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ObjectiveRefractory psychiatric disease is a major cause of morbidity and mortality worldwide, and there is a great need for new treatments. In the last decade, investigators piloted novel deep brain stimulation (DBS)-based therapies for depression and obsessive-compulsive disorder (OCD). Results from recent pivotal trials of these therapies, however, did not demonstrate the degree of efficacy expected from previous smaller trials. To discuss next steps, neurosurgeons, neurologists, psychiatrists and representatives from industry convened a workshop sponsored by the American Society for Stereotactic and Functional Neurosurgery in Chicago, Illinois, in June of 2016.DesignHere we summarise the proceedings of the workshop. Participants discussed a number of issues of importance to the community. First, we discussed how to interpret results from the recent pivotal trials of DBS for OCD and depression. We then reviewed what can be learnt from lesions and closed-loop neurostimulation. Subsequently, representatives from the National Institutes of Health, the Food and Drug Administration and industry discussed their views on neuromodulation for psychiatric disorders. In particular, these third parties discussed their criteria for moving forward with new trials. Finally, we discussed the best way of confirming safety and efficacy of these therapies, including registries and clinical trial design. We close by discussing next steps in the journey to new neuromodulatory therapies for these devastating illnesses.ConclusionInterest and motivation remain strong for deep brain stimulation for psychiatric disease. Progress will require coordinated efforts by all stakeholders.

Context: Health-related quality of life (HRQOL) is a multi-dimensional construct including aspects of life quality or function that are affected by physical health and symptoms, psychosocial factors, and psychiatric conditions. HRQOL gives a broader measure of the burden of disease than physical impairment or disability levels. Purpose: To identify factors associated with HRQOL among people with multiple sclerosis (MS) utilizing the SF-8 Health Survey. Methods: Data presented in this study were collected in a survey of 1,518 people with MS living in all 50 states. The survey sample was randomly selected from the database of the National Multiple Sclerosis Society, using ZIP codes to recruit the survey sample. A multiple linear regression model was employed to analyze the survey data, with the Physical Component Summary and the Mental Component Summary of the SF-8 the dependent variables. Independent variables were demographic characteristics, MS-disease characteristics, and health services utilized. Findings: People with MS in rural areas tended to report lower physically related HRQOL. Worsening MS symptoms were associated with reduced physical and mental dimensions of HRQOL. In addition, people with MS who received a diagnosis of depression tended to have reduced physical and mental dimensions of HRQOL. Receiving MS care at an MS clinic was associated with better physically related HRQOL, while having a neurologist as principal care physician was associated with better mental-related HRQOL. Conclusion: The challenge is to increase the access that people living with MS in rural areas have to MS-focused specialty care.

Purpose: Advance directives are important planning and decision-making tools for individuals in nursing homes. Design and Methods: By using the nursing facility Minimum Data Set, we examined the prevalence of advance directives at admission and 12 months post-admission. Results: The prevalence of having any advance directive at admission declined slightly from 2000 to 2004, whereas the prevalence of having any advanced directive at 12 months after admission increased slightly during the same period. Compared with admissions, residents at 12 months post-admission were more likely to have their decisions made by family members and to have advance directives of any type. Implications: The results suggest that greater use of advance directives in nursing homes may depend on additional information and support from nursing facility personnel and the health and social services professionals who are in contact with individuals moving toward nursing home admission, as well as those who remain in facilities over time. (Contains 1 table.)

Context: Advance directives promote patient autonomy and encourage greater awareness of final care options while reducing physician and family uncertainty regarding patient preferences. Purpose: To investigate differences in decision making authority and the use of advance directives among nursing home residents admitted from urban and rural areas. Methods: A total of 551,208 admission assessments in the Minimum Data Set were analyzed for all residents admitted to a nursing facility in 2001. Using the Rural Urban Commuting Areas (RUCA) methodology and ZIP code of primary residence before admission, these residents were classified into 4 urban/rural areas. Findings: Residents from rural areas were significantly more likely to have executed a durable power of attorney for health care or for financial decisions than residents admitted from the other areas, with the largest differences observed between residents admitted from urban and rural areas. Almost 6 residents in 10 from urban areas had no advance directives in place at admission compared with only 4 residents in 10 admitted from rural areas. Conclusions: Health providers and social workers in both rural and urban areas should advise patients about the value of advance directives.

