Epidemiology and health service resource allocation policy for alcohol, drug abuse, and mental disorders

Data from the NIMH Epidemiologic Catchment Area (ECA) Study in Baltimore, Md., are used to illustrate the association between alcohol, drug abuse, and mental disorder diagnoses with health service use. A probability sample of 3,481 adult (age 18 and over) residents of a geographically defined Baltimore City population of 175,000 was found to have a 23.4 per 100 population, 6-month prevalence of 13 specific alcohol, drug, and mental disorders. Of this population, 7.1 percent sought outpatient mental health treatment from both general medical physicians and mental health specialists in a 6-month period. The presence of a mental disorder diagnosis increased the average number of visits to all health providers from 1.91 to 4.06 during the same 6-month period. Although the presence of a mental disorder diagnosis clearly increased the probability of using both general medical and mental health services, only 15.6 percent of the persons with a mental disorder sought any mental health treatment during this 6-month timeframe--leaving 84 percent of those with mental disorders not seeking any outpatient treatment during the same period. The addition of a measure of high symptomatology (a score of 4 or more on the General Health Questionnaire) increased the percentage of persons with mental disorder using services to 30.5 percent. When a measure of disability was added to the diagnosis and the high symptom level score, 54.7 percent of the population could be predicted to use some mental health service. These data demonstrate the necessity of having additional patient assessment measures with a diagnosis to predict probable service use. However, even in the most comprehensive multidimensional model, more research is required to explore the phenomena of presumed unmet need--the 45 percent of those with a diagnosis, disability, and high symptoms who do not use services. Hence, epidemiologists who wish to participate in setting policy for resource allocation must join with their colleagues in economics, sociology, and health services research to identify all factors in addition to disease states that either predispose population groups to use services or represent additional resource allocation needs.     

Gamma-interferon modulates human monocyte/macrophage transferrin receptor expression

Although circulating human monocytes do not express transferrin (Tf) receptors, cultured adherent blood cells display high-affinity Tf binding sites. In the present studies, effects of various cytokines and biologically active proteins on human monocyte/macrophage Tf receptors were investigated. After culture, Tf receptor expression by adherent blood cells was time dependent and plateaued by 7 days. The addition of interleukin-1 (IL-1), alpha-interferon (alpha-IFN), granulocyte/macrophage-colony stimulating factor (GM-CSF), or human IgG to macrophages cultured for 4 days did not alter Tf receptor expression. Fe-saturated, human Tf caused a significant, dose-dependent decrease in receptor expression. At a dose of 100 U/mL, gamma- interferon (gamma-IFN) significantly increased Tf receptor expression by macrophages cultured for 4 (230% +/- 51% of control) or 7 days (150% +/- 22%). Scatchard analyses showed increased binding sites but no change in receptor affinity. Northern and slot blot analysis of cellular mRNA from macrophages cultured for 4 to 7 days and exposed to gamma-IFN showed a two- to fivefold increase in Tf receptor mRNA, but less than or equal to 30% increase in beta-actin mRNA. Ferritin content of gamma-IFN-treated macrophages was 47% to 63% of control cells. Net uptake of 59Fe from Tf by gamma-IFN-treated cells was 10% to 17% of control, but uptake of radiolabeled Tf was comparable. When macrophages were labeled with 59Fe and then exposed to gamma-IFN, cell-associated Fe was reduced by 43%, indicating that gamma-IFN caused macrophage Fe release. gamma-IFN specifically modulates Tf receptor display by inducing Fe release and reducing cellular Fe content. Regulation of Tf receptor expression in macrophages is controlled by cellular Fe content and is thus similar to regulatory mechanisms in dividing cells.     

