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Weight Change Following Diagnosis With Psychosis: A 25 Year Perspective in Greater Manchester, UK
- Adrian Heald, Lamiece Hassan, Joseph Firth, Mark Livingston, Martin Gibson, Christopher Daly
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- Journal:
- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, pp. S51-S52
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Aims
Weight gain in the months/years after diagnosis/treatment severe enduring mental illness (SMI) is a major predictor of future diabetes, dysmetabolic profile and increased cardiometabolic risk in people treated with antipsychotic agents. There is limited data on the longer term profile of weight change in people with a history of SMI and how this may differ between individuals. We here report a 25-year perspective on weight change post-SMI diagnosis in Greater Manchester UK, an ethnically and culturally diverse community, with particular focus on a history of psychosis vs bipolar affective disorder.
MethodsWe undertook an anonymised search in the Greater Manchester Care Record (GMCR). We reviewed the health records of anyone who had been diagnosed for the first time with first episode psychosis, schizophrenia, schizoaffective disorder, delusional disorder (non-affective psychosis = NAP) also bipolar disorder = BPD). We analysed body mass index (BMI) change in the period before and after first prescription of anti-psychotic medication.
ResultsWe identified 9125 people with the diagnoses above. NAP (n = 5618; 37.5% female) mean age 49.3 years; BPD (n = 4131; 63.3% female) mean age 48.1 years. Follow-up period was up to 25 years. 27.0% of NAP were of non-white ethnicity vs 17.8% of BAP individuals.
A higher proportion of people diagnosed with NAP were in the highest quintile of social disadvantage 52.4% vs 39.5% for BPD. There were no significant differences in baseline BMI profile but mean HbA1c in those 2103 people where available was higher in NAP at baseline at 40.4mmol/mol vs 36.7mmol/mol for BPD.
At 5-year follow-up 53.6% of those NAP with a normal healthy BMI transitioned to obese / overweight BMI vs 55.6% with BPD. 43.7% of those NAP with normal BMI remained at a healthy BMI vs 42.7 % with BPD. At 5-year FU for NAP, 83.1% of those with BMI ≥30kg/m2 stayed in this category vs 81.5% of BPD.
At 5-year follow-up there was similarity in the overall % NAP in the obese ≥30kg/m2 category (42.4%) vs BPD (44.1%).
ConclusionThe results of this 25-year real world longitudinal cohort study suggest that the changes in BMI with treatment of non-affective psychosis vs bipolar disorder are not significantly different, highlighting the importance of regular physical health monitoring in all people with SMI.
Using longitudinal population data in this way has the potential to open up new avenues of research in psychiatry in terms of physical and mental health outcomes.
Diagnostic stewardship of C. difficile testing: a quasi-experimental antimicrobial stewardship study
- Alyssa B. Christensen, Viktorija O. Barr, David W. Martin, Morgan M. Anderson, Amanda K. Gibson, Brian M. Hoff, Sarah H. Sutton, Valerie Widmaier, Asra A. Salim, Christina Silkaitis, Chao Qi, Teresa R. Zembower, Michael J. Postelnick, Nathaniel J. Rhodes
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 40 / Issue 3 / March 2019
- Published online by Cambridge University Press:
- 21 February 2019, pp. 269-275
- Print publication:
- March 2019
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Objective:
We evaluated whether a diagnostic stewardship initiative consisting of ASP preauthorization paired with education could reduce false-positive hospital-onset (HO) Clostridioides difficile infection (CDI).
Design:Single center, quasi-experimental study.
Setting:Tertiary academic medical center in Chicago, Illinois.
Patients:Adult inpatients were included in the intervention if they were admitted between October 1, 2016, and April 30, 2018, and were eligible for C. difficile preauthorization review. Patients admitted to the stem cell transplant (SCT) unit were not included in the intervention and were therefore considered a contemporaneous noninterventional control group.
Intervention:The intervention consisted of requiring prescriber attestation that diarrhea has met CDI clinical criteria, ASP preauthorization, and verbal clinician feedback. Data were compared 33 months before and 19 months after implementation. Facility-wide HO-CDI incidence rates (IR) per 10,000 patient days (PD) and standardized infection ratios (SIR) were extracted from hospital infection prevention reports.
