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BackgroundIn 2023, President Biden issued an executive order requiring cost-benefit analyses for new regulations to account for distributional effects. To inform new tobacco regulations, we estimate for the first time racial and ethnic disparities in spending and outcomes associated with smoking.MethodsWith the 2008–2019 Medical Expenditure Panel Survey linked to the National Health Interview Survey, n=118 084 adults-years, logit models estimate the per cent of the top 10 health conditions attributable to smoking. Two-part regression models estimate the share of and total annual healthcare spending attributable to smoking.ResultsWhite adults had higher ever-smoked rates, but minority smoking adults had twice as much of their annual medical spending associated with smoking than white smoking adults, 25% vs 12% (p<0.01). minority adults who smoked had 41% (p<0.05) higher risks of multiple chronic conditions associated with smoking than white adults. While the share of white smoking adults trying to quit declined to 53% in 2019, this desire increased to 63% for minorities. From 2008–2016, smoking comprised 7.5% of the nation’s spending for white adults and 10.7% for minorities (p<0.05). In 2017–2019, this declined to 2.5% of the nation’s spending for white adults and 8.9% for minorities (p<0.05). For any new antitobacco regulation, the cost savings would be $134 million per year for every 100 000 minorities averted from initiating smoking, 135% more than the $57 million saved annually for 100 000 white adults averted.ImplicationsMinority adults may benefit substantially more from antitobacco regulations and past federal cost-benefit analyses would have overlooked this.

It is known that smoking is associated with greater chronic pain. However, little is known about the magnitude of this relationship and its association with prescription opioid use. We examine the association between smoking status and three sets of outcomes: (1) starting and discontinuing opioids, (2) intensity of opioid use, and (3) opioid use and pain outcomes after quitting smoking. We use multinomial logit on adults in the nationally representative 2013–2021 Medical Expenditure Panel Survey linked to the National Health Interview Survey (N = 36,796). Smoking adults made up 16% of the population but used 30% of all opioid prescriptions and 40% of all annual Morphine Milligram Equivalents (MMEs). The 1% of the population that smoked and had severe work limitations due to pain used 20% of all MMEs. Smoking adults were 24% more likely than never-smoking adults to have chronic pain. Among those with pain, smoking adults had 46% higher relative risk of starting opioids compared to never-smoking adults (p < .01), and smoking adults had 6.6 times higher relative risk of continuing opioids the next year compared to never-smoking adults (p < .01). Those smoking and using opioids had 95% higher odds of using a prescribed dosage of 50 MME or more than never-smoking adults. A year after quitting smoking, opioid use declined by 20% and pain declined by 7% compared to those continuing to smoke, with no difference from never-smoking adults after 12 years. Integrating smoking cessation into pain management programs could be highly beneficial to adults with chronic pain.

On July 22, two veteran warships, the last two of the five Tarawa-class amphibious assault ships USS Nassau (LHA 4) and USS Peleliu (LHA 5), turned over a watch near [...]

To improve breast cancer control among Latinas, it is important to understand culturally based beliefs that may influence the way women view this disease. We did a telephone survey of randomly selected Latinas and non-Hispanic white (Anglo) women in Orange County, California, to explore such beliefs using questions from previous national surveys and an ethnographic study of breast cancer. Respondents included 803 Latinas and 422 Anglo women. Latinas were more likely than Anglo women to believe that factors such as breast trauma (71% versus 39%) and breast fondling (27% versus 6%) increased the risk of breast cancer, less likely to know that symptoms such as breast lumps (89% versus 98%) and bloody breast discharge (69% versus 88%) could indicate breast cancer, and more likely to believe that mammograms were necessary only to evaluate breast lumps (35% versus 11%) (P < .01 for each). After adjusting for age, education, employment status, insurance status, and income, logistic regression analysis confirmed that Latino ethnicity and acculturation levels were significant predictors of these beliefs. We conclude that Latinas' beliefs about breast cancer differ in important ways from those of Anglo women and that these beliefs may reflect the moral framework within which Latinas interpret diseases. These findings are important for the development of culturally sensitive breast cancer control programs and for practicing physicians., (Hubbell FA, Chavez LR, Mishra SI, Valdez RB: Differing beliefs about breast cancer among Latinas and Anglo women. West J Med 1996; 164:405-409) Despite advances in screening and treatment during [...]

