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Obstacles and opportunities in providing mental health services through a faith-based network in Los Angeles.

This study surveyed attitudes toward mental health services and barriers to providing these services within the agencies of QueensCare Health and Faith Partnership, a network of faith-based organizations, and parish nurses who provided health care in a low-income, ethnically diverse area of Los Angeles. Representatives from 42 organizations responded. Informal counseling was the most frequently provided service (57 percent); yet only 19 percent reported that counselors had at least a moderate amount of training. Although 69 percent felt that referrals to nonreligious counselors were appropriate, 50 percent were reluctant to collaborate with government agencies. Barriers to providing mental health services included limited professional training, reluctance to partner with government programs, and financial and staffing limitations.

Crisis Intervention↗

A cost-effectiveness evaluation of primary health care projects for the poor.

A cost-effectiveness analysis was conducted to determine the relative efficacy of nine primary health care projects serving low income persons in urban and rural areas of Texas. The projects were created as part of a government program to provide services in medically underserved areas of the state by contracting with local public and private providers. While they vary widely in terms of sponsoring organizations, service strategy, and scope of services, the projects share a similar goal of providing an array of basic medical and preventive care services to the poor. This study compares the average cost per encounter for diagnosis/treatment, emergency, family planning, and preventive health screening services provided by the various projects during the first year of operation. After adjusting for differences in input prices and patient volume, the cost differences are examined and related to organizational model and personnel mix. Those projects with the highest ratio of nonphysician to physician practitioners proved more cost-effective, as did those projects following the public clinic model of service delivery.

Community Health Centers↗

Loss of seizure control associated with generic substitution of carbamazepine.

OBJECTIVE: We report two cases of lost seizure control associated with the generic substitution of carbamazepine, review pertinent literature, and discuss the impact of this substitution on patient care. DATA SOURCES: Case studies, abstracts, and research publications identified in MEDLINE and bibliographic review. DATA EXTRACTION: One author reviewed cases supplied by the other authors and abstracted information from published literature sources. DATA SYNTHESIS: The first case describes a 15-year-old boy who received valproic acid and carbamazepine for partial seizures. A change in government program policies caused him to receive generic carbamazepine. This resulted in loss of seizure control and a decrease in his serum carbamazepine concentration from 12.4 to 6.7 micrograms/mL. When his carbamazepine concentration returned to previous levels, seizure control was not reestablished. A second case involves a 21-year-old woman who substituted generic carbamazepine because of financial problems. After being seizure-free for at least five years on phenobarbital and carbamazepine, she experienced seizures related to the product change. Her carbamazepine concentration decreased from 11.8 to 8.5 micrograms/mL; she also became pregnant at that time. Seizure control was not reestablished. At least three other studies do not support these observations, but the tightly controlled conditions in these studies may not have simulated actual clinical practice. CONCLUSIONS: When generic substitution of carbamazepine is required, serum concentrations should be carefully monitored. The extra care required may negate the financial advantages of the substitution.

Adolescent↗

The relationship between differentiation and proliferation in late gestation fetal rat hepatocytes.

Hepatocyte proliferation and differentiation occur simultaneously during late mammalian gestation. We hypothesized that regulation of hepatocyte growth and differentiation would be coordinated in late gestation fetal hepatocyte cultures such that proliferation would be most active in a population of less well-differentiated cells. Cultured fetal hepatocytes (embryonic d 19 and 21; E19 and E21) were studied using double staining immunofluorescent microscopy. Differentiation was assessed as staining for alpha-fetoprotein (AFP), three markers of enzymic differentiation (glucokinase [GK], phosphoenolpyruvate carboxykinase [PEPCK], and carbamoyl phosphate synthase [CPS]), and a hepatocyte cell-cell adhesion molecule (C-CAM). Proliferation was assessed using immunocytochemical detection of proliferating cell nuclear antigen (PCNA) or 5-bromo-2'-deoxy-uridine (BrdU) incorporation into DNA. Fetal hepatocyte cultures consisted of a heterogeneous population of cells, slightly more than half of which were proliferative under defined, growth factor-free conditions. These cultures were heterogeneous for AFP expression. There was no correlation between the expression of AFP and PCNA or AFP and S-phase entry (BrdU staining) during the first 48 h in culture. Similar results were obtained in staining for the enzymic differentiation markers and C-CAM. In addition, the differentiation status of cultured fetal hepatocytes was unrelated to a presumed indicator of mature growth regulation, mitogenic responsiveness to transforming growth factor alpha (TGFalpha), and hepatocyte growth factor (HGF). Finally, absence of any correlation between proliferation and differentiated phenotype was supported by in vivo studies using staining for PCNA, AFP, CPS, and PEPCK in liver sections. These results indicate that the developmental program governing differentiation of late gestation fetal rat hepatocytes is independent from mechanisms controlling proliferation.