Results:During the entire 52 month period, the mean facility-wide HO-CDI-IR was 7.8 per 10,000 PD and the SIR was 0.9 overall. The mean ± SD HO-CDI-IR (8.5 ± 2.0 vs 6.5 ± 2.3; P < .001) and SIR (0.97 ± 0.23 vs 0.78 ± 0.26; P = .015) decreased from baseline during the intervention. Segmented regression models identified significant decreases in HO-CDI-IR (Pstep = .06; Ptrend = .008) and SIR (Pstep = .1; Ptrend = .017) trends concurrent with decreases in oral vancomycin (Pstep < .001; Ptrend < .001). HO-CDI-IR within a noninterventional control unit did not change (Pstep = .125; Ptrend = .115).
Conclusions:A multidisciplinary, multifaceted intervention leveraging clinician education and feedback reduced the HO-CDI-IR and the SIR in select populations. Institutions may consider interventions like ours to reduce false-positive C. difficile NAAT tests.
Verbal Initiation, Suppression, and Strategy Use and the Relationship with Clinical Symptoms in Schizophrenia
- Andrew K. Martin, Emily C. Gibson, Bryan Mowry, Gail A. Robinson
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- Journal:
- Journal of the International Neuropsychological Society / Volume 22 / Issue 7 / August 2016
- Published online by Cambridge University Press:
- 22 June 2016, pp. 735-743
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Objectives: Individuals with schizophrenia have difficulties on measures of executive functioning such as initiation and suppression of responses and strategy development and implementation. The current study thoroughly examines performance on the Hayling Sentence Completion Test (HSCT) in individuals with schizophrenia, introducing novel analyses based on initiation errors and strategy use, and association with lifetime clinical symptoms. Methods: The HSCT was administered to individuals with schizophrenia (N=77) and age- and sex-matched healthy controls (N=45), along with background cognitive tests. The standard HSCT clinical measures (initiation response time, suppression response time, suppression errors), composite initiation and suppression error scores, and strategy-based responses were calculated. Lifetime clinical symptoms [formal thought disorder (FTD), positive, negative] were calculated using the Lifetime Dimensions of Psychosis Scale. Results: After controlling for baseline cognitive differences, individuals with schizophrenia were significantly impaired on the suppression response time and suppression error scales. For the novel analyses, individuals with schizophrenia produced a greater number of initiation errors and subtly wrong errors, and produced fewer responses indicative of developing an appropriate strategy. Strategy use was negatively correlated with FTD symptoms in individuals with schizophrenia. Conclusions: The current study provides further evidence for deficits in the initiation and suppression of verbal responses in individuals with schizophrenia. Moreover, an inability to attain a strategy at least partly contributes to increased semantically connected errors when attempting to suppress responses. The association between strategy use and FTD points to the involvement of executive deficits in disorganized speech in schizophrenia. (JINS, 2016, 22, 735–743)
Contributors