Objective. We explore the contribution of income and ethnicity to geographic variation in utilization of surgical procedures. Data Sources/Study Setting. We assessed the use of eight procedures from 1986 through 1988 among residents of Los Angeles County using data from the California Discharge Dataset, the 1980 census, and other secondary sources. Procedures chosen for evaluation were coronary artery bypass grafting (CABG), coronary artery angioplasty, permanent pacemaker insertion, mastectomy, simple hysterectomy, transurethral prostate resection (TURP), carotid endarterectomy, and appendectomy. Study Design. The amount of inter-zip code variation for each procedure was first measured using various estimates including the analysis of variance coefficient of variation (CVA). Population weighted multivariate regression analysis was used to model variation in age and gender--adjusted rates of procedure use among 236 residential zip codes. Principal Findings. Highest-variation procedures were coronary artery angioplasty (CVA = .392) and carotid endarterectomy (CVA = .374). The procedures with the lowest degree of variation were cardiac pacemaker implantation (CVA = .194) and hysterectomy (CVA = .195). Variation was significantly related to income (carotid endarterectomy) and either African American or Latino zip code ethnicity for all procedures except pacemaker implantation. For all procedures except appendectomy, the direction of the effect was toward fewer procedures with lower income. However, the effect of African American or Latino population ethnicity varied. Conclusions. In this large urban area both population ethnicity and socioeconomic status are significantly associated with the geographic utilization of selected surgical procedures. Key Words. Small-area analysis, practice variation, socioeconomic factors, race, ethnicity, Analyses of geographic variation in rates of medical procedure use have historically focused on demographically homogeneous rural areas or on international comparisons, obscuring the perception that two factors, socioeconomic status [...]

Direct gas thickening is a conventional mobility control method to improve volumetric sweep efficiency for miscible gas injection (MGI) projects. However, the viability of this approach with technically feasible thickeners has not been verified at the field-scale due to a combination of high costs and/or environmental issues. One approach to make this technique economically more attractive is the implementation of an alternating injection scheme (similar to water-alternating-gas (WAG)) that would require less of the thickened gas compared with a continuous injection scheme. In this study, the effectiveness of this approach where a miscible alternating injection of thickened associated gas (TAG) or thickened CO2(TCO2) with unthickened AG is explored in both nonfractured and fractured composite carbonate cores. Twelve core-flooding experiments were conducted using different injection schemes (i.e., continuous unthickened, continuous thickened, and alternating thickened–unthickened). These tests demonstrate that overall the experimental results indicate that the alternating injection of TAG or TCO2with unthickened AG mixture as an enhanced recovery technique may produce results similar to those with continuous thickened gas injection. This reduces the consumption of thickening agents noticeably resulting in reduced operational costs and improved economic viability for this method.

Mexican Americans represent the largest Latina/o subpopulation and have the lowest levels of educational attainment in the United States. Mexican Americans are underrepresented in all professional fields, including academia, and thus warrant attention. The purposes of this study are to describe the experiences of early and mid-career Mexican American faculty, emphasizing key sources of inspiration, support, and mentoring, perceived discrimination, and their coping responses; assess the ways in which these factors influence their careers; and examine differences by gender and maternal education. Mixed methods were used to obtain information from 133 Mexican American faculty who participated in a larger national study of underrepresented minority (URM) faculty at research universities. Five major findings emerged: (1) early life course support sustained and encouraged educational aspirations, (2) mentorship from significant others provided valuable advice in developing social capital throughout higher education and early faculty experiences, (3) female respondents were more likely to report inadequate mentoring and higher levels of distress due to recurrent experiences of racially gendered discrimination, (4) strategies of resistance reveal high levels of emotional labor as respondents deconstruct the hidden curriculum to perform effectively in environments that are imbued with implicit bias, and (5) maternal education contributed to improved mentoring experiences and active resistance strategies. The findings suggest that expanding social capital–driven strategies and increasing understanding of persistent anti-Mexican social policy that leads to misidentification and implicit bias are key in retention and professional success for Mexican American faculty.

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Objective:We studied whether cerebral blood pressure autoregulation and kidney and liver injuries are associated in neonatal encephalopathy (NE).Study design:We monitored autoregulation of 75 newborns who received hypothermia for NE in the neonatal intensive care unit to identify the mean arterial blood pressure with optimized autoregulation (MAPOPT). Autoregulation parameters and creatinine, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were analyzed using adjusted regression models.Results:Greater time with blood pressure within MAPOPTduring hypothermia was associated with lower creatinine in girls. Blood pressure below MAPOPTrelated to higher ALT and AST during normothermia in all neonates and boys. The opposite occurred in rewarming when more time with blood pressure above MAPOPTrelated to higher AST.Conclusions:Blood pressures that optimize cerebral autoregulation may support the kidneys. Blood pressures below MAPOPTand liver injury during normothermia are associated. The relationship between MAPOPTand AST during rewarming requires further study.

