Methodological approaches to situational analysis in global mental health: a scoping review.

Global inequity in access to and availability of essential mental health services is well recognized. The mental health treatment gap is approximately 50% in all countries, with up to 90% of people in the lowest-income countries lacking access to required mental health services. Increased investment in global mental health (GMH) has increased innovation in mental health service delivery in LMICs. Situational analyses in areas where mental health services and systems are poorly developed and resourced are essential when planning for research and implementation, however, little guidance is available to inform methodological approaches to conducting these types of studies. This scoping review provides an analysis of methodological approaches to situational analysis in GMH, including an assessment of the extent to which situational analyses include equity in study designs. It is intended as a resource that identifies current gaps and areas for future development in GMH. Formative research, including situational analysis, is an essential first step in conducting robust implementation research, an essential area of study in GMH that will help to promote improved availability of, access to and reach of mental health services for people living with mental illness in low- and middle-income countries (LMICs). While strong leadership in this field exists, there remain significant opportunities for enhanced research representing different LMICs and regions.

Consistency of ethnic differences in children's pressor reactivity. 1987 to 1992.

In this prospective investigation, all children enrolled in the public third-grade classrooms of an entire county (n = 474) had blood pressure measured both at rest and during a stressful television video game. Examinations were repeated in 4 subsequent years when cohort children as well as newly enrolled children were in grades 4, 5, 7, and 8. Both cross-sectional and longitudinal analyses indicated that black children demonstrated significantly greater systolic and diastolic pressor reactivity than white children. These data suggest that ethnic differences in children's pressor reactivity presage ethnic differences in adulthood hypertension.

Ethnicity, pressor reactivity, and children's blood pressure. Five years of observations.

During the 5 years of this investigation, resting blood pressure and pressor reactivity were measured in 292 white children and 46 black children in 1987, 1988, 1989, and 1991. In 1987, all children were in the third grade; in 1991, the children were in the seventh grade. Reactivity was assessed with a standardized psychological stressor, a television video game. Children displayed significant stability of absolute blood pressure and heart rate reactivity between grades 3 and 7. At all examinations, black children demonstrated blood pressure reactivity that was significantly greater in magnitude (both absolute level and change from resting measurements) than that of white children. Black children exhibited significantly greater heart rate reactivity only when defined as change from the resting measurements; absolute levels of heart rate reactivity were comparable for blacks and whites. For black children, blood pressure reactivity in 1987 was the strongest predictor of resting blood pressure (both systolic and diastolic) in 1991. Among white children, resting blood pressure was the strongest predictor of future resting blood pressure. Further research is needed to determine if ethnic differences in children's pressor reactivity are associated with ethnic differences in the prevalence of hypertension.

Race and cardiovascular reactivity. A neglected relationship.

The magnitude of the cardiovascular response to stress has been implicated in the pathogenesis of cardiovascular disease. Psychological stress procedures have received increased usage as an alternative to expensive physical (exercise) stress procedures. In the present investigation, 213 healthy, black or white, male or female children between the ages of 6 and 18 years were exposed to the psychological stress of a video game. The video game challenge was administered by a black or a white experimenter and was played under three levels of increasing stress, 1) personal challenge, 2) experimenter's challenge, and 3) experimenter's challenge accompanied by a financial incentive, while blood pressure and heart rate were monitored. Results indicated that the video games provoked significant and incremental cardiovascular reactivity across the games. Black children demonstrated significantly greater reactivity than white children; the racial difference was more reliably observed for systolic and diastolic blood pressure than for heart rate. Furthermore, the race of the experimenter exerted a significant effect and often interacted with the race of the child, such that greater reactivity occurred in same-race pairings than in mixed-race pairings. These results suggest that reactivity is affected by an individual's race and social milieu and that reactivity may be one mechanism responsible for the greater prevalence of hypertension among blacks.

Investigation and characterization of receptors for pituitary adenylate cyclase-activating polypeptide in human brain by radioligand binding and chemical cross-linking.