Animals↗

Transcriptional regulation of cardiac development: implications for congenital heart disease and DiGeorge syndrome.

In recent years, impressive advances have occurred in our understanding of transcriptional regulation of cardiac development. These insights have begun to elucidate the mystery of congenital heart disease at the molecular level. In addition, the molecular pathways emerging from the study of cardiac development are being applied to the understanding of adult cardiac disease. Preliminary results support the contention that a thorough understanding of molecular programs governing cardiac morphogenesis will provide important insights into the pathogenesis of human cardiac diseases. This review will focus on examples of transcription factors that play critical roles at various phases of cardiac development and their relevance to cardiac disease. This is an exciting and burgeoning area of investigation. It is not possible to be all-inclusive, and the reader will note important efforts in the areas of cardiomyocyte determination, left-right asymmetry, cardiac muscular dystrophies, electrophysiology and vascular disease are not covered. For a more complete discussion, the reader is referred to recent reviews including the excellent compilation of observations assembled by Harvey and Rosenthal (1).

Abnormalities, Multiple↗

Understanding physicians' decisions to practice in rural areas as a basis for developing recruitment and retention strategies.

The shortage of providers in rural areas is threatening the quality and availability of health care in many communities. The causes of the provider shortage are many and varied-from economic to social to personal. Government programs have addressed the issue of provider supply by offering scholarships and loan repayment programs for medical students who then must fulfil service obligations in underserved settings, among which are rural areas. Experience has shown that once providers complete their obligations under these grant programs, retention of providers in rural areas becomes an even more critical issue. Using focus group research, this study explores the practice setting choices of a group of physicians currently practicing in rural areas. The discussion reveals that personal values are one of the primary motivators for choosing to practice in rural settings while lack of availability of career opportunities for spouses and educational opportunities for children are major obstacles. The health care system poses barriers to success for providers in rural settings. The key rewards from rural practice are the ability to become integrated into the local community and the provider/patient relationships that develop in such settings. These findings are used as the basis for proposing recruitment and retention strategies for providers to improve access to medical care by patients in rural areas.

Career Choice↗

Infant feeding styles: barriers and opportunities for good nutrition in India.

India has the lion's share of malnourished children in the world. Poverty and social exclusion contribute to this rate of malnutrition, but care practices also play a role. Breastfeeding is rarely exclusive, sanitation tends to be limited, complementary feeding often begins late, and the quantities are small. In the past, government programs have focused on the supply of food rather than caring practices. A research agenda will include both operational research on the nutrition programs, and formative and intervention research to improve caring practices, particularly those around infant and young child feeding.

Bottle Feeding↗

Induced abortion and unintended pregnancy in Guatemala.

CONTEXT: Although Guatemalan law permits induced abortion only to save a woman's life, many women obtain abortions, often under unsafe conditions and in response to an unintended pregnancy. Recent studies indicate that unsafe abortion is a key factor contributing to maternal morbidity and mortality in the country, but no national data on the incidence of abortion exist. METHODS: Surveys of all hospitals that treat women for postabortion complications and of 74 professionals who are knowledgeable about the conditions of abortion provision in Guatemala were conducted in 2003. Indirect estimation techniques were used to calculate the number of induced abortions performed annually. Abortion rates and ratios and the level of unintended pregnancy were calculated for the nation and its eight regions. RESULTS: Nearly 65,000 induced abortions are performed annually in Guatemala, and about 21,600 women are hospitalized for treatment of complications. Abortions occur at a rate of 24 per 1,000 women aged 15-49, and there is one abortion for every six births. The abortion rate is higher than average in the Southwest (less developed, mainly indigenous population) and Metropolitan (more developed, mainly nonindigenous population) regions (29-30 per 1,000 women). Over a quarter of all births are unplanned; combining unplanned births with abortions yields estimates that 32% of pregnancies in Guatemala are unintended, with an unintended pregnancy rate of 66 per 1,000 women. CONCLUSIONS: Unsafe abortion has a significant impact on women's health in Guatemala. Comprehensive government programs are needed to address the issues of unintended pregnancy and unsafe abortion, with attention to regional differences.

Abortion, Induced↗

Spatiotemporal profile of an optimal host response to virus infection in the primate central nervous system.