Hydrocarbon-miscible gas flooding typically involves injection of an associated gas (AG) mixture containing mainly methane (CH4) enriched with light hydrocarbon fractions and possibly acid gases. The AG mixture has been recognized as an excellent candidate for miscible gas injection (MGI). However, in general, the viscosity of the AG at reservoir conditions is significantly lower than that of crude oil leading to an unfavorable mobility ratio and low volumetric sweep efficiency during flooding. This study assesses the suitability of a library of commercially available polymers to thicken AG as a means of mobility control. The focus of the study is on the Field A located in the Harweel cluster in southern Oman. First, soluble polymeric thickeners for an AG mixture (CH460%, C2H69%, C3H86%, and CO225%) were identified using a parallel gravimetric extraction technique combined with cloud point measurements. Then, the viscosity of the identified soluble polymeric candidates in AG mixture was measured in a capillary viscometer at reservoir conditions. Three polymers were found to be completely or partially soluble in the AG mixture at 377 K and 55 MPa including poly(1-decene) (P-1-D), poly(methyl hydro siloxane) (PMHS), and poly(dimethylsiloxane) (PDMS). P-1-D found to be an effective thickener in AG mixture under conditions relevant to Field A, i.e., high temperatures and pressures. The polymer is soluble in the concentration range of 1.5–9 wt%. The viscosity of the P-1-D- thickened AG mixture increased by 2.2–7.4 times greater than AG mixture viscosity at 358–377 K. Furthermore, reservoir condition core flooding experiments were performed to examine the effectiveness of P-1-D-thickened AG gas mixture flooding to enhance oil recovery. The thickened-AG mixture flooding resulted in delayed gas breakthrough and subsequently 10–12% additional oil recovery.

Fe2O3and Co3O4phases are synthesized by the thermal treatment in an air-flow of hydrated salts based on Fe and Co. The materials are characterized by X-ray diffraction, energy dispersive spectroscopy, scanning electron microscopy, thermogravimetric analysis and surface area measurements. Fe2O3and Co3O4were tested for nitric oxide reduction with carbon monoxide in a 1:5 gas phase ratio and showed reaction rates in a range from 8.7 × 10−11to 5.9 × 10−10mol s−1g−1with an activation energy interval from 50.2 to 54.4 kJ mol−1. Fe2O3and Co3O4achieved (100 and 98) % NO conversion with (96 and 80) % selectivity to N2at (275 and 350) °C. Fe2O3and Co3O4have the advantages such as facile synthesis, low-cost, good thermal stability, high activity and selective to N2. These results regarding activity and selectivity are better or similar to some catalysts based on noble metals (Rh, Pt and Pd) currently used for air pollutants control.

Long‐distance drift of eggs and larvae has been identified as a possible cause of downstream displacement and poor recruitment of the endangered Rio Grande silvery minnow (Hybognathus amarus; silvery minnow). Seven experiments were conducted using artificial eggs to estimate silvery minnow egg drift and retention in the Albuquerque and Isleta reaches of the regulated Middle Rio Grande, New Mexico, USA over a range of flows during expected spawning times. Bead retention varied by reach, discharge, and shape of the hydrograph. Highest retention (6.9 and 9.7% per km in the Albuquerque and Isleta reaches, respectively) occurred on the ascending limb of a high flow in areas where there was substantial floodplain inundation. Retention was maximized at different flows in each reach (97 and 140 m3/s, respectively), possibly associated with reach‐specific floodplain inundation thresholds. Lowest retention in each reach (2.1 and 1.7%, respectively) occurred on the descending limb of low and high flows, respectively. Of the silvery minnow eggs produced in the combined Albuquerque and Isleta reaches in 2005, 8–14% are predicted to have been retained in the Albuquerque Reach (67 km) and 49–83% in the Isleta Reach (86 km) based on the distribution of adult fish and measured bead retention rates. Although silvery minnow propagules are capable of drifting long distances, our study suggests that considerable retention occurs in the Middle Rio Grande. Habitat restoration to increase channel habitat complexity, and flow management to promote floodplain inundation should help to retain a greater proportion of propagules in upstream reaches. Copyright © 2010 John Wiley & Sons, Ltd.

