Effect of a Legal Clinic Program Within an Urban Primary Health Care Center on Social Determinants of Health: A Program Evaluation.

BACKGROUND: Individuals living in poverty often visit primary healthcare clinics for health problems stemming from unmet legal needs. We examined the impact of a medical-legal partnership on improving the social determinants of health (SDoH), health-related quality of life, and perceived health status of attendees of a Legal Clinic Program (LCP). METHODS: This was a pre-post program evaluation of a weekly LCP established within an urban primary healthcare clinic to provide free legal consultation. Patients aged 18 years or older were either approached or referred to complete a screening tool to identify potential legal needs. Those identified with potential legal needs were offered an appointment with LCP lawyers who provided legal counsel, referrals, and services. For those who attended the LCP, changes in SDoH and health indicators were collected via a self-reported survey 6 months after they attended the LCP and compared to their baseline scores using paired t-tests, McNemar's test for paired proportions, and the Wilcoxon Signed Rank Test for related samples. RESULTS: During the 6-month evaluation period, 31 participants attended the LCP and completed both the baseline and 6-month surveys; 67.8% were female, 64.5% were white, 90.3% were not working full-time, and 61.3% had a household income of $700 to 1800 per month. At follow-up, 25.8% were receiving at least 1 new benefit and there was a statistically significant reduction in food insecurity (35.5% vs 9.7%, P < .05). Also, perceived health status using the visual analog scale (ranges from 0 to 100) significantly improved from 42.5 points (SD = 25.3) at baseline to 56.6 points (SD = 19.6) after 6 months (P < .05). CONCLUSIONS: The LCP has the potential to improve the health and wellbeing of patients in primary healthcare clinics by addressing unmet legal needs and SDoH.

Legal needs of patients attending an urban family practice in Hamilton, Ontario, Canada: an observational study of a legal health clinic.

BACKGROUND: Individuals living in poverty often visit their primary care physician for health problems resulting from unmet legal needs. Providing legal services for those in need may therefore improve health outcomes. Poverty is a social determinant of health. Impoverished areas tend to have poor health outcomes, with higher rates of mental illness, chronic disease, and comorbidity. This study reports on a medical-legal collaboration delivered in a healthcare setting between health professionals and lawyers as a novel way to approach the inaccessibility of legal services for those in need. METHODS: In this observational study, patients aged 18 or older were either approached or referred to complete a screening tool to identify areas of concern. Patients deemed to have a legal problem were offered an appointment at the Legal Health Clinic, where lawyers provided legal advice, referrals, and services for patients of the physicians. Fisher's exact test was used to compare populations. Binary logistic regression was used to determine the factors predicting booking an appointment with the clinic. RESULTS: Eighty-four percent (n = 648) of the 770 patients screened had unmet legal needs and could benefit from the intervention, with an average of 3.44 (SD = 3.42) legal needs per patient screened. Patients with legal needs had significantly higher odds of attending the Legal Health Clinic if they were an ethnicity that was not white (OR = 2.48; 95% CI 1.14-5.39), did not have Canadian citizenship (OR = 4.40; 95% CI 1.48-13.07), had housing insecurity (OR = 3.33; 95% CI 1.53-7.24), and had difficulty performing their usual activities (OR = 2.83; 95% CI 1.08-7.43). As a result of the clinic consultations, 58.0% (n = 40) were referred to either Legal Aid Ontario or Hamilton Community Legal Clinic, 21.74% (n = 15) were referred to a private lawyer; one case was taken on by the clinic lawyer. CONCLUSION: The Legal Health Clinic was found to fulfill unmet legal needs which were abundant in this urban family practice. This has important implications for the future health of patients and clinical practice. Utilizing a Legal Health Clinic could translate into improved health outcomes for patients by helping overcome barriers in accessing legal services and addressing social causes of adverse health outcomes.

Sevoflurane and the feto-placental vasculature: the role of nitric oxide and vasoactive eicosanoids.

BACKGROUND: The effects and mechanisms of action of volatile anesthetics on the feto-placental vasculature are not known. We aimed to quantify the vasoactive effects of sevoflurane and determine the role of nitric oxide (NO) and of vasoactive eicosanoids in mediating these effects in isolated human chorionic plate arterial rings. METHODS: Quadruplicate ex vivo human chorionic plate arterial rings were used in all studies. Series 1 quantified the vasodilation produced by sevoflurane in rings preconstricted with the thromboxane analog U46619. Series 2A-C examined the role of NO in sevoflurane-mediated vasodilation. In separate experiments, we examined the potential for the nonspecific NO inhibitors, L-NAME, L-nMMA, and the inactive D-NAME, to modulate the vasodilation produced by sevoflurane. Series 2D determined whether sevoflurane altered vascular smooth muscle sensitivity to exogenous NO. Series 3A-D examined the role of vasoactive eicosanoids in sevoflurane-mediated vasodilation. In separate experimental series, we examined whether the nonspecific cyclooxygenase inhibitor, indomethacin, or the 5-lipoxygenase inhibitor, nordihydroguaiaretic acid, modulated sevoflurane-mediated vasodilation. RESULTS: Sevoflurane produced dose-dependent vasodilation of preconstricted chorionic plate arterial rings, with mean ring vasodilation increasing from 15 +/- 7% at 2% sevoflurane to 67 +/- 17% (mean +/- sd) at 8% sevoflurane. Blockade of NO synthase did not attenuate the vasodilator effects of sevoflurane. Sevoflurane did not alter smooth muscle sensitivity to NO. Indomethacin augmented sevoflurane vasodilation at 10(-5) M, but not at 10(-6) M. Conversely, nordihydroguaiaretic acid attenuated sevoflurane-mediated vasodilation at 3 x 10(-6) M but not at 3 x 10(-7) M. CONCLUSIONS: Sevoflurane was a vasodilator in the feto-placental vasculature in this in vitro model. Sevoflurane-mediated vasodilation is NO and cyclooxygenase-independent and appears to be mediated in part via a lipoxygenase generated vasodilator eicosanoid.