Medicaid Expansion Under the Affordable Care Act: Potential Changes in Receipt of Mental Health Treatment Among Low-Income Nonelderly Adults With Serious Mental Illness.

OBJECTIVES: We designed this study to examine differences in receipt of mental health treatment between low-income uninsured nonelderly adults with serious mental illness (SMI) who were eligible for Medicaid under the Affordable Care Act (ACA) and their existing Medicaid counterparts. Assessing these differences might estimate the impact of the Medicaid expansion efforts under the ACA on receipt of mental health treatment among uninsured nonelderly adults with SMI. METHODS: We examined data from 2000 persons aged 18 to 64 years who participated in the 2008 to 2013 National Survey on Drug Use and Health, had income below 138% of the federal poverty level, met SMI criteria, and either were uninsured (n = 1000) or had Medicaid-only coverage (n = 1000). We defined SMI according to the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act. We used descriptive analyses and logistic regression modeling. RESULTS: In the 28 states currently expanding Medicaid, the model-adjusted prevalence (MAP) of receiving mental health treatment among Medicaid-only enrollees with SMI (MAP = 71.3%; 95% confidence interval [CI] = 65.74%, 76.29%) was 30.1% greater than their uninsured counterparts (MAP = 54.8%; 95% CI = 48.16%, 61.33%). In the United States, the MAP of receiving mental health treatment among Medicaid-only enrollees with SMI (MAP = 70.4%; 95% CI = 65.67%, 74.70%) was 35.9% higher than their uninsured counterparts (MAP = 51.8%; 95% CI = 46.98%, 56.65%). CONCLUSIONS: Estimated increases in receipt of mental health treatment because of enrolling in Medicaid among low-income uninsured adults with SMI might help inform planning and implementation efforts for the Medicaid expansion under the ACA.

An introduction to sensitivity analysis for unobserved confounding in nonexperimental prevention research.

Despite the fact that randomization is the gold standard for estimating causal relationships, many questions in prevention science are often left to be answered through nonexperimental studies because randomization is either infeasible or unethical. While methods such as propensity score matching can adjust for observed confounding, unobserved confounding is the Achilles heel of most nonexperimental studies. This paper describes and illustrates seven sensitivity analysis techniques that assess the sensitivity of study results to an unobserved confounder. These methods were categorized into two groups to reflect differences in their conceptualization of sensitivity analysis, as well as their targets of interest. As a motivating example, we examine the sensitivity of the association between maternal suicide and offspring's risk for suicide attempt hospitalization. While inferences differed slightly depending on the type of sensitivity analysis conducted, overall, the association between maternal suicide and offspring's hospitalization for suicide attempt was found to be relatively robust to an unobserved confounder. The ease of implementation and the insight these analyses provide underscores sensitivity analysis techniques as an important tool for nonexperimental studies. The implementation of sensitivity analysis can help increase confidence in results from nonexperimental studies and better inform prevention researchers and policy makers regarding potential intervention targets.

Social norms, social networks, and HIV risk behavior among injection drug users.

Social network structure and norms are linked to HIV risk behavior. However little is known about the gradient of norm of HIV risk that exists among social networks. We examined the association between injection risk network structure and HIV risk norms among 818 injection drug users (IDUs). IDUs were categorized into four distinct groups based on their risk behaviors with their drug networks: no network members with whom they shared cookers or needles, only cooker-sharing member, one needle-sharing member, and multiple needle-sharing members. The riskiest group, networks of multiple needle sharers, was more likely to endorse both risky needle-sharing and sex norms. Networks of only cooker sharers were less likely to endorse high-risk norms, as compared to the networks with no sharing. There were also differences based on gender. Future HIV prevention interventions for IDUs should target both injection and sex risk norms, particularly among IDUs in the multiple needle-sharing networks.

The impact of parental suicide on child and adolescent offspring.

Child and adolescent survivors of parental suicide experience two stressful events simultaneously: (1) the loss of a primary caregiver, and (2) suicidal death of a significant person. These youths are thought to be at increased risk for mental health problems, but a systematic review of studies on these survivors has not yet been conducted. A comprehensive search for published literature identified nine studies. The existent studies provided modest yet inconsistent evidence on the impact of parental suicide on offspring psychiatric and psychosocial outcomes. More methodologically rigorous research is needed to inform and guide postvention efforts for these survivors.