Pituitary adenylate cyclase-activating polypeptide (PACAP) is a novel peptide of hypothalamic origin which increases adenylate cyclase activity in rat anterior pituitary cell cultures. The 38-amino acid peptide shows a close sequence homology to vasoactive intestinal peptide (VIP). Binding sites for PACAP in membranes from postmortem human brain tissue were studied using [125I]PACAP27 as the radioligand. High specific binding sites (amount of specific binding measured at 0.25 nM [125I]PACAP27 in femtomoles per mg protein +/- SEM; n = 4) were present in hypothalamus (344.5 +/- 13.0), brain stem (343.0 +/- 29.3), cerebellum (292.0 +/- 21.1), cortex (259.6 +/- 19.8), and basal ganglia (259.2 +/- 50.3). Specific binding sites in pituitary, although present, were less abundant (35.0 +/- 8.9). Binding of [125I]PACAP27 was reversible and time, pH, and temperature dependent. Despite the homology with VIP, VIP was a poor inhibitor of [125I]PACAP27 binding (IC50, greater than 1 microM) compared with PACAP27 (IC50, 0.5-1.3 nM) and PACAP38 (IC50, 0.2-1.3 nM). Scatchard plots of [125I]PACAP27 binding showed the presence of both high and lower affinity sites. Chemical cross-linking of PACAP-binding sites revealed that [125I]PACAP27 was bound to polypeptide chains of 67,000 and 48,000 mol wt. Thus, we have demonstrated the presence of PACAP-specific receptors in human brain which are not VIP receptors. This opens the possibility of PACAP functioning as a novel neurotransmitter/neuromodulator in human brain.

Race and cardiovascular reactivity. A replication.

In a previous study, we reported that black children demonstrated greater cardiovascular reactivity than did white children to the psychological stress of a television video game. Reliance on urban volunteers and the wide age range of the children may have limited conclusions concerning the generalizability of those results. In the present study, 481 of 484 children enrolled in the third grade of the public schools of an entire rural county in Tennessee were examined with the same video game procedure used previously. Results indicated greater heart rate and blood pressure reactivity among black children than among white children. Thus, the previous results were replicated. The greater prevalence of hypertension among black adults may relate to the greater reactivity among black children; reactivity may be either a marker or a mechanism in the development of hypertension.

Endothelin in human brain and pituitary gland: presence of immunoreactive endothelin, endothelin messenger ribonucleic acid, and endothelin receptors.

The presence of immunoreactive (IR) endothelin, endothelin mRNA, and endothelin receptors in human brain and pituitary gland has been studied by RIA, Northern blot hybridization, and receptor assay. IR endothelin was detected in all five brain regions examined (cerebral cortex, cerebellum, brain stem, basal ganglia, and hypothalamus) (6-10 fmol/g wet wt) and spinal cord (22 +/- 6 fmol/g wet wt, n = 7, mean +/- SEM). Higher concentrations of IR endothelin were found in the pituitary gland (147 +/- 30 fmol/g wet wt). Fast protein liquid chromatographic analysis of the IR endothelin in pituitary gland showed a large IR peak in the position of endothelin-3 and a smaller peak in the position of endothelin-1, whereas IR endothelin in the hypothalamus and brain stem was mainly endothelin-1. Endothelin messenger RNA was detected by Northern blot hybridization in the pituitary but not in hypothalamus. The receptor assay showed that 125I-endothelin-1 binding sites were present in large numbers in all five brain regions but were much less abundant in the pituitary gland. Binding capacity and dissociation constant were 5052 +/- 740 fmol/mg protein and 0.045 +/- 0.007 nM in brain stem and 963 +/- 181 fmol/mg protein and 0.034 +/- 0.009 nM in hypothalamus. In the pituitary gland, there were two classes of binding sites for endothelin with dissociation constants of 0.059 +/- 0.002 nM (binding capacity = 418 +/- 63 fmol/mg protein) and 0.652 +/- 0.103 nM (binding capacity = 1717 +/- 200 fmol/mg protein). Endothelin-1, -2 and -3 were almost equipotent in displacing the binding (IC50 approximately 0.04 nM). These findings are in accord with the possibility that endothelin acts as a neurotransmitter, neuromodulator or neurohormone in man.

Aerobic fitness and the diurnal rhythm of blood pressure in adolescents.

