The mental health of Asian and Pacific Island elders: implications for research and mental health administration

According to the 1990 census, the highly diverse Asian and Pacific Islander (API) American population has doubled in size from 1980 to 1990, and is now the nation's fastest growing minority group. Several studies have documented this population's comparative underuse of mental health services. A review of recent studies on the mental health of Asian and Pacific Island elders identifies a number of risk factors and protectors. Elder APIs appear to have poorer mental health compared to white counterparts, but not the poorest mental health within their own ethnic group. Within-group differences emerge, with recent immigrant groups and colonized populations appearing as most at-risk for mental health problems. A critical variable on this population's mental health status appears to be socioeconomic status,and yet an analysis of other demographic variables, notably nativity and gender, remain contradictory. A research agenda is proposed and implications for mental health administrators are suggested.     

Bone marrow and recombinant human bone morphogenetic protein-2 in osseous repair

Bone marrow stem cells and recombinant human bone morphogenetic protein-2 each has the capacity to repair osseous defects. Recombinant human bone morphogenetic proteins require the presence of progenitor cells to function. It is hypothesized that a composite graft of recombinant human bone morphogenetic protein-2 and marrow would be synergistic and could result in superior grafting to autogenous bone graft. Syngeneic Lewis rats with a 5-mm critical sized femoral defect were grafted with recombinant human bone morphogenetic protein-2 and marrow, recombinant human bone morphogenetic protein-2, marrow, syngeneic cancellous bone graft, or carrier alone (control). Serial radiographs (3, 6, 9, 12 weeks) and torque testing (12 weeks) were performed. Bone formation and union were determined. The recombinant human bone morphogenetic protein-2 and marrow composite grafts achieved 100% union at 6 weeks. Recombinant human bone morphogenetic protein alone achieved 80% union by week 12. Both groups yielded a higher union rate and superior mechanical properties than did either syngeneic bone graft (38%) or marrow (47%) alone. The superior performance of recombinant human bone morphogenetic protein-2 combined with bone marrow in comparison with each component alone strongly supports a biologic synergism. This experimentation shows the clinical importance of establishing operative site proximity for the osteoinductive factors and responding progenitor cells.     

Community Care for People with Chronic Conditions: An Analysis of Nine Studies of Health and Social Service Utilization in Ontario

A series of studies conducted in the same region found that programmatic, community-based health and social service interventions have a positive impact on client well-being. These proactive interventions, designed to address the full range of health and social needs, were usually provided at the same–or even lower–costs as uncoordinated, illness-focused care. The results of this series suggest that across-the-board health care reduction, atleast in a system of national health insurance, will produce poorer results, at higher cost, for people with chronic conditions living in the community. Policy planners need more research that concentrates on comparisons of outcomes between and within different models of health and social service delivery. The studies should be designed to help them determine who benefits from different serviceconfigurations carried out within a range of policy environments at various costs.     

Pilot study of a visitor volunteer programme for community elderly people receiving home health care

There is a need to evaluate community support programmes for elderly people. In this randomized control trial (RCT), we determined the effectiveness of 'friendly visitors' in a volunteer programme of a visiting nurses organization in Southern Ontario, Canada. The Volunteer Friendly Visitor Programme was developed to support elderly people receiving homemaking and nursing care in the community. Volunteers are screened, trained, interviewed and matched to homebound elderly clients for general interest, visit expectations and personality. Volunteers spend three to four hours on average per week with clients socializing in mutually agreed-upon ways. The nursing staff identified clients who were lonely for this additional support. These newly-referred clients were randomly allocated to receive a friendly visitor or not for six weeks. Those receiving the volunteer visitor improved in life satisfaction and two social support measures: worth and social integration. Thus, the addition of volunteer visitors to planned homemaking and nursing care made a difference for elderly in the community.     

Stereoselective and substrate-dependent inhibition of hepatic mitochondria beta-oxidation and oxidative phosphorylation by the non-steroidal anti-inflammatory drugs ibuprofen, flurbiprofen, and ketorolac

Non-steroidal anti-inflammatory drugs (NSAIDs) cause a range of adverse effects, some of which have been associated with perturbances of lipid metabolic pathways. Previous data demonstrating stereoselective formation of the CoA thioester of R-ibuprofen in particular were suggestive of possible stereoselective effects on lipid metabolism. Our aim was to characterise the relative stereoselectivity of the effects of ibuprofen, flurbiprofen, and ketorolac (0.01-1.0 mM) on both the beta-oxidation of palmitate and oxidative phosphorylation in rat hepatic mitochondria as a means of dissecting prostaglandin related from non-prostaglandin-related events. Beta-oxidation was inhibited stereoselectively by R-ibuprofen (P = 0.015), non-stereoselectively by R- and S-flurbiprofen (P = 0.002 and P = 0.004, respectively), and was essentially unaffected by either enantiomer of ketorolac. At 0.25 mM, inhibition by R-ibuprofen and both flurbiprofen enantiomers was partially reversed by increasing CoA concentrations (0-200 microM). Mitochondrial respiration was moderately inhibited by both enantiomers of ibuprofen and flurbiprofen (P < 0.01), but only by high concentrations (> or = 1 mM) of the enantiomers of ketorolac (P < 0.01). Uncoupling of oxidative phosphorylation measured as stimulation of State 4 respiration contributed to these effects. The data support interactions involving both stereoselective CoA-dependent and non-CoA-dependent mechanisms. The plasma drug concentrations required to achieve these effects are not likely to be attained in the majority of patients, although these concentrations are achievable in the gastrointestinal tract and may contribute to the well-known spectrum of adverse effects in this organ. Some patients do experience systemic adverse events which may be mediated by these mechanisms.     

