ASSESSING AND TREATING PATIENTS WITH ANXIETY DISORDERS NURS 6630
Sample Answer for ASSESSING AND TREATING PATIENTS WITH ANXIETY DISORDERS NURS 6630 Included After Question
Assessing and Treating Patients With Anxiety Disorders
Common symptoms of anxiety disorders include chest pains, shortness of breath, and other physical symptoms that may be mistaken for a heart attack or other physical ailment. These manifestations often prompt patients to seek care from their primary care providers or emergency departments. Once it is determined that there is no organic basis for these symptoms, patients are typically referred to a psychiatric mental health practitioner for anxiolytic therapy. For this Assignment, as you examine the patient case study in this week’s Learning Resources, consider how you might assess and treat patients presenting with anxiety disorders.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
To prepare for this Assignment:
- Review this week’s Learning Resources, including the Medication Resources indicated for this week.
- Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients requiring anxiolytic therapy.
The Assignment: 5 pages
Examine Case Study: A Middle-Aged Caucasian Man With Anxiety. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.
Introduction to the case (1 page)
- Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)
- Which decision did you select?
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)
- Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.
Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting
By Day 7
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Rubric
NURS_6630_Week6_Assignment_Rubric
| NURS_6630_Week6_Assignment_Rubric | ||||||
| Criteria | Ratings | Pts | ||||
| This criterion is linked to a Learning Outcome Introduction to the case (1 page)Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient. |
|
10 pts | ||||
| This criterion is linked to a Learning Outcome Decision #1 (1–2 pages)• Which decision did you select?• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome Decision #2 (1–2 pages)• Which decision did you select?• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome Decision #3 (1–2 pages)• Which decision did you select?• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome Conclusion (1 page)• Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature. |
|
15 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list. |
|
5 pts | ||||
| Total Points: 100 | ||||||
A Sample Answer For the Assignment: ASSESSING AND TREATING PATIENTS WITH ANXIETY DISORDERS NURS 6630
Title: ASSESSING AND TREATING PATIENTS WITH ANXIETY DISORDERS NURS 6630
This case study is about a 46-ar-old white male who came to the clinic as a referral by his primary care provider for what he felt as a heart attack. The patient reported symptoms that included chest tightness, shortness of breath, and feeling of impending doom. His medical history is significant for mid hypertension, overweight, and tonsillectomy. EKG results were normal. According to the patient, the shortness of breath and chest tightness are anxiety attacks. He reports occasional use of ETOH, consumes 3-4 beers per night, single, and fears losing his job. The HAM-A score is 26. The client denied any use of psychotropic medications.
A mental status examination was administered to the patient. It showed that the patient was oriented to place, time, person, and events. His speech was clear, goal-oriented, and coherent. The client reported feeling nervous, bleh mood, blunted affect, with no visual or auditory hallucinations. There were no paranoid or delusional thought processes, homicidal or suicidal ideation. The client was diagnosed with generalized anxiety disorder based on these findings. Therefore, this paper focuses on three treatment decisions that will be adopted for this patient. The factors that will affect the selected treatments will include his HAM-A score, medical history, treatment response, and substance use.
Decision 1
Selected Decision
Begin Paxil 10 mg po daily
Reason for the Selection
Paxil is a selective serotonin inhibitor that has been recommended in America for use in anxiety disorders. Paxil inhibits the reuptake of serotonin, which increases its synaptic concentration, extra-synaptic diffusion, and mood. Paxil has broad spectrum efficacy in treating anxiety disorders both in short and long-term. Its tolerance level is also high (Strawn et al., 2018). Besides improving anxiety symptoms, Paxil also enhances daily functioning and improvement in HAM-A score.
Why the other Two were not Selected
The decision to begin with Imipramine 25 mg po BID was not selected since Imipramine is considered in patients that have proven unresponsive to first-line treatments such as selective serotonin reuptake inhibitors. It also has the side effect of weight gain, which may worsen the currently overweight patient’s status. It can also cause QT prolongation and cardiac arrythmias. Buspirone 10 mg po BID was not selected since it is a second line of treatment for generalized anxiety disorder (Strawn et al., 2018).
