The organization and financing of health services for persons with disabilities

Americans with disabilities are rarely considered a distinct group of health care users in the same way as are older Americans, children, racial and ethnic minorities, and others who are perceived to have different needs and access issues. Indeed, to some extent individuals with disabilities overlap with all these groups. But they also have distinct needs with material implications for the organization, delivery, and financing of health care services. Despite the disproportionate health care needs and expenditures of many--though not all--individuals with disabilities, the mainstream health services research community has largely neglected them. This article outlines the most pressing health service research issues in addressing the health care needs of individuals with disabilities.     

Relationship between risperidone and 9-hydroxy-risperidone plasma concentrations and CYP2D6 enzyme activity in psychiatric patients

The implication of cytochrome P450 CYP2D6 enzyme activity in the metabolism of the antipsychotic drug risperidone has been reported in vitro and in studies of healthy volunteers. Around 7 % of Caucasians have inherited impaired capacity of this enzyme (poor metabolisers). These subjects might be prone to higher plasma concentrations of risperidone. The aim of the study was to determine the relationship between the debrisoquine metabolic ratio (MR), a marker of CYP2D6 enzyme activity, and risperidone plasma levels in psychiatric patients. A population of 40 Spanish and Hungarian schizophrenic patients was studied. The possible inhibition of CYP2D6 enzyme was also evaluated in a subgroup of patients co-medicated with inhibitors of CYP2D6. The risperidone/9-hydroxy-risperidone ratio correlated significantly with debrisoquine MR (p < 0.001). In patients co-medicated with strong inhibitors of CYP2D6, the plasma levels of risperidone (p < 0.05) and debrisoquine MR (p < 0.01) and risperidone/9-hydroxy-risperidone ratio were higher compared to patients with monotherapy. According to the present data, the evaluation of the risperidone/9-hydroxy-risperidone ratio may reflect the actual enzyme activity of CYP2D6. Therefore, the use of this ratio may help to assess potential pharmacokinetic interactions and to improve risperidone treatment.     

Neural correlates of visual-motion perception as object- or self-motion

Both self-motion and objects moving in our visual field generate visual motion by displacing images on the retina. Resolving this ambiguity may seem effortless but large-field visual-motion stimuli can yield perceptual rivalry between the real percept of object-motion and the illusory percept of self-motion (vection). We used functional magnetic resonance imaging to record brain activity in human observers exposed to constant-velocity roll-motion. This stimulus induced responses in areas reaching from calcarine to parieto-occipital and to ventral and lateral temporo-occipital cortex and the anterior insula. During vection, early motion-sensitive visual areas and vestibular parieto-insular cortex deactivated, whereas higher-order parieto- and temporo-occipital areas known to respond to optical flow retained identical activity levels. Within this sustained response, these latter areas displayed transient activations in response to each perceptual switch as identified in event-related analyses. Our results thus show that these areas are responsive to the type of visual motion stimulus and highly sensitive to its perceptual bistability. The only region to be more active during perceived self-motion was in, or close to, the cerebellar nodulus. This activation may correspond to the gain increase of torsional optokinetic nystagmus during vection and/or to changes in sensory processing related to the rotational percept. In conclusion, we identified neural correlates of perceiving self-motion from vision alone, i.e., in the absence of confirmatory vestibular or proprioceptive input. These functional properties preserve the organism's ability to move accurately in its environment by relying on visual cues under conditions when the other spatial senses fail to provide such information.     

Influence of action and expectation on visual control of posture

Previous studies have shown that human subjects presented with a moving visual environment initiate a postural re-adjustment in the direction of motion. The present study investigated how active control or expectation of the displacement of a visual scene affects this postural response. Center of foot pressure (COP) and head displacement were recorded using a sway platform and a tracking system, respectively. The subjects faced a visual scene (1 x 1 m, at a distance of 45 cm) which moved transiently (with a velocity of 1 cm/s) in a direction parallel to the interaural axis. When the displacement of the visual scene was under the active control of the subjects, visually induced body sway was strongly inhibited, in comparison with the response to unexpected stimuli. Prior knowledge of the characteristics of the forthcoming displacement was sufficient, in most subjects, to reduce postural re-adjustment, even when subjects did not exert active control. Finally, the visually induced postural response was strongly reduced even when subjects only triggered the stimulus, without any knowledge about the direction of motion. In conclusion, it appears that although vision is of primary importance in the control of postural orientation, high level processes such as expectation can modulate its impact by providing cues as to whether forthcoming visual flow is the consequence of self-motion or object-motion.