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1.
Artigo em Inglês | MEDLINE | ID: mdl-38951297

RESUMO

INTRODUCTION: Discharge "against medical advice" (AMA) in the obstetric population is overall under-studied but disproportionally affects marginalized populations and is associated with worse perinatal outcomes. Reasons for discharges AMA are not well understood. The objective of this study is to identify the obstacles that prevent obstetric patients from accepting recommended care and highlight the structural reasons behind AMA discharges. METHODS: Electronic health records of patients admitted to antepartum, peripartum, or postpartum services between 2008 and 2018 who left "AMA" were reviewed. Progress notes from clinicians and social workers were extracted and analyzed. Reasons behind discharge were categorized using qualitative thematic analysis. RESULTS: Fifty-seven (0.12%) obstetric patients were discharged AMA. Reasons for discharge were organized into two overarching themes: extrinsic (50.9%) and intrinsic (40.4%) obstacles to accepting care. Eleven participants (19.3%) had no reason documented for their discharge. Extrinsic obstacles included childcare, familial responsibilities, and other obligations. Intrinsic obstacles included disagreement with provider regarding medical condition or plan, emotional distress, mistrust or discontent with care team, and substance use. DISCUSSION: The term "AMA" casts blame on individual patients and fails to represent the systemic barriers to staying in care. Obstetric patients were found to encounter both extrinsic and intrinsic obstacles that led them to leave AMA. Healthcare providers and institutions can implement strategies that ameliorate structural barriers. Partnering with patients to prevent discharges AMA would improve maternal and infant health and progress towards reproductive justice.

3.
J Immigr Minor Health ; 26(1): 164-180, 2024 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-37665540

RESUMO

The health system in Aotearoa New Zealand is predicated on equity in access to health services as a fundamental objective yet barriers to equitable access for migrant and refugees continue to exist. There is a paucity of studies that synthesise the experiences and realities of migrants, refugees and healthcare providers that hinder access to healthcare and provide recommendations to improve services. This review synthesised these barriers and recommendations, with an aim to improve equitable access to healthcare to migrants and refugees. An integrative review of 13 peer-reviewed research studies from EBSCOhost research databases published between January 2016 and September 2022. Studies included: (i) related to Aotearoa; (ii) had a focus on equitable delivery of healthcare to migrants and refugees; and (iii) had a full English text available. The PRISMA framework guided the reporting of the review. The findings were thematically analysed and presented using a narrative empirical synthesis. The findings were organised into three broad themes: attitudinal barriers, structural barriers, and recommendations. Attitudinal barriers included the lack of culturally competent healthcare providers, discrimination by healthcare providers, and personal, social, and cultural attributes. Structural barriers referred to policies and frameworks that regulated the accessibility of health services such as the cost of healthcare, accessibility and acceptability of interpreter services, length of allocated appointments and long waiting times for an appointment, difficulties navigating the health system, and logistical barriers. Recommendations focused on promoting a sense of belonging, enabling a whole-of-society approach that brings together all sectors involved in providing health care for collective impact, and advocating for government policies to create a system that addresses the core health service access needs. This review provides rich context-specific findings on the barriers to equitable access to healthcare and proposed interventions to enhance equitable health outcomes for migrants and refugees in Aotearoa. The review contributes to relevant policy decisions and has practical implications to build responsive health systems which are inclusive, equitable and best address the health needs of populations from diverse cultural backgrounds.


Assuntos
Refugiados , Migrantes , Humanos , Nova Zelândia , Acessibilidade aos Serviços de Saúde , Pessoal de Saúde , Pesquisa Qualitativa
4.
PeerJ ; 11: e16500, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-38047028

RESUMO

Background: Seagrass meadows provide valuable ecosystem services but are threatened by global change pressures, and there is growing concern that the functions seagrasses perform within an ecosystem will be reduced or lost without intervention. Restoration has become an integral part of coastal management in response to major seagrass declines, but is often context dependent, requiring an assessment of methods to maximise restoration success. Here we investigate the use of different restoration strategies for the endangered Zostera capensis in South Africa. Methods: We assessed restoration feasibility by establishing seagrass transplant plots based on different transplant source materials (diameter (ø) 10 cm cores and anchored individual shoots), planting patterns (line, dense, bullseye) and planting site (upper, upper-mid and mid-intertidal zones). Monitoring of area cover, shoot length, and macrofaunal diversity was conducted over 18 months. Results: Mixed model analysis showed distinct effects of transplant material used, planting pattern and site on transplant survival and area cover. Significant declines in seagrass cover across all treatments was recorded post-transplantation (2 months), followed by a period of recovery. Of the transplants that persisted after 18 months of monitoring (~58% plots survived across all treatments), seagrass area cover increased (~112%) and in some cases expanded by over >400% cover, depending on type of transplant material, planting arrangement and site. Higher bioturbator pressure from sandprawns (Kraussillichirus kraussi) significantly reduced transplant survival and area cover. Transplant plots were colonised by invertebrates, including seagrass specialists, such as South Africa's most endangered marine invertebrate, the false-eelgrass limpet (Siphonaria compressa). For future seagrass restoration projects, transplanting cores was deemed the best method, showing higher long-term persistence and cover, however this approach is also resource intensive with potentially negative impacts on donor meadows at larger scales. There is a clear need for further research to address Z. capensis restoration scalability and improve long-term transplant persistence.


