Using law to fight a silent epidemic: the role of health literacy in health care access, quality, & cost

The dominant rhetoric in the health care policy debate about cost has assumed an inherent tension between access and quality on the one hand, and cost effectiveness on the other; but an emerging discourse has challenged this narrative by presenting a more nuanced relationship between access, quality, and cost. This is reflected in the discourse surrounding health literacy, which is viewed as an important tool for achieving all three goals. Health literacy refers to one's ability to obtain, understand and use health information to make appropriate health decisions. Research shows that improving patients' health literacy can help overcome access barriers and empower patients to be better health care partners, which should lead to better health outcomes. Promoting health literacy can also reduce expenditures for unnecessary or inappropriate treatment. This explains why, as a policy matter, improving health literacy is an objective that has been embraced by almost every sector of the health care system. As a legal matter, however, the role of health literacy in ensuring quality and access is not as prominent. Although the health literacy movement is relatively young, it has roots in longstanding bioethical principles of patient autonomy, beneficence, and justice as well as the corresponding legal principles of informed consent, the right to quality care, and antidiscrimination. Assumptions and concerns about health literacy seem to do important, yet subtle work in these legal doctrines--influencing conclusions about patient understanding in informed consent cases, animating decisions about patient responsibility in malpractice cases, and underlying regulatory guidance concerning the quality of language assistance services that are necessary for meaningful access to care. Nonetheless, health literacy is not explicitly treated as a legally relevant factor in these doctrines. Moreover, there is no coherent legal framework for incorporating health literacy research that challenges traditional assumptions about patient comprehension and decision-making, and that emphasizes the need for providers to improve communication and take affirmative steps to assess patient understanding. The absence of a clear and robust consideration of health literacy in these doctrines undermines core access and quality aims, and it means that such laws are of limited efficacy in promoting health literacy. Returning to the theme that the health literacy problem reflects a complementary view of access, quality and cost, it is likely that the cost implications of this problem (and not concerns about quality and access) will motivate the kind of health literacy reform that may ultimately strengthen existing quality and access standards. One recent example of this can be seen in reforms linked to government, insurer and provider attempts to reduce costly medication errors.     

Developing and Validating a New Classroom Climate Observation Assessment Tool

The climate of school classrooms, shaped by a combination of teacher practices and peer processes, is an important determinant for children's psychosocial functioning and is a primary factor affecting bullying and victimization. Given that there are relatively few theoretically-grounded and validated assessment tools designed to measure the social climate of classrooms, our research team developed an observation tool through participatory action research (PAR). This article details how the assessment tool was designed and preliminarily validated in 18 third-, fourth-, and fifth-grade classrooms in a large urban public school district. The goals of this study are to illustrate the feasibility of a PAR paradigm in measurement development, ascertain the psychometric properties of the assessment tool, and determine associations with different indices of classroom levels of relational and physical aggression.     

谈新疆少数民族吸食大麻人员焦虑心理的自我矫正

新疆消费大麻具有悠久的历史。由于大麻对各类疾病的治疗有明显的疗效,且吸食麻烟易戒断,因此,尽管不少人认识到吸食大麻成瘾会罹患精神疾病,但大麻还是在新疆少数民族百姓生活中使用较频繁。近几年来发现吸食大麻的少数民族人群中出现焦虑症状较突出,他们会经常无缘无故的、没有明确对象和内容的焦急、紧张、恐惧和不安,经常感觉到威胁即将来临,但又说不出究竟存在何种威胁或危险。中外研究成果表明吸食大麻易导致精神异常。对此类人群自身应采取增强自信、自我刺激、自我放松、自我脱敏、自我催眠、自我放松等自救措施,以通过自我矫正改变因吸食大麻而形成的焦虑心理。     

Patella sex determination by 3D statistical shape models and nonlinear classifiers

Sex determination is one of the essential steps in personal identification of an individual from skeletal remains. Most elements of the skeleton have been subjected to discriminant function analysis for sex estimation, but little work has been done in terms of the patella. This paper proposes a new sex determination method from the patella using a novel automated feature extraction technique. A dataset of 228 patellae (95 females and 133 males) was amassed from the William M. Bass Donated Skeletal Collection from the University of Tennessee and was subjected to noninvasive high resolution computed tomography (CT). After the CT data were segmented, a set of features was automatically extracted, normalized, and ranked. The segmentation process with surface smoothing minimizes the noise from enthesophytes and ultimately allows our methods to distinguish variations in patellar morphology. These features include geometric features, moments, principal axes, and principal components. A feature vector of dimension 45 for each subject was then constructed. A set of statistical and supervised neural network classification methods were used to classify the sex of the patellar feature vectors. Nonlinear classifiers such as neural networks have been used in previous research to analyze several medical diagnosis problems, including quantitative tissue characterization and automated chromosome classification. In this paper, different classification methods were compared. Classification success ranged from 83.77% average classification rate using labels from a Fuzzy C-Means (FCM) clustering step, to 90.3% for linear discriminant classification (LDC). We obtained results of 96.02% and 93.51% training and testing classification rates, respectively, using feed-forward backpropagation neural networks (NN). These promising results using newly developed features and the application of nonlinear classifiers encourage the usage of these methods in forensic anthropology for identifying the sex of an individual from incomplete skeletons retaining at least one patella.     

