Evidence-based medicine and values-based medicine : partners in clinical education as well as in clinical practice

The best clinical decisions are based on both evidence and values in what is known as the ‘twofeet principle’. Anecdotally, educationalists find teaching clinicians to become more evidence based is relatively simple in comparison to encouraging them to become more values based. One reason is likely to be the importance of values awareness. As valuesbased practice is premised on a mutual respect for the diversity of values, clinicians need to develop the skills to ascertain patient values and to get in touch with their own beliefs and preferences in order to understand those at play in any consultation. Only then can shared decision-making processes take place within a shared framework of values. In a research article published in BMC Medicine, AltamiranoBustamante and colleagues highlight difficulties that clinicians face in getting in touch with their own values. Despite finding that healthcare personnel’s core values were honesty and respect, autonomy was initially low ranked by participants. One significant aspect of this work is that this group has demonstrated that the extent to which clinicians value ‘autonomy’ and ‘openness to change’ can both be positively influenced by well designed education

Heterogeneity in Health Insurance Coverage Among US Latino Adults

We sought to determine the differences in observed and unobserved factors affecting rates of health insurance coverage between US Latino adults and US Latino adults of Mexican ancestry. Our hypothesis was that Latinos of Mexican ancestry have worse health insurance coverage than their non-Mexican Latino counterparts. The National Health Interview Survey (NHIS) database from 1999–2007 consists of 33,847 Latinos. We compared Latinos of Mexican ancestry to non-Mexican Latinos in the initial descriptive analysis of health insurance coverage. Disparities in health insurance coverage across Latino categories were later analyzed in a multivariable logistic regression framework, which adjusts for confounding variables. The Blinder-Oaxaca technique was applied to parse out differences in health insurance coverage into observed and unobserved components. US Latinos of Mexican ancestry consistently had lower rates of health insurance coverage than did US non-Mexican Latinos. Approximately 65% of these disparities can be attributed to differences in observed characteristics of the Mexican ancestry population in the US (e.g., age, sex, income, employment status, education, citizenship, language and health condition). The remaining disparities may be attributed to unobserved heterogeneity that may include unobserved employment-related information (e.g., type of employment and firm size) and behavioral and idiosyncratic factors (e.g., risk aversion and cultural differences). This study confirmed that Latinos of Mexican ancestry were less likely to have health insurance than were non-Mexican Latinos. Moreover, while differences in observed socioeconomic and demographic factors accounted for most of these disparities, the share of unobserved heterogeneity accounted for 35% of these differences

Effects of Health Insurance on Perceived Quality of Care Among Latinos in the United States

There is suggestive evidence that lower rates of health insurance coverage increases the gaps in quality and access to care among Latinos as compared with non-Latino whites. In order to examine these potential disparities, we assessed the effects of insurance coverage and multiple covariates on perceived quality of care. To assess the distribution of perceived quality of care received in a national Latino population sample, and the role of insurance in different patient subgroups. Telephone interviews conducted between 2007 and 2008 using the Pew Hispanic Center/Robert Wood Johnson Foundation Latino Health Surveys (Waves 1 and 2). Randomly selected Latino adults aged ≥18 years living in the United States. Pearson χ2 tests identified associations among various demographic variables by quality of care ratings (poor, fair, good, excellent) for the insured and uninsured (Wave 1: N = 3545). Subgroup analyses were conducted among Wave 2 participants reporting chronic conditions (N = 1067). Bivariate and multivariate analyses were conducted to estimate the effects of insurance, demographic variables and consumer characteristics on quality of care. Insurance availability had an odds ratio of 1.47 (95% CI, 1.22–1.76) net of confounders in predicting perceived quality of care among Latinos. The largest gap in rates of excellent/good ratings occurred among the insured with eight or more doctor visits compared to the uninsured (76.2% vs. 54.6%, P < .05). Future research can gain additional insights by examining the impact of health insurance on processes of care with a refined focus on specific transactions between consumers and providers’ support staff and physicians guided by the principles of patient-centered care

Long Delays and Missed Opportunities in Diagnosing Smear-Positive Pulmonary Tuberculosis in Kampala, Uganda: A Cross-Sectional Study

