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Early hospital and medical plans offered by insurance companies paid either a fixed amount for specific diseases or medical procedures (schedule benefits) or a percentage of the provider's fee. The relationship between the patient and the medical provider was not changed. The patient received medical care and was responsible for paying the provider. If the service was covered by the policy, the insurance company was responsible for reimbursing or indemnifying the patient based on the provisions of the insurance contract ("reimbursement benefits"). Health insurance plans that are not based on a network of contracted providers, or that base payments on a percentage of provider charges, are still described as indemnity or fee-for-service plans.
Germans are offered three kinds of social security insurance dealing with the physical status of a person and which are co-financed by employer and employee: health insurance, accident insurance, and long-term care insurance. Long-term care insurance (Gesetzliche Pflegeversicherung) emerged in 1994 and is mandatory. Accident insurance (gesetzliche Unfallversicherung) is covered by the employer and basically covers all risks for commuting to work and at the workplace.
The terms "open panel" and "closed panel" are sometimes used to describe which health care providers in a community have the opportunity to participate in a plan. In a "closed panel" HMO, the network providers are either HMO employees (staff model) or members of large group practices with which the HMO has a contract. In an "open panel" plan the HMO or PPO contracts with independent practitioners, opening participation in the network to any provider in the community that meets the plan's credential requirements and is willing to accept the terms of the plan's contract.
Opposite to high-deductible plans are plans which provide limited benefits—up to a low level—have also been introduced. These limited medical benefit plans pay for routine care and do not pay for catastrophic care, they do not provide equivalent financial security to a major medical plan. Annual benefit limits can be as low as $2,000. Lifetime maximums can be very low as well.
Cost assistance is available to help lower the monthly expense of health insurance. Know as a tax credit or tax subsidy, federal money helps those that make between 100%-400% of the Federal Poverty Level. (For an individual that is between $11,770 – $47,080, depending on the state.) With cost assistance, individuals paid an average of less than $100 a month for a plan on the marketplace in 2015. That is a $268 savings each month.
In general, the amount the employer must include is the amount by which the fair market value of the benefits is more than the sum of what the employee paid for it plus any amount that the law excludes. There are other special rules that employers and employees may use to value certain fringe benefits. See Publication 15-B, Employers' Tax Guide to Fringe Benefits, for more information.
Conversely, an IBD/TIPP poll of 1,376 physicians showed that 45% of doctors "would consider leaving or taking early retirement" if Congress passes the health care plan wanted by the White House and Democrats. This poll also found that 65% of physicians oppose the White House and Democratic version of health reform. Statistician and polling expert Nate Silver has criticized that IBD/TIPP poll for what he calls its unusual methodology and bias and for the fact that it was incomplete when published as responses were still coming in.
Health insurance is a type of insurance coverage that pays for medical and surgical expenses incurred by the insured. Health insurance can reimburse the insured for expenses incurred from illness or injury, or pay the care provider directly. It is often included in employer benefit packages as a means of enticing quality employees. The cost of health insurance premiums is deductible to the payer, and the benefits received are tax-free.
Insurance plans with higher out-of-pocket costs generally have smaller monthly premiums than plans with low deductibles. When shopping for plans, individuals must weigh the benefits of lower monthly costs against the potential risk of large out-of-pocket expenses in the case of a major illness or accident. Health insurance has many cousins, such as disability insurance, critical (catastrophic) illness insurance, and long-term care (LTC) insurance.
However, with the Patient Protection and Affordable Care Act, effective since 2014, federal laws have created some uniformity in partnership with the existing state-based system. Insurers are prohibited from discriminating against or charging higher rates for individuals based on pre-existing medical conditions and must offer a standard set of coverage.
Broader levels of health insurance coverage generally have higher premium costs. In many cases, the insured party is responsible for paying his/her healthcare provider an up-front, tax deductible amount called co-pay. Health insurance companies then may compensate healthcare providers directly or reimburse the policy holder based on the remaining portion of an itemized bill.
Private insurers offer a variety of supplemental coverages in both the group and individual markets. These are not designed to provide the primary source of medical or disability protection for an individual, but can assist with unexpected expenses and provide additional peace of mind for insureds. Supplemental coverages include Medicare supplement insurance, hospital indemnity insurance, dental insurance, vision insurance, accidental death and dismemberment insurance and specified disease insurance.
Historically, health insurance has been regulated by the states, consistent with the McCarran-Ferguson Act. Details for what health insurance could be sold were up to the states, with a variety of laws and regulations. Model acts and regulations promulgated by the National Association of Insurance Commissioners (NAIC) provide some degree of uniformity state to state. These models do not have the force of law and have no effect unless they are adopted by a state. They are, however, used as guides by most states, and some states adopt them with little or no change.
High-quality health care affects health and wellness. A health insurance policy is a contract between an insurance company and a policy holder intended to safeguard against high and unexpected health care costs. Although policy-holders pay a monthly premium, co-payments, co-insurance, and deductibles, it is expected that the total is far less than that required if paid fully out-of-pocket.
Carrin, Guy; James, Chris (January 2005). "Social health insurance: Key factors affecting the transition towards universal coverage" (PDF). International Social Security Review. 58 (1): 45–64. doi:10.1111/j.1468-246x.2005.00209.x. Retrieved 10 March 2013. Initially the health insurance law of 1883 covered blue-collar workers in selected industries, craftspeople and other selected professionals.6 It is estimated that this law brought health insurance coverage up from 5 to 10 per cent of the total population.
