Healthcare use and costs in the last six months of life by level of care and cause of death.

BACKGROUND: Existing knowledge on healthcare use and costs in the last months of life is often limited to one patient group (i.e., cancer patients) and one level of healthcare (i.e., secondary care). Consequently, decision-makers lack knowledge in order to make informed decisions about the allocation of healthcare resources for all patients. Our aim is to elaborate the understanding of resource use and costs in the last six months of life by describing healthcare use and costs for all causes of death and by all levels of formal care. METHOD: Using five national registers, we gained access to patient-level data for all individuals who died in Norway between 2009 and 2013. We described healthcare use and costs for all levels of formal care-namely primary, secondary, and home- and community-based care -in the last six months of life, both in total and differentiated across three time periods (6-4 months, 3-2 months, and 1-month before death). Our analysis covers all causes of death categorized in ten ICD-10 categories. RESULTS: During their last six months of life, individuals used an average of healthcare resources equivalent to €46,000, ranging from €32,000 (Injuries) to €64,000 (Diseases of the nervous system and sense organs). In terms of care level, 63% of healthcare resources were used in home- and community-based care (i.e., in-home nursing, practical assistance, or nursing home care), 35% in secondary care (mostly hospital care), and 2% in primary care (i.e., general practitioners). The amount and level of care varied by cause of death and by time to death. The proportion of home- and community-based care which individuals received during their last six months of life varied from 38% for cancer patients to 92% for individuals dying with mental diseases. The shorter the time to death, the more resources were needed: nearly 40% of all end-of-life healthcare costs were expended in the last month of life across all causes of death. The composition of care also differed depending on age. Individuals aged 80 years and older used more home- and community-based care (77%) than individuals dying at younger ages (40%) and less secondary care (old: 21% versus young: 57%). CONCLUSIONS: Our analysis provides valuable evidence on how much healthcare individuals receive in their last six months of life and the associated costs, broken down by level of care and cause of death. Healthcare use and costs varied considerably by cause of death, but were generally higher the closer a person was to death. Our findings enable decision-makers to make more informed resource-allocation decisions and healthcare planners to better anticipate future healthcare needs.

Landscape of T Follicular Helper Cell Dynamics in Human Germinal Centers.

T follicular helper (Tfh) cells play a very important role in mounting a humoral response. Studies conducted in mouse models have revealed with good kinetic and spatial resolution the dynamics of these cells in germinal centers (GC) and their cross-talk with B cells upon an immune response. However, whether a similar migratory behavior is performed by human Tfh cells is unclear, as technology to track them in situ has been lacking. In this study, we combined traditional immunohistochemistry and real-time fluorescent imaging approaches on fresh human adenoid slices to provide static and dynamic information on Tfh cells. Our data indicate that GC light zones are composed of two distinct areas in terms of Tfh cell distribution and migration. In the outer GC light zones, Tfh cells migrate actively and with a high ability to form dynamic clusters showing intense and rapid reorganization. In these outer regions, Tfh cells demonstrate multiple interactions between each other. Conversely, in central regions of GC light zones, Tfh cells are much more static, forming long-lasting conjugates. These findings reveal for the first time, to our knowledge, the dynamic behavior whereby Tfh cells migrate in human GC and highlight the heterogeneity of GC for Tfh cell motility.

A Norwegian 15D value algorithm: proposing a new procedure to estimate 15D value algorithms.

PURPOSE: So far there is no Norwegian value algorithm to inform healthcare decision making. The 15D health state values estimated with the original 15D valuation procedure tend to be higher than the values of other generic preference-based health-related quality of life (HRQoL) instruments. The main purpose of this study was to use a new 15D valuation procedure to estimate Norwegian 15D health state values and to explore their empirical performance. METHODS: The visual analogue scale was used to collect 15D valuation data in a representative sample of the Norwegian general population. The new procedure used fewer valuation tasks and anchored the 15D health state values in an empirically assessed range. The Norwegian 15D health state values were compared to the values of five HRQoL instruments which were provided by Norwegian residents belonging to seven disease groups and a healthy population. RESULTS: The Norwegian 15D health state values ranged from 1 to - 0.52. Compared to 15D health state values estimated with the original procedure, the Norwegian 15D health state values were lower and more in line with values of other HRQoL instruments. CONCLUSIONS: The new 15D valuation procedure is simpler, links the 15D health state values better to the requirements of the QALY model, and provides an empirically-based range. We recommend using the new valuation procedure in future 15D valuation studies, and the Norwegian health state values for use in 15D-based health economic analyses in Norway.

