[Epidemiology of suicide in older persons]. / Epidemiologie von Suizidalität im Alter.

The suicide risk in Germany increases with age. The suicide rates follow the so called "Hungarian" pattern. Especially the percentage of older females among all suicides has increased unproportionally in recent years in relation to their percentage in the population. Every second suicide of a female is today a suicide of a female older than 60 years. The main suicide method among older persons is hanging. Suicide attempts are rare among older persons; however, the rates are increasing among the oldest age groups. The suicide attempts of older persons are committed with a higher lethality and show rarely appellative components. Suicide attempt methods are often poisoning with pharmaceuticals. In total the suicide and suicide attempt rates among elderly are underestimated due to indirect methods (passive reactions, e.g. noneating). Reasons for suicides and suicide attempts among older persons are often psychic illnesses (mostly depression), motives often include loss of partners, loss of the social network, fear of the consequences of somatic illnesses and loss of freedom of action. Thus, often the social situation of older persons with suicide attempts changed before suicide was attempted.

Sexual orientation data collection and progress toward Healthy People 2010.

Without scientifically obtained data and published reports, it is difficult to raise awareness and acquire adequate resources to address the health concerns of lesbian, gay, and bisexual Americans. The Department of Health and Human Services must recognize gaps in its information systems regarding sexual orientation data and take immediate steps to monitor and eliminate health disparities as delineated in Healthy People 2010. A paper supported by funding from the Office of the Assistant Secretary for Planning and Evaluation explores these concerns and suggests that the department (1) create work groups to examine the collection of sexual orientation data; (2) create a set of guiding principles to govern the process of selecting standard definitions and measures; (3) recognize that racial/ethnic, immigrant-status, age, socioeconomic, and geographic differences must be taken into account when standard measures of sexual orientation are selected; (4) select a minimum set of standard sexual orientation measures; and (5) develop a long-range strategic plan for the collection of sexual orientation data.

Cost-effectiveness of elective cesarean delivery in human immunodeficiency virus-infected women(1).

OBJECTIVE: To evaluate the cost-effectiveness of an elective cesarean delivery strategy in human immunodeficiency virus (HIV)-infected women receiving zidovudine therapy to prevent perinatal transmission. METHODS: A decision-analysis model was constructed to compare two delivery strategies in HIV-infected women: usual care and recommendation for elective cesarean delivery. The model followed a hypothetical cohort of 7000 HIV-infected pregnant women in the United States who were receiving zidovudine therapy for 1 year. The third-party payer perspective was taken. Cost of delivery method with and without complications and lifetime medical care cost for pediatric HIV infection were considered. The main outcome measure was cases of perinatal HIV transmission prevented. RESULTS: Compared with the usual care strategy, the elective cesarean delivery strategy resulted in an additional 3486 cesarean deliveries each year, prevented 142 cases (52.4%) of perinatal HIV transmission, and resulted in incremental overall cost savings to society of $5.3 million per year ($37,284 saved per case of perinatal transmission prevented). With other estimates held constant, the elective cesarean delivery strategy would not be cost saving when the baseline perinatal HIV transmission rates were all reduced by 43.3%. CONCLUSIONS: Elective cesarean delivery in HIV-infected women receiving zidovudine is one management strategy for prevention of perinatal HIV transmission and can be cost saving. However, if other strategies, such as use of combination antiretroviral therapy and/or measurement of viral load, result in at least 50% reduction of the baseline perinatal HIV transmission rates, elective cesarean delivery will not be cost saving.

The cost effectiveness of strategies for the treatment of intestinal parasites in immigrants.