The employer typically makes a substantial contribution towards the cost of coverage. Typically, employers pay about 85% of the insurance premium for their employees, and about 75% of the premium for their employees' dependents. The employee pays the remaining fraction of the premium, usually with pre-tax/tax-exempt earnings. These percentages have been stable since 1999. Health benefits provided by employers are also tax-favored: Employee contributions can be made on a pre-tax basis if the employer offers the benefits through a section 125 cafeteria plan.
Provider networks can be used to reduce costs by negotiating favorable fees from providers, selecting cost effective providers, and creating financial incentives for providers to practice more efficiently. A survey issued in 2009 by America's Health Insurance Plans found that patients going to out-of-network providers are sometimes charged extremely high fees.
Today, this system is more or less intact. All citizens and legal foreign residents of France are covered by one of these mandatory programs, which continue to be funded by worker participation. However, since 1945, a number of major changes have been introduced. Firstly, the different health care funds (there are five: General, Independent, Agricultural, Student, Public Servants) now all reimburse at the same rate. Secondly, since 2000, the government now provides health care to those who are not covered by a mandatory regime (those who have never worked and who are not students, meaning the very rich or the very poor). This regime, unlike the worker-financed ones, is financed via general taxation and reimburses at a higher rate than the profession-based system for those who cannot afford to make up the difference. Finally, to counter the rise in health care costs, the government has installed two plans, (in 2004 and 2006), which require insured people to declare a referring doctor in order to be fully reimbursed for specialist visits, and which installed a mandatory co-pay of €1 for a doctor visit, €0.50 for each box of medicine prescribed, and a fee of €16–18 per day for hospital stays and for expensive procedures.
Form 1095-C is a tax form under the Affordable Care Act ("ACA") which contains information about your health care insurance coverage. Form 1095-C is distributed to all full-time employees working an average of 30 hours or more per week, for all or part of the calendar year. For information about Form 1095-B, please contact your health care provider directly.
The 1960 Kerr-Mills Act provided matching funds to states assisting patients with their medical bills. In the early 1960s, Congress rejected a plan to subsidize private coverage for people with Social Security as unworkable, and an amendment to the Social Security Act creating a publicly run alternative was proposed. Finally, President Lyndon B. Johnson signed the Medicare and Medicaid programs into law in 1965, creating publicly run insurance for the elderly and the poor. Medicare was later expanded to cover people with disabilities, end-stage renal disease, and ALS. | <urn:uuid:5eec4d02-1aad-489b-9784-f819d5c6611c> | {
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"Becker's" References in the ICD-10-CM Index to Diseases and Injuries
- cardiomyopathy - I42.8 Other cardiomyopathies
- dystrophy - G71.01 Duchenne or Becker muscular dystrophy
- pigmented hairy nevus - D22.5 Melanocytic nevi of trunk
Applicable Clinical Terms Definitions
Cardiomyopathies: A group of diseases in which the dominant feature is the involvement of the CARDIAC MUSCLE itself. Cardiomyopathies are classified according to their predominant pathophysiological features (DILATED CARDIOMYOPATHY; HYPERTROPHIC CARDIOMYOPATHY; RESTRICTIVE CARDIOMYOPATHY) or their etiological/pathological factors (CARDIOMYOPATHY, ALCOHOLIC; ENDOCARDIAL FIBROELASTOSIS).
Disease: A definite pathologic process with a characteristic set of signs and symptoms. It may affect the whole body or any of its parts, and its etiology, pathology, and prognosis may be known or unknown. | <urn:uuid:8c55b09e-073e-4ff5-83ed-b1993031cd2d> | {
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Section 1: Epidemiology and aetiology
Eating disorders are a group of mental illnesses characterised by severe disturbances in eating habits and distress, and excessive preoccupation about weight and shape. They include anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) and atypical variants.
Eating disorders can occur at any weight. Obesity is not classified as an eating disorder, since it is defined by a weight metric rather than by thoughts and behaviours. However, obesity is a risk factor for onset of eating disorders because it is associated with high levels of body image dissatisfaction and dieting behaviour, and can also be a marker of disordered eating, in particular binge eating.
Eating disorders have the highest mortality rates among psychiatric disorders and are increasingly recognised as an important cause of morbidity and mortality in young individuals. Due to the nature of these illnesses and their impact on both psychological and physical well-being, treatment and recovery is often a long and complex process requiring a robust multidisciplinary team approach.
A report commissioned by the charity Beat in 2015 found that more than 725,000 people in the UK are affected by an eating disorder with an upward trend in prevalence over time (approximately 7% each year). The increase was largely accounted for by increases in atypical presentations, and presentations in boys and men.
The onset of AN is typically around 15-24 years of age with the highest incidence occurring in adolescent girls between 15-19 years (2 per 1000). BN has a slightly later peak of incidence, and BED even later - often into adult maturity. Eating disorders affect women approximately 7-10 times more than men, although this ratio is changing.
Causation is bio-psychosocial and multifactorial, involving the following:
- Genetic factors: first-degree female relatives and monozygotic twin offspring of patients with eating disorders have higher rates of AN and BN. A child is 10 times more likely to suffer from an eating disorder if they have a family history of eating disorders and bulimia is 4 times more likely to occur in relatives of patients suffering with the condition.
- Neurobiological factors: characteristic neuropsychological profiles have been found in adults with restrictive AN on recovery. Body and brain changes at puberty are thought to play a part.
- Social factors: eating disorders are associated with perfectionism, and are therefore found in high achieving individuals, although in most studies IQ is not significantly above average. Certain professions, such as ballet dancers and gymnasts, have a higher incidence of eating disorders. The influence of the media and in particular the rise of social media, along with the increasing popularity of what is termed `clean eating' and diets excluding entire food groups may also contribute towards the recent rise in eating disorders.
