Introduction: Trypanosoma cruzi (Tc) infection is usually acquired in childhood in endemic areas, leading to Chagas disease, which progresses to Chagas cardiomyopathy in 20-30% of infected individuals over decades. The pathogenesis of Chagas cardiomyopathy involves the host inflammatory response to T. cruzi, in which upstream caspase-1 activation prompts the cascade of inflammatory chemokines/cytokines, cardiac remodeling, and myocardial dysfunction. The aim of the present study was to examine the association of two caspase-1 single nucleotide polymorphisms (SNPs) with cardiomyopathy. Methods: We recruited infected (Tc+, n = 149) and uninfected (Tc−, n = 87) participants in a hospital in Santa Cruz, Bolivia. Cardiac status was classified (I, II, III, IV) based on Chagas cardiomyopathy-associated electrocardiogram findings and ejection fractions on echocardiogram. Genotypes were determined using Taqman probes via reverse transcription-polymerase chain reaction of peripheral blood DNA. Genotype frequencies were analyzed according to three inheritance patterns (dominant, recessive, additive) using logistic regression adjusted for age and sex. Results: The AA allele for the caspase-1 SNP rs501192 was more frequent in Tc+ cardiomyopathy (classes II, III, IV) patients compared to those with a normal cardiac status (class I) [odds ratio (OR) = −2.18, p = 0.117]. This trend approached statistical significant considering only Tc+ patients in class I and II (OR = −2.64, p = 0.