The impact of lurasidone on functioning and indirect costs in adults with bipolar depression: a post-hoc analysis

OBJECTIVE

The aim of this post-hoc analysis was to assess the impact of lurasidone monotherapy on functional impairment, productivity, and associated indirect costs in patients with bipolar depression.

METHODS

Data were analyzed from a 6-week randomized, double-blind (DB; NCT00868699), placebo-controlled trial of lurasidone monotherapy and a 6-month open label extension (OLE; NCT00868959) study. Patients with bipolar depression who completed the 6-week DB trial were subsequently enrolled in the OLE. Analysis of the OLE was limited to patients who either continued lurasidone (LUR-LUR) or switched from placebo to lurasidone monotherapy (PBO-LUR). The Sheehan Disability Scale (SDS), which measures functional impairment and productivity, was collected at DB baseline, DB week 6/OLE baseline, OLE month 3, and OLE month 6. Annual indirect costs were calculated based on days lost or unproductive from work/school due to symptoms. Effect sizes (ES) in functioning and days lost/unproductive were reported for the DB trial and mean changes for the OLE.

RESULTS

A total of 485 patients were enrolled in the DB trial (lurasidone: n = 323; placebo: n = 162) and 316 were in the lurasidone monotherapy group during the OLE (LUR-LUR: n = 210; PBO-LUR: n = 106). In the DB trial, improvements in functioning (work: ES = 0.36, p = .0071; social: ES = 0.55, p < .0001; family: ES = 0.50, p < .0001) were significantly greater for lurasidone compared to placebo. Reductions in days lost (ES = 0.33, p = .0050) and unproductive (ES = 0.45, p = .0001) were significantly higher for lurasidone vs. placebo. This resulted in a greater reduction in indirect costs for lurasidone vs. placebo (least squares mean (standard error) = -$32,322 ($2,100) vs. -$20,091 ($2,838)). Improvements in functioning and productivity were sustained during the 6-month OLE for both LUR-LUR and PBO-LUR.

CONCLUSIONS

Lurasidone monotherapy for the treatment of bipolar depression significantly improved functioning and reduced indirect costs vs. placebo at week 6. Significant improvements in functioning and productivity were sustained for 6 months for both LUR-LUR and PBO-LUR.

Placement of iliosacral screws using 3D image-guided (O-Arm) technology and Stealth Navigation: comparison with traditional fluoroscopy

AIMS

We compared the accuracy, operating time and radiation exposure of the introduction of iliosacral screws using O-arm/Stealth Navigation and standard fluoroscopy.

MATERIALS AND METHODS

Iliosacral screws were introduced percutaneously into the first sacral body (S1) of ten human cadavers, four men and six women. The mean age was 77 years (58 to 85). Screws were introduced using a standard technique into the left side of S1 using C-Arm fluoroscopy and then into the right side using O-Arm/Stealth Navigation. The radiation was measured on the surgeon by dosimeters placed under a lead thyroid shield and apron, on a finger, a hat and on the cadavers.

RESULTS

There were no neuroforaminal breaches in either group. The set-up time for the O-Arm was significantly longer than for the C-Arm, while total time for placement of the screws was significantly shorter for the O-Arm than for the C-Arm (p = 0.001). The mean absorbed radiation dose during fluoroscopy was 1063 mRad (432.5 mRad to 4150 mRad). No radiation was detected on the surgeon during fluoroscopy, or when he left the room during the use of the O-Arm. The mean radiation detected on the cadavers was significantly higher in the O-Arm group (2710 mRem standard deviation (sd) 1922) than during fluoroscopy (11.9 mRem sd 14.8) (p < 0.01).

CONCLUSION

O-Arm/Stealth Navigation allows for faster percutaneous placement of iliosacral screws in a radiation-free environment for surgeons, albeit with the same accuracy and significantly more radiation exposure to cadavers, when compared with standard fluoroscopy.

TAKE HOME MESSAGE

Placement of iliosacral screws with O-Arm/Stealth Navigation can be performed safely and effectively. Cite this article: Bone Joint J 2016;98-B:696-702.