We examined the effects of aerobic fitness and race on the diurnal rhythm of blood pressure of 175 healthy adolescents who performed a cycle ergometer maximal exercise test while oxygen consumption was measured. A median split of maximum oxygen consumption for boys and girls separately classified them as either "more-fit" or "less-fit" subjects. Ambulatory blood pressure recordings were also performed, and the data were analyzed for means while subjects were awake and asleep. Less-fit black boys had higher systolic pressures than more-fit black boys while awake (124 vs. 115 mm Hg; p less than 0.009) and asleep (117 vs. 108; p less than 0.001). Less-fit black boys also had higher systolic pressures than less-fit white boys while awake (114; p less than 0.002) and asleep (105; p less than 0.001), and they had higher systolic pressures than more-fit white boys while asleep (105; p less than 0.01). Less-fit black girls had higher systolic pressures than more-fit black girls while awake (116 vs. 109; p less than 0.004) and asleep (109 vs. 100; p less than 0.001). Less-fit black girls also had higher diastolic pressures than more-fit black girls while awake (71 vs. 66; p less than 0.002) and asleep (66 vs. 61; p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Race and gender influence ambulatory blood pressure patterns of adolescents.

The purpose of this study was to examine ambulatory blood pressure and heart rate patterns in healthy, normotensive adolescents and to determine the influence of race and gender on these patterns. Ambulatory blood pressure recordings were performed on 199 adolescents; 42 were black males, 55 were white males, 65 were black females, and 37 were white females. The mean age (+/- SD) was 13 +/- 2 years. Blood pressure readings were obtained with an automatic, noninvasive recorder. Black adolescents and white adolescents had similar blood pressures while awake (116/69 vs. 116/69 mm Hg), with boys having higher levels of systolic blood pressure (118 vs. 114 mm Hg) and comparable levels of diastolic blood pressure (69 vs. 69 mm Hg) relative to girls. The patterns while the adolescents were asleep, however, were different. White boys (106 mm Hg), white girls (105 mm Hg), and black girls (105 mm Hg) had similar systolic blood pressures during sleep. Black boys (112 mm Hg), however, had significantly higher systolic blood pressures while asleep. Black adolescents, as a group, had significantly higher diastolic blood pressures than white adolescents while asleep (64 vs. 61 mm Hg). Changes in blood pressure from awake to asleep were not related to changes in heart rate. Results of this study indicate that both race and gender are important determinants of the diurnal pattern of blood pressure and heart rate in adolescents.

Effects of doxepin on withdrawal symptoms in smoking cessation.

In a double-blind study, 15 cigarette smokers self-monitored 10 withdrawal symptoms. For the first 21 days (baseline), subjects received doxepin hydrochloride, up to 150 mg/day, or inert medication while continuing to smoke. On day 22, they were instructed to stop smoking; medication was continued. Withdrawal symptoms on the first 28 days of treatment (baseline and 7 days of attempted cessation) were analyzed. During cessation, subjects taking doxepin reported significantly less craving for cigarettes. Results from this study and others suggest that antidepressants may attenuate the severity of symptoms during withdrawal from addictive substances.

Doxepin as an adjunct to smoking cessation: a double-blind pilot study.

In a double-blind study, 19 adults received bedtime doses of either 150 mg of doxepin hydrochloride (N = 9) or placebo (N = 10). After 3 weeks the subjects were instructed to stop smoking and continue taking medication for 4 additional weeks. Cessation was reported by all nine doxepin subjects 1 week after cessation and by seven doxepin subjects 9 weeks after cessation. One placebo subject reported cessation. Cotinine assays generally confirmed cessation but were subject to interpretation. Doxepin assays suggested that the precessation level was associated with cessation. Further studies with larger samples and extended follow-up are needed to determine the reliability of these results.

Modulation of the alveolar macrophage respiratory burst by hydroperoxides.