Viral infections of the central nervous system (CNS) are a major cause of morbidity largely due to lack of prevention and inadequate treatments. While mortality from viral CNS infections is significant, nearly two thirds of the patients survive. Thus, it is important to understand how the human CNS can successfully control virus infection and recover. Since it is not possible to study the human CNS throughout the course of viral infection at the cellular level, here we analyzed a non-lethal viral infection in the CNS of nonhuman primates (NHPs). We inoculated NHPs intracerebrally with a high dose of La Crosse virus (LACV), a bunyavirus that can infect neurons and cause encephalitis primarily in children, but with a very low (≤ 1%) mortality rate. To profile the CNS response to LACV infection, we used an integrative approach that was based on comprehensive analyses of (i) spatiotemporal dynamics of virus replication, (ii) identification of types of infected neurons, (iii) spatiotemporal transcriptomics, and (iv) morphological and functional changes in CNS intrinsic and extrinsic cells. We identified the location, timing, and functional repertoire of optimal transcriptional and translational regulation of the primate CNS in response to virus infection of neurons. These CNS responses involved a well-coordinated spatiotemporal interplay between astrocytes, lymphocytes, microglia, and CNS-border macrophages. Our findings suggest a multifaceted program governing an optimal CNS response to virus infection with specific events coordinated in space and time. This allowed the CNS to successfully control the infection by rapidly clearing the virus from infected neurons, mitigate damage to neurophysiology, activate and terminate immune responses in a timely manner, resolve inflammation, restore homeostasis, and initiate tissue repair. An increased understanding of these processes may provide new therapeutic opportunities to improve outcomes of viral CNS diseases in humans.

Animals↗

Risk factors for prophylaxis failure in patients receiving aerosol pentamidine for Pneumocystis carinii pneumonia prophylaxis.

OBJECTIVE: The purposes of this study were (1) to determine the incidence of prophylaxis failure in HIV-infected patients receiving aerosol pentamidine (AP) for Pneumocystis carinii pneumonia (PCP) prophylaxis, and (2) to identify risk factors for PCP prophylaxis failure. SETTING AND DESIGN: In Ontario, Canada, AP has been made available for outpatient PCP prophylaxis through a centralized government program, the Ontario Drug Distribution and Monitoring Program. Data from this administrative observational database were extracted for 2,227 patients who received AP between May 1989 and December 1998. OUTCOME MEASUREMENTS: The incidence of breakthrough PCP (BPCP) was calculated from the database. A Cox regression model with time-varying covariates was created to examine factors associated with BPCP. The follow-up time was divided into three eras: 1989 to 1991, 1992 to 1994, and 1995 to 1998. These eras were meant to reflect major changes in antiretroviral medication regimens. RESULTS: The overall risk of BPCP was 16.2% over a mean follow-up of 1.67 years. The overall BPCP rate was 9.7/100 patient-years, with rates of 8.8/100, 13.1/100, and 6.3/100 patient-years in each of the three treatment eras. In the multivariate analysis, significant risk factors for prophylaxis failure were low CD4 count, previous diagnosis of PCP, history of AIDS-defining conditions other than PCP, and antiretroviral treatment era defined above. CONCLUSION: The overall rate of PCP prophylaxis failure has decreased significantly after 1995, coincident with the era of highly active antiretroviral therapies. Initiation of PCP prophylaxis remains necessary in patients with risk factors.

Adult↗

Genetics of pigment cells: lessons from the tyrosinase gene family.

In mammals, the melanin pigment is produced in two cell types of distinct developmental origins. The melanocytes of the skin originate form the neural crest whereas the retinal pigment epithelium (RPE) of the eye originates from the optic cup. The genetic programs governing these two cell types are thus quite different but have evolved to allow the expression of pigment cell-specific genes such as the three members of the tyrosinase-related family. Tyrosinase, Tyrp1 and Dct promoters contain a motif termed E-box which is bound by the transcription factor Mitf. These E-boxes are also found in the promoters of the corresponding fish genes, thus highlighting the pivotal role of Mitf in pigment cell-specific gene regulation. Mitf, which displays cell type-specific isoforms, transactivates the promoters of the tyrosinase gene family in both pigment cell lineages. However, specific DNA motifs have been found in these promoters, and they correspond to binding sites for RPE-specific factors such as Otx2 or for melanocyte-specific factors such as Sox10 or Pax3. The regulation of pigment cell-specific expression is also controlled by genetic elements located outside of the promoter, such as the tyrosinase distal regulatory element located at -15 kb which acts as a melanocyte-specific enhancer but also protects from spreading of condensed chromatin. Thus, by using the tyrosinase gene family as a model, it is possible to define the transcription factor networks that govern pigment production in either melanocytes or RPE.

Animals↗

Risky sexual behavior among female entertainment workers in China: implications for HIV/STD prevention intervention.

