Patient Choice of Health Care Providers in China: Primary Care Facilities versus Hospitals

As China’s health system is faced with challenges of overcrowded hospitals, there is a great need to better understand the recent patterns and determinants of people’s choice between primary care facilities and hospitals for outpatient care. Based on recent individual-level data from the China Health and Retirement Longitudinal Survey (CHARLS) and official province-level data from China health statistical yearbooks, we examine the patterns of outpatient visits to primary care facilities versus hospitals among middle-aged and older individuals and explore both supply- and demand-side correlates that explain these patterns. We find that 53% of outpatient visits were paid to primary care facilities as opposed to hospitals in 2015, compared to 60% in 2011. Both supply and demand factors were associated with this decline. On the supply side, we find that the density of primary care facilities did not account for this decline, but higher densities of hospitals and licensed doctors were associated with lower use of primary care facilities. On the demand side, we find that individuals with higher socioeconomic status and greater health care needs were less likely to use primary health care facilities. Our findings suggest that a high concentration of health care professionals in hospitals diverts patients away from primary care facilities. Staffing the primary care facilities with a well-trained health care workforce is the key to a well-functioning primary care system. The findings also suggest a need to address demand-side inequality issues

The Effect of the L'Aquila Earthquake on Labour Market Outcomes

In this paper we analyse the effects of the L'Aquila earthquake on labour market outcomes for a period of fifteen months after its occurrence. Our estimates are based on a difference-in-differences strategy that compares residents of L'Aquila with residents of a control area before and after the earthquake. Three main results emerge from our empirical analysis: (1) the earthquake led to a modest, but significant, reduction in the probability of participating in the labour force for a period of nine months after the event; (2) while the employment likelihood decreased in the quarter immediately after the earthquake, it increased in the next four quarters; and (3) there is evidence of significant heterogeneous effects by gender and level of education

Morphine inhibits cortisol and stimulates prolactin secretion in man

The role of opioids in endocrine regulation has been the subject of numerous studies. Surprisingly, however, the acute endocrine effects of morphine on basal hormonal levels in man have not been adequately documented. We report here the effects of intravenous morphine (5 mg) on plasma cortisol and prolactin. Fourteen healthy volunteers (nine male, five female) received morphine at 0930 hr. Blood samples were collected immediately before and 30, 60, 90, 120 and 180 min after the injection. In six of the male subjects the procedure was repeated with a placebo (normal saline) injection. Morphine stimulated prolactin release. There was a trend for a greater response in females compared to male subjects. Cortisol secretion was markedly suppressed by morphine. In sharp contrast to the results obtained with placebo, cortisol levels following morphine declined progressively at a rate consistent with the half-life of cortisol. This downward trend of cortisol values continued uninterrupted for the duration of the experiment in all 14 subjects. These results are consistent with the presence of an inhibitory opioid mechanism in the human hypothalamopituitary-adrenal axis.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/25007/1/0000434.pd

Escape from dexamethasone suppression: Possible role of an impaired inhibitory opioid mechanism

1. 1. Several lines of evidence indicate that the activity of the hypothalamus-pituitary-adrenal (HPA) axis in depression is disinhibited.2. 2. Escape from dexamethasone suppression, although not limited to is more frequent in patients with endogenous depression compared to normals or patients with other psychiatric diagnoses.3. 3. Norepinephrine, serotonin and acetylcholine have been implicated in the pathophysiology of this neuroendocrine abnormality.4. 4. Morphine, 5 mg intravenously, suppressed Cortisol secretion in healthy volunteers (n = 4) and the majority of 32 psychiatric inpatients.5. 5. However, patients with endogenous depression abnormal dexamethasone suppression test results show early resumption (escape) of cortisol secretion following the initial suppression induced by morphine.6. 6. It is concluded that the pathophysiology of this neuroendocrine abnormality is not limited to classical neurotransmitter-HPA axis interaction but that it also involves opioid inhibitory mechanisms.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/25429/1/0000878.pd

Dexamethasone suppression test and selection of antidepressant medications

Endogenous depressives with abnormal dexamethasone suppression tests (DSTs) respond better to somatic antidepressant treatments than those with normal DSTs. Whether the DST also aids in the selection of specific antidepressants has not been determined. A pilot report suggested that patients with abnormal DSTs might be noradrenaline-deficient and respond preferentially to imipramine or desipramine, whereas those with normal DSTs might be serotonin-deficient and respond best to amitriptyline or clomipramine. Attempting to replicate this observation, we studied 26 patients diagnosed with Research Diagnostic Criteria as major depressive disorder, endogenous subtype, and with DSM-III as having melancholia. All were drug-free during baseline evaluation. All had abnormal DST results, with post-dexamethasone plasma cortisol levels exceeding 5 [mu]g/dl. We treated subjects with either imipramine or amitriptyline and compared clinical response with weekly Hamilton Depression Rating Scales, completed by raters blind to both DST results and the research question. Therapeutic plasma levels were documented. We found no significant differences in treatment response between the subgroups. Twenty of the 26 subjects did well. The imipramine-treated group failed to have either earlier response or better final outcome. These data fail to replicate suggestions that DST results assist in the selection of either imipramine or amitriptyline.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/24183/1/0000442.pd