- Individual factors: childhood temperament and personality traits, such as perfectionism, rigidity, drive for thinness and obsessive-compulsive traits, may be predisposing factors. Puberty and significant life events (school changes, bereavement, or trauma) may further increase the risk and act as a trigger for the onset of illness. High personal expectations, low self-esteem and early traumatic experiences are risk factors.
- Family factors: studies suggest that non-shared factors (patient specific) are more important than shared (within the family) in terms of risk. Family factors and relationship dynamics within the home may be more important in maintaining eating disorders than in their causation.
The ICD-10 and DSM-5 are the mostly widely used classification systems used to diagnose eating disorders.
Anorexia nervosa is characterised by intentional weight loss, low body weight (less than 15% of that expected or BMI <17.5), body image distortion, excessive weight or shape concerns, avoidance of fattening foods and other behaviours contributing to weight loss and endocrine disturbances (possible sexual dysfunction, amenorrhoea, poor growth, and delay or arrest of pubertal changes).
Bulimia nervosa is characterised by recurrent episodes of binge eating (uncontrolled consumption of large amounts of food in a short space of time) followed by compensatory behaviours (fasting, self-induced vomiting, excessive exercise, or laxative/diuretic abuse) occurring at least once a week for 3 months, and an undue influence of body weight and shape in self-evaluation.
The remaining eating disorders differ depending on the classification system used. They include binge eating disorder (recurrent binge episodes without associated compensatory behaviours) and atypical variants (typically one defining feature is absent, or the frequency of behaviours is below the diagnostic threshold). All feeding and eating disorders included in the ICD-10 and DSM-5 are listed in table 1 (below).
|Box 1: Eating disorders according to the main classification systems|
|ICD-10* Eating disorders||DSM-5 Feeding and eating disorders|
|F50.0 Anorexia nervosa||307.1 Anorexia nervosa|
|F50.1 Atypical anorexia nervosa||307.51 Bulimia nervosa|
|F50.2 Bulimia nervosa||307.51 Binge eating disorder|
|F50.3 Atypical bulimia nervosa||307.59 Avoidant/restrictive food intake disorder (ARFID)|
|F50.4 Overeating associated with other psychological disturbances||307.53 Rumination disorder|
|F50.5 Vomiting associated with other psychological disturbances||307.52 Pica|
|F50.8 Other eating disorders||307.59 Other specified feeding or eating disorder|
|F50.9 Eating disorder, unspecified||307.50 Unspecified feeding or eating disorder|
* Note: In ICD 10 feeding disorders appear in a separate section of disorders first diagnosed in childhood and early infancy. DSM 5 has removed the diagnosis ‘feeding disorder’, which is now subsumed within ARFID. ICD 11 is likely to follow a similar model.
Section 2: Making the diagnosis
Patients with eating disorders are often taken to see their family GP or another healthcare professional by concerned relatives/friends, sometimes against their will and when the illness has already become established.
If the sufferer themselves is the one seeking help, it may be covert - in other words they may seek help for other symptoms due to shame or fear of stigma. It is therefore vital to identify signs early and to undertake steps towards treatment with the help of a experienced GP, practice nurse, dietitian and counsellor.
Once an eating disorder is suspected, referral to secondary care for specialist advice and management is recommended in most cases, with a view to transfer back to the primary care once stable or in remission. Occasionally, treatment may be delivered in a primary care setting, under the overall supervision of a specialist community eating disorders team. The urgency of the referral will depend on an initial risk assessment.
The pathway for referral to treatment for a young person (<18 years="" with="" an="" eating="" disorder="" within="" england="" is="" now="" subject="" to="" a="" href="http://www.england.nhs.uk/wp-content/uploads/2015/07/cyp-eating-disorders-access-waiting-time-standard-comm-guid.pdf" target="_blank" data-mce-href="http://www.england.nhs.uk/wp-content/uploads/2015/07/cyp-eating-disorders-access-waiting-time-standard-comm-guid.pdf">access and waiting times standards, with the aim that all patients receive an empirically-supported treatment within four weeks from the point of identification, or sooner if urgent. Treatment is delivered in the context of specialist community eating disorders services for young people (CYP-EDS).
The guidance includes the requirement of GPs to contact the CYP-EDS via telephone or electronically following discussion with the child or young person and their parents or carers, as soon as an eating disorder is first identified.
In a minority of cases, where the child or young person is extremely physically compromised or where there is very high psychiatric risk (for example, suicidality), the GP should arrange immediate paediatric and/or psychiatric care to manage risk via local protocols and should inform the CYP-EDS accordingly. These standards are good practice for care across the age range, although as yet these are not mandated for adult care.
When making a diagnosis and assessing risk to establish the urgency of referral, it is important to consider the following:
- A detailed history of eating difficulties and weight/shape concerns, taking into account parent/carer concerns as well as those of the young person
- Methods used by the patient to control weight such as dietary restriction, laxative abuse, self-induced vomiting, excessive exercise, inappropriate use of diuretics and so on
- Presence of any subjective/objective binge episodes
- Current weight expressed as BMI (kg/m2) adjusted for age and gender by plotting on a BMI centile chart or calculating %BMI/median BMI for age and gender. BMI <15 or="" 9th="" centile="" 85="" median="" bmi="" a="" history="" of="" very="" rapid="" weight="" loss="">1 kg/ week) suggest further physical examination is needed to establish the degree of medical compromise (see box 2)
- Presence of other comorbid psychiatric illnesses (depression and anxiety disorders are common)
- Mental state examination
- Menstrual history
- General medical history
- Medication history
- Family history including any history of eating difficulties within the family
Behavioural indicators of an eating disorder include avoidance or reluctance to seek professional help, seeking help for physical symptoms, resisting weighing and examination, covering the body, being secretive or evasive when symptoms are being explored, increased energy (and in some cases agitation), and appearing angry or distressed when asked about eating problems.
