Plasma cortisol levels and illness appraisal in deficit syndrome schizophrenia

Research investigating the association between negative symptoms and plasma cortisol levels in individuals with schizophrenia has produced inconsistent findings. This study investigated whether deficit syndrome schizophrenia (characterized by high levels of primary negative symptoms) is associated with comparatively high morning plasma cortisol levels, more negative appraisals about illness and higher levels of depression. Participants were 85 individuals diagnosed with schizophrenia and 85 individuals with no history of contact with psychiatric services matched for age and gender. All participants provided fasting 9.00 a.m. plasma cortisol samples. There were no significant differences between the schizophrenia and control participants in plasma cortisol levels. The Proximal Deficit Syndrome method was used to identify individuals with deficit syndrome schizophrenia. Contrary to what had been hypothesized, participants with deficit syndrome schizophrenia had significantly lower plasma cortisol levels than both non-deficit syndrome participants and control participants. Participants with the deficit syndrome reported significantly less negative appraisals about illness (assessed by PBIQ) and lower levels of depression (assessed by BDI-II). Differences in cortisol levels continued to trend toward significance when levels of depression were controlled for. The patterns of illness-related appraisals and plasma cortisol levels raise the possibility that the deficit syndrome could be a form of adaptation syndrome.

An Appraisal of End-of-Life Care in Persons with Chronic Kidney Disease Dying in Hospital Wards

AIM: To review end-of-life care provided by renal healthcare professionals to hospital in-patients with chronic kidney disease, and their carers, over a 12-month period in Northern Ireland.

METHODS: Retrospective review of 100 patients.

RESULTS: Mean age at death was 72 years (19-95) and 56% were male. Eighty three percent of patients had a 'Not For Attempted Resuscitation' order during their last admission and this was implemented in 42%. Less than 20% of all patients died in a hospital ward. No patients had an advanced care plan, although 42% had commenced the Liverpool Care Pathway for the Dying Patient. Patients suffered excessive end-of-life symptoms. In addition, there was limited documentation of carer involvement and carer needs were not formally assessed.

CONCLUSION: End-of-life care for patients with advanced chronic renal disease can be enhanced. There is significant variation in the recording of discussions regarding impending death and little preparation. There is poor recording of the patients' wishes regarding death. Those with declining functional status, including those frequently admitted to hospital require holistic assessment regarding end-of-life needs. More effective communication between the patient, family and multi-professional team is required for patients who are dying and those caring for them.

Inhabiting Sound: Tactile-sonic links in musical meaning

Connections can be suggested between music’s occupation of physical space, its relative ‘presence’ (using Edward Hall’s notion of proxemics), and the various senses of movement which pervade it. Movement might be seen to operate with respect to music at a variety of levels of metaphorisation – as increasingly complex chains of analogy which point back to our early physical experience of the world. But of course music is, fundamentally, action. Humans put energy into systems - external or internal to themselves - which transduce that energy into the movement of air. At the acoustic level music is, emphatically and unmetaphorically, movement. Perhaps such simple physical perceptions form one route through which we might understand and explore shared senses of meaning and their capacity for ‘transduction’ between multiple individuals. Our (developmentally) early sensory models of the world, built from encounters with its physical resistances and affordances, might be a route to understanding our more clearly encultured and abstracted ('higher' level) understandings of music.

Cross-border Movement of Patients in the EU: A Re-Appraisal

The national welfare state, so it seems, has come under attack by European integration. This article focuses on one facet of the welfare state, that is, health care and on one specific dimension, that is, cross-border movement of patients. The institution which has played a pivotal role in the development of the framework regulating the migration of patients is the European Court of Justice (ECJ). The Court’s activity in this sensitive area has not remained without critics. This was even more so since the Court invoked Treaty (primary) law which not only has made it difficult to overturn case law but also has left the legislator with very little room for manoeuvre in relation to any future (secondary) EU law. What is therefore of special interest in terms of legitimacy is the legal reasoning by which the Court has made its contribution to the development of this framework. This article is a re-appraisal of the legal development in this field.