Using qualitative information from in-depth interviews of 40 female entertainment workers (FEWs) in Shanghai, this article explores factors associated with unprotected sex and barriers to consistent condom use among FEWs. Results suggest that not all FEWs were at high risk, nor did they all engage in unprotected sex for the same reasons. Prevalence of unprotected sex varied by individual characteristics, across different settings where commercial sex took place, and by the FEWs' relationship to pimps or establishment owners. Factors contributing to unprotected sex included lack of HIV transmission knowledge, economic hardship, client refusal/coercion, and control by pimps/establishment owners. Incorrect beliefs also contributed to use of methods that offered no protection. Study participants endorsed the need for HIV/sexually transmitted disease prevention, but were suspicious about government programs. Prevention interventions need to target simultaneously clients of commercial sex and pimps/business owners and to promote a social environment supportive of 100% condom use in commercial sex.

Adult↗

Mammalian male germ cells are fertile ground for expression profiling of sexual reproduction.

Recent large-scale transcriptional profiling experiments of mammalian spermatogenesis using rodent model systems and different types of microarrays have yielded insight into the expression program of male germ cells. These studies revealed that an astonishingly large number of loci are differentially expressed during spermatogenesis. Among them are several hundred transcripts that appear to be specific for meiotic and post-meiotic germ cells. This group includes many genes that were previously implicated in spermatogenesis and/or fertility and others that are as yet poorly characterized. Profiling experiments thus reveal candidates for regulation of spermatogenesis and fertility as well as targets for innovative contraceptives that act on gene products absent in somatic tissues. In this review, consolidated high density oligonucleotide microarray data from rodent total testis and purified germ cell samples are analyzed and their impact on our understanding of the transcriptional program governing male germ cell differentiation is discussed.

Animals↗

Why pediatricians need lawyers to keep children healthy.

Pediatricians recognize that social and nonmedical factors influence child health and that there are many government programs and laws designed to provide for children's basic needs. However, gaps in implementation result in denials of services, leading to preventable poor health outcomes. Physician advocacy in these arenas is often limited by lack of knowledge, experience, and resources to intervene. The incorporation of on-site lawyers into the health care team facilitates the provision of crucial legal services to vulnerable families. Although social workers and case managers play a critical role in assessing family stability and finding appropriate resources for families, lawyers are trained to identify violations of rights and to take the appropriate legal steps to hold agencies, landlords, schools, and others accountable on behalf of families. The incorporation of lawyers in the clinical setting originated at an urban academic medical center and is being replicated at >30 sites across the country. Lawyers can help enhance a culture of advocacy in pediatrics by providing direct legal assistance and case consultation for providers, as well as jointly addressing systemic issues affecting children and families. Until laws to promote health and safety are consistently applied and enforced, pediatricians will need lawyers to effectively care for vulnerable children.

Child↗

[Permanent education in the context of nursing and health].

In this essay authors discuss the current proposal of permanent education by the Health Ministry, which is focused on the formation of human resources for the Public Health System. It covers education as a whole and specifically adult education, an issue that directly affects nursing, as nursing contributes with the largest number of healthcare workers, constituting the central focus of public policies. In this way authors present the main controversies and suggest adherence to the government program, understanding that for the first time there is a comprehensive project in this area that is intended to be permanent.

Education, Nursing, Continuing↗

[Community health centers: an alternative for the health system]

Reflecting on the current reorganization of the relationship between the state and civil society, the health care field is involved in an intense debate over the organization and use of government and private health services. The authors propose an alternative, consisting of the implementation of primary health care clinics, managed by local institutions and funded by the Unified Health System. To support this proposition, they report on the current experience at the Rocinha slum in Rio de Janeiro, where a community health center was built by the neighborhood association 12 years ago and has been managed by the community since then. The hospital referral rate at the clinic, requests for laboratory tests, and use of precriptions have been considerably limited, although these services are available. These low rates are attributed to the possibility of closer social control by the community, as well as to the geographical features of the center, favoring a broader perception of both health problems and treatment. In order to provide more substantial support to the proposed centers, some suggestions are presented, like the implementation of direct agreements between the government and neighborhood associations (not allowed under current legislation) and expanding potential sources of funding for the health centers, currently restricted to government programs.

Journal Article↗

An international look at school-based children's dental services.

School-based dental clinics, when well-managed, can bring good quality care to children where they normally congregate, thus avoiding many of the problems found where children must be taken to private offices out of school hours. Both capital and running expenses for primary care can be substantially reduced. Utilization figures for school-based dental services now reach 98 per cent of eligible children in New Zealand, where dental nurses do simple operative dentistry including cavity preparation and fillings. Australia, where a modified New Zealand plan has been expanding for about 12 years, is moving rapidly to attain similar utilization. In Sweden, 95 per cent of the school-age population is reported to receive school-managed dental service through a government program. In the United States, however, it is commonly reported that less than one-half the school-age population receives good periodic dental care.

Adolescent↗