ABSTRACT
OBJECTIVE: In this study, the authors sought to ascertain the availability of outpatient child psychiatric appointments in three U.S. cities. METHODS: Using a simulated-patient methodology, investigators called 322 psychiatrists who were listed in a major insurer's database for three U.S. cities, and they attempted to make appointments for a child with three payment types: Blue Cross-Blue Shield, Medicaid, and self-pay. RESULTS: Initial appointments were available 11% of the time, and it was most difficult to obtain an appointment under Medicaid coverage. Nineteen percent of phone numbers were wrong, and 25% of psychiatrists were not accepting new patients. CONCLUSIONS: These results are concerning given the current mental health crisis among youths and suggest the need for more psychiatrists, higher reimbursement rates for psychiatric services, and continued efforts to increase access to care. This study also highlights the need for insurance companies to maintain accurate information in their databases.
Subject(s)
COVID-19 , Outpatients , United States , Humans , Child , Adolescent , Cities , Medicaid , Ambulatory Care , Appointments and Schedules , Health Services AccessibilityABSTRACT
The fungus Cryptococcus neoformans is a major human pathogen with a remarkable intracellular survival strategy that includes exiting macrophages through non-lytic exocytosis (Vomocytosis) and transferring between macrophages (Dragotcytosis) by a mechanism that involves sequential events of non-lytic exocytosis and phagocytosis. Vomocytosis and Dragotcytosis are fungal driven processes, but their triggers are not understood. We hypothesized that the dynamics of Dragotcytosis could inherit the stochasticity of phagolysosome acidification and that Dragotcytosis was triggered by fungal cell stress. Consistent with this view, fungal cells involved in Dragotcytosis reside in phagolysosomes characterized by low pH and/or high oxidative stress. Using fluorescent microscopy, qPCR, live cell video microscopy, and fungal growth assays we found that the that mitigating pH or oxidative stress reduced Dragotcytosis frequency, whereas ROS susceptible mutants of C. neoformans underwent Dragotcytosis more frequently. Dragotcytosis initiation was linked to phagolysosomal pH, oxidative stresses, and macrophage polarization state. Dragotcytosis manifested stochastic dynamics thus paralleling the dynamics of phagosomal acidification, which correlated with the inhospitality of phagolysosomes in differently polarized macrophages. Hence, randomness in phagosomal acidification randomly created a population of inhospitable phagosomes where fungal cell stress triggered stochastic C. neoformans non-lytic exocytosis dynamics to escape a non-permissive intracellular macrophage environment.