Cabazitaxel for Hormone-Relapsed Metastatic Prostate Cancer Previously Treated With a Docetaxel-Containing Regimen: An Evidence Review Group Perspective of a NICE Single Technology Appraisal

As part of its single technology appraisal (STA) process, the National Institute for Health and Care Excellence (NICE) invited the company that manufactures cabazitaxel (Jevtana(®), Sanofi, UK) to submit evidence for the clinical and cost effectiveness of cabazitaxel for treatment of patients with metastatic hormone-relapsed prostate cancer (mHRPC) previously treated with a docetaxel-containing regimen. The School of Health and Related Research Technology Appraisal Group at the University of Sheffield was commissioned to act as the independent Evidence Review Group (ERG). The ERG produced a critical review of the evidence for the clinical and cost effectiveness of the technology based upon the company's submission to NICE. Clinical evidence for cabazitaxel was derived from a multinational randomised open-label phase III trial (TROPIC) of cabazitaxel plus prednisone or prednisolone compared with mitoxantrone plus prednisone or prednisolone, which was assumed to represent best supportive care. The NICE final scope identified a further three comparators: abiraterone in combination with prednisone or prednisolone; enzalutamide; and radium-223 dichloride for the subgroup of people with bone metastasis only (no visceral metastasis). The company did not consider radium-223 dichloride to be a relevant comparator. Neither abiraterone nor enzalutamide has been directly compared in a trial with cabazitaxel. Instead, clinical evidence was synthesised within a network meta-analysis (NMA). Results from TROPIC showed that cabazitaxel was associated with a statistically significant improvement in both overall survival and progression-free survival compared with mitoxantrone. Results from a random-effects NMA, as conducted by the company and updated by the ERG, indicated that there was no statistically significant difference between the three active treatments for both overall survival and progression-free survival. Utility data were not collected as part of the TROPIC trial, and were instead taken from the company's UK early access programme. Evidence on resource use came from the TROPIC trial, supplemented by both expert clinical opinion and a UK clinical audit. List prices were used for mitoxantrone, abiraterone and enzalutamide as directed by NICE, although commercial in-confidence patient-access schemes (PASs) are in place for abiraterone and enzalutamide. The confidential PAS was used for cabazitaxel. Sequential use of the advanced hormonal therapies (abiraterone and enzalutamide) does not usually occur in clinical practice in the UK. Hence, cabazitaxel could be used within two pathways of care: either when an advanced hormonal therapy was used pre-docetaxel, or when one was used post-docetaxel. The company believed that the former pathway was more likely to represent standard National Health Service (NHS) practice, and so their main comparison was between cabazitaxel and mitoxantrone, with effectiveness data from the TROPIC trial. Results of the company's updated cost-effectiveness analysis estimated a probabilistic incremental cost-effectiveness ratio (ICER) of £45,982 per quality-adjusted life-year (QALY) gained, which the committee considered to be the most plausible value for this comparison. Cabazitaxel was estimated to be both cheaper and more effective than abiraterone. Cabazitaxel was estimated to be cheaper but less effective than enzalutamide, resulting in an ICER of £212,038 per QALY gained for enzalutamide compared with cabazitaxel. The ERG noted that radium-223 is a valid comparator (for the indicated sub-group), and that it may be used in either of the two care pathways. Hence, its exclusion leads to uncertainty in the cost-effectiveness results. In addition, the company assumed that there would be no drug wastage when cabazitaxel was used, with cost-effectiveness results being sensitive to this assumption: modelling drug wastage increased the ICER comparing cabazitaxel with mitoxantrone to over £55,000 per QALY gained. The ERG updated the company's NMA and used a random effects model to perform a fully incremental analysis between cabazitaxel, abiraterone, enzalutamide and best supportive care using PASs for abiraterone and enzalutamide. Results showed that both cabazitaxel and abiraterone were extendedly dominated by the combination of best supportive care and enzalutamide. Preliminary guidance from the committee, which included wastage of cabazitaxel, did not recommend its use. In response, the company provided both a further discount to the confidential PAS for cabazitaxel and confirmation from NHS England that it is appropriate to supply and purchase cabazitaxel in pre-prepared intravenous-infusion bags, which would remove the cost of drug wastage. As a result, the committee recommended use of cabazitaxel as a treatment option in people with an Eastern Cooperative Oncology Group performance status of 0 or 1 whose disease had progressed during or after treatment with at least 225 mg/m(2) of docetaxel, as long as it was provided at the discount agreed in the PAS and purchased in either pre-prepared intravenous-infusion bags or in vials at a reduced price to reflect the average per-patient drug wastage.