What I was hoping to Achieve
I was hoping to achieve a reduction in the client’s symptoms of generalized anxiety disorder. I was also hoping to lower the client’s HAM-A score by at least 25% within the first four weeks. I was also hoping to improve the client’s functioning since studies have demonstrated symptom improvements with the use of Paxil (Strawn et al., 2018).
Ethical Considerations
Psychiatric mental health nurse practitioners must prioritize safety and quality in treating mental health problems. They make their decisions based on evidence-based data, patient factors, and their expertise. Evidence-based data supports Paxil use as first-line treatment in generalized anxiety disorder (Strawn et al., 2018). Therefore, by adopting Paxil, I anticipated enhanced outcomes such as safety, quality, and efficiency, hence, the influence of ethics in the treatment process.
Decision 2
Selected Decision
Increase dose to 20 mg po daily
Reason for the Selection
The initial decision to start the patient on Paxil 10 mg po daily led to moderate improvement in symptoms. The client came after four weeks reporting that he no longer has chest tightness or shortness of breath. He also reports decreased worries about work over the last 4 or 5 days and reduction in HAM-A score to 18. An effective decision would be to increase the dosage of Paxil to 20 mg po daily to improve symptoms of generalized anxiety disorder. A systematic titration of the dose is recommended until optimum symptom improvement is achieved. For example, the study by Serdarević et al., (2018) investigated the effectiveness of Paxil 20 mg dose in generalized anxiety disorder over 12-months period. The results showed statistically significant reduction in the severity of anxiety disorder among the participants. Therefore, increasing the dose to 20 mg is safe, tolerable, and efficient in improving the patient’s symptoms.
Why the other Two were not Selected
I did not select the decision to increase the dose of Paxil to 40 mg po daily because of safety concerns. A sharp quadrupling of the dosage increases the risk of the patient developing adverse effects of Paxil such as erectile dysfunction, xerostomia, and insomnia. I did not select the decision not to change the drug/dose at this time because it would not yield further improvement in symptoms (Baldwin, 2020). The required plasma concentration of Paxil has not been achieved. As a result, maintaining the current dose is not recommended.
What I was hoping to Achieve
I was hoping to further reduce symptoms of generalized anxiety disorder. I was also hoping for at least 50% reduction in HAM-A score. I also anticipated improved patient’s functioning (Strawn et al., 2018).
Ethical Considerations
The ethical principle of ensuring non-maleficence informed the decision made in this step. Psychiatric mental health nurses must ensure that the adopted treatments minimize patient harm while optimizing on its benefits. As a result, I selected the decision to titrate the dosage upwards with the aim of improving symptoms and minimizing harm (Butts & Rich, 2022). Quadrupling the dosage could have increased the risk of adverse events.
Decision 3
Selected Decision
Maintain the current dose
Reason for the Selection
The client returned to the clinic after four weeks with reports of further symptom improvement. The HAM-A score decreased to 10, translating into 61% reduction in symptoms. The assessment findings demonstrate that the treatment outcomes have been achieved. Therefore, it is appropriate to maintain the current dosage for optimum symptom management. The client has also demonstrated tolerance to the treatment (He et al., 2019). A further increase in dosage may led to the development of adverse reactions and potential poor treatment adherence by the patient.
Why the other Two were not Selected
I did not select the decision to increase the dosage to 30 mg po daily due to safety concerns. As noted above, the desired treatment outcomes have been achieved. Increasing the dosage further may lead to unwanted side and adverse effects, which will affect safety and quality of treatment, as well as adherence. I did no select the decision to add augmentation agent such as buspirone since Paxil has been effective in improving symptoms of generalized anxiety disorder. Adding another drug at this stage is not recommended (Baldwin, 2020).