Exposure of alveolar macrophages to hydroperoxides (ROOH) inhibits subsequent stimulation of O2.- production (the respiratory burst). Previous studies (under nonoxidant stress conditions) have shown that elevation of intracellular free calcium ([Ca2+]i) participates in both initiation and termination of O2.- production. In this investigation, the effects of sublethal ROOH exposure on [Ca2+]i and the respiratory burst of rat alveolar macrophages were compared. Exposure to a sublethal range of H2O2 or tert-butylhydroperoxide (10-100 pmol/10(6) cells; initially 10-100 microM under the experimental conditions) for 15 min resulted in dose-dependent effects on the respiratory burst stimulated by various agents, ADP, ATP, zymosan-activated serum, and phorbol myristate acetate. Low concentrations of the ROOH (10 or 25 pmol/10(6) cells) were found to enhance stimulation, whereas exposure to 75 or 100 pmol/10(6) cells resulted in significant inhibition for all of the stimuli. All concentrations of ROOH caused a rapid elevation in [Ca2+]i. For those concentrations of ROOH that produced enhancement of subsequent stimulation of the respiratory burst, [Ca2+]i returned to near baseline before the end of the 15-min preincubation. The temporal- and concentration-dependent effects of ROOH on [Ca2+]i correlate with subsequent enhancement or inhibition of stimulated O2.- production. Similarities between the ROOH-induced changes in [Ca2+]i and the effect of [Ca2+]i changes in physiological regulation of the respiratory burst suggest a potential relationship.

A comparison of two automated monitors in the measurement of blood pressure reactivity. Trials of Hypertension Prevention Collaborative Research Group.

Cardiovascular reactivity is the change in blood pressure, pulse, and other parameters of cardiovascular function in response to a challenging task. During the conduct of cardiovascular reactivity protocols, researchers frequently use automated blood pressure devices to measure blood pressure reactivity. However, the accuracy of automated devices in measuring blood pressure reactivity is unknown. To investigate the accuracy and precision of the Dinamap 1846 SXP and the VitaStat 2600B in the measurement of blood pressure reactivity, we compared blood pressure reactivity recorded by the VitaStat and Dinamap with that obtained by observers using a conventional mercury sphygmomanometer. At three sites, 159 normotensive subjects performed the same task twice, once with blood pressure reactivity measured by the manual observers and once by the VitaStat (n = 79) or Dinamap (n = 80), with the order determined at random. Ratios (VitaStat/Dinamap) of aggregate within-person variance for baseline and task, systolic and diastolic blood pressures ranged from 1.53 to 4.93 (all P < 0.01), suggesting that the Dinamap has better precision than the VitaStat. For both diastolic and systolic blood pressure reactivity and for both types of automated devices, the mean differences in blood pressure reactivity between manual and automated measurements were small (range, -1.8 to 0.8 mm Hg). However, the VitaStat versus manual scatter plot of diastolic blood pressure reactivity showed greater dispersion (correlation coefficient r = 0.16, P = 0.15) than the Dinamap versus manual scatter plot (r = 0.36, P = 0.001). For systolic blood pressure reactivity, the VitaStat versus manual and Dinamap versus manual scatter plots were similar. Our data indicate that the Dinamap is superior to the VitaStat in the measurement of blood pressure reactivity. The substantial performance differences between the VitaStat and Dinamap suggest that other automated blood pressure monitors must be evaluated prior to use in cardiovascular reactivity studies.

Stress management intervention for primary prevention of hypertension: detailed results from Phase I of Trials of Hypertension Prevention (TOHP-I).

PURPOSE: Stress Management Intervention (SMI) was one of seven nonpharmacologic approaches evaluated in Phase I Trials of Hypertension Prevention (TOHP-I) for efficacy in lowering diastolic blood pressure (BP) in healthy men and women aged 30 to 54 years with diastolic BP 80-89 mm Hg. METHODS: A total of 242 and 320 participants were randomized to SMI or an "assessment only" SMI Control, respectively, at four clinical centers. The SMI consisted of 37 contact hours in 21 group and two individual meetings over 18 months and included: training in four relaxation methods, techniques to reduce stress reactions, cognitive approaches, communication skills, time management, and anger management within a general problem-solving format. Standardized protocols detailed methods and timing for collecting BP, psychosocial measures, and urinary samples from both SMI and SMI Control participants. RESULTS: In intention-to-treat analyses, although significant baseline to termination BP reductions were observed in both groups, net differences between the SMI and SMI Control groups' BP changes (mean (95% CI)) were not significant: -0.82 (-1.86, 0.22) for diastolic BP, and -0.47 (-1.96, 1.01) for systolic BP. Extensive adherence sub-group analyses found one effect: a significant 1.36 mm Hg (p = 0.01) reduction in diastolic BP relative to SMI Controls at the end of the trial for SMI participants who completed 61% or more of intervention sessions. CONCLUSIONS: While the TOHP-I SMI was acceptable to participants as evident from high levels of session completion, the absence of demonstrated BP lowering efficacy in intention-to-treat analyses suggests that the TOHP-I SMI is an unlikely candidate for primary prevention of hypertension in a general population sample similar to study participants. The isolated finding of significant diastolic BP lowering in SMI participants with higher adherence provides very weak evidence of SMI BP lowering efficacy and may be a chance finding. Whether similar or other stress management interventions can produce significant BP lowering in populations selected for higher levels of BP, stress, or intervention adherence remains to be demonstrated.