Multiple sclerosis (MS) is the most common neurologic disease that disables younger adults, affecting as many as 350,000 Americans. Purpose: The objectives of this study are to develop profiles of nursing home residents with MS from rural areas and compare them to residents with MS who lived in urban areas, suburban areas, and large towns. Methods: We analyzed all admission assessments for residents with MS (13,357 assessments) in the Minimum Data Set between June 23, 1998, and December 31, 2000, that also had the resident?s ZIP code of primary residence before admission. Findings: Urban and rural comparisons of residents with MS demonstrate a range of significant demographic differences. Significantly greater proportions of MS residents from rural areas exhibited a sense of initiative or involvement in activities of the nursing facility compared with residents with MS from urban and suburban areas. The differences in the utilization of physical and occupational therapies were striking, with MS residents from rural areas averaging significantly fewer minutes of these therapies. We also found that MS residents from rural areas averaged fewer minutes of psychological therapy in the nursing facility and also were less likely to have seen a licensed mental health specialist than MS residents from urban areas. Conclusions: Nursing home residents with MS from rural areas receive fewer therapies and less mental health care than residents with MS from other areas.

Functional imaging studies indicate that the insula encodes the salience of stimuli and deviations from expectations, signals that can mobilize cognitive resources and facilitate learning. However, there is no information about the physiological underpinnings of these phenomena beyond changing BOLD signals. To shed light on this question, we analyzed intracerebral local field potentials (LFPs) in five patients with epilepsy of both genders performing a virtual reality task that featured varying odds of monetary rewards and losses. Upon outcome disclosure, the anterior (but not the posterior) insula generated bursts of beta oscillations whose amplitudes were lower for neutral than positive and negative outcomes, consistent with a salience signal. Moreover, beta burst power was higher when outcomes deviated from expectations, whether the outcome was better or worse than expected, indicating that the insula provides an unsigned prediction error signal. Last, in relation to insular beta bursts, many higher-order cortical areas exhibited robust changes in LFP activity that ranged from spectrally nonspecific or differentiated increases in gamma power to bursts of beta activity that closely resembled the insular beta bursts themselves. Critically, the activity of these other cortical regions was more closely tied in time to insular bursts than task events, suggesting that they are associated with particularly significant cognitive phenomena. Overall, our findings suggest that the insula signals salience and prediction errors via amplitude modulations of beta bursts, which coincide with the near simultaneous recruitment of vast cortical territories. [ABSTRACT FROM AUTHOR]

President George W. Bush has proposed modest increases, when he has proposed any at all, in funding for the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act during his administration, and Congress has appropriated little funding increase since fiscal year 2004. Growing numbers of Americans living with HIV or AIDS, 40000 people newly infected with HIV each year, and Centers for Disease Control and Prevention--recommended efforts to identify people with undiagnosed HIV infection indicate an increasing need for services funded by CARE Act programs. Inadequate CARE Act funding harms the most vulnerable people with HIV. (doi:10.2105/AJPH.2006.107573)

Abstract The purpose of the study was to compare nursing home residents with Alzheimer's disease (AD) in special care units (SCUs) to other AD residents. We analyzed 49,627 admission assessments [...]

Nursing home patients who have HIV infection and dementia are more likely than other HIV patients to have other health problems as well. These health problems included anemia, hepatitis, kidney failure, cancer, depression, schizophrenia, and memory disorders.

The effectiveness of the social safety net in making highly active antiretroviral thereapy and additional AIDS treatment available to HIV patients without other health insurance coverage is discussed.

Responses on questionnaires mailed to directors of state health departments were analyzed to determine the role of public programs in financing tuberculosis (TB) and HIV-related health services. The results revealed that public health departments in all of the states have followed the programs suggested by TB experts. This finding, together with the increase in funding for TB control and prevention from the federal government, accounted for the decrease in the number of reported TB cases.

