Inequalities In The Structure And Delivery Of U.s. Health Care

Although healthcare inequalities by race-ethnicity and nativity have been widely explored, more research is needed to investigate how these inequalities result from structures of racial stratification and immigrant exclusion operating within U.S. health care. My dissertation employs hand coded restricted-access medical record data, linked survey data, and rich administrative data to examine the factors generating healthcare inequalities experienced by both patients and physicians. I contextualize these inequalities within a broader U.S. landscape characterized by structural racism and nativism. In the first chapter, I examine the impact of state immigration policy contexts on healthcare access of U.S. agricultural workers representing various racial-ethnic identities and legal statuses between 2005-2012. I find state-level immigration policy contexts are strongly associated with healthcare access among documented non-White Latinx agricultural workers, who report lower levels of healthcare access and greater barriers to care-seeking in increasingly restrictive policy contexts. In the second chapter, I use hand coded electronic medical record data to examine provider-patient communication disparities. Black and Latinx patients are less likely than White patients to receive provider communication regarding a new incidental medical finding diagnosis. This disparity may reflect interpersonal racism between providers and patients of color, resulting from the perpetuation of racial mythologies in medicine. In the third chapter, I use geocoded data from the American Medical Association to explore whether subgroups of international medical graduates (IMGs) experience career stratification based on their country of medical education. I find IMGs trained in developing countries chart more marginalized U.S. career paths relative to those trained in developed countries, suggesting that nativism and racism within the medical profession intersect to disadvantage physicians from developing countries, who often are also people of color. My dissertation generates empirical evidence to show how racism and nativism operating within the U.S. healthcare system generate inequalities among people of color and immigrants. These findings have important implications not only for our understanding of racial inequality and social stratification broadly, but also for informing policy and intervention to promote equity within U.S. health care

In Search of Cardiovascular Risk Genes

Hypertension, or elevated arterial blood pressure is a substantial public health problem, affecting about 25 % of the adult population. This disorder is a major risk factor for common causes of morbidity and mortality including stroke, myocardial infarction, heart failure, and end-stage renal disease. Despite the morbid consequences of hypertension, its pathogenesis remains to be fully elucidated. Difficulties in defining the causes of hypertension from physiological studies alone have motivated studies to search for genetic factors in the etiology of hypertension. Identification of genes influencing blood pressure variation may confer more insight into the physiological mechanisms underlying blood pressure variation and reveal pathways and targets for therapeutical intervention. In recent years, several genes responsible for rare Mendelian forms of hypertension have been identified

Patients suffering from psychological impairments following critical illness are in need of information

Background: Because critical illness survivors frequently experience several long-term psychological impairments altering quality of life after ICU, there is a trend towards increasing follow-up care, mainly via ICU follow-up clinics. Despite these and other initiatives, understanding of patient's post-ICU needs to help them cope with their problems and subsequently improve quality of life is largely lacking. Our aim was therefore to assess the needs, expectations and wishes in ICU survivors to receive information with the purpose to help them better grasp ICU treatment. In addition, we assessed the perceived burden of psychological trauma after ICU treatment and the health-related quality of life (HRQoL) up to 2.5 years after ICU discharge. Methods: In a multicentre, retrospective cross-sectional cohort study, the needs and preferred intervention methods were assessed using a self-composed inventory in adult mechanically ventilated ICU survivors (n = 43). Additionally, the Impact of Event Scale Revised, the Beck Depression Inventory, the EuroQol-5D-5L, and the Short-Form 12 were used to assess psychological burden and HRQoL. Results: A substantial proportion of all ICU survivors (59%, 95% CI 44% to 74%) suffered from psychological impairments after ICU treatment. Seventy-five percent of these patients expressed a wish to receive information, but only 36% desired to receive this information using a commonly used information brochure. In contrast, 71% of these patients had a wish to receive information using a video film/VR. Furthermore, only 33% of these patients was satisfied with the information provided by their treating hospital. Patients with psychological PICS reported a worse HRQoL as compared to a normative Dutch sample (P < 0.001) and as compared to patients without psychological PICS (P < 0.01). Conclusions: In a Dutch cohort of critical illness survivors, a substantial part of ICU survivors suffer from psychological impairments, such as PTSD and depression, which was associated with a worse HRQoL. These patients are in need of information, have no desire using an information brochure, but are willing to receive information using a video film/virtual reality module. These results support the exploration of such an intervention

Early life patterns of criminal legal system involvement: Inequalities by race/ethnicity, gender, and parental education