An Enactive Approach to the Design of New Tangible Musical Instruments

In this paper, we propose a theoretical framework for the design of tangible interfaces for musical expression. The main insight for the proposed approach is the importance and utility of familiar sensorimotor experiences for the creation of engaging and playable new musical instruments. In particular, we suggest exploiting the commonalities between different natural interactions by varying the auditory response or tactile details of the instrument within certain limits. Using this principle, devices for classes of sounds such as coarse grain collision interactions or friction interactions can be designed. The designs we propose retain the familiar tactile aspect of the interaction so that the performer can take advantage of tacit knowledge gained through experiences with such phenomena in the real world.

Performance Management in the UK Public Sector: addressing multiple stakeholder complexity

Purpose The aim of this paper is to explore the issues involved in developing and applying performance management approaches within a large UK public sector department using a multiple stakeholder perspective and an accompanying theoretical framework. Design/methodology/approach An initial short questionnaire was used to determine perceptions about the implementation and effectiveness of the new performance management system across the organisation. In total, 700 questionnaires were distributed. Running concurrently with an ethnographic approach, and informed by the questionnaire responses, was a series of semi-structured interviews and focus groups. Findings Staff at all levels had an understanding of the new system and perceived it as being beneficial. However, there were concerns that the approach was not continuously managed throughout the year and was in danger of becoming an annual event, rather than an ongoing process. Furthermore, the change process seemed to have advanced without corresponding changes to appraisal and reward and recognition systems. Thus, the business objectives were not aligned with motivating factors within the organisation. Research limitations/implications Additional research to test the validity and usefulness of the theoretical model, as discussed in this paper, would be beneficial. Practical implications The strategic integration of the stakeholder performance measures and scorecards was found to be essential to producing an overall stakeholder-driven strategy within the case study organisation. Originality/value This paper discusses in detail the approach adopted and the progress made by one large UK public sector organisation, as it attempts to develop better relationships with all of its stakeholders and hence improve its performance. This paper provides a concerted attempt to link theory with practice.

Cutaneous Grooves: Composing for the Sense of Touch

What if the traditional relationship between touch and music was essentially turned upside down, making the tactile sensation the aesthetic end? This paper presents a novel coupling of haptics technology and music, introducing the notion of tactile composition or aesthetic composition for the sense of touch. A system that facilitates the composition and perception of intricate, musically structured spatio-temporal patterns of vibration on the surface of the body is described. Relevant work from disciplines including sensory substitution, electronic musical instrument design, simulation design, entertainment technology, and visual music is considered. The psychophysical parameter space for our sense of touch is summarized and the building blocks of a compositional language for touch are explored. A series of concerts held for the skin and ears is described, as well as some of the lessons learned along the way. In conclusion, some potential evolutionary branches of tactile composition are posited.