BACKGROUND: Currently, more than 600,000 immigrants enter the United States each year from countries where intestinal parasites are endemic. At entry persons with parasitic infections may be asymptomatic, and stool examinations are not a sensitive method of screening for parasitosis. Albendazole is a new, broad-spectrum antiparasitic drug, which was approved recently by the Food and Drug Administration. International trials have shown albendazole to be safe and effective in eradicating many parasites. In the United States there is now disagreement about whether to screen all immigrants for parasites, treat all immigrants presumptively, or do nothing unless they have symptoms. METHODS: We compared the costs and benefits of no preventive intervention (watchful waiting) with those of universal screening or presumptive treatment with 400 mg of albendazole per day for five days. Those at risk were defined as immigrants to the United States from Asia, the Middle East, sub-Saharan Africa, Eastern Europe, and Latin America and the Caribbean. Cost effectiveness was expressed both in terms of the cost of treatment per disability-adjusted life-year (DALY) averted (one DALY is defined as the loss of one year of healthy life to disease) and in terms of the cost per hospitalization averted. RESULTS: As compared with watchful waiting, presumptive treatment of all immigrants at risk for parasitosis would avert at least 870 DALYs, prevent at least 33 deaths and 374 hospitalizations, and save at least $4.2 million per year. As compared with watchful waiting, screening would cost $159,236 per DALY averted. CONCLUSIONS: Presumptive administration of albendazole to all immigrants at risk for parasitosis would save lives and money. Universal screening, with treatment of persons with positive stool examinations, would save lives but is less cost effective than presumptive treatment.

Metropolitan governance, residential segregation, and mortality among African Americans.

OBJECTIVES: This study tested the hypothesis that the degree to which local government is metropolitanized is associated with mortality rates for African Americans and with residential segregation, which has itself previously been shown to be positively associated with mortality among African Americans. METHODS: One hundred fourteen US standard metropolitan statistical areas were examined. The primary dependent variable was the age-adjusted, race- and sex-specific all-cause mortality rate, averaged for 1990 and 1991. The 2 primary independent variables were residential segregation, as measured by the index of dissimilarity, and metropolitanization of government, as measured by the central city's elasticity score. RESULTS: Mortality rates for male and female African Americans were lower in metropolitan statistical areas with more metropolitanized local governments and lower levels of residential segregation. Mortality for male and female Whites was not associated in either direction with residential segregation. White male mortality showed no association with level of metropolitanization, but lower White female mortality rates were associated with less metropolitanization. CONCLUSIONS: This study suggests the need for further research into whether policy changes in areas not traditionally thought of as "health policy" areas can improve the health of urban minorities.

PIP: The relationship between metropolitanization and mortality among African Americans in the United States is analyzed using data from 114 standard metropolitan statistical areas for 1991-1992 taken from the NCHS Mortality Detail Files and the census. The results confirm the finding that segregation is positively associated with mortality among adult African Americans. The results also indicate that less metropolitanization is associated with more segregation.

The influence of program acceptability on the effectiveness of public health policy: a study of directly observed therapy for tuberculosis.

OBJECTIVES: This study examined how patient acceptability influences the effectiveness of directly observed therapy for tuberculosis. METHODS: Decision and sensitivity analyses were used in assessing influences. RESULTS: If mandatory directly observed therapy discourages 6% of initial tuberculosis patients (range: 4% to 10%) from seeking care, then such therapy will be less effective than self-administered therapy. Directly observed therapy is more effective than repeated self-administered therapy for patients failing to complete initial treatment unless 32% (range: 27% to 38%) of patients avoid seeking care. CONCLUSIONS: Patient acceptability must be taken into consideration before selecting public health strategies.

Defining and measuring sexual orientation: a review.

How to define and identify sexual orientations for the purpose of constructing representative samples of homosexuals, bisexuals, and heterosexuals is unclear and confusing to researchers. Different definitions and measures have been proposed and used to develop samples since the 1860s when sexual orientations first gained widespread research interest. Unfortunately, the definitions and measurement tools used since then result in the selection of divergent and incomparable samples. If advances in the understanding of sexual orientations are to be made, it is critical that definitions and measures of sexual orientation be standardized. This paper reviews and critiques definitions and measures of sexual orientation that have been proposed and used by researchers over the past century. This review is intended to further our understanding of this subject and to encourage researchers to be critical of how they classify subjects based upon sexual orientation.