BACKGROUND: Early detection and treatment of tuberculosis cases are the hallmark of successful tuberculosis control. We conducted a cross-sectional study at public primary health facilities in Kampala city, Uganda to quantify diagnostic delay among pulmonary tuberculosis (PTB) patients, assess associated factors, and describe trajectories of patients' health care seeking. METHODOLOGY/PRINCIPAL FINDINGS: Semi-structured interviews with new smear-positive PTB patients (≥ 15 years) registered for treatment. Between April 2007 and April 2008, 253 patients were studied. The median total delay was 8 weeks (IQR 4-12), median patient delay was 4 weeks (inter-quartile range [IQR] 1-8) and median health service delay was 4 weeks (IQR 2-8). Long total delay (>14 weeks) was observed for 61/253 (24.1%) of patients, long health service delay (>6 weeks) for 71/242 (29.3%) and long patient delay (>8 weeks) for 47/242 (19.4%). Patients who knew that TB was curable were less likely to have long total delay (adjusted Odds Ratio [aOR] 0.28; 95%CI 0.11-0.73) and long patient delay (aOR 0.36; 95%CI 0.13-0.97). Being female (aOR 1.98; 95%CI 1.06-3.71), staying for more than 5 years at current residence (aOR 2.24 95%CI 1.18-4.27) and having been tested for HIV before (aOR 3.72; 95%CI 1.42-9.75) was associated with long health service delay. Health service delay contributed 50% of the total delay. Ninety-one percent (231) of patients had visited one or more health care providers before they were diagnosed, for an average (median) of 4 visits (range 1-30). All but four patients had systemic symptoms by the time the diagnosis of TB was made. CONCLUSIONS/SIGNIFICANCE: Diagnostic delay among tuberculosis patients in Kampala is common and long. This reflects patients waiting too long before seeking care and health services waiting until systemic symptoms are present before examining sputum smears; this results in missed opportunities for diagnosis

Calcium modulates force sensing by the von Willebrand factor A2 domain

von Willebrand factor (VWF) multimers mediate primary adhesion and aggregation of platelets. VWF potency critically depends on multimer size, which is regulated by a feedback mechanism involving shear-induced unfolding of the VWF-A2 domain and cleavage by the metalloprotease ADAMTS-13. Here we report crystallographic and single-molecule optical tweezers data on VWF-A2 providing mechanistic insight into calcium-mediated stabilization of the native conformation that protects A2 from cleavage by ADAMTS-13. Unfolding of A2 requires higher forces when calcium is present and primarily proceeds through a mechanically stable intermediate with non-native calcium coordination. Calcium further accelerates refolding markedly, in particular, under applied load. We propose that calcium improves force sensing by allowing reversible force switching under physiologically relevant hydrodynamic conditions. Our data show for the first time the relevance of metal coordination for mechanical properties of a protein involved in mechanosensing

Functional KV10.1 Channels Localize to the Inner Nuclear Membrane

Ectopically expressed human KV10.1 channels are relevant players in tumor biology. However, their function as ion channels at the plasma membrane does not totally explain their crucial role in tumors. Both in native and heterologous systems, it has been observed that a majority of KV10.1 channels remain at intracellular locations. In this study we investigated the localization and possible roles of perinuclear KV10.1. We show that KV10.1 is expressed at the inner nuclear membrane in both human and rat models; it co-purifies with established inner nuclear membrane markers, shows resistance to detergent extraction and restricted mobility, all of them typical features of proteins at the inner nuclear membrane. KV10.1 channels at the inner nuclear membrane are not all transported directly from the ER but rather have been exposed to the extracellular milieu. Patch clamp experiments on nuclei devoid of external nuclear membrane reveal the existence of channel activity compatible with KV10.1. We hypothesize that KV10.1 channels at the nuclear envelope might participate in the homeostasis of nuclear K+, or indirectly interact with heterochromatin, both factors known to affect gene expression

Effective Rheology of Bubbles Moving in a Capillary Tube

We calculate the average volumetric flux versus pressure drop of bubbles moving in a single capillary tube with varying diameter, finding a square-root relation from mapping the flow equations onto that of a driven overdamped pendulum. The calculation is based on a derivation of the equation of motion of a bubble train from considering the capillary forces and the entropy production associated with the viscous flow. We also calculate the configurational probability of the positions of the bubbles.Comment: 4 pages, 1 figur