Editorâs note ventolin expectorant capsule price investigate this site. This blog post is the first in a series celebrating ODEPâs 20th anniversary in 2021. For those of us in the U.S ventolin expectorant capsule price.
Department of Laborâs Office of Disability Employment Policy, this year is a momentous one, marking 20 years since our establishment. Itâs a time for both celebration and reflection, especially as we work to ensure all Americans are included in our economic recovery from the impacts of asthma treatment. ODEP was established by Congress in fiscal year 2001, but our roots trace back to the Presidential Task Force on Employment of Adults with Disabilities that was formed ventolin expectorant capsule price in 1998.
The task force proposed and designed ODEP, establishing the interagency connections that are the hallmark of our work today. ODEPâs creation also heralded an important shift in how we talk about disability and employment in America, one focused not on whether people with disabilities can work, but rather the strategies and supports that drive the change needed to make work happen. And how do we know what ventolin expectorant capsule price those strategies and supports are?.
The answer lies in evidence-based data. One of ODEPâs early endeavors was to develop a means for reliable and ventolin expectorant capsule price accurate monthly data collection on the employment status of people with disabilities. Following more than seven years of extensive research and testing, we partnered with the departmentâs Bureau of Labor Statistics in 2008 to add six disability-related questions to the monthly Current Population Survey, the official source for estimates on U.S.
Labor force participation, employment and unemployment. As a ventolin expectorant capsule price result, monthly data on the employment status of people with disabilities were released for the first time in January 2009 â and have been every month since. In addition, ODEP collaborated with BLS and the departmentâs Chief Evaluation Office to gather additional data through supplements to the Current Population Survey in May 2012 and July 2019.
Through these supplements, ODEP gleaned critical information on prior work experience, career and financial assistance, workplace improvement requests, barriers to employment and other related topics from respondents with disabilities. For example, data from the supplements ventolin expectorant capsule price pinpointed a lack of transportation as an ongoing barrier to work for many people with disabilities. As a result, in partnership with the U.S.
Department of Transportation and the U.S ventolin expectorant capsule price. Access Board, ODEP is engaging disability advocates and private industry to promote more accessible transportation options â especially inclusive autonomous vehicles that can help people with disabilities get to work. Data on effectiveness is key to the success of our State Exchange on Employment and Disability initiative that supports state and local governments as they adopt and implement inclusive employment policies.
Among these are âstate as model employerâ policies, which can have a significant impact on the employment of people with disabilities and serve as a model for the private ventolin expectorant capsule price sector. Data allow us to measure progress made and opportunity to come, and in the case of disability employment, they help drive change toward a more inclusive workforce â the crux of our mission at ODEP since day one. From evidence-based data to policy to employment supports, we have been driving change and creating opportunity for 20 years.
We look forward to highlighting these efforts and building upon them as ventolin expectorant capsule price we continue to strive for full workforce inclusion. Jennifer Sheehy is the deputy assistant secretary of labor for disability employment policy at the U.S. Department of Labor..
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OxTREC 528-17), and it received local ethical approval in Thailand from the Mae Fah Luang University Research Ethics Committee on Human Research (Ref. REH 60099). The service evaluation of the photo exhibition involved anonymised data collection and received a waiver for ethical approval from the University of Warwick Humanities &.
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The âdesirabilityâ of the responses was field coded by the survey team. Sample responses (as instructed through the survey manual) for âdesirableâ answers included, for example, âOnly if the doctor says that I shouldâ. Sample responses for âundesirableâ answers included âYes, you can buy it in the shop over there!.
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The poster making sessions in Chiang Rai demonstrated for instance how our conversations about drug resistance and the introduction of messages from the World Health Organization entailed at times problematic interpretations like, âYou shouldnât take medicines that you have never seen beforeââthe research team responded to such interpretations directly in order to avoid misunderstandings. In addition, previous behavioural analyses documented that, while workshop participants demonstrated higher levels of awareness of drug resistance, alignment of antibiotic use with global health recommendations was mixed, and in one case, a villager started selling antibiotics after the workshop. For more details on the behavioural analysis, see Nutcha Charoenboon et al.
(2019) and Marco Haenssgen et al. (2018).155. For example, Redfern, et al., Spreading the message of antimicrobial resistance.
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GRIPP2 reporting checklists. Tools to improve reporting of patient and public involvement in research.158. Jerke, et al.
Smoking cessation in mental health communities. A living newspaper applied theatre project.159. Switzer, Whatâs in an image?.
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Doi. 10.1177/1468794112446104IntroductionIn Australia, the USA and the UK, the number of hospital beds required for forensic mental health treatment doubled between 1996 and 2016.1 Current trends and future predictions suggest this demand will continue to grow. But, in an age where evidence-based practice is highly valued, the demand for new facilities already outpaces the availability of credible evidence to guide designers.
This article reports findings from a desktop survey of current design practice across 31 psychiatric hospitals (24 forensic, 7 non-forensic) constructed or scheduled for completion between 2006 and 2022. Desktop surveys, as a form of research, are heavily relied on in architectural practice. Photographs and architectural drawings are analysed to understand both typical and innovative approaches to designing a particular building type.
While desktop surveys are sometimes supplemented by visits to exemplar projects (which might also be termed âfieldworkâ), time pressures and budgetary constraints often preclude this. As the result of an academicâindustry partnership, the research reported herein embraced practice-based research methods in conjunction with an academic approach. The data set available for the desktop survey was rich but incomplete.
Security requirements restrict the public availability of complete floor plans and postoccupancy evaluations. To mitigate these limitations, knowledge was integrated from other disciplines, including environmental psychology, architectural history and professional practice. With regard to the latter, knowledge is specifically around the design and consultation processes that guide the construction of these facilities.
This knowledge was used to identify three contemporary hospitals that challenge accepted design practice and, we argue, in doing so have the potential to act as change-agents in the delivery of forensic mental healthcare. We define innovation as variation/s to common, or typical, architectural solutions that can positively improve patientsâ2 experience of these facilities in ways that directly support one, or a number, of key values underpinning forensic mental healthcare. While this article does not provide postoccupancy data to quantify the value of these innovations, we hope to encourage both designers and researchers to more closely consider these projectsâparticularly the way that spaces have been designed to benefit patient well-beingâand the questions these designs raise for the future of forensic mental healthcare delivery.Now regarded as naïve is the 19th-century belief that architecture and landscape, if appropriately designed, can restore sanity.3 Yet contemporary research from the field of evidence-based design confirms that the built environment does play a role in the therapeutic process, even if that role does not determine therapeutic outcomes.4 Research regarding the design of forensic mental healthcare facilities remains limited.
An article by Ulrich et al recommended that to reduce aggression patients should be accommodated in single rooms. Communal areas should have movable furniture. Wards should be designed for low social densities.
And accessible gardens should be provided.5 An earlier study by Tyson et al showed that lower ward densities can also positively improve patientâstaff interactions.6 Commonly, however, the studies referenced above compared older-style mental health units with their contemporary replacements.7 There is little comparative research available that examines contemporary facilities for forensic mental healthcare, with the exception of one article that provided a comparative analysis of nine Swedish facilities, designed between 1990 and 2008.8 However, this article merely described the design aspirations and physical composition of each hospital without investigating the link between design aspiration, patient well-being and the resulting physical environment.There are two further limitations to evidence-based design research. The first is the extent to which data do not provide directly applicable design tactics. Systematic literature reviews typically provide a set of design recommendations but without suggesting to designers what the corresponding physical design tactics to achieve those recommendations might actually be.9 This is consistent for general hospital design.
For example, architects have been advised to provide spaces that are âpsychosocially supportiveâ since 2000, yet it was 2016 before a spatially focused definition of this term was provided, offering designers a more tangible understanding of what they should be aiming for.10 The second limitation is the breadth of research currently available. While rigorous and valuable, evidence-based design often overlooks the fact that architects must design across scales, from the master-planning scaleâdeciding where to place buildings of various functions within a site, and how to manage the safe movement of staff and patients between those buildingsâto the scale of a bathroom door. How do you design a bathroom door to meet antiligature and surveillance requirements, to maintain patient safety, while still communicating dignity and respect for patients?.
The available literature provides much to contemplate, but in terms of credible evidence much of this research is based on a single study, typically conducted within a single hospital context and often focused on a single aspect of design. This raises the question, is there really a compelling basis for regarding evidence-based design knowledge as more credible than knowledge generated about this building type from other disciplines?. In light of the small amount of evidence available in this field, is there not a responsibility to use all the available knowledge?.
While the discipline of evidence-based design has existed for three decades,11 purpose-designed buildings for the treatment of mental illness have been constructed for over three centuries. Researchers working within the field of architectural history also understand that patient experience is partially determinedâfor better or worseâby the decisions that designers make, and that models of care have been used to drive design outcomes since the establishment of the York Retreat in 1796. With their focus on moral treatment, the York Retreat influenced a shift in the way asylum design was approached, from the provision of safe custody to finding architectural solutions to support the restoration of sanity.12 Architectural historians also bring evidence to bear in respect of this design challenge, specifically knowledge of how the best architectural intentions can result in unanticipated (sometimes devastating) outcomesâand of the conditions that gave rise to those outcomes.13 There is a third, rich source of knowledge available to guide designers that, broadly speaking, academic researchers have yet to tap into.
It is the knowledge produced by practitioners themselves. Architects learn through experience, across multiple projects and through practice-based forms of enquiry that include desktop surveys (also referred to as precedent studies), user group consultations and gathering (often informal) postoccupancy data from their clients. Architects have already offered a range of tangible solutions to meet particular aspirations related to patient care.
There is value in examining these existing design solutions to identify those capable of providing direct benefits to patients that might justify implementation across multiple projects. In understanding how the physical design of forensic psychiatric hospitals can best support the therapeutic journey of patients, all available knowledge should be valued and integrated.Methodology. Embracing âmode twoâ researchThis research was conducted within the context of a masterÂ-planning and feasibility study, commissioned by a state government department, to investigate various international design solutions to inform future planning around forensic mental health service provisions in Victoria, Australia.
The industry-led nature of this project demanded a less conventional and more inclusive methodological approach. Tight timeframes precluded employing research methods that required ethics approvals (interviewing patients was not possible), while the timeframe and budget precluded the research team from conducting fieldwork. The following obstacles further limited a conventional approach:Postoccupancy evaluations of forensic psychiatric hospital facilities are seldom conducted and/or not made publicly available.14Published floor plans that would enable researchers to derive an understanding of the functional layouts and corresponding habits of occupancy within these facilities are limited owing to the security needs surrounding forensic psychiatric hospital sites.Available literature relevant to the design of forensic psychiatric hospital facilities provides few direct architectural recommendations to offer tactics for how the built environment might support the delivery of treatment.The team had to find a way to navigate these challenges in order to address the important question of how the physical design of forensic psychiatric hospitals can best support the therapeutic journey of patients.âMode twoâ is a methodological approach that draws on the strength of collaborations between academia and industry to produce âsocially robust knowledgeâ whose reliability extends âbeyond the laboratoryâ to real-world contexts.15 It shares commonalities with a phenomenological approach that attributes value to the prolonged, firsthand exposure of the researcher with the phenomenon in question.16 The inclusion of practising architects and academic researchers within the research team provided considerable expertise in the design, consultation and documentation of these facilities, alongside an understanding of the kinds of challenges that arise following the occupation of this building type.
Mode two, as a research approach, also recognises that, while architects reference evidence-based design literature, this will not replace the processes through which practitioners have traditionally assembled knowledge about particular building types, predominantly desktop surveys.A desktop survey was undertaken to understand contemporary design practice within this building type. Forty-four projects were identified as relevant for the period 2006â2022 (31 forensic and 13 non-forensic psychiatric hospitals). These included facilities from the UK, the USA, Canada, Denmark, Norway, Sweden, the United Arab Emirates and Ireland (online supplementary appendix 1).
Sufficient architectural information was not available for 13 of these projects and they were excluded from the study. For the remaining 31 facilities, 24 accommodated forensic patients and 7 did not. Non-forensic facilities were included to enable an awareness of any significant programmatic or functional differences in the design responses created for forensic versus non-forensic mental health patients.
Architectural drawings and photographs were analysed to identify general trends, alongside points of departure from common practice. Borrowing methods from architectural history, the desktop survey was supplemented by other available information, including a mix of hospital-authored guidebooks (as provided to patients and visitors), architectsâ statements, newspaper articles and literature from the field of evidence-based design. Available data varied for each of the 31 hospitals.
Adopting a method from architectural theorist Thomas Markus, the materiality and placement of external and internal boundary lines were closely studied (assisted by Google Earth).17 When read in conjunction with the architectural drawings, boundary placement revealed information regarding patient access to adjacent landscape spaces.Supplemental materialA desktop survey has limitations. It cannot provide a conclusive understanding of how these spaces operate when occupied by patients and staff. While efforts were made to contact individual practices and healthcare providers to obtain missing details, such requests typically went unanswered.
This is likely owing to concerns of security, alongside the realities of commercial practice, concerns around intellectual property, and complex client and stakeholder arrangements that can act to prohibit the sharing of this information. To deepen the teamâs understanding, a 2-day workshop was hosted to which two international architectural practices were invited to attend, one from the UK and one from the USA. Both practices had recently completed a significant forensic psychiatric hospital project.
While neither of these facilities had been occupied at the time of the workshops, the architects were able to share their experiences relative to the research, design, and client and patient consultation processes undertaken. The Australian architects who led the research team also brought extensive experience in acute mental healthcare settings, which assisted in data analysis.To further mitigate the limitations of the desktop survey, understandings developed by the team were used as a basis for advisory panel discussions with staff. Feedback was sought from five 60âmin long, advisory panel sessions, each including four to six clinical/facilities staff (who attended voluntarily during work hours) from a forensic psychiatric hospital in Australia, where several participants recounted professional experience in both the Australian and British contexts.
Each advisory panel session was themed relative to various aspects of contemporary design. (1) site/hospital layout, (2) inpatient accommodation, (3) landscape design and access, (4) staff amenities, and (5) treatment hubs (referred to as âtreatment mallsâ in the American context). These sessions enabled the research team to double-check our analysis of the plans and photographs, particularly our assumptions regarding the likely use, practicality and therapeutic value of particular spaces.Model for analysisWithin general hospital design, a range of indicators are used to measure the contribution of architecture to healing, such as the optimisation of lighting to support sleep, the minimisation of patient falls, or whether the use of single patient rooms assists with control.18 In mental health, however, where the therapeutic journey is based more on psychology than physiology, what metrics should be employed to evaluate the success of one design response over another in supporting patient care?.
We suggest the first step is to acknowledge the values that underpin contemporary approaches to mental healthcare. The second step is to translate those treatment values into corresponding spatial values using a value-led spatial framework.19 This provides a checklist for relating particular spatial conditions to specific values around patient care. For example, if the design intent is to optimise privacy and dignity for patients, then the design of bathrooms, relaxation and de-esculation spaces are all important spaces in respect of that therapeutic value.
Highlighting this relationship can assist decision makers to more closely interrogate areas that matter most relative to achieving these values. To put this in context, optimising a bathroom design to prioritise a direct line of sight for staff might improve safety but also obstruct privacy and dignity for patients. While such decisions will always need to be carefully balanced, a value-led spatial framework can provide a touchstone for designers and stakeholders to revisit throughout the design process.To analyse the 31 projects examined within this project, we developed a framework (Table 1).
It recognises that a common approach to patient care can be identified across contemporary Australian, British and Canadian models:View this table:Table 1 Value-led spatial framework. Correlating treatment values with corresponding spaces within the hospitalâs physical environmentThat patients be extended privacy and dignity to the broadest degree possible without impacting their personal safety or that of other patients or staff.That patients be treated within the least restrictive environment possible relative to the severity of their illness and the legal (or security) requirements attached to their care.That patients be afforded choice and independence relative to freedom of movement within the hospital campus (as appropriate to the individual), extending to a choice of social, recreational and treatment spaces.That patientsâ progression through their treatment journey is reflected in the way the architecture communicates to hospital users.That opportunities for peer-led therapeutic processes and involvement of family and community-based care providers be optimised within a hospital campus. 20Table 1 assigns a range of architectural spaces and features that are relevant to each of the five treatment values listed.
Architectural decisions related to these values operate across three scales. Context, hospital and individual. Context decisions are those made in respect of a hospitalâs location, including proximity to allied services, connections to public transport and distances to major metropolitan hubs.
Decisions of this type are important relative to staffing recruitment and retention, and opportunities for research relative to the psychiatric hospitalâs proximity to general (teaching) hospitals or university precincts. Architectural decisions operating at the hospital scale include considerations of how secure site boundaries are provided. How buildings are laid out on a site.
And how spatial and functional links are set up between those buildings. This is important relative to the movement of patients and staff across a site, including the location and functionality of therapeutic hubs. But it can also impact patient and community psychology.
The design of external fences, in particular, can compound feelings of confinement for patients. Focus community attention on the custodial role of a facility over and above its therapeutic function. And influence perceptions of safety and security for the community immediately surrounding the hospital.
Architectural decisions operating at the âindividualâ scale are those that more closely impact the daily experience of a hospital for patients and staff. These include the various arrangements for inpatient accommodation. Tactics for providing patients with landscape access and views.
And the question of staff spaces relative to safety, ease of communication and collaboration. Approaches to landscape, inpatient accommodation and concerns of staff supervision are closely intertwined.Findings. What we learnt from 31 contemporary psychiatric hospital projectsForensic psychiatric hospitals treat patients who require mental health treatment in addition to a history of criminal offending or who are at risk of committing a criminal offence.
Primarily, these include patients who are unfit to stand trial and those found not guilty on account of their illness.21 Accommodation is typically arranged according to low, medium or high security needs, alongside clinical need, and whether an acute, subacute, extended or translational rehabilitation setting is required. Security needs are determined based on the risk a patient presents to themselves and/or others, alongside their risk of absconding from the facility. The challenge that has proven intractable for centuries is how can architects balance privacy and dignity for patients, while maintaining supervision for their own safety, alongside that of their fellow patients, the staff providing care and, in some cases, the community beyond.22 In this section we present overall trends regarding the layout of buildings within hospital sites, including the placement of treatment hubs and the design of inpatient wards.
Access to landscape is not explicitly addressed in this section but is implicit in decisions around site layout and inpatient accommodation.Design approaches to site layoutWe identified two approaches to site layoutâthe âvillageâ (4 from 31 hospitals) and the âcampusâ (27 from 31 hospitals) (figure 1). Similar in their functional arrangement, these are differentiated according to the degree of exterior circulation required to move between patient-occupied spaces. Village hospitals comprise a number of buildings sitting within the landscape, while campus hospitals have interconnected buildings with access provided by internal corridors that prevent the need to go outside.
Neither approach is new. Both follow the models first used within the 19th century. The village hospital follows the model designed by Dr Albrecht Paetz in 1878 (Alt Scherbitz, Germany), which included detached cottages accommodating patients in groups of between 24 and 100, set within gardens.23 Paetz created this design in response to his belief that upwards of 1000 patients should not be accommodated in a single building, with security measures determined in relation to those patients whose behaviour was the least predictable.24 The resulting monotony of the daily routine and restrictions on patient movement were believed to âcripple the intelligence and depress the spiritâ.25 Paetzâs model allowed doctors to classify patients into smaller groups and unlock doors to allow patients with predictable behaviour to wander freely within the secure outer boundaries of the hospital.26 This remained the preferred approach to patient accommodation for over a century, as endorsed by the WHO in their report of 1953.27 Broadmoor Hospital (UK, 2019) provides an example of the village model.The Broadmoor Hospital (left) follows a âvillageâ arrangement and includes an âinternalâ treatment hub.
The Worcester Recovery Center and Hospital (right) follows a âcampusâ arrangement and includes an âon-edgeâ treatment hub." data-icon-position data-hide-link-title="0">Figure 1 The Broadmoor Hospital (left) follows a âvillageâ arrangement and includes an âinternalâ treatment hub. The Worcester Recovery Center and Hospital (right) follows a âcampusâ arrangement and includes an âon-edgeâ treatment hub.The campus model is not dissimilar to the approach propagated by Dr Henry Thomas Kirkbride, a 19th-century psychiatrist who was active in the design of asylums and whose influence saw this planning arrangement dominate asylum constructions in the USA for many decades.28 Asylums of the âKirkbride planâ arranged patient accommodation in a series of pavilions linked by corridors. While corridors can be heavily glazed, where this action is not taken, the campus approach can compromise patient and staff connections to landscape views.
Examples of campus hospitals include the Worcester Recovery Center and Hospital (USA, 2012) and the Nixon Forensic Center (USA, under construction).Treatment hubs are a contemporary addition to forensic psychiatric hospitals. These cluster a range of shared patient spaces, including recreational, treatment and vocational training facilities, and thus drive patient movement around or through a hospital site. Two different treatment hub arrangements are in use.
Âinternalâ and âon-edgeâ. Those arranged internally typically place these functions at the heart of the campus and at a significant distance from the secure boundary line. Those arranged on-edge are placed at the far end of campus-model hospitals and, in the most extreme cases, occur adjacent to one of the siteâs external boundaries (refer to Figure 1).
Both arrangements aspire to make life within the hospital resemble life beyond the hospital as closely as possible, as the daily practice of walking from an accommodation area to a treatment hub mimics the practice of travelling from home to a place of work or study.With evidence mounting regarding the psychological benefits to patients of landscape access, it should not be assumed that the current preference for campus hospitals over the village model indicates âbest practiceâ. A campus arrangement offers security benefits for the movement of patients across a hospital site, while avoiding the associated risks of contraband concealed within landscaped spaces. However, the existence of village hospitals for forensic cohorts suggests it is possible to successfully manage these challenges.
Why then do we see such a strong persistence of the campus hospital?. This preference may be driven by cultural expectations. From 24 forensic psychiatric hospitals surveyed, 10 were located within the USA and all employed the campus model.
Yet nine of those hospitals occupied rural sites where the village model could have been used, suggesting the influence of the Kirkbride plan prevails. The four village hospitals within the broader sample of 31, spanning forensic and non-forensic settings, all occurred within the UK3 and Ireland1. Paetzâs villa model had been the preferred approach to new constructions in these countries since its introduction at close of the 19th century.29 However, a look at UK hospitals in isolation revealed a more even spread of village and campus arrangements, with two of the four UK-based campus hospitals occupying constrained urban sites that required multi-story solutions.
The village model would be inappropriate for achieving this as it does not lend well to urban locations where land availability is scarce.Design approaches to inpatient accommodationThree approaches to inpatient accommodation were identified. Âpeninsulaâ, ârace-trackâ and âcourtyardâ (Figure 2). The peninsula model is characterised by rows of inpatient wings, along a single-loaded or double-loaded corridor that stretches into the surrounding landscape.
This typically enables an exterior view from all patient bedrooms and is not dissimilar to the traditional âpavilionâ model that emerged within 19th-century hospital design.30 In the racetrack model bedrooms are arranged around a cluster of staff-only (or service) spaces, still enabling exterior views from all patient bedrooms. The courtyard model is similar to the racetrack but includes a central landscape space. Information on the design of inpatient room layouts was available for 24 of the 31 projects analysed (15 of these 24 were forensic).Common inpatient accommodation configurations.
(1) Peninsula. Single-loaded version shown (patient rooms on one side only. Double-loaded versions have patient rooms on two sides of the corridor).
(2) racetrack and (3) courtyard (landscaped). Staff-occupied spaces and support spaces (social space and so on) shown in grey." data-icon-position data-hide-link-title="0">Figure 2 Common inpatient accommodation configurations. (1) Peninsula.
Single-loaded version shown (patient rooms on one side only. Double-loaded versions have patient rooms on two sides of the corridor). (2) racetrack and (3) courtyard (landscaped).
Staff-occupied spaces and support spaces (social space and so on) shown in grey.Ten forensic hospitals employed a peninsula plan and five employed a courtyard plan. Of the non-forensic psychiatric hospitals five employed the courtyard, three the racetrack and only one the peninsula plan. While the sample size is too small to generalise, the peninsula plan appears to be favoured for a forensic cohort.
However, cultural trends again emerge. Of the 10 peninsula plan hospitals, 6 were located within the USA, and among the broader sample of 24 (including the non-forensic facilities) none of the courtyard hospitals were located there. Courtyard layouts for forensic patients occurred within the UK, Ireland, Denmark and Sweden.
However, within these countries, a mix of courtyard and peninsula plans were used, suggesting no clear preference for one plan over the other.Each plan type has advantages and disadvantages (Table 2). Courtyard accommodation provides the following benefits. Greater opportunity for patient access to landscape since these are easier for staff to maintain surveillance over.
Additional safety for staff owing to continuous circulation (staff cannot get caught in âdead-endsâ. However, the presence of corners which are difficult to see around is a drawback). Natural light is more easily available.
And âswing bedroomsâ can be supported (this is the ability to reconfigure the number of observable bedrooms on a nursing ward by opening and closing doors at different points within a corridor). However, courtyard accommodation requires a larger site area so is better suited to rural locations than urban and is not well suited to multi-story facilities. Peninsula accommodation enables geographical separation, giving medical teams greater opportunity to manage which patients are housed together (âcohortingâ).
Blind corners can be avoided to assist safety and surveillance. Travel distances can be minimised. Finally, the absence of continuous circulation provides greater flexibility for creating social spaces for patients with graduated degrees of (semi-)privacy.View this table:Table 2 Advantages and disadvantages of peninsula versus courtyard accommodationAnother important consideration related to inpatient accommodation is ward size.
The number of bedrooms clustered together, alongside the amount of dedicated living space associated with these bedrooms. Ward size can influence patient agitation and aggression, alongside ease of supervision, staff anxiety and safety.31 The most common ward sizes were 24 or 32 beds, further subdivided into subclusters of 8 beds. Typically, each ward was provided with one large living space that all 24 or 32 patients used together.
More advanced approaches gave patients a choice of living spaces. For example, at Coalinga Hospital, patients could occupy a small living space available to only 8 patients, or a larger space that all 24 patients had access to. We describe this approach as more advanced since both 19th-century understandings alongside recent research by Ulrich et al confirm that social density (the number of persons per room) is âthe most consistently important variable for predicting crowding stress and aggressive behaviourâ.32 Only six hospitals had plans detailed enough to calculate the square-metre provision of living space per patient, and this varied between 5 and 8 square metres.Limitations of the desktop surveyData from a desktop survey are insufficient to obtain a comprehensive understanding of how design contributes to patient experience.