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- By Mitchell Aboulafia, Frederick Adams, Marilyn McCord Adams, Robert M. Adams, Laird Addis, James W. Allard, David Allison, William P. Alston, Karl Ameriks, C. Anthony Anderson, David Leech Anderson, Lanier Anderson, Roger Ariew, David Armstrong, Denis G. Arnold, E. J. Ashworth, Margaret Atherton, Robin Attfield, Bruce Aune, Edward Wilson Averill, Jody Azzouni, Kent Bach, Andrew Bailey, Lynne Rudder Baker, Thomas R. Baldwin, Jon Barwise, George Bealer, William Bechtel, Lawrence C. Becker, Mark A. Bedau, Ernst Behler, José A. Benardete, Ermanno Bencivenga, Jan Berg, Michael Bergmann, Robert L. Bernasconi, Sven Bernecker, Bernard Berofsky, Rod Bertolet, Charles J. Beyer, Christian Beyer, Joseph Bien, Joseph Bien, Peg Birmingham, Ivan Boh, James Bohman, Daniel Bonevac, Laurence BonJour, William J. Bouwsma, Raymond D. Bradley, Myles Brand, Richard B. Brandt, Michael E. Bratman, Stephen E. Braude, Daniel Breazeale, Angela Breitenbach, Jason Bridges, David O. Brink, Gordon G. Brittan, Justin Broackes, Dan W. Brock, Aaron Bronfman, Jeffrey E. Brower, Bartosz Brozek, Anthony Brueckner, Jeffrey Bub, Lara Buchak, Otavio Bueno, Ann E. Bumpus, Robert W. Burch, John Burgess, Arthur W. Burks, Panayot Butchvarov, Robert E. Butts, Marina Bykova, Patrick Byrne, David Carr, Noël Carroll, Edward S. Casey, Victor Caston, Victor Caston, Albert Casullo, Robert L. Causey, Alan K. L. Chan, Ruth Chang, Deen K. Chatterjee, Andrew Chignell, Roderick M. Chisholm, Kelly J. Clark, E. J. Coffman, Robin Collins, Brian P. Copenhaver, John Corcoran, John Cottingham, Roger Crisp, Frederick J. Crosson, Antonio S. Cua, Phillip D. Cummins, Martin Curd, Adam Cureton, Andrew Cutrofello, Stephen Darwall, Paul Sheldon Davies, Wayne A. Davis, Timothy Joseph Day, Claudio de Almeida, Mario De Caro, Mario De Caro, John Deigh, C. F. Delaney, Daniel C. Dennett, Michael R. DePaul, Michael Detlefsen, Daniel Trent Devereux, Philip E. Devine, John M. Dillon, Martin C. Dillon, Robert DiSalle, Mary Domski, Alan Donagan, Paul Draper, Fred Dretske, Mircea Dumitru, Wilhelm Dupré, Gerald Dworkin, John Earman, Ellery Eells, Catherine Z. Elgin, Berent Enç, Ronald P. Endicott, Edward Erwin, John Etchemendy, C. Stephen Evans, Susan L. Feagin, Solomon Feferman, Richard Feldman, Arthur Fine, Maurice A. Finocchiaro, William FitzPatrick, Richard E. Flathman, Gvozden Flego, Richard Foley, Graeme Forbes, Rainer Forst, Malcolm R. Forster, Daniel Fouke, Patrick Francken, Samuel Freeman, Elizabeth Fricker, Miranda Fricker, Michael Friedman, Michael Fuerstein, Richard A. Fumerton, Alan Gabbey, Pieranna Garavaso, Daniel Garber, Jorge L. A. Garcia, Robert K. Garcia, Don Garrett, Philip Gasper, Gerald Gaus, Berys Gaut, Bernard Gert, Roger F. Gibson, Cody Gilmore, Carl Ginet, Alan H. Goldman, Alvin I. Goldman, Alfonso Gömez-Lobo, Lenn E. Goodman, Robert M. Gordon, Stefan Gosepath, Jorge J. E. Gracia, Daniel W. Graham, George A. Graham, Peter J. Graham, Richard E. Grandy, I. Grattan-Guinness, John Greco, Philip T. Grier, Nicholas Griffin, Nicholas Griffin, David A. Griffiths, Paul J. Griffiths, Stephen R. Grimm, Charles L. Griswold, Charles B. Guignon, Pete A. Y. Gunter, Dimitri Gutas, Gary Gutting, Paul Guyer, Kwame Gyekye, Oscar A. Haac, Raul Hakli, Raul Hakli, Michael Hallett, Edward C. Halper, Jean Hampton, R. James Hankinson, K. R. Hanley, Russell