Fear of recurrence: results of a randomized trial of relapse detection in schizophrenia.

OBJECTIVE: We aimed to develop and establish the reliability and validity of a measure of Fear of Recurrence, measuring cognitive appraisals of relapse rather than standard early signs of relapse. We also aimed to establish the sensitivity and specificity to relapse. METHOD: Participants diagnosed with schizophrenia or a related disorder were randomized to one of two early signs monitoring conditions, using either the Early Signs Scale or the Fear of Recurrence Scale (FoRSe). Participants were followed up for 6-months or until relapse. RESULTS: A total of 169 participants were randomized to Standard (n = 86) or FoRSe (n = 83) monitoring. We found good evidence supporting reliability and validity of the FoRSe. In addition, a cut-off point of ≥ 5 was associated with an optimal sensitivity in both Standard (n = 26:79%, 95% CI = 62-89) and FoRSe (n = 18:72%, 95% CI = 52-86) monitoring. However, this degree of sensitivity was associated with a lower specificity in Standard (n = 30:35%, 96% CI = 23-50) and FoRSe (n = 25:46%, 95% CI = 32-60). Finally, Fear of Relapse was a significant predictor of time to relapse [Exp(ß) = 1.20, 95% CI = 1.01-1.42, p < .05]. CONCLUSION: The study provides evidence that Fear of Recurrence may be an important clinical construct linked to increased risk of relapse and poorer emotional recovery in people diagnosed with schizophrenia. PRACTITIONER POINTS: Monitoring Fear of Recurrence is as sensitive to relapse detection as monitoring early signs alone. Greater Fear of Relapse was associated with shorter duration to actual relapse. Fear of recurrence may be an important clinical feature linked to poorer emotional recovery and increased risk of relapse. Fear of Recurrence may be an important focus of psychological therapy to promote emotional recovery and prevention of relapse.

Bundled payments: bundled risk or bundled reward?

One potential option of President Obama's proposed health care plan is to change from fee-for-service to episode-of-care payments. These global payments would combine physician and hospital reimbursement from admission to discharge. In an effort to further evaluate this strategy, CMS has initiated a pilot study called the Acute Care Episode (ACE) Demonstration. Five hospitals in the United States have been chosen to participate. The authors review the history of bundled payments, the current ACE Demonstration, and the opinions of those radiologists involved and attempt to outline a plan for hospital-based practices to prepare for this possible scenario.

Administration of drug and nutritional components in nano-engineered form to increase delivery ratio and reduce current inefficient practice.

The article critically discusses parenteral delivery of self-assembled lipid or amphiphile nanoparticles, in the form of aggregated clusters or particles (capsules). The end-product or drug form is for application by administration of the medicine active in encapsulated form. This is used for site-specific cell manipulation and clinical therapy and introduces this directly to the body via the systemic route. The technology discussed represents a platform formulation that can be modified for a range of specific cellular targets. The components of the nanoparticle are assembled piece-by-piece and this provides an element of design flexibility, with the core particle being built-up in a succession of layers to ensure circulatory longevity and storage stability. This strategy excludes a more generalised delivery and widespread lack of active targeting and thus low dosage rather than avoidance of target, which is at best detrimental and at worst catastrophic in terms of non-targeted cell death. However, in some cases such as the AmBisome nanoparticle this drug delivery approach can work. This "better focussing" is achieved by a dual use of i) biocompatible particle coating chemistry and a ii) cell-ligand imprinted nanoparticle surface that furnishes the engineered nanoparticle with a recognition element to form a complex but more efficacious dispersible fusogenic pro-drug moiety. Non-targeted delivery of drugs such as those commonly forming the basis of transdermal delivery have been generically based on topical or adhesive patch-based delivery (emulsions) systems. This procedure even with recent advancements and patents is customarily inefficient in dosage and payload delivery, inconsistent in terms of product potency and inflexible to further modification or purpose-related enhancement. The assembly and delivery methodologies discussed here take the new experimental medicine and review them in a more focused and purposeful therapy-constructed manner. It is the use of a smart platform technology that is responsible for increased efficacy when applied to the disorder of interest.