Eradication diminishes enhancing effects of Helicobacter pylori infection on glandular stomach carcinogenesis in Mongolian gerbils.

To investigate the nature of the link between Helicobacter pylori (Hp) infection and stomach carcinogenesis, a study of the glandular stomach of Mongolian gerbils (MGs) was performed. MGs were treated with N-methyl-N-nitrosourea (MNU), followed by inoculation with Hp (groups 1 and 2) or without Hp (group 3), or infected with Hp (groups 4 and 5) or inoculation without Hp (group 6) followed by MNU administration. At week 21, the animals in groups 2 and 5 underwent an eradication procedure. At week 50, the incidences of adenocarcinomas in group 1 (15 of 23) and group 4 (9 of 26) were significantly higher than in group 3 (1 of 15) and group 6 (1 of 18), respectively. Moreover, those in group 2 (5 of 24) and group 5 (2 of 22) were lower than in groups 1 and 4, respectively. This study shows that Hp eradication may be useful as a prevention approach against stomach cancer.

Effect of monosialoganglioside (GM1) on transected monoaminergic pathways.

The effects of exogenous monosialogangliosides (GM1) on transected monoaminergic cerebral cortical pathways were investigated in mice. Norepinephrine (NE), 5-hydroxytryptamine (5-HT), and 5-hydroxyindole-3-acetic acid (5-HIAA) contents were determined in cerebral cortex rostral and caudal to unilateral coronal transection sites. The transmitter contents were expressed as a ratio of those in the unlesioned contralateral cortex. In the caudal cortex, NE ratios fell to 70% within a week after transection and decreased further to 35-40% by 4 weeks. Treatment with exogenous GM1 for 2 weeks starting shortly after the lesion increased NE concentrations in the caudal cortex to 47.4-55.0% at 4 weeks, significantly greater than control animals (p less than 0.01, Mann-Whitney U-test). GM1 treatment for 2 and 4 weeks, starting 2 weeks after the lesion, yielded similar results. The 5-HT and 5-HIAA ratios in the caudal cortex also rose significantly after GM1 treatment. Thus, GM1 increased monoaminergic levels nonspecifically in the cortex caudal to the cortical lesion. The treatment effect did not depend on the timing or duration of treatment. These results indicate that exogenous GM1 treatment has a nonspecific restorative effect on the central nervous system after axonal lesions.

Lymphocytic hypophysitis and pulmonary sarcoidosis. Report of a case.

Lymphocytic hypophysitis is one of the causes of hypopituitarism in the postpartum period. Some of these patients have been reported to have other organ-specific autoimmune diseases, and the disease is considered to be autoimmune in nature. The authors describe a unique case of lymphocytic hypophysitis in a young woman. She had hemianopia that developed three days after delivery. Computed tomography scans revealed an intrasellar mass lesion. Secretions of adrenocorticotropic hormone and growth hormone were decreased. Although no organ-specific autoantibodies were detected in her serum, OKT4-positive helper T lymphocytes were increased in peripheral blood. Pituitary biopsy at craniotomy showed typical features of lymphocytic hypophysitis. Pulmonary and eye sarcoidosis developed 11 months after the delivery. This is, to the authors' knowledge, the first case of lymphocytic hypophysitis associated with sarcoidosis in other organs.

Floating gallbladder associated with histologically distinct double cancers.

A case of unusually hypermobile floating gallbladder in a 79-year-old woman with histologically distinct double cancers of the gallbladder is described. The patient presented with an abdominal cystic mass, which was palpable with easy mobility from the right lower quadrant practically to the left upper quadrant. Exploratory laparotomy was performed and the cystic mass was found to be a floating gallbladder. The cystic duct was elongated and obstructed, and had a long mesentery. After the operation, latent double cancers of the gallbladder were discovered on histopathological examination. The obstruction of the cystic duct was due to chronic inflammation and had resulted in hydrops of the gallbladder. This was suspected to have played an important role in the carcinogenesis. We believe that this is the first report of a floating gallbladder associated with double gallbladder cancers.

New animal model of glandular stomach carcinogenesis in Mongolian gerbils infected with Helicobacter pylori and treated with a chemical carcinogen.