Hardin, Robert M. Harnish, William Harper, David Harrah, Kevin Hart, Ali Hasan, William Hasker, John Haugeland, Roger Hausheer, William Heald, Peter Heath, Richard Heck, John F. Heil, Vincent F. Hendricks, Stephen Hetherington, Francis Heylighen, Kathleen Marie Higgins, Risto Hilpinen, Harold T. Hodes, Joshua Hoffman, Alan Holland, Robert L. Holmes, Richard Holton, Brad W. Hooker, Terence E. Horgan, Tamara Horowitz, Paul Horwich, Vittorio Hösle, Paul Hoβfeld, Daniel Howard-Snyder, Frances Howard-Snyder, Anne Hudson, Deal W. Hudson, Carl A. Huffman, David L. Hull, Patricia Huntington, Thomas Hurka, Paul Hurley, Rosalind Hursthouse, Guillermo Hurtado, Ronald E. Hustwit, Sarah Hutton, Jonathan Jenkins Ichikawa, Harry A. Ide, David Ingram, Philip J. Ivanhoe, Alfred L. Ivry, Frank Jackson, Dale Jacquette, Joseph Jedwab, Richard Jeffrey, David Alan Johnson, Edward Johnson, Mark D. Jordan, Richard Joyce, Hwa Yol Jung, Robert Hillary Kane, Tomis Kapitan, Jacquelyn Ann K. Kegley, James A. Keller, Ralph Kennedy, Sergei Khoruzhii, Jaegwon Kim, Yersu Kim, Nathan L. King, Patricia Kitcher, Peter D. Klein, E. D. Klemke, Virginia Klenk, George L. Kline, Christian Klotz, Simo Knuuttila, Joseph J. Kockelmans, Konstantin Kolenda, Sebastian Tomasz Kołodziejczyk, Isaac Kramnick, Richard Kraut, Fred Kroon, Manfred Kuehn, Steven T. Kuhn, Henry E. Kyburg, John Lachs, Jennifer Lackey, Stephen E. Lahey, Andrea Lavazza, Thomas H. Leahey, Joo Heung Lee, Keith Lehrer, Dorothy Leland, Noah M. Lemos, Ernest LePore, Sarah-Jane Leslie, Isaac Levi, Andrew Levine, Alan E. Lewis, Daniel E. Little, Shu-hsien Liu, Shu-hsien Liu, Alan K. L. Chan, Brian Loar, Lawrence B. Lombard, John Longeway, Dominic McIver Lopes, Michael J. Loux, E. J. Lowe, Steven Luper, Eugene C. Luschei, William G. Lycan, David Lyons, David Macarthur, Danielle Macbeth, Scott MacDonald, Jacob L. Mackey, Louis H. Mackey, Penelope Mackie, Edward H. Madden, Penelope Maddy, G. B. Madison, Bernd Magnus, Pekka Mäkelä, Rudolf A. Makkreel, David Manley, William E. Mann (W.E.M.), Vladimir Marchenkov, Peter Markie, Jean-Pierre Marquis, Ausonio Marras, Mike W. Martin, A. P. Martinich, William L. McBride, David McCabe, Storrs McCall, Hugh J. McCann, Robert N. McCauley, John J. McDermott, Sarah McGrath, Ralph McInerny, Daniel J. McKaughan, Thomas McKay, Michael McKinsey, Brian P. McLaughlin, Ernan McMullin, Anthonie Meijers, Jack W. Meiland, William Jason Melanson, Alfred R. Mele, Joseph R. Mendola, Christopher Menzel, Michael J. Meyer, Christian B. Miller, David W. Miller, Peter Millican, Robert N. Minor, Phillip Mitsis, James A. Montmarquet, Michael S. Moore, Tim Moore, Benjamin Morison, Donald R. Morrison, Stephen J. Morse, Paul K. Moser, Alexander P. D. Mourelatos, Ian Mueller, James Bernard Murphy, Mark C. Murphy, Steven Nadler, Jan Narveson, Alan Nelson, Jerome Neu, Samuel Newlands, Kai Nielsen, Ilkka Niiniluoto, Carlos G. Noreña, Calvin G. Normore, David Fate Norton, Nikolaj Nottelmann, Donald Nute, David S. Oderberg, Steve Odin, Michael O’Rourke, Willard G. Oxtoby, Heinz Paetzold, George S. Pappas, Anthony J. Parel, Lydia Patton, R. P. Peerenboom, Francis Jeffry Pelletier, Adriaan T. Peperzak, Derk Pereboom, Jaroslav Peregrin, Glen Pettigrove, Philip Pettit, Edmund L. Pincoffs, Andrew Pinsent, Robert B. Pippin, Alvin