Comparing 15D Valuation Studies in Norway and Finland-Challenges When Combining Information from Several Valuation Tasks.

BACKGROUND: The 15D is a generic preference-based health-related quality-of-life instrument developed in Finland. Values for the 15D instrument are estimated by combining responses to three distinct valuation tasks. The impact of how these tasks are combined is relatively unexplored. OBJECTIVES: To compare 15D valuation studies conducted in Norway and Finland in terms of scores assigned in the valuation tasks and resulting value algorithms, and to discuss the contributions of each task and the algorithm estimation procedure to observed differences. METHODS: Norwegian and Finnish scores from the three valuation tasks were compared using independent samples t tests and Lin concordance correlation coefficients. Covariance between tasks was assessed using Pearson product-moment correlations. Norwegian and Finnish value algorithms were compared using concordance correlation coefficients, total ranges, and ranges for individual dimensions. Observed differences were assessed using minimal important difference. RESULTS: Mean scores in the main valuation task were strikingly similar between the two countries, whereas the final value algorithms were less similar. The largest differences between Norway and Finland were observed for depression, vision, and mental function. CONCLUSIONS: 15D algorithms are a product of combining scores from three valuation tasks by use of methods involving multiplication. This procedure used to combine scores from the three tasks by multiplication serves to amplify variance from each task. From relatively similar responses in Norway and Finland, diverging value algorithms are created. We propose to simplify the 15D algorithm estimation procedure by using only one of the valuation tasks.

"When I saw walking I just kind of took it as wheeling": interpretations of mobility-related items in generic, preference-based health state instruments in the context of spinal cord injury.

BACKGROUND: In health economic analyses, health states are typically valued using instruments with few items per dimension. Due to the generic (and often reductionist) nature of such instruments, certain groups of respondents may experience challenges in describing their health state. This study is concerned with generic, preference-based health state instruments that provide information for decisions about the allocation of resources in health care. Unlike physical measurement instruments, preference-based health state instruments provide health state values that are dependent on how respondents interpret the items. This study investigates how individuals with spinal cord injury (SCI) interpret mobility-related items contained within six preference-based health state instruments. METHODS: Secondary analysis of focus group transcripts originally collected in Vancouver, Canada, explored individuals' perceptions and interpretations of mobility-related items contained within the 15D, Assessment of Quality of Life 8-dimension (AQoL-8D), EQ-5D-5L, Health Utilities Index (HUI), Quality of Well-Being Scale Self-Administered (QWB-SA), and the 36-item Short Form health survey version 2 (SF-36v2). Ritchie and Spencer's 'Framework Approach' was used to perform thematic analysis that focused on participants' comments concerning the mobility-related items only. RESULTS: Fifteen individuals participated in three focus groups (five per focus group). Four themes emerged: wording of mobility (e.g., 'getting around' vs 'walking'), reference to aids and appliances, lack of suitable response options, and reframing of items (e.g., replacing 'walking' with 'wheeling'). These themes reflected item features that respondents perceived as relevant in enabling them to describe their mobility, and response strategies that respondents could use when faced with inaccessible items. CONCLUSION: Investigating perceptions to mobility-related items within the context of SCI highlights substantial variation in item interpretation across six preference-based health state instruments. Studying respondents' interpretations of items can help to understand discrepancies in the health state descriptions and values obtained from different instruments. This line of research warrants closer attention in the health economics and quality of life literature.

Safety and efficacy of lysergic acid diethylamide-assisted psychotherapy for anxiety associated with life-threatening diseases.

A double-blind, randomized, active placebo-controlled pilot study was conducted to examine safety and efficacy of lysergic acid diethylamide (LSD)-assisted psychotherapy in 12 patients with anxiety associated with life-threatening diseases. Treatment included drug-free psychotherapy sessions supplemented by two LSD-assisted psychotherapy sessions 2 to 3 weeks apart. The participants received either 200 µg of LSD (n = 8) or 20 µg of LSD with an open-label crossover to 200 µg of LSD after the initial blinded treatment was unmasked (n = 4). At the 2-month follow-up, positive trends were found via the State-Trait Anxiety Inventory (STAI) in reductions in trait anxiety (p = 0.033) with an effect size of 1.1, and state anxiety was significantly reduced (p = 0.021) with an effect size of 1.2, with no acute or chronic adverse effects persisting beyond 1 day after treatment or treatment-related serious adverse events. STAI reductions were sustained for 12 months. These results indicate that when administered safely in a methodologically rigorous medically supervised psychotherapeutic setting, LSD can reduce anxiety, suggesting that larger controlled studies are warranted.