In 1994 WHO/IARC concluded that "Helicobacter pylori is a definite carcinogen" based on epidemiological studies, but there have been few reports demonstrating a relation between H. pylori and stomach cancer in animal models. We have succeeded in producing adenocarcinomas in the glandular stomachs of Mongolian gerbils with N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) or N-methyl-N-nitrosourea as carcinogens and hope to establish an experimental stomach carcinogenesis model using H. pylori. Male Mongolian gerbils, 7 weeks old, were infected with H. pylori followed by MNNG administration at a concentration of 100ppm administration or treated with MNNG at a concentration of 300ppm in their drinking water followed by inoculation with H. pylori. They were then killed sequentially, and their excised stomachs underwent microbiological and histopathological examinations. H. pylori were detected in all infected gerbils. Hyperplastic change of pyloric mucosa was observed with high 5-bromo-2'-deoxyuridine incorporation in affected animals. H. pylori infection persists on administration of MMNG and enhances glandular stomach proliferation in Mongolian gerbils. Whether long-term colonization promotes carcinogenesis in the glandular stomach of Mongolian gerbils is a matter of great interest.

Immunohistochemical prognostic indicators of gastrointestinal carcinoid tumours.

AIMS: The aim of this study was to determine whether expression of the oncoproteins p21, p53, E-cadherin (EC), cyclin D1, bcl-2 and Rb and the proliferation marker Ki-67 is predictive of malignant behaviour in gastrointestinal carcinoid tumours. METHODS: Immunohistochemical (IHC) staining was performed on carcinoid tumours from 41 patients (31 rectal, eight gastrointestinal, two appendiceal lesions). The six tumours that had invaded deeply into the muscularis propria or beyond, had metastasized to regional lymph nodes or had metastasized to a distant site were classified as the malignant group, and the other 35 tumours formed the benign group. IHC expression was compared between the two groups, and the prognostic value of each marker was assessed. RESULTS: Of the six tumours in the malignant group, 66.7% were p21 positive, 0% were p53 positive, 33.3% were EC positive, 100% were cyclin D1 positive, 33.3% were Rb positive, 16.7% were bcl-2 positive and 50% were Ki-67 positive. Of the 35 tumours in the benign group, 17.1% were p21 positive, 0% were p53 positive, 100% were EC positive, 94.3% were cyclin D1 positive, 8.6% were Rb positive, 17.1% were bcl-2 positive and 0% were Ki-67 positive. CONCLUSIONS: These data show that p53, cyclin D1, Rb, bcl-2 and Ki-67 staining does not correlate with malignant behaviour but that overexpression of p21 (P=0.02) and reduced staining of EC (P=0.005) do correlate with malignant behaviour. These two parameters may therefore be useful as prognostic indicators for gastrointestinal carcinoid tumours.

Intraorbital optic nerve hemangioblastoma with von Hippel-Lindau disease. Case report.

An intraorbital hemangioblastoma of the optic nerve is reported in a 23-year-old woman with von Hippel-Lindau disease. The absence of dural attachment and the microscopic findings were characteristic of hemangioblastoma. Four years later the patient developed a cystic hemangioblastoma in the left cerebellum which was successfully treated.

Sparganosis of the brain. Case report.

A rare case of cerebral sparganosis occurring in a 7-year-old boy is reported. Since his clinical symptoms fluctuated and diagnostic evaluation demonstrated multiple lesions, he was examined for a parasitic infection. Emphasis is placed on the difficulties involved in diagnosing cerebral sparganosis.

Analysis of epidural pressure pulse wave (EDP-PW) and common carotid blood velocity (CBFV) in acute intracranial hypertension.

The changes in the two consistent components of epidural pressure pulse wave (EDP-PW), P1 and P2 waves, and mean velocity of common carotid blood flow (CBFV) were studied in 21 patients with acute intracranial hypertension to investigate the origin of th the amplitude change in these components. The amplitudes of P2 wave increased progressively with the rise of EDP, but those of P1 wave remained nearly invariable at EDP of more than 20-30 mmHg which is incompatible with the changes in CBFV. Jugular vein compression caused in rapid rise of EDP and a proportionate increase in the magnitudes of both waves. Hyperventilation and mannitol administration caused a disproportionate reduction in the amplitudes of P2 wave with a fall of EDP. But mannitol at high EDP (more than 40 mmHg) caused a mild fall of EDP and some increase in the amplitudes of P2 wave. These results indicate that the variations in the amplitudes of P1 wave reflect the changes in vascular resistance of the large intracranial conductive arteries, while those of P2 wave result from the changes in the volume of the cerebral bulk. The increase in the amplitudes of P2 wave induced by mannitol at high EDP may suggest a defective autoregulation of the cerebral vessels.