Plantinga, Louis P. Pojman, Richard H. Popkin, John F. Post, Carl J. Posy, William J. Prior, Richard Purtill, Michael Quante, Philip L. Quinn, Philip L. Quinn, Elizabeth S. Radcliffe, Diana Raffman, Gerard Raulet, Stephen L. Read, Andrews Reath, Andrew Reisner, Nicholas Rescher, Henry S. Richardson, Robert C. Richardson, Thomas Ricketts, Wayne D. Riggs, Mark Roberts, Robert C. Roberts, Luke Robinson, Alexander Rosenberg, Gary Rosenkranz, Bernice Glatzer Rosenthal, Adina L. Roskies, William L. Rowe, T. M. Rudavsky, Michael Ruse, Bruce Russell, Lilly-Marlene Russow, Dan Ryder, R. M. Sainsbury, Joseph Salerno, Nathan Salmon, Wesley C. Salmon, Constantine Sandis, David H. Sanford, Marco Santambrogio, David Sapire, Ruth A. Saunders, Geoffrey Sayre-McCord, Charles Sayward, James P. Scanlan, Richard Schacht, Tamar Schapiro, Frederick F. Schmitt, Jerome B. Schneewind, Calvin O. Schrag, Alan D. Schrift, George F. Schumm, Jean-Loup Seban, David N. Sedley, Kenneth Seeskin, Krister Segerberg, Charlene Haddock Seigfried, Dennis M. Senchuk, James F. Sennett, William Lad Sessions, Stewart Shapiro, Tommie Shelby, Donald W. Sherburne, Christopher Shields, Roger A. Shiner, Sydney Shoemaker, Robert K. Shope, Kwong-loi Shun, Wilfried Sieg, A. John Simmons, Robert L. Simon, Marcus G. Singer, Georgette Sinkler, Walter Sinnott-Armstrong, Matti T. Sintonen, Lawrence Sklar, Brian Skyrms, Robert C. Sleigh, Michael Anthony Slote, Hans Sluga, Barry Smith, Michael Smith, Robin Smith, Robert Sokolowski, Robert C. Solomon, Marta Soniewicka, Philip Soper, Ernest Sosa, Nicholas Southwood, Paul Vincent Spade, T. L. S. Sprigge, Eric O. Springsted, George J. Stack, Rebecca Stangl, Jason Stanley, Florian Steinberger, Sören Stenlund, Christopher Stephens, James P. Sterba, Josef Stern, Matthias Steup, M. A. Stewart, Leopold Stubenberg, Edith Dudley Sulla, Frederick Suppe, Jere Paul Surber, David George Sussman, Sigrún Svavarsdóttir, Zeno G. Swijtink, Richard Swinburne, Charles C. Taliaferro, Robert B. Talisse, John Tasioulas, Paul Teller, Larry S. Temkin, Mark Textor, H. S. Thayer, Peter Thielke, Alan Thomas, Amie L. Thomasson, Katherine Thomson-Jones, Joshua C. Thurow, Vzalerie Tiberius, Terrence N. Tice, Paul Tidman, Mark C. Timmons, William Tolhurst, James E. Tomberlin, Rosemarie Tong, Lawrence Torcello, Kelly Trogdon, J. D. Trout, Robert E. Tully, Raimo Tuomela, John Turri, Martin M. Tweedale, Thomas Uebel, Jennifer Uleman, James Van Cleve, Harry van der Linden, Peter van Inwagen, Bryan W. Van Norden, René van Woudenberg, Donald Phillip Verene, Samantha Vice, Thomas Vinci, Donald Wayne Viney, Barbara Von Eckardt, Peter B. M. Vranas, Steven J. Wagner, William J. Wainwright, Paul E. Walker, Robert E. Wall, Craig Walton, Douglas Walton, Eric Watkins, Richard A. Watson, Michael V. Wedin, Rudolph H. Weingartner, Paul Weirich, Paul J. Weithman, Carl Wellman, Howard Wettstein, Samuel C. Wheeler, Stephen A. White, Jennifer Whiting, Edward R. Wierenga, Michael Williams, Fred Wilson, W. Kent Wilson, Kenneth P. Winkler, John F. Wippel, Jan Woleński, Allan B. Wolter, Nicholas P. Wolterstorff, Rega Wood, W. Jay Wood, Paul Woodruff, Alison Wylie, Gideon Yaffe, Takashi Yagisawa, Yutaka Yamamoto, Keith E. Yandell, Xiaomei Yang, Dean Zimmerman, Günter Zoller, Catherine Zuckert, Michael Zuckert, Jack A. Zupko (J.A.Z.)