Preliminary investigation of the effect of pulse rate on judgments of swallowing impairment and treatment recommendations.

Reducing fluoroscopic pulse rate, a method used to reduce radiation exposure from modified barium swallow studies (MBSSs), decreases the number of images available from which to judge swallowing impairment. It is necessary to understand the impact of pulse rate reduction on judgments of swallowing impairment and, consequentially, treatment recommendations. This preliminary study explored differences in standardized MBSS measurements [Modified Barium Swallow Impairment Profile (MBSImP™©) and Penetration Aspiration Scale (PAS) Scores] between two pulse rates: 30 and simulated 15 pulses per second (pps). Two reliable speech-language pathologists (SLPs) scored all five MBSSs. Five SLPs reported treatment recommendations based on those scores. Differences in judgments of swallowing impairment were found between 30 and simulated 15 pps in all five MBSSs. These differences were in six physiological swallowing components: initiation of pharyngeal swallow, anterior hyoid excursion, epiglottic movement, pharyngeal contraction, pharyngeal-esophageal segment opening, and tongue base retraction. Differences in treatment recommendations were found between 30 and simulated 15 pps in all five MBSSs. These findings suggest that there are differences in both judgment of swallowing impairment and treatment recommendations when pulse rates are reduced from 30 to 15 pps to minimize radiation exposure.

Determining "in control" versus "not in control" glucose management of medical/surgical community hospital patients.

PURPOSE: To move beyond the correlation analysis between glucose statistics and patient outcome and to benchmark summary statistics calculated on all glucose values taken during an entire individual patient-stay. METHOD: The sample consisted of 141 patient-stays with multiple finger-stick blood glucose (BG) measurements resulting in 5,428 total BGs. Glucose control assessments of the BG profiles for each patient-stay were independently conducted by two endocrinologists. Summary statistics (mean, standard deviation, mean absolute glucose [MAG], percentage of hours of patient-stay with BG over threshold) were calculated for BG using patient-stay as the unit of analysis. RESULTS: Produced numerical benchmarks for the mean (148 mg/dL), SD (40 mg/dL), MAG (6.2), and the percentage of patient-stay hours over 200 mg/dL (10%). Specificity and sensitivity were high, ranging from 91% to 89% for specificity and from 90% to 81% for sensitivity. CONCLUSION: This study demonstrated that benchmarks developed on specific patient populations can be used to evaluate glycemic control in a straightforward, computationally simple system.

Close-up of the immunogenic α1,3-galactose epitope as defined by a monoclonal chimeric immunoglobulin E and human serum using saturation transfer difference (STD) NMR.

Anaphylaxis mediated by carbohydrate structures is a controversially discussed phenomenon. Nevertheless, IgE with specificity for the xenotransplantation antigen α1,3-Gal (α-Gal) are associated with a delayed type of anaphylaxis, providing evidence for the clinical relevance of carbohydrate epitopes in allergy. The aim of this study was to dissect immunoreactivity, interaction, and fine epitope of α-Gal-specific antibodies to obtain insights into the recognition of carbohydrate epitopes by IgE antibodies and their consequences on a molecular and cellular level. The antigen binding moiety of an α-Gal-specific murine IgM antibody was employed to construct chimeric IgE and IgG antibodies. Reactivity and specificity of the resulting antibodies were assessed by means of ELISA and receptor binding studies. Using defined carbohydrates, interaction of the IgE and human serum was assessed by mediator release assays, surface plasmon resonance (SPR), and saturation transfer difference NMR analyses. The α-Gal-specific chimeric IgE and IgG antibodies were proven functional regarding interaction with antigen and Fc receptors. SPR measurements demonstrated affinities in the micromolar range. In contrast to a reference antibody, anti-Gal IgE did not induce mediator release, potentially reflecting the delayed type of anaphylaxis. The α1,3-Gal epitope fine structures of both the recombinant IgE and affinity-purified serum were defined by saturation transfer difference NMR, revealing similar contributions of carbohydrate residues and participation of both galactose residues in interaction. The antibodies generated here constitute the principle underlying α1,3-Gal-mediated anaphylaxis. The complementary data of affinity and fine specificity may help to elucidate the recognition of carbohydrates by the adaptive immune response and the molecular requirements of carbohydrate-based anaphylaxis.