Non-invasive measurement in intracranial pressure and analysis of the pulse waveform.

Non-invasive measurement of the intracranial pressure (ICP) via the anterior fontanelle by using an applanation transducer has been performed. Recently, a new fontanometer using an applanation transducer has been developed in our department by improving the conventional Statham transducer, P-50 which is currently accepted for its high reliability. In this study, by analysing patterns of the ICP pulse waves obtained from this new fontanometer, its clinical evaluation has been made in 27 neonates and infants in intracranial pathologies. Analysing the ICP waveforms, the first peak (P1) was divided by the following second peak (P2) and the changes in P1/P2 were examined. A differential amplifier, a dP/dt detector, was also used to make it easier to identify the turning point on the pulse waves. The results obtained demonstrated that the waveforms of ICP in neonates as well as infants are influenced by not only the intracranial constituents but compliance of the container such as the scalp, cranium and the meninges.

Noninvasive study of critical thresholds of intracranial pressure and cerebral perfusion pressure for cerebral circulation and brain function.

To ascertain the critical thresholds of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) for cerebral circulation and brain function, the extra- and intracranial haemodynamics and electrical brain responses were evaluated noninvasively with Doppler ultrasonography and multimodality evoked potentials (MEP's) in 50 patients with severe head injury. Both extra- and intracranial blood flow velocities changed monotonically depending on the changes in ICP and CPP. They were decreased when ICP increased to 20-30 mmHg and when CPP decreased to 40-50 mmHg. The changes in elasticity index of the pulse wave of the common carotid artery was proportional to those of blood flow velocities. The frequency and degree of abnormalities of MEP's were proportionally increased with the rise of ICP and reduction of CPP. When ICP increased to higher than 31 mmHg, MEP's were classified as moderately or severely abnormal in more than 76% of the recordings. These results indicate that noninvasive study by use of Doppler ultrasonography and MEP's can provide valuable information on critical brain ischaemia and brain dysfunction in patients with acute intracranial hypertension.

A case of holoprosencephaly: with possible association of Dandy-Walker cyst.

The authors described a case of alobar holoprosencephaly with a huge cyst in the posterior fossa, possible representing a Dandy-Walker cyst, and marked cerebellar agenesis in the absence of median facial dysmorphias that has recently been encountered at our clinic.

Pleomorphic xanthoastrocytoma with desmoplastic reaction: angiomatous variant. Report of two cases.

Two cases of cerebral pleomorphic xanthoastrocytomas (PXA-s) with prominent vascularity and desmoplastic changes occurring in young subjects are presented. The tumors displayed the marked pleomorphism characteristic of PXA-s and had variable cellularity. The cytoplasm of many tumor cells contained an abundance of lipid droplets. Most tumor cells were positive for glial fibrillary acidic protein. The unusual feature about these tumors was the presence of very large numbers of tiny blood vessels with variable thickness of their walls. In many areas the small vessels and the neoplastic astrocytes were in close proximity to each other, with capillaries adjacent to or protruding into tumor cell cytoplasm, reminiscent of the pattern seen in highly vascularized or "angiomatous" meningiomas. In other areas extensive fibrosis was seen. We feel that the latter, as in the cases of comparably vascular meningiomas, had its origin in congelation and secondary organization of plasma proteins that have exuded through leaky walls of newly formed blood vessels. These are the first reported cases of PXA with an angiogliomatous pattern.

Arachnoid cyst of the quadrigeminal cistern.

The case report of an infant girl with hydrocephalus due to an arachnoid cyst situated at the posterior end of the third ventricle is described. The mechanism of fluid accumulation in the cyst and the choice of surgical treatment are discussed.

"True" posterior communicating artery aneurysm.

A "true" posterior communicating artery aneurysm was noted in our series of 490 intracranial aneurysms among 419 patients. The possible surgical significance of this type of aneurysm is discussed.

Traumatic intracranial hematomas in hemophiliac children.

Three cases of traumatic acute subdural hematoma in hemophilia A children underwent surgical interventions. There were two functional survivors and one death. The management of intracranial hematoma in hemophiliac patients is discussed.