Clinicians should be aware of physical features, such as emaciation, dry skin, hair changes, amenorrhoea, constipation, delayed gastric emptying, syncope, myopathy, enamel erosion (from repeated vomiting), callused knuckles (from scraping against incisors when inducing vomiting) and swollen salivary glands.
The patient's beliefs and fears are best elicited through a face to face assessment, although disordered behaviours may be better reported by family members. The SCOFF questionnaire, although only validated in adults, can provide a framework for screening. The SCOFF questions are:
- Do you make yourself Sick because you feel uncomfortably full?
- Do you worry that you have lost Control over how much you eat?
- Have you recently lost more than One stone (14 lb) in a 3-month period?
- Do you believe yourself to be Fat when others say you are too thin?
- Would you say that Food dominates your life?
The ICD-10 and DSM-5 criteria can be used to help establish a diagnosis. The Eating Disorders Examination Interview or Questionnaire (EDE/EDE-Q) has been validated for use in children (>8 years) and adults, and is often used by specialist eating disorder teams for diagnosis and research purposes. It also provides a useful springboard to explore eating disorder psychopathology in detail with patients during the initial assessment process.
|Box 2: Examination and investigations|
The common differential diagnoses can either be physical or psychiatric in origin. A good psychiatric history, physical examination and investigation screen are essential in making the correct diagnosis. However, the relatively common occurrence of eating disorders (affecting up to 13% of adolescents) should be borne in mind when considering alternative diagnoses.
- Chronic wasting diseases: malignancy, peptic ulcer disease, coeliac disease, inflammatory bowel disease, chronic infection.
- Endocrine disorders: Addison's disease, hyperthyroidism, anterior pituitary insufficiency, diabetes mellitus.
- Mood disorders - depression
- Anxiety disorders - obsessive compulsive disorder, generalised anxiety disorder
- Autistic spectrum disorder
- Pervasive refusal syndrome, an oppositional defiant disorder
Other causes of amenorrhoea:
- Pregnancy, primary ovarian failure, prolactinoma, polycystic ovary syndrome, uterine problems and other hypothalamic causes.
Section 3: Managing the condition
Once an eating disorder is identified, the findings of examination and risk assessment should be fed back to the parents and young person together with information about eating disorders or direction to relevant resources, together with actions agreed regarding onward referral.
The needs of the patient should be the primary basis for decisions on referral. Referrals should be accompanied by a full referral letter explaining why a particular route has been chosen. The letter should include current weight and height as well as other information relevant to assessing risk such as physical observations and the results of any medical investigations including recent blood test results. Include any previous measures of weight or height, for a sense of how severe and long standing the problem is.
Risk assessment will guide how urgently and where treatment should take place, and should be communicated to the patient and carer(s) in a clear and non-judgemental manner. For young people, the risk assessment framework in the Junior MARSIPAN guidelines are useful in making referrals, determining the level of urgency for intervention and informing future management.
The most severe cases should be directed straight to emergency care. The MARSIPAN checklist aims to identify those at risk of refeeding complications and can be applied across the age range.
Refeeding syndrome is rare, and occurs when patients who have undergone a period of insufficient nutrition rapidly increase their dietary intake over a short period of time.This can occur in hospital where acutely unwell patients with eating disorders are admitted to be fed, or in the community where patients may binge following a period of fasting/severe dietary restriction. It is most often observed in patients with rapid weight loss and very low BMI, who have eaten little or nothing in the past week or have abnormal biochemical parameters.
Patients and parents should be advised not to increase dietary intake rapidly without advice and close monitoring from an experienced clinical team. Although dieticians/clinicians vary in what is an acceptable starting energy requirement for an individual and how quickly this should be increased, it is agreed that if the risk of refeeding syndrome is high, regular monitoring of physical observations (BP, pulse, presence of oedema) and electrolytes (calcium, phosphate and magnesium) during the initial phase is essential. It is important for clinicians to note that insufficient nutrition (underfeeding) is more likely to cause complications than overfeeding.
If the risk of refeeding is deemed to be high enough to require daily blood tests, the patient should be referred for paediatric or medical admission.
Until they are seen in the specialist clinic, the patient should be seen at least weekly for weight monitoring, blood tests and ECG. Where there is a continued role for GPs in monitoring physical health, regular communication is good practice.
Patients who express or display risk of harm to themselves should be referred to the local child and adolescent or adult eating disorders team. Comorbid mental health problems, such as depression, may resolve with improved nutrition and should be treated as part of a comprehensive eating disorders treatment plan.
In recent years there has been a move away from inpatient psychiatric care for all but the most severe cases, meaning higher-risk patients are being managed by specialist teams in the community. Effective involvement of families, particularly in children, has proved important in improving outcomes and limiting the burden of these disorders.
Eating disorders can be complicated and it can be difficult to predict the outcome. A significant proportion of patients have residual symptoms and relapses throughout their lifetime. The average time to recovery is around five years, depending on age of onset and other prognostic factors.
The medical and psychological consequences of eating disorders may persist throughout life in the patients who remain chronically ill.
Research to date suggests that adolescents have a better prognosis than the adult population, showing long term recovery rates of 70%, compared to 50% in adults. The reason for the better prognosis in adolescents is unknown; it may be due to the support provided by families for the young patient, which may be lacking in adults, or perhaps as a result of the developmental plasticity of adolescence.