Significance of nonrespiratory airflow during swallowing.

This study was designed to further our understanding of a potentially significant clinical event of negative nasal airflow near the end of the respiratory pause (inhibition) to accommodate swallowing. This negative flow, referred to as "SNIF," or swallow noninspiratory flow, occurs at the onset of airway reestablishment at the conclusion of the oropharyngeal swallow. Using simultaneous digital video fluoroscopic and nasal respiratory airflow recordings on 82 healthy adults (21-97 years old), the objectives of this study were to determine (1) the frequency of occurrence of SNIF during a 5-ml natural cup-drinking task, (2) differences in SNIF occurrence by age group, and (3) the temporal relationship between SNIF and other swallowing events. Results revealed that for most participants SNIF was observed in both swallowing trials. There was a statistically significant difference in SNIF occurrence by age category, with SNIF observed less frequently in the oldest participants. The peak onset of SNIF is closely related to the first release of contact between the soft palate and tongue base with the posterior pharyngeal wall and opening of the laryngeal vestibule. Based on this, and in agreement with previous investigators, we suggest that this negative flow may be related to a partial vacuum established by the relaxation of pharyngeal contraction near the conclusion of the pharyngeal swallow. The more frequent occurrence of SNIF in younger adults and less in older adults suggests a reduction in pharyngeal pressure associated with healthy aging.

Live Imaging of Resident T-Cell Migration in Human Lymphoid Tissue Slices Using Confocal Microscopy.

In order to mount a potent immune response, immune cells must move actively through tissues. As an example, T-cell need to migrate within lymph nodes in order to scan the surface of many dendritic cells and recognize rare expressed antigens. The recent development of improved imaging approaches, such as two-photon microscopy, and the use of powerful mouse models have shed light on some of the mechanisms that regulate the migration of immune cells in many organs. Whereas such systems have provided valuable insights, they do not always predict human responses. In human, our knowledge in the field mainly comes from a description of fixed tissue samples. However, these studies lack a temporal dimension since samples have been fixed. In order to overcome some of these limitations, we describe, in this methodology chapter, an experimental system of fresh human adenoid slices to monitor the dynamics of resident T-lymphocytes that have been stained with directly-coupled fluorescent antibodies. Combined with confocal fluorescent imaging, this preparation offers an effective approach to imaging immune cells in a three-dimensional (3D) human lymphoid tissue environment.

A descriptive study of skin temperature, tissue perfusion, and tissue oxygen in patients with chronic venous disease.

Chronic inflammation and microcirculatory disturbances of the skin have been implicated as causative factors of complications associated with chronic venous disease (CVD). The purpose of this study is to describe the mean differences between and correlations among three measures of microcirculation: skin temperature (Tsk), tissue perfusion/blood flow (BF), and tissue oxygen (tcPO(2)) of CVD-inflamed skin compared to normal controls. In a convenience sample of 55 patients with CVD (n = 31) and without CVD (n = 24), Tsk was measured with an infrared thermometer, BF with a laser Doppler flowmeter, and tcPO( 2) with a transcutaneous oximeter across three measurements periods 1 week apart (Times 1, 2, and 3) at the medial aspect of both lower legs. Tsk was higher (1.2 degrees C) across all measurement periods (p < .05), BF was higher at Times 1 and 3 (p = .002 and .012, respectively), and tcPO(2) was lower at Times 1 and 3 (p = .013 and .050, respectively) in the CVD group as compared to the non-CVD group. BF and Tsk were positively correlated at Times 1 and 2 (r = .516, p < .005; r = 0.278, p = .04) but not at Time 3 (r = 0.235, p > .05). No consistently significant correlations were found between tcPO(2) and BF or tcPO(2) and Tsk (p > .05). Tsk and BF were higher in the skin of lower legs affected by CVD than in those not affected. Pathological processes in the skin produce heat detectable by an infrared thermometer. Measurement and monitoring of Tsk can augment clinical findings and guide treatment when localized inflammation is suspected. Future studies of Tsk should be directed toward the usefulness of infrared technology to develop a CVD leg ulcer prediction model.

Delayed initiation of the pharyngeal swallow: normal variability in adult swallows.

