Exploring the Factors that Influence Ethical Spanish Use among Medical Students and Solutions for Improvement.

IssueThere is a need for greater access to Spanish language services in United States healthcare. One approach to increasing language concordant care is the use of second language skills by healthcare staff. The desire to use second language skills may have unintended consequences when individuals step beyond their language abilities and can cause more harm than do good for limited-English proficiency patients. Medical students are in a unique position that places them at increased risk for inappropriately using second language skills. Evidence: The use of qualified healthcare interpreters has been shown to mitigate some of the disparities seen with limited-English proficiency patients including poorer healthcare outcomes, less access to care, and lower patient satisfaction. In spite of this knowledge, studies have demonstrated the phenomenon of residents and physicians "getting by" without the use of an interpreter, even when they recognized that their language competency was insufficient to provide high quality care. Regardless of language ability, medical students are asked to engage in conversations with Spanish speaking patients that are beyond their level of language competency. Students vary in their perceived language ability and level of comfort engaging in different clinical scenarios with limited-English proficiency patients. Implications: Students are in a unique position of vulnerability to pressures to use second language skills in situations that step beyond their abilities. We explore how hierarchy intensifies previously established factors, including a lack of adequate training or evaluation and other structural barriers, in contributing to medical students' inappropriate use of Spanish with limited-English proficiency patients. We propose an approach that includes student education, standardization of clinic rules regarding interpretation, and comprehensive faculty development to address this important patient care issue.

N- and O-linked glycosylation of total plasma glycoproteins in galactosemia.

Classic galactosemia is a potentially lethal metabolic disorder that results from profound impairment of the enzyme galactose-1-phosphate uridylyltransferase (GALT); despite decades of research, the underlying mechanism of pathophysiology remains unclear. Previous studies of plasma and tissue samples from patients with classic galactosemia have revealed defects of protein and lipid glycosylation, however, the underlying bases for these defects and their clinical significance, if any, has remained unclear. As a step toward addressing these questions we characterized both the N- and O-linked glycomes of plasma proteins from neonates, infants, children, and adults with galactosemia using mass spectrometry and asked (1) whether similar or disparate defects exist for N-linked and O-linked modifications, (2) what factors correlate with the severity of these defects in different patients, and perhaps most important, (3) whether there is any apparent relationship between chronic glycosylation defects and long-term outcome in patients. We found that some but not all of the galactosemic neonates tested exhibited abnormal N- and O-linked glycosylation of plasma proteins. The types of abnormalities seen were similar between N- and O-linked moieties, but the extent of the defects varied between patients. Age, gender, GALT genotype, and predicted residual GALT activity all failed to explain the extent of the glycosylation defect in the samples studied. Dietary galactose restriction markedly normalized both the N- and O-linked glycosylation patterns for all infants tested; however, any remaining glycosylation defects evident in the plasma of older children or adults on galactose-restricted diets showed no correlation with clinical outcome. These data cannot rule out the possibility that subtle or localized glycosylation defects, not detectable by our methods or not reflected in plasma, may contribute to acute or long-term outcome severity.

Ovarian function in Duarte galactosemia.

OBJECTIVE: To determine if girls with Duarte variant galactosemia (DG) have an increased risk of developing premature ovarian insufficiency based on prepubertal anti-Müllerian hormone (AMH) levels. DESIGN: Cross-sectional study. SETTING: University research laboratory. PATIENT(S): Study volunteers included 57 girls with DG, 89 girls with classic galactosemia (GG), and 64 control girls between the ages of <1 month and 10.5 years. INTERVENTION(S): Blood sampling. MAIN OUTCOME MEASURE(S): We determined AMH and FSH levels in study volunteers with and without Duarte variant or GG. RESULT(S): FSH levels were significantly higher and AMH levels significantly lower in girls with GG than in age-stratified control girls, but there was no significant difference between FSH and AMH levels in girls with DG and control girls. CONCLUSION(S): Although >80% of girls with GG in this study demonstrated low to undetectable AMH levels consistent with diminished ovarian reserve, 100% of girls with DG in our study demonstrated no apparent decrease in AMH levels or increase in FSH levels, suggesting that these girls are not at increased risk for premature ovarian insufficiency.