Collaborative Planning in an Uncollaborative World

The purpose of this paper is to expose the concept of collaborative planning to the reality of planning, thereby assessing its efficacy for informing and explaining what planners 'really' do and can do. In this systematic appraisal, collaborative planning is disaggregated into four elements that can enlighten such conceptual frameworks: ontology, epistemology, ideology and methodology. These four lenses help delimit and clarify collaborative planning's strengths and weaknesses. The conceptual debate is related to an empirical investigation of planning processes, ranging from region-wide to local and from statutory to visionary in an arena where special care has been invested in participatory deliberation processes. The final analysis provides a systematic gauge of collaborative planning in light of the extensive empirical evidence, deploying the four conceptual dimensions introduced in part one. This exposes a range of problems not only with the concept itself but also regarding its affinity with the uncollaborative world within which it has to operate. The former shed light on those aspects where collaborative planning as a conceptual tool for practitioners needs to be renovated, while the latter highlight inconsistencies in a political framework that struggles to accommodate both global competitiveness and local democratic collaboration.

Validity, trustworthiness and rigour:reasserting realism in qualitative research

Aim The aim of this paper is to challenge recent sceptical approaches to the possibility of validating qualitative research and to underline the benefits of adopting a realist approach to validity. Background In recent discussion about the methodological bases for qualitative research it has been argued that, because different methodologies take different approaches to validity, attempts to develop a common set of validation criteria are futile. On the basis of this sceptical view, a number of strategies for judging qualitative research have been proposed. These include suggestions that: it should be judged according to aesthetic or rhetorical criteria, rather than epistemological validity; responsibility for appraisal should move from researchers to readers; each methodology should be assessed individually according to its own merits. Discussion None of these suggestions provide a viable alternative to validity, defined as the extent to which research reflects accurately that to which it refers. Because the form of research does not determine its content, replacement of epistemology by aesthetics is unsustainable. Because research reports mediate between writer and reader, a one-sided approach to this relationship constitutes a false dichotomy. If we accept the criterion of practitioner confidence as a means of judging methodological approaches, this involves rejection of judgement according to a methodology�s own merits. Conclusion If qualitative research is actually about something, and if it is required to provide beneficial information, then a realist approach to validity holds out greatest promise.

Grading gems: Appraising the quality of research about social work and social care.

The impetus towards basing practice and policy decisions more explicitly on sound research requires tools to facilitate the systematic appraisal of the quality of research encompassing a diverse range of methods and designs. Five exemplar tools were developed and assessed in terms of their usefulness in selecting studies for inclusion in a systematic review. The widely used ‘hierarchy of evidence’ was adapted and used to appraise internal validity. Four tools were then developed to appraise the external validity dimensions of generalizability (two scales) and methods of data collection (two scales). Methods of combining the scores generated by each tool were explored. Qualitative and quantitative studies were appraised, not separated into two spheres but by using complementary tools developed to appraise different aspects of rigour. There was a high level of agreement between researchers in applying the tools to twenty-two studies on decision making by professionals about the longterm care of older people. The scales for internal validity and generalizability discriminated between the qualities of studies appropriately. The two tools to appraise data collection gave diverse results. Excluding studies that scored in the lowest category on any scale appeared to be the scoring system that was most justifiable. This approach is presented to stimulate debate about the practical application of the evidence-based initiative to social work and social care. This study may assist in developing clearer definitions and common language about appraising rigour that should further the process of selecting robust research for synthesis to inform practice and policy decisions.

Maternal appraisals of risk, coping and prenatal attachment among women hospitalised with pregnancy complications

One goal of pregnancy is the development of maternal emotional attachment to
the unborn baby, and this attachment has been shown to be related to later
relationships and development. There are many factors which may hinder the
development of prenatal attachment, including the presence of complications,
hospitalisation, and anxiety. However, women’s appraisals of risk may not be
congruent with medical assessments of risk. The current study sought to model
the relationships between risk (maternal perceptions and medical ratings), coping, psychological well-being, and maternal–foetal attachment among 87 women hospitalised for pregnancy-related complications. Analysis indicated that positive appraisal as a coping strategy mediates the relationship between maternal appraisals of risk and maternal–foetal attachment, and that medical ratings of risk were not predictive of maternal–foetal attachment. Awareness of the potential incongruence between patients’ and health professionals’ perceptions of risk is important within the clinical environment. The potential benefits of promoting positive appraisal in high-risk pregnancy merit further research.