Considering a Health Insurance Exchange: Lessons From the Rhode Island Experience

Describes Rhode Island's public process to clarify and prioritize stakeholders' goals for a health insurance exchange, evaluate its components, consider the state's market characteristics, and identify and evaluate options. Outlines lessons learned

Crafted Things in the Old English Phoenix

Crafted things abound in The Phoenix, from the ornamented trees in the phoenix’s paradise, to the gem-like bird itself: in the world of the poem, beauty is synonymous with the skilful design of material things. In spite of this emphasis on construction and creation, the poem also foreshadows the necessary destruction of all the ornaments of this world. This paper reconsiders the crafted things in the poem, including not only the famous description of the phoenix itself, but also the phoenix’s nest, and the mysterious ball it fashions out of its own bones and ashes, reading these crafted things alongside analogues from both Old and Middle English literature. This new reading reveals that the crafted things of the poem are central to the poem’s message about the certainty of the resurrection and the cessation of all cycles of creation and destruction. Although, in the end, the poem reveals that all the crafted things of this world must eventually be exchanged for the lasting home and gleaming ornaments of heaven, the treasures of The Phoenix have an enduring vibrancy which remains even in the face of the destroying Judgement Day fires

Treasure and the life course in Genesis A and Beowulf

In Old English heroic poetry, significant moments of transition in the life course are accompanied by the transmission of wealth. In the genealogical sections of Genesis A, for example, the cycles of death and succession are punctuated with the inheritance and distribution of wealth, just as in Beowulf succession tends to be marked by a valuable gift. Though the body of the parent perishes, their legacy continues in the form of their heir, and the treasure which that heir controls. This paper firstly identifies a model for death and succession, used repeatedly in Genesis A, which combines the central elements of this heroic ideal: the death of the leader, their wealth, their heir and what the heir does with this wealth. Secondly, this paper argues that the failure of this model at the end of Beowulf reflects the poet’s preoccupation with uncertain dynastic succession at the end of the poem

RELIABILITY OF A TRUNK MOUNTED ACCELEROMETER WHEN DETERMINING GAIT PARAMETERS IN PEOPLE WITH STROKE

Wearable sensors and accelerometers can objectively and reliably assess gait parameters in both healthy individuals and stroke patients. The purpose of this study was to determine whether a wireless tri-axial accelerometer is reliable when measuring spatio-temporal gait parameters in patients with stroke. Thirty-one chronic stroke patients (age: 59.5±13.6 years; time since stroke: 28.1±17.8 months) completed three repeated walks along a 10m flat walkway whilst wearing a trunk mounted accelerometer (BTS G-Walk) secured around the waist of the participant over the L5 vertebrae. Outcome measures included cadence, speed, stride length, %stride length/height, gait cycle duration, step length, stance and swing phase duration, single and double support duration for both symptomatic and asymptomatic lower limbs where relevant. Reliability was assessed via intraclass correlation coefficient (ICC), standard error of the mean (SEM) and smallest detectable change (SDC) values. ICCs were \u3e 0.75 for all parameters, excluding step length on the asymptomatic side (ICC = 0.70). SEM and the SDC were marginally larger for the symptomatic limb than the asymptomatic limb for gait cycle duration and step length, but smaller for all other outcomes. The study showed that the BTS G-Walk is a reliable tool for measuring spatio-temporal parameters in patients with stroke. Physiotherapists and clinicians often prefer detailed information on gait ability. As advanced technologies could help with specific goals relating to gait performance, such devices could be reliably implemented as an alternative to the gold standard in clinical and community settings to monitor patients outside of a lab-based environment

Using robotic-assisted technology to improve lower-limb function in people with stroke

Robotic-assisted gait training is becoming an important component of the rehabilitation strategy when working with patients diagnosed with a stroke. To date, research has largely focused on the effect of using robotic-assisted devices on lower limb function through the assessment of gait and balance parameters in sub-acute and chronic stroke patients, in a clinical setting. However, there may be significant benefit of implementing robotic-assisted gait training devices in the acute hospital setting soon after stroke diagnosis, but also with chronic stroke patients as a home-based rehabilitation tool. This article concludes that further research is needed when considering the influence of robotic-assisted technology on the early mobilisation (i.e., ability to stand and walk with and/or without the support from a therapist) of stroke patients in the hospital setting, their implementation in a home-based environment, and the need to incorporate more robust, quantifiable and scientific techniques to evaluate stroke patient progress through a variety of biomechanical assessment parameters

Examining the Potential Disconnect Between Parents’ Perceptions and Reality Regarding the Physical Activity Levels of Their Children

Background: Parental support plays an important role in facilitating the participation of children in physical activity. However, there is evidence that parents overestimate their child’s level of physical activity – this may lead to inaction in promotion attempts by parents. This potential disconnect between parental perceptions and reality was recently the focus of the ‘Think Again’ social marketing campaign developed by PartipACTION. Purpose: To qualitatively explore parents’ perceptions of the Think Again advertisements, and the possible disconnect between perceptions and reality regarding their children’s physical activity levels. Method: Semi-structured interviews were conducted with 12 mothers and 12 fathers of children aged 5-11 years attending a supervised recreation class. A thematic analysis was applied to the collected data. Results: The advertisements were generally well received by the parents in serving as a reminder of how much physical activity their children should be getting. Less than half of parents believed their children were attaining physical activity guidelines although the majority believed they were sufficiently active given perceived time constraints for both them and their child. Most parents believed they could accurately estimate how active their child was but that other parents may have difficulty due to reliance on schools and organized recreation to provide opportunities for physical activity. Conclusion: PSAs have a role to play in increasing parental awareness of physical activity guidelines and communicating the importance of physical activity. More creative approaches will be needed to address the disconnect in the perceptions between sufficient and recommended levels of physical activity