Assuntos
Ecossistema , Zosteraceae , África do Sul
10.
AMA J Ethics ; 24(9): E906-912, 2022 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-36170425

RESUMO

The US Supreme Court overturned Roe v Wade in June 2022, and now each state's legislature will decide if and when its citizens will have legal access to abortion care and if and when its physicians will be criminalized for providing what is considered to be the standard of care by multiple health-related organizations. This extraordinary change in the medico-legal landscape requires reevaluation of health profession codes of ethics related to clinician conscience. This article argues that these codes must now be expanded to address 2 newly critical areas: physician advocacy to make abortion illegal and affirmative protection for "conscientious provision" in hostile environments on par with protection of conscientious refusal.


Assuntos
Aborto Legal , Consciência , Atenção à Saúde , Feminino , Instalações de Saúde , Humanos , Gravidez , Recusa em Tratar
11.
Am J Bioeth ; 22(8): 22-30, 2022 08.
Artigo em Inglês | MEDLINE | ID: mdl-35621314

RESUMO

The majority of U.S. abortion patients are poor women, and Black and Hispanic women. Therefore, this article encourages bioethicists and equity advocates to consider whether the need for abortion care should be considered a health disparity, and if yes, whether framing it this way would increase the ability of poor women and women of color to get the medical care they need. In order to engage with these critical questions, bioethicists must avoid abortion exceptionalism and respect patients as moral agents. Centering the conscience of pregnant people shifts our analysis away from the ethics of the act of abortion, and toward the ethics of access to abortion care. Because the Supreme Court is on the brink of shifting the question of abortion's legality to state legislatures, this is the moment for all bioethicists to clarify and strengthen their thinking, writing, and teaching in abortion ethics.


Assuntos
Aborto Induzido , Aborto Legal , Ética , Feminino , Humanos , Princípios Morais , Gravidez , Estados Unidos
13.
J Genet Couns ; 31(5): 1193-1205, 2022 10.
Artigo em Inglês | MEDLINE | ID: mdl-35617028

RESUMO

Psychosocial counseling is the foundation of genetic counseling. Genetic counseling students are required to receive in-depth training on psychosocial counseling techniques. In other medical disciplines, "medical improv," an educational method derived from improvisational theatre, has been used to allow trainees to practice clinical skills without also having to focus on medical knowledge they've not yet mastered. The present study aims to investigate the acceptability of medical improv as an educational tool for genetic counseling students. Fourteen genetic counseling students and new genetic counselors completed a 2-hr medical improv workshop and participated in follow-up interviews to discuss the workshop. Participants' responses to the intervention were positive, with 92.9% of participants responding that they would recommend medical improv training to other genetic counseling students. Participants described the medical improv workshop as helping build psychosocial skills in a safe environment, which may facilitate the use of more advanced counseling skills in clinical situations. By training students to practice psychosocial skills and building students' confidence, medical improv may help genetic counseling students and genetic counselors be more effective in challenging clinical situations, and to feel more comfortable in experimenting with new ideas and psychosocial techniques in their clinical practice.


Assuntos
Aconselhamento Genético , Estudantes de Medicina , Competência Clínica , Aconselhamento , Currículo , Aconselhamento Genético/psicologia , Humanos , Estudantes , Estudantes de Medicina/psicologia
14.
Neurosci Res ; 174: 19-24, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-34352294

RESUMO

Hippocampal integrity is highly susceptible to metabolic dysfunction, yet its mechanisms are not well defined. We studied 126 healthy individuals aged 23-61 years. Insulin resistance (IR) was quantified by measuring steady-state plasma glucose (SSPG) concentration during the insulin suppression test. Body mass index (BMI), adiposity, fasting insulin, glucose, leptin as well as structural neuroimaing with automatic hippocampal subfield segmentation were performed. Data analysis using unsupervised machine learning (k-means clustering) identified two subgroups reflecting a pattern of more pronounced hippocampal volume reduction being concurrently associated with greater adiposity and insulin resistance; the hippocampal volume reductions were uniform across subfields. Individuals in the most deviant subgroup were predominantly women (79 versus 42 %) with higher BMI [27.9 (2.5) versus 30.5 (4.6) kg/m2], IR (SSPG concentration, [156 (61) versus 123 (70) mg/dL] and leptinemia [21.7 (17.0) versus 44.5 (30.4) µg/L]. The use of person-based modeling in healthy individuals suggests that adiposity, insulin resistance and compromised structural hippocampal integrity behave as a composite phenotype; female sex emerged as risk factor for this phenotype.