With specific regard to anorexia, studies have shown that less than half of patients recover fully, a third improve, and approximately a fifth will remain chronically unwell or deteriorate.
The standardised mortality rate is 5.86 for anorexia nervosa and approximately 2 for bulimia and atypical eating disorders.The mortality from anorexia nervosa is estimated to increase by 5% every decade a patient remains ill.
The mortality of atypical eating disorders is also high, because comorbidity is higher in this group.
Almost 50% of deaths occurring in eating disorders are due to medical complications of the illness. Of these, cardiac complications are the most common followed by other physiological and biochemical disturbances such as electrolyte abnormalities, or refeeding syndrome. The remainder of deaths have been registered as being due to suicide (25%) and the remaining from unknown causes (25%).
Section 5: Case study
K, a 14-year-old girl with a six-month history of weight loss, was brought to the GP by her mother.
On presentation she appeared cachexic, weak and pale. On examination, her weight was 40kg and her height was 160cm. From her previous records (six months before) she weighed 53kg.
Her mother brought her to see the doctor because she was losing weight and becoming isolated and withdrawn. K was angry about this because she did not feel that anything was wrong with her.
She told the GP that she was in good health until six months ago. Following a move with her family to a different city, she voluntarily restricted her intake and began a regular strenuous exercise programme.
Her mother was concerned because she was no longer eating breakfast and only eating a small salad and a cup of tea for dinner. Her mother recalled herself having some eating problems when she was young. K's mother informed the GP that K had missed her menstrual periods for three months.
Her mother was also concerned about fights around meal times. As K lost increasing amounts of weight, her appetite diminished and she found it easier to diet. She refused to discuss her eating patterns with her GP.
In view of K's rapid decline in weight, her GP examined her physically and ordered blood investigations and an ECG. The examination findings were discussed with K and her mother and the rationale for the investigations explained.
K seemed neither surprised nor concerned when she was told that she had lost more than 25% of her body weight. She was referred to the eating disorders team for management.
Her GP arranged a follow-up appointment for two weeks' time, and gave K's mother advice on when to seek urgent medical assessment.
Section 6: Evidence base
There are a limited number of clinical trials showing evidence of superiority of one treatment over another.
In general, a family-based approach is taken for new onset, young patients, whereas for adults an individual psychological intervention is the usual first step.
- A randomised controlled multicentre trial of treatments for adolescent anorexia nervosa including assessment of cost-effectiveness and patient acceptability - the TOuCAN trial. Health Technol Assess 2010; 14(15): 1-98.
Analysis demonstrated no difference in effectiveness for inpatient compared with outpatient treatment, or specialist over generalist treatment, but specialist treatment had advantages increasing over time and was most cost effective.
Outcome from inpatient treatment was poor for those patients who were referred due to failed outpatient treatment.
- Stepped care and cognitive-behavioural therapy for bulimia nervosa: randomised trial. Br J Psychiatry 2011; 198: 391-7.
This study compared the best available treatment for bulimia nervosa, CBT augmented by fluoxetine if indicated, with a stepped-care treatment approach in order to enhance treatment effectiveness.
Therapist-assisted self-help was an effective first-level treatment in the stepped-care sequence, and the full sequence was more effective than CBT at one year, suggesting that treatment of the disorder is enhanced with a more individualised approach.
- NICE. Eating disorders: recognition and treatment. NG69. May 2017
- MARSIPAN: Management of Really Sick Patients with Anorexia Nervosa (CR162), Royal College of Psychiatrists, London.
- Junior MARSIPAN: Management of Really Sick Patients under the age of 18 with Anorexia Nervosa (CR168). Royal College of Psychiatrists, London. (January 2012)
- MARSIPAN Checklist: for use with all ages
- Fairburn C, Harrison PJ, Brownell K. Eating disorders. Lancet 2003; 361: 407-16.
- Treasure J, Claudino AM, Zucker N. Eating disorders. Lancet 2010; 375: 583-93.
Beating Eating Disorders.
Academy for Eating Disorders.
Royal College of Psychiatrists Faculty of Eating Disorders
- Dr Dasha Nicholls is consultant child and adolescent psychiatrist, Great Ormond Street Hospital, London; and chair, Eating Disorders Faculty, Royal College of Psychiatrists
- Dr Farhana Ahmed is specialist registrar in child and adolescent psychiatry, Great Ormond Street Hospital, London
This is an updated version of an article that was first published in January 2012.
- Klump KL, Bulik CM, Kaye WH et al. Academy for eating disorders position paper: eating disorders are serious mental illnesses Int J Eat Disord 2009; 42(2): 97-103.
- Arcelus J, Mitchell AJ, Wales J et al. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry 2011; 68(7): 724-31.
- American Psychiatric Association. (fourth ed). Washington, DC, American Psychiatric Association, 2000.
- Fairburn C, Harrison PJ, Brownell K. Eating Disorders. Lancet 2003, 361: 407-16.
- Nicholls DE, Lynn R, Viner RM. Childhood eating disorders: British national surveillance study. Br J Psychiatry 2011; 198: 295-301.
- Machado PP, Machado BC, Goncalves S et al. The prevalence of eating disorders not otherwise specified. Int J Eat Disord 2007; 40(3): 212-17.
- Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders BMJ 1999; 319(7223): 1467-8.
- Strober M, Freeman R, Morrell W et al. The long-term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse, and outcome predictors over 10-15 years in a prospective study. Int J Eat Disord 1997; 22(4): 339-60.
- Steinhausen HC. The outcome of anorexia nervosa in the 20th century. Am J Psychiatry 2002; 159(8): 1284-93.