To overcome this limitation, the following sections combine knowledge about how people use space from environmental psychology, knowledge about the design and consultation processes that guide the construction of these facilities, and understandings from architectural history. History suggests that seemingly small changes to typical design practice can effect significant change in the delivery of mental healthcare, the daily experience of hospitalised patients and more broadly public perceptions of mental illness. This integrated approach is used to identify three forensic psychiatric hospitals that challenge accepted design practice to varying degrees and, in doing so, have the potential to act as change-agents in the delivery of forensic mental healthcare.
But first it is important to understand the context in which architectural innovation is able, or unable, to emerge relative to forensic mental healthcare.Accepting the challenge. Using history to help us see beyond the roadblocks to innovationArchitects tasked with designing forensic mental health facilities respond to what is called a âfunctional briefâ. This documents the specific performance requirements of the hospital in question.
Much consultation goes into formulating and refining a functional brief through the initial and developed design stages. Consultation is typically undertaken with a variety of different user groups, and in a sequential fashion that includes a greater cross-section of users as the design progresses, including patients, families, and clinical and security staff. Despite the focus on patient experience within contemporary models of care, functional briefs tend to prioritise safety and security, making them the basis on which most major architectural decisions are made.33 In large part this is simply the reality of accommodating a patient cohort who pose a risk of harm towards themselves and/or others.
A comment from Tom Brooks-Pilling, a member of the design team for the Nixon Forensic Center (Fulton, Missouri), provides insight into this approach and the concerns that drive it. He explained that borrowing a âspoked wheelâ arrangement from prison design eliminated blind spots and hiding places to enable a centrally located staff member to:see everything thatâs going on in that unitâ¦[they are] basically watching the other staffâs back [sic] to make sure that they can focus on treatment and not worry about who might be sneaking up on them or what activities might be going on behind their backs.34Advisory panel feedback confirmed that when the architectural design of a facility heightens staff anxiety this has direct ramifications for the therapeutic process. For example, in spaces where staff could become isolated from one another, and where clear lines of sight were obstructed, such as ill-designed elevators or stairwells, this can lead to movement being reduced across the patient cohort to avoid putting staff in those spaces where they feel unsafe.The architects consulted during the course of this research, including those who were part of the research team, articulated how the necessary prioritisation of safety, in turn, leads to compromises in the attainment of an ideal environment to support treatment.
In the various forensic and acute psychiatric hospital projects they had been involved with, all observed a sincere commitment on the part of those engaged in project briefing to upholding ideals around privacy, dignity, autonomy and freedom of movement for patients. They reported, however, that the commitment to these ideals was increasingly obstructed as the design process progressed by the more pressing concerns of safety. Examples of the kinds of architectural implications of this prioritisation are things like spatially separated nursing stations (enclosed, often fully glazed), when a desire for less-hierarchical interactions between patients and staff had been expressed at the beginning of the briefing process.
Or the substitution of harder-wearing materials, with a more âinstitutionalâ feel when a âhome-likeâ atmosphere had been prioritised initially. There is nothing surprising or unusual about this process since design is, by its nature, a process of seeking improvements on accepted practice while systematically checking the suitability of proposed solutions against a set of performance requirements. In the context of forensic psychiatric hospitals, safety is the performance requirement that most often frustrates the implementation of innovative design.
Thus, amid the complexities of design and procurement relative to forensic psychiatric hospitals, innovation, however humble, and particularly where it can be seen to contribute positively to the patient experience, is worth a closer look.In the historical development of the psychiatric hospital as a building type, two significant departures from accepted design practice facilitated positive change in the treatment of mental illness. The first was Paetzâs development of the village hospital which sought to replace high fences, locked doors and barred windows with âhumane but stringent supervisionâ.35 While this planning approach may not have significantly altered models of care, it was regarded as âan essential, vital developmentâ, providing architectural support to the prevailing approach to treatment of the timeâthat of moral treatmentâwhich aimed to extend kindness and respect to patients, in an environment that was as unrestrictive as possible. The York Retreat is worthy of acknowledgement here as a leading proponent of moral treatment whose influence shifted approaches to asylum design, from focusing on the provision of safe custody to supporting the restoration of sanity.
Architecturally, however, the differences in the York Retreatâs approach were mainly focused on interior details that encouraged patients to maintain civil habits. Dining rooms had white tablecloths and flower vases adorned mantelpieces, door locks were custom-made to close quietly, and window bars fashioned to look like domestic window frames.36 The York Retreat was originally a small institution, in line with Samuel Tukeâs preference for a maximum asylum size of 30 patients. History confirms the extent to which this approach was not scalable and thus unable to be replicated widely for asylum construction.
For these reasons, it has not been considered here as a significant departure from accepted design practice.The second significant departure from accepted design practice was the development of acute treatment hospitals, located within cities, adjacent to general hospitals and medical research facilities. The first hospital of this type was the Maudsley Hospital, led by doctors Henry Maudsley and Frederick Mott, in London. The design intent for this hospital was announced in 1908 but it was not opened until 1923.37 In proposing this hospital, Maudsley and Mott were motivated to bring psychiatry âinto line with the other branches of medical scienceâ.38 This 100-bed facility, located directly across the road from the Kingâs College (Teaching) Hospital, emulated the general hospital typology in offering both outpatient and short-duration inpatient care, specifically targeted at patients with recent-onset illnesses.
The aspirations were threefold. To avoid the stigma associated with large public asylums. To advance the medical understanding of mental illness through research collaborations with general hospitals and medical schools and via improved teaching programmes.
And to both enable and encourage patients to access early, voluntary treatment on an outpatient basis.38 Today the Maudsley appears unremarkable, an unassuming three-storied building on a busy London street. But the significance of what this building communicated at the time it was constructed, and the extent to which it challenged accepted practice, should not be underestimated. The Maudsley sent a clear message to the public that mental illness was no longer to be regarded as different from any other illness treated within a general hospital setting.
That it was no longer okay to isolate those suffering from mental illness from their families or the neighbourhoods in which they lived.39 Following the announcement of the Maudsley, the âpsychopathic hospitalâ rose to prominence within the USA with Johns Hopkins University Hospital opening the Phipps Psychiatric Clinic, in Baltimore, in 1913. The psychopathic hospital similarly promoted urban locations and closer connections to teaching and research. The Maudsley can be seen to have played a significant role in the shift to treating acute mental illness within general hospital settings.In any discussion of the history of institutional care, there is a responsibility to acknowledge that the aspiration to provide buildings that support care and recovery have not always manifested in ways that improved daily life for patients.
The five treatment values that underpinned the analysis framework for this project are not new values. The extension of privacy and dignity to patients and the delivery of care within the least restrictive environment possible were both firmly embedded in the 19th-century approach of moral treatment. Yet the rapid growth of asylum care frustrated the delivery of those values to patients.40 Choice and independence for patients, the desire for a patientâs recovery progress to be reflected in their environment, and opportunities for peer support and family involvement have been present in approaches to mental health treatment since the formal endorsement of the âtherapeutic communityâ approach to hospital construction and administration in the WHOâs report of 1953.41 History reminds us, therefore, that differences can arise between the stated values on which an institution is designed and those which it is constructed and operated.
The three hospitals discussed in the following section include innovative solutions that hold the promise of positive benefits for patients. Yet we acknowledge this a theoretical analysis. For concrete evidence of a positive relationship between these design outcomes and patient well-being, postoccupancy evaluations are required.Three hospitals contributing to positive change in forensic mental healthcareBroadmoor Hospital.
Optimising the value of the village model for patientsNineteenth-century beliefs and contemporary research are in accord regarding the importance of greenspace in reducing agitation within forensic psychiatric hospital environments and in promoting positive patterns of socialisation.42 It is surprising, therefore, that enshrining daily landscape access for patients is not widespread within current design practice. The Irish National Forensic Mental Hospital and the State Hospital at Carstairs (Scotland) both follow the model of the village hospital, but only in that they comprise a number of accommodation buildings set within the landscape, enclosed by an external boundary fence. At the Irish National Forensic Mental Hospital, the scale of the landscapeâthe distance between buildings and the lack of intermediate boundaries within the landscapeâsuggests it is highly unlikely that patients are allowed to navigate this landscape on a regular basis.
By comparison, the architectural response developed for Broadmoor Hospital (2019) shows an exemplary commitment to patient views and access to landscape (Figure 3).Likely extent of landscape occupation by patients as indicated by the position of inner and outer secure boundary lines. (1) Broadmoor Hospital (rural site, UK), (2) Irish National Forensic Mental Hospital (rural site) and (3) Roseberry Hospital (suburban site, UK)." data-icon-position data-hide-link-title="0">Figure 3 Likely extent of landscape occupation by patients as indicated by the position of inner and outer secure boundary lines. (1) Broadmoor Hospital (rural site, UK), (2) Irish National Forensic Mental Hospital (rural site) and (3) Roseberry Hospital (suburban site, UK).Five contemporary hospitals follow the logic of a traditional villa hospital, yet Broadmoor is the only one that optimises the benefits offered by this spatial configuration.
Comprising a gateway building and a central treatment hub, with a series of patient accommodation buildings positioned around it, the landscape becomes the only available circulation route for patients travelling off-ward to the shared therapy, recreation and vocational training spaces. Most patients will thus engage with the outdoors at least twice daily on their way to and return from these shared spaces. But in addition to accessing this central landscape, landscape views from patient rooms have been prioritised, and each ward is allocated its own large greenspace.
Multiple, internal boundary fences enable patient access to the adjacent landscape to the greatest possible degree (refer to Figure 3). This approach provides patients with a diversity of landscape experiences. This is important given the patterns of landscape use between forensic and non-forensic hospitals.
In non-forensic facilities, patients are likely to have the choice of accessing multiple landscape spaces, whereas in forensic facilities access to a particular space is often restricted to one cohort, for example, a single ward group. This highlights a limitation of the courtyard model for forensic patients. Roseberry Park Hospital (2012) provides an example of how a high degree of landscape access can be similarly achieved for patients on constrained urban site, using a courtyard layout (refer to Figure 3).Providing patients with daily landscape access provides challenges to maintaining safety and security.
Trees with low branches can be used as weapons, while tall branches can be used for self-harm, and ground cover landscaping increases opportunities to conceal contraband. At the Australian hospital where advisory panel sessions were conducted (constructed in 2000), the landscape is occupied in a similar way and staff conveyed the constant effort required to ensure safe patient access to this greenspace. Significant costs are incurred annually by facilities staff in keeping the greenspace free from contraband and from several varieties of wild mushroom that grow seasonally on the site.
Despite this cost, staff reported that both they and the patients value the opportunity to circulate through the landscaped grounds (even in inclement weather). Hence, the benefits to well-being are perceived as significant enough to justify this cost. These examples make evident that placing a hospital within a landscape is not enough to ensure patients are extended the well-being benefits of ongoing access.
Instead this requires that hospitals factor in the additional supervisory and maintenance requirements to maintain landscape access for patients.Worcester Recovery Center and Hospital. Spaces to support choice and a sense of controlResearch in environmental psychology, conducted within residential and hospital settings, confirms that the ability to regulate social contact can have a dramatic impact on well-being. The physical layout of spaces has been linked to both the likelihood of developing socially supportive relationships and impeding this development, with direct implications for communication, concentration, aggression and a personâs resilience to irritation.43 These problems can be more pronounced in a forensic psychiatric hospital as there is an over-representation of patients who have suffered trauma.
Architects working in forensic psychiatric hospital design acknowledge that patients need space to withdraw from the busy hospital environment, spaces where they can âobserve everything that is going on around them until they feel ready to join inâ.44 It is surprising, therefore, that many contemporary forensic psychiatric hospitals still continue to provide a single social space for all 24 or 32 patients occupying a ward. The Worcester Recovery Center, by comparison, provides patients with a choice of social spaces that are designed to enable graduated degrees of social engagement. This can support a sense of control to limit socially induced stress.Worcester is conceptualised as three distinct zones designed to resemble life beyond the hospital.
The âhouseâ, âneighbourhoodâ and âdowntownâ (Figure 4). The house zones include patient accommodation, employing a peninsula model. Each comprises 26 patient rooms, clustered into groups of 6 or 10 single bedrooms that face a collection of shared spaces dedicated to that cluster, including sitting areas, lounges and therapeutic spaces.
A shared kitchen and dining room is provided for each house. Three houses feed into a neighbourhood zone that includes shared spaces for therapy and vocational training, while the downtown zone serves a total of 14 houses. The downtown zone can be accessed by patients based on a merit system and includes a café, bank and retail spaces, music room, health club, chapel, green house, library and art rooms, alongside large interior public spaces.
This array of amenities does not seem distinctly different from other contemporary facilities, where therapy and vocational training happen in a mix of on-ward and off-ward (often within a central treatment hub). The difference lies in the sensitivity of how these spaces are articulated.Details of the social spaces provided on each ward at the Worcester Recovery Center and the proximity of the âhouseâ (or ward) to the âneighbourhoodâ and âdowntownâ." data-icon-position data-hide-link-title="0">Figure 4 Details of the social spaces provided on each ward at the Worcester Recovery Center and the proximity of the âhouseâ (or ward) to the âneighbourhoodâ and âdowntownâ.The generosity of providing separate living spaces for every 6â10 patients and locating these directly across the corridor from the patient rooms supports a sense of control and choice for patients. Frank Pitts, an architect who worked on the Worcester project, has written that this was done to enable patients to âdecide whether they are ready to step out and socialise or return to the privacy of their roomâ.45 This approach filters throughout the facility, providing a slow graduation of social engagement opportunities for patients, from opportunities to socialise with their cluster of 6â10 individuals, to their house of 26, to their neighbourhood of 78 people, to the full downtown experience.
According to the architects, the neighbourhood thus provides an intermediary zone between the quiet house and the active downtown, which can be overwhelming for some patients.46 Importantly the scale of the architecture responds to this transition from personal to public space, providing visual indicators to reflect patientsâ movement through their treatment journey. Spaces become larger as they move further from the ward. This occurs because instead of providing a single, large shared living space, patients are provided a choice of smaller spaces to occupyâthese are not much bigger than a patient bedroom.
Dining spaces are slightly larger, while downtown spaces have a civic quality. These are double-height, providing a greater sense of light and airiness. These are arranged in a semicircle, opening onto a large veranda and greenspace.
The sensitive articulation of these spaces, with regard to both their graduated physical scale and the proximity of the social spaces to the patient bedrooms, provides spatial support to these social transitions while empowering patients to control their own level of social interaction.Margaret and Charles Juravinski Centre for Integrated Healthcare. Creating opportunities for greater public engagement and supporting readjustment to the world beyond the hospitalOne of the most significant barriers to mental health treatment is the stigma associated with admission to a psychiatric hospital. We know that discrimination poses an obstacle to recovery and that the media fuels public fears related to forensic mental health patients.47 Two further challenges to mental health delivery include the disconnection patients can experience from the community, including from family and educational opportunities, and the risk of readmission in the period immediately following discharge.48 If architecture is capable of acting as a change-agent in the delivery of mental healthcare, then it needs to show leadership, not only in the provision of a better experience for patients but more broadly in taking steps to help shift public perceptions around mental illness.
The Margaret and Charles Juravinski Centre for Integrated Healthcare (MCJC) (Canada) displays several similarities with the approach taken to the Maudsley Hospital. Its appearance communicates a modern, cutting-edge healthcare facility. It does not hide on a rural site or behind walls.
At five stories, and extensively glazed, MCJC communicates a strong civic presence. Its proximity to McMaster University (6âkm) and to neighbouring general hospitals, including Juravinski Hospital (4âkm) and Hamilton General Hospital (4âkm), positions it well for research collaborations to occur, while its proximity to the Mohawk Community College, across the road, can enable patients with leave privileges to access vocational training. More importantly, it employs three innovative design tactics to target the challenges of contemporary forensic mental healthcare, providing an example for how architecture might broker positive change.The first innovative design strategy is the co-location of support services for outpatient mental healthcare.
The risk of readmission is highest immediately following discharge. A lack of collaboration between outpatient support services can result in fragmented care when patients are most vulnerable to the stresses associated with readjustment to the world beyond.49 MCJC includes outpatient facilities allowing patients to use the hospital as a stable base, or touchstone, in adjusting to life after discharge. Bringing these services onto the same physical site can also improve opportunities for coordination between inpatient and outpatient support services which can support continuity of care.
The second design strategy is the co-location of a medical ambulatory care centre which includes diagnostic imaging, educational and research facilities. This creates reasons for the general public to visit this facility, setting up the opportunity for greater public interaction. This could potentially advance understandings of the role of this facility and the patients it treats.The third innovative design strategy was to optimise the on-edge treatment hub for public engagement.
While adopted across a number of hospitals, including Hawaii State Hospital, Helix Forensic Psychiatry Clinic (Sweden) and the Worcester Recovery Center, the on-edge treatment hubs at these hospitals are buried deep inside the secure outer boundary. At MCJC, the treatment hub is placed adjacent to the public zones of the hospitalâalthough on the second floorâand this can be viewed as extension of the public realm and enables the potential for the public to be brought right up to the secure boundary line (which occurs within the building). MCJC is divided into four zones.
The public zone, the galleria (the name given to the treatment hub), the clinical corridor and inpatient accommodation (Figure 5). The galleria functions similarly to the downtown at the Worcester Recovery Center. Patients are given graduated access to a series of spaces that support their recovery journey.
These include a gym, wellness centre, spiritual centre, library, café, beauty salon, and retail and financial services, alongside patient and family support services. While the galleria was initially intended to be accessible by the general public, this was not immediately implemented on the facilitiesâ opening and it is unclear whether this has now occurred.50 Nonetheless, the potential for movement of patients outwards, and families inwards, has been built into the physical fabric of this building, meaning opportunities for social interaction and fostering greater public understanding are possible. If understanding is the antidote to discrimination, then exposing the public to the role of this facility and the patients it treats is an important step in the right direction.Zoning configuration at the Margaret and Charles Juravinski Centre for Integrated Healthcare.
The galleria zone is on the second floor (shown in black). The arrows indicate main access points to the galleria. Lifts (L) and stairwell (S) positions are indicated." data-icon-position data-hide-link-title="0">Figure 5 Zoning configuration at the Margaret and Charles Juravinski Centre for Integrated Healthcare.
The galleria zone is on the second floor (shown in black). The arrows indicate main access points to the galleria. Lifts (L) and stairwell (S) positions are indicated.ConclusionThe question of how architecture can support the therapeutic journey of forensic mental health patients is a critical one.
Yet the availability of evidence-based design literature to guide designers cannot keep pace with growing global demand for new forensic psychiatric hospital facilities, while limitations remain relative to the breadth and usability of this research. A narrow view of what constitutes credible evidence can overlook the value of knowledge embedded in architectural practice, alongside that held by architectural historians and lessons from environmental psychology. In respect of such a pressing and important problem, there is a responsibility to integrate knowledge from across these disciplines.
Accepting the limitations of a theoretical analysis and of the desktop survey method, we also argue for its value. Architects learn through experience, across multiple projects. This gives weight to the value of examining existing, contemporary design solutions to identify architectural innovations capable of providing benefits to patients and thus perhaps worthy of implementation across multiple projects.
History gives us reason to believe that small changes to typical design practice can improve the delivery of mental healthcare, the daily experience of hospitalised patients and more broadly public perceptions of mental illness. Architecture has the capacity to contribute to positive change.Here, we have provided a nuanced way for architects and decision makers to think about the relationship between architectural space and treatment values. An institutionâs model of care and the therapeutic values that underpin that model of care should be placed at the centre of architectural decision making.
A survey of contemporary architectural solutions confirms that, generally speaking, innovation is lacking in this field. There will always be real obstacles to innovation, and the argument presented here does not suggest it is necessarily practical to prioritise therapeutic values at the cost of patient, staff and community safety. Instead, it challenges architects and decision makers to properly interrogate any architectural decision that compromises an initial commitment to supporting a patientâs treatment journeyâto be more idealistic in the pursuit of positive change.Tangible examples exist of architectural innovations capable of positively improving patient experience by supporting key values that underpin contemporary treatment approaches.
The Broadmoor Hospital optimises the value of the village model for patients, prioritising patient needs for frequent landscape engagement to support their therapeutic journey. The Worcester Recovery Center provides a generous choice and graduation of social spaces to support the social reintegration of patients at their own pace. MCJC co-located facilities to support a patientâs readjustment to daily life postdischarge, while creating opportunities for public engagement that has the potential to foster greater public understanding of the role of these institutions and the patients they treat.
In identifying these three innovative design approaches, we provide architects with tangible design tactics, while encouraging researchers to look more closely at these examples with targeted, postoccupancy studies. These projects provide hope that with a shared vision and commitment, innovation is possible in forensic psychiatric hospital design, with tangible benefits for patients.Data availability statementAll data relevant to the study are included in the article or uploaded as supplementary information. The primary method undertaken for this research relied on data publicly available on the internet.Ethics statementsPatient consent for publicationNot required.AcknowledgmentsThe opportunity to conduct this project arose out of a multidisciplinary master-planning and feasibility study, commissioned by the Victorian Health and Human Services Building Authority, to investigate various international solutions to inform future planning and design around forensic mental health service provision.
The following people contributed their time and expertise in shaping the research process that enabled this article. Neel Charitra, Stefano Scalzo, Les Potter, Margaret Grigg, Lousie Bawden, Matthew Balaam, Martin Gilbert, John MacAllister, Crystal James, Jo Ryan, Julie Anderson, Jo Wasley, Sophie Patitsas, Meagan Thompson, Judith Hemsworth, James Watson, Viviana Lazzarini, Krysti Henderson, Nadia Jaworski, Jack Kerlin and Jan Merchant.Notes1. Jamie O'Donahoo and Janette Graetz Simmonds (2016), âForensic Patients and Forensic Mental Health in Victoria.
Legal Context, Clinical Pathways, and Practice Challenges,â Australian Social Work 69, no. 2. 169â80.2.
The challenge of which terminology to select when writing about psychiatric hospital design remains difficult relative to the stigmas that surround this field. The term âpatientâ has been used throughout, instead of âconsumerâ, as this article spans both historical and contemporary developments. In the context of this timespan, consumer is a relatively recent term, introduced around 1985.3.
B Edginton (1994), âThe Well-Ordered Body. The Quest for Sanity through Nineteenth-Century Asylum Architecture,â Canadian Bulletin of Medical History 11, no. 2.
375â86. Clare Hickman (2009), âCheerful Prospects and Tranquil Restoration. The Visual Experience of Landscape as Part of the Therapeutic Regime of the British Asylum, 1800-60,â History of Psychiatry 20, no.
4 Pt 4. 425â41. Rebecca McLaughlan, 2012), âPost-Rationalisation and Misunderstanding.
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61â125. Jill Maben et al. (2015), âEvaluating a Major Innovation in Hospital Design.
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Ulrich et al. (2018), âPsychiatric Ward Design Can Reduce Aggressive Behavior,â Journal of Environmental Psychology 57. 53â66.6.
Graham A Tyson, Gordon Lambert, and Lyn Beattie (2002), âThe Impact of Ward Design on the Behaviour, Occupational Satisfaction and Well-Being of Psychiatric Nurses,â International Journal of Mental Health Nursing 11, no. 2. 94â102.7.
For further examples of this see Jon E. Eggert et al. (2014), âPerson-Environment Interaction in a New Secure Forensic State Psychiatric Hospital,â Behavioral Sciences &.
C.C. Whitehead et al. (1984), âObjective and Subjective Evaluation of Psychiatric Ward Redesign,â The American Journal of Psychiatry 141, no.
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1527â38.8. Morgan Andersson et al. (2013), âNew Swedish Forensic Psychiatric Facilities.
Visions and Outcomes,â Facilities 31, no 1/2. 24â88.9. For examples see Kathleen Connellan et al.
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Allen and R.G. Nairn, 1997. Alan Dilani, 2000, âPsychosocially Supportive Design - Scandinavian Health Care Design,â World Hospitals and Health Services 37.
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91â9. Jeremy Taylor (1991), Hospital and Asylum Architecture in England 1849â1914. Building for Health Care (London.
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Although not fitting a strict definition of postoccupancy evaluation, the following articles were notable exceptions to this finding. Eggert et al., âPerson-Environment Interaction,â 527â38. Roger S.
Ulrich et al. (2018), âPsychiatric Ward Design Can Reduce Aggressive Behavior,â 53â66. Catherine Clark Ahern et al.
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Refer to McLaughlan, âOne Dose of Architecture, Taken Daily.â20. The following documents were referenced in compiling this list. Joint Commission Panel for Mental Health, NHS, UK (2013), âGuidance for Commissioners of Forensic Mental Health Services,â May, https://www.jcpmh.info/resource/guidance-for-commissioners-of-forensic-mental-health-services/.
Cannon Design (2014), âSt Josephâs Integrated Healthcare Hamilton, Margaret and Charles Juravinski Centre for Integrated Healthcare,â Healthcare Design Showcase, September. Health Nexus Group, 2017, âForensicare Model of Care Report,â April, Australia (access provided by the Victorian Health and Human Services Building Authority). Donald Cant Watts Corke (2014), âService Plan for Forensic Mental Health Services,â July, Australia (access provided by the Victorian Health and Human Services Building Authority).21.
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Morgan Andersson et al. (2013), âNew Swedish Forensic Psychiatric Facilities,â 24â38. Eggert et al., âPerson-Environment Interaction.â23.
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Jon E. Eggert et al. (2014), âPerson-Environment Interaction,â 527â38.34.
Tom Brooks-Pilling cited in Mike Lear (2015), âDesigner. New Fulton State Hospital Will Be Better, Safer,â Missourinet, January 5, https://www.missourinet.com/2015/01/05/designer-new-fulton-state-hospital-will-be-better-safer/35. Leslie Topp (2007), âThe Modern Mental Hospital in Late Nineteenth-Century Germany and Austria.
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Anon (1908), âProposed New Hospital for Mental Diseases,â The Lancet 171, no. 4410. 728â9.38.
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A transdisciplinary approach.124. WHO (2016). World Antibiotic Awareness Week. 2016 campaign toolkit.
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Based on subsequently collected survey data).126. Nutcha Charoenboon et al. (2019)127. We thank an anonymous reviewer for highlighting the potential hazards of reproducing hierarchies through methods intended to challenge them in the first place.128.
The research was reviewed and approved by the University of Oxford Tropical Research Ethics Committee (Ref. OxTREC 528-17), and it received local ethical approval in Thailand from the Mae Fah Luang University Research Ethics Committee on Human Research (Ref. REH 60099). The service evaluation of the photo exhibition involved anonymised data collection and received a waiver for ethical approval from the University of Warwick Humanities &.