- Edited by Robert Audi, University of Notre Dame, Indiana
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- The Cambridge Dictionary of Philosophy
- Published online:
- 05 August 2015
- Print publication:
- 27 April 2015, pp ix-xxx
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In vitro fermentation of NUTRIOSE® soluble fibre in a continuous culture human colonic model system
- M. R. Hobden, A. Martin-Morales, L. Guérin-Deremaux, E. R. Deaville, A. Costabile, G. E. Walton, I. Rowland, O. B. Kennedy, G. R. Gibson
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- Journal:
- Proceedings of the Nutrition Society / Volume 72 / Issue OCE4 / 2013
- Published online by Cambridge University Press:
- 30 August 2013, E186
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The Canadian Galactic Plane Survey
- J. English, A. R. Taylor, J. A. Irwin, S. M. Dougherty, S. Basu, C. Beichman, J. Brown, Y. Cao, C. Carignan, D. Crabtree, P. Dewdney, N. Duric, M. Fich, E. Gagnon, J. Galt, S. Germain, N. Ghazzali, S. J. Gibson, S. Godbout, A. Gray, D. A. Green, C. Heiles, M. Heyer, L. Higgs, S. Jean, D. Johnstone, G. Joncas, T. Landecker, W. Langer, D. Leahy, P. Martin, H. Matthews, W. McCutcheon, G. Moriarity-Scheiven, S. Pineault, C. Purton, R. Roger, D. Routledge, N. St-Louis, K. Tapping, S. Terebey, F. Vaneldik, D. Watson, H. Wendker, T. Willis, X. Zhang
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- Publications of the Astronomical Society of Australia / Volume 15 / Issue 1 / 1998
- Published online by Cambridge University Press:
- 05 March 2013, pp. 56-59
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The Dominion Radio Astrophysical Observatory (DRAO) is carrying out a survey as part of an international collaboration to image the northe, at a common resolution, in emission from all major constituents of the interstellar medium; the neutral atomic gas, the molecular gas, the ionised gas, dust and relativistic plasma. For many of these constituents the angular resolution of the images (1 arcmin) will be more than a factor of 10 better than any previous studies. The aim is to produce a publicly-available database of high resolution, high-dynamic range images of the Galaxy for multi-phase studies of the physical states and processes in the interstellar medium. We will sketch the main scientific motivations as well as describe some preliminary results from the Canadian Galactic Plane Survey/Releve Canadien du Plan Galactique (CGPS/RCPG).
A Change Agenda for Reserving. Report of the General Insurance Reserving Issues Taskforce (GRIT)
- A. R. Jones, P. J. Copeman, E. R. Gibson, N. J. S. Line, J. A. Lowe, P. Martin, P. N. Matthews, D. S. Powell
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- British Actuarial Journal / Volume 12 / Issue 3 / 01 September 2006
- Published online by Cambridge University Press:
- 10 June 2011, pp. 435-599
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Reserving is important to our profession as it is a core activity for actuaries. The members of the General Insurance Reserving Issues Taskforce (GRIT) have been considering how actuaries can improve the way in which we do reserving in general insurance. We gathered our thoughts and recommendations together in a Consultation Paper which has been discussed widely in the profession. We are very grateful to everyone who shared their views and comments with us, particularly those who gave us written feedback. We have considered carefully all the feedback which we received and adapted our final report in response to this.
Given the scope and importance of our remit, it is perhaps not surprising that this is not a short paper. We hope that Section 1 provides a reasonable summary.
Generally, our view is that there are many things on which our profession should focus. However, it is also important to remind ourselves of the positive items of feedback which we heard from our stakeholders. In addition to many suggestions for things to do better, we consistently heard the message that actuaries play an extremely valuable role in general insurance.
This is a major testimony to the progress which the actuarial profession has made in recent years in its ability to contribute to the general insurance industry. Perhaps it is because of this progress that now is an appropriate time for us, as a profession, to take a hard look at what we do in reserving, and ask ourselves whether there are any things which we could do differently. We hope that GRIT's report will facilitate this debate.
GRIT's recommendations fall under the following key themes:
— Providing more transparency to our reserving methods and helping our stakeholders have more insight into the key reserving assumptions and decisions.
— Providing more information on uncertainty in our reserve estimates. In particular, we recommend that actuaries provide a quantitative indication of the range of outcomes for future claim payments, and that our profession defines a common vocabulary for communicating uncertainty.
— Understanding better the business we are reserving. We suggest a range of analyses and activities for doing this.
