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Achieving equitable healthcare access is a global challenge. Improving whole-population mental health and reducing the global burden of mental disorders is a key recommendation of the 2018 Lancet Global Mental Health Commission, which proposed monitoring national indicators, including the proportion of people with severe mental disorders who are service-users. This study aims to derive an equity indicator from national datasets integrating need, service utilisation and socioeconomic status, and demonstrate its utility in identifying gaps in mental health service use amongst those with the greatest need, thereby guiding equitable healthcare delivery.
Methods
We present a case study of a universal health insurance scheme (Medicare) in Australia. We developed the equity indicator using three national datasets. Geographic areas were linked to an area-based socioeconomic deprivation quintile (Census 2016). Per geographic area, we estimated the number with a mental healthcare need using scores ≥30 on the Kessler-10 (Australian National Health Surveys 2015 and 2018), and obtained the number of services used, defined as mental health-related contacts with general practitioners and mental health professionals (Medicare administrative data 2015–2019). We divided the number of services by the population with an estimated mental healthcare need and averaged these use-rates across each socioeconomic deprivation quintile. The equity indicator is the ratio of the use-rates in the least versus most deprived quintiles.
Results
Those estimated to have the greatest need for mental healthcare in 2019 ranged between 8.2% in the most disadvantaged area quintile (Q1) and 2.4% in the least (Q5), corresponding to a proportional increase of 27.7% in Q1 and 19.5% in Q5 since 2015. Equity-indicator-adjusted service rates of 4.2 (3.8–4.6) and 23.9 (22.4–25.4) showed that individuals with the highest need for care residing in Q1 areas received a stark 6 times fewer services compared to their Q5 counterparts, producing an equity indicator of 6.
Conclusions
As the global prevalence of common mental disorders may be increasing, it is crucial to calculate robust indicators evaluating the equity of mental health service use. In this Australian case study, we developed an equity indicator enabling the direct comparison of geographic areas with different need profiles. The results revealed striking inequities that persisted despite publicly-funded universal healthcare, recent service reforms and being a high-income country. This study demonstrates the importance and feasibility of generating such an indicator to inform and empower communities, healthcare providers and policymakers to pursue equitable service provision.
Reward and threat processes work together to support adaptive learning during development. Adolescence is associated with increasing approach behavior (e.g., novelty-seeking, risk-taking) but often also coincides with emerging internalizing symptoms, which are characterized by heightened avoidance behavior. Peaking engagement of the nucleus accumbens (NAcc) during adolescence, often studied in reward paradigms, may also relate to threat mechanisms of adolescent psychopathology.
Methods:
47 typically developing adolescents (9.9–22.9 years) completed an aversive learning task during functional magnetic resonance imaging, wherein visual cues were paired with an aversive sound or no sound. Task blocks involved an escapable aversively reinforced stimulus (CS+r), the same stimulus without reinforcement (CS+nr), or a stimulus that was never reinforced (CS−). Parent-reported internalizing symptoms were measured using Revised Child Anxiety and Depression Scales.
Results:
Functional connectivity between the NAcc and amygdala differentiated the stimuli, such that connectivity increased for the CS+r (p = .023) but not for the CS+nr and CS−. Adolescents with greater internalizing symptoms demonstrated greater positive functional connectivity for the CS− (p = .041).
Conclusions:
Adolescents show heightened NAcc-amygdala functional connectivity during escape from threat. Higher anxiety and depression symptoms are associated with elevated NAcc-amygdala connectivity during safety, which may reflect poor safety versus threat discrimination.
Angiostrongylus cantonensis has been found in Florida, USA, from the panhandle in the north to Miami and surrounding areas in the southern parts of the state, in both definitive and intermediate hosts in a limited studies completed in 2015. Additional studies have identified this parasite in a variety of intermediate hosts, both native and non-native gastropod species, with new host species recorded. Many areas in Florida with higher A. cantonensis prevalence were those with a high human population density, which suggests it is a matter of time before human infections occur in Florida. Case reports in the state currently involve non-human primates and include a gibbon and orangutan in Miami. Here, we report the current status of A. cantonensis in the state, as well as the infection in a capuchin monkey and presumptive infection in a red ruffed lemur in Gainesville, Florida.