Social Sciences Research Ethics Committee (HSSREC). However, all evaluation form respondents explicitly consented to the data being reported in research publications.129. Marco J Haenssgen et al. (2018)130.
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The questionnaire did so by showing all survey respondents three images of common antibiotic capsules being used in Chiang Rai (green-blue. Amoxicillin. Red-black. Cloxacillin.
White-blue. Azithromycinâsee questionnaire page 10 in the online supplementary material). Respondents were asked to name what they saw, and all their answers were recorded (field-coded and as free text).147. The âdesirabilityâ of the responses was field coded by the survey team.
Sample responses (as instructed through the survey manual) for âdesirableâ answers included, for example, âOnly if the doctor says that I shouldâ. Sample responses for âundesirableâ answers included âYes, you can buy it in the shop over there!. Â The variable should be interpreted as âthe fraction of respondents who uttered a âdesirableâ responseââthe inverse is the fraction of responses that could not be deemed âdesirableâ (eg, âdo not knowâ or âno opinionâ).148. Because recalled descriptions of medicine tend to be ambiguous, we limited our analysis to medicines where we had a high degree of certainty that they were an antibiotic.
This was specifically the case if survey respondents mentioned common antibiotic descriptions such as âanti-inflammatoryâ, âamoxiâ or âcolemâ, if they indicated explicitly that they know what âanti-inflammatory medicineâ is (noting that the term describes antibiotics unambiguously in Thai), and if they subsequently mentioned any of the previously mentioned antibiotics during their description of an illness episode (conversely, we excluded cases were the medicine could not be confirmed as either antibiotic or non-antibiotic, including descriptions like âwhite powderâ or âgreen capsuleâ).149. Aristotle (1954). Rhetoric. Translated by Roberts.
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Amsterdam Institute for Social Science Research.154. Although this was not the focus of the current paper, we note for full disclosure that the workshops, too, had mixed behavioural impacts. The poster making sessions in Chiang Rai demonstrated for instance how our conversations about drug resistance and the introduction of messages from the World Health Organization entailed at times problematic interpretations like, âYou shouldnât take medicines that you have never seen beforeââthe research team responded to such interpretations directly in order to avoid misunderstandings. In addition, previous behavioural analyses documented that, while workshop participants demonstrated higher levels of awareness of drug resistance, alignment of antibiotic use with global health recommendations was mixed, and in one case, a villager started selling antibiotics after the workshop.
For more details on the behavioural analysis, see Nutcha Charoenboon et al. (2019) and Marco Haenssgen et al. (2018).155. For example, Redfern, et al., Spreading the message of antimicrobial resistance.
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10.1177/1468794112446104IntroductionIn Australia, the USA and the UK, the number of hospital beds required for forensic mental health treatment doubled between 1996 and 2016.1 Current trends and future predictions suggest this demand will continue to grow. But, in an age where evidence-based practice is highly valued, the demand for new facilities already outpaces the availability of credible evidence to guide designers. This article reports findings from a desktop survey of current design practice across 31 psychiatric hospitals (24 forensic, 7 non-forensic) constructed or scheduled for completion between 2006 and 2022. Desktop surveys, as a form of research, are heavily relied on in architectural practice.
Photographs and architectural drawings are analysed to understand both typical and innovative approaches to designing a particular building type. While desktop surveys are sometimes supplemented by visits to exemplar projects (which might also be termed âfieldworkâ), time pressures and budgetary constraints often preclude this. As the result of an academicâindustry partnership, the research reported herein embraced practice-based research methods in conjunction with an academic approach. The data set available for the desktop survey was rich but incomplete.
Security requirements restrict the public availability of complete floor plans and postoccupancy evaluations. To mitigate these limitations, knowledge was integrated from other disciplines, including environmental psychology, architectural history and professional practice. With regard to the latter, knowledge is specifically around the design and consultation processes that guide the construction of these facilities. This knowledge was used to identify three contemporary hospitals that challenge accepted design practice and, we argue, in doing so have the potential to act as change-agents in the delivery of forensic mental healthcare.
We define innovation as variation/s to common, or typical, architectural solutions that can positively improve patientsâ2 experience of these facilities in ways that directly support one, or a number, of key values underpinning forensic mental healthcare. While this article does not provide postoccupancy data to quantify the value of these innovations, we hope to encourage both designers and researchers to more closely consider these projectsâparticularly the way that spaces have been designed to benefit patient well-beingâand the questions these designs raise for the future of forensic mental healthcare delivery.Now regarded as naïve is the 19th-century belief that architecture and landscape, if appropriately designed, can restore sanity.3 Yet contemporary research from the field of evidence-based design confirms that the built environment does play a role in the therapeutic process, even if that role does not determine therapeutic outcomes.4 Research regarding the design of forensic mental healthcare facilities remains limited. An article by Ulrich et al recommended that to reduce aggression patients should be accommodated in single rooms. Communal areas should have movable furniture.
Wards should be designed for low social densities. And accessible gardens should be provided.5 An earlier study by Tyson et al showed that lower ward densities can also positively improve patientâstaff interactions.6 Commonly, however, the studies referenced above compared older-style mental health units with their contemporary replacements.7 There is little comparative research available that examines contemporary facilities for forensic mental healthcare, with the exception of one article that provided a comparative analysis of nine Swedish facilities, designed between 1990 and 2008.8 However, this article merely described the design aspirations and physical composition of each hospital without investigating the link between design aspiration, patient well-being and the resulting physical environment.There are two further limitations to evidence-based design research. The first is the extent to which data do not provide directly applicable design tactics. Systematic literature reviews typically provide a set of design recommendations but without suggesting to designers what the corresponding physical design tactics to achieve those recommendations might actually be.9 This is consistent for general hospital design.
For example, architects have been advised to provide spaces that are âpsychosocially supportiveâ since 2000, yet it was 2016 before a spatially focused definition of this term was provided, offering designers a more tangible understanding of what they should be aiming for.10 The second limitation is the breadth of research currently available. While rigorous and valuable, evidence-based design often overlooks the fact that architects must design across scales, from the master-planning scaleâdeciding where to place buildings of various functions within a site, and how to manage the safe movement of staff and patients between those buildingsâto the scale of a bathroom door. How do you design a bathroom door to meet antiligature and surveillance requirements, to maintain patient safety, while still communicating dignity and respect for patients?. The available literature provides much to contemplate, but in terms of credible evidence much of this research is based on a single study, typically conducted within a single hospital context and often focused on a single aspect of design.
This raises the question, is there really a compelling basis for regarding evidence-based design knowledge as more credible than knowledge generated about this building type from other disciplines?. In light of the small amount of evidence available in this field, is there not a responsibility to use all the available knowledge?. While the discipline of evidence-based design has existed for three decades,11 purpose-designed buildings for the treatment of mental illness have been constructed for over three centuries. Researchers working within the field of architectural history also understand that patient experience is partially determinedâfor better or worseâby the decisions that designers make, and that models of care have been used to drive design outcomes since the establishment of the York Retreat in 1796.
With their focus on moral treatment, the York Retreat influenced a shift in the way asylum design was approached, from the provision of safe custody to finding architectural solutions to support the restoration of sanity.12 Architectural historians also bring evidence to bear in respect of this design challenge, specifically knowledge of how the best architectural intentions can result in unanticipated (sometimes devastating) outcomesâand of the conditions that gave rise to those outcomes.13 There is a third, rich source of knowledge available to guide designers that, broadly speaking, academic researchers have yet to tap into. It is the knowledge produced by practitioners themselves. Architects learn through experience, across multiple projects and through practice-based forms of enquiry that include desktop surveys (also referred to as precedent studies), user group consultations and gathering (often informal) postoccupancy data from their clients. Architects have already offered a range of tangible solutions to meet particular aspirations related to patient care.
There is value in examining these existing design solutions to identify those capable of providing direct benefits to patients that might justify implementation across multiple projects. In understanding how the physical design of forensic psychiatric hospitals can best support the therapeutic journey of patients, all available knowledge should be valued and integrated.Methodology. Embracing âmode twoâ researchThis research was conducted within the context of a masterÂ-planning and feasibility study, commissioned by a state government department, to investigate various international design solutions to inform future planning around forensic mental health service provisions in Victoria, Australia. The industry-led nature of this project demanded a less conventional and more inclusive methodological approach.
Tight timeframes precluded employing research methods that required ethics approvals (interviewing patients was not possible), while the timeframe and budget precluded the research team from conducting fieldwork. The following obstacles further limited a conventional approach:Postoccupancy evaluations of forensic psychiatric hospital facilities are seldom conducted and/or not made publicly available.14Published floor plans that would enable researchers to derive an understanding of the functional layouts and corresponding habits of occupancy within these facilities are limited owing to the security needs surrounding forensic psychiatric hospital sites.Available literature relevant to the design of forensic psychiatric hospital facilities provides few direct architectural recommendations to offer tactics for how the built environment might support the delivery of treatment.The team had to find a way to navigate these challenges in order to address the important question of how the physical design of forensic psychiatric hospitals can best support the therapeutic journey of patients.âMode twoâ is a methodological approach that draws on the strength of collaborations between academia and industry to produce âsocially robust knowledgeâ whose reliability extends âbeyond the laboratoryâ to real-world contexts.15 It shares commonalities with a phenomenological approach that attributes value to the prolonged, firsthand exposure of the researcher with the phenomenon in question.16 The inclusion of practising architects and academic researchers within the research team provided considerable expertise in the design, consultation and documentation of these facilities, alongside an understanding of the kinds of challenges that arise following the occupation of this building type. Mode two, as a research approach, also recognises that, while architects reference evidence-based design literature, this will not replace the processes through which practitioners have traditionally assembled knowledge about particular building types, predominantly desktop surveys.A desktop survey was undertaken to understand contemporary design practice within this building type. Forty-four projects were identified as relevant for the period 2006â2022 (31 forensic and 13 non-forensic psychiatric hospitals).
These included facilities from the UK, the USA, Canada, Denmark, Norway, Sweden, the United Arab Emirates and Ireland (online supplementary appendix 1). Sufficient architectural information was not available for 13 of these projects and they were excluded from the study. For the remaining 31 facilities, 24 accommodated forensic patients and 7 did not. Non-forensic facilities were included to enable an awareness of any significant programmatic or functional differences in the design responses created for forensic versus non-forensic mental health patients.
Architectural drawings and photographs were analysed to identify general trends, alongside points of departure from common practice. Borrowing methods from architectural history, the desktop survey was supplemented by other available information, including a mix of hospital-authored guidebooks (as provided to patients and visitors), architectsâ statements, newspaper articles and literature from the field of evidence-based design. Available data varied for each of the 31 hospitals. Adopting a method from architectural theorist Thomas Markus, the materiality and placement of external and internal boundary lines were closely studied (assisted by Google Earth).17 When read in conjunction with the architectural drawings, boundary placement revealed information regarding patient access to adjacent landscape spaces.Supplemental materialA desktop survey has limitations.
It cannot provide a conclusive understanding of how these spaces operate when occupied by patients and staff. While efforts were made to contact individual practices and healthcare providers to obtain missing details, such requests typically went unanswered. This is likely owing to concerns of security, alongside the realities of commercial practice, concerns around intellectual property, and complex client and stakeholder arrangements that can act to prohibit the sharing of this information. To deepen the teamâs understanding, a 2-day workshop was hosted to which two international architectural practices were invited to attend, one from the UK and one from the USA.
Both practices had recently completed a significant forensic psychiatric hospital project. While neither of these facilities had been occupied at the time of the workshops, the architects were able to share their experiences relative to the research, design, and client and patient consultation processes undertaken. The Australian architects who led the research team also brought extensive experience in acute mental healthcare settings, which assisted in data analysis.To further mitigate the limitations of the desktop survey, understandings developed by the team were used as a basis for advisory panel discussions with staff. Feedback was sought from five 60âmin long, advisory panel sessions, each including four to six clinical/facilities staff (who attended voluntarily during work hours) from a forensic psychiatric hospital in Australia, where several participants recounted professional experience in both the Australian and British contexts.
Each advisory panel session was themed relative to various aspects of contemporary design. (1) site/hospital layout, (2) inpatient accommodation, (3) landscape design and access, (4) staff amenities, and (5) treatment hubs (referred to as âtreatment mallsâ in the American context). These sessions enabled the research team to double-check our analysis of the plans and photographs, particularly our assumptions regarding the likely use, practicality and therapeutic value of particular spaces.Model for analysisWithin general hospital design, a range of indicators are used to measure the contribution of architecture to healing, such as the optimisation of lighting to support sleep, the minimisation of patient falls, or whether the use of single patient rooms assists with control.18 In mental health, however, where the therapeutic journey is based more on psychology than physiology, what metrics should be employed to evaluate the success of one design response over another in supporting patient care?. We suggest the first step is to acknowledge the values that underpin contemporary approaches to mental healthcare.
The second step is to translate those treatment values into corresponding spatial values using a value-led spatial framework.19 This provides a checklist for relating particular spatial conditions to specific values around patient care. For example, if the design intent is to optimise privacy and dignity for patients, then the design of bathrooms, relaxation and de-esculation spaces are all important spaces in respect of that therapeutic value. Highlighting this relationship can assist decision makers to more closely interrogate areas that matter most relative to achieving these values. To put this in context, optimising a bathroom design to prioritise a direct line of sight for staff might improve safety but also obstruct privacy and dignity for patients.
While such decisions will always need to be carefully balanced, a value-led spatial framework can provide a touchstone for designers and stakeholders to revisit throughout the design process.To analyse the 31 projects examined within this project, we developed a framework (Table 1). It recognises that a common approach to patient care can be identified across contemporary Australian, British and Canadian models:View this table:Table 1 Value-led spatial framework. Correlating treatment values with corresponding spaces within the hospitalâs physical environmentThat patients be extended privacy and dignity to the broadest degree possible without impacting their personal safety or that of other patients or staff.That patients be treated within the least restrictive environment possible relative to the severity of their illness and the legal (or security) requirements attached to their care.That patients be afforded choice and independence relative to freedom of movement within the hospital campus (as appropriate to the individual), extending to a choice of social, recreational and treatment spaces.That patientsâ progression through their treatment journey is reflected in the way the architecture communicates to hospital users.That opportunities for peer-led therapeutic processes and involvement of family and community-based care providers be optimised within a hospital campus. 20Table 1 assigns a range of architectural spaces and features that are relevant to each of the five treatment values listed.
Architectural decisions related to these values operate across three scales. Context, hospital and individual. Context decisions are those made in respect of a hospitalâs location, including proximity to allied services, connections to public transport and distances to major metropolitan hubs. Decisions of this type are important relative to staffing recruitment and retention, and opportunities for research relative to the psychiatric hospitalâs proximity to general (teaching) hospitals or university precincts.
Architectural decisions operating at the hospital scale include considerations of how secure site boundaries are provided. How buildings are laid out on a site. And how spatial and functional links are set up between those buildings. This is important relative to the movement of patients and staff across a site, including the location and functionality of therapeutic hubs.
But it can also impact patient and community psychology. The design of external fences, in particular, can compound feelings of confinement for patients. Focus community attention on the custodial role of a facility over and above its therapeutic function. And influence perceptions of safety and security for the community immediately surrounding the hospital.
Architectural decisions operating at the âindividualâ scale are those that more closely impact the daily experience of a hospital for patients and staff. These include the various arrangements for inpatient accommodation. Tactics for providing patients with landscape access and views. And the question of staff spaces relative to safety, ease of communication and collaboration.
Approaches to landscape, inpatient accommodation and concerns of staff supervision are closely intertwined.Findings. What we learnt from 31 contemporary psychiatric hospital projectsForensic psychiatric hospitals treat patients who require mental health treatment in addition to a history of criminal offending or who are at risk of committing a criminal offence. Primarily, these include patients who are unfit to stand trial and those found not guilty on account of their illness.21 Accommodation is typically arranged according to low, medium or high security needs, alongside clinical need, and whether an acute, subacute, extended or translational rehabilitation setting is required. Security needs are determined based on the risk a patient presents to themselves and/or others, alongside their risk of absconding from the facility.
The challenge that has proven intractable for centuries is how can architects balance privacy and dignity for patients, while maintaining supervision for their own safety, alongside that of their fellow patients, the staff providing care and, in some cases, the community beyond.22 In this section we present overall trends regarding the layout of buildings within hospital sites, including the placement of treatment hubs and the design of inpatient wards. Access to landscape is not explicitly addressed in this section but is implicit in decisions around site layout and inpatient accommodation.Design approaches to site layoutWe identified two approaches to site layoutâthe âvillageâ (4 from 31 hospitals) and the âcampusâ (27 from 31 hospitals) (figure 1). Similar in their functional arrangement, these are differentiated according to the degree of exterior circulation required to move between patient-occupied spaces. Village hospitals comprise a number of buildings sitting within the landscape, while campus hospitals have interconnected buildings with access provided by internal corridors that prevent the need to go outside.
Neither approach is new. Both follow the models first used within the 19th century. The village hospital follows the model designed by Dr Albrecht Paetz in 1878 (Alt Scherbitz, Germany), which included detached cottages accommodating patients in groups of between 24 and 100, set within gardens.23 Paetz created this design in response to his belief that upwards of 1000 patients should not be accommodated in a single building, with security measures determined in relation to those patients whose behaviour was the least predictable.24 The resulting monotony of the daily routine and restrictions on patient movement were believed to âcripple the intelligence and depress the spiritâ.25 Paetzâs model allowed doctors to classify patients into smaller groups and unlock doors to allow patients with predictable behaviour to wander freely within the secure outer boundaries of the hospital.26 This remained the preferred approach to patient accommodation for over a century, as endorsed by the WHO in their report of 1953.27 Broadmoor Hospital (UK, 2019) provides an example of the village model.The Broadmoor Hospital (left) follows a âvillageâ arrangement and includes an âinternalâ treatment hub. The Worcester Recovery Center and Hospital (right) follows a âcampusâ arrangement and includes an âon-edgeâ treatment hub." data-icon-position data-hide-link-title="0">Figure 1 The Broadmoor Hospital (left) follows a âvillageâ arrangement and includes an âinternalâ treatment hub.
The Worcester Recovery Center and Hospital (right) follows a âcampusâ arrangement and includes an âon-edgeâ treatment hub.The campus model is not dissimilar to the approach propagated by Dr Henry Thomas Kirkbride, a 19th-century psychiatrist who was active in the design of asylums and whose influence saw this planning arrangement dominate asylum constructions in the USA for many decades.28 Asylums of the âKirkbride planâ arranged patient accommodation in a series of pavilions linked by corridors. While corridors can be heavily glazed, where this action is not taken, the campus approach can compromise patient and staff connections to landscape views. Examples of campus hospitals include the Worcester Recovery Center and Hospital (USA, 2012) and the Nixon Forensic Center (USA, under construction).Treatment hubs are a contemporary addition to forensic psychiatric hospitals. These cluster a range of shared patient spaces, including recreational, treatment and vocational training facilities, and thus drive patient movement around or through a hospital site.
Two different treatment hub arrangements are in use. Âinternalâ and âon-edgeâ. Those arranged internally typically place these functions at the heart of the campus and at a significant distance from the secure boundary line. Those arranged on-edge are placed at the far end of campus-model hospitals and, in the most extreme cases, occur adjacent to one of the siteâs external boundaries (refer to Figure 1).
Both arrangements aspire to make life within the hospital resemble life beyond the hospital as closely as possible, as the daily practice of walking from an accommodation area to a treatment hub mimics the practice of travelling from home to a place of work or study.With evidence mounting regarding the psychological benefits to patients of landscape access, it should not be assumed that the current preference for campus hospitals over the village model indicates âbest practiceâ. A campus arrangement offers security benefits for the movement of patients across a hospital site, while avoiding the associated risks of contraband concealed within landscaped spaces. However, the existence of village hospitals for forensic cohorts suggests it is possible to successfully manage these challenges. Why then do we see such a strong persistence of the campus hospital?.
This preference may be driven by cultural expectations. From 24 forensic psychiatric hospitals surveyed, 10 were located within the USA and all employed the campus model. Yet nine of those hospitals occupied rural sites where the village model could have been used, suggesting the influence of the Kirkbride plan prevails. The four village hospitals within the broader sample of 31, spanning forensic and non-forensic settings, all occurred within the UK3 and Ireland1.
Paetzâs villa model had been the preferred approach to new constructions in these countries since its introduction at close of the 19th century.29 However, a look at UK hospitals in isolation revealed a more even spread of village and campus arrangements, with two of the four UK-based campus hospitals occupying constrained urban sites that required multi-story solutions. The village model would be inappropriate for achieving this as it does not lend well to urban locations where land availability is scarce.Design approaches to inpatient accommodationThree approaches to inpatient accommodation were identified. Âpeninsulaâ, ârace-trackâ and âcourtyardâ (Figure 2). The peninsula model is characterised by rows of inpatient wings, along a single-loaded or double-loaded corridor that stretches into the surrounding landscape.
This typically enables an exterior view from all patient bedrooms and is not dissimilar to the traditional âpavilionâ model that emerged within 19th-century hospital design.30 In the racetrack model bedrooms are arranged around a cluster of staff-only (or service) spaces, still enabling exterior views from all patient bedrooms. The courtyard model is similar to the racetrack but includes a central landscape space. Information on the design of inpatient room layouts was available for 24 of the 31 projects analysed (15 of these 24 were forensic).Common inpatient accommodation configurations. (1) Peninsula.
Single-loaded version shown (patient rooms on one side only. Double-loaded versions have patient rooms on two sides of the corridor). (2) racetrack and (3) courtyard (landscaped). Staff-occupied spaces and support spaces (social space and so on) shown in grey." data-icon-position data-hide-link-title="0">Figure 2 Common inpatient accommodation configurations.
(1) Peninsula. Single-loaded version shown (patient rooms on one side only. Double-loaded versions have patient rooms on two sides of the corridor). (2) racetrack and (3) courtyard (landscaped).
Staff-occupied spaces and support spaces (social space and so on) shown in grey.Ten forensic hospitals employed a peninsula plan and five employed a courtyard plan. Of the non-forensic psychiatric hospitals five employed the courtyard, three the racetrack and only one the peninsula plan. While the sample size is too small to generalise, the peninsula plan appears to be favoured for a forensic cohort. However, cultural trends again emerge.
Of the 10 peninsula plan hospitals, 6 were located within the USA, and among the broader sample of 24 (including the non-forensic facilities) none of the courtyard hospitals were located there. Courtyard layouts for forensic patients occurred within the UK, Ireland, Denmark and Sweden. However, within these countries, a mix of courtyard and peninsula plans were used, suggesting no clear preference for one plan over the other.Each plan type has advantages and disadvantages (Table 2). Courtyard accommodation provides the following benefits.
Greater opportunity for patient access to landscape since these are easier for staff to maintain surveillance over. Additional safety for staff owing to continuous circulation (staff cannot get caught in âdead-endsâ. However, the presence of corners which are difficult to see around is a drawback). Natural light is more easily available.
And âswing bedroomsâ can be supported (this is the ability to reconfigure the number of observable bedrooms on a nursing ward by opening and closing doors at different points within a corridor). However, courtyard accommodation requires a larger site area so is better suited to rural locations than urban and is not well suited to multi-story facilities. Peninsula accommodation enables geographical separation, giving medical teams greater opportunity to manage which patients are housed together (âcohortingâ). Blind corners can be avoided to assist safety and surveillance.
Travel distances can be minimised. Finally, the absence of continuous circulation provides greater flexibility for creating social spaces for patients with graduated degrees of (semi-)privacy.View this table:Table 2 Advantages and disadvantages of peninsula versus courtyard accommodationAnother important consideration related to inpatient accommodation is ward size. The number of bedrooms clustered together, alongside the amount of dedicated living space associated with these bedrooms. Ward size can influence patient agitation and aggression, alongside ease of supervision, staff anxiety and safety.31 The most common ward sizes were 24 or 32 beds, further subdivided into subclusters of 8 beds.
Typically, each ward was provided with one large living space that all 24 or 32 patients used together. More advanced approaches gave patients a choice of living spaces. For example, at Coalinga Hospital, patients could occupy a small living space available to only 8 patients, or a larger space that all 24 patients had access to. We describe this approach as more advanced since both 19th-century understandings alongside recent research by Ulrich et al confirm that social density (the number of persons per room) is âthe most consistently important variable for predicting crowding stress and aggressive behaviourâ.32 Only six hospitals had plans detailed enough to calculate the square-metre provision of living space per patient, and this varied between 5 and 8 square metres.Limitations of the desktop surveyData from a desktop survey are insufficient to obtain a comprehensive understanding of how design contributes to patient experience.
To overcome this limitation, the following sections combine knowledge about how people use space from environmental psychology, knowledge about the design and consultation processes that guide the construction of these facilities, and understandings from architectural history. History suggests that seemingly small changes to typical design practice can effect significant change in the delivery of mental healthcare, the daily experience of hospitalised patients and more broadly public perceptions of mental illness. This integrated approach is used to identify three forensic psychiatric hospitals that challenge accepted design practice to varying degrees and, in doing so, have the potential to act as change-agents in the delivery of forensic mental healthcare. But first it is important to understand the context in which architectural innovation is able, or unable, to emerge relative to forensic mental healthcare.Accepting the challenge.
Using history to help us see beyond the roadblocks to innovationArchitects tasked with designing forensic mental health facilities respond to what is called a âfunctional briefâ. This documents the specific performance requirements of the hospital in question. Much consultation goes into formulating and refining a functional brief through the initial and developed design stages. Consultation is typically undertaken with a variety of different user groups, and in a sequential fashion that includes a greater cross-section of users as the design progresses, including patients, families, and clinical and security staff.
Despite the focus on patient experience within contemporary models of care, functional briefs tend to prioritise safety and security, making them the basis on which most major architectural decisions are made.33 In large part this is simply the reality of accommodating a patient cohort who pose a risk of harm towards themselves and/or others. A comment from Tom Brooks-Pilling, a member of the design team for the Nixon Forensic Center (Fulton, Missouri), provides insight into this approach and the concerns that drive it. He explained that borrowing a âspoked wheelâ arrangement from prison design eliminated blind spots and hiding places to enable a centrally located staff member to:see everything thatâs going on in that unitâ¦[they are] basically watching the other staffâs back [sic] to make sure that they can focus on treatment and not worry about who might be sneaking up on them or what activities might be going on behind their backs.34Advisory panel feedback confirmed that when the architectural design of a facility heightens staff anxiety this has direct ramifications for the therapeutic process. For example, in spaces where staff could become isolated from one another, and where clear lines of sight were obstructed, such as ill-designed elevators or stairwells, this can lead to movement being reduced across the patient cohort to avoid putting staff in those spaces where they feel unsafe.The architects consulted during the course of this research, including those who were part of the research team, articulated how the necessary prioritisation of safety, in turn, leads to compromises in the attainment of an ideal environment to support treatment.