Presence of subclinical rejection (SCR) with IF/TA in protocol biopsies of renal allografts has been shown to be an independent predictor factor of graft loss. Also, intragraft Foxp3+ Tregcells in patients with SCR has been suggested to differentiate harmful from potentially protective infiltrates. Nonetheless, whether presence of Foxp3 Tregcells in patients with SCR and IF/TA may potentially protect from a deleterious graft outcome has not yet been evaluated. This is a case‐control study in which 37 patients with the diagnosis of SCR and 68 control patients with no cellular infiltrates at 6‐month protocol biopsies matched for age and time of transplantation were evaluated. We first confirmed that numbers of intragraft Foxp3‐expressing T cells in patients with SCR positively correlates with Foxp3 demethylation at the Treg‐specific demethylation region. Patients with SCR without Foxp3+ Tregcells within graft infiltrates showed significantly worse 5‐year graft function evolution than patients with SCR and Foxp3+ Tregcells and those without SCR. When presence of SCR and IF/TA were assessed together, presence of Foxp3+ Tregcould discriminate a subgroup of patients showing the same graft outcome as patients with a normal biopsy. Thus, presence of Foxp3+ Tregcells in patients with SCR even with IF/TA is associated with a favorable long‐term allograft outcome.

The article discusses a study which examined the serum cortisol concentration of free-living, wild California sea lion pups. Cortisol levels of 11 rookeries along the Gulf of California were analysed using radioimmunoassay. Results showed similarities between the body condition and bodyweight of rookeries while cortisol differed significantly between Southern and Midriff rookeries. The study suggests that serum cortisol level analysis is a valuable tool to assess welfare in wild populations of sea lions.

This paper proposes a methodology to analyze the resolution and variations in the positions of the 3RRR planar parallel mechanism driven by electrical actuators of discrete steps. This methodology consists of graphing and plotting all the possible combinations of angular movements of a three legs mechanism. This generates a “cloud of points” that will be the boundary of the control limits, so as to find the closest trajectory to a straight line. It was found that resolution, accuracy, and the approximation error improves when micro-steps are employed. For this purpose, it is necessary to determine direct and inverse kinematics, in order to calculate the workspace. A prototype was built to validate the methodology proposed.

Abstract: Time resolved thermal lens (TL) spectrometry is applied to the study of the thermal diffusivity of edible oils such as olive, and refined and thermally treated avocado oils. A two laser mismatched-mode experimental configuration was used, with a He–Ne laser as a probe beam and an Ar+ laser as the excitation one. The characteristic time constant of the transient thermal lens was obtained by fitting the experimental data to the theoretical expression for a transient thermal lens. The results showed that virgin olive oil has a higher thermal diffusivity than for refined and thermally treated avocado oils. This measured thermal property may contribute to a better understanding of the quality of edible oils, which is very important in the food industry. The thermal diffusivity results for virgin olive oil, obtained from this technique, agree with those reported in the literature.

Thermal diffusivity measurements are carried out in nanofluids, solutions containing gold nanoparticles (~ 10–40 nm size), using the mode-mismatched dual-beam thermal lens technique. An Ar+ laser is used as the heating source, and an intensity stabilized He–Ne laser serves as the probe beam. This technique provides a reliable photothermal alternative for measuring thermal diffusivities of nanofluids and semitransparent samples. The characteristic time constant of the transient thermal lens was obtained by fitting the experimental data to the theoretical expression for the transient thermal lens. From this characteristic time, the fluid thermal diffusivity, which increases when the particle sizes increase was obtained. The size of the nanoparticles was obtained from transmission electron microscopy (TEM) analysis.Thermal diffusivity measurements are carried out in nanofluids, solutions containing gold nanoparticles (~ 10–40 nm size), using the mode-mismatched dual-beam thermal lens technique. An Ar+ laser is used as the heating source, and an intensity stabilized He–Ne laser serves as the probe beam. This technique provides a reliable photothermal alternative for measuring thermal diffusivities of nanofluids and semitransparent samples. The characteristic time constant of the transient thermal lens was obtained by fitting the experimental data to the theoretical expression for the transient thermal lens. From this characteristic time, the fluid thermal diffusivity, which increases when the particle sizes increase was obtained. The size of the nanoparticles was obtained from transmission electron microscopy (TEM) analysis.