Assuntos
Resistência à Insulina , Glicemia , Índice de Massa Corporal , Feminino , Hipocampo/diagnóstico por imagem , Humanos , Insulina
15.
Obstet Gynecol ; 137(4): 657-661, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33706362

RESUMO

In this commentary, we describe historical and other influences that drive "double discrimination" in gynecologic surgery-lower pay in the area of surgery that boasts the largest proportion of female surgeons and is focused on female patients and explore how it results in potentially lower quality care. Insurers reimburse procedures for women at a lower rate than similar procedures for men, although there is no medically justifiable reason for this disparity. The wage gap created by lower reimbursement rates disproportionately affects female surgeons, who are disproportionately represented among gynecologic surgeons. This contributes to a large wage gap in surgery for women. Finally, poor reimbursement for gynecologic surgery pushes many obstetrics and gynecology surgeons to preferentially perform obstetric services, resulting in a high prevalence of low-volume gynecologic surgeons, a metric that is closely tied to higher complication rates. Creating equity in reimbursement for gynecologic surgery is one important and ethically required step forward to gender equity in medicine for patients and surgeons.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/economia , Qualidade da Assistência à Saúde , Salários e Benefícios , Feminino , Procedimentos Cirúrgicos em Ginecologia/normas , Humanos , Médicas , Estados Unidos
16.
World Psychiatry ; 19(3): 329-330, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32931103
17.
Front Immunol ; 11: 786, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32582139

RESUMO

Antimicrobial therapy has provided the main component of chemotherapy against bacterial pathogens. The effectiveness of this strategy has, however, been increasingly challenged by the emergence of antimicrobial resistance which now threatens the sustained utility of this approach. Humans and animals are constantly exposed to bacteria and have developed effective strategies to control pathogens involving innate and adaptive immune responses. Impaired pathogen handling by the innate immune system is a key determinant of susceptibility to bacterial infection. However, the essential components of this response, specifically those which are amenable to re-calibration to improve host defense, remain elusive despite extensive research. We provide a mini-review focusing on therapeutic targeting of microbicidal responses in macrophages and neutrophils to de-stress reliance on antimicrobial therapy. We highlight pre-clinical and clinical data pointing toward potential targets and therapies. We suggest that developing focused host-directed therapeutic strategies to enhance "pauci-inflammatory" microbial killing in myeloid phagocytes that maximizes pathogen clearance while minimizing the harmful consequences of the inflammatory response merits particular attention. We also suggest the importance of One Health approaches in developing host-based approaches through model development and comparative medicine in informing our understanding of how to deliver this strategy.


Assuntos
Infecções Bacterianas/terapia , Farmacorresistência Bacteriana/imunologia , Interações Hospedeiro-Patógeno/imunologia , Macrófagos/imunologia , Neutrófilos/imunologia , Animais , Anti-Infecciosos/uso terapêutico , Bactérias/imunologia , Reposicionamento de Medicamentos , Humanos , Imunidade Inata
18.
J Alzheimers Dis ; 75(3): 903-910, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32390619

RESUMO

BACKGROUND: The apolipoprotein epsilon 4 (APOE4) allele is a well-established genetic risk factor for Alzheimer's disease (AD). However, there are mixed findings as to how the APOE4 allele modifies the effects of both higher low-density lipoprotein cholesterol (LDL) and statin use on cognitive functioning. OBJECTIVE: This study sought to examine the effects of LDL levels and statin use on verbal learning and memory, as modified by the presence of the APOE4 allele, in a sample of cognitively unimpaired, older adults at risk for AD. METHODS: Neuropsychological, LDL, statin use, and APOE4 data were extracted from an ongoing longitudinal study at the Banner Alzheimer's Institute in Arizona. Participants were cognitively unimpaired based on Mini-Mental State Examination scores within a normal range, aged 47-75, with a family history of probable AD in at least one first-degree relative. RESULTS: In the whole sample, higher LDL was associated with worse immediate verbal memory in APOE4 non-carriers, but did not have an effect on immediate verbal memory in APOE4 carriers. In APOE4 non-carriers, statin use was associated with better verbal learning, but did not have an effect on verbal learning in APOE4 carriers. Among women, higher LDL in APOE4 carriers was associated with worse verbal learning than in APOE4 non-carriers, and statin use in APOE4 non-carriers was associated with better verbal learning and immediate and delayed verbal memory but worse performances on these tasks in APOE4 carriers. CONCLUSION: LDL and statin use may have differential effects on verbal learning and/or memory depending on genetic risk for AD. Women appear to be particularly vulnerable to statin use depending on their APOE4 status.


Assuntos
Doença de Alzheimer , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Memória , Aprendizagem Verbal , Idoso , Doença de Alzheimer/tratamento farmacológico , Doença de Alzheimer/genética , Doença de Alzheimer/metabolismo , Doença de Alzheimer/psicologia , Apolipoproteína E4/genética , LDL-Colesterol , Feminino , Predisposição Genética para Doença , Humanos , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Fatores de Risco
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