In the various forensic and acute psychiatric hospital projects they had been involved with, all observed a sincere commitment on the part of those engaged in project briefing to upholding ideals around privacy, dignity, autonomy and freedom of movement for patients. They reported, however, that the commitment to these ideals was increasingly obstructed as the design process progressed by the more pressing concerns of safety. Examples of the kinds of architectural implications of this prioritisation are things like spatially separated nursing stations (enclosed, often fully glazed), when a desire for less-hierarchical interactions between patients and staff had been expressed at the beginning of the briefing process. Or the substitution of harder-wearing materials, with a more âinstitutionalâ feel when a âhome-likeâ atmosphere had been prioritised initially.
There is nothing surprising or unusual about this process since design is, by its nature, a process of seeking improvements on accepted practice while systematically checking the suitability of proposed solutions against a set of performance requirements. In the context of forensic psychiatric hospitals, safety is the performance requirement that most often frustrates the implementation of innovative design. Thus, amid the complexities of design and procurement relative to forensic psychiatric hospitals, innovation, however humble, and particularly where it can be seen to contribute positively to the patient experience, is worth a closer look.In the historical development of the psychiatric hospital as a building type, two significant departures from accepted design practice facilitated positive change in the treatment of mental illness. The first was Paetzâs development of the village hospital which sought to replace high fences, locked doors and barred windows with âhumane but stringent supervisionâ.35 While this planning approach may not have significantly altered models of care, it was regarded as âan essential, vital developmentâ, providing architectural support to the prevailing approach to treatment of the timeâthat of moral treatmentâwhich aimed to extend kindness and respect to patients, in an environment that was as unrestrictive as possible.
The York Retreat is worthy of acknowledgement here as a leading proponent of moral treatment whose influence shifted approaches to asylum design, from focusing on the provision of safe custody to supporting the restoration of sanity. Architecturally, however, the differences in the York Retreatâs approach were mainly focused on interior details that encouraged patients to maintain civil habits. Dining rooms had white tablecloths and flower vases adorned mantelpieces, door locks were custom-made to close quietly, and window bars fashioned to look like domestic window frames.36 The York Retreat was originally a small institution, in line with Samuel Tukeâs preference for a maximum asylum size of 30 patients. History confirms the extent to which this approach was not scalable and thus unable to be replicated widely for asylum construction.
For these reasons, it has not been considered here as a significant departure from accepted design practice.The second significant departure from accepted design practice was the development of acute treatment hospitals, located within cities, adjacent to general hospitals and medical research facilities. The first hospital of this type was the Maudsley Hospital, led by doctors Henry Maudsley and Frederick Mott, in London. The design intent for this hospital was announced in 1908 but it was not opened until 1923.37 In proposing this hospital, Maudsley and Mott were motivated to bring psychiatry âinto line with the other branches of medical scienceâ.38 This 100-bed facility, located directly across the road from the Kingâs College (Teaching) Hospital, emulated the general hospital typology in offering both outpatient and short-duration inpatient care, specifically targeted at patients with recent-onset illnesses. The aspirations were threefold.
To avoid the stigma associated with large public asylums. To advance the medical understanding of mental illness through research collaborations with general hospitals and medical schools and via improved teaching programmes. And to both enable and encourage patients to access early, voluntary treatment on an outpatient basis.38 Today the Maudsley appears unremarkable, an unassuming three-storied building on a busy London street. But the significance of what this building communicated at the time it was constructed, and the extent to which it challenged accepted practice, should not be underestimated.
The Maudsley sent a clear message to the public that mental illness was no longer to be regarded as different from any other illness treated within a general hospital setting. That it was no longer okay to isolate those suffering from mental illness from their families or the neighbourhoods in which they lived.39 Following the announcement of the Maudsley, the âpsychopathic hospitalâ rose to prominence within the USA with Johns Hopkins University Hospital opening the Phipps Psychiatric Clinic, in Baltimore, in 1913. The psychopathic hospital similarly promoted urban locations and closer connections to teaching and research. The Maudsley can be seen to have played a significant role in the shift to treating acute mental illness within general hospital settings.In any discussion of the history of institutional care, there is a responsibility to acknowledge that the aspiration to provide buildings that support care and recovery have not always manifested in ways that improved daily life for patients.
The five treatment values that underpinned the analysis framework for this project are not new values. The extension of privacy and dignity to patients and the delivery of care within the least restrictive environment possible were both firmly embedded in the 19th-century approach of moral treatment. Yet the rapid growth of asylum care frustrated the delivery of those values to patients.40 Choice and independence for patients, the desire for a patientâs recovery progress to be reflected in their environment, and opportunities for peer support and family involvement have been present in approaches to mental health treatment since the formal endorsement of the âtherapeutic communityâ approach to hospital construction and administration in the WHOâs report of 1953.41 History reminds us, therefore, that differences can arise between the stated values on which an institution is designed and those which it is constructed and operated. The three hospitals discussed in the following section include innovative solutions that hold the promise of positive benefits for patients.
Yet we acknowledge this a theoretical analysis. For concrete evidence of a positive relationship between these design outcomes and patient well-being, postoccupancy evaluations are required.Three hospitals contributing to positive change in forensic mental healthcareBroadmoor Hospital. Optimising the value of the village model for patientsNineteenth-century beliefs and contemporary research are in accord regarding the importance of greenspace in reducing agitation within forensic psychiatric hospital environments and in promoting positive patterns of socialisation.42 It is surprising, therefore, that enshrining daily landscape access for patients is not widespread within current design practice. The Irish National Forensic Mental Hospital and the State Hospital at Carstairs (Scotland) both follow the model of the village hospital, but only in that they comprise a number of accommodation buildings set within the landscape, enclosed by an external boundary fence.
At the Irish National Forensic Mental Hospital, the scale of the landscapeâthe distance between buildings and the lack of intermediate boundaries within the landscapeâsuggests it is highly unlikely that patients are allowed to navigate this landscape on a regular basis. By comparison, the architectural response developed for Broadmoor Hospital (2019) shows an exemplary commitment to patient views and access to landscape (Figure 3).Likely extent of landscape occupation by patients as indicated by the position of inner and outer secure boundary lines. (1) Broadmoor Hospital (rural site, UK), (2) Irish National Forensic Mental Hospital (rural site) and (3) Roseberry Hospital (suburban site, UK)." data-icon-position data-hide-link-title="0">Figure 3 Likely extent of landscape occupation by patients as indicated by the position of inner and outer secure boundary lines. (1) Broadmoor Hospital (rural site, UK), (2) Irish National Forensic Mental Hospital (rural site) and (3) Roseberry Hospital (suburban site, UK).Five contemporary hospitals follow the logic of a traditional villa hospital, yet Broadmoor is the only one that optimises the benefits offered by this spatial configuration.
Comprising a gateway building and a central treatment hub, with a series of patient accommodation buildings positioned around it, the landscape becomes the only available circulation route for patients travelling off-ward to the shared therapy, recreation and vocational training spaces. Most patients will thus engage with the outdoors at least twice daily on their way to and return from these shared spaces. But in addition to accessing this central landscape, landscape views from patient rooms have been prioritised, and each ward is allocated its own large greenspace. Multiple, internal boundary fences enable patient access to the adjacent landscape to the greatest possible degree (refer to Figure 3).
This approach provides patients with a diversity of landscape experiences. This is important given the patterns of landscape use between forensic and non-forensic hospitals. In non-forensic facilities, patients are likely to have the choice of accessing multiple landscape spaces, whereas in forensic facilities access to a particular space is often restricted to one cohort, for example, a single ward group. This highlights a limitation of the courtyard model for forensic patients.
Roseberry Park Hospital (2012) provides an example of how a high degree of landscape access can be similarly achieved for patients on constrained urban site, using a courtyard layout (refer to Figure 3).Providing patients with daily landscape access provides challenges to maintaining safety and security. Trees with low branches can be used as weapons, while tall branches can be used for self-harm, and ground cover landscaping increases opportunities to conceal contraband. At the Australian hospital where advisory panel sessions were conducted (constructed in 2000), the landscape is occupied in a similar way and staff conveyed the constant effort required to ensure safe patient access to this greenspace. Significant costs are incurred annually by facilities staff in keeping the greenspace free from contraband and from several varieties of wild mushroom that grow seasonally on the site.
Despite this cost, staff reported that both they and the patients value the opportunity to circulate through the landscaped grounds (even in inclement weather). Hence, the benefits to well-being are perceived as significant enough to justify this cost. These examples make evident that placing a hospital within a landscape is not enough to ensure patients are extended the well-being benefits of ongoing access. Instead this requires that hospitals factor in the additional supervisory and maintenance requirements to maintain landscape access for patients.Worcester Recovery Center and Hospital.
Spaces to support choice and a sense of controlResearch in environmental psychology, conducted within residential and hospital settings, confirms that the ability to regulate social contact can have a dramatic impact on well-being. The physical layout of spaces has been linked to both the likelihood of developing socially supportive relationships and impeding this development, with direct implications for communication, concentration, aggression and a personâs resilience to irritation.43 These problems can be more pronounced in a forensic psychiatric hospital as there is an over-representation of patients who have suffered trauma. Architects working in forensic psychiatric hospital design acknowledge that patients need space to withdraw from the busy hospital environment, spaces where they can âobserve everything that is going on around them until they feel ready to join inâ.44 It is surprising, therefore, that many contemporary forensic psychiatric hospitals still continue to provide a single social space for all 24 or 32 patients occupying a ward. The Worcester Recovery Center, by comparison, provides patients with a choice of social spaces that are designed to enable graduated degrees of social engagement.
This can support a sense of control to limit socially induced stress.Worcester is conceptualised as three distinct zones designed to resemble life beyond the hospital. The âhouseâ, âneighbourhoodâ and âdowntownâ (Figure 4). The house zones include patient accommodation, employing a peninsula model. Each comprises 26 patient rooms, clustered into groups of 6 or 10 single bedrooms that face a collection of shared spaces dedicated to that cluster, including sitting areas, lounges and therapeutic spaces.
A shared kitchen and dining room is provided for each house. Three houses feed into a neighbourhood zone that includes shared spaces for therapy and vocational training, while the downtown zone serves a total of 14 houses. The downtown zone can be accessed by patients based on a merit system and includes a café, bank and retail spaces, music room, health club, chapel, green house, library and art rooms, alongside large interior public spaces. This array of amenities does not seem distinctly different from other contemporary facilities, where therapy and vocational training happen in a mix of on-ward and off-ward (often within a central treatment hub).
The difference lies in the sensitivity of how these spaces are articulated.Details of the social spaces provided on each ward at the Worcester Recovery Center and the proximity of the âhouseâ (or ward) to the âneighbourhoodâ and âdowntownâ." data-icon-position data-hide-link-title="0">Figure 4 Details of the social spaces provided on each ward at the Worcester Recovery Center and the proximity of the âhouseâ (or ward) to the âneighbourhoodâ and âdowntownâ.The generosity of providing separate living spaces for every 6â10 patients and locating these directly across the corridor from the patient rooms supports a sense of control and choice for patients. Frank Pitts, an architect who worked on the Worcester project, has written that this was done to enable patients to âdecide whether they are ready to step out and socialise or return to the privacy of their roomâ.45 This approach filters throughout the facility, providing a slow graduation of social engagement opportunities for patients, from opportunities to socialise with their cluster of 6â10 individuals, to their house of 26, to their neighbourhood of 78 people, to the full downtown experience. According to the architects, the neighbourhood thus provides an intermediary zone between the quiet house and the active downtown, which can be overwhelming for some patients.46 Importantly the scale of the architecture responds to this transition from personal to public space, providing visual indicators to reflect patientsâ movement through their treatment journey. Spaces become larger as they move further from the ward.
This occurs because instead of providing a single, large shared living space, patients are provided a choice of smaller spaces to occupyâthese are not much bigger than a patient bedroom. Dining spaces are slightly larger, while downtown spaces have a civic quality. These are double-height, providing a greater sense of light and airiness. These are arranged in a semicircle, opening onto a large veranda and greenspace.
The sensitive articulation of these spaces, with regard to both their graduated physical scale and the proximity of the social spaces to the patient bedrooms, provides spatial support to these social transitions while empowering patients to control their own level of social interaction.Margaret and Charles Juravinski Centre for Integrated Healthcare. Creating opportunities for greater public engagement and supporting readjustment to the world beyond the hospitalOne of the most significant barriers to mental health treatment is the stigma associated with admission to a psychiatric hospital. We know that discrimination poses an obstacle to recovery and that the media fuels public fears related to forensic mental health patients.47 Two further challenges to mental health delivery include the disconnection patients can experience from the community, including from family and educational opportunities, and the risk of readmission in the period immediately following discharge.48 If architecture is capable of acting as a change-agent in the delivery of mental healthcare, then it needs to show leadership, not only in the provision of a better experience for patients but more broadly in taking steps to help shift public perceptions around mental illness. The Margaret and Charles Juravinski Centre for Integrated Healthcare (MCJC) (Canada) displays several similarities with the approach taken to the Maudsley Hospital.
Its appearance communicates a modern, cutting-edge healthcare facility. It does not hide on a rural site or behind walls. At five stories, and extensively glazed, MCJC communicates a strong civic presence. Its proximity to McMaster University (6âkm) and to neighbouring general hospitals, including Juravinski Hospital (4âkm) and Hamilton General Hospital (4âkm), positions it well for research collaborations to occur, while its proximity to the Mohawk Community College, across the road, can enable patients with leave privileges to access vocational training.
More importantly, it employs three innovative design tactics to target the challenges of contemporary forensic mental healthcare, providing an example for how architecture might broker positive change.The first innovative design strategy is the co-location of support services for outpatient mental healthcare. The risk of readmission is highest immediately following discharge. A lack of collaboration between outpatient support services can result in fragmented care when patients are most vulnerable to the stresses associated with readjustment to the world beyond.49 MCJC includes outpatient facilities allowing patients to use the hospital as a stable base, or touchstone, in adjusting to life after discharge. Bringing these services onto the same physical site can also improve opportunities for coordination between inpatient and outpatient support services which can support continuity of care.
The second design strategy is the co-location of a medical ambulatory care centre which includes diagnostic imaging, educational and research facilities. This creates reasons for the general public to visit this facility, setting up the opportunity for greater public interaction. This could potentially advance understandings of the role of this facility and the patients it treats.The third innovative design strategy was to optimise the on-edge treatment hub for public engagement. While adopted across a number of hospitals, including Hawaii State Hospital, Helix Forensic Psychiatry Clinic (Sweden) and the Worcester Recovery Center, the on-edge treatment hubs at these hospitals are buried deep inside the secure outer boundary.
At MCJC, the treatment hub is placed adjacent to the public zones of the hospitalâalthough on the second floorâand this can be viewed as extension of the public realm and enables the potential for the public to be brought right up to the secure boundary line (which occurs within the building). MCJC is divided into four zones. The public zone, the galleria (the name given to the treatment hub), the clinical corridor and inpatient accommodation (Figure 5). The galleria functions similarly to the downtown at the Worcester Recovery Center.
Patients are given graduated access to a series of spaces that support their recovery journey. These include a gym, wellness centre, spiritual centre, library, café, beauty salon, and retail and financial services, alongside patient and family support services. While the galleria was initially intended to be accessible by the general public, this was not immediately implemented on the facilitiesâ opening and it is unclear whether this has now occurred.50 Nonetheless, the potential for movement of patients outwards, and families inwards, has been built into the physical fabric of this building, meaning opportunities for social interaction and fostering greater public understanding are possible. If understanding is the antidote to discrimination, then exposing the public to the role of this facility and the patients it treats is an important step in the right direction.Zoning configuration at the Margaret and Charles Juravinski Centre for Integrated Healthcare.
The galleria zone is on the second floor (shown in black). The arrows indicate main access points to the galleria. Lifts (L) and stairwell (S) positions are indicated." data-icon-position data-hide-link-title="0">Figure 5 Zoning configuration at the Margaret and Charles Juravinski Centre for Integrated Healthcare. The galleria zone is on the second floor (shown in black).
The arrows indicate main access points to the galleria. Lifts (L) and stairwell (S) positions are indicated.ConclusionThe question of how architecture can support the therapeutic journey of forensic mental health patients is a critical one. Yet the availability of evidence-based design literature to guide designers cannot keep pace with growing global demand for new forensic psychiatric hospital facilities, while limitations remain relative to the breadth and usability of this research. A narrow view of what constitutes credible evidence can overlook the value of knowledge embedded in architectural practice, alongside that held by architectural historians and lessons from environmental psychology.
In respect of such a pressing and important problem, there is a responsibility to integrate knowledge from across these disciplines. Accepting the limitations of a theoretical analysis and of the desktop survey method, we also argue for its value. Architects learn through experience, across multiple projects. This gives weight to the value of examining existing, contemporary design solutions to identify architectural innovations capable of providing benefits to patients and thus perhaps worthy of implementation across multiple projects.
History gives us reason to believe that small changes to typical design practice can improve the delivery of mental healthcare, the daily experience of hospitalised patients and more broadly public perceptions of mental illness. Architecture has the capacity to contribute to positive change.Here, we have provided a nuanced way for architects and decision makers to think about the relationship between architectural space and treatment values. An institutionâs model of care and the therapeutic values that underpin that model of care should be placed at the centre of architectural decision making. A survey of contemporary architectural solutions confirms that, generally speaking, innovation is lacking in this field.
There will always be real obstacles to innovation, and the argument presented here does not suggest it is necessarily practical to prioritise therapeutic values at the cost of patient, staff and community safety. Instead, it challenges architects and decision makers to properly interrogate any architectural decision that compromises an initial commitment to supporting a patientâs treatment journeyâto be more idealistic in the pursuit of positive change.Tangible examples exist of architectural innovations capable of positively improving patient experience by supporting key values that underpin contemporary treatment approaches. The Broadmoor Hospital optimises the value of the village model for patients, prioritising patient needs for frequent landscape engagement to support their therapeutic journey. The Worcester Recovery Center provides a generous choice and graduation of social spaces to support the social reintegration of patients at their own pace.
MCJC co-located facilities to support a patientâs readjustment to daily life postdischarge, while creating opportunities for public engagement that has the potential to foster greater public understanding of the role of these institutions and the patients they treat. In identifying these three innovative design approaches, we provide architects with tangible design tactics, while encouraging researchers to look more closely at these examples with targeted, postoccupancy studies. These projects provide hope that with a shared vision and commitment, innovation is possible in forensic psychiatric hospital design, with tangible benefits for patients.Data availability statementAll data relevant to the study are included in the article or uploaded as supplementary information. The primary method undertaken for this research relied on data publicly available on the internet.Ethics statementsPatient consent for publicationNot required.AcknowledgmentsThe opportunity to conduct this project arose out of a multidisciplinary master-planning and feasibility study, commissioned by the Victorian Health and Human Services Building Authority, to investigate various international solutions to inform future planning and design around forensic mental health service provision.
The following people contributed their time and expertise in shaping the research process that enabled this article. Neel Charitra, Stefano Scalzo, Les Potter, Margaret Grigg, Lousie Bawden, Matthew Balaam, Martin Gilbert, John MacAllister, Crystal James, Jo Ryan, Julie Anderson, Jo Wasley, Sophie Patitsas, Meagan Thompson, Judith Hemsworth, James Watson, Viviana Lazzarini, Krysti Henderson, Nadia Jaworski, Jack Kerlin and Jan Merchant.Notes1. Jamie O'Donahoo and Janette Graetz Simmonds (2016), âForensic Patients and Forensic Mental Health in Victoria. Legal Context, Clinical Pathways, and Practice Challenges,â Australian Social Work 69, no.
2. 169â80.2. The challenge of which terminology to select when writing about psychiatric hospital design remains difficult relative to the stigmas that surround this field. The term âpatientâ has been used throughout, instead of âconsumerâ, as this article spans both historical and contemporary developments.
In the context of this timespan, consumer is a relatively recent term, introduced around 1985.3. B Edginton (1994), âThe Well-Ordered Body. The Quest for Sanity through Nineteenth-Century Asylum Architecture,â Canadian Bulletin of Medical History 11, no. 2.
375â86. Clare Hickman (2009), âCheerful Prospects and Tranquil Restoration. The Visual Experience of Landscape as Part of the Therapeutic Regime of the British Asylum, 1800-60,â History of Psychiatry 20, no. 4 Pt 4.
425â41. Rebecca McLaughlan, 2012), âPost-Rationalisation and Misunderstanding. Mental Hospital Architecture in the New Zealand Media,â Fabrications 22, no. 2.
232â56.4. Roger S Ulrich et al. (2008), âA Review of the Research Literature on Evidence-Based Healthcare Design,â HERD 1, no. 3.
61â125. Jill Maben et al. (2015), âEvaluating a Major Innovation in Hospital Design. Workforce Implications and Impact on Patient and Staff Experiences of All Single Room Hospital Accommodation,â Health Services and Delivery Research 3.
1â304. Penny Curtis and Andy Northcott (2017), âThe Impact of Single and Shared Rooms on Family-Centred Care in Childrenâs Hospitals,â Journal of Clinical Nursing 26, no. 11â12. 1584â96.5.
Roger S. Ulrich et al. (2018), âPsychiatric Ward Design Can Reduce Aggressive Behavior,â Journal of Environmental Psychology 57. 53â66.6.
Graham A Tyson, Gordon Lambert, and Lyn Beattie (2002), âThe Impact of Ward Design on the Behaviour, Occupational Satisfaction and Well-Being of Psychiatric Nurses,â International Journal of Mental Health Nursing 11, no. 2. 94â102.7. For further examples of this see Jon E.
Eggert et al. (2014), âPerson-Environment Interaction in a New Secure Forensic State Psychiatric Hospital,â Behavioral Sciences &. The Law 32, no. 4.
527â38. C.C. Whitehead et al. (1984), âObjective and Subjective Evaluation of Psychiatric Ward Redesign,â The American Journal of Psychiatry 141, no.
5. 639â44. Gabriela Novotná et al. (2011), âClient-Centered Design of Residential Addiction and Mental Health Care Facilities.
Staff Perceptions of Their Work Environment,â Qualitative Health Research 21, no. 11. 1527â38.8. Morgan Andersson et al.
(2013), âNew Swedish Forensic Psychiatric Facilities. Visions and Outcomes,â Facilities 31, no 1/2. 24â88.9. For examples see Kathleen Connellan et al.
(2013), âStressed Spaces. Mental Health and Architecture,â HERD. Health Environments Research &. Design Journal 6, no.
4. 127â168. Constantina Papoulias et al. (2014), âThe Psychiatric Ward as a Therapeutic Space.
Systematic Review,â British Journal of Psychiatry 205, no. 3. 171â6.10. R.
Allen and R.G. Nairn, 1997. Alan Dilani, 2000, âPsychosocially Supportive Design - Scandinavian Health Care Design,â World Hospitals and Health Services 37. 20â4.
Rebecca McLaughlan (2018), âPsychosocially Supportive Design. The Case for Greater Attention to Social Space within the Pediatric Hospital," HERD 11, no. 2. 151â62.11.
Rebecca McLaughlan (2017), âLearning From Evidence-Based Medicine. Exclusions and Opportunities within Health Care Environments Research,â Design for Health 1. 210â28.12. B Edginton (1997), âMoral Architecture.
The Influence of the York Retreat on Asylum Design,â Health &. Place 3, no. 2. 91â9.
Jeremy Taylor (1991), Hospital and Asylum Architecture in England 1849â1914. Building for Health Care (London. Mansell Publishing Limited). Anne Digby (1985), Madness, Morality and Medicine.
A Study of the York Retreat 1796â1914 (New York. Cambridge University Press).13. Digby, Madness, Morality and Medicine. Erving Goffman (1961), Asylums.
Essays on the Social Situation of Mental Patients and Other Inmates (New York. Doubleday). Ivan Belknap (1956), Human Problems of a State Mental Hospital (New York. Blakiston Division, McGraw-Hill).
Andrew Scull (1979), Museums of Madness. The Social Organization of Insanity in 19th Century England (London. Allen Lane). Leonard Smith (1999), Cure, Comfort and Safe Custody.
Public Lunatic Asylums in Early Nineteenth-Century England (London. Leicester University Press). Rebecca McLaughlan (2014), âOne Dose of Architecture, Taken Daily. Building for Mental Health in New Zealandâ (PhD diss., Victoria University of Wellington, New Zealand).14.
Although not fitting a strict definition of postoccupancy evaluation, the following articles were notable exceptions to this finding. Eggert et al., âPerson-Environment Interaction,â 527â38. Roger S. Ulrich et al.
(2018), âPsychiatric Ward Design Can Reduce Aggressive Behavior,â 53â66. Catherine Clark Ahern et al. (2016), âA Recovery-Oriented Care Approach. Weighing the Pros and Cons of a Newly Built Mental Health Facility,â Journal of Psychosocial Nursing and Mental Health Services 54, no.
2. 39â48.15. M Gibbons (2000), âMode 2 Society and the Emergence of Context-Sensitive Science,â Science and Public Policy 27. 161.16.
D Seamon, 2000, âA Way of Seeing People and Place,â in Theoretical Perspectives in Environment-Behavior Research, ed. S. Wapner, J. Demick, T.
Yamamoto and H. Minami (New York. Plenum), 157â78.17. Thomas A Markus (1982), Order in Space and Society.
Architectural Form and Its Context in the Scottish Enlightenment (Edinburgh. Mainstream Publishing Company).18. Ulrich et al., âA Review of the Research Literature,â 61â125.19. This was first created by first author for use for historical analysis during her PhD and is applied here to a contemporary setting.
Refer to McLaughlan, âOne Dose of Architecture, Taken Daily.â20. The following documents were referenced in compiling this list. Joint Commission Panel for Mental Health, NHS, UK (2013), âGuidance for Commissioners of Forensic Mental Health Services,â May, https://www.jcpmh.info/resource/guidance-for-commissioners-of-forensic-mental-health-services/. Cannon Design (2014), âSt Josephâs Integrated Healthcare Hamilton, Margaret and Charles Juravinski Centre for Integrated Healthcare,â Healthcare Design Showcase, September.
Health Nexus Group, 2017, âForensicare Model of Care Report,â April, Australia (access provided by the Victorian Health and Human Services Building Authority). Donald Cant Watts Corke (2014), âService Plan for Forensic Mental Health Services,â July, Australia (access provided by the Victorian Health and Human Services Building Authority).21. Sometimes this includes patients with no history of criminal behaviour but who are unable to be treated safely in a general hospital environment.22. W.A.F Browne (1991), "What Asylums Were, Are and Ought to Be (1837),â reprinted in The Asylum as Utopia.
