Consequences of the North American Free Trade Agreement for health services: a perspective from Mexico.

OBJECTIVES. The purposes of the study were to assess the potential impact of the North American Free Trade Agreement (NAFTA) on medical care in Mexico and to identify internal measures Mexico could take to increase the benefits and minimize the risks of free trade. METHODS. The dual nature of the health sector is examined; the Mexican, Canadian, and US health care systems are compared; and modes and consequences of international exchange of health services are analyzed. RESULTS. Four issues require immediate attention: accreditation of health care facilities, licensing and certification of professionals, technology assessment, and financial equity. CONCLUSIONS. NAFTA offers opportunities for positive developments in Mexico, provided risks can be anticipated and preventive measures can be taken to avoid negative impacts on the health system. Medical services, like other elements of the Mexican economy, must be modernized to respond to the demands of global competition. The Mexican National Academy of Medicine has recommended to the Mexican government (1) internal strengthening of the Mexican health care system to improve its ability to respond to the new conditions created by NAFTA and (2) a gradual process to facilitate equitable and mutually beneficial interactions among the three countries.     

A double-blind comparison of valproate and lithium in the treatment of acute mania.

OBJECTIVE: This study was carried out to compare the efficacy of lithium carbonate with that of valproate in acute mania and to determine whether pretreatment clinical characteristics, such as the presence of a mixed affective state, might predict a differential response to the two drugs. METHOD: Twenty-seven patients meeting DSM-III-R criteria for acute manic episodes underwent a 3-week, randomized, double-blind, parallel-groups trial of treatment with lithium carbonate or valproate. Symptom severity was measured by using the Schedule for Affective Disorders and Schizophrenia, change version (SADS-C), the Global Assessment Scale (GAS), and the Brief Psychiatric Rating Scale (BPRS). Drug effects were compared by using repeated measures analysis of variance (ANOVA). RESULTS: At the end of the study, nine of 14 patients treated with valproate and 12 of 13 patients treated with lithium had responded favorably, as measured by changes in the SADS-C mania, BPRS, and GAS scores. Elevated pretreatment SADS-C depression scores were associated with good response to valproate. ANOVA revealed a significant interaction between drug and mixed affective state with respect to treatment response. CONCLUSIONS: Lithium and valproate were both effective in improving manic symptoms, and lithium was slightly more efficacious overall. Unlike the case with lithium, favorable response to valproate was associated with high pretreatment depression scores. Therefore, treatment with valproate alone may be particularly effective in manic patients with mixed affective states.     

Access to medical care for black and white Americans. A matter of continuing concern

A 1986 national survey of use of health services shows a significant deficit in access to health care among black compared with white Americans. This gap was experienced by all income levels of black Americans. In addition, the study points to significant underuse by blacks of needed medical care. Moreover, blacks compared with whites are less likely to be satisfied with the qualitative ways their physicians treat them when they are ill, more dissatisfied with the care they receive when hospitalized, and more likely to believe that the duration of their hospitalizations is too short.     

Post-implantation whole embryo culture and the study of teratogenesis

The two major applications of whole post-implantation rat embryo culture (WEC) are as a test for teratogenicity in safety evaluation studies and as a tool in the investigation of mechanisms of teratogenesis. As a test system, WEC possesses many of the characteristics necessary for an in vitro screen. However, its use on a large scale is disqualified for reasons of cost and the demand for technical expertise to perform cultures and interpret findings, compared with other in vitro teratogenicity screens, although its use might be preferred when only a few compounds require testing. The major value of WEC lies in its use for studying mechanisms of teratogenesis. The opportunity to study the embryo in isolation and the versatility afforded by the technique offer considerable advantages in this context.     

Late luteal phase dysphoric disorder in 670 women evaluated for premenstrual complaints.

OBJECTIVE: The American Psychiatric Association's DSM-IV Work Group on Late Luteal Phase Dysphoric Disorder (LLPDD) reanalyzed existing data from prospective, daily symptom ratings to evaluate the DSM-III-R criteria for LLPDD. The objectives were to 1) evaluate the individual symptoms presently required for the diagnosis and other symptoms, 2) determine the proportion of treatment-seeking women who meet the LLPDD criteria, and 3) explore the association between LLPDD and other mental disorders. METHOD: Data from over 1,000 women seeking evaluation for premenstrual complaints at five U.S. sites were examined. The data from 670 of these women were sufficiently complete to warrant evaluation by four different methods of assessing symptom change. RESULTS: Depending on the assessment method used, 14% to 45% of the women met the criteria for LLPDD. The current DSM-III-R symptoms were classified as positive for 7% to 54% of the women. Each of these symptoms was significantly more common among women with LLPDD regardless of the assessment method used. Five symptoms not presently included were also significantly more common. Women who had had mental disorders in the past, but not present, showed a significantly greater, but very small, relative risk of LLPDD. CONCLUSIONS: The variability in the frequency of LLPDD diagnosis according to method of assessing symptom change underscores the need for a uniform assessment method. The five additional symptoms with frequencies comparable to those of the DSM-III-R symptoms should be studied further for possible inclusion in the criteria.     

