Patient, Physician, and Community Demographics and Physicians' Perceptions of Patients, Their Practice, and the Management of Diabetes.

A growing body of health services research shows that African Americans, when compared to whites, are more likely to perceive discrimination in health care, be the target of negative stereotypes from health care providers, and receive lower quality of care for a broad range of services even after controlling for socioeconomic status. Less well documented are the physician- and setting-related factors that predict or protect against negative stereotypes and unequal treatment. Through a mail-based questionnaire administered to primary care physicians and endocrinologists in the greater-Southeast Michigan area, this research investigated these factors with the goal of improving our understanding of the intersections among race, place, socioeconomic status, and health care as it relates to the management of diabetes. Specifically, this dissertation explored physicians’ perceptions of patients, how these perceptions are associated with patients’ and physicians’ demographics, and how patients’ and physicians’ demographics are correlated with physicians’ decision making and strategies to manage diabetes. An overarching principle guiding this research is the notion that successful management of diabetes requires more than the provision of medical care; it requires balancing input from multiple influences across the ecological spectrum. Findings suggest that when physicians assess patients or when they make decisions on how to provide care they take into account not only information about patients’ illness or disease but are influenced by patients’ demographics, their own demographic and professional backgrounds, and the settings in which care is provided. After controlling for a broad set of covariates, physicians’ gender and training background proved to be the most salient predictors of physicians’ perceptions of patients, strategies to manage diabetes, and decision making style; results were not consistent with the notion that physicians respond more negatively or with biased attitudes when working with African American patients versus patients generally. Findings from this research indicate that (a) increasing physicians’ competency in social determinant of health, (b) promoting policies that finance patient centered medical homes, and (c) rewarding health systems that grow the primary care physician workforce in urban settings may help to improve the quality of diabetes care for the populations living in such areas.PHDHealth Services Organization & PolicyUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/96150/1/cshultz_1.pd

A Systems Approach to Improving Tdap Immunization Within 5 Community-Based Family Practice Settings: Working Differently (and Better) by Transforming the Structure and Process of Care.

OBJECTIVES: We examined how family medicine clinic physicians and staff worked in collaborative teams to implement an automated clinical reminder to improve tetanus, diphtheria, and acellular pertussis (Tdap) booster vaccine administration and documentation. METHODS: A clinical reminder was developed at 5 University of Michigan family medicine clinics to identify patients 11 to 64 years old who were in need of the Tdap booster vaccine. Quality improvement cycles were used to improve clinic care processes. Immunization rates from 2008 to 2011 were compared with rates at 4 primary care control clinics. RESULTS: Vaccination rates among eligible patients increased from 15.5% to 47.3% within the family medicine clinics and from 14.1% to 30.2% within the control clinics. After adjustment for covariates, family medicine patients had a higher probability of vaccination than control patients during each measurement period (0.17 vs 0.15 at baseline, 0.53 vs 0.22 during year 1, and 0.50 vs 0.30 during year 2). CONCLUSIONS: Automated clinical reminders, when designed and implemented via a consensus-based framework that addresses the process of care, can dramatically improve provision of preventive health care

The importance of the altricial – precocial spectrum for social complexity in mammals and birds:A review

Various types of long-term stable relationships that individuals uphold, including cooperation and competition between group members, define social complexity in vertebrates. Numerous life history, physiological and cognitive traits have been shown to affect, or to be affected by, such social relationships. As such, differences in developmental modes, i.e. the ‘altricial-precocial’ spectrum, may play an important role in understanding the interspecific variation in occurrence of social interactions, but to what extent this is the case is unclear because the role of the developmental mode has not been studied directly in across-species studies of sociality. In other words, although there are studies on the effects of developmental mode on brain size, on the effects of brain size on cognition, and on the effects of cognition on social complexity, there are no studies directly investigating the link between developmental mode and social complexity. This is surprising because developmental differences play a significant role in the evolution of, for example, brain size, which is in turn considered an essential building block with respect to social complexity. Here, we compiled an overview of studies on various aspects of the complexity of social systems in altricial and precocial mammals and birds. Although systematic studies are scarce and do not allow for a quantitative comparison, we show that several forms of social relationships and cognitive abilities occur in species along the entire developmental spectrum. Based on the existing evidence it seems that differences in developmental modes play a minor role in whether or not individuals or species are able to meet the cognitive capabilities and requirements for maintaining complex social relationships. Given the scarcity of comparative studies and potential subtle differences, however, we suggest that future studies should consider developmental differences to determine whether our finding is general or whether some of the vast variation in social complexity across species can be explained by developmental mode. This would allow a more detailed assessment of the relative importance of developmental mode in the evolution of vertebrate social systems