Predictors of new and severe vertebral fractures: results from the HORIZON Pivotal Fracture Trial

We examined prevalent and recent vertebral fractures in 1 year as predictors of new vertebral fractures over subsequent 2 years using data from RCT placebo patients. We found that prevalent and recent vertebral fractures strongly and independently predicted subsequent vertebral fractures including those which were severe.

INTRODUCTION

While several studies have shown that prevalent vertebral fractures (pVFx) increase the risk of new vertebral fractures (VFx), the impact of recent vertebral fractures on future fractures is less studied.

METHODS

Data from the placebo arm of the HORIZON Pivotal Fracture Trial, an international trial of zoledronic acid in postmenopausal, osteoporotic women between 65 and 85 years, were used. We included the subset of 2677 women with annual spinal radiographs to study the impact of vertebral fractures in year 1 (Y1 VF) on those occurring in years 2 and 3 using morphometric and semiquantitative (SQ) criteria. In addition, a subset of severe VFx was defined using SQ criteria. Logistic regression examined the impact of pVFx and Y1 VF on all incident VFx and on severe incident VFx.

RESULTS

Two hundred fourty-five (9.1%) women sustained a new VFx in years 2-3. VFx risk in years 2-3 was 3.9% in those without pVFx or VFy1 and 29.8% in those with both risk factors. Both pVF and VFy1 remained independent predictors for future VF when they were both entered into a logistic regression model (odds ratio (OR) = 3.3; 95% confidence interval (CI), 2.3-4.7; OR = 3.7, 95% CI, 2.3, 5.8, respectively). ORs were similar after adjustment. Of the total number of women, 4.1% had severe VFx. PVFx and Y1 VF were also significant predictors of severe VFx; however, Y1 VF appeared more strongly predictive of severe VFx.

CONCLUSIONS

Prevalent and incident vertebral fractures are highly predictive of subsequent new and severe vertebral fractures. Women with both of these risk factors are likely to benefit from anti-osteoporosis treatment.

Impact of bipolar disorder: results from a screening study

OBJECTIVE

To characterize the extent and impact of bipolar I and II disorders and rapid cycling in a managed care population using both coded diagnostic claims and clinical screening.

METHOD

The Mood Disorder Questionnaire (MDQ) was used to identify bipolar disorder among patients attending the psychiatry service of a large Midwestern health system. Suicidal ideation screening questions were also asked, along with a brief set of relevant history and medication questions. Patients scoring positive on the MDQ or identified as bipolar-positive according to DSM-IV criteria by the screening clinician were administered the Work and Social Adjustment Scale and an Employment questionnaire. Descriptive statistics were used to summarize results. The study was conducted from July 2004 to November 2004.

RESULTS

Seventy (6.4%) of 1087 patients had bipolar disorder, 59 of whom completed the entire study. For these patients, the mean time with bipolar disorder was 9.3 (SD 10.2) years. The mean length of the current episode was 10.4 (SD 14.4) weeks, with 22% of patients experiencing a mixed episode, 5% manic-predominant, 12% hypomanic-predominant, and 46% a depressive-predominant episode. Twenty-four percent of patients with bipolar disorder were rapid cycling at the time of their visit; for 5 of these patients, rapid cycling was thought to be related to antidepressant use. Sixty-one percent of patients with bipolar disorder were taking an antidepressant; 69.5% were taking a mood stabilizer. Of these patients with bipolar disorder, 19% were evaluated as high suicidality risk, while 47% were considered moderate risk. Bipolar disorder patients reported problems with employment/employability and social adjustment. About one quarter of these patients ranked problems with family and relationships as marked or severe. Fifty percent of these bipolar disorder patients reported missing at least 1 week of work during the past month; 41% reported fearing the loss of their current job due to their emotional state; and 20% reported being fired/laid off during the past 5 years due to their emotional state.

CONCLUSIONS

This research documents some of the clinical features and social and labor-force impact of bipolar disorder in a managed care population and adds several dimensions to data published to date. Fully two thirds of our study subjects with bipolar disorder were found to be at substantial risk of suicide, and bipolar disorder patients in this study reported substantial problems with employment/employability and social functioning.