Sampling homosexuals, bisexuals, gays, and lesbians for public health research: a review of the literature from 1990 to 1992.

Our objective was to examine the representativeness of samples of homosexuals, bisexuals, gays, and lesbians obtained for public health research. We identified journal articles cited in Medline and published between 1990 and 1992 that sampled individuals and classified them as homosexual, bisexual, gay, and/or lesbian. Information was abstracted from these articles to evaluate four components of sample selection affecting the representativeness of samples: (1) how the population is conceptually defined, (2) how the sampled population is operationally identified, (3) the setting from which samples are selected, and (4) the use of probability sampling to select subjects. We identified 152 public health articles published between 1990 and 1992 that sampled homosexuals, bisexuals, gays, and/or lesbians. We found articles (1) rarely (4/152) conceptually defined the population they were sampling, (2) used a range of incomparable methods to identify and select subjects, (3) sampled from settings representative of dramatically different populations, and (4) rarely (3/152) used probability sampling. Overall, we find methods used to identify homosexuals, bisexuals, gays, and lesbians for public health research produce samples representative of different and sometimes unidentifiable populations. To understand these populations from a public health perspective, it is imperative that steps be taken by researchers to standardize population definitions and sampling methodologies.

Health values of patients infected with human immunodeficiency virus. Relationship to mental health and physical functioning.

To assess the health values of patients infected with human immunodeficiency virus (HIV) and examine the relationships between their health values and health status at two points in time, the authors sought to determine whether patients' physical and mental health statuses were good predictors of how they valued their current state of health. One hundred thirty-nine patients with various stages of HIV infection were interviewed in a prospective cohort study based in a primary care practice of a community-based teaching hospital. Patients were interviewed twice at 6-month intervals using three health value measures--the time trade off, rating scale, and Quality of Well-being Scale--and three health status measures: the 18-item Mental Health Inventory, the Dyspnea-Fatigue Index, and the Medical Outcomes Study SF-36 Health Survey. The health status of HIV-infected patients was compromised and, with the exception of mental health, generally was worse among patients with more advanced HIV-infection. Rating scale and Quality of Well-being Scale scores were related inversely to disease stage, but time-trade off scores generally were higher regardless of disease stage. Health value measures showed moderate relationships with measures of physical functioning (r = 0.34-0.68) but only a fair relationship with mental health (r = 0.00-0.48). The health status of HIV-infected patients who remained asymptomatic or remained symptomatic but without developing acquired immunodeficiency syndrome (AIDS) changed little over 6 months, whereas the health status of patients with AIDS and of patients manifesting progression of HIV-infection deteriorated over time. In contrast, health values, particularly time-tradeoff scores, remained stable even in the face of changes in health status and disease progression. With the exception of mental health, the impact of HIV infection on health status tends to parallel the clinical stage of disease. Health values of HIV-infected patients, however, generally are high and correlate better with physical functioning than with mental health.

The prevalence of homosexual behavior and attraction in the United States, the United Kingdom and France: results of national population-based samples.

Researchers determining the prevalence of homosexuality in nationally representative samples have focused upon determining the prevalence of homosexual behavior, ignoring those individuals whose sexual attraction to the same sex had not resulted in sexual behavior. We examine the use of sexual attraction as well as sexual behavior to estimate the prevalence of homosexuality in the United States, the United Kingdom, and France using the Project HOPE International Survey of AIDS-Risk Behaviors. We find that 8.7, 7.9, and 8.5% of males and 11.1, 8.6, and 11.7% of females in the United States, the United Kingdom, and France, respectively, report some homosexual attraction but no homosexual behavior since age 15. Further, considering homosexual behavior and homosexual attraction as different but overlapping dimensions of homosexuality, we find 20.8, 16.3, and 18.5% of males, and 17.8, 18.6, and 18.5% of females in the United States, the United Kingdom, and France report either homosexual behavior or homosexual attraction since age 15. Examination of homosexual behavior separately finds that 6.2, 4.5, and 10.7% of males and 3.6, 2.1, and 3.3% of females in the United States, the United Kingdom, and France, respectively, report having had sexual contact with someone of the same sex in the previous 5 years. Our findings highlight the importance of using more than just homosexual behavior to examine the prevalence of homosexuality.