Stability of ethnic differences in children's pressor responses during three annual examinations.

In this study, 395 healthy children had blood pressure and heart rate measured both at rest and during a stressful video game. Identical measurement procedures were used for three annual examinations. Consistently, black children demonstrated significantly greater pressor responses than white children. In view of the greater prevalence of hypertension among black adults than white adults, these data suggest that blacks exhibit hemodynamic irregularities well before the onset or diagnosis of hypertension.

The diagnostic value and cost effectiveness of routine fungal stains in a dermatopathology service of a district general hospital.

AIMS: To evaluate the use and effectiveness of fungal stains in a dermatopathology service of a district general hospital. METHODS: A retrospective analysis of skin biopsies submitted over three years, where fungal stains were used; the results were correlated with clinical history and case notes. RESULTS: In total, 99 cases were studied for fungi with the periodic acid Schiff stain with diastase. Fungi were present in seven cases; fungi had been suggested in the differential diagnosis of three of these cases but were an unexpected finding in four cases. CONCLUSION: Non-specific clinical details should prompt early fungal staining and non-specific microscopic findings or inappropriate well recognised skin reaction patterns should warrant the exclusion of fungal infection. The finding of at least one case of unexpected fungal infection is justified financially and for patient best management where clinical and microscopic findings are non-specific or inappropriate.

Demonstration of Epstein-Barr virus in primary brain lymphoma by in situ DNA hybridisation in paraffin wax embedded tissue.

Tumour tissue from 29 patients with primary brain lymphoma was reviewed to determine if there was an aetiological association between Epstein-Barr virus and polyclonal and monoclonal lymphoproliferations. The morphology and immunophenotype in 24 patients for whom paraffin wax embedded tissue was available were studied. A high grade pleomorphic tumour morphology with plasmacytoid features was seen in 13 tumours. Because of the large number of pleomorphic lymphomas, all tumours were examined for the presence of the Epstein-Barr virus genome using in situ DNA hybridisation. A panel of three biotinylated probes to different sequences in the Epstein-Barr virus genome was used. Positive hybridisation with one or more probes was shown in tumours from 11 patients. The remaining tumours gave no hybridisation signal. There was no correlation between positive hybridisation and morphological subtype or clinical outcome.

Gender and ethnicity in children's cardiovascular reactivity: 7 years of study.

A total of 295 children (127 White boys, 15 Black boys, 133 White girls, and 20 Black girls) participated in reactivity examinations in 1987 (all were in 3rd grade; age, M = 9.1 years), 1988, 1989, 1991, 1992 and 1993 (all were in 9th grade; age, M = 15.1 years). An analysis of residualized reactivity change values indicated consistent and significant ethnicity effects (Blacks greater than Whites) for systolic and diastolic blood pressure and for heart rate. Gender effects were also apparent for both systolic and diastolic blood pressure (boys greater than girls). These data suggest that the transition from childhood to adolescence is associated with a significant pattern of ethnic differences in reactivity, although the association of this pattern with the development of cardiovascular risk and disease remains to be ascertained.

The validity of children's self-reports of physical activity: a preliminary study.

Ninety-two healthy children provided self-reports of their physical activity. Self-reports were based upon posters depicting children performing typical childhood activities and were validated by measured oxygen uptake during maximal cycle ergometry. Results indicated that when children were classified as sedentary or active by their poster selection, active children had significantly greater oxygen uptake than sedentary children. These results, while preliminary, are the first to indicate that children's self-reports can provide a valid index of maximal oxygen uptake, the 'gold standard' of aerobic fitness.