Objectives. The purpose of this study was to review instruments that assess the level of preparedness of state and local public health departments to respond to health threats such as bioterrorism.Methods. The authors examined 27 published population-based instruments for planning or evaluating preparedness that were mostly unavailable in the peer-reviewed literature. Using the Essential Public Health Services framework, the instruments were evaluated for (1) clarity of measurement parameters, (2) balance between structural and process measures, (3) evidence of effectiveness, and (4) specification of an accountable entity.Results. There was a great deal of overlap but little consistency in what constitutes “preparedness” or how it should be measured. Most instruments relied excessively on subjective or structural measures, lacked scientific evidence for measures assessed, and failed to clearly define what entity was accountable for accomplishing the task or function.Conclusion. Strategies for improvement include measure standardization, better interagency communication, and investment in public health practice research to develop the underlying evidence base required for developing quality measures and assessments.

There is a strong innate immunity in calves to infection with Babesia bovis. Interleukin (IL)-12 and IL-10 have been shown in vitroto be important immunoregulatory cytokines. Here we demonstrate in vivothat the protective innate response in young calves to infection with virulent B. bovisinvolves the early appearance of IL-12 and interferon-? (IFN-?) transcripts in the spleen. In contrast, IL-12 and IFN-? mRNA expression in the spleens of adult cattle that succumbed to the infection was delayed and depressed and occurred within the context of IL-10 expression. Also in contrast with calves, there was no detectable antibody response before death in adults. A vigorous CD8T-cell expansion occurred in the spleens of both calves and adults.

Waldenström macroglobulinemia (WM) and its associated hyperviscosity syndrome (HVS) are generally caused by lymphoplasmacytoid lymphoma or other small B-cell lymphoproliferative disorders. WM associated with extranodal marginal zone B-cell-mucosa-associated lymphoid tissue lymphoma (EMZL/MALT-type) has not been emphasized. We describe 4 men and 2 women (age, 40-79 years) with clinical and laboratory manifestations of WM and EMZL/MALT-type involving one or more sites: lung, pericardium/pleura, ocular adnexa, nasopharynx, minor salivary gland, glossopharyngeal fold, skin, and stomach. The following immunophenotypic patterns were observed: CD20+, 6; CD43+, 3; kappa light chain restriction, 5; and lambda light chain restriction, 1. All were negative for CD5, CD10, and cyclin D1 expression. A clonal paraproteinemia was present in each (IgM kappa, 4; IgM lambda, 1; biclonal IgM kappa/IgA kappa, 1). All 4 patients tested had elevated plasma viscosity; clinical HVS occurred in 3, and 2 required emergency plasmapheresis. These findings suggest that EMZL/MALT-type can cause WM and that the laboratory evaluation of EMZL/MALT-type should include serum protein electrophoresis/immunofixation, and plasma viscosity measurements and urine immunofixation in select cases. EMZL/MALT-type should be considered in the differential diagnosis in patients with clinicopathologic features of WM.

Thymectomized calves were selectively depleted of CD4T lymphocytes with a monoclonal antibody (mAb) specific for the bovine CD4 monomer (ILA-11). Calves were treated with high loading doses of ILA-11 during the first week of the study then treated with subsequent lower maintenance doses. Depletion of CD4T lymphocytes was assessed weekly by flow cytometric analysis of PBMC and mononuclear cells from lymph node and spleen biopsies. Treatment with high doses of ILA-11 resulted in rapid and marked depletion of CD4T lymphocytes from the peripheral blood, peripheral lymph nodes, and spleen. Although CD4T lymphocytes slowly returned to the peripheral blood, peripheral lymph nodes, and spleen by day 21 post-treatment, the numbers of CD4T lymphocytes in depleted calves remained below pre-depletion levels for the duration of the study. CD4T lymphocytes failed to be effectively depleted from a non-thymectomized calf treated with the mAb ILA-11. Development of a T lymphocyte depletion model in thymectomized calves will permit testing of the hypothesis that CD4T lymphocytes and IFN-? are required in cattle for control of acute anaplasmosis. In subsequent planned studies, thymectomized calves depleted of CD4T lymphocytes will be experimentally infected with A. marginale and parameters of disease compared between depleted and non-depleted calves.