Definition and measurement of sexual orientation.

Measurement and definition of sexual orientations have increasingly become a central focus in both research design and public policy debates. This paper reviews major methods, and their theoretical underpinnings, for the definition and measurement of sexual orientation, highlighting their limitations and pitfalls, both practical and conceptual. The increasing politicization of this area is discussed and cautioned against. Recommendations, both general and geared toward measurement concerns with adolescent populations, are made. A specific measurement strategy, which can be utilized at a number of different levels, is detailed.

HIV screening of surgeons and dentists: a cost-effectiveness analysis.

OBJECTIVE: To assess the cost-effectiveness of human immunodeficiency virus (HIV) screening strategies of surgeons and dentists. DESIGN: We constructed a model to project costs and HIV transmissions prevented over 15 years for four screening scenarios: 1) one-time voluntary screening, 2) one-time mandatory screening, 3) annual voluntary screening, and 4) annual mandatory screening. One-time screening occurs only in the first year of the program; annual screening occurs once each year. Under mandatory screening, all practitioners are tested and risks of practitioner-to-patient transmission are eliminated for all practitioners testing positive. Voluntary screening assumes 90% of HIV-positive and 50% of HIV-negative practitioners are tested, and risks of transmission in the clinical setting are eliminated for 90% of HIV-positive surgeons and dentists. All costs and benefits are discounted at 5% per annum over 15 years. RESULTS: Using "best-case" scenario assumptions, we find for surgeons that a one-time voluntary screening program would be most cost-effective, at $899,336 for every HIV transmission prevented. For dentists, the one-time voluntary program also is the most cost-effective, at $139,571 per transmission prevented. Annual mandatory programs were least cost-effective for both surgeons and dentists, at $63.3 million and $2.2 million per transmission prevented, respectively. CONCLUSIONS: HIV screening of surgeons and dentists ranks among the more expensive medical lifesaving programs, even using liberal assumptions about program effectiveness. Frequency of screening and whether testing is mandatory or voluntary dramatically affect cost per transmission prevented; these features should be considered carefully in designing specific HIV screening programs.

Extracellular matrix preparation of expanded polytetrafluoroethylene grafts seeded with endothelial cells: influence on early platelet deposition, cellular growth, and luminal prostacyclin release.

The importance of blood and extracellular matrix precoating of expanded polytetrafluoroethylene (ePTFE) grafts on the effectiveness of endothelial cell (EC) seeding was assessed in a canine experimental model. Part I of the study documented ex vivo platelet deposition in 256 ePTFE grafts, 6 cm x 4 mm internal diameter, after implantation as femoral artery-femoral vein or carotid artery-jugular vein arteriovenous shunts. These conduits were precoated with blood, fibronectin, laminin, or collagen type IV with laminin, after which they were seeded with enzymatically derived and cultivated venous canine endothelium at a density of 30,000 to 40,000 EC/cm2 of graft surface. Luminal deposition of Indium 111-labeled platelets, expressed as 10(8) platelets/cm2, at 30 minutes (n = 176) and 24 hours (n = 80), respectively, was 2.29 and 0.30 for blood, 2.83 and 0.37 for fibronectin, 0.99 and 0.08 for laminin, and 0.98 and 0.11 for collagen type IV with laminin. Part II of the study documented in vivo luminal EC coverage at 14 days of 6 cm x 4 mm internal diameter ePTFE femoral or carotid arterial grafts (n = 8) prepared in the same manner as part I ex vivo shunt grafts. EC coverage with blood, fibronectin, laminin, and collagen type IV with laminin preparation was 42%, 49%, 44%, and 52%, respectively. The graft:carotid artery ratio of luminal 6-keto-PGF1 alpha release at 14 days with these same four preparations was 0.38, 0.31, 0.35, and 0.32, respectively. Precoatings of ePTFE prostheses with fibronectin, laminin, and collagen type IV are known to enhance the initial attachment of seeded EC. Fibronectin caused an insignificant increase in early platelet accumulation; laminin or laminin with collagen type IV preparations were associated with significantly less (p less than 0.005) deposition of platelets when compared to whole blood preparations. Most importantly, none of the four preparation techniques resulted in different in vivo rates of EC growth or luminal release of prostacyclin from conduits studied 14 days after implantation.