Atypical retinitis in patients with the acquired immunodeficiency syndrome

We examined three patients with AIDS who had large, sharply demarcated areas of thinned retina consistent with inactive cytomegalovirus retinitis and who were not treated with ganciclovir. These lesions appeared identical to clinically inactive areas of cytomegalovirus retinitis after effective antiviral treatment. All patients were receiving azidothymidine or ribavirin, or both, which have activity against the human immunodeficiency virus and which may improve immune function. All patients also received oral acyclovir at doses ineffective against cytomegalovirus retinitis.     

The ''think test'': a further technique to elicit hyperventilation.

Hyperventilation can undermine cardiovascular homeostasis by generating autonomic imbalance, sympathetic dominance, hypokalaemia, and intracellular alkalosis with calcium ion shifts. The role of hyperventilation in episodic disorders such as arrhythmia and coronary vasospasm can be difficult to identify if the patient does not present in an attack and so a provocation challenge is required. Today, the standard challenge is the forced hyperventilation provocation test (FHPT). A capnograph enables the resting end-tidal PCO2 to be compared with the level 3 min after the period of overbreathing. We report the use of a patient-specific challenge. After the FHPT, the subject is invited to close his eyes and think about the circumstances of an attack, feelings and sensations experienced (breathing is not mentioned) or topics that were seen to disturb the rhythm of breathing when the medical history was taken. A fall of end-tidal PCO2 of 10 mmHg or more lasting at least one minute was taken as a positive response. Out of 57 patients with cardiovascular symptoms suggesting a hypocapnic influence, resting hypocapnia (end-tidal PCO2 = 30 mmHg) was present in 3 (5%). Of the remaining 54, the FHPT was positive in 16 (30%) and the 'think test' in 33 (61%). This suggests that patient-specific stimulation has advantages over an unspecific challenge in testing for episodic hypocapnia.     

Persistent sciatic artery. Report of three cases and literature review

Persistence of the sciatic artery (SA) is a rare vascular anomaly, resulting from lack of regression of an embryonal artery to the lower extremity. Forty-nine cases have been published in the world literature since 1832. The persistent sciatic artery (PSA) is particularly prone to undergo aneurysm formation or atherosclerosis. It originates from the internal iliac artery, courses in close proximity to the sciatic nerve, and provides the main supply to the popliteal artery because a hypoplastic superficial femoral artery (SFA), contributing only collaterals to the knees, is usually associated with a PSA. This anomaly should be kept in mind in the clinical assessment of a pulsatile gluteal mass. It also presents a potential hazard during hip and renal transplant surgery.     

Transformation of alveolar type 2 cells to type 1 cells following exposure to NO2.

This research was undertaken to study the fate of Type 2 cells after they have divided. To accomplish this, male rats were exposed to NO₂ to increase the number of dividing Type 2 cells. Dividing cells were labeled with ³H-TdR and studied with autoradiographic techniques in the electron microscope for up to 14 days after labeling. The results show that initially most of the ³H-TdR labeled cells were Type 2. However, by 2 days there was a decrease in frequency of labeled Type 2 cells and a large increase in labeled Type 1 cells. The new frequencies of labeled alveolar epithelial cells were stable from 2 through 14 days. This evidence supports the interpretation that Type 2 cells may transform into Type 1 cells. In addition, it was shown that under the conditions of this experiment: (1) the time for transformation was about 2 days, and (2) during this process an intermediate cell type was present.     

Increased rate of DNA recovery from United Kingdom epidemic Clostridium difficile PCR ribotype 1 strains stored cryogenically

We noted that some Clostridium difficile isolates are nonrecoverable after frozen storage and so used molecular typing analysis to characterize DNA from these strains. The recovery rate of C. difficile PCR ribotype 1 was statistically significantly greater than that of other strains. This observation has implications for C. difficile epidemiological studies.