What I was hoping to Achieve
I was hoping to witness a further reduction in symptoms. I was also hoping to see a decrease in HAM-A score to almost zero. I was also hoping that the patient will report return to his previous level of functioning.
Ethical Considerations
Patients have a right to informed care when receiving psychiatry services. As a result, the patient in this case study should be informed about any treatment decisions made and changes in the current regime. The patient should also be involved in his care for empowerment, sustainable change, and satisfaction with the care given to him (Butts & Rich, 2022).
Conclusion
In summary, the decision to begin the patient on Paxil was effective. Its effectiveness could be seen from the evidence that Paxil is the recommended first-line drug of choice for generalized anxiety disorder. The drug has enhanced efficacy in symptom improvement and enhancing patient’s functioning (Strawn et al., 2018). The other options such as starting the patient on Imipramine and buspirone were not selected in the first step because of their associated safety issues. The decision to increase the dosage of Paxil in the second step was effective. It led to optimum symptom improvement, as evidenced by the reduction in HAM-A score by more than 50% and symptoms of generalized anxiety disorder. The decisions to maintain the current dose and quadruple the dosage of Paxil were not selected due to safety concerns and the potential of minimal symptom improvements. The optimum improvement in symptoms informed the decision to maintain the dose of Paxil in the third step (Baldwin, 2020). It also informed the decision not to increase the dosage further or augment the treatment.
Ethical considerations informed the decisions made in this case study. Accordingly, evidence-based data was used to select the best treatment for the patient. Sources of evidence-based data such as journals provided insights into the safety and efficacy of the different drugs used for treating generalized anxiety. Evidence-based decisions optimize on outcomes such as safety, quality, and efficiency in disease management. The other ethical considerations that informed the treatment decisions included non-maleficence and justice (Butts & Rich, 2022). Justice was maintained by informing and involving the patient in the treatment process.
References
Baldwin, D. S. (2020). Pharmacological Treatment of Generalized Anxiety Disorder (GAD). In Generalized Anxiety Disorder and Worrying (pp. 297–318). John Wiley & Sons, Ltd. https://doi.org/10.1002/9781119189909.ch14
Butts, J. B., & Rich, K. L. (2022). Nursing Ethics: Across the Curriculum and Into Practice. Jones & Bartlett Learning.
He, H., Xiang, Y., Gao, F., Bai, L., Gao, F., Fan, Y., Lyu, J., & Ma, X. (2019). Comparative efficacy and acceptability of first-line drugs for the acute treatment of generalized anxiety disorder in adults: A network meta-analysis. Journal of Psychiatric Research, 118, 21–30. https://doi.org/10.1016/j.jpsychires.2019.08.009
Serdarević, A. M., Halilović, Z., Bahto, A., Kapo, B., & Delić, D. (2018). Observational multicenter study of efficacy of paroxetine film-coated tablet in the treatment of anxiety disorder. Medicinski Glasnik, 15(2).
Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: An evidence-based treatment review. Expert Opinion on Pharmacotherapy, 19(10), 1057–1070. https://doi.org/10.1080/14656566.2018.1491966
A Sample Answer 2 For the Assignment: ASSESSING AND TREATING PATIENTS WITH ANXIETY DISORDERS NURS 6630
Title: ASSESSING AND TREATING PATIENTS WITH ANXIETY DISORDERS NURS 6630
Anxiety disorders are characterized by pathologically elevated levels of anxiety. One of the common anxiety disorders is generalized anxiety disorder (GAD). It is characterized by anxiety, tension, worry, and fears about various day-to-day events and problems. Patients with GAD experience difficulties controlling excessive worries (DeMartini et al., 2019). GAD’s excessive anxiety and worry cannot be accounted for by a medical condition or substance use. The purpose of this paper is to discuss the case scenario of a patient with an anxiety disorder and describe the treatment and ethical considerations that may impact treatment.
