documentation of target symptoms. They also suggest areas for
improvement, such as the frequency and quality of review of long-term
medication. Strategies to reduce antipsychotic use should take account of
the demographic and clinical variables predicting increased likelihood of