W.A.F. Browne and the Mid-Nineteenth Century Consolidation of Psychiatry, ed. Andrew Scull (London. Tavistock).
Morgan Andersson et al. (2013), âNew Swedish Forensic Psychiatric Facilities,â 24â38. Eggert et al., âPerson-Environment Interaction.â23. Anon (1895), âReview.
The Colonization of the Insane in Connection with the Open-Door System. Its Historical Development and the Mode in Which It Is Carried Out at Alt Scherbitz Manor. By Dr. Albrecht Paetz, Director of the Provincial Institution for the Insane (Berlin.
Springer, 1983),â The Journal of Mental Science 41. 697â703.24. Theodore Gray (1958), The Very Error of the Moon (Ilfracombe &. Devon.
Arthur H. Stockwell Ltd), 64.25. John Galt (1854), âThe Farm of St. Anne,â American Journal of Insanity II (1854).
352.26. Galt, âThe Farm of St. Anne,â 352.27. Martin James (1948), âDiagnostic Measures,â in Modern Trends in Psychological Medicine, ed.
Noel Haris (London. Buttefwork &. Co. Ltd), 146.
World Health Organization (1953), The Community Mental Hospital. Third Report of the Expert Committee on Mental Health (Geneva. WHO).28. Carla Yanni (2007), The Architecture of Madness.
Insane Asylums in the United States. Minneapolis (London. University of Minnesota Press).29. Key British examples included the 1923 rebuild of Londonâs Bethlem Hospital which followed the villa model, alongside Shenley Park Mental Hospital (Middlesex County) and Barrow Mental Hospital (Somerset), both constructed in the early 1930s.30.
Taylor, Hospital and Asylum Architecture in England.31. Ulrich et al., âPsychiatric Ward Design Can Reduce Aggressive Behavior,â 53â66. O. Jenkins, S.
Dye and C. Foy (2015) (Oliver Jenkins et al., 2015), âA Study of Agitation, Conï¬ict and Containment in Association With Change in Ward Physical Environment,â Journal of Psychiatric Intensive Care 11, no. 01. 27â35.
M. Daï¬ern, M.M. Mayer, and T. Martin (2004), âEnvironmental Contributors to Aggression in Two Forensic Psychiatric Hospitals,â International Journal of Forensic Mental Health 3 no.
(1994), âPatient Overcrowding in Psychiatric Hospital Units. Effects on Seclusion and Restraint,â Administration and Policy in Mental Health 22, no. 2. 133â44.
T. T Palmstierna, B Huitfeldt, and B Wistedt (1991), âThe Relationship of Crowding and Aggressive Behavior on a Psychiatric Intensive Care Unit,â Psychiatric Services 42, no. 12. 1237â40.32.
Ulrich et al., âPsychiatric Ward Design Can Reduce Aggressive Behavior,â 57. Charles Mercier (1894), Lunatic Asylums. Their Organisation and Management (London. Charles Griffin and Company), 135.33.
Morgan Andersson et al. (2013), âNew Swedish Forensic Psychiatric Facilities,â 24â38. Joel A Dvoskin et al. (2002), âArchitectural Design of a Secure Forensic State Psychiatric Hospital,â Behavioral Scients &.
Enser and D. Maclnnes (1999), âThe Relationship between Building Design and Escapes from Secure Units,â Journal of the Royal Society for the Promotion of Health 119, no. 3. 170â4.
Jon E. Eggert et al. (2014), âPerson-Environment Interaction,â 527â38.34. Tom Brooks-Pilling cited in Mike Lear (2015), âDesigner.
New Fulton State Hospital Will Be Better, Safer,â Missourinet, January 5, https://www.missourinet.com/2015/01/05/designer-new-fulton-state-hospital-will-be-better-safer/35. Leslie Topp (2007), âThe Modern Mental Hospital in Late Nineteenth-Century Germany and Austria. Psychiatric Space and Images of Freedom and Control,â in Madness, Architecture and the Built Environment. Psychiatric Spaces in Historical Context, ed.
Leslie Topp, James Moran and Jonathan Andrews (London and New York. Routledge), 244.36. McLaughlan, âOne Dose of Architecture, Taken Daily,â 35. Digby, Madness, Morality and Medicine.37.
Anon (1908), âProposed New Hospital for Mental Diseases,â The Lancet 171, no. 4410. 728â9.38. Anon, âProposed New Hospital for Mental Diseases.â39.
McLaughlan, âOne Dose of Architecture, Taken Daily.â40. Samuel Tuke (1964), âDescription of the Retreat (1813),â reprinted in Description of the Retreat With an Introduction by Richard Hunter and Ida Macalpine (London. Dawsons of Paul Mall). Scull, Museums of Madness.
Digby, Madness, Morality and Medicine. Smith, Cure, Comfort and Safe Custody.41. World Health Organization (1953), The Community Mental Hospital. Also refer to T.F Main (1946), âThe Hospital as a Therapeutic Institutionâ, Bulletin of the Menninger Clinic 10, no.
3. 66â71. David Clark (1965), âThe Therapeutic Community Concept, Practice and Future,â The Journal of Mental Science 111. 947â54.42.
Jolanda Maas et al. (2009), âSocial Contacts as a Possible Mechanism behind the Relation between Green Space and Health,â Health &. Place 15, no. 2.
586â95. Gayle Souter-Brown (2015), Landscape and Urban Design for Health and Well-Being. Using Healing, Sensory and Therapeutic Gardens (Oxon &. New York.
Routledge). Ulrich et al., âA Review of the Research Literature,â 61â125.43. Leon Festinger et al. (1950), Social Pressures in Informal Groups.
A Study of Human Factors in Housing, vol. 11 (New York. Harper Bros). David Halpern (1995), Mental Health and the Built Environment.
More than Bricks and Mortar?. (London. Taylor and Francis). A.
Baum and G.E. Davis (1980), âReducing the Stress of High-Density Living. An Architectural Intervention,â Journal of Personality and Social Psychology 38, no. 3.
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Brooks &. Cole Publishing). Gary W Evans (2003), âThe Built Environment and Mental Health,â Journal of Urban Health. Bulletin of the New York Academy of Medicine 80 no.
4. 536â55. Ulrich et al., âPsychiatric Ward Design Can Reduce Aggressive Behavior,â 53â66.44. Stence Guldager cited in Troldtekt, âInnovative Architecture is Good for Mental Health,â https://www.troldtekt.com/News/Themes/Healing_architecture/Innovative_architecture_is_good_for_mental_health (accessed June 30, 2019).
Clare Hickman and âCheerful Prospects (2009).45. Frank Pitts cited in Patricia Wen (2012), âFor Mentally Ill, A Design Departure,â B News, August 16, https://www.boston.com/news/local-news/2012/08/16/for-mentally-ill-a-design-departure46. Ellenzweig with Architecture Plus, âMassachusetts Department of Mental Health, Worcester Recovery Center and Hospital â Worcester, MA,â Healthcare Design (2013), July 30, https://www.healthcaredesignmagazine.com/architecture/massachusetts-department-mental-health-worcester-recovery-center-and-hospital-worcester-ma/47. Sane Australia (2003), âA Life Without Stigma,â July 25, http://apo.org.au/resource/life-without-stigma.
Otto F Wahl (2012), âStigma as a Barrier to Recovery from Mental Illness,â Trends in Cognitive Sciences 16, no. 1. 9â10. New Zealand Ministry of Health and Health Promotion Agency (2014), âLike Minds, Like Mine National Plan 2014â2019.
Programme to Increase Social Inclusion and Reduce Stigma and Discrimination for People with Experience of Mental Illness,â May 20, https://www.likeminds.org.nz/assets/National-Plans/like-minds-like-mine-national-plan-2014-2019-may14.pdf. G Moon (2000), âRisk and Protection. The Discourse of Confinement in Contemporary Mental Health Policy," Health &. Place 6, no.
Nairn (1997), âMedia Depictions of Mental Illness. An Analysis of the Use of Dangerousness,â Australian &. New Zealand Journal of Psychiatry 31, no. 3.
375â81. Greg Philo et al. (1994), âThe Impact of the Mass Media on Public Images of Mental Illness. Media Content and Audience Belief,â Health Education Journal 53, no.
3. 271â81.48. G Moon (2000), âRisk and Protection,â 239â50. T.F Main (1948), âRehabilitation and the Individual,â in Modern Trends in Psychological Medicine, ed.
Noel Haris (London. Buttefwork &. Co. Ltd).
D.A Fuller, E. Sinclair, and J. Snook (2016), âReleased, Relapsed, Rehospitalized. Length of Stay and Readmission Rates in State Hospitals.
A Comparative State Survey,â 2016, https://www.treatmentadvocacycenter.org/storage/documents/released-relapsed-rehospitalized.pdf. Leila Salem et al. (2015), âSupportive Housing and Forensic Patient Outcomes,â Law and Human Behavior 39, no. 3.
311.49. National Institute for Health and Clinical Excellence, Manchester (2016), âTransition between Inpatient Mental Health Settings and Community or Care Home Settings. Guideline,â August, https://www.nice.org.uk/guidance/ng53/evidence/full-guideline-pdf-260695191750. Catherine Clark Ahern et al.
If you miss a dose, take it as soon as you can. If it is almost time for your next dose, take only that dose. Do not take double or extra doses.
Shutterstock check The U.S ventolin medication. Centers for Disease Control and Prevention (CDC) recently announced it has expanded its 500 Cities Project and rebranded it Population Level Analysis and Community Estimates (PLACES).The 2016 initiative provides city- and neighborhood-level health estimates to show the prevalence of chronic diseases and their impact on communities. It has been expanded to include the entire country ventolin medication. Insights gleaned from PLACES will allow community organizations and local and state health departments to better target resources. Identify emerging health problems and priority health risk behaviors.
Identify health ventolin medication inequity. Understand geographic health-related issues. And target prevention activities, ventolin medication programs, and policies.âPLACES is truly a game-changer,â CDC Director Robert R. Redfield said. ÂAs our nation faces an unprecedented health crisis, it is more important than ever to have health information at the local level to help inform decision making.
For the first time, we have a wide variety of health data for all smaller cities and rural areas.âPLACES examines counties, incorporated and census-designated ventolin medication places, census tracts, and zip codes and provides data estimates for 27 health measures, including unhealthy behaviors, health outcomes, and prevention practices that substantially impact peopleâs health. The information is available to the public through the PLACES website. The interactive website allows users to view and download data.Shutterstock West Virginia Gov ventolin medication. Jim Justice recently awarded the West Virginia Department of Health and Human Resources (DHHR) a $4.2 million grant.DHHR will use the funding to expand the West Virginia QLA Early Intervention Program into the areas with the highest need. The program includes three initiatives.The Angel Initiative allows the state police to refer people to substance use disorder treatment.Law Enforcement Assisted Diversion provides community-based supportive services as an alternative to the criminal justice system in cases involving low-level offenses.
Quick Response Teams work with individuals in 22 counties who experienced an overdose, providing ventolin medication links to treatment options, social service referrals, and recovery support. ÂThis grant will allow the state to create a comprehensive approach to effectively divert people with substance use disorder out of local jails and prisons, and move them into treatment services,â said Dr. Matthew Christiansen, DHHR Office of Drug Control ventolin medication Policy director. ÂWe are grateful to Governor Justice for directing these funds to ODCP to address the ongoing opioid epidemic.âThe U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Assistance provided the grant funding.
The Justice and Community Services Section of the West Virginia Division of Administrative Services will administer it.Shutterstock On Tuesday, the World Health Organization (WHO) announced it would be launching a year-long campaign urging millions worldwide to quit ventolin medication smoking. The campaign will lead up to World No Tobacco Day 2021 and is called âCommit to Quit.â The new WHO Quit Challenge was launched Tuesday on WhatsApp, and the publication âMore than 100 reasons to quit tobaccoâ was released Tuesday as well. According to the WHO, the asthma treatment ventolin has led to millions of tobacco users ventolin medication saying they want to quit. The WHOâs campaign will support at least 100 million people in their efforts to give up tobacco. ÂâCommit to Quitâ will help create healthier environments that are conducive to quitting tobacco by advocating for strong tobacco cessation policies.
Increasing access ventolin medication to cessation services. Raising awareness of tobacco industry tactics, and empowering tobacco users to make successful quit attempts through âquit &. Winâ initiatives,â ventolin medication the organization said. The campaign will focus on 22 countries across the globe, including the United States, Mexico, Germany, Brazil, Iran, Pakistan, China, Poland, Turkey, and Russia, among others â countries where most of the worldâs tobacco users live. Along with its partners, WHO will create and build-up digital communities where those wishing to quit can find social support.
ÂSmoking kills 8 million people a year, but if users need more motivation to kick the habit, the ventolin provides the right incentive,â said WHO Director-General Dr. Tedros Adhanom Ghebreyesus.Earlier this year, WHO released briefs that showed smokers are at a higher risk of developing complications from asthma treatment and face a higher risk of dying from the disease. Tobacco is also a risk factor for diseases like cardiovascular disease, cancer, respiratory disease, and diabetes, all of which put people living with those diseases at higher risk of complications from asthma treatment..
Shutterstock The U.S ventolin expectorant capsule price. Centers for Disease Control and Prevention (CDC) recently announced it has expanded its 500 Cities Project and rebranded it Population Level Analysis and Community Estimates (PLACES).The 2016 initiative provides city- and neighborhood-level health estimates to show the prevalence of chronic diseases and their impact on communities. It has been ventolin expectorant capsule price expanded to include the entire country. Insights gleaned from PLACES will allow community organizations and local and state health departments to better target resources.
Identify emerging health problems and priority health risk behaviors. Identify health inequity ventolin expectorant capsule price. Understand geographic health-related issues. And target prevention ventolin expectorant capsule price activities, programs, and policies.âPLACES is truly a game-changer,â CDC Director Robert R.
Redfield said. ÂAs our nation faces an unprecedented health crisis, it is more important than ever to have health information at the local level to help inform decision making. For the first time, we have a wide variety of health data for all smaller cities and rural areas.âPLACES examines counties, incorporated and census-designated places, census tracts, and zip codes and provides data estimates for 27 health measures, including unhealthy behaviors, health outcomes, and prevention practices that substantially ventolin expectorant capsule price impact peopleâs health. The information is available to the public through the PLACES website.
The interactive website allows users ventolin expectorant capsule price to view and download data.Shutterstock West Virginia Gov. Jim Justice recently awarded the West Virginia Department of Health and Human Resources (DHHR) a $4.2 million grant.DHHR will use the funding to expand the West Virginia QLA Early Intervention Program into the areas with the highest need. The program includes three initiatives.The Angel Initiative allows the state police to refer people to substance use disorder treatment.Law Enforcement Assisted Diversion provides community-based supportive services as an alternative to the criminal justice system in cases involving low-level offenses. Quick Response Teams work with individuals in 22 counties who experienced an overdose, providing links ventolin expectorant capsule price to treatment options, social service referrals, and recovery support.
ÂThis grant will allow the state to create a comprehensive approach to effectively divert people with substance use disorder out of local jails and prisons, and move them into treatment services,â said Dr. Matthew Christiansen, DHHR Office ventolin expectorant capsule price of Drug Control Policy director. ÂWe are grateful to Governor Justice for directing these funds to ODCP to address the ongoing opioid epidemic.âThe U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Assistance provided the grant funding.
The Justice ventolin expectorant capsule price and Community Services Section of the West Virginia Division of Administrative Services will administer it.Shutterstock On Tuesday, the World Health Organization (WHO) announced it would be launching a year-long campaign urging millions worldwide to quit smoking. The campaign will lead up to World No Tobacco Day 2021 and is called âCommit to Quit.â The new WHO Quit Challenge was launched Tuesday on WhatsApp, and the publication âMore than 100 reasons to quit tobaccoâ was released Tuesday as well. According to the WHO, the asthma treatment ventolin has led to millions of tobacco users saying they want to ventolin expectorant capsule price quit. The WHOâs campaign will support at least 100 million people in their efforts to give up tobacco.
ÂâCommit to Quitâ will help create healthier environments that are conducive to quitting tobacco by advocating for strong tobacco cessation policies. Increasing access ventolin expectorant capsule price to cessation services. Raising awareness of tobacco industry tactics, and empowering tobacco users to make successful quit attempts through âquit &. Winâ initiatives,â the ventolin expectorant capsule price organization said.
The campaign will focus on 22 countries across the globe, including the United States, Mexico, Germany, Brazil, Iran, Pakistan, China, Poland, Turkey, and Russia, among others â countries where most of the worldâs tobacco users live. Along with its partners, WHO will create and build-up digital communities where those wishing to quit can find social support. ÂSmoking kills 8 million people a year, but if users need more motivation to kick the habit, the ventolin provides the right incentive,â said WHO Director-General Dr. Tedros Adhanom Ghebreyesus.Earlier this year, WHO released briefs that showed smokers are at a higher risk of developing complications from asthma treatment and face a higher risk of dying from the disease.
Tobacco is also a risk factor for diseases like cardiovascular disease, cancer, respiratory disease, and diabetes, all of which put people living with those diseases at higher risk of complications from asthma treatment..
By Ernie Mundell and asthma ventolin Robin FosterHealthDay Reporters WEDNESDAY, July 28, 2021 (HealthDay News) -- President Joe Biden is considering a mandate that would require all civilian federal employees to get a asthma treatment or submit to regular testing, masking and travel restrictions. White House officials said Tuesday they would reveal more about the president's plans later this week, while Biden said he would deliver a speech on Thursday about "the next steps in our effort to get more Americans vaccinated," The New York Times reported. The latest news illustrates the growing concern among top federal health officials about the spread of the highly contagious Delta variant, but that concern must be balanced against the possibility that mandates could fuel further opposition to vaccination, officials asthma ventolin told the Times.
The idea being debated is similar to a mandate New York City announced on Monday, which would require all 300,000 city employees to be vaccinated or to have to do weekly testing, officials told the Times. It was not clear if Biden was planning to do the same with the military, although he does have the authority to do so, the Times said. Defense Secretary asthma ventolin Lloyd Austin III has said he would not be comfortable with a treatment mandate until the U.S.
Food and Drug Administration fully approves asthma treatments. The lack of full approval hasn't stopped mayors, chief executives, hospital administrators and college presidents around the country from requiring vaccinations. In California, Gov asthma ventolin.
Gavin Newsom said Monday that the state's 246,000 employees would have to be vaccinated by Aug. 2 or asthma ventolin would be tested at least once a week. With the Delta variant threatening a surge of cases in the fall, Biden must decide how far he should go to protect the American people from the asthma.
"You want to be careful," Dr. Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials, told the asthma ventolin Times. "You don't want to put wind in the sails of the anti-vax movement." But other experts say Biden must protect Americans first and foremost.
Dr. Paul Offit, director of the treatment Education Center at the Children's Hospital of Philadelphia, told the Times that Biden should mandate treatments to the degree that he can, among federal employees and the military. Continued "Sure, it will cause a backlash -- so what?.
" Offit said. "It isn't a personal choice. It's a choice for others.
It's not an American's right to potentially catch and spread a fatal ." In the last six months, nearly half of the country -- 163.3 million people -- has been vaccinated, including 80 percent of those 65 and older, data from the U.S Centers for Disease Control and Prevention shows. But tens of millions of people remain unprotected against what CDC Director Dr. Rochelle Walensky has described as one of the most contagious respiratory diseases known to scientists.
Experts say a refusal to get vaccinated puts others at risk â especially those who cannot get shots for medical reasons, or whose immune systems are too weak to respond to the treatment. "The ongoing transmission of this ventolin is in fact largely due to the unvaccinated," Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, told the Times.
On Tuesday, Biden made his frustration with people who refuse to get a shot clear. "The more we learn about this ventolin and the Delta variation, the more we have to be worried or concerned," Biden said. "And only one thing we know for sure.
If those other 100 million people got vaccinated, we'd be in a very different world." WebMD News from HealthDay Copyright © 2013-2020 HealthDay. All rights reserved..
By Ernie Mundell and Robin FosterHealthDay Reporters WEDNESDAY, July 28, 2021 (HealthDay News) -- President Joe Biden is considering a mandate that would require all civilian federal employees http://www.feuerwehr-kirchhoerde.de/where-to-buy-viagra-online/ to get a asthma treatment or submit to regular testing, masking ventolin expectorant capsule price and travel restrictions. White House officials said Tuesday they would reveal more about the president's plans later this week, while Biden said he would deliver a speech on Thursday about "the next steps in our effort to get more Americans vaccinated," The New York Times reported. The latest news illustrates the growing concern among top federal health officials about the spread of the highly contagious Delta variant, but that concern must be balanced against the possibility ventolin expectorant capsule price that mandates could fuel further opposition to vaccination, officials told the Times.
The idea being debated is similar to a mandate New York City announced on Monday, which would require all 300,000 city employees to be vaccinated or to have to do weekly testing, officials told the Times. It was not clear if Biden was planning to do the same with the military, although he does have the authority to do so, the Times said. Defense Secretary ventolin expectorant capsule price Lloyd Austin III has said he would not be comfortable with a treatment mandate until the U.S.
Food and Drug Administration fully approves asthma treatments. The lack of full approval hasn't stopped mayors, chief executives, hospital administrators and college presidents around the country from requiring vaccinations. In California, ventolin expectorant capsule price Gov.
Gavin Newsom said Monday that the state's 246,000 employees would have to be vaccinated by Aug. 2 or would be ventolin expectorant capsule price tested at least once a week. With the Delta variant threatening a surge of cases in the fall, Biden must decide how far he should go to protect the American people from the asthma.
"You want to be careful," Dr. Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials, ventolin expectorant capsule price told the Times. "You don't want to put wind in the sails of the anti-vax movement." But other experts say Biden must protect Americans first and foremost.
(2) familial aggregation ventolin mdi review of GC. (3) family history of cancer, other than gastric. (4) negative genetic test for germline CDH1 coding sequence mutations (exclusion of HDGC).
And (5) negative genetic test for germline for the promoter 1B of APC ventolin mdi (exclusion of GAPPS). The 17 HDGC probands were negative for CDH1 germline coding mutations and selected as a control group. Forty-seven patients with SIGC were collected in Portugal.Multigene panel sequencing, variant calling and filteringDNA from normal gastric mucosa (germline) and tumour tissue from 50 FIGC and 17 HDGC-CDH1 mutation-negative probands were sequenced using three Illumina MiSeq custom panels.
TruSeq Custom Amplicon Assay 1, TruSeq Custom Amplicon Assay 2 and ventolin mdi Nextera custom panel (online supplementary table 1). The selection of genes deposited in each panel was based on their implication in upper gastrointestinal tract cancers or in cancer susceptibility syndromes identified through literature review (online supplementary table 2). FASTQ files were aligned to the RefSeq Human Genome GRCh38 using bwa-mem, and variants were called using Samtools.24 25 Called variants were defined as germline or somatic by normal-tumour pair comparison and annotated with Ensembl and Catalogue Of Somatic Mutations In Cancer (COSMIC (FATHMM- Functional Analysis through Hidden Markov Models).26 27 High-quality (HQ) germline or somatic variants were defined as presenting â¥20 reads per allele and genotype quality â¥90âand call quality â¥100.
Next, all single nucleotide polymorphism database (dbSNP) identifiers available for FIGC germline variants (regardless of quality criteria) were screened in four ventolin mdi European populations from 1000 Genomes. (1) 107 normal individuals from Tuscany (Italy, TSI). (2) 91 normal individuals from Great Britain (GBR).
(3) 99 normal ventolin mdi individuals from Finland (FIN). And (4) 107 normal individuals from Spain (IBS).28 Germline variants without dbSNP identifiers available in the 1000 Genomes were screened using Ensembl VEP for truncating consequences. Detected truncating variants presented on average less than four reads, that is, were of low quality and discarded.
FIGC germline, rare HQ exclusive variants were selected if they (1) displayed genotypes in FIGCs distinct from GBR, FIN and IBS populations and below 1% in the TSI population ventolin mdi. (2) presented â¥20 reads per allele, genotype quality â¥90âand call quality â¥100. (3) displayed genotypes distinct from HDGCs and SIGCs.
And (4) presented allele frequency in ExAC and gnomAD populations below 1%.29Supplemental materialSupplemental materialValidation of FIGC germline, rare HQ ventolin mdi exclusive variants by Sanger sequencingTwelve out of 32 FIGC germline, rare HQ exclusive variants were validated by PCR-Sanger sequencing. Briefly, 20â50âng of DNA from normal and matched tumour was amplified using Multiplex PCR Kit (Qiagen) and custom primers flanking each variant. PCR products were purified with ExoSAP-IT Express (Applied Biosystems) and sequenced on an ABI3100 Genetic Analyzer using BigDye Terminator V.3.1 Cycle Sequencing Kit (Applied Biosystems).Intronic germline variants were analysed using the splice site prediction software NetGene2 V.2.4.30Somatic second-hit analysisLoss of heterozygosity (LOH) and somatic second mutations were determined by calculating the variant allele frequency (VAF) and screening genes with FIGC germline, rare HQ exclusive variants, respectively.
In particular, VAF ventolin mdi was calculated by dividing the number of reads for the variant allele by the total number of reads both for the normal and for the corresponding tumour samples. LOH was defined when more than 20% increase of VAF over normal was observed.Germline and somatic landscape analysis of 50 FIGC casesFIGC germline and somatic landscapes were analysed on a per-variant and per-gene basis, considering the number of FIGC germline, rare HQ exclusive variants detected per proband (0, 1 or >1). The similarities/differences for the germline and somatic variant and gene landscapes per FIGC class were analysed using unsupervised hierarchical clustering using R package ggplot2 for heatmap and dendrogram construction.31 For somatic variant/gene landscape analysis, FIGC classes were also divided according to microsatellite instable status and compared using analysis of variance statistics with R.
The number of microsatellite instable (MSI) and microsatellite stable (MSS) tumours per FIGC class was compared using Pearsonâs Ï2 test.Comparison of germline and somatic landscapes for ventolin mdi FIGC, SIGC and HDGCVCF files obtained from whole genome sequencing (Complete Genomics platform) of 47 SIGCs and VCF files of 17 HDGCs were analysed to detect germline and somatic variants, using the same germline/somatic variant definition and sequencing quality criteria previously described for FIGC cases. Of note, due to the differential resolution between whole genome sequencing and targeted sequencing, only variants detected in the 47 SIGCs in the same regions targeted by the custom panels were selected for downstream analysis.Germline and somatic landscapes of FIGC, SIGC and HDGC cases were performed on a per-gene basis. Each gene was classified as presenting 0 or â¥1 germline/somatic variants.