Objectives. This research examined incentives implemented by public health departments to encourage tuberculosis patients to comply with tuberculosis drug regimens. Methods. A questionnaire addressing incentives was mailed to the directors of each state's health department during May 1995. All 50 states and the District of Columbia returned questionnaires. Results. The survey results indicate that public health departments in almost all states are implementing the incentives advocated by tuberculosis experts. Conclusions. The implementation of these incentives may help to explain why the incidence of tuberculosis resumed its long-term decline in the United States during 1993 after a decade of resurgence. (Am J Public Health. 1997;87: 2014-2017)

The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act was introduced in August 1990, aimed at improving care for AIDS patients and their families. The legislation allows for various grants to state health departments and support services. Title II funding allows states to allocate funds to four areas of health care, namely: medical treatment provision, private health insurance coverage, home-based health services and HIV care consortia. Analysis of completed questionnaires from AIDS program directors shows that the largest share of Title II funding is spent, in most states, on HIV consortia.

Assessment of a rehabilitation client's appropriateness for home health care must include an analysis of potential payment sources such as Medicaid. The purpose of this study is to examine each state's Medicaid policies that define reimbursement, utilization, and coverage of the home health care needed by persons with disabilities. The study also identifies any states that have utilized the Medicaid home and community-based care waiver to develop special Medicaid policies or programs for home health care needs of Medicaid recipients living in the community., Within recent years, the United States has experienced phenomenal growth in the provision of both formal (e.g., by paid agencies and professional personnel) and informal (e.g., by family members or [...]

The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990 was designed to give people with the human immunodeficiency virus and their families greater access to care and enhance the quality of such care. Title II of the law authorizes grants to states to upgrade the quality, availability and organization of health and health-related support services. The manner in which the states are using Title II funds to enforce health insurance continuation programs is evaluated.

The Ryan White Comprehensive AIDS Resource Emergency (CARE) Act seeks to ensure the availability of services to HIV-positive individuals and AIDS victims. Various Home and Community-Based Care (HCBC) services were funded by Title II of the CARE Act in several states during 1995, including personal/attendant care, homemaker or chore services and home IV therapy. The medical and financial criteria needed for individuals to avail of the HCBC services are discussed.

Federal-funded HIV-related healthcare is provided under Title II of the Ryan White Comprehensive AIDS Resource Emergency (CARE) Act of 1990 for people with a higher income than required for eligibility for Medicaid, thus enhancing the public-sector funding safety net. However, federal funding must be sufficient to keep pace with demand so that all eligible people can obtain the appropriate services. An analysis is presented of the provision of treatments under Title II-funded drug-assistance programs by state, including focus on the required financial and medical criteria and the coverage of medications.

A survey of the HIV consortia services, funded by Title II of the Ryan White Comprehensive AIDS Resource Emergency Act, was conducted in various states in 1995. Case management, primary health care, medication, home and dental care were the most effective consortia services provided. State Title II programs have been flexible in terms of the income eligibility standards. The separate administration of the Medicaid and Title II programs, and the Medicaid eligibility process are barriers to the integration of the two services.

Low Medicaid fees result in fewer physicians opting for providing healthcare to Medicaid recipients, which also leads to treatment of fewer Medicaid patients. A wide variation in Medicaid policies in different states also cause problems for Medicaid covered AIDS patients to get physician's care. The ratio of Medicare payments to Medicaid fees averaged 1.42, and private insurers payments averaged 2.23. Federal mandates to standardize Medicaid payment policies and utilization limits on physician's services across states will help in alleviating the problem.

Medicaid programs with policy inducements are motivating factors for health workers engaged in providing home health and hospice services to Medicaid recipients with AIDS. The increasing number of people with AIDS necessitates its comprehensive management with a well defined system of medical, nursing, social, and personal services. Comprehensive hospital-based acute care systems are also required. Enhanced payments, commensurate with the cost of providing care, need to be considered for providers who serve AIDS patients, over 60% of whom are financed by Medicaid programs.

A study conducted on 49 Medicaid programs in different US states shows that the programs vary in different states so that some people with AIDS (PWA) benefit more than others. The PWAs require more hours of nursing care by highly trained individuals and nursing homes have to spend more money on AIDS-related nursing than on other diseases. Since most of the PWAs are economically weaker, to allow them access to Medicaid, it is important for the federal government to homogenize the rules for payment to nursing homes.

As the Medicaid programs become increasingly important payers of AIDS-related care, state governments will face difficult policy choices in allocating limited Medicaid resources among many competing health needs. The state [...]