Lethal paradoxical cerebral vein thrombosis due to suspicious anticoagulant rodenticide intoxication with chlorophacinone

Superwarfarin exposure is a growing health problem, described in many countries. The authors report a case of suspicious chlorophacinone poisoning with a problematic diagnosis. They review the literature and discuss particularities of anticoagulant rodenticide intoxication, as well as the apparent contradiction between anticoagulant intoxication and lethal thrombosis.     

STR data for the AmpFlSTR identifier loci from an old settlement in northwestern Turkey

The polymorphism of 15 STR loci has been studied in a population sample of 193 healthy unrelated individuals from the population of Duzce, a city in the northwestern Turkey. The most valuable loci, from forensic point of view according to their power of discrimination values, were D2S1338, D18S51, FGA, and D19S433 where CSF1PO appeared to be the least powerful one. From paternity point of view, FGA, D21S11 were found to be the loci with highest exclusion value whereas D3S1358 and TPOX were the locus with the lowest exclusion.     

STR data for the 15 AmpFlSTR identifiler loci in the Western Romanian population

Allele frequencies for the 15 tetranucleotide short tandem repeat loci contained in the AmpFlSTR Identifiler kit were obtained from a population sample of 219 unrelated individuals born in the western part of Romania.     

Narrative identity and offender rehabilitation

The rehabilitation of offenders is an evaluative and capability-building process and is concerned with promoting primary goods and managing risk. At the heart of this process is the construction of a more adaptive narrative identity and the acquisition of capabilities to enable offenders to secure important values in their postrelease environments. In this article, the authors examine the idea of narrative identity and its relationship to values and to assessment and treatment.     

Female recidivists speak about their experience in drug court while engaging in appreciative inquiry

Eleven female drug-court participants looked at current and past experiences to assess their program and envision future program innovations. From these women's perspective, the strongest component of drug court was being surrounded by staff dedicated to their progress and recovery. Graduated supervision and accurate drug testing were appreciated rather than resented when the participants were not humiliated and were treated with respect. Wraparound services, resources, and referral; treatment facilities that accepted children; and individualized treatment plans and therapy with offenders who are ex-addicts, and preferably females, allowed for greater involvement and active participation in recovery. Progressing through three phases, acquiring skills, a job, and visitation rights to see their children or regaining custody, increased these women's sense of self-efficacy perception and confidence in their ability to lead a drug-free, meaningful life. Findings show the importance of qualitative criteria in evaluating drug-court participants' progress and the process of recovery.     

Age estimation by pulp/tooth ratio in canines by peri-apical X-rays

Estimation of age in individuals has received considerable attention in forensic science, in which it is a widely used method for individual identification, together with paleo-demographic analyses to establish mortality patterns in past populations. The present investigation, which is a continuation of a previously published pilot study, was conducted to examine the possible application of the pulp/tooth area ratio by peri-apical images as an indicator of age at death. A total of 200 peri-apical X-rays of upper and lower canines were assembled from 57 male and 43 female skeletons of Caucasian origin, aged between 20 and 79 years. They belong to the Frassetto osteological collection of Sassari (Sardinia) and are housed in the Museum of Anthropology, Department of Experimental and Evolutionistic Biology, University of Bologna. For each skeleton, dental maturity was evaluated by measuring the pulp/tooth area ratio on upper (x(1)) and lower (x(2)) canines. Very good agreement was found between intraobserver measurements. Statistical analysis was performed in order to obtain multiple regression formulae for dental age calculation, with chronological age as dependent variable, and gender, and upper and lower canines as independent variables. Stepwise regression analysis showed that gender did not contribute significantly to the fit (p=0.881) whereas variables x(1) and x(2) and the first-order interaction between them did. These two variables explained 92.5% of variations in estimated chronological age and the residual standard error was 4.06 years. Lastly, two simple linear regression equations were obtained for age estimation using canines from the maxilla and mandible separately. Both models explained 86% of variations in estimated chronological age and allowed an age-at-death estimate with a residual standard error of about 5.4 years.