Germline and somatic joint landscape was defined by counting the ventolin mdi number of germline and somatic variants for each gene, which was classified as displaying no germline or somatic variants. Â¥1 germline and 0 somatic variants. 0 germline and â¥1 somatic variants.
Or â¥1 germline and â¥1 somatic ventolin mdi variants. Results were plotted in a heatmap and a dendrogram, and principal component analysis was performed using R. The frequency of genes with germline/somatic variants in FIGCs, SIGCs and HDGCs was calculated, and genes with a frequency difference â¥50% were represented in a bar plot and in a heatmap using R.ResultsAge of onset and disease spectrum in FIGCOf the 50 FIGC probands (table 1), 18 were female and 32 were male.
The mean ventolin mdi age at diagnosis was 71.8±8.0 years. From the 50 families depicted in table 1, 5 (10%) had >1 FDR with GC (mean age. 68.8±7.5 years).
14 (28%) had concomitantly FDR and SDR or FDR and third-degree relatives with GC (mean ventolin mdi age. 68.7±8.4 years). 29 (58%) had a single FDR with GC (mean age.
73.6±7.2 years) ventolin mdi. And 2 (4%) had only SDR affected with GC (mean. 74±15.6 years).View this table:Table 1 Clinical characteristics of FIGC probands and their family historyWhen considering the disease spectrum in these FIGC families, 19 different phenotypes have been observed affecting 208 family members (figure 1, table 1).
The most prevalent phenotype was GC, detected in 138 of 208 (66.3%) family ventolin mdi members. 50 probands with IGC and 88 additional patients with unknown GC histology. The second and third most prevalent phenotypes were colorectal/colon and breast cancer observed in nine patients from seven families.
Of note, eight patients from six ventolin mdi families were affected with gastric ulcer, a non-cancerous lesion, which is the third most common disease phenotype in this cohort. Besides these phenotypes, positive history of lung cancer was observed in six families. Leukaemia in five families.
Laryngotracheal and hepatobiliary cancer in ventolin mdi four families. Osteosarcoma in three families. Prostate, liver, melanoma, gynaecological, bladder and brain cancers were detected in two families each.
And thyroid, kidney and oral cancer in ventolin mdi one family. Moreover, 11 families had relatives affected by an unidentified type of cancer that often coexisted with other cancer types such as colon, leukaemia, breast, liver and prostate.Disease spectrum of FIGC families. The disease spectrum of FIGC encompassed 19 different phenotypes affecting 208 family members.
The most ventolin mdi prevalent phenotype was gastric cancer, detected in 138 of 208, followed by colorectal/colon and breast cancers in 9 of 208. FIGC, familial intestinal gastric cancer." data-icon-position data-hide-link-title="0">Figure 1 Disease spectrum of FIGC families. The disease spectrum of FIGC encompassed 19 different phenotypes affecting 208 family members.
The most prevalent phenotype was gastric cancer, detected in 138 of 208, followed by colorectal/colon and breast cancers in 9 ventolin mdi of 208. FIGC, familial intestinal gastric cancer.Germline and somatic variant discovery across FIGC probandsMultigene panel sequencing analysis of normal-tumour DNA of 50 FIGC probands revealed a total of 10â062 variants (â¥1 read covering the alternative allele). Of these, 4998 (49.7%) were detected in normal DNA and defined as germline variants.
The remaining 5064 (50.3%) were called as somatic ventolin mdi variants due to exclusive presence in tumour DNA. We started by exploring germline variants, focusing on rare variants in single genes (monogenic hypothesis) or variants co-occurring in several genes, regardless of their population frequency (oligogenic/polygenic hypothesis).Monogenic hypothesis. FIGC-associated rare germline variants and somatic second-hitsTo identify rare germline FIGC-predisposing variants, we performed a systematic analysis of all germline variants, focusing on their frequency across normal populations and GC cohorts, and sequencing quality.We identified 4998 germline variants in the 50 patients with FIGC (figure 2A).
From the 4998 FIGC germline variants, the genotype frequency of 1038 (20.8%) was available for four 1000 Genomes European populations.28 From the 79.2% of variants absent from 1000 Genomes, only 1.3% (n=53) presented truncating effects, however supported on average by less than ventolin mdi four reads, that is, of very low quality and hence confidently discarded. From the 1038 variants present in 1000 Genomes, 121 (11.7%) presented genotypes absent from the four populations screened. Of these 121 variants, only 60 presented the abovementioned sequencing quality criteria.
From these, 43 variants were exclusively detected in FIGC ventolin mdi comparing with HDGC-CDH1 mutation-negative and SIGC cohorts. With regard to the 17 discarded variants, all were found in at least one HDGC proband and none in SIGC.90âand a call quality >100). From these, 43 variants presented the RefSeq genotype in the HDGC-CDH1 mutation-negative and sporadic GC cohorts.
A final set of 32 germline, rare and high-quality FIGC-exclusive variants were selected by screening ventolin mdi the allele frequency of these variants in all ExAC and gnomAD populations available. (B) Germline variant burden of FIGC families with 0, 1 or >1ârare germline variants. P value was determined by ANOVA statistics.
(C) Heatmap and dendrogram of 710 HQ FIGC germline variants of FIGC family classes (Z-score normalised ventolin mdi expression level. White, no detected variants. Purple, detected variants.
(D) Heatmap and dendrogram of 64 genes with the 710 germline variants of FIGC family classes (Z-score normalised expression levels ventolin mdi. White, genes with no detected variants. Light salmon, genes with a single variant.
Pink, gene carrying 2â5 ventolin mdi distinct variants. Purple, gene with 6â10 distinct variants. Dark purple, gene with 11â15 distinct variants.
ANOVA, analysis ventolin mdi of variance. FIGC, familial intestinal gastric cancer. GC, gastric cancer.
HDGC, hereditary ventolin mdi diffuse gastric cancer. HQ, high-quality." class="highwire-fragment fragment-images colorbox-load" rel="gallery-fragment-images-178618009" data-figure-caption="Co-occurrence of rare germline variants does not define a specific germline landscape. (A) Discovery of FIGC rare germline predisposition variants.
A total of 4998 germline variants were detected ventolin mdi in normal stomach using multigene panel sequencing. From these, 1038 were identified by the 1000 Genomes Project, and 121 were absent from four distinct normal European populations. Of these 121 variants, only 60 were classified as variants of high quality (with at least 20 reads for each allele, a genotype quality >90âand a call quality >100).
From these, 43 variants presented the RefSeq genotype in the HDGC-CDH1 mutation-negative and sporadic GC ventolin mdi cohorts. A final set of 32 germline, rare and high-quality FIGC-exclusive variants were selected by screening the allele frequency of these variants in all ExAC and gnomAD populations available. (B) Germline variant burden of FIGC families with 0, 1 or >1ârare germline variants.
P value was ventolin mdi determined by ANOVA statistics. (C) Heatmap and dendrogram of 710 HQ FIGC germline variants of FIGC family classes (Z-score normalised expression level. White, no detected variants.
Purple, detected variants ventolin mdi. (D) Heatmap and dendrogram of 64 genes with the 710 germline variants of FIGC family classes (Z-score normalised expression levels. White, genes with no detected variants.
Light salmon, genes with a single ventolin mdi variant. Pink, gene carrying 2â5 distinct variants. Purple, gene with 6â10 distinct variants.
Dark purple, gene with 11â15 ventolin mdi distinct variants. ANOVA, analysis of variance. FIGC, familial intestinal gastric cancer.
GC, gastric cancer ventolin mdi. HDGC, hereditary diffuse gastric cancer. HQ, high-quality." data-icon-position data-hide-link-title="0">Figure 2 Co-occurrence of rare germline variants does not define a specific germline landscape.
(A) Discovery of ventolin mdi FIGC rare germline predisposition variants. A total of 4998 germline variants were detected in normal stomach using multigene panel sequencing. From these, 1038 were identified by the 1000 Genomes Project, and 121 were absent from four distinct normal European populations.
Of these 121 variants, only 60 were ventolin mdi classified as variants of high quality (with at least 20 reads for each allele, a genotype quality >90âand a call quality >100). From these, 43 variants presented the RefSeq genotype in the HDGC-CDH1 mutation-negative and sporadic GC cohorts. A final set of 32 germline, rare and high-quality FIGC-exclusive variants were selected by screening the allele frequency of these variants in all ExAC and gnomAD populations available.
(B) Germline variant burden of FIGC families ventolin mdi with 0, 1 or >1ârare germline variants. P value was determined by ANOVA statistics. (C) Heatmap and dendrogram of 710 HQ FIGC germline variants of FIGC family classes (Z-score normalised expression level.
White, no detected ventolin mdi variants. Purple, detected variants. (D) Heatmap and dendrogram of 64 genes with the 710 germline variants of FIGC family classes (Z-score normalised expression levels.
White, genes ventolin mdi with no detected variants. Light salmon, genes with a single variant. Pink, gene carrying 2â5 distinct variants.
Purple, gene with 6â10 ventolin mdi distinct variants. Dark purple, gene with 11â15 distinct variants. ANOVA, analysis of variance.
FIGC, familial ventolin mdi intestinal gastric cancer. GC, gastric cancer. HDGC, hereditary diffuse gastric cancer.
HQ, high-quality.From the 43 germline, rare and HQ FIGC-exclusive variants, 31 (72.1%) displayed very low allele frequency ventolin mdi in all ExAC and gnomAD populations (figure 2A, online supplementary table 3), and were present in 21 of 50 (42%) FIGC probands (7 missense, 7 3âuntranslated (UTR), 2 5âUTR, 12 intronic and 3 synonymous in 18 genes. Online supplementary table 4). Fifteen probands carried a single variant and six exhibited co-occurrence of two or more variants (online supplementary table 5).
After excluding variants classified as benign and predicted as intronic, synonymous or not impacting splicing, 12 variants were validated by Sanger sequencing (table 2).Supplemental materialSupplemental materialSupplemental materialView this table:Table 2 FIGC rare germline variants validated by Sanger sequencingA missense variant in PMS1 (c.224C>T), predicted as pathogenic, deleterious and probably damaging by FATHMM, SIFT and PolyPhen, respectively (table 2, online supplementary table 3), was found in family P1 (table 1, online supplementary table 4) ventolin mdi. The probands, who developed an MSS IGC at 59 years, had an FDR with GC at 80 and two other FDR and SDR with unidentified cancers at 50 and 75 years, respectively. The only supporting evidence for the role of this variant in FIGC was its COSMIC record as somatic in one GC sample (COSM6198026) (online supplementary table 3).The proband of family P27 presented three germline variants of uncertain significance, two in SMAD4 (c.424+5G>A.
C.454+38G>C) and one in PRSS1 (c.201-99G>C) (online supplementary table ventolin mdi 4). Variants c.424+5G>A in SMAD4 and c.201â99G>C in PRSS1 were the only intronic variants predicted to disrupt RNA splicing (table 2, online supplementary tables 3 and 5,). In particular, SMAD4 variant c.424+5G>A decreases the confidence of a donor splice site, which may lead to intron 3 retention, a premature termination codon and generation of a 142 amino acid truncated protein.
On the ventolin mdi other hand, PRSS1 variant c.201-99G>C creates a new, high-confidence acceptor splice site within intron 2, which may lead to a truncated 69 amino acid protein. Proband P27 developed an MSS IGC at age 64 and had family history of GC, gastric ulcer, laryngotracheal, gynaecological and hepatobiliary cancers (table 1, online supplementary table 4). The presence of these phenotypes seems to exclude juvenile polyposis and hereditary pancreatitis as underlying syndromes of this family, but could support a potential role for SMAD4 together with PRSS1 in FIGC.We then screened the primary tumours of P1 and P27 FIGC probands for somatic second-hit inactivating mechanisms (LOH, somatic mutation) in germline-affected genes.
None of the two FIGC probands showed evidence of deleterious somatic variants nor LOH of the wild-type allele of the germline targeted genes (data not shown).Although interesting, these ventolin mdi findings are insufficient to support the monogenic hypothesis for FIGC and a potentially causal role for the abovementioned affected genes.Oligogenic/polygenic hypothesis. Co-occurrence of rare germline variants determines somatic landscapes of FIGC tumoursWe then proceeded with the oligogenic/polygenic hypothesis, which takes into consideration the co-occurrence of germline variants, regardless of their population frequency, as a risk factor for this disease, which would determine the subsequent somatic events necessary for malignant transformation.We categorised the 50 FIGC probands according to the presence of rare germline variants. Families with no variants (n=30).
Families with a single variant (n=14) ventolin mdi. And families with multiple variants (n=6). To understand the germline and somatic variant burden for each of these three FIGC classes, we applied the previously described quality criteria obtaining 710 HQ germline variants and 344 HQ somatic variants.
The average number of HQ germline variants was identical across the three classes of FIGC families (75.7, 77.4 and 74.5 for families without ventolin mdi (0), with one (1) or more than one (>1) rare germline variants, respectively. Figure 2B). Germline landscape unsupervised hierarchical clustering revealed no associations between variants or variant-bearing genes and a particular FIGC family class (figure 2C,D).Concerning the somatic variant burden, no significant differences were observed across the three FIGC classes (15.0, 13.8 and 11.2 for families with 0, 1 or >1ârare germline variants, respectively.
Figure 3A) ventolin mdi. Again, no clustering of specific variants/genes and particular FIGC classes was observed (figure 3B,C).1ârare germline variants. P value was determined by ANOVA statistics.
(B) Heatmap and dendrogram of 344 FIGC somatic variants of FIGC family classes (Z-score normalised expression level ventolin mdi. White, no detected variants. Orange, detected variants.
(C) Heatmap and ventolin mdi dendrogram of 46 genes with the 344 somatic variants of FIGC family classes (Z-score normalised expression levels. White, gene with no detected variants. Yellow, gene with a single variant.
Orange, gene carrying 2â5 distinct ventolin mdi variants. Light brown, gene with 6â10 distinct variants. Brown, gene with 11â15 distinct variants.
(D) Somatic variant burden of FIGC families with ventolin mdi 0, 1 or >1ârare germline variants subdivided according to MSI status. P value was determined by ANOVA statistics. ANOVA, analysis of variance.
FIGC, familial intestinal gastric cancer ventolin mdi. HQ, high-quality. MSI, microsatellite instable.
MSS, microsatellite stable." class="highwire-fragment fragment-images colorbox-load" rel="gallery-fragment-images-178618009" data-figure-caption="Rare germline variants are not major ventolin mdi determinants of FIGC somatic events. (A) Somatic variant burden of FIGC families with 0, 1 or >1ârare germline variants. P value was determined by ANOVA statistics.
(C) Heatmap ventolin mdi and dendrogram of 46 genes with the 344 somatic variants of FIGC family classes (Z-score normalised expression levels. White, gene with no detected variants. Yellow, gene with a single variant.
(D) Somatic variant burden of FIGC families with 0, ventolin mdi 1 or >1ârare germline variants subdivided according to MSI status. P value was determined by ANOVA statistics. ANOVA, analysis of variance.
MSS, microsatellite ventolin mdi stable." data-icon-position data-hide-link-title="0">Figure 3 Rare germline variants are not major determinants of FIGC somatic events. (A) Somatic variant burden of FIGC families with 0, 1 or >1ârare germline variants. P value was determined by ANOVA statistics.
(B) Heatmap and ventolin mdi dendrogram of 344 FIGC somatic variants of FIGC family classes (Z-score normalised expression level. White, no detected variants. Orange, detected variants.
(C) Heatmap and dendrogram of 46 genes with the 344 somatic variants of FIGC family ventolin mdi classes (Z-score normalised expression levels. White, gene with no detected variants. Yellow, gene with a single variant.
Orange, gene carrying 2â5 ventolin mdi distinct variants. Light brown, gene with 6â10 distinct variants. Brown, gene with 11â15 distinct variants.
(D) Somatic variant burden of FIGC families with 0, 1 or >1ârare germline variants subdivided according to MSI ventolin mdi status. P value was determined by ANOVA statistics. ANOVA, analysis of variance.
MSS, microsatellite stable.We verified that 38% of the FIGC tumours in our series displayed the MSI phenotype, and further investigated whether MSI could influence the somatic variant burden and landscape in families with 0, 1 ventolin mdi or >1ârare germline variants. After subdividing each FIGC class according to its MSI status, no significant differences were observed both in terms of somatic variant burden and landscape between categories (figure 3BâD). Nevertheless, we observed that among FIGC families with multiple rare germline variants (>1), MSI tumours showed an average number of HQ somatic variants twofold higher than that of MSS tumours (17 vs 10 HQ somatic variants per case, respectively.
Figure 3D, online ventolin mdi supplementary figure 1A). This observation prompted us to explore the influence of rare germline variants, independently of their number, on tumour instability and consequent somatic variant burden. Despite the lack of statistical significance, we observed an enrichment of MSI tumours in FIGC families carrying rare germline variants comparing with MSI tumours from families lacking rare germline variants (online supplementary figure 1B).
Concerning the average of somatic variants, whereas MSI and MSS tumours from FIGC lacking rare germline variants displayed a similar average number, there was a non-significant ventolin mdi trend for higher average number of HQ somatic variants in MSI tumours versus MSS tumours from FIGC families with rare germline variants (â¥1. Online supplementary figure 1C).Supplemental materialAlthough our data did not support the hypothesis that co-occurrence of rare germline variants is a major determinant of FIGC-related somatic landscapes, these pinpointed a potential correlation between the coexistence of rare and common germline variants, high average number of somatic variants and MSI phenotype in FIGC.FIGC is genetically distinct from SIGC and from HDGC-CDH1 mutation-negativeSince the late age of onset in FIGC probands and their relatives makes it hard to distinguish bona fide FIGCs from SIGCs, we compared the age of onset of FIGC probands with the age of onset of a series of SIGC cases. We found that FIGC probands developed GC approximately 10 years earlier than patients with SIGC (p=4.5E-03.
Figure 4E).FIGC ventolin mdi is a genetic entity distinct from SIGC. (A) Principal component analysis of genes with germline variants. (B) Principal component analysis of genes with somatic variants.
(C) Frequency of genes with germline or somatic variants enriched in FIGC cases in comparison with SIGC ventolin mdi cases. Purple for genes with germline events and orange for genes with somatic events. (D) Heatmap and dendrogram of a panel of genes with the highest frequency of germline and/or somatic variants in FIGC (n=50) versus SIGC (n=47).
(E) Age at diagnosis of FIGC (n=50) and SIGC cases (n=47) ventolin mdi. (F) Average number of somatic variants detected in FIGC (n=50) and SIGC cases (n=47). White, gene with no variants.
Purple, gene with ventolin mdi germline variants. Orange, gene with somatic variants. Red, gene with germline and somatic variants.
P values calculated with Wilcoxon signed-rank test ventolin mdi. FIGC, familial intestinal gastric cancer. SIGC, sporadic intestinal gastric cancer, PC1, principal component 1.
PC2, principal component 2." data-icon-position data-hide-link-title="0">Figure 4 FIGC is a genetic entity distinct ventolin mdi from SIGC. (A) Principal component analysis of genes with germline variants. (B) Principal component analysis of genes with somatic variants.
(C) Frequency of genes with germline or somatic variants enriched ventolin mdi in FIGC cases in comparison with SIGC cases. Purple for genes with germline events and orange for genes with somatic events. (D) Heatmap and dendrogram of a panel of genes with the highest frequency of germline and/or somatic variants in FIGC (n=50) versus SIGC (n=47).
(E) Age at diagnosis of FIGC ventolin mdi (n=50) and SIGC cases (n=47). (F) Average number of somatic variants detected in FIGC (n=50) and SIGC cases (n=47). White, gene with no variants.
Purple, gene with germline ventolin mdi variants. Orange, gene with somatic variants. Red, gene with germline and somatic variants.
P values ventolin mdi calculated with Wilcoxon signed-rank test. FIGC, familial intestinal gastric cancer. SIGC, sporadic intestinal gastric cancer, PC1, principal component 1.
PC2, principal component 2.We next explored whether these FIGC and SIGC were also distinct at the germline and/or somatic levels ventolin mdi. Principal component analysis revealed that certain genes were differentially associated with FIGCs and SIGCs (figure 4A,B). Specifically, common germline variants in TP53 were present in more than 50% of FIGC probands, while only 11% of SIGC cases presented these germline variants (figure 4A,C).
At the somatic level, the frequency of BRCA2, ATM, FOXF1, FHIT, SDHB, MSH6, CTNNA1 and PXN could distinguish FIGC from SIGC tumours, with more than 50% of FIGC displaying common variants in these genes, as compared with very low frequencies in SIGC (figure 4B,C).By combining all germline and somatic landscapes of 50 FIGCs and 47 SIGCs focusing only on the ventolin mdi abovementioned genes, and using unsupervised hierarchical clustering, two main clusters were evidenced separating most FIGCs from SIGCs (figure 4D). Whereas FIGCs carried both germline and somatic variants in TP53, BRCA2, ATM, FOXF1, FHIT, SDHB, MSH6, CTNNA1 and PXN genes, SIGCs lacked TP53 and FHIT germline and somatic variants and mainly presented BRCA2, ATM, FOXF1, SDHB, MSH6, CTNNA1 and PXN somatic variants.Further supporting that FIGC represents a different entity likely evolving for longer than SIGCs is the fact that FIGC tumours presented statistically significantly more somatic common variants than SIGC tumours (p=4.2E-06), even if arising from patients 10âyears younger on average (figure 4E,F).To further understand whether FIGC is a genetic entity also distinct from HDGC-CDH1 mutation-negative, we compared the germline and somatic landscapes of 7 FIGCs and 17 HDGCs sequenced with the same Next Generation Sequencing (NGS) panel. We verified that indeed FIGC and HDGC also display considerable differences between germline and somatic landscapes (online supplementary figure 2)().
However, the low number of FIGC cases possible to analyse, which was due to sequencing panel differences, hampers more formal conclusions.Overall, our results suggest that FIGC, rather than a monogenic disease, is likely a polygenic disease with distinctive germline and ventolin mdi somatic landscapes from SIGC and HDGC-CDH1-negative.DiscussionFIGC presents an autosomal dominant inheritance pattern of IGC, without gastric polyposis, and has been clinically defined by analogy to the Amsterdam criteria for HNPCC.9 However, lack of novel data supporting familial aggregation of IGC at a given age of onset as well as the non-existence of tumour spectrum descriptions have impeded the redefinition of FIGC testing criteria, useful for identification and management of these families.The primary strength of this study is the use of a large homogeneous cohort of probands with IGC, familial aggregation of GC, detailed personal/family history, age of disease onset and disease spectrum. This series does not present clinical criteria compatible with any other gastrointestinal cancer-associated syndrome, is clearly enriched in GC and mainly of intestinal type, which suggests this is the first data-driven testing criteria for FIGC families. We propose that any family presenting two GC cases, one confirmed of intestinal histology, independently of age, and with or without colorectal cancer, breast cancer or gastric ulcers in other family members, could be considered FIGC.Besides potential testing criteria, our study also reported the first large-scale sequencing analysis of the germline and somatic landscapes of FIGC and respective comparisons with comparable landscapes of SIGC and HDGC-CDH1 mutation-negative.
We used these data to explore the unknown inherited ventolin mdi nature of FIGC. Among the FIGC-exclusive germline rare variants found, the missense PMS1 c.224C>T variant was the only one predicted as pathogenic in family P1. Deleterious variants in this DNA mismatch repair protein (PMS1, OMIM:600258) can be found in HNPCC families, either alone or co-occurring with mutations in other HNPCC-related genes.32 33 However, the real contribution of PMS1 germline mutations for HNPCC predisposition is still debatable.
Liu et al33 detected PMS1 and MSH2 germline mutations ventolin mdi in an HNPCC proband with an MSI tumour, and observed that only the MSH2 germline mutation was shared with another member of the family affected with colorectal cancer, thus demonstrating that MSH2 is the real predisposing gene to colorectal cancer in this family. Notwithstanding, they postulated that the PMS1 mutation could contribute to the unusual number of lung cancer cases in this HNPCC family.33 Our FIGC proband (P1) carrying a PMS1 germline variant displayed an MSI-low tumour, consistent with the fact that Pms1-deficient mice do not show an increased mutation rate (MSI) in the colonic epithelium.34 Although we lack full evidence for the potentially causative role of this PMS1 variant in family P1, namely a second-hit in the tumour and segregation analysis, this remains an open possibility. The same applied to family P27, where potentially truncating variants are simultaneously found in SMAD4 and PRSS1, but no second somatic-hits are found in these genes.
Overall, these findings do not strongly support a monogenic nature for FIGC, at least as evident as that seen for ventolin mdi CDH1-associated HDGC or GAPPS.In the last decade, several studies have integrated large-scale normal and tumour sequencing data to ascertain the impact of germline variation on tumour evolution.35â38 For example, Carter et al36 identified germline variants that can either dramatically increase the frequency of somatic mutations or influence the site where a tumour develops. Others have shown that rare germline truncations in cancer susceptibility genes, including BRCA1, BRCA2, FANCM and MSH6, are significantly associated with increased somatic mutation frequencies in specific cancer types, suggesting that germline and somatic levels are intrinsically linked.37 Our findings revealed that, independently of the presence of rare germline variants, FIGC families displayed similar germline and somatic variant burden and landscapes, suggesting that this type of inherited variation may not be a major determinant of tumour development in these families. Interestingly, we found that MSI and MSS tumours from FIGC families lacking rare germline variants displayed a similar somatic variant burden, while MSI tumours from families carrying single/multiple germline rare variants tend to harbour more somatic variants than MSS tumour-bearing families.
Altogether, these findings suggest that rare germline defects involving the DNA repair system may extend to the somatic ventolin mdi level, as previously demonstrated in other cancer types.37 38Our study, as the previous ones, failed to find the monogenic factor that genetically determined the occurrence of FIGC. However, before excluding the possibility of considering our FIGC series as a sporadic cohort, we explored the average age of onset of probands, number of somatic variants, and their germline and somatic landscapes as compared with other GC entities. This analysis showed that FIGC probands developed GC at least 10 years earlier and carried more TP53 germline common variants than SIGC, that 38% of FIGC tumours were MSI, but also that FIGC tumours displayed significantly more somatic common variants than SIGC tumours, as well as a specific germline and somatic variant profile.