Background: Contacts with the criminal legal system have consequences for a host of outcomes. Still, early life age patterns of system involvement remain to be better understood. Objective: We estimate cumulative risks of arrest, probation, and incarceration from childhood through early adulthood and assess disparities by race/ethnicity, gender, and parental education. Methods: Data come from the Transition to Adulthood Supplement of the Panel Study of Income Dynamics (n = 2,736). We use Kaplan-Meier curves and Cox regression models to estimate cumulative risks of arrest, probation, and incarceration across the early life course and document disparities by race/ethnicity, gender, and parental education, as well as at their intersections. Results: Criminal legal system involvement is common among recent cohorts, but Black and Latinx boys and young men face especially high risks. Among Black men whose highest-educated parent completed high school or less, an estimated six in ten had been arrested, four in ten had experienced probation, and four in ten had been incarcerated by age 26. Among Latinx men whose highest-educated parent completed high school or less, an estimated four in ten had been arrested and one in four had been incarcerated by age 26. Black women also experienced high risks, with an estimated one in four arrested by age 26. Contribution: We document early life patterns of criminal legal system involvement among young people who came of age during the expansion of proactive policing and mass incarceration in the United States, providing important context for understanding the role of the system in generating and exacerbating life course inequalities

Unusual exanthema combined with cerebral vasculitis in pneumococcal meningitis: a case report

<p>Abstract</p> <p>Introduction</p> <p>Bacterial meningitis is a complex, rapidly progressive disease in which neurological injury is caused in part by the causative organism and in part by the host's own inflammatory responses.</p> <p>Case presentation</p> <p>We present the case of a two-year-old Greek girl with pneumococcal meningitis and an atypical curvilinear-like skin eruption, chronologically associated with cerebral vasculitis. A diffusion-weighted MRI scan showed lesions with restricted diffusion, reflecting local areas of immunologically mediated necrotizing vasculitis.</p> <p>Conclusions</p> <p>Atypical presentations of bacterial meningitis may occur, and they can be accompanied by serious unexpected complications.</p

Genome-wide association study identifies six new loci influencing pulse pressure and mean arterial pressure.

Numerous genetic loci have been associated with systolic blood pressure (SBP) and diastolic blood pressure (DBP) in Europeans. We now report genome-wide association studies of pulse pressure (PP) and mean arterial pressure (MAP). In discovery (N = 74,064) and follow-up studies (N = 48,607), we identified at genome-wide significance (P = 2.7 × 10(-8) to P = 2.3 × 10(-13)) four new PP loci (at 4q12 near CHIC2, 7q22.3 near PIK3CG, 8q24.12 in NOV and 11q24.3 near ADAMTS8), two new MAP loci (3p21.31 in MAP4 and 10q25.3 near ADRB1) and one locus associated with both of these traits (2q24.3 near FIGN) that has also recently been associated with SBP in east Asians. For three of the new PP loci, the estimated effect for SBP was opposite of that for DBP, in contrast to the majority of common SBP- and DBP-associated variants, which show concordant effects on both traits. These findings suggest new genetic pathways underlying blood pressure variation, some of which may differentially influence SBP and DBP

Urban space and the social control of incivilities: perceptions of space influencing the regulationof anti-social behaviour

Contemporary cities are increasingly governed through space. In this article,we examine how urban space and perceptions thereof can influence the social control inthe area of incivilities. To this end, we first inspect the existing literature, in particularthe socio-spatial studies that emphasise the importance of culture and values in theinteraction with social control. Partly drawing on examples from our previous studies,we suggest that people’s perceptions of urban space (influenced by cultural symbols,social and media representations, aesthetics and other values) affect their perceptions ofincivilities, while the latter often determine or at least importantly contribute to theshaping of the social control of incivilities. We further highlight the role of gentrifica-tion as a medium and a tool of social control. The paper concludes by discussingimplications of this for the possible future, more integrated and interdisciplinaryresearch on the social control of incivilities in the city

Inequalities in the Structure and Delivery of U.S. Health Care

Although healthcare inequalities by race-ethnicity and nativity have been widely explored, more research is needed to investigate how these inequalities result from structures of racial stratification and immigrant exclusion operating within U.S. health care. My dissertation employs hand coded restricted-access medical record data, linked survey data, and rich administrative data to examine the factors generating healthcare inequalities experienced by both patients and physicians. I contextualize these inequalities within a broader U.S. landscape characterized by structural racism and nativism. In the first chapter, I examine the impact of state immigration policy contexts on healthcare access of U.S. agricultural workers representing various racial-ethnic identities and legal statuses between 2005-2012. I find state-level immigration policy contexts are strongly associated with healthcare access among documented non-White Latinx agricultural workers, who report lower levels of healthcare access and greater barriers to care-seeking in increasingly restrictive policy contexts. In the second chapter, I use hand coded electronic medical record data to examine provider-patient communication disparities. Black and Latinx patients are less likely than White patients to receive provider communication regarding a new incidental medical finding diagnosis. This disparity may reflect interpersonal racism between providers and patients of color, resulting from the perpetuation of racial mythologies in medicine. In the third chapter, I use geocoded data from the American Medical Association to explore whether subgroups of international medical graduates (IMGs) experience career stratification based on their country of medical education. I find IMGs trained in developing countries chart more marginalized U.S. career paths relative to those trained in developed countries, suggesting that nativism and racism within the medical profession intersect to disadvantage physicians from developing countries, who often are also people of color. My dissertation generates empirical evidence to show how racism and nativism operating within the U.S. healthcare system generate inequalities among people of color and immigrants. These findings have important implications not only for our understanding of racial inequality and social stratification broadly, but also for informing policy and intervention to promote equity within U.S. health care