Prevalence of dementia in Latin America: a collaborative study of population-based cohorts

Background: Dementia is becoming a major public health problem in Latin America (LA), yet epidemiological information on dementia remains scarce in this region. This study analyzes data from epidemiological studies on the prevalence of dementia in LA and compares the prevalence of dementia and its causes across countries in LA and attempts to clarify differences from those of developed regions of the world. Methods: A database search for population studies on rates of dementia in LA was performed. Abstracts were also included in the search. Authors of the publications were invited to participate in this collaborative study by sharing missing or more recent data analysis with the group. Results: Eight studies from six countries were included. The global prevalence of dementia in the elderly (≥65 years) was 7.1% (95% CI: 6.8–7.4), mirroring the rates of developed countries. However, prevalence in relatively young subjects (65–69 years) was higher in LA studies The rate of illiteracy among the elderly was 9.3% and the prevalence of dementia in illiterates was two times higher than in literates. Alzheimer’s disease was the most common cause of dementia. Conclusions: Compared with studies from developed countries, the global prevalence of dementia in LA proved similar, although a higher prevalence of dementia in relatively young subjects was evidenced, which may be related to the association between low educational level and lower cognitive reserve, causing earlier emergence of clinical signs of dementia in the LA elderly population

Foodways in transition: food plants, diet and local perceptions of change in a Costa Rican Ngäbe community

Background Indigenous populations are undergoing rapid ethnobiological, nutritional and socioeconomic transitions while being increasingly integrated into modernizing societies. To better understand the dynamics of these transitions, this article aims to characterize the cultural domain of food plants and analyze its relation with current day diets, and the local perceptions of changes given amongst the Ngäbe people of Southern Conte-Burica, Costa Rica, as production of food plants by its residents is hypothesized to be drastically in recession with an decreased local production in the area and new conservation and development paradigms being implemented. Methods Extensive freelisting, interviews and workshops were used to collect the data from 72 participants on their knowledge of food plants, their current dietary practices and their perceptions of change in local foodways, while cultural domain analysis, descriptive statistical analyses and development of fundamental explanatory themes were employed to analyze the data. Results Results show a food plants domain composed of 140 species, of which 85 % grow in the area, with a medium level of cultural consensus, and some age-based variation. Although many plants still grow in the area, in many key species a decrease on local production–even abandonment–was found, with much reduced cultivation areas. Yet, the domain appears to be largely theoretical, with little evidence of use; and the diet today is predominantly dependent on foods bought from the store (more than 50 % of basic ingredients), many of which were not salient or not even recognized as ‘food plants’ in freelists exercises. While changes in the importance of food plants were largely deemed a result of changes in cultural preferences for store bought processed food stuffs and changing values associated with farming and being food self-sufficient, Ngäbe were also aware of how changing household livelihood activities, and the subsequent loss of knowledge and use of food plants, were in fact being driven by changes in social and political policies, despite increases in forest cover and biodiversity. Conclusions Ngäbe foodways are changing in different and somewhat disconnected ways: knowledge of food plants is varied, reflecting most relevant changes in dietary practices such as lower cultivation areas and greater dependence on food from stores by all families. We attribute dietary shifts to socioeconomic and political changes in recent decades, in particular to a reduction of local production of food, new economic structures and agents related to the State and globalization

Prolactin response to TRH in depression

We studied the prolactin response to TRH in 53 unmedicated psychiatric inpatients. The prolactin response of females was significantly greater than the response of male subjects. There was no significant difference in the prolactin response to TRH between depressed patients and those with other psychiatric diagnoses. There was no significant relationship between the prolactin response to TRH and the severity of depression, the TSH response to TRH or the resistance to suppression of cortisol secretion by dexamethasone.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/26341/1/0000428.pd

Comparison of early and delayed inpatient dexamethasone suppression tests

Ninety-five inpatients completed a dexamethasone suppression test (DST) within 72 hours after admission and again after at least 1 week of medication-free hospital care. The frequency of cortisol nonsuppression in patients with endogenous depression (ED) was high and not significantly different at both tests. In patients with diagnoses other than ED, the higher rate of cortisol nonsuppression at the first DST was associated with a significant decrease in test specificity. Change in postdexamethasone cortisol levels at repeat testing was associated with a decrease in depressive symptomatology, but was not related to weight change during hospitalization.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/28066/1/0000509.pd