Bipolar disorder detection, ascertainment, and treatment: primary care physician knowledge, attitudes, and awareness

OBJECTIVE

To describe knowledge, attitudes, and awareness of bipolar disorder detection, ascertainment, and treatment among primary care physicians in a managed care setting.

METHOD

Quota sampling was used to obtain 102 completed surveys assessing knowledge, attitudes, and awareness of bipolar disorder from a pool of 350 primary care physicians in a large, vertically integrated Midwestern health system from June 2004 through August 2004. Descriptive statistics were used to characterize the distribution of the study results at the physician level.

RESULTS

Primary care physicians are experiencing challenges in diagnosing and treating bipolar patients, who can be difficult and time-consuming. In answering questions about major depressive episode and manic episode symptoms, at least 15% of respondents assessed most symptoms incorrectly. In analyzing 3 case studies, 9%, 11%, and 28% of respondents, respectively, answered all of the questions correctly. When asked which drugs are U.S. Food and Drug Administration-approved for the maintenance treatment of adults with bipolar I disorder, no survey respondent replied correctly for all drugs listed. Importantly, our survey also indicates that these physicians are very willing to refer bipolar patients to psychiatrists for evaluation and treatment, which may help to ensure optimal care.

CONCLUSIONS

Opportunities for improvement exist in diagnosing and treating patients with bipolar disorder in the primary care setting, perhaps aided by guidelines, education, and a collaborative care model with psychiatry.

Medicaid payment mechanisms: impact on medication adherence and health care service utilization in type 2 diabetes enrollees

The purpose of this retrospective cohort study was to examine the impact of the type of health plan (capitated vs. fee for service [FFS]) on outcomes (medication adherence and health care service utilization) in type 2 diabetes Medicaid enrollees. Subjects were 8581 Medicaid enrollees with type 2 diabetes who newly started oral pharmacotherapy and were followed for 6 months before and 12 months after the index antidiabetic medication to collect data on medication adherence and health care service utilization. Multiple log-linear regression analysis was used to predict medication adherence while negative binomial regressions were used to examine health care service utilization. Medication adherence was found to be significantly lower for patients in capitated plans (5%, P < 0.05). Moreover, patients in capitated plans were associated with 14% more hospitalizations and 16% increased odds of emergency room visits, but 27% fewer outpatient visits compared to those in FFS plans (all P < 0.05). Although Medicaid programs use capitated managed care plans primarily as a cost-containment strategy, these plans may not be cost-effective for the long-term management of chronic conditions such as diabetes.

The h-e-B value-based health management program: impact on asthma medication adherence and healthcare cost

BACKGROUND

Recent publications have shown that copayment reductions increase medication adherence above the effects of existing disease management programs, demonstrating an additive effect of combining a value-based insurance design with a disease management program. This effect, however, has yet to be demonstrated for medications used for the treatment of asthma.

OBJECTIVE

To evaluate the impact of a value-based health management asthma program-which included providing patient education and lowering copayments for select asthma controller medications-on medication adherence and healthcare utilization and costs.

STUDY DESIGN

The study involved a quasi-experimental intervention versus control group design of insured patients diagnosed with asthma.

METHOD

After applying the inclusion/exclusion criteria for study participation, we obtained informed consent from the intervention group; those eligible to participate who did not return the forms served as the control group. The final sample size included 764 patients with asthma-298 in the intervention group and 466 in the control group. The intervention consisted of a reduction in copayment for select asthma controller medications from an average of $20 to $30 down to $5, as well as 3 mailings of educational materials for asthma management. Medical and pharmacy claims data for the study population were used to evaluate all study parameters and outcomes. Medication possession ratio was used to measure adherence to asthma controller medications. Statistical models were used to study differences in the 2 study groups during the 12-month follow-up period for adherence and cost outcomes.

RESULTS

Participation in the value-based health management asthma program increased patients' 12-month medication adherence by 10 absolute percentage points in the intervention group (53.9% for intervention vs 43.9% for control group, P <.001) and significantly decreased average monthly medical costs ($170 intervention vs $229 control, P = .004). This increase in adherence resulted in greater monthly pharmacy costs ($181 intervention vs $124 control, P <.001). However, the increase in pharmacy costs was offset by lower medical costs, leading to a nonsignificant increase in average monthly total healthcare costs ($362 intervention vs $337 control, P = .276).