Primary health care progress and problems

The 1st generation of primary health care efforts were assessed in order to temper future efforts with implementation realities. With support from the US Agency for International Development (USAID), the American Public Health Association (APHA) studied 52 primary health care (PHC) projects from 1980-82, documenting the numerous lessons learned. The contrast between the ideology of PHC and field realities provides valuable insights which must be fed back into 2nd generation projects. The projects were in 33 developing countries in Asia, Latin America, Africa, and the Near East. Approximately 1/3 were national level efforts; one-half, variously sized regional efforts; and the remainder, small scale pilot efforts. The sources of information were project documents and interviews with individuals who knew field activities firsthand. All the projects had as their primary goal provision of low-cost health services to previously unserved rural communities, using community personnel, and strengthening community institutions. Regarding overall assessment, while data continue to be limited on the impact of the approach on health status, there are some positive indications, especially for the projects of longer duration. For example, in Nepal and Thailand, there were modest improvements in health status of the target population in 2 project areas. A project in Kitui, Kenya reported reductions in infant mortality rates. A PHC program in Panama was responsible for decreases in the incidence of diarrhea, parasites, and typhoid. Many of the projects have been successful in setting up a PHC structure that extends coverage for health measures such as immunizations, family planning, and prenatal care. Many new facilities are in place. Skills of health workers have been upgraded, and new categories of paraprofessionals have been trained. Additionally, sizable numbers of community health workers have been trained and deployed. There is some evidence that in a few cases projects have been instrumental in changing government attitudes. Some common implementation problems raise important issues for all PHC projects: provision of support services, project financing, community participation, and appropriate and effective use of community health workers, and balancing the perceived needs of the community with those of health professionals. By identifying some of the obstacles to PHC implementation, this study sets the agenda which the next generation of projects must address.     

Virilizing adrenal adenoma in a 2-year-old girl

A 2-year-old girl with virilization had an adrenal tumor that produced testosterone with little evidence of excessive urinary androgen excretion. Plasma testosterone concentration was 407 ng/dL and urinary 17-ketosteroid (17KS) levels were 3 and 2 mg/day. Excretion of 17KS decreased to 1.8 mg/day after suppression of dexamethasone therapy, but urinary 17-hydroxycorticosteroid excretion did not change from 1.0 to 0.7 mg/day after administration of dexamethasone. She had a blunted response to administration of metyrapone and insulin and a small diurnal variation in cortisol concentration suggesting suppression of corticotropin secretion, even though the plasma cortisol concentration was in the normal range and there were no clinical signs of cortisol excess. High-performance liquid chromatography was used to analyze the steroid content of tumor tissue. Those portions of the tumor that were rich in steroids contained predominantly testosterone.     

Unusual and fatal complications of rhinoplasty

Serious complications of cosmetic rhinoplasty are extremely rare. However, awareness of their existence is essential so that the surgeon can minimize the potential hazards of the procedure. This demands a careful preoperative examination, a meticulous intraoperative technique, and a careful postoperative monitoring of the patient. The complications of rhinoplasty have been classified into infectious, traumatic, hemorrhagic, systemic, and miscellaneous groups. The pertinent literature is reviewed, as well as cases of inclusion cyst formation, disturbance of eye closure, local activation of systemic disease, and fatalities from intracranial injury with brain laceration and pneumocephalus.     

Lack of greater seroconversion of rhesus monkeys after subcutaneous inoculation of dengue type 2 live-virus vaccine combined with infection-enhancing antibodies.

Four groups of six nonimmune male rhesus monkeys were inoculated subcutaneously with formulations of dengue type 2 vaccine virus DEN-2/S-1. Group A received 1.9 x 10(4) plaque-forming units of vaccine in normal human serum albumin diluent. Group B received the same dose combined with a dengue type 2-immune human serum diluted 1:1,600, beyond its neutralization endpoint of 1:300, but having an immune enhancement titer of 250,000. Groups C and D received 10-fold dilutions of these respective formulations. No migration-inhibitory factor was found when peripheral blood mononuclear leukocytes obtained on day 68 post-immunization from monkeys of all experimental groups were tested. No viremia was detected in any of the monkeys when sera taken on postvaccination days 1 through 12 were inoculated into adult Toxorhynchites amboinensis mosquitoes and LLC-MK2 cells. By day 89, four of the six monkeys had seroconverted by the neutralization test in each of groups A, B, and C, and three of five monkeys in group D (one monkey died from cardiac collapse after anesthesia) had seroconverted. Immune enhancement of dengue virus infection is known to occur in humans and monkeys circulating heterologous flavivirus antibodies. In this study, there was no enhancing effect when antibody was mixed with dengue type 2 vaccine virus and injected subcutaneously.     

Ejection fraction derived by M-mode echocardiography: A table and comments

Left ventricular ejection fraction is frequently quantitated by M-mode echocardiography despite limitations, including 1) the ability to measure an accurate left ventricular short axis, 2) the mathematic and geometric assumptions used to derive the volumes from which the ejection fraction is calculated, and 3) the lack of applicability to asynergic ventricles. Nevertheless, using a cubed function or correction formula, ejection fraction can be calculated for symmetrically contracting, normally sized, and enlarged left ventricles. A table and accompanying comments are presented.     

Eosinophilic cystitis.

Allergy is an unlikely cause of the eosinophilic cystitis in the case presented because of the young age of the patient and the insignificant levels of IgE (immunoglobulin E) found in her serum.