- Gowers SG, Clark AF, Roberts C et al. A randomised controlled multicentre trial of treatments for adolescent anorexia nervosa including assessment of cost-effectiveness and patient acceptability - the TOuCAN trial. Health Technol Assess 2010; 14(15): 1-98.
- Mitchell JE, Agras S, Crow S et al.Stepped care and cognitive-behavioural therapy for bulimia nervosa: randomised trial. Br J Psychiatry 2011; 198(5): 391-7.
- The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Description and Diagnostic Guidelines, 1992. World Health Organisation, Geneva
- The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,2013. American Psychiatric Association
|Suggested further CPD activity|
These further action points may allow you to earn more credits. | <urn:uuid:32227e0b-3052-4827-b86c-59f2907d9788> | {
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Here are some interesting facts about ICD-10 that may not be commonly known.
International Classification of Diseases (ICD) was created by the World Health Organization (WHO), which has served the healthcare community for over a century. While most industrialized countries moved to the ICD’s “tenth revision” – ICD-10 – 30 years ago (1983), the United States only transitioned in October 2015.
There are differences, however, between what WHO publishes and what the US actually utilizes.
WHO’s ICD-10 classification system is for diagnosis codes only, and does not contain any procedural codes.
ICD-10-CM (Clinical Modification) is a US clinical modification of WHO’s ICD-10, developed to support US health information needs. ICD-10-CM is designed for classifying and reporting diseases in all US healthcare settings. WHO gave the US permission for these modifications. I have not been able to find out why these modifications were made or what specifically was modified, but the technology systems of US healthcare organizations that operate internationally – either now or in the future – will need to accommodate for both the US ICD-10-CM codes and the WHO’s standard ICD-10 codes.
ICD-10-PCS (Procedure Classification System) was developed by the Centers for Medicare & Medicaid Services (CMS) and is not based on WHO’s coding system. ICD-10-PCS replaced the ICD-9-PCS and are only required for facilities reporting procedures on hospital inpatient services.
When speaking of these new classifications in the US, the term “ICD-10” is often used for both code sets (ICD-10-CM and ICD-10-PCS), but it is important to understand that they serve very different purposes.
…On the forefront, WHO has already released a BETA version of ICD-11. | <urn:uuid:5e6355d7-6df4-4796-b2bb-7dd5c3b151e0> | {
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Before moving to Diabetes ICD 10, Diabetes Mellitus ICD 10, Diabetes Insipidus ICD 10 and coding guidelines with examples, first let us learn the definition of those terms for better understanding.
Diabetes is one of the most prevalent chronic conditions affecting around 463 million people across the world. This makes it one of the most frequently coded diagnosis. The two categories of Diabetes are Diabetes mellitus and Diabetes insipidus.
Diabetes mellitus arises due to the body’s inability to produce enough insulin to regulate the blood glucose or the inability to effectively use the produced insulin.
Diabetes mellitus can be categorized into
- Type 1 and
- Type 2
Type 1 Diabetes mellitus is also known as Juvenile Diabetes or Insulin dependent Diabetes (IDDM). It is called “Juvenile” as this form of Diabetes appears before 18 years of age. IDDM is an autoimmune disease caused because of selective destruction of the insulin producing Beta cells of the pancreas which leads to little or no production of insulin.
Type 2 Diabetes mellitus is an adult-onset Diabetes also known as non-Insulin dependent Diabetes mellitus (NIDDM). This is the most common type of Diabetes mellitus seen in the elderly population caused due to inadequate insulin production by the pancreas or due to the inability of the body to use the insulin effectively.
The classic symptoms of Diabetes mellitus are feeling excessively thirsty and hungry, frequent urination, unintentional weight loss and fatigue, blurred vision, irritability.
Diabetes Mellitus ICD 10:
The Diabetes ICD 10 Codes are found in Chapter 4, Endocrine, Nutritional and Metabolic diseases. Diabetes mellitus ICD 10 Codes may be single or combination codes which includes the following-
- The type of Diabetes mellitus represented by the category (secondary diabetes, drug induced, type 1 or type 2)
- The affected body system
- The complications
The diabetic condition needs to be completely coded using as many codes as required to describe all the associated complications.
Diabetes ICD 10 Coding Guidelines (Source- ICD-10-CM Official Guidelines for Coding and Reporting FY 2021)
Diabetes mellitus ICD 10 Codes:
Complications of Diabetes mellitus ICD 10 codes:
Chronic diabetes mellitus leads to many complications like ketoacidosis, chronic kidney disease, peripheral neuropathies, diabetic retinopathy, diabetic cataract and other skin complications. These must be accurately coded choosing the appropriate category, complication code and additional codes from other chapters, specifying the complication. The default category for unspecified Diabetes mellitus is Type 2.
Diabetes Insipidus ICD 10 code – E23.2
Diabetes insipidus is a rare disorder of fluid metabolism in the body characterized by intense thirst and heavy urination. Deficiency of the hormone ADH produced by the hypothalamus and stored in the posterior pituitary causes this condition.
Polydipsia, polyuria, colorless urine, nocturia, bed wetting, constipation, dry skin and weak muscles are the symptoms of Diabetes insipidus.
Diabetes ICD 10 Coding examples
|Diabetes ICD 10 Example 1
A 70-year-old Type 1 Diabetic male patient visits the clinic with left foot ulcer. What will be the appropriate ICD-10-CM diagnosis codes?