CONCLUSION

Adoption of a value-based health management program that combines patient education with lowered copayments has a positive impact on medication adherence, resulting in a reduction in associated medical costs and no significant increase in total costs.

Sumatriptan/Naproxen Sodium for Migraine: Efficacy, Health Related Quality of Life, and Satisfaction Outcomes

OBJECTIVE

To describe the pain relief, satisfaction, and health-related quality of life results of moderate or severe migraines treated with a sumatriptan/naproxen sodium combination tablet.

METHODS

Sumatriptan and naproxen sodium as a single-dose formulation tablet was used to treat moderate to severe migraines over a 12-month period in a phase 3, open-label, multicenter study (n = 565) in patients with at least 6 months' history of migraine headaches.

RESULTS

Seventy percent of all attacks were treated with 1 dose of sumatriptan/naproxen sodium. Overall subjects treated 24,485 attacks; of these, 81% attacks achieved pain relief and 60% pain-free by 2 hours. At 3 months, the percentage of patients satisfied or very satisfied increased from baseline on all 8 Patient Perception of Migraine Questionnaire (PPMQ) items and remained high throughout the study. Mean Migraine-Specific Quality of Life Questionnaire (MSQ) domain scores also increased by 13-15 points from baseline during this time and remained high.

CONCLUSIONS

Sumatriptan/naproxen sodium provides consistent relief of migraine attacks over 12 months, resulting in improved patient satisfaction and migraine specific quality of life.

The clinical history and costs associated with delayed diagnosis of bipolar disorder

The purpose of this reported study was to determine healthcare utilization and costs associated with delayed diagnosis of bipolar disorder. With use of automated data from a large integrated health system in the Midwest, all patients with newly diagnosed bipolar disorder recorded in any inpatient or outpatient encounter from January 1, 2000 to August 31, 2002 were identified. The date of initial diagnosis was the index date. For each patient in the bipolar cohort, 5 comparison patients were randomly selected from the general population of health system members and matched with the bipolar patients by sex, race, and age (-/+ 5 years). Data on healthcare utilization (inpatient, outpatient, emergency department, pharmacy) were collected with a focus on mental health, from January 1, 1990, through 1 year after the index date. The cohort is 62% female and 64% White. Median time between initial mental health diagnosis and bipolar diagnosis was 21 months, with 33% of subjects receiving a bipolar diagnosis within 6 months of their initial mental health diagnosis; however, for 31% of the remaining bipolar subjects, the time of their initial mental health presentation to bipolar diagnosis was 4 years or more. The number and duration of treatment with antidepressants increased as time to bipolar diagnosis increased. Patients with bipolar disorder had at least twice the number of interactions with the healthcare system before the index date than the non-bipolar comparison group. Mean monthly costs before and after bipolar diagnosis were not strikingly different for patients with bipolar disorder, but costs after bipolar diagnosis increased with increasing time to bipolar diagnosis. Bipolar disorder is a costly illness for which the impact on the healthcare system may vary depending on how quickly it is diagnosed. Delays in diagnosis appear related to additional costs after diagnosis.

Photodynamic therapy for the treatment of vertebral metastases in a rat model of human breast carcinoma

The feasibility and efficacy of photodynamic therapy (PDT) for the treatment of vertebral metastases using a minimally invasive surgical technique adapted from vertebroplasty was evaluated in a rodent model. Initial validation included photosensitizer (benzoporphyrin-derivative monoacid-ring A) drug uptake studies and in vitro confirmation of PDT efficacy. Intracardiac injection of human MT-1 breast cancer cells was performed in athymic rats. In 63 rats that developed vertebral metastases 21 days post-inoculation, single treatment of PDT was performed using a parapedicular approach placing an optical fiber adjacent to targeted vertebrae. Two milligrams per kilogram of photosensitizer drug was administered intravenously followed by 150 mW of 690 nm light illumination at varying drug-light intervals and light energies. Histologic and immunohistochemical analysis was performed assessing treatment effect. Local tumor viability and growth was quantified by bioluminescence imaging pre and 48 h post-treatment. PDT demonstrated an ablative effect on vertebral metastases (light energies 25-150 J). The effect varied in proportion to light energy with the greatest anti-tumor effect observed at 150 J using a 3 h drug-light interval. 9/22 rodents in the 3 h drug-light interval developed hindlimb paralysis following treatment, consistent with drug uptake studies demonstrating an increase in spinal cord uptake 3h following drug administration. The observations of paralysis following treatment highlight the importance of closely defining the therapeutic window of treatment in safety and efficacy.