— Applying our standard actuarial reserving methods more consistently. We identify a list of specific areas where we believe that there is scope for improvement. Also, we believe that the actuarial training syllabus should be extended, and this leads to consideration of whether a more specialised general insurance actuarial qualification is needed.
— Understanding the implications of the underwriting cycle, which, we believe, influences the behaviour of claims development in a way that our reserving models do not currently capture. We suggest what we believe may be the foundations of a potentially more cycle proof methodology, but this is an area which we believe will require much more research.
— Helping actuaries understand how behaviour can affect the reserve estimation process, particularly in the face of uncertainty. We make various suggestions in this area, including helping actuaries manage pressure from third parties.
We are convinced that, for our profession to implement these suggestions, it will require a concerted change management strategy and set of actions to embed changes into the way in which actuaries work. We believe that this will include:
— increasing the level of debate and research in the profession on claims reserving;
— a broader communication programme with the general insurance industry, covering, amongst other things, uncertainty and data quality;
— a sub-group of the GI Board with a specific focus on reserving, responsible for implementing GRIT's recommendations and dealing with new issues as they arise; and
— our profession resolving the conflicting pressures which will arise out of the extra work required for reserving by the GRIT recommendations.
There is one specific item where we have not made a recommendation. It has been suggested to us that many of the standard reserving methods in common use, such as the chain ladder, are not sophisticated, and that more sophisticated mathematical and statistical methods should be a priority. We do not agree with this. Whereas, in the longer term, this might be an important issue for our profession, we believe that the current focus for actuaries should be in the areas set out in this paper, such as understanding the business better.
GRIT believes that the issues which we have identified are important for the future of our profession and the contribution which we can make to the general insurance industry.
33 - Priority setting
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- By Douglas K. Martin, Associate Professor University of Toronto, Jennifer L. Gibson, Assistant Professor University of Toronto, Peter A. Singer, Professor University of Toronto
- Edited by Peter A. Singer, University of Toronto, A. M. Viens, University of Oxford
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- The Cambridge Textbook of Bioethics
- Published online:
- 30 October 2009
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- 31 January 2008, pp 251-256
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Summary
Dr. B is on the seventh day of his rotation as medical director of the intensive care unit (ICU) when he receives a referral call about a patient in emergency who needs ICU admission for ventilation support. Dr. B examines his ICU census and notes that not only are there no ICU beds available but there is also a request from a thoracic surgeon for an ICU bed for a patient currently in the observation room, and there is a request from a nearby hospital to transfer one of their patients to Dr. B's ICU.
Dr. C, a pediatrician, has been asked to chair her hospital drug formulary committee to examine new drugs and determine which ones should be provided from the hospital budget. She is aware that these decisions are complex and often controversial and is unsure how to proceed.
What is priority setting?
Priority setting involves deciding which resources to allocate to competing needs. It is a key component of every health system because, whether wealthy or poor, no system can afford to provide every service that it may wish to provide. Both publicly and privately funded systems have the challenge of delivering quality care within the limits of government budgets or enrollee and employer contributions.
Within health systems, priority setting occurs at each decision level: micro (at the bedside or in clinical programs), meso (in hospitals or regional institutions), and macro (at the system-wide level).
A substitution model of dietary manipulation is an effective means of optimising lipid profile, reducing C-reactive protein and increasing insulin-like growth factor-1
- Adrian H. Heald, Cheryl Golding, Reena Sharma, Kirk Siddals, Sara Kirk, Clare Lawton, Simon Anderson, J. Martin Gibson, Janet E. Cade
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- Journal:
- British Journal of Nutrition / Volume 92 / Issue 5 / November 2004
- Published online by Cambridge University Press:
- 09 March 2007, pp. 809-818
- Print publication:
- November 2004
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There are two key methods in which fat intake may be manipulated; the ‘substitution model’ and the ‘reduction model’. However insufficient information is known about the mechanisms of dietary fat reduction in individuals who have successfully reduced their fat intake, to be clear as to which strategy offers the greatest chance of success. Our objective was to ascertain the most effective dietary intervention for improving cardiovascular risk profile. Eighty female volunteers (high fat consumers) were recruited. Each subject was randomly allocated into one of the following groups. Substitution of high-fat foods was made with reduced-fat products, by the reduction of high-fat foods, by a combination of substitution and reduction strategies, or no advice was given. Each intervention lasted 3 months. Anthropometric measures and fasting blood samples were taken at baseline and follow-up. The substitution intervention resulted in weight loss (mean −1.4 (95% CI −2.4, −0.2) kg) and reduced percentage body fat (mean −1.3 (95% CI −2.0, −0.5)%). There was no significant weight change with the other interventions. Fasting triacylglycerols (−0.2 (SEM 0.07) mM; P=0.04), cholesterol and C-reactive protein (CRP) levels (0.8 (SEM 0.2) mg/l; P=0.04) fell with the substitution intervention, but not with the other interventions. Insulin-like growth factor-1 increased with both substitution and reduction (P=0.02). There was no significant change in fasting insulin or glucose with any intervention. The substitution model of dietary intervention is effective even over a relatively short interval of time in reducing fasting total cholesterol, triacylglycerols and CRP. Although the group size for the present study was small and involved females only, it has significant implications for population intervention strategies.