PURPOSE: The purpose of this investigation was to determine bolus head timing and location relations with the onset of hyoid movement at the initiation of the pharyngeal swallow and at the onset of swallow-related apnea. METHOD: Bolus head timing and location and the timing of swallow-related apnea were recorded from frame-by-frame analyses of 5-ml single liquid swallows using dual-modality videofluoroscopy and nasal airflow recordings in 82 consecutive, healthy volunteers. The presence, depth, and response to airway entry were also recorded and related to the bolus head location and the onset of hyoid movement. RESULTS: The majority of participants-80% on at least 1 trial-produced the onset of hyoid movement at pharyngeal swallow initiation after the bolus head passed the posterior angle of the mandible. There was a trend in older participants for later onset of hyoid movement and onset of apnea relative to bolus head arrival at the posterior angle of the mandible. CONCLUSION: Although entry of the bolus head into the pharynx prior to hyoid movement may result in a threat to the laryngeal airway, these data demonstrate that a "delay" by itself cannot be assumed to indicate a disordered swallow without coexisting impairments of swallowing physiology.

Coordination of swallowing and respiration in normal sequential cup swallows.

OBJECTIVES: To establish normative data on laryngeal vestibular closure patterns and respiratory phase patterns during sequential cup swallows in healthy adults. STUDY DESIGN: Cross-sectional study. METHODS: Combined videofluoroscopic and respiratory phase recordings were analyzed in 70 healthy adults during 50 mL sequential liquid cup swallows. The following dependent variables were measured offline from the digitized recordings: 1) number of swallows, 2) number of ingestion cycles (IC) (period of sustained apnea including 1 or more swallows), 3) opening of the laryngeal vestibule after each swallow, and 4) respiratory phase surrounding each IC. Patients were grouped according to the position of the larynx after each swallow. RESULTS: The mean number of swallows was 4.35, and the mean number of ICs was 3.28. Laryngeal vestibular opening after swallows was categorized into three groups: Always Open = 67.1%, Mixed (Open and Closed) = 31.4%, Always Closed = 1.4%. Statistical differences were not found in laryngeal opening pattern by age or sex, but the Always Open group had fewer swallows (4.02 vs. 5.23, P = .008) and a greater number of ICs (3.62 vs. 2.41, P = .001) than the Mixed Group. Respiratory phase after IC was expiration in 79% and inspiration in 21%. CONCLUSIONS: Normal patterns of laryngeal vestibular closure and respiratory phase coordination during sequential swallowing have been described for the first time. The high occurrence of inspiration and laryngeal vestibular opening that surrounds sequential liquid cup swallows when compared with previous findings in single, discrete swallows may place patients with swallowing disorders at greater risk during this task.

A pilot study on the effects of aquatic exercises on discomforts of pregnancy.

OBJECTIVES: To estimate the impact of an aquatic exercise program on perception of body image, participation in health-promoting behaviors, barriers to health-promoting participation, level of physical discomfort, and mobility. DESIGN: A two-group, quasi-experimental, pretest/posttest design. SAMPLE AND SETTING: A convenience sample of 40 nonexercising pregnant women who were at least 19 weeks gestation were recruited. Sixty percent of the sample was African American. Participants self-selected assignment to either the exercise or nonexercise group. Both groups completed self-report measures and underwent a mobility assessment. The exercise group participated in a 60-minute, 6-week aquatic exercise program three sessions per week. The control group was instructed to continue their normal activities of daily living. RESULTS: Women who had participated in the aquatic exercise program reported significantly less physical discomfort, improved mobility, and improved body image and health-promoting behaviors as compared to control subjects. CONCLUSIONS: Aquatic exercise during pregnancy may enhance physical functioning, decreasing maternal discomfort, improving maternal body image, and improving health-promoting behaviors.

The Northern Ireland life review/life storybook project for people with dementia.

There are few interventions that help people with dementia retain or regain a sense of self. Thus, a controlled pilot study examined a life review/life storybook intervention, delivered by familiar care assistants to 30 people with dementia residing in assisted living facilities in Northern Ireland. A multivariate analysis of covariance showed significant change by group (F = 5.01, p < 0.014), particularly on depression (F = 7.54, p < 0.015), communication (F = 23.36, p < 0.005), positive mood (F = 9.47, p < 0.008), and cognition (F = 20.77, p < 0.005), suggesting a potentially promising technique to assist people with dementia.

Are infrared and thermistor thermometers interchangeable for measuring localized skin temperature?