Leucovorin, 5-fluorouracil,and gemcitabine: A phase I study

Gemcitabine is a chemotherapy agent with efficacy in the treatment of lung, pancreas, bladder and breast cancer. It inhibits DNA synthesis by interfering with cytidine triphosphate production and also inhibits the activity of ribonucleotide reductase. Gemcitabine may potentiate fluorouracil's inhibition of thymidylate synthase. This inhibition would be expected to be sequence dependent, occurring only if gemcitabine were administered following fluorouracil (5FU).The combination of leucovorin, 5-FU, and gemcitabine was assessed in this phase I trial. Eligibility requirements included refractory solid tumor malignancy; adequate hematologic, renal and hepatic reserve; no prior therapy with the combination of leucovorin and 5FU, or with gemcitabine; ECOG performance status 0–2, and signed informed consent.Eleven men and nine women were eligible. The median age was 52.5 years and the median performance status was 1. All but three patients had prior chemotherapy. The starting doses were leucovorin 20 mg/m², 5FU 255 mg/m² and gemcitabine 600 mg/m². 5FU and gemcitabine were escalated in tandem to 340 mg/m² and 800 mg/m² and thereafter to 425 mg/m² and 1000 mg/m², respectively. Gemcitabine administration always followed that of 5FU by 30 minutes. The median number of cycles was 2 (range 1–32). Two patients at the starting dose had disease progression within the first cycle with one death on day 28. One patient with cholangiocarcinoma had a partial response and remained on study for 40 months. There were no other responses.The maximum tolerated dose is leucovorin 20 mg/m², 5FU 340 mg/m², and gemcitabine 800 mg/m². The impact of drug sequence remains undetermined.     

Sensitivity analysis of the effect of bioavailability or dosage form content on mean steady state phenytoin concentration

Stochastic simulations were used to examine the sensitivity of mean phenytoin steady state concentrations (Css) to changes in the effective dosing rate produced by differences in average product content or bioavailability. Changes of +/- 4%, +/- 6%, +/- 8% and +/- 10% in the effective dosing rate (based on a starting dose yielding a Css of 15 mg/L) were examined. Monte Carlo simulations were performed for each change in dosing rate assuming a one-compartment open model with parallel Michaelis-Menten and first-order elimination. Parameter sets were comprised of a combination of values for maximal rate of saturable elimination (410 or 510 mg/day), the concentration at which the rate of saturable elimination is half maximum (Km, 4.4 or 5.7 mg/L), and linear clearance (CL, 0.15 or 1.5 L/day). These parameters were assumed to be log-normally distributed with coefficients of variation of 30%, 50%, and 15%. The percentages of "individuals" who would be predicted to have Css of less than 10 mg/L following a reduction in the effective dosing rate increased with decreasing Km and CL values. For a Km of 5.7 mg/L and CL of 1.5 L/day, 5% of the "individuals" had Css values of less than 10 mg/L with an 8% decrease in the dosing rate. If the dosing rate was reduced by 10%, then 14-16% of the "individuals" were predicted to have concentrations of less than 10 mg/L. All other combinations of Km and CL values yielded higher percentages of "individuals" with Css of less than 10 mg/L.(ABSTRACT TRUNCATED AT 250 WORDS)     

Quality, efficiency, and cost of a physician-assistant-protocol system for managment of diabetes and hypertension.

Briefly trained physicians assistants using protocols (clinical algorithms) for diabetes, hypertension, and related chronic arteriosclerotic and hypertensive heart disease abstrated information from the medical record and obtained history and physical examination data on every patient-visit to a city hospital chronic disease clinic over a 18-month period. The care rendered by the protocol system was compared with care rendered by a "traditional" system in the same clinic in which physicians delegated few clinical tasks. Increased thoroughness in collecting clinical data in the protocol system led to an increase in the recognition of new pathology. Outcome criteria reflected equivalent quality of care in both groups. Efficiency time-motion studies demonstrated a 20 per cent saving in physician time with the protocol system. Coct estimates, based on the time spent with patients by various providers and on the laboratory-test-ordering patterns, demonstrated equivalent costs of the two systems, given optimal staffing patterns. Laboratory tests were a major element of the cost of patient care,and the clinical yield per unit cost of different tests varied widely.     

Bipartite parietal bone: A rare cause of plagiocephaly

A case of an infant with an asymmetrical head is presented. On clinical assessment the patient displayed features of deformational plagiocephaly. With the aid of three‐dimensional CT imaging of the skull, a bipartite parietal bone was diagnosed. The prevalence and possible aetiology of a bipartite parietal bone is discussed as well as a brief overview of the common causes of plagiocephaly.