In vitro fermentability of dextran, oligodextran and maltodextrin by human gut bacteria
- Estibaliz Olano-Martin, Konstantinos C. Mountzouris, Glenn R. Gibson, Robert A. Rastall
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- Journal:
- British Journal of Nutrition / Volume 83 / Issue 3 / March 2000
- Published online by Cambridge University Press:
- 09 March 2007, pp. 247-255
- Print publication:
- March 2000
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Anaerobic batch culture fermenters were used for a preliminary screening of the in vitro utilization by human gut microflora of dextran and novel oligodextrans (I, II and III) produced in the University of Reading (UK). Glucose and fructooligosaccharides (FOS) were used as reference carbohydrates. As expected, FOS acted as a good prebiotic in that it selectively increased numbers of bifidobacteria in the early stages of the fermentation. Dextran and oligodextrans each resulted in an enrichment of bifidobacteria in the batch cultures, with high levels of persistence up to 48 h. They also produced elevated levels of butyrate ranging from 5 to 14·85 mmol/l. To more effectively simulate conditions that prevail in different regions of the large intestine, a three-stage continuous culture cascade system was used to study further the fermentation of dextran, a low-molecular-mass oligodextran (IV) and maltodextrin. Oligodextran IV was shown to be the best substrate for bifidobacteria and lactobacilli with steady-state populations of bifidobacteria and lactobacilli being higher in all three vessels of the gut model than the respective populations resulting from dextran and maltodextrin. A maximum difference of 1·9 log was observed in vessel 1 for both bifidobacteria and lactobacilli in the case of dextran fermentation, while 1·4 log and 0·8 log in vessel 3 were the maximum differences for bifidobacteria and lactobacilli when maltodextrin was used as the carbohydrate source. Moreover, dextran and oligodextran appeared to stimulate butyrate production, with a maximum production up to 25·39 mmol/l in vessel 3 when fermenting dextran, followed by 21·70 mmol/l in the case of oligodextran IV and only 12·64 mmol/l in the case of maltodextrin.
Equilibration in Amorphous Silicon Nitride Alloys
- Bruce Dunnett, Christopher H. Cooper, Darren T. Murley, Roderick A. G. Gibson, David I. Jones, Martin J. Powell, Steven C. Deane, Ian D. French
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- Journal:
- MRS Online Proceedings Library Archive / Volume 377 / 1995
- Published online by Cambridge University Press:
- 15 February 2011, 349
- Print publication:
- 1995
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- Article
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Several series of amorphous silicon nitride thin films have been grown by plasma-enhanced chemical vapour deposition, where the ratio of ammonia and silane feed gases was held constant for each series while the deposition temperature was varied from 160 °C to 550 °C, and all other deposition conditions were held constant. Photothermal Deflection Spectroscopy measurements were used to determine the Urbach slope E0 and the defect density ND. It is found that ND is determined by E0 for most of these samples, suggesting that defect equilibration occurs in a-SiNx:H for x up to at least 0.6. The growth temperature at which the disorder is minimised increases to higher values with increasing x, which is explained in terms of a hydrogen-mediated bond equilibration reaction. Fourier Transform Infra Red spectroscopy measurements were performed to determine the changes in hydrogen bonding with growth temperature. The results suggest that a second bond equilibration reaction also occurs at the growing surface, but that equilibrium cannot be reached at higher temperatures because of hydrogen evolution from Si-H bonds.