Localized skin temperature must be measured by accurate and reliable thermometers to effectively evaluate treatment outcomes, monitor changes, and predict potential complications. This study compared localized skin temperature measurements with a contact thermistor thermometer used as a reference standard and a noncontact infrared (IR) skin thermometer to determine their interchangeability with calculated Bland-Altman limits of agreement. Fifty-five adults ages 50 to 89 participated in the study in which data were collected in a climate-controlled room over 3 measurement periods, 1 week apart. The thermistor and IR thermometers were interchangeable with a limit of agreement of +/- 1.5 degrees C. This limit of agreement is acceptable as a reference standard for IR thermometers to measure localized skin temperature in clinical settings.

Breathing and swallowing dynamics across the adult lifespan.

BACKGROUND: Aberrations in the physiologic components of normal oropharyngeal swallowing have been linked to aspiration events and to predisposition to aspiration pneumonia, a common, deadly disease in elderly persons. Studies have demonstrated a temporal, physiologic link between breathing and the principal physiologic swallowing components involved in airway protection during swallowing. We developed a normative model of integrated breathing and swallowing patterns using concomitant videofluoroscopic images and nasal respiratory airflow recordings. OBJECTIVES: To establish normative temporal and respiratory-phase pattern relationships between breathing and swallowing in adult human beings across the aging continuum; to relate any alterations in these patterns to swallowing abnormality, an aspiration event during swallowing, and predisposition to aspiration pneumonia; and to develop clinically practical evaluation methods for identifying breathing and swallowing discoordination. SETTING: Fluoroscopy suite in an acute care hospital. PARTICIPANTS: Eighty-two healthy adult volunteers gave informed consent. All eligible healthy volunteers were welcome and were screened for age, race, and sex for equal distribution of each. INTERVENTION: Respiratory-phase patterns and the onset and duration of 11 predetermined swallowing events and associated respiratory activities were studied. All participants' single-liquid barium swallow examinations were studied with simultaneous videofluoroscopy and respiratory recordings. MAIN OUTCOME MEASURES: Onset of each of the 11 predetermined breathing and swallowing events was digitally recorded and analyzed. The phases of breathing before and after swallowing were identified. The presence, depth, and response to airway penetration were recorded and related to respiratory pattern. RESULTS: Four respiratory-phase patterns were identified that changed with advanced age. The correlation analyses of the temporal breathing and swallowing events revealed a normal pattern of 4 clearly distinguishable functional units. Differences in apnea duration and apnea offset occurred with advanced age. CONCLUSION: This research provides evidence for clearly distinguishable patterns and functional groupings of breathing and swallowing events, a necessary first step toward determining whether abnormal breathing and swallowing patterns in patients with dysphagia are associated with health outcome.

Physiologic model of oropharyngeal swallowing revisited.

OBJECTIVE: The purposes of this investigation were to determine whether the temporal onsets of swallow events segment into oral and pharyngeal phases, to test the interdependence of temporal onsets of swallow events, and to determine the influence of age on total swallow duration. STUDY DESIGN AND SETTING: The onsets of swallowing and respiratory measures were studied in 76 healthy normal individuals. RESULTS: Confirmatory factor analysis revealed a 2-factor solution but did not support the hypothesized 2-phase structure (ie, oral and pharyngeal). Two of the onsets, apnea onset and apnea offset, formed a single factor that explained 12.6% of the variation among the 11 onset times. The other 9 onsets formed a second factor that explained 66.4% of the variation. Age accounted for modest variation in total swallow duration. CONCLUSIONS: The two factors, oropharyngeal and respiratory, explained 79% of the variation among the 11 onset times. SIGNIFICANCE: This finding speaks to the overlap between the initiation of oral and pharyngeal components of swallowing in adults and highlights the artificiality of separating the swallowing continuum into isolated phases.

The well-being picture scale: a revision of the index of field energy.

This paper reports the development and psychometric properties of the Well-Being Picture Scale, a 10-item non-language based pictorial scale that measures general well-being, based on Martha Rogers'view of human beings as energy fields in continual mutual process with their environment. The Well-Being Picture Scale was designed for use with the broadest possible range of adult populations, including persons who are unable to respond to English-based text or lengthy, complex measurement instruments. Psychometric properties were established in a sample of more than 2,000 individuals from the United States, Taiwan, Japan, and Africa. The overall Cronbach's alpha is .8795.