We studied circadian thyrotropin (TSH) and prolactin (PRL) response to synthetic thyrotropin-releasing-hormone (protirelin) infusion (200μg IV) at 8 am and 11 pm in 35 drug-free inpatients with DSM III-R Major Depressive Episode and in 22 hospitalized controls. In each group, maximum TSH and PRL responses were lower at 8 am than at 11 pm. The difference between 11 pm-ΔTSH and 8 am-ΔJTSH (ΔΔTSH) was significantly lower in depressed patients compared to controls. No such blunting was observed in PRL responses to protirelin in depressed patients. In the overall population, TSH response to protirelin (ie8 am-ΔTSH, 11 pm-ΔTSH, ΔΔTSH) correlated significantly with TSH circadian parameters (ie mesor and amplitude). These correlations were also observed with PRL (except for ΔΔPRL). TSH mesor and amplitude were lower in depressives than in controls. In contrast, PRL mesor and amplitude were not significantly different between diagnostic groups. ΔΔTSH is thus a chronobiological refinement to the measure of thyroid axis dysfunction in major depression. The blunted TSH response to protirelin suggests that the TRH receptors of the pituitary thyrotrophs are hyposensitive in major depression.
Although cognitive-behavioural therapy (CBT) is an effective treatment for depression, less than half of patients achieve satisfactory symptom reduction during treatment. Targeting known psychopathological processes such as rumination may increase treatment efficacy. The aim of this study was to test whether adding group rumination-focused CBT (RFCBT) that explicitly targets rumination to routine medical management is superior to adding group CBT to routine medical management in treating major depression.
Methods
A total of 131 outpatients with major depression were randomly allocated to 12 sessions group RFCBT v. group CBT, each in addition to routine medical management. The primary outcome was observer-rated symptoms of depression at the end of treatment measured on the Hamilton Rating Scale for Depression. Secondary outcomes were rumination at post-treatment and depressive symptoms at 6 months follow-up (Trial registered: NCT02278224).
Results
RFCBT significantly improved observer-rated depressive symptoms (Cohen's d 0.38; 95% CI 0.03–0.73) relative to group CBT at post-treatment on the primary outcome. No post-treatment differences were found in rumination or in depressive symptoms at 6 months follow-up, although these secondary analyses may have been underpowered.
Conclusions
This is the first randomized controlled trial providing evidence of benefits of RFCBT in major depression compared with CBT. Group RFCBT may be a beneficial alternative to group CBT for major depression.
This article presents a conceptual clarification of asymmetric hypotheses and a discussion of methodologies available to test them. Despite the existence of a litany of theories that posit asymmetric hypotheses, most empirical studies fail to capture their core insight: boundaries separating zones of data from areas that lack data are substantively interesting. We discuss existing set-theoretic and large-N approaches to the study of asymmetric hypotheses, introduce new ones from the literatures on stochastic frontier and data envelopment analysis, evaluate their relative merits, and give three examples of how asymmetric hypotheses can be studied with this suite of tools.
To investigate an outbreak of Pseudomonas aeruginosa infections and colonization in a neonatal intensive care unit.
DESIGN
Infection control assessment, environmental evaluation, and case-control study.
SETTING
Newly built community-based hospital, 28-bed neonatal intensive care unit.
PATIENTS
Neonatal intensive care unit patients receiving care between June 1, 2013, and September 30, 2014.
METHODS
Case finding was performed through microbiology record review. Infection control observations, interviews, and environmental assessment were performed. A matched case-control study was conducted to identify risk factors for P. aeruginosa infection. Patient and environmental isolates were collected for pulsed-field gel electrophoresis to determine strain relatedness.
RESULTS
In total, 31 cases were identified. Case clusters were temporally associated with absence of point-of-use filters on faucets in patient rooms. After adjusting for gestational age, case patients were more likely to have been in a room without a point-of-use filter (odds ratio [OR], 37.55; 95% confidence interval [CI], 7.16–∞). Case patients had higher odds of exposure to peripherally inserted central catheters (OR, 7.20; 95% CI, 1.75–37.30) and invasive ventilation (OR, 5.79; 95% CI, 1.39–30.62). Of 42 environmental samples, 28 (67%) grew P. aeruginosa. Isolates from the 2 most recent case patients were indistinguishable by pulsed-field gel electrophoresis from water-related samples obtained from these case-patient rooms.
CONCLUSIONS
This outbreak was attributed to contaminated water. Interruption of the outbreak with point-of-use filters provided a short-term solution; however, eradication of P. aeruginosa in water and fixtures was necessary to protect patients. This outbreak highlights the importance of understanding the risks of stagnant water in healthcare facilities.