International migration among Egyptian elites: where they've been; where they're going?

Aspects of the international migration of Egypt's urban educated elite are examined using data from a 1987 survey of 874 Egyptian university students. "Specific questions considered are: What has been the migration experience of these elites? In what ways has this experience changed over time and what changes are likely to occur in the future? What are some of the characteristics of the potential participants in these changes? How do answers to these questions vary among different segments of this elite and what can be inferred about the class nature of Egyptian migration processes?"

Egyptian international labor migration and social processes: toward regional integration.

PIP: This article reviews evidence that contemporary Egyptian international labor migration to oil-rich Arab countries has followed a classic social process which starts with a homo economicus phase, advances into a goal reorientation phase, and ends with the establishment of diaspora communities in destination societies. The history of Egyptian migration, current estimates of migration, the role of Egyptians in selected Arab countries, and emergent processes all were found to support the predictions of the social process model. Particularly important support comes from the finding that all social classes participated in this migration. For 1982, the Ministry for Foreign Affairs, based on individual consulate figures, reported 2.9 million migrants in oil-rich countries. Conclusions suggest the likelihood that Egyptian migration processes will promote economic and perhaps social integration in the region.^ieng

Karyotype analysis of cell sex to determine the source of vascular graft luminal linings following autologous and nonautologous endothelial cell seeding.

Endothelial cell-seeded bilateral carotid ePTFE grafts were studied in 11 dogs to determine the source of their eventual luminal linings. One graft was prepared with autologous cells and the other with nonautologous cells. Immunosuppression was accomplished with cyclosporin and prednisolone. At 2 and 3 weeks post implantation, grafts were removed, revealing 9 of 11 autologous and 8 of 11 nonautologous seeded conduits to be patent. Linings were harvested enzymatically and grown in tissue culture, with karyotype analysis limited to cultures that exhibited greater than or equal to 50% endothelium (n5 autologous, n7 nonautologous). Sex type was classified in 20 cells from each graft. All five autologous cell-seeded grafts revealed host cells. Among the seven nonautologous cell-seeded grafts, one harbored only non-autologous cells, three revealed only autologous cells, and three exhibited a predominance of autologous cells with lesser numbers of nonautologous endothelium. All 100 cells from the autologous-seeded grafts were the same sex as seeded cells, while only 28 of the 140 cells from the nonautologous seeded grafts were the same sex as seeded cells (P less than 0.001). Thus, nonautologous endothelial cell seeding with immunosuppression did not uniformly produce nonautologous cell linings, but was more often associated with autologous endothelial cell linings that may have been promoted by the nonautologous cell seeding.

Age structure, the life course and "aged heterogeneity": prospects for research and theory.

A widespread generalization in the study of aging is that old people are the most heterogeneous of any age group on a wide variety of characteristics. This phenomenon has several implications for thinking about aging. First, if cohorts or age strata vary systematically in their distributions on a given characteristic, then the dominant practice of comparing them primarily on measures of central tendency may obscure significant aspects of aging. Second, attention to systematic differences in variability points to the need to distinguish life-course, cohort and period dynamics in the production of patterns of variability. From a life-course perspective the construction of intracohort trajectories of variability for successive cohorts can disentangle these potentially confounded processes. Examining intracohort variability as outcome, we consider several hypothetical trajectories of variability, describe the kinds of processes likely to underlie each, and suggest hypothetical examples of characteristics to which each may apply. Finally, we consider the possible influence of age strata differences in intrastratum variability upon other aspects of social structure and upon individual aging.