Case Overview
The case scenario portrays a 46-year-old white male referred by his PCP after visiting the ER due to the fear of having a heart attack. The client mentions that he experienced chest tightness, dyspnea, and a feeling of impending doom. He has a history of mild hypertension and is overweight by roughly 15 lbs, but the rest of his medical history is unremarkable. His EKG and physical exam findings were normal, and myocardial infarction was ruled out. The client reports that he still experiences chest tightness and episodes of dyspnea, which he calls anxiety attacks. He also has infrequent feelings of impending doom and a need to escape. He scores 26 on the Hamilton Anxiety Rating Scale and is diagnosed with GAD.
The patient factors that may influence medication prescribing include age, the severity of the patient’s GAD, treatment preferences, current medical condition and medications, and previous medication trials (DeMartini et al., 2019). The clinician needs to consider the patient’s current hypertension and overweight and prescribe a drug that will not aggravate the conditions.
Decision #1
Start Zoloft 50 mg orally daily.
Why I Selected This Decision
Sertraline, a selective serotonin reuptake inhibitor (SSRI), was chosen because it is the most cost-effective SSRI. It is also indicated in the first-line treatment of GAD in adults. Strawn et al. (2018) found that the potential side effects of Zoloft are relatively well-tolerated, which leads to a higher compliance rate and better patient outcomes.
Why I Did Not Select the Other Options
Imipramine was not an ideal choice because it is a 2nd line therapy used when SSRIs are unsuccessful in alleviating GAD symptoms. Besides, Imipramine is associated with anticholinergic unpleasant side effects such as dry mouth, sedation, and constipation (Strawn et al., 2018). The side effects may contribute to a low compliance rate, which delays achieving the desired treatment effects. In addition, Buspirone was not ideal since it has no antipanic activity. Thus, it would not adequately alleviate the anxiety attacks in the client. Furthermore, Buspirone has a prolonged onset of action and is not recommended as monotherapy in treating GAD (Strawn et al., 2018).
What I Was Hoping To Achieve
I hoped that Zoloft would improve the GAD symptoms by at least 50% by the fourth week, and the HAM-A score would improve to 12. According to Garakani et al. (2020), SSRIs such as Zoloft have been established to be efficacious in treating anxiety disorders.
How Ethical Considerations May Impact the Treatment Plan
Ethical principles that may affect the treatment plan include beneficence (duty to do good) and nonmaleficence (duty to cause no harm) (Bipeta, 2019). The PMHNP upheld beneficence and nonmaleficence by prescribing Zoloft, which is associated with the best treatment outcomes and least side effects. The other drugs were not prescribed due to their associated treatment outcomes and side effects.
Decision #2
Increase Zoloft to 75 mg daily.
Why I Selected This Decision
The Zoloft dose was increased because the patient’s anxiety symptoms had not fully abated. Although he reported that the chest tightness and dyspnea had abated, he still experienced some degree of worry, and the HAM-A sore showed a partial response. Increasing the dose was thus an ideal choice to promote full remission of GAD symptoms (Strawn et al., 2018). Besides, the dose increase was gradual since it allows the PMHNP to monitor the drug’s side effects adequately.
Why I Did Not Select the Other Options
Increasing Zoloft to 100 mg was inappropriate since it is a high dose increase. Thus, it does not allow the clinician to effectively monitor the drug’s effect on the patient and its side effects. It is recommended that the dose is gradually increased to promote successful therapy. In addition, changing the dose was not ideal because the patient exhibited a partial treatment response to the initial dose. Treatment guidelines recommend that the drug be changed only when there is no positive response to therapy after eight weeks or adverse effects (Garakani et al., 2020).
What I Was Hoping To Achieve
I hoped that gradually increasing the dose would help to fully alleviate the depressive symptoms while at the same time monitoring the drug’s associated side effects. The initial dose of Zoloft is 25 to 75 mg daily, while the usual dose range is 50-200 mg daily (Garakani et al., 2020). Thus, 75 mg is an acceptable dose for this patient.
How Ethical Considerations May Impact the Treatment Plan
Nonmaleficence was upheld in this decision by gradually increasing the dose, which would allow the PMHNP to monitor the drug’s effect, thus preventing harm to the patient (Bipeta, 2019). Besides, beneficence was upheld by increasing the dose to promote complete remission of symptoms and better patient outcomes.