Ans: E10.621, L97.529
|Diabetes ICD 10 Example 2
A 45-year-old female patient, Annie comes to visit her physician with drug induced diabetes mellitus with severe proliferative diabetic retinopathy with macular edema of the right eye. Assign the appropriate ICD-10-CM diagnosis code for her condition.
|Diabetes Mellitus ICD 10 Example 3
Peter, a 55-year-old male patient who is a chronic diabetic comes to the clinic with diabetic peripheral angiopathy with gangrene and diabetic retinopathy without macular edema. He is on insulin and oral hypoglycemic. Code the scenario with appropriate ICD-10-CM diagnosis codes.
Ans: E11.319, E11.52, Z79.4 (Unspecified Diabetes mellitus is coded as type 2)
|Diabetes Mellitus ICD 10 Example 4
A 70-year-old female patient with a long history of type 2 diabetes mellitus was admitted with hyperosmolar coma with blood sugars out of control. The insulin regimen was modified, and the patient was monitored carefully throughout her stay. She also had a diagnosis of diabetic chronic kidney disease with stage 4 chronic kidney failure and is on dialysis. The patient was discharged on a modified insulin regimen with an instruction to follow up till her diabetes stabilizes. Assign the appropriate ICD 10-CM codes for the scenario.
Ans: E11.01, E11.22, N18.4, Z79.4, Z99.2
|Diabetes Mellitus ICD 10 Example 5
Martha, a 65-year-old female patient who was diagnosed with diabetes mellitus secondary to pancreatitis comes in with nephropathy which is a complication of her secondary diabetes. She is on oral antidiabetic drug. Code the scenario with the appropriate ICD-10-CM diagnosis codes.
Ans: K85.90, E08.21
|Diabetes Insipidus ICD 10 Example 6
A 45-year-old male patient comes to the clinic with symptoms of nocturia, excessive thirst, uncontrolled hunger and fatigue. His blood test and urine analysis revealed that he has Diabetes insipidus. Assign the appropriate ICD-10-CM codes for his condition. | <urn:uuid:efebdb59-fb5e-4248-b56b-892f1ab653ca> | {
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|Total Games||49 (28 present)|
|← (none)||(none) →|
The Acorn Archimedes was Acorn Computers' first general-purpose home computer based on their own 32-bit ARM architecture RISC CPU. The name is also commonly used to describe computers which were based on the same architecture, even where Acorn did not include 'Archimedes' in the official name.
Description and History
The first models were released in June 1987, as the 300 and 400 series. The 400 series included 4 expansion slots (although a 2 slot backplane could be added to the 300 series as an official upgrade, and third parties produced their own 4 slot backplanes) and an ST506 controller for an internal hard drive. Both models included the Arthur OS (later called RISC OS), BBC BASIC and an emulator for Acorn's earlier BBC Micro, and were mounted in two-part cases with a small central unit, monitor on top, and a separate keyboard and three-button mouse. All models featured on-board 8 channel stereo sound and were capable of displaying 256 colours on screen.
Four models were initially released with different amounts of memory, the A305, A310, A410 and A440. The 300 and 400 were followed by a number of machines with minor changes and upgrades:
A3000 and A5000
Work began on a successor to the Arthur operating system, initially named Arthur 2, but with the release of the Hollywood movie of the same name it was renamed to RISC OS 2. A number of new machines were introduced along with it, and in May 1989 the 300 series was phased out in favour of the new Acorn A3000 (the 400 series was kept in production). The earlier models could be upgraded to RISC OS 2 by replacing the ROM chips containing the operating system.
The A3000 used an 8 MHz ARM2 and was supplied with 1 MB of RAM. Unlike the previous models, the A3000 came in a single-part case similar to the Amiga 500 and Atari ST computers, with the keyboard integrated in the base unit. This kind of housing consumes a lot of desktop space, a problem that Acorn tried to overcome by offering a monitor stand that attached to the base unit. The new model only sported a single expansion slot, which was physically different from that of the earlier models, although electrically similar.
In 1991, the A5000 was launched. It featured the new 25 MHz ARM3 processor, 2 or 4 MB of RAM, either a 40 MB or an 80 MB hard drive and a more conventional two-part case. Its enhanced video capabilities allowed the A5000 to comfortably display VGA resolutions of up to 800×600 pixels. It was the first Archimedes to feature a High Density capable floppy disc drive as standard. This supported various formats including MS-DOS and Atari discs. A later version of the A5000 featured a 33 MHz ARM3, 4 or 8 MB of RAM, an 80 or 120 MB hard drive and a revised OS (RISC OS 3.10).
The A5000 ran the new 3.0 version of RISC OS 3.0. As previously, earlier machines were capable of being upgraded to the new RISC OS 3, though some needed help, as well as the ARM3 CPU. Earlier models could also benefit from the video performance of the A5000 via a third party upgrade.
New range and a laptop
In 1992, a new range was produced, using the ARM250 microprocessor, an ARM2 processor with integrated memory and video controllers, performing better thanks to an increase in clock frequency, and running RISC OS 3.10. The A30x0 series had a one-piece design, similar to the A3000 but far smaller, while the A4000 looked like a slightly slimmer A5000. The A3010 model was intended to be a home computing machine, featuring a TV modulator and joystick ports, while the A3020 targeted the home office and educational markets, featuring a built-in 2.5" hard drive and a dedicated network interface socket . Technically, the A4000 was almost identical to the A3020, only differing in hard disk size (3.5" in the A4000), though it sported a different appearance. All three ARM250-based machines could be upgraded to 4MB with plug-in chips (though the A3010 was designed for 2MB, third party upgrades overcame this) and one "mini-podule" slot as used for internal expansion in the A3000.