Intrarenal haemodynamics and renal dysfunction in endotoxaemia: effects of nitric oxide synthase inhibition

1. This study investigated the effects of low dose endotoxin (lipopolysaccharide, LPS) on (i) systemic haemodynamics, (ii) renal blood flow (RBF), (iii) renal cortical and medullary perfusion and (iv) renal function in the anaesthetized rat. We have also investigated the effects of nitric oxide (NO) synthase (NOS) inhibition with N(G)-methyl-L-arginine (L-NMMA) on the alterations in systemic and renal haemodynamics and renal function caused by endotoxin. 2. Infusion of low dose LPS (1 mg kg(−1) over 30 min, n=6) caused a late fall in mean arterial blood pressure (MAP, at 5 and 6 h after LPS), but did not cause an early (at 1–4 h after LPS) hypotension. The pressor effect of noradrenaline (NA, 1 μg kg(−1), i.v.) was significantly reduced at 1 to 6 h after LPS (vascular hyporeactivity). Infusion of L-NMMA (50 μg kg(−1) min(−1) commencing 60 min before LPS and continued throughout the experiment, n=7) abolished the delayed hypotension and significantly attenuated the vascular hyporeactivity to NA (at 2–6 h). 3. Infusion of LPS (1 mg kg(−1) over 30 min, n=6) caused a rapid (within 2 h) decline in renal function (measured by inulin clearance) in the absence of a significant fall in MAP or renal blood flow (RBF). L-NMMA (n=7) attenuated the impairment in renal function caused by LPS so that the inulin clearance in LPS-rats treated with L-NMMA was significantly greater than in LPS-rats treated with vehicle (control) at 3–6 h after infusion of LPS. 4. Endotoxaemia also caused a significant reduction in renal cortical, but not medullary perfusion (measured as Laser Doppler flux). Infusion of L-NMMA caused a significant further fall in cortical perfusion and a significant fall in medullary perfusion in the absence of changes in RBF. 5. Infusion of LPS resulted in a progressive increase in the plasma levels of nitrite/nitrate (an indicator of the formation of NO), so that the plasma concentration of nitrite/nitrate was significantly higher than baseline at 150 to 330 min after LPS. Infusion of L-NMMA attenuated the rise in the plasma concentration of nitrite/nitrate (at 270 and 330 min, P<0.05) caused by LPS. 6. Thus, the renal dysfunction caused by injection of low dose of endotoxin in the rat occurs in the absence of significant falls in blood pressure or total renal blood flow. Inhibition of NOS activity with L-NMMA attenuates the renal dysfunction caused by endotoxin (without improving intrarenal haemodynamics), suggesting that an overproduction of NO may contribute to the development of renal injury and dysfunction by causing direct cytotoxic effects

Foreword to Supplement 1: research on a polar species—the Arctic fox

The Arctic fox has a circumpolar distribution and is intensively studied because it is adapted to extreme environments and influences the ecology of many other species. We introduce here a collection of 12 articles on Arctic fox biology and management. After summarizing the main biological features of the species, we explore the peer-reviewed literature dealing with the Arctic fox through a bibliometric network analysis which identifies clusters of papers sharing a high similarity of cited literature. We visualize with a word cloud analysis 10 clusters comprising 97% of 755 articles published by 1742 authors from 1996–2015. Behavioural and ecological questions, including conservation science, dominate this recent literature. The collection of papers published in the supplement offers an excellent representation of current research dealing with Arctic fox biology and management