In addition, this germline ventolin mdi and somatic variant profile was also different from that presented by HDGC cases lacking CDH1 germline causal variants. Therefore, the analysis of the large-scale normal and tumour sequencing data from FIGC, SIGC and HDGC-CDH1 mutation-negative cases was instrumental to define FIGC as a distinct clinical and molecular entity.Altogether, these data support the idea of a so far unrecognised genetically determined factor(s) that promotes IGC in probands and GC in their close relatives, with an apparent pattern of autosomal inheritance, and that despite late onset it presents earlier than SIGC. Further, FIGC seems to evolve through a different path from SIGC, starting the accumulation of somatic variants earlier and often triggering MSI, as part of their evolution.Our study displayed some limitations, such as the fact that our custom NGS panels did not account for all possible cancer predisposition genes, hence other genes may contribute to FIGC risk.
(2) search for evidence for a Mendelian and monogenic pattern of ventolin expectorant capsule price inheritance. And (3) search for evidence of alternative oligogenic/polygenic modes of inheritance.Herein, we gathered evidence that FIGC is likely a genetically determined, GC-predisposing disease, different at the clinical, germline and somatic levels from SIGC and HDGC. We further proposed the first testing criteria for FIGC families.MethodsPatient selectionFifty FIGC and 17 HDGC-CDH1 mutation-negative probands were admitted at the Division of General Surgery and Surgical Oncology, University of Siena, Italy.
The selection ventolin expectorant capsule price of FIGC families was based on the following criteria. (1) proband presenting with GC of intestinal histology. (2) familial aggregation of GC.
(3) family ventolin expectorant capsule price history of cancer, other than gastric. (4) negative genetic test for germline CDH1 coding sequence mutations (exclusion of HDGC). And (5) negative genetic test for germline for the promoter 1B of APC (exclusion of GAPPS).
The 17 HDGC probands ventolin expectorant capsule price were negative for CDH1 germline coding mutations and selected as a control group. Forty-seven patients with SIGC were collected in Portugal.Multigene panel sequencing, variant calling and filteringDNA from normal gastric mucosa (germline) and tumour tissue from 50 FIGC and 17 HDGC-CDH1 mutation-negative probands were sequenced using three Illumina MiSeq custom panels. TruSeq Custom Amplicon Assay 1, TruSeq Custom Amplicon Assay 2 and Nextera custom panel (online supplementary table 1).
The selection of genes deposited in each panel was based on their implication in upper gastrointestinal tract cancers or in cancer susceptibility syndromes identified through literature review (online supplementary table ventolin expectorant capsule price 2). FASTQ files were aligned to the RefSeq Human Genome GRCh38 using bwa-mem, and variants were called using Samtools.24 25 Called variants were defined as germline or somatic by normal-tumour pair comparison and annotated with Ensembl and Catalogue Of Somatic Mutations In Cancer (COSMIC (FATHMM- Functional Analysis through Hidden Markov Models).26 27 High-quality (HQ) germline or somatic variants were defined as presenting â¥20 reads per allele and genotype quality â¥90âand call quality â¥100. Next, all single nucleotide polymorphism database (dbSNP) identifiers available for FIGC germline variants (regardless of quality criteria) were screened in four European populations from 1000 Genomes.
(1) 107 normal individuals from Tuscany ventolin expectorant capsule price (Italy, TSI). (2) 91 normal individuals from Great Britain (GBR). (3) 99 normal individuals from Finland (FIN).
And (4) 107 normal individuals from Spain (IBS).28 Germline variants without dbSNP identifiers available in the 1000 Genomes were screened using Ensembl VEP ventolin expectorant capsule price for truncating consequences. Detected truncating variants presented on average less than four reads, that is, were of low quality and discarded. FIGC germline, rare HQ exclusive variants were selected if they (1) displayed genotypes in FIGCs distinct from GBR, FIN and IBS populations and below 1% in the TSI population.
(2) presented â¥20 reads per allele, ventolin expectorant capsule price genotype quality â¥90âand call quality â¥100. (3) displayed genotypes distinct from HDGCs and SIGCs. And (4) presented allele frequency in ExAC and gnomAD populations below 1%.29Supplemental materialSupplemental materialValidation of FIGC germline, rare HQ exclusive variants by Sanger sequencingTwelve out of 32 FIGC germline, rare HQ exclusive variants were validated by PCR-Sanger sequencing.
Briefly, 20â50âng of DNA from normal and matched tumour was amplified using Multiplex PCR Kit (Qiagen) and custom ventolin expectorant capsule price primers flanking each variant. PCR products were purified with ExoSAP-IT Express (Applied Biosystems) and sequenced on an ABI3100 Genetic Analyzer using BigDye Terminator V.3.1 Cycle Sequencing Kit (Applied Biosystems).Intronic germline variants were analysed using the splice site prediction software NetGene2 V.2.4.30Somatic second-hit analysisLoss of heterozygosity (LOH) and somatic second mutations were determined by calculating the variant allele frequency (VAF) and screening genes with FIGC germline, rare HQ exclusive variants, respectively. In particular, VAF was calculated by dividing the number of reads for the variant allele by the total number of reads both for the normal and for the corresponding tumour samples.
LOH was ventolin expectorant capsule price defined when more than 20% increase of VAF over normal was observed.Germline and somatic landscape analysis of 50 FIGC casesFIGC germline and somatic landscapes were analysed on a per-variant and per-gene basis, considering the number of FIGC germline, rare HQ exclusive variants detected per proband (0, 1 or >1). The similarities/differences for the germline and somatic variant and gene landscapes per FIGC class were analysed using unsupervised hierarchical clustering using R package ggplot2 for heatmap and dendrogram construction.31 For somatic variant/gene landscape analysis, FIGC classes were also divided according to microsatellite instable status and compared using analysis of variance statistics with R. The number of microsatellite instable (MSI) and microsatellite stable (MSS) tumours per FIGC class was compared using Pearsonâs Ï2 test.Comparison of germline and somatic landscapes for FIGC, SIGC and HDGCVCF files obtained from whole genome sequencing (Complete Genomics platform) of 47 SIGCs and VCF files of 17 HDGCs were analysed to detect germline and somatic variants, using the same germline/somatic variant definition and sequencing quality criteria previously described for FIGC cases.
Of note, due to the differential resolution between whole genome sequencing and targeted sequencing, only variants detected in the 47 SIGCs in the same regions targeted by the custom panels were selected for downstream analysis.Germline and somatic landscapes of FIGC, SIGC and HDGC cases were performed on a per-gene ventolin expectorant capsule price basis. Each gene was classified as presenting 0 or â¥1 germline/somatic variants. Germline and somatic joint landscape was defined by counting the number of germline and somatic variants for each gene, which was classified as displaying no germline or somatic variants.
Â¥1 germline and 0 somatic variants ventolin expectorant capsule price. 0 germline and â¥1 somatic variants. Or â¥1 germline and â¥1 somatic variants.
Results were plotted in a heatmap and ventolin expectorant capsule price a dendrogram, and principal component analysis was performed using R. The frequency of genes with germline/somatic variants in FIGCs, SIGCs and HDGCs was calculated, and genes with a frequency difference â¥50% were represented in a bar plot and in a heatmap using R.ResultsAge of onset and disease spectrum in FIGCOf the 50 FIGC probands (table 1), 18 were female and 32 were male. The mean age at diagnosis was 71.8±8.0 years.
From the 50 families ventolin expectorant capsule price depicted in table 1, 5 (10%) had >1 FDR with GC (mean age. 68.8±7.5 years). 14 (28%) had concomitantly FDR and SDR or FDR and third-degree relatives with GC (mean age.
68.7±8.4 years) ventolin expectorant capsule price. 29 (58%) had a single FDR with GC (mean age. 73.6±7.2 years).
And 2 (4%) had only ventolin expectorant capsule price SDR affected with GC (mean. 74±15.6 years).View this table:Table 1 Clinical characteristics of FIGC probands and their family historyWhen considering the disease spectrum in these FIGC families, 19 different phenotypes have been observed affecting 208 family members (figure 1, table 1). The most prevalent phenotype was GC, detected in 138 of 208 (66.3%) family members.
50 probands with IGC and 88 additional patients with unknown GC histology ventolin expectorant capsule price. The second and third most prevalent phenotypes were colorectal/colon and breast cancer observed in nine patients from seven families. Of note, eight patients from six families were affected with gastric ulcer, a non-cancerous lesion, which is the third most common disease phenotype in this cohort.
Besides these phenotypes, positive history of ventolin expectorant capsule price lung cancer was observed in six families. Leukaemia in five families. Laryngotracheal and hepatobiliary cancer in four families.
Osteosarcoma in three ventolin expectorant capsule price families. Prostate, liver, melanoma, gynaecological, bladder and brain cancers were detected in two families each. And thyroid, kidney and oral cancer in one family.
Moreover, 11 families had relatives ventolin expectorant capsule price affected by an unidentified type of cancer that often coexisted with other cancer types such as colon, leukaemia, breast, liver and prostate.Disease spectrum of FIGC families. The disease spectrum of FIGC encompassed 19 different phenotypes affecting 208 family members. The most prevalent phenotype was gastric cancer, detected in 138 of 208, followed by colorectal/colon and breast cancers in 9 of 208.
FIGC, familial intestinal gastric cancer." data-icon-position data-hide-link-title="0">Figure ventolin expectorant capsule price 1 Disease spectrum of FIGC families. The disease spectrum of FIGC encompassed 19 different phenotypes affecting 208 family members. The most prevalent phenotype was gastric cancer, detected in 138 of 208, followed by colorectal/colon and breast cancers in 9 of 208.
FIGC, familial intestinal gastric cancer.Germline and ventolin expectorant capsule price somatic variant discovery across FIGC probandsMultigene panel sequencing analysis of normal-tumour DNA of 50 FIGC probands revealed a total of 10â062 variants (â¥1 read covering the alternative allele). Of these, 4998 (49.7%) were detected in normal DNA and defined as germline variants. The remaining 5064 (50.3%) were called as somatic variants due to exclusive presence in tumour DNA.
We started by exploring germline variants, focusing on rare variants in single genes (monogenic hypothesis) or variants ventolin expectorant capsule price co-occurring in several genes, regardless of their population frequency (oligogenic/polygenic hypothesis).Monogenic hypothesis. FIGC-associated rare germline variants and somatic second-hitsTo identify rare germline FIGC-predisposing variants, we performed a systematic analysis of all germline variants, focusing on their frequency across normal populations and GC cohorts, and sequencing quality.We identified 4998 germline variants in the 50 patients with FIGC (figure 2A). From the 4998 FIGC germline variants, the genotype frequency of 1038 (20.8%) was available for four 1000 Genomes European populations.28 From the 79.2% of variants absent from 1000 Genomes, only 1.3% (n=53) presented truncating effects, however supported on average by less than four reads, that is, of very low quality and hence confidently discarded.
From the 1038 variants present in 1000 Genomes, 121 (11.7%) presented genotypes absent ventolin expectorant capsule price from the four populations screened. Of these 121 variants, only 60 presented the abovementioned sequencing quality criteria. From these, 43 variants were exclusively detected in FIGC comparing with HDGC-CDH1 mutation-negative and SIGC cohorts.
With regard ventolin expectorant capsule price to the 17 discarded variants, all were found in at least one HDGC proband and none in SIGC.90âand a call quality >100). From these, 43 variants presented the RefSeq genotype in the HDGC-CDH1 mutation-negative and sporadic GC cohorts. A final set of 32 germline, rare and high-quality FIGC-exclusive variants were selected by screening the allele frequency of these variants in all ExAC and gnomAD populations available.
(B) Germline variant burden of FIGC ventolin expectorant capsule price families with 0, 1 or >1ârare germline variants. P value was determined by ANOVA statistics. (C) Heatmap and dendrogram of 710 HQ FIGC germline variants of FIGC family classes (Z-score normalised expression level.
White, no detected variants ventolin expectorant capsule price. Purple, detected variants. (D) Heatmap and dendrogram of 64 genes with the 710 germline variants of FIGC family classes (Z-score normalised expression levels.
White, genes with no detected ventolin expectorant capsule price variants. Light salmon, genes with a single variant. Pink, gene carrying 2â5 distinct variants.
Purple, gene ventolin expectorant capsule price with 6â10 distinct variants. Dark purple, gene with 11â15 distinct variants. ANOVA, analysis of variance.
FIGC, familial ventolin expectorant capsule price intestinal gastric cancer. GC, gastric cancer. HDGC, hereditary diffuse gastric cancer.
HQ, high-quality." class="highwire-fragment fragment-images colorbox-load" rel="gallery-fragment-images-178618009" data-figure-caption="Co-occurrence of rare germline ventolin expectorant capsule price variants does not define a specific germline landscape. (A) Discovery of FIGC rare germline predisposition variants. A total of 4998 germline variants were detected in normal stomach using multigene panel sequencing.
From these, 1038 were identified by the 1000 Genomes Project, and 121 were absent from four distinct normal European populations ventolin expectorant capsule price. Of these 121 variants, only 60 were classified as variants of high quality (with at least 20 reads for each allele, a genotype quality >90âand a call quality >100). From these, 43 variants presented the RefSeq genotype in the HDGC-CDH1 mutation-negative and sporadic GC cohorts.
A final set of 32 germline, rare and high-quality FIGC-exclusive variants were selected by screening the allele frequency of ventolin expectorant capsule price these variants in all ExAC and gnomAD populations available. (B) Germline variant burden of FIGC families with 0, 1 or >1ârare germline variants. P value was determined by ANOVA statistics.
(C) Heatmap and dendrogram of 710 HQ ventolin expectorant capsule price FIGC germline variants of FIGC family classes (Z-score normalised expression level. White, no detected variants. Purple, detected variants.
(D) Heatmap and dendrogram of 64 genes ventolin expectorant capsule price with the 710 germline variants of FIGC family classes (Z-score normalised expression levels. White, genes with no detected variants. Light salmon, genes with a single variant.
Pink, gene carrying 2â5 distinct ventolin expectorant capsule price variants. Purple, gene with 6â10 distinct variants. Dark purple, gene with 11â15 distinct variants.
ANOVA, analysis ventolin expectorant capsule price of variance. FIGC, familial intestinal gastric cancer. GC, gastric cancer.
HDGC, hereditary diffuse ventolin expectorant capsule price gastric cancer. HQ, high-quality." data-icon-position data-hide-link-title="0">Figure 2 Co-occurrence of rare germline variants does not define a specific germline landscape. (A) Discovery of FIGC rare germline predisposition variants.
A total of 4998 germline variants were detected ventolin expectorant capsule price in normal stomach using multigene panel sequencing. From these, 1038 were identified by the 1000 Genomes Project, and 121 were absent from four distinct normal European populations. Of these 121 variants, only 60 were classified as variants of high quality (with at least 20 reads for each allele, a genotype quality >90âand a call quality >100).
From these, 43 variants presented the RefSeq genotype in the HDGC-CDH1 ventolin expectorant capsule price mutation-negative and sporadic GC cohorts. A final set of 32 germline, rare and high-quality FIGC-exclusive variants were selected by screening the allele frequency of these variants in all ExAC and gnomAD populations available. (B) Germline variant burden of FIGC families with 0, 1 or >1ârare germline variants.
P value ventolin expectorant capsule price was determined by ANOVA statistics. (C) Heatmap and dendrogram of 710 HQ FIGC germline variants of FIGC family classes (Z-score normalised expression level. White, no detected variants.
Purple, detected ventolin expectorant capsule price variants. (D) Heatmap and dendrogram of 64 genes with the 710 germline variants of FIGC family classes (Z-score normalised expression levels. White, genes with no detected variants.
Light salmon, genes with a ventolin expectorant capsule price single variant. Pink, gene carrying 2â5 distinct variants. Purple, gene with 6â10 distinct variants.
Dark purple, ventolin expectorant capsule price gene with 11â15 distinct variants. ANOVA, analysis of variance. FIGC, familial intestinal gastric cancer.
GC, gastric cancer ventolin expectorant capsule price. HDGC, hereditary diffuse gastric cancer. HQ, high-quality.From the 43 germline, rare and HQ FIGC-exclusive variants, 31 (72.1%) displayed very low allele frequency in all ExAC and gnomAD populations (figure 2A, online supplementary table 3), and were present in 21 of 50 (42%) FIGC probands (7 missense, 7 3âuntranslated (UTR), 2 5âUTR, 12 intronic and 3 synonymous in 18 genes.
Online supplementary ventolin expectorant capsule price table 4). Fifteen probands carried a single variant and six exhibited co-occurrence of two or more variants (online supplementary table 5). After excluding variants classified as benign and predicted as intronic, synonymous or not impacting splicing, 12 variants were validated by Sanger sequencing (table 2).Supplemental materialSupplemental materialSupplemental materialView this table:Table 2 FIGC rare germline variants validated by Sanger sequencingA missense variant in PMS1 (c.224C>T), predicted as pathogenic, deleterious and probably damaging by FATHMM, SIFT and PolyPhen, respectively (table 2, online supplementary table 3), was found in family P1 (table 1, online supplementary table 4).
The probands, who developed an MSS IGC at 59 years, had ventolin expectorant capsule price an FDR with GC at 80 and two other FDR and SDR with unidentified cancers at 50 and 75 years, respectively. The only supporting evidence for the role of this variant in FIGC was its COSMIC record as somatic in one GC sample (COSM6198026) (online supplementary table 3).The proband of family P27 presented three germline variants of uncertain significance, two in SMAD4 (c.424+5G>A. C.454+38G>C) and one in PRSS1 (c.201-99G>C) (online supplementary table 4).
Variants c.424+5G>A in SMAD4 and c.201â99G>C in PRSS1 were the only intronic variants predicted to disrupt RNA splicing (table ventolin expectorant capsule price 2, online supplementary tables 3 and 5,). In particular, SMAD4 variant c.424+5G>A decreases the confidence of a donor splice site, which may lead to intron 3 retention, a premature termination codon and generation of a 142 amino acid truncated protein. On the other hand, PRSS1 variant c.201-99G>C creates a new, high-confidence acceptor splice site within intron 2, which may lead to a truncated 69 amino acid protein.
Proband P27 developed an MSS IGC at age 64 and had family history of GC, gastric ulcer, laryngotracheal, gynaecological and hepatobiliary cancers (table 1, online ventolin expectorant capsule price supplementary table 4). The presence of these phenotypes seems to exclude juvenile polyposis and hereditary pancreatitis as underlying syndromes of this family, but could support a potential role for SMAD4 together with PRSS1 in FIGC.We then screened the primary tumours of P1 and P27 FIGC probands for somatic second-hit inactivating mechanisms (LOH, somatic mutation) in germline-affected genes. None of the two FIGC probands showed evidence of deleterious somatic variants nor LOH of the wild-type allele of the germline targeted genes (data not shown).Although interesting, these findings are insufficient to support the monogenic hypothesis for FIGC and a potentially causal role for the abovementioned affected genes.Oligogenic/polygenic hypothesis.
Co-occurrence of rare germline variants determines somatic landscapes of FIGC tumoursWe then proceeded with the oligogenic/polygenic hypothesis, which takes into consideration the co-occurrence of germline variants, regardless of their population frequency, as a risk factor for this disease, which would determine the subsequent somatic events necessary for malignant transformation.We categorised the 50 FIGC probands ventolin expectorant capsule price according to the presence of rare germline variants. Families with no variants (n=30). Families with a single variant (n=14).
And families with ventolin expectorant capsule price multiple variants (n=6). To understand the germline and somatic variant burden for each of these three FIGC classes, we applied the previously described quality criteria obtaining 710 HQ germline variants and 344 HQ somatic variants. The average number of HQ germline variants was identical across the three classes of FIGC families (75.7, 77.4 and 74.5 for families without (0), with one (1) or more than one (>1) rare germline variants, respectively.
Figure 2B) ventolin expectorant capsule price. Germline landscape unsupervised hierarchical clustering revealed no associations between variants or variant-bearing genes and a particular FIGC family class (figure 2C,D).Concerning the somatic variant burden, no significant differences were observed across the three FIGC classes (15.0, 13.8 and 11.2 for families with 0, 1 or >1ârare germline variants, respectively. Figure 3A).
Again, no clustering of specific variants/genes and particular FIGC classes ventolin expectorant capsule price was observed (figure 3B,C).1ârare germline variants. P value was determined by ANOVA statistics. (B) Heatmap and dendrogram of 344 FIGC somatic variants of FIGC family classes (Z-score normalised expression level.
White, no detected ventolin expectorant capsule price variants. Orange, detected variants. (C) Heatmap and dendrogram of 46 genes with the 344 somatic variants of FIGC family classes (Z-score normalised expression levels.
White, gene with ventolin expectorant capsule price no detected variants. Yellow, gene with a single variant. Orange, gene carrying 2â5 distinct variants.
Light brown, gene with 6â10 ventolin expectorant capsule price distinct variants. Brown, gene with 11â15 distinct variants. (D) Somatic variant burden of FIGC families with 0, 1 or >1ârare germline variants subdivided according to MSI status.
P value was ventolin expectorant capsule price determined by ANOVA statistics. ANOVA, analysis of variance. FIGC, familial intestinal gastric cancer.
HQ, high-quality ventolin expectorant capsule price. MSI, microsatellite instable. MSS, microsatellite stable." class="highwire-fragment fragment-images colorbox-load" rel="gallery-fragment-images-178618009" data-figure-caption="Rare germline variants are not major determinants of FIGC somatic events.
(A) Somatic variant burden of FIGC families with 0, 1 ventolin expectorant capsule price or >1ârare germline variants. P value was determined by ANOVA statistics. (B) Heatmap and dendrogram of 344 FIGC somatic variants of FIGC family classes (Z-score normalised expression level.
White, no ventolin expectorant capsule price detected variants. Orange, detected variants. (C) Heatmap and dendrogram of 46 genes with the 344 somatic variants of FIGC family classes (Z-score normalised expression levels.
White, gene ventolin expectorant capsule price with no detected variants. Yellow, gene with a single variant. Orange, gene carrying 2â5 distinct variants.
Light brown, gene ventolin expectorant capsule price with 6â10 distinct variants. Brown, gene with 11â15 distinct variants. (D) Somatic variant burden of FIGC families with 0, 1 or >1ârare germline variants subdivided according to MSI status.
P value was determined by ANOVA statistics ventolin expectorant capsule price. ANOVA, analysis of variance. FIGC, familial intestinal gastric cancer.
HQ, high-quality ventolin expectorant capsule price. MSI, microsatellite instable. MSS, microsatellite stable." data-icon-position data-hide-link-title="0">Figure 3 Rare germline variants are not major determinants of FIGC somatic events.
(A) Somatic variant burden of FIGC families with 0, 1 or ventolin expectorant capsule price >1ârare germline variants. P value was determined by ANOVA statistics. (B) Heatmap and dendrogram of 344 FIGC somatic variants of FIGC family classes (Z-score normalised expression level.
Light brown, gene with 6â10 distinct ventolin expectorant capsule price variants. Brown, gene with 11â15 distinct variants. (D) Somatic variant burden of FIGC families with 0, 1 or >1ârare germline variants subdivided according to MSI status.
P value was determined by ANOVA ventolin expectorant capsule price statistics. ANOVA, analysis of variance. FIGC, familial intestinal gastric cancer.
HQ, high-quality ventolin expectorant capsule price. MSI, microsatellite instable. MSS, microsatellite stable.We verified that 38% of the FIGC tumours in our series displayed the MSI phenotype, and further investigated whether MSI could influence the somatic variant burden and landscape in families with 0, 1 or >1ârare germline variants.
After subdividing each FIGC class according to its MSI status, no ventolin expectorant capsule price significant differences were observed both in terms of somatic variant burden and landscape between categories (figure 3BâD). Nevertheless, we observed that among FIGC families with multiple rare germline variants (>1), MSI tumours showed an average number of HQ somatic variants twofold higher than that of MSS tumours (17 vs 10 HQ somatic variants per case, respectively. Figure 3D, online supplementary figure 1A).
This observation prompted us to explore the influence of rare germline variants, independently of their number, on tumour instability and consequent somatic variant burden ventolin expectorant capsule price. Despite the lack of statistical significance, we observed an enrichment of MSI tumours in FIGC families carrying rare germline variants comparing with MSI tumours from families lacking rare germline variants (online supplementary figure 1B). Concerning the average of somatic variants, whereas MSI and MSS tumours from FIGC lacking rare germline variants displayed a similar average number, there was a non-significant trend for higher average number of HQ somatic variants in MSI tumours versus MSS tumours from FIGC families with rare germline variants (â¥1.
Online supplementary figure 1C).Supplemental materialAlthough our data did not ventolin expectorant capsule price support the hypothesis that co-occurrence of rare germline variants is a major determinant of FIGC-related somatic landscapes, these pinpointed a potential correlation between the coexistence of rare and common germline variants, high average number of somatic variants and MSI phenotype in FIGC.FIGC is genetically distinct from SIGC and from HDGC-CDH1 mutation-negativeSince the late age of onset in FIGC probands and their relatives makes it hard to distinguish bona fide FIGCs from SIGCs, we compared the age of onset of FIGC probands with the age of onset of a series of SIGC cases. We found that FIGC probands developed GC approximately 10 years earlier than patients with SIGC (p=4.5E-03. Figure 4E).FIGC is a genetic entity distinct from SIGC.
(A) Principal component analysis of genes with germline variants ventolin expectorant capsule price. (B) Principal component analysis of genes with somatic variants. (C) Frequency of genes with germline or somatic variants enriched in FIGC cases in comparison with SIGC cases.
Purple for ventolin expectorant capsule price genes with germline events and orange for genes with somatic events. (D) Heatmap and dendrogram of a panel of genes with the highest frequency of germline and/or somatic variants in FIGC (n=50) versus SIGC (n=47). (E) Age at diagnosis of FIGC (n=50) and SIGC cases (n=47).
(F) Average number of somatic variants detected in FIGC (n=50) and SIGC cases (n=47) ventolin expectorant capsule price. White, gene with no variants. Purple, gene with germline variants.
Orange, gene ventolin expectorant capsule price with somatic variants. Red, gene with germline and somatic variants. P values calculated with Wilcoxon signed-rank test.
FIGC, familial ventolin expectorant capsule price intestinal gastric cancer. SIGC, sporadic intestinal gastric cancer, PC1, principal component 1. PC2, principal component 2." data-icon-position data-hide-link-title="0">Figure 4 FIGC is a genetic entity distinct from SIGC.
(A) Principal component analysis of genes with ventolin expectorant capsule price germline variants. (B) Principal component analysis of genes with somatic variants. (C) Frequency of genes with germline or somatic variants enriched in FIGC cases in comparison with SIGC cases.