Also in 1992, Acorn introduced a laptop computer called A4 that featured an ARM3 processor like the A5000, even though it had a slightly lower clock speed, and a LCD screen capable of displaying a maximum resolution of 640 × 480 pixels in 15 levels of grey. However, it did feature a monitor port which offered the same display capabilities as an A5000. A notable omission from the machine was a built-in pointing device, requiring users to navigate with the cursor keys or attach a conventional Acorn three-button mouse.
The A7000, despite its name being reminiscent of the Archimedes naming conventions, was actually more similar to the Risc PC — the line of RISC OS computers that succeeded the Archimedes in 1994. It lacked, however, the DEBI expansion slots and multi-slice case that characterized the RiscPC (though by removing the CDROM, a backplane with one slot could be fitted).
List of models
|Model||Memory (RAM)||Hard disk space||Launch date||UK retail price at launch||Notes|
|BBC Archimedes 305||512 KB (512 KB)||N/A||July 1987||£899||N/A|
|BBC Archimedes 310||1 MB (1 MB)||N/A||July 1987||£999||N/A|
|BBC Archimedes 310M||1 MB||N/A||July 1987||£||Includes emulation software for PC emulation|
|Acorn Archimedes 410||1 MB||N/A||July 1987||£1299||Appears only in marketing literature; may never have been produced|
|Acorn Archimedes 440||4 MB||20 MB||July 1987||£1499||N/A|
|BBC A3000||1 MB||N/A||May 1989||£799||This model was the last ever BBC Microcomputer|
|Acorn Archimedes 410/1||1 MB||N/A (ST506 interface on motherboard)||June 1989||£999||Improved MEMC1A memory controller over previous 410 model|
|Acorn Archimedes 420/1||2 MB||20 MB ST506||June 1989||£1099||N/A|
|Acorn Archimedes 440/1||4 MB||40 MB ST506||June 1989||£1299||Improved MEMC1A memory controller over previous 440 model|
|Acorn R140||4 MB||47 MB ST506||June 1989||£3,500||RISC iX workstation|
|Acorn Archimedes 540/1||4 MB||100 MB SCSI||June 1990||£||ARM3 processor|
|Acorn R225||4 MB||N/A||July 1990||£||ARM3 processor, RISC iX network workstation|
|Acorn R260||8 MB||100 MB SCSI||July 1990||£||ARM3 processor, RISC iX workstation|
|Acorn A5000||1 MB or 4 MB||0 MB to 160 MB IDE||September 1991||£999 or £1499||ARM3 processor, launched with various sub-models|
|Acorn A4||2 MB or 4 MB||0 MB or 60 MB IDE (2.5")||June 1992||£1399 or £1699||Notebook model with ARM3 processor clocked at 24MHz (1 MHz slower than usual), 640x480 greyscale LCD screen|
|Acorn A3010||1 MB||N/A||September 1992||£499||ARM250 processor|
|Acorn A3020||2 MB||0 MB - 80 MB IDE (2.5")||September 1992||£799||ARM250 processor|
|Acorn A4000||2 MB||0 MB - 210 MB IDE||September 1992||£999||ARM250 processor|
Also produced, but never sold commercially were:
- A500 - 4 RAM, ST506 interface, Archimedes development machine
- A680 and M4 - 8 MB RAM, SCSI on motherboard, RISC iX development machines
Significance and impact
The Archimedes was one of the most powerful home computers available during the late 1980s and early 1990s; its main CPU was faster than the 68000 microprocessors found in the more popular Atari ST and Commodore Amiga machines. An 8 MHz 68000 had an average performance of roughly 1 MIPS. The 8MHz ARM2 yields 4.5-4.8 MIPS in repeatable benchmark tests
The Archimedes won significant market share in the education markets of the UK, Ireland and Australia; the success of the Archimedes in British schools was due partly to its predecessor the BBC Micro and later to the Computers for Schools scheme organised by the Tesco supermarket chain in association with Acorn, and most students and pupils in these countries in the early 90s were exposed to an Archimedes or A-series computer. Despite a technical edge, the Archimedes only ever met a moderate success beyond the education sector, becoming a 'minority' platform outside of certain niche markets. These niche markets included professional work such as radio, medical and railway station management and music publishing. Another reason why schools chose the Acorn Archimedes over the Commodore Amiga and Atari ST was that students may have taken games into school from their Amiga or ST games collection and would have distracted them from their school work.
By the early 1990s, the UK educational market began to turn away from the Archimedes. Apple Macintosh computers or IBM compatible PCs eclipsed the Archimedes in their multimedia capabilities, which led to an erosion of the Archimedes market share. The Tesco Computers for Schools scheme later changed partnership from Acorn to RM plc and many other computer-related suppliers, which also led to the decrease of the Archimedes' educational market share.
Pages in category "Acorn Archimedes"
The following 28 pages are in this category, out of 28 total. | <urn:uuid:8d9cb150-aab1-4863-93c2-6ccf1002452b> | {
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"Social Relationships and Schizophrenia. Christine Barrowclough\nOn the Psychology of Psychosis. Ric(...TRUNCATED) | <urn:uuid:da78b8fa-94fb-49d1-ab9b-ac458ee1c110> | {"dataset":"HuggingFaceFW/fineweb-edu","dump":"CC-MAIN-2017-47","file_path":"s3://commoncrawl/crawl-(...TRUNCATED) |
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"SUBSTANCE-RELATED AND ADDICTIVE DISORDERS\nCarolyn A. Baird\nEXPECTED LEARNING OUTCOMES\nAfter comp(...TRUNCATED) | <urn:uuid:323bfe99-354f-4b42-a8b4-03df4552bea9> | {"dataset":"HuggingFaceFW/fineweb-edu","dump":"CC-MAIN-2020-34","file_path":"s3://commoncrawl/crawl-(...TRUNCATED) |
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