• To evaluate health access and health services utilization of homeless families we selected a systematic sample of 194 homeless families from 10 shelters in Los Angeles and 196 housed poor families from the same geographic regions of Los Angeles selected from welfare offices. Both samples relied primarily on Medicaid for their health insurance (61% and 96%). However, more homeless families than housed poor families were currently uninsured (26% vs 2%), had lost health insurance over the past year (50% vs 21%), and had spent a greater percentage of the past year uncovered by health insurance (22% vs 6%). Homeless families were much less likely to report a regular provider for preventive care (81% vs 94%) or for sick care (72% vs 95%). Moreover, of those reporting a regular provider, homeless families were more likely than housed poor families to use emergency departments or clinics rather than private offices for both preventive care (35% vs 15%) and sick care (37% vs 26%). Barriers to health care more frequently prevented homeless families from obtaining care (38% vs 28%). These findings suggest that homeless families have greater problems of access to health care than other poor families, related to lack of insurance, lack of a regular primary care provider, and other barriers. Programs to address these barriers for homeless families are presented.(AJDC. 1991;145:1109-1115)

This study takes issue with the conventional application of regression analysis to the problem of detecting predictive bias of IQ tests toward minorities. Jensen (1968, 1980) and Reynolds (1982) rejected the hypothesis that IQ tests are unfair. However, the statistical techniques employed by these and other researchers in the analysis of this problem are of questionable sensitivity to predictive bias. In the present study, the predictive relationship between the WISC-R and PIAT and WRAT achievement scores of 125 Mexican-American and 125 non-minority students was analyzed using four separate methods of analysis. Conventional methods were found to be insensitive to and inappropriate for the detection of predictive bias. An alternative means of detecting predictive bias is proposed.

We conducted a telephone survey of randomly selected Latinas (n=208) and Anglo women (n=222) to determine predictors of mammography use. The cooperation rate was 78.5%. Relatively high proportions of Latinas (61%) and Anglo women (79%) reported mammography use within the past 2 years. A logistic regression analysis revealed that knowledge and attitudes did not independently predict use. On the other hand, having health insurance, being married, and being Latino were consistent independent predictors. We conclude that mammography use among Latinas and Anglo women is increasing. However, further gains in use must address difficult barriers such as lack of health insurance.

Our objective was to examine the demographic and other predictors of fatalistic beliefs among Latinas (Hispanic women) and Anglo (non-Hispanic Caucasian) women and to assess the impact of these beliefs on the use of cervical cancer screening services.

Almost haylof the 10,544 cases of AIDS reported among Hispanics are associated with sexual transmission of the human immunodeficiency virus. As a result, the use of condoms has assumed a central role in the prevention of AIDS. In order to determine the readability of Spanish instructions provided with condoms, twentyfive brands were purchased in Los Angeles. Only half of the manufacturers of condoms available in Los Angeles provided instructions in Spanish. Seven different Spanish texts were identified from the thirteen marketed brands. Readability tests indicate that these texts pose difficulties in comprehension for anyone whose reading skills are below the ninth grade level. These instructions inadequately serve the majority of the Hispanic community whose limited reading skills inhibit comprehension of high school level materials. These results suggest the need to modify AIDS education and prevention materials to increase the level of information available to the Hispanic community.

• Reductions in the generosity of fee-for-service insurance lower the use of general medical and mental health services, but do they lead to lower mental health status for the covered population? We addressed this question using data from the RAND Corporation Health Insurance Experiment. Families in six sites in the United States were randomly assigned to one of 14 insurance plans for three- or five-year periods. On average, there were no significant adverse effects of cost-sharing plans, relative to a free-care plan, on either psychological well-being or psychological distress, when the cost-sharing plans included full catastrophic coverage. Those with high mental health status but low income at baseline had significantly more favorable mental health outcomes on the cost-sharing plans than on the free-care plan. We cannot definitively comment on the effects of insurance generosity for the sick poor. Our findings apply in the context of mandated comprehensive mental and general health coverage for a general nonelderly, nondisabled household population.

Recent data indicate that low-birthweight adults are at a higher risk than their high-birthweight peers of developing ischaemic heart disease or a cluster of conditions known as the IRS, which includes dyslipidaemias, hypertension, unfavourable body fat distribution and NIDDM. Thus far these observations have been limited to Caucasians from the United Kingdom. We extended these observations to a broader segment of the general population by studying the association of birthweight and adult health outcomes in a biethnic population of the United States. We divided a group of 564 young adult Mexican-American and non-Hispanic white men and women participants of the San Antonio Heart Study into tertiles of birthweight and compared metabolic, anthropometric, haemodynamic, and demographic characteristics across these tertile categories. Additionally, we studied birthweight as a predictor of the clustering of diseases associated with the IRS, defined as any two or more of the following conditions: hypertension, NIDDM or impaired glucose tolerance, dyslipidaemia. Normotensive, non-diabetic individuals whose birthweight was in the lowest tertile had significantly higher levels of fasting serum insulin and a more truncal fat deposition pattern than individuals whose birthweight was in the highest tertile, independently of sex, ethnicity, and current socioeconomic status. Also, the odds of expressing the IRS increased 1.72 times (95% confidence interval: 1.16–2.55) for each tertile decrease in birthweight. These findings were independent of sex, ethnicity, and current levels of socioeconomic status or obesity. In conclusion, low birthweight could be a major independent risk factor for the development of adult chronic conditions commonly associated with insulin resistance in the general population.

Summary: Microalbuminuria is associated with increased cardiovascular mortality in both diabetic and non-diabetic subjects. A number of studies have indicated that insulin resistance, increased blood pressure and dyslipidaemia precede the onset of clinical diabetes. We examined various correlates of microalbuminuria in 1,298 non-diabetic subjects who participated in the Mexico city Diabetes Study, a population-based study of diabetes and cardiovascular risk factors. Both parental history of diabetes and impaired glucose tolerance were significantly associated with microalbuminuria. These results were not explained by differences in age or blood pressure between subjects with or without a parental history of diabetes or impaired glucose tolerance. In addition, subjects with microalbuminuria had increased 2-h insulin and triglyceride concentrations, a higher prevalence of hypertension, and decreased high density lipoprotein cholesterol concentrations relative to subjects without microalbuminuria. These results suggest that microalbuminuria may be a feature of the prediabetic state.

We have previously shown that concanavalin A (ConA) induction of suppressor cell activity is impaired in patients with lepromatous leprosy (LL). In this study, we demonstrated that the proportion of cells bearing the Leu8 antigen (associated with suppressor-inducer cells) is low in LL patients and tends to normalize during the erythema nodosum leprosum (ENL) episode. Antigen-induced suppressor cell function was evaluated by a two-stage assay. In the first stage, peripheral blood mononuclear cells (PBMC) were cultured for 5 days either in the presence of gamma-irradiated Mycobacterium leprae or in tissue culture medium as a control. In the second stage, mitomycin C-treated suppressor or control cells were added to phytohemagglutinin (PHA)- or ConA-stimulated autologous PBMC. The results indicate that the ability of M. leprae to induce suppressor activity was lower in LL patients than in patients with tuberculoid (TT) and intermediate clinical (BB, BL, BT) forms and Mycobacterium bovis BCG-immunized normal controls. In ENL patients, the percent suppression was between that of TT and normal individuals. M. leprae-induced suppression was more effective on ConA- than on PHA-triggered T-cell proliferation in all groups. In contrast, normal PBMC cultured for 5 days in RPMI 1640 medium (N-C) and cells from patients with leprosy (TT-C and LL-C) had effects of their own on PHA- or ConA-induced proliferation. LL-C depressed the response to ConA and enhanced PHA-induced proliferation of autologous cells. Conversely, TT-C reduced PHA-induced proliferation and increased the ConA response. Suppression of proliferation could not be overcome with exogenous interleukin-2 and was not related to the induction of the Tac antigen. The abilities of LL, TT, ENL, and normal cells to proliferate upon PHA or ConA stimulus were similar, indicating that the defect in the generation of in vitro suppression by M. leprae in LL patients occurred during the induction period (step 1 of assay).

Hyperinsulinemia is associated with an adverse pattern of cardiovascular risk factors, including obesity, elevated triglyceride levels, low levels of high-density lipoprotein (HDL) cholesterol, and elevated blood pressure. Whether hyperinsulinemia precedes (and perhaps causes) this deterioration in the risk factors or merely accompanies the deterioration is controversial. We therefore examined the 8-year changes in lipids, lipoproteins, and blood pressure as a function of baseline levels of fasting insulin in 1,383 nondiabetic Mexican-American and non-Hispanic white subjects enrolled between October 1979 and November 1982 in the San Antonio Heart Study, a population-based longitudinal study of cardiovascular risk factors and diabetes in San Antonio, Texas. After age and concomitant changes in body mass index were adjusted for, fasting insulin at baseline was found to be correlated positively with 8-year changes in triglyceride levels and negatively with 8-year changes in HDL cholesterol levels (p less than 0.05). Among the non-Hispanic whites, insulin was more strongly correlated with a decline in HDL cholesterol levels in women than in men (p less than 0.001). Fasting insulin was also positively correlated with changes in both systolic and diastolic blood pressure in non-Hispanic whites, but not in Mexican Americans, although these correlations were slightly diminished and no longer achieved statistical significance after subjects receiving antihypertensive medications were excluded. These results support the hypothesis that in nondiabetic subjects, insulin has a direct regulatory effect on triglyceride and HDL cholesterol levels. These data provide evidence for a possible role for insulin in blood pressure regulation, at least in non-Hispanic whites, although further analysis of this issue is warranted.