Photodynamic therapy for the treatment of metastatic lesions in bone: studies in rat and porcine models

This study represents the first reported use of photodynamic therapy (PDT) for metastatic bone lesions and specifically, as a treatment for spinal metastases. A model of bone metastasis in rat confirmed the efficacy of benzoporphyrin derivative-monoacid-mediated PDT for treating lesions within the spine and appendicular bone. Fluorimetry confirmed the selective accumulation of drug into the tumor(s) at 3 h post-injection. 48 h post-light delivery into the vertebral body of the rat spine loss of bioluminescent signal and histological analyses of sectioned spine confirmed MT-1 tumor cell kill in vivo as previously confirmed in vitro using an established cell viability assay. Porcine vertebrae provided a model comparable to that of human for light propagation and PDT response. Histological examination of vertebrae 48 h post-PDT revealed a necrotic radius of 0.6 cm with an average fluence rate of 4.3 mW/cm2. Non-necrotic tissue damage was evident up to 2 cm out from the treatment fiber. Results support the application of PDT to the treatment of primary or metastatic lesions within bone.

Volume CT with a flat-panel detector on a mobile, isocentric C-arm: Pre-clinical investigation in guidance of minimally invasive surgery

A mobile isocentric C-arm (Siemens PowerMobil) has been modified in our laboratory to include a large area flat-panel detector (in place of the x-ray image intensifier), providing multi-mode fluoroscopy and cone-beam computed tomography (CT) imaging capability. This platform represents a promising technology for minimally invasive, image-guided surgical procedures where precision in the placement of interventional tools with respect to bony and soft-tissue structures is critical. The image quality and performance in surgical guidance was investigated in pre-clinical evaluation in image-guided spinal surgery. The control, acquisition, and reconstruction system are described. The reproducibility of geometric calibration, essential to achieving high three-dimensional (3D) image quality, is tested over extended time scales (7 months) and across a broad range in C-arm angulation (up to 45 degrees), quantifying the effect of improper calibration on spatial resolution, soft-tissue visibility, and image artifacts. Phantom studies were performed to investigate the precision of 3D localization (viz., fiber optic probes within a vertebral body) and effect of lateral projection truncation (limited field of view) on soft-tissue detectability in image reconstructions. Pre-clinical investigation was undertaken in a specific spinal procedure (photodynamic therapy of spinal metastases) in five animal subjects (pigs). In each procedure, placement of fiber optic catheters in two vertebrae (L1 and L2) was guided by fluoroscopy and cone-beam CT. Experience across five procedures is reported, focusing on 3D image quality, the effects of respiratory motion, limited field of view, reconstruction filter, and imaging dose. Overall, the intraoperative cone-beam CT images were sufficient for guidance of needles and catheters with respect to bony anatomy and improved surgical performance and confidence through 3D visualization and verification of transpedicular trajectories and tool placement. Future investigation includes improvement in image quality, particularly regarding x-ray scatter, motion artifacts and field of view, and integration with optical tracking and navigation systems.

Phencyclidine-induced dysregulation of dopamine response to amphetamine in prefrontal cortex and striatum

Phencyclidine (PCP) administration in rodents has been used to model aspects of schizophrenia. One aspect of such treatment has been the enhancement of amphetamine-induced increase of dopamine in the prefrontal cortex and striatum. To further characterize this mechanism rats were treated for 2 weeks with continuous PCP (15 mg/kg per day via Alzet minipump). Rats were implanted with a microdialysis probe into the prefrontal cortex (PFC) or striatum. Amphetamine was administered locally via the dialysis probe during one collection period and changes in extracellular dopamine were monitored. The effect of local administration of the dopamine uptake blocker nomifensine was also measured. Amphetamine (10 microM) and nomifensine (10 microM) increased the level of dopamine in both the PFC and striatum. PCP administration did not alter the response to amphetamine or nomifensine in the PFC, but reduced this response about 2-fold in striatum. To examine effects of continuous PCP administration on dopamine autoreceptor function, release of [3H]dopamine in response to electrical stimulation and in the presence of a dopamine agonist or antagonist was tested in striatal and prefrontal cortical tissue. Autoreceptor responses were similar in control and PCP-treated tissues. We conclude that the brain region-specific enhancement of dopamine release by peripheral amphetamine administration in rats after PCP is not likely mediated by alterations in the dopamine autoreceptors or changes in the dopamine transporter. The selective local responses of amphetamine indicates heterogeneous regional effects of continuous PCP on NMDA receptor function; effects that influence both regional excitatory responses and the overall dynamics of tonic excitatory/inhibitory inputs to the PFC and striatum.

Collaboration, facilities and communities in day care services for older people

Collaborative working in care for older people is often seen as a desirable goal. However, there can be problems with this approach. This paper reports on a single blind randomized controlled trial which was carried out to compare outcomes of rehabilitation in two settings: a day hospital and social services day centres augmented by visiting therapists. The subjects were 105 older patients. Principal outcome measures were the Barthel Index, Philadelphia Geriatric Centre Morale Scale and the Caregiver Strain Index. Two aspects of the trial are examined here. Firstly, we investigated whether trial patients were more disabled than regular day centre attendees. Levels of health and well being amongst trial patients were compared with those of a random sample of 20 regular attendees from both of the participating day centres and an additional voluntary sector day centre. Secondly, key staff from the different settings were interviewed to assess how well the day centre model had worked in practice. Trial patients were significantly more disabled than regular day centre attendees according to the Barthel Index (P < 0.001), but this difference was no longer significant after three months of treatment. The day centre model had several problems, principally discharge policy, acceptability, facilities and attitudes of staff and regular attendees. Positive aspects of the day centre model, as well as successful rehabilitation, included shared skills, knowledge and resources. This paper suggests that collaborative working in day centres requires multipurpose facilities. If health staff maintain a permanent presence, benefits can include improved joint working, easier access to health care and the use of rehabilitative therapy as a preventative strategy. Day care settings can be analyzed as representing different types of communities. Allowing older users a greater degree of choice in facilities may increase the acceptability of care.

The Huntingdon Day Hospital Trial: secondary outcome measures

OBJECTIVE

To compare day hospital to day centre rehabilitation using scales to measure mobility, activities of daily living and quality of life.

DESIGN

Single blind randomized controlled trial with home assessments at baseline (twice), six weeks and three months.

SETTING

Mainly rural health district. Day hospital and social services day centres in market towns.

INTERVENTIONS

Day hospital treatment or day centre rehabilitation by a physiotherapist and two health support workers.

MAIN OUTCOME MEASURES

World Health Organization mobility scale scored with and without aid, Nottingham Extended Activities of Daily Living Scale and Nottingham Health Profile.

SUBJECTS

One hundred and five physically disabled older patients living at home referred for day hospital rehabilitation or maintenance before discharge from hospital (66) or referred as outpatients (39).

RESULTS

At three months there were no statistically significant differences between rehabilitation at day hospital and day centre for any of the outcome measurements. However, there were significant improvements between baseline and three months for the following subscales [mean change per six-week period (95% confidence interval) ]: WHO mobility subscale (with aid) -0.67 (-0.99,-0.35); Nottingham Health Profile mobility subscale -10 (-15.5,-4.5) Nottingham extended ADL mobility subscale +3.08 (1.78,4.37); Nottingham extended ADL leisure subscale +1.66 (0.96,2.36).

CONCLUSION

There were no differences between day hospital and day centre in the outcomes measured. Day rehabilitation appeared to improve functional ability and mobility and scales reflecting these domains deserve further evaluation as outcome measures in this patient group. However, no improvement in quality of life was observed.

A randomized controlled trial of day hospital and day centre therapy

OBJECTIVE

To compare the outcome of day hospital to day centre rehabilitation.

DESIGN

Single blind randomized controlled trial with home assessments at baseline (twice), six weeks and three months.

SETTING

Mainly rural health district. Day hospital and social services day centres in market towns.

SUBJECTS

One hundred and five physically disabled older patients living at home referred for day hospital rehabilitation or maintenance before discharge from hospital (66) or referred as outpatients (39).

INTERVENTIONS

Day hospital treatment or day centre rehabilitation by a physiotherapist and two health support workers.

MAIN OUTCOME MEASURES

Barthel Index, Philadelphia Geriatric Morale Scale and Caregiver Strain Index.

RESULTS

More day centre (23/55) than day hospital patients (6/50) (p <0.001) withdrew from allocated treatment by choice or because of operational difficulties. Both groups improved significantly in functional ability and reduction of care-giver strain by three months but there was no significant difference between groups. The mean improvement in Barthel Index (standard error) for day hospital = +1.5 (0.41) (n = 34) and day centres = +1.5 (0.48) (n = 38). The mean difference (95% confidence interval) between day hospital and day centre was 0 (-1.28, +1.28). Likewise the mean Philadelphia Geriatric Morale Scale improvement for day hospital +1.8 (0.66) (n = 35) and day centres was +0.9 (0.63) (n = 38). The mean difference was -0.88 (-2.7, +0.95). The mean reduction in Caregiver Strain for day hospital was -1.45 (0.5) (n = 23) and day centre was -1.59 (0.47) (n = 27). The difference was -0.14 (1.52, +1.24). (These analyses are all on an intention-to-treat basis.)

CONCLUSION

Whilst the improvement in functional ability and care-giver strain was similar in both groups, day centre rehabilitation was less popular and had practical difficulties. If these difficulties can be overcome the model should be tested elsewhere.

Consciousness: how does it relate to health?

The purpose of this article is to clarify the concept consciousness as it relates to human health and invite nurses to examine a variety of perspectives on the concept that may influence practice, education, and research. A review of American nursing, medical, psychological, and philosophical literature reveals a considerable range of theories that seem to connect, forming a broad foundation for further study. Initial analysis of the concept yields a working definition that consciousness is the fundamental and thoroughly pervasive implicit field of all existence, both seen and unseen. Additionally, the North American Nursing Diagnosis Association human response patterns were found to provide a useful set of empirical referents. Further exploration and testing of these referents may stimulate important insights into the fundamental domains of nursing.

Verification of optical distance indicator accuracy

The purpose of the optical distance indicator, or rangefinder, is to set the patient at a certain distance from the radiotherapy source when using either fixed SSD or an isocentric technique. If the distance that is set is not accurate, then the tumor dose calculated using this distance is also incorrect. Unfortunately, an ODI that is not properly aligned may show an accurate reading on a flat surface and may give an inaccurate reading on a sloped surface.

Comparison of evidenced and expected ADN competencies

These study findings indicate that nursing service administrators in the State of Mississippi expect strong technical level skills from the ADN. Congruency between nursing education and nursing service was validated. The predominance of role competencies outlined by nurse educators were validated as both expected and evidenced for the ADN in the State of Mississippi. Competencies need to be continually evaluated to reflect changes in the health delivery system as related to the ADN.

Comparison of Expected and Evidenced Baccalaureate Degree Competencies

The defining of beginning competencies for the baccalaureate degree in nursing education has been an issue over the past decade. Many researchers have attempted to investigate the performance of graduates of the basic nursing preparation programs. At present, there is little that links education to practice. The purposes of this study were to validate whether the competencies of graduates of baccalaureate degree nursing programs were as expected by nursing service administrators, and whether the expected competencies were evidenced in the work setting. A two-part questionnaire was administered to 142 directors of nursing in health-care settings in Mississippi. The research project requested an evaluation of the baccalaureate competency statement from two perspectives. On a five-point Likert scale, administrators were asked to evaluate if the competency should be expected of a baccalaureate graduate. The administrators then evaluated to what extent the competency statement was evidenced. Analysis of the data was done using descriptive statistics. A mean for each competency was calculated for expected and evidenced responses. A difference of 30% between the expected and evidenced responses was deemed to be significant. Conclusions were drawn and recommendations for further study made.