Prognostic value of test(s) for O6-methylguanine–DNA methyltransferase (MGMT) promoter methylation for predicting overall survival in people with glioblastoma treated with temozolomide

BACKGROUND: Glioblastoma is an aggressive form of brain cancer. Approximately five in 100 people with glioblastoma survive for five years past diagnosis. Glioblastomas that have a particular modification to their DNA (called methylation) in a particular region (the O(6)‐methylguanine–DNA methyltransferase (MGMT) promoter) respond better to treatment with chemotherapy using a drug called temozolomide. OBJECTIVES: To determine which method for assessing MGMT methylation status best predicts overall survival in people diagnosed with glioblastoma who are treated with temozolomide. SEARCH METHODS: We searched MEDLINE, Embase, BIOSIS, Web of Science Conference Proceedings Citation Index to December 2018, and examined reference lists. For economic evaluation studies, we additionally searched NHS Economic Evaluation Database (EED) up to December 2014. SELECTION CRITERIA: Eligible studies were longitudinal (cohort) studies of adults with diagnosed glioblastoma treated with temozolomide with/without radiotherapy/surgery. Studies had to have related MGMT status in tumour tissue (assessed by one or more method) with overall survival and presented results as hazard ratios or with sufficient information (e.g. Kaplan‐Meier curves) for us to estimate hazard ratios. We focused mainly on studies comparing two or more methods, and listed brief details of articles that examined a single method of measuring MGMT promoter methylation. We also sought economic evaluations conducted alongside trials, modelling studies and cost analysis. DATA COLLECTION AND ANALYSIS: Two review authors independently undertook all steps of the identification and data extraction process for multiple‐method studies. We assessed risk of bias and applicability using our own modified and extended version of the QUality In Prognosis Studies (QUIPS) tool. We compared different techniques, exact promoter regions (5'‐cytosine‐phosphate‐guanine‐3' (CpG) sites) and thresholds for interpretation within studies by examining hazard ratios. We performed meta‐analyses for comparisons of the three most commonly examined methods (immunohistochemistry (IHC), methylation‐specific polymerase chain reaction (MSP) and pyrosequencing (PSQ)), with ratios of hazard ratios (RHR), using an imputed value of the correlation between results based on the same individuals. MAIN RESULTS: We included 32 independent cohorts involving 3474 people that compared two or more methods. We found evidence that MSP (CpG sites 76 to 80 and 84 to 87) is more prognostic than IHC for MGMT protein at varying thresholds (RHR 1.31, 95% confidence interval (CI) 1.01 to 1.71). We also found evidence that PSQ is more prognostic than IHC for MGMT protein at various thresholds (RHR 1.36, 95% CI 1.01 to 1.84). The data suggest that PSQ (mainly at CpG sites 74 to 78, using various thresholds) is slightly more prognostic than MSP at sites 76 to 80 and 84 to 87 (RHR 1.14, 95% CI 0.87 to 1.48). Many variants of PSQ have been compared, although we did not see any strong and consistent messages from the results. Targeting multiple CpG sites is likely to be more prognostic than targeting just one. In addition, we identified and summarised 190 articles describing a single method for measuring MGMT promoter methylation status. AUTHORS' CONCLUSIONS: PSQ and MSP appear more prognostic for overall survival than IHC. Strong evidence is not available to draw conclusions with confidence about the best CpG sites or thresholds for quantitative methods. MSP has been studied mainly for CpG sites 76 to 80 and 84 to 87 and PSQ at CpG sites ranging from 72 to 95. A threshold of 9% for CpG sites 74 to 78 performed better than higher thresholds of 28% or 29% in two of three good‐quality studies making such comparisons

What if we decided to take care of everyone who needed treatment? Workforce planning in Mozambique using simulation of demand for HIV/AIDS care

Background: The growing AIDS epidemic in southern Africa is placing an increased strain on health systems, which are experiencing steadily rising patient loads. Health care systems are tackling the barriers to serving large populations in scaled-up operations. One of the most significant challenges in this effort is securing the health care workforce to deliver care in settings where the manpower is already in short supply. Methods: We have produced a demand-driven staffing model using simple spreadsheet technology, based on treatment protocols for HIV-positive patients that adhere to Mozambican guidelines. The model can be adjusted for the volumes of patients at differing stages of their disease, varying provider productivity, proportion who are pregnant, attrition rates, and other variables. Results: Our model projects the need for health workers using three different kinds of goals: 1) the number of patients to be placed on anti-retroviral therapy (ART), 2) the number of HIV-positive patients to be enrolled for treatment, and 3) the number of patients to be enrolled in a treatment facility per month. Conclusion: We propose three scenarios, depending on numbers of patients enrolled. In the first scenario, we start with 8000 patients on ART and increase that number to 58 000 at the end of three years (those were the goals for the country of Mozambique). This would require thirteen clinicians and just over ten nurses by the end of the first year, and 67 clinicians and 47 nurses at the end of the third year. In a second scenario, we start with 34 000 patients enrolled for care (not all of them on ART), and increase to 94 000 by the end of the third year, requiring a growth in clinician staff from 18 to 28. In a third scenario, we start a new clinic and enrol 200 new patients per month for three years, requiring 1.2 clinicians in year 1 and 2.2 by the end of year 3. Other clinician types in the model include nurses, social workers, pharmacists, phlebotomists, and peer counsellors. This planning tool could lead to more realistic and appropriate estimates of workforce levels required to provide high-quality HIV care in a low-resource settings