Decision #3
Maintain the current dose.
Why I Selected This Decision
The current dose was maintained at 75 mg because the patient demonstrated an adequate positive response to the dose. The patient reported a further decrease in the depressive symptoms with a 61% reduction in symptoms, and the HAM-A score improved to 10. Besides, there were no reported side effects, and thus, maintaining the dose was ideal to avoid adverse effects if the dose was increased (He et al., 2019).
Why I Did Not Select the Other Options
Increasing Zoloft to 100 mg was not an appropriate choice because the patient had an adequate positive response to the current 75 mg dose. Increasing to 100 mg may alleviate the symptoms further but poses the risk of side effects which may affect the drug compliance rate (He et al., 2019). Besides, an augmenting agent was not added to the plan because the patient had an adequate response with Zoloft monotherapy. Besides, monotherapy is highly recommended to prevent polypharmacy.
What I Was Hoping To Achieve
I was hoping that maintaining the dose would promote a progressive remission of the GAD symptoms and further improve the HAM-A score while at the same time causing no harm to the patient through side effects. Strawn et al. (2018) found that Zoloft continues to improve GAD symptoms over time regardless of a fixed dose.
How Ethical Considerations May Impact the Treatment Plan
The ethical principle of autonomy may impact the treatment plan if the patient does not consent to the medications or requests a change in treatment due to side effects. The PMHNP must obtain informed consent and explain the benefit of the prescribed medication and potential side effects (Bipeta, 2019).
Conclusion
The specific patient factors that may influence decisions on medication in the above patient include age, the severity of GAD, patient’s treatment preferences, current medical condition and medications, and previous medication trials. The patient was initiated with Zoloft 50 mg daily. The drug was selected because it is indicated as a first-line treatment in GAD and is associated with effective treatment outcomes (Strawn et al., 2018). Besides, it is associated with minimal side effects compared to Imipramine. Buspirone was not selected due to the lack of antipanic activity, which is crucial in managing the patient’s anxiety attacks. The initial dose led to a partial decrease in GAD symptoms, which led to increasing Zoloft to 75 mg daily (Strawn et al., 2018). The aim of this decision was to alleviate the GAD symptoms further. The dose was not increased to 100 mg daily to allow monitoring of side effects. Besides, the drug was not changed because the patient demonstrated a positive response to the initial drug, and no side effects were reported.
The patient’s symptoms decreased with Zoloft 75 mg with a 61% remission in symptoms. The dose was then maintained at 75 mg to allow for a progressive decrease in symptoms and monitoring of side effects. Augmentation was not recommended to avoid polypharmacy (Garakani et al., 2020). Ethical principles of beneficence and nonmaleficence influenced the treatment plan. The clinician selected medication known to have the best treatment outcomes and the least adverse effects to promote better health outcomes (Bipeta, 2019). Autonomy should also be respected by considering the client’s decisions when developing the treatment plan.
References
Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19
DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized Anxiety Disorder. Annals of internal medicine, 170(7), ITC49–ITC64. https://doi.org/10.7326/AITC201904020
Garakani, A., Murrough, J. W., Freire, R. C., Thom, R. P., Larkin, K., Buono, F. D., & Iosifescu, D. V. (2020). Pharmacotherapy of anxiety disorders: current and emerging treatment options. Frontiers in psychiatry, 1412. https://doi.org/10.1176/appi.focus.19203
He, H., Xiang, Y., Gao, F., Bai, L., Gao, F., Fan, Y., … & Ma, X. (2019). Comparative efficacy and acceptability of first-line drugs for the acute treatment of generalized anxiety disorder in adults: a network meta-analysis. Journal of psychiatric research, 118, 21-30. https://doi.org/10.1016/j.jpsychires.2019.08.009
Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy, 19(10), 1057–1070. https://doi.org/10.1080/14656566.2018.1491966