(F) Average number ventolin expectorant capsule price of somatic variants detected in FIGC (n=50) and SIGC cases (n=47). White, gene with no variants. Purple, gene with germline variants.
FIGC, familial intestinal ventolin expectorant capsule price gastric cancer. SIGC, sporadic intestinal gastric cancer, PC1, principal component 1. PC2, principal component 2.We next explored whether these FIGC and SIGC were also distinct at the germline and/or somatic levels.
Principal component analysis revealed that certain genes were differentially associated with FIGCs and ventolin expectorant capsule price SIGCs (figure 4A,B). Specifically, common germline variants in TP53 were present in more than 50% of FIGC probands, while only 11% of SIGC cases presented these germline variants (figure 4A,C). At the somatic level, the frequency of BRCA2, ATM, FOXF1, FHIT, SDHB, MSH6, CTNNA1 and PXN could distinguish FIGC from SIGC tumours, with more than 50% of FIGC displaying common variants in these genes, as compared with very low frequencies in SIGC (figure 4B,C).By combining all germline and somatic landscapes of 50 FIGCs and 47 SIGCs focusing only on the abovementioned genes, and using unsupervised hierarchical clustering, two main clusters were evidenced separating most FIGCs from SIGCs (figure 4D).
Whereas FIGCs carried both germline and somatic variants in TP53, BRCA2, ATM, FOXF1, FHIT, SDHB, MSH6, CTNNA1 and PXN genes, SIGCs lacked TP53 and FHIT germline and somatic variants and mainly presented BRCA2, ATM, FOXF1, SDHB, MSH6, CTNNA1 and PXN somatic variants.Further supporting that FIGC represents a different entity likely evolving for longer than SIGCs is the fact that FIGC tumours presented statistically significantly more somatic common variants than SIGC tumours (p=4.2E-06), even if arising from patients 10âyears younger on average (figure 4E,F).To further ventolin expectorant capsule price understand whether FIGC is a genetic entity also distinct from HDGC-CDH1 mutation-negative, we compared the germline and somatic landscapes of 7 FIGCs and 17 HDGCs sequenced with the same Next Generation Sequencing (NGS) panel. We verified that indeed FIGC and HDGC also display considerable differences between germline and somatic landscapes (online supplementary figure 2)(). However, the low number of FIGC cases possible to analyse, which was due to sequencing panel differences, hampers more formal conclusions.Overall, our results suggest that FIGC, rather than a monogenic disease, is likely a polygenic disease with distinctive germline and somatic landscapes from SIGC and HDGC-CDH1-negative.DiscussionFIGC presents an autosomal dominant inheritance pattern of IGC, without gastric polyposis, and has been clinically defined by analogy to the Amsterdam criteria for HNPCC.9 However, lack of novel data supporting familial aggregation of IGC at a given age of onset as well as the non-existence of tumour spectrum descriptions have impeded the redefinition of FIGC testing criteria, useful for identification and management of these families.The primary strength of this study is the use of a large homogeneous cohort of probands with IGC, familial aggregation of GC, detailed personal/family history, age of disease onset and disease spectrum.
This series does not present clinical criteria compatible with any other gastrointestinal cancer-associated syndrome, is clearly enriched in GC and mainly of intestinal type, which suggests this is the first data-driven testing criteria for ventolin expectorant capsule price FIGC families. We propose that any family presenting two GC cases, one confirmed of intestinal histology, independently of age, and with or without colorectal cancer, breast cancer or gastric ulcers in other family members, could be considered FIGC.Besides potential testing criteria, our study also reported the first large-scale sequencing analysis of the germline and somatic landscapes of FIGC and respective comparisons with comparable landscapes of SIGC and HDGC-CDH1 mutation-negative. We used these data to explore the unknown inherited nature of FIGC.
Among the FIGC-exclusive germline rare variants found, the missense PMS1 c.224C>T ventolin expectorant capsule price variant was the only one predicted as pathogenic in family P1. Deleterious variants in this DNA mismatch repair protein (PMS1, OMIM:600258) can be found in HNPCC families, either alone or co-occurring with mutations in other HNPCC-related genes.32 33 However, the real contribution of PMS1 germline mutations for HNPCC predisposition is still debatable. Liu et al33 detected PMS1 and MSH2 germline mutations in an HNPCC proband with an MSI tumour, and observed that only the MSH2 germline mutation was shared with another member of the family affected with colorectal cancer, thus demonstrating that MSH2 is the real predisposing gene to colorectal cancer in this family.
Notwithstanding, they ventolin expectorant capsule price postulated that the PMS1 mutation could contribute to the unusual number of lung cancer cases in this HNPCC family.33 Our FIGC proband (P1) carrying a PMS1 germline variant displayed an MSI-low tumour, consistent with the fact that Pms1-deficient mice do not show an increased mutation rate (MSI) in the colonic epithelium.34 Although we lack full evidence for the potentially causative role of this PMS1 variant in family P1, namely a second-hit in the tumour and segregation analysis, this remains an open possibility. The same applied to family P27, where potentially truncating variants are simultaneously found in SMAD4 and PRSS1, but no second somatic-hits are found in these genes. Overall, these findings do not strongly support a monogenic nature for FIGC, at least as evident as that seen for CDH1-associated HDGC or GAPPS.In the last decade, several studies have integrated large-scale normal and tumour sequencing data to ascertain the impact of germline variation on tumour evolution.35â38 For example, Carter et al36 identified germline variants that can either dramatically increase the frequency of somatic mutations or influence the site where a tumour develops.
Others have shown that rare germline truncations in cancer susceptibility genes, including BRCA1, BRCA2, FANCM and MSH6, are significantly associated with increased somatic mutation frequencies in specific cancer types, suggesting that germline and somatic levels are intrinsically linked.37 Our findings revealed that, independently of the presence of rare germline variants, FIGC families displayed similar germline and somatic variant burden and landscapes, suggesting that this type of inherited variation may not be a major determinant ventolin expectorant capsule price of tumour development in these families. Interestingly, we found that MSI and MSS tumours from FIGC families lacking rare germline variants displayed a similar somatic variant burden, while MSI tumours from families carrying single/multiple germline rare variants tend to harbour more somatic variants than MSS tumour-bearing families. Altogether, these findings suggest that rare germline defects involving the DNA repair system may extend to the somatic level, as previously demonstrated in other cancer types.37 38Our study, as the previous ones, failed to find the monogenic factor that genetically determined the occurrence of FIGC.
Since individual market coverage is regulated and marketed at the state how often can ventolin be used level, a new plan is needed when you move from one state to another. But prior to 2014, health insurance was often an how often can ventolin be used obstacle for people who wanted to move to a new state. In all but five states, individual market coverage was medically underwritten, so people with pre-existing conditions often found it difficult, expensive, or impossible to enroll in new coverage if they were going to need to purchase their own plan (as opposed to getting coverage from an employer, Medicare, or Medicaid).Many states had state-run high-risk pools, and federal pre-existing condition insurance pools (PICP) were implemented in the years leading up to 2014.
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Here, youâll find how often can ventolin be used information about the many types of health insurance coverage available. You can find the basics of the Minnesota health insurance marketplace and how open enrollment and special enrollment periods work. A brief overview of Medicaid expansion in how often can ventolin be used Minnesota.
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Buying a new plan entails starting over with a new deductible.Read more about short-term health insurance coverage in Minnesota.The Affordable Care Act in the North Star StateIn the 2010 passage of the Affordable Care Act, Minnesotaâs two Democratic senators â Amy Klobuchar and Al Franken â both voted in support of health reform. Franken is credited for the inclusion of a medical loss ratio (MLR) requirement in the reform bill, which has resulted in marketplace insurers sending rebates â often substantial ones â to enrollees when the percentage of collected premiums spent on enrolleesâ medical bills is below the allowable minimum.One of the early, popular provisions of the ACA, MLR requires insurance companies to issue refunds if they spend more than 20 percent of premiums on administrative items (15 percent for large-group plans). The MLR rule resulted in $1.1 billion in refunds in 2012, and by the end of 2019, total cumulative refunds had reached more than $5 billion.Franken resigned in 2017, and Minnesotaâs Lieutenant Governor, Tina Smith, was appointed to fill his spot in the Senate.
Smith then won the special election for the seat in 2018. Klobuchar also won her re-election bid in 2018, so both of Minnesotaâs Senators continue to be Democrats.Minnesotaâs eight representatives split their votes on the ACA in 2009/2010, with Democrat Collin Peterson joining three Republicans in voting no. Peterson did not support 2017 House Republicans in their efforts to pass the American Health Care Act, a partial ACA repeal bill, but his votes on health care reform have been a mixed bag over the years, and he continues to represent the rural, fairly conservative 7th District, winning his 15th term in 2018.Minnesotaâs House delegation consists of three Republicans and five Democrats in 2020.
Four districts (1st, 2nd, 3rd, and 8th) flipped in the 2018 election, but two flipped to the Democrats and two flipped to the Republicans.Minnesotaâs former governor, Mark Dayton, had long been a proponent of Obamacare. Dayton chose not to run for a third term in 2018, but Tim Walz, the DFL (Democratic-Farmer-Labor) candidate, won the election, so the governorâs seat continues to be occupied by a Democrat.After Democrats gained control of Minnesotaâs House and Senate in the 2012 election, legislation was passed to implement a state-run health insurance exchange. Minnesota also expanded Medicaid, which it calls Medical Assistance, to residents with household incomes up to 138 percent of the federal poverty level.
Medicaid expansion was a key ACA strategy to reduce the uninsured rate. And as noted above, Minnesota also created a Basic Health Program under the Affordable Care Act, further protecting residents with income a little above the Medicaid eligibility cut-off.Has Obamacare helped Minnesotans?. Minnesota has enjoyed a low uninsured rate for years due to generous Medicaid eligibility standards and MinnesotaCare, a health insurance program for uninsured, working residents.
Under the Affordable Care Act, Minnesota not only expanded Medicaid, it also created a state-based health insurance exchange called MNsure.As of the first half of 2020, there were nearly 107,000 people with private individual market coverage through MNsure. All of them have coverage for the ACAâs essential health benefits with no lifetime or annual caps on the benefits. And more than 59,000 of them were receiving premium subsidies that make health insurance more affordable.According to U.S.
Census data, Minnesotaâs uninsured rate fell from 8.2 percent in 2013 to 4.1 percent in 2016. But it increased slightly, to 4.4 percent as of 2018, and increased again, to 4.9 percent, as of 2019. That uptick in the uninsured rate was common across the country after the Trump administration took office.
It was due in part to new federal policies that undercut the ACA, but also to rising health insurance premiums â themselves due in part to Trump administration and GOP congressional actions â that made coverage less affordable for people who donât qualify for premium subsidies.Does Minnesota have a high-risk pool?. Before the ACA reformed the individual health insurance market, coverage was underwritten in nearly every state, including Minnesota. As a result, people with pre-existing conditions were often unable to purchase coverage in the private market, or if coverage was available it came with a higher premium or with pre-existing condition exclusion riders.The Minnesota Comprehensive Health Association (MCHA) was created in 1976 to give people an alternative if they were ineligible to purchase individual health insurance because of their medical history.
(Only Connecticut has a risk pool as old as Minnesota.)Under the ACA, all new health insurance policies became guaranteed-issue starting on January 1, 2014. This change largely eliminated the need for high-risk pools and MCHA stopped enrolling new members as of December 31, 2013. It remained operational for existing members until the end of 2014.Medicare coverage and enrollment in MinnesotaBy October 2020, there were 1,051,433 people enrolled in Medicare in Minnesota.Minnesotans can choose Medicare Advantage plans instead of Original Medicare if they wish to obtain additional benefits and donât mind the restrictions (including network restrictions) that go along with having a private plan.
Nearly half of all Medicare beneficiaries in Minnesota are enrolled in private plans â mostly Medicare Advantage, but also Medicare Cost plans, a form of commercial Medicare coverage that pre-dates Medicare Advantage. Minnesota has long had the nationâs highest enrollment in Medicare Cost plans, but about 300,000 enrollees had to switch to different coverage (Original Medicare or Medicare Advantage) when their Cost plans were phased out in 2019.Read more about Medicare in Minnesota, including details related to Medigap plans and Medicare Part D.Minnesota health insurance resources State-based health reform legislationScroll to the bottom of this page to see a summary of recent Minnesota health reform legislation.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.
Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts..
Since individual market coverage is regulated and marketed at the state level, a new plan is needed when you move from one state ventolin expectorant capsule price to another. But prior ventolin expectorant capsule price to 2014, health insurance was often an obstacle for people who wanted to move to a new state. In all but five states, individual market coverage was medically underwritten, so people with pre-existing conditions often found it difficult, expensive, or impossible to enroll in new coverage if they were going to need to purchase their own plan (as opposed to getting coverage from an employer, Medicare, or Medicaid).Many states had state-run high-risk pools, and federal pre-existing condition insurance pools (PICP) were implemented in the years leading up to 2014. But high-risk pools could impose waiting periods for new arrivals to the state, and coverage through the risk pools was often prohibitively expensive and generally had benefit caps that werenât always adequate.Thatâs all a thing of the past, thanks to the Affordable ventolin expectorant capsule price Care Act. In every state, health insurance is guaranteed-issue for all applicants during open enrollment and special enrollment periods â and moving to a new state will trigger a special enrollment period as long as you already had coverage before your move.
And the price is the ventolin expectorant capsule price same regardless of whether you have pre-existing conditions. Premiums can vary based on age, zip code, and tobacco use, so you might find that coverage in your new area is priced differently. But if youâre eligible for premium subsidies, the subsidy amount will adjust to reflect the cost of the benchmark plan in your new ventolin expectorant capsule price area.How do I get new health insurance coverage when I move to a different state?. If you work for a large employer that has business locations throughout the country, you may find that your coverage remains unchanged with your move. But if you buy your health insurance in the individual market, youâll have to purchase a new plan.Individual market coverage is guaranteed-issue thanks to Obamacare, but itâs only available for purchase during open enrollment, and during ventolin expectorant capsule price special enrollment periods triggered by qualifying events.
Moving to an area where different health plans are available (which includes moving to a new state) is a qualifying event, as long as you already had coverage in your prior location. (This prior coverage requirement took effect in July 2016.)So you cannot move to a new state in order ventolin expectorant capsule price to take advantage of a special enrollment period if you were uninsured prior to the move. But as long as you had coverage before the move, youâll have a 60-day enrollment window during which you can pick a new plan â in the exchange or off-exchange â in your new state.Itâs optional for exchanges to allow access to special enrollment periods in advance of a move (as opposed to only after the move has occurred), but thereâs no requirement that exchanges offer this feature. So your enrollment period likely wonât begin until the day you move, and the earliest ventolin expectorant capsule price effective date youâll be eligible for will be the first of the following month. (Normal effective date rules are followed in this case, which means that in most states, you need to enroll by the 15th of the month in order to have coverage effective the first of the following month.
This requirement will no longer be used by HealthCare.gov as of 2022, when they will simply allow coverage to be ventolin expectorant capsule price effective the first of the month after you enroll, regardless of the date you enroll.)That means you may end up having a gap in coverage, depending on the date you move and how far into your 60-day enrollment period you are when you select a new plan in your new state. Youâll want to find out how your current health insurance plan works in your new state. You may only have coverage for emergencies once you leave the state in which your policy was issued.If youâre ventolin expectorant capsule price concerned about the possibility of having a gap in coverage, you could enroll in a short-term plan to cover you until your new plan takes effect. Short-term plans are not regulated by the ACA, and they donât count as minimum essential coverage. But theyâre specifically designed to cover short gaps in coverage, and theyâre perfect for a situation ventolin expectorant capsule price in which your new plan will be taking effect within a few weeks and you only need âjust in caseâ coverage in the meantime.A short-term plan can have an effective date as early as the day after you apply, and short-term plans are available in nearly every state.
Be aware, however, that they generally donât cover any pre-existing conditions, and they can also reject your application if you have significant pre-existing medical conditions.How will my health insurance provider network change when I move to ventolin expectorant capsule price a new state?. Particularly in the individual market, health insurers have been moving towards HMOs and narrower networks. So itâs becoming rare for plans to offer ventolin expectorant capsule price network coverage in multiple states. Be prepared for the fact that you will almost certainly have a new provider network with your new plan.Itâs also important to note that even if your health insurer is a big-name carrier that offers plans throughout the country, it will have different individual market plans in each state. So although you might have a ventolin expectorant capsule price Cigna plan already, and Cigna might also be available in the individual market in the state where youâre moving, youâll need to re-enroll in the new plan once you move.And although Blue Cross Blue Shield is a household name in the health insurance market, their coverage varies from state to state.
The Blue Cross Blue Shield name is licensed by 36 different health insurance carriers across the country. A Blue Cross Blue Shield plan in one state is not the same as a ventolin expectorant capsule price Blue Cross Blue Shield plan in another state.Additional resourcesYou can also browse our extensive collection of state health insurance resources, and details about the health insurance exchanges in each state. If your income doesnât exceed 138 percent of the poverty level (or even higher, if youâre pregnant or looking for coverage for your children), youâll want to pay attention to the details about how each stateâs Medicaid program works and what you need to know about switching to a new stateâs Medicaid program.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the ventolin expectorant capsule price Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.Health insurance in Minnesota This page is dedicated to helping consumers quickly find health insurance resources in the state of Minnesota.
Here, youâll find information about the many types of health insurance coverage ventolin expectorant capsule price available. You can find the basics of the Minnesota health insurance marketplace and how open enrollment and special enrollment periods work. A brief overview of Medicaid expansion ventolin expectorant capsule price in Minnesota. A quick look at short-term health insurance rules in the state. Statistics about state-specific ventolin expectorant capsule price Medicare rules.
As well as a collection of Minnesota health insurance resources for residents.Minnesotaâs health insurance marketplaceMinnesotaâs marketplace enrollment uses a state-run exchange. MNsure. In 2017, state lawmakers voted to convert MNSure to a federally run marketplace, but the legislation was vetoed by then-Governor Mark Dayton.MNsure is a place where people can purchase individual/family health insurance. This is a valuable service for people who are not eligible for Medicare or employed by a company that provides group health insurance. Medicaid enrollment can also be done through MNsure, although enrollment in some types of Medicaid (for the elderly, disabled, etc.) is done through the stateâs Medicaid office.Minnesota open enrollment period and datesRead our detailed overview of the Minnesota health insurance marketplace â including news updates and exchange history.For 2021 coverage, open enrollment ran from November 1 to December 22, 2020.
This was one week longer than open enrollment in states that use HealthCare.gov. Enrollment is still possible for people experiencing a qualifying event, including loss of other coverage, but the application will require proof of the qualifying event.In response to the asthma treatment ventolin, MNSure created a month-long emergency Special Enrollment Period in the spring of 2020. During that period, anyone who was uninsured could enroll without certifying the kind of âlife change,â such as loss of job-based insurance, normally required for enrollment outside of the annual open enrollment period. Partly as a result of the SEP, nearly 100,000 Minnesotans enrolled in private or public medical insurance plans from March 1 through June 21.Six insurers â Blue Plus, Group Health, Medica, UCare, Quartz, and PreferredOne â offer individual market coverage in Minnesota (Quartz is new for 2021). PreferredOne offers only off-exchange coverage, while the other five all make their plans available through MNsure.
For 2021, they have implemented overall average rate increases that range from about 1 percent to about 4 percent. The insurers have varying service areas, so more plans are available in some areas than in others.Minnesotaâs enrollment dropped for the first time in 2019, when 113,552 people enrolled in individual market plans through MNsure. But it climbed again, to 117,520, during the open enrollment period for 2020 coverage, and to 122,269 people who enrolled during the open enrollment period for 2021 coverage.Read more about Minnesotaâs health marketplace.Medicaid expansion and Basic Health Program in MinnesotaIn February 2013, Governor Mark Dayton signed HF9, a bill that expanded access to Minnesotaâs Medicaid program under the ACA. From late 2013 to August 2020, enrollment in Minnesota Medicaid plans (Medical Assistance) and CHIP plans increased by 28 percent. During the asthma treatment ventolin, enrollment in Minnesotaâs managed Medicaid plans surged nearly 17% from February through October 2020.Minnesota also established a Basic Health Program (BHP) under the ACA, and is one of only two states to do so (New York is the other).
Basic Health Programs provide robust, low-premium coverage to people with income between the Medicaid eligibility threshold and 200 percent of the poverty level, as well as to legally present non-citizens with incomes below 138 percent FPL who are time-barred from enrolling in Medicaid. In Minnesota, the Basic Health Program is known as MinnesotaCare, a program that predates the ACA but was revamped to serve as a BHP as of January 2015.[New York also created a BHP as of 2016. To date, New York and Minnesota are the only states that have BHPs, although DCâs Medicaid eligibility extends to 210 percent of the poverty level.]Premiums and out-of-pocket costs in MinnesotaCare are lower than in plans offered at low incomes in other ACA marketplaces. At various points Minnesota lawmakers have considered extending access to MinnesotaCare to higher income levels or even all income levels, but such plans have not been enacted.Read more about Minnesotaâs Medicaid expansion.Short-term health insurance in MinnesotaShort-term health insurance plans in Minnesota cannot last more than 185 days unless the insured is in the hospital on the day that the plan would have terminated and the insurer extends the coverage until the end of the hospital stay.Short-term plans are nonrenewable in Minnesota, but a person can buy additional plans as long as their total time with short-term coverage doesnât exceed 365 days out of any 555-day period â plus any days that a plan is extended to cover an insured who is in the hospital on the day the plan would have ended. Buying a new plan entails starting over with a new deductible.Read more about short-term health insurance coverage in Minnesota.The Affordable Care Act in the North Star StateIn the 2010 passage of the Affordable Care Act, Minnesotaâs two Democratic senators â Amy Klobuchar and Al Franken â both voted in support of health reform.
Franken is credited for the inclusion of a medical loss ratio (MLR) requirement in the reform bill, which has resulted in marketplace insurers sending rebates â often substantial ones â to enrollees when the percentage of collected premiums spent on enrolleesâ medical bills is below the allowable minimum.One of the early, popular provisions of the ACA, MLR requires insurance companies to issue refunds if they spend more than 20 percent of premiums on administrative items (15 percent for large-group plans). The MLR rule resulted in $1.1 billion in refunds in 2012, and by the end of 2019, total cumulative refunds had reached more than $5 billion.Franken resigned in 2017, and Minnesotaâs Lieutenant Governor, Tina Smith, was appointed to fill his spot in the Senate. Smith then won the special election for the seat in 2018. Klobuchar also won her re-election bid in 2018, so both of Minnesotaâs Senators continue to be Democrats.Minnesotaâs eight representatives split their votes on the ACA in 2009/2010, with Democrat Collin Peterson joining three Republicans in voting no. Peterson did not support 2017 House Republicans in their efforts to pass the American Health Care Act, a partial ACA repeal bill, but his votes on health care reform have been a mixed bag over the years, and he continues to represent the rural, fairly conservative 7th District, winning his 15th term in 2018.Minnesotaâs House delegation consists of three Republicans and five Democrats in 2020.
Four districts (1st, 2nd, 3rd, and 8th) flipped in the 2018 election, but two flipped to the Democrats and two flipped to the Republicans.Minnesotaâs former governor, Mark Dayton, had long been a proponent of Obamacare. Dayton chose not to run for a third term in 2018, but Tim Walz, the DFL (Democratic-Farmer-Labor) candidate, won the election, so the governorâs seat continues to be occupied by a Democrat.After Democrats gained control of Minnesotaâs House and Senate in the 2012 election, legislation was passed to implement a state-run health insurance exchange. Minnesota also expanded Medicaid, which it calls Medical Assistance, to residents with household incomes up to 138 percent of the federal poverty level. Medicaid expansion was a key ACA strategy to reduce the uninsured rate. And as noted above, Minnesota also created a Basic Health Program under the Affordable Care Act, further protecting residents with income a little above the Medicaid eligibility cut-off.Has Obamacare helped Minnesotans?.
Minnesota has enjoyed a low uninsured rate for years due to generous Medicaid eligibility standards and MinnesotaCare, a health insurance program for uninsured, working residents. Under the Affordable Care Act, Minnesota not only expanded Medicaid, it also created a state-based health insurance exchange called MNsure.As of the first half of 2020, there were nearly 107,000 people with private individual market coverage through MNsure. All of them have coverage for the ACAâs essential health benefits with no lifetime or annual caps on the benefits. And more than 59,000 of them were receiving premium subsidies that make health insurance more affordable.According to U.S. Census data, Minnesotaâs uninsured rate fell from 8.2 percent in 2013 to 4.1 percent in 2016.
But it increased slightly, to 4.4 percent as of 2018, and increased again, to 4.9 percent, as of 2019. That uptick in the uninsured rate was common across the country after the Trump administration took office. It was due in part to new federal policies that undercut the ACA, but also to rising health insurance premiums â themselves due in part to Trump administration and GOP congressional actions â that made coverage less affordable for people who donât qualify for premium subsidies.Does Minnesota have a high-risk pool?. Before the ACA reformed the individual health insurance market, coverage was underwritten in nearly every state, including Minnesota. As a result, people with pre-existing conditions were often unable to purchase coverage in the private market, or if coverage was available it came with a higher premium or with pre-existing condition exclusion riders.The Minnesota Comprehensive Health Association (MCHA) was created in 1976 to give people an alternative if they were ineligible to purchase individual health insurance because of their medical history.
(Only Connecticut has a risk pool as old as Minnesota.)Under the ACA, all new health insurance policies became guaranteed-issue starting on January 1, 2014. This change largely eliminated the need for high-risk pools and MCHA stopped enrolling new members as of December 31, 2013. It remained operational for existing members until the end of 2014.Medicare coverage and enrollment in MinnesotaBy October 2020, there were 1,051,433 people enrolled in Medicare in Minnesota.Minnesotans can choose Medicare Advantage plans instead of Original Medicare if they wish to obtain additional benefits and donât mind the restrictions (including network restrictions) that go along with having a private plan. Nearly half of all Medicare beneficiaries in Minnesota are enrolled in private plans â mostly Medicare Advantage, but also Medicare Cost plans, a form of commercial Medicare coverage that pre-dates Medicare Advantage. Minnesota has long had the nationâs highest enrollment in Medicare Cost plans, but about 300,000 enrollees had to switch to different coverage (Original Medicare or Medicare Advantage) when their Cost plans were phased out in 2019.Read more about Medicare in Minnesota, including details related to Medigap plans and Medicare Part D.Minnesota health insurance resources State-based health reform legislationScroll to the bottom of this page to see a summary of recent Minnesota health reform legislation.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006.
She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts..