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PubMed1999

Gatekeeping and authorization.

Managed care techniques first used in the private sector are increasingly being applied to control costs in the public sector. When the system places the burden of recognizing, diagnosing, and even treating mental illness on the primary care physician, however, a number of problems can result.

Adult↗
PubMed1977

The bartender as a mental health service gatekeeper: a role analysis.

Efforts to expand mental health manpower have taken three major directions: (1) increased use of consultation, (2) creating entirely new roles, and (3) offering training to persons engaged in roles or occupations presumably at strategic points of contact between the public and the mental health system. Among such roles are clergy, police, hairdressers, and bartenders. Little effort has been made to analyze systematically this third approach to assess its true utility for mental health service. In this paper the role of the bartender is analyzed along four dimensions: personality component, functional centrality, role distance, and nonperson status. Functional centrality appears as a clear asset. Role distance and nonperson status have mixed value depending on the activity envisioned. These role attributed will be generally incompatible with relationships requiring sustained intimacy but could facilitate initial opening up and revelation of sensitive personal information. The lack of protracted professional socialization poses some risk with respect to obtrussion of personal idiosyncracies.

Alcohol Drinking↗
PubMed2006

Clinical implication of adenosine-stress cardiac magnetic resonance imaging as potential gatekeeper prior to invasive examination in patients with AHA/ACC class II indication for coronary angiography.

BACKGROUND: Real world cardiology is faced with a low diagnostic yield of coronary angiography (CXA) in patients presenting with ACC/AHA class II CXA indication. Our aim was to analyze the clinical implication of a Cardiac MR (CMR) protocol including adenosine stress perfusion in this patient population. We examined whether CMR could enhance appropriate CXA indication and thus reduce the rate of pure diagnostic CXA. In addition, we compared the relative impact of CMR exam components (perfusion, function and viability assessment) in achieving this target. METHODS: 176 patients were referred for CXA with class II indication. 171 underwent complete additional CMR exam in a 1.5-T whole body CMR-scanner for myocardial function, ischemia and viability prior to CXA. The routine protocol for assessment of CAD consisted of functional imaging (long and short axes), adenosine stress- and rest-perfusion in short axis orientation and "late enhancement" imaging in long and short axes. Images were analyzed by two independent and blinded investigators. Interobserver differences were resolved by a third reader. RESULTS: There was a high association between CMR results and subsequent invasive findings (chi square for CMR perfusion deficit and stenosis >70% in CXA: 113.7, p<0.0001). 109 (63.7%) of our patients had relevant perfusion deficits as seen by CMR and matching coronary artery stenosis >70%. Four (2.3%) patients had false negative CMR findings. In 58 patients (33.9%) no relevant coronary artery stenosis could be observed, correctly predicted by CMR in 48 cases; in 10 (5.8%) patients CMR provided false positive results. Sensitivity of CMR to detect relevant CAD (>70% luminal narrowing) was 0.96, specificity 0.83, positive predictive value 0.92 and negative predictive value 0.92. Of the CMR components, perfusion deficit was the strongest independent predictor (odds ratio 132.3, p < 0.0001). CONCLUSION: In a great number of patients being referred to cath lab with ACC/AHA class II indication for CXA, CMR provides a high accuracy for decision making regarding appropriateness of the invasive exam. CMR prior to CXA could substantially reduce pure diagnostic coronary angiographies in patients with intermediate probability for CAD, in our patient-cohort from approximately 34% to 6%. Further studies are warranted to identify rare false negative CMR results.

Adenosine↗
PubMed2005

Is iodine a gatekeeper of the integrity of the mammary gland?

This paper reviews evidence showing iodine as an antioxidant and antiproliferative agent contributing to the integrity of normal mammary gland. Seaweed is an important dietary component in Asian communities and a rich source of iodine in several chemical forms. The high consumption of this element (25 times more than in Occident) has been associated with the low incidence of benign and cancer breast disease in Japanese women. In animal and human studies, molecular iodine (I(2)) supplementation exerts a suppressive effect on the development and size of both benign and cancer neoplasias. This effect is accompanied by a significant reduction in cellular lipoperoxidation. Iodine, in addition to its incorporation into thyroid hormones, is bound into antiproliferative iodolipids in the thyroid called iodolactones, which may also play a role in the proliferative control of mammary gland. We propose that an I(2) supplement should be considered as an adjuvant in breast cancer therapy.

Antioxidants↗
PubMed2005

Nicastrin: gatekeeper of the gamma-secretase complex.

The gamma-secretase intramembrane protease cleaves many type I membrane proteins including amyloid precursor protein and Notch, generating peptide fragments that are important signaling components. In this issue of Cell, Shah et al. (2005) reveal the function of nicastrin, the largest member of the gamma-secretase complex. They show that the nicastrin extracellular domain is essential for recognition of substrate by the gamma-secretase.

Amyloid Precursor Protein Secretases↗
PubMed2004

Regulatory T cells and transcription factors: gatekeepers in allergic inflammation.

Antigen-provoked polarization of CD4+ T cells along the Th1 pathway is often associated with autoimmune and chronic inflammatory diseases, whereas extreme skewing of the response toward a Th2 phenotype has been linked to atopy and allergic diseases. Intense interest in the underlying molecular mechanisms that control polarization has revealed a contingent of regulatory transcription factors, which not only help to define these pathways but also suggest potential sites for interventional tactics. Moreover, the recent identification of transcription factors specifically associated with CD4(+)CD25+ regulatory T-cells provides new clues regarding manipulation of this population in pursuit of directed immune regulation. Continued unraveling of the pathways underlying the development of deleterious immune responses and their control will guide new avenues of investigation and intervention.

Animals↗