Supernovae play an integral role in the feedback of processed material back into the interstellar medium (ISM) of galaxies and are responsible for most of the chemical enrichment of the universe. The rate of supernovae can also reveal the star formation histories. In a sample of 11 nearby galaxies observed with SINFONI, a strong linear correlation between [FeII]1.26 luminosity and Starburst 99-derived supernova rate is found on a pixel-pixel basis. In the very nearby archetypal starburst galaxy NGC 253, the excitation of molecular gas is a subject of debate. Using the correlation between [FeII] and supernova rate, we can determine if supernovae can account for the excitation of the bright observed near-infrared H2 emission.
Trajectory analysis of the windfields at 10 m and 1.5 km was used to determine the direction and extent of windborne movements of insects trapped in spring and summer in south-eastern and eastern Asia for the period 1968 to 1985. Approximately 2500 trajectories, depicting the movements of airborne particles, were constructed where temperatures were high enough (>=10°C) to allow flight and where wind speeds (> =5 kmh−1) were expected to lead to downwind displacements. Trap catches were dominated (97%) by delphacid species (e.g. Nilaparvata lugens Stål and Sogatella furcifera (Horváth)), with Cicadellidae (1.1%) and Diptera (0.7%) as the next most numerous. Very few Lepidoptera were reported. Most trajectories were less than or equal to 40 h in duration. The previously recognized northwards migration along a broad front in prevailing Summer Monsoon and Trade winds was confirmed, as was the important role of frontal depressions in the windborne migration of insects in temperate areas. Nearly 50% of the trajectories were constructed in mobile weather systems which both disturbed and strengthened the prevailing winds and led to pronounced differences in the direction and distance of sources for insects caught at any catching site. Similarly, fluctuations in position of quasi-stationary fronts induced considerable mixing of populations from different sources and influenced the northern extent of each phase of rice pest migration. The results supported earlier findings that migrations occurred between the tropics and temperate areas during the spring and summer, but also indicated that migrations within the tropics at this time of year were a more frequent occurrence than had been considered previously.
The turtle's optokinetic response is described by a simple model that incorporates visual-response properties of neurons in the pretectum and accessory optic system. Using data from neuronal and eye-movement recordings that have been previously published, the model was realized using algebraic-block simulation software. It was found that the optokinetic response, modelled as a simple negative feedback system, was similar to that measured from a behaving animal. Because the responses of retinal-slip detecting neurons corresponded to the nonlinear, closed-loop optokinetic response, it was concluded that the visual signals encoded in these neurons could provide sufficient sensory information to drive the optokinetic reflex. Furthermore, it appears that the low gain of optokinetic eye movements in turtles, which have a negligible velocity storage time constant, may allow stable oculomotor output in spite of neuronal delays in the reflex pathway. This model illustrates how visual neurons in the pretectum and accessory optic system can contribute to visually guided eye movements.
Some countries have introduced mandatory folic acid fortification, whereas others support periconceptional supplementation of women in childbearing age. Several European countries are considering whether to adopt a fortification policy. Projections of the possible beneficial effects of increased folic acid intake assume that the measure will result in a considerable reduction in neural-tube defects (NTD) in the target population. Therefore, the objective of the present study is to evaluate the beneficial effects of different levels of folic acid administration on the prevalence of NTD. Countries with mandatory fortification achieved a significant increase in folate intake and a significant decline in the prevalence of NTD. This was also true for supplementation trials. However, the prevalence of NTD at birth declined to approximately five cases at birth per 10 000 births and seven to eight cases at birth or abortion per 10 000 births. This decline was independent of the amount of folic acid administered and apparently reveals a ‘floor effect’ for folic acid-preventable NTD. This clearly shows that not all cases of NTD are preventable by increasing the folate intake. The relative decline depends on the initial NTD rate. Countries with NTD prevalence close to the observed floor may have much smaller reductions in NTD rates with folic acid fortification. Additionally, potential adverse effects of fortification on other vulnerable population groups have to be seriously considered. Policy decisions concerning national mandatory fortification programmes must take into account realistically projected benefits as well as the evidence of risks to all vulnerable groups.
Reproduction errors have occured in figures 1–4 of this paper, published in these proceedings, pages 112–119. The complete corrected paper is reproduced here for clarity.
Cambridge University Press apologise to the authors and readers for these errors.
We present 21 cm observations of 5×1 square degrees centered on the local Abell cluster 1367 obtained as part of the Arecibo Galaxy Environment Survey. This represents the first HI selected sample covering the core and the outskirts of a local cluster of galaxies. Combining the HI data with SDSS optical imaging we show that in HI selected samples follow scaling relations similar to the ones usually observed in optically selected samples. The most striking difference between HI and optically selected samples resides in their large scale distribution: while optical and X-ray observations trace the cluster potential very well, at radio wavelengths there is almost no evidence of the cluster presence.