There is considerable evidence that lipoprotein(a) (Lp(a)) is a strong independent risk factor for coronary heart disease. Based on their risk factor profile, Mexican Americans have an increased risk of coronary heart disease, yet Mexican Americans have coronary heart disease mortality similar to or lower than that of non-Hispanic whites. The authors therefore attempted to determine whether Mexican Americans had decreased Lp(a) concentrations relative to non-Hispanic whites in the San Antonio Heart Study, a population-based study of diabetes and cardiovascular disease. Lp(a) concentrations (mg/dl) were significantly lower in Mexican Americans (n = 316) than in non-Hispanic whites (n = 242) (men: 10.4 vs. 16.3; women: 11.5 vs. 16.4). In addition, the proportion of persons with Lp(a) concentrations of > or = 30 mg/dl (the threshold at which increased risk of coronary heart disease is believed to occur) was significantly higher in non-Hispanic whites than in Mexican Americans (18.6% vs. 7.6%; Mantel-Haenszel odds ratio (adjusted for sex) = 2.79). Age, obesity, body fat distribution, cigarette smoking, alcohol consumption, and glucose and insulin concentrations were not significantly related to Lp(a) levels. Decreased Lp(a) concentrations may account in part for Mexican Americans' relative protection from coronary heart disease mortality.

The involvement of CD4+ T lymphocytes in the defense mechanisms against intracellular pathogens is widely recognized. Little information is available on the generation and specificity of the cytotoxic cells that eliminate human monocytes/macrophages infected with mycobacteria. In this work, we tested whether mononuclear cells from leprosy patients could generate cytotoxic T-cell activity against autologous macrophages pulsed with Mycobacterium leprae or purified protein derivative (PPD) in a 4-h 51Cr release assay. Peripheral blood mononuclear cells from normal Mycobacterium bovis BCG-immunized controls or from leprosy patients stimulated with antigen for 7 days were used as effector cells. Paucibacillary (PB) patients and normal controls yielded more active effector cells in this system than multibacillary (MB) patients. MB patients were able to develop cytotoxicity against M. leprae, BCG, or PPD, in contrast with the immunological anergy widely described. We did not find cytotoxicity against unpulsed macrophages. Cross-reactivity was observed between PPD, BCG, and M. leprae. Only antigen-pulsed autologous macrophages were suitable as target cells. M. leprae-induced cytotoxic cells were found in both CD4+ CD8- and CD4- CD8+ T-cell subsets, whereas CD4+ cells were the main component of PPD-induced cytotoxicity. In MB patients, BCG-induced cytotoxic cells were better killers of M. leprae-pulsed macrophages than cells induced by M. leprae. This is an interesting finding in view of the ongoing vaccination trials. The involvement of CD4- or CD8-mediated cytotoxicity may be important in the balance between protection and tissue or nerve damage.

Recently, the presence of small dense low density lipoprotein (LDL) has been postulated to be a stronger risk factor for coronary heart disease than large LDL. While small dense LDL has been associated with individual components of the insulin resistance syndrome such as hypertension, high triglyceride level, low high density (HDL) cholesterol, and diabetess mellitus, there has been little work exploring whether LDL size is decreased in subjects with multiple metabolic disorders. We examined the association of LDL size and pattern to specific insulin (which does not cross-react with proinsulin), proinsulin, increased triglyceride, decreased HDL, hypertension and impaired glucose tolerance in 488 non-diabetic subjects from the San Antonio Heart Study. LDL size was significantly related to specific insulin, proinsulin and the fasting proinsulin/insulin ratio. Small dense LDL was significantly associated with high triglyceride level, decreased HDL cholesterol, hypertension and impaired glucose tolerance. LDL size (å) decreased in a stepwise fashion with increasing number of the metabolic disorders described above (zero 262.6±9.4; one 257.0±9.3; two 256.4±9.4; three 249.0±9.1; and four 244.9±9.0). These results were similar in men and women and in non-Hispanic whites and Mexican Americans. The association between LDL size and the number of metabolic disorders remained statistically significant even after adjustment for obesity, body fat distribution, gender, ethnicity, proinsulin and insulin concentrations. Furthermore, decreases in LDL size are also significantly associated with both a selective beta-cell defect (as estimated by the fasting proinsulin/insulin ratio) and insulin resistance (as estimated by the fasting insulin concentrations) although the association was some-what stronger for the latter. We conclude that small dense LDL may form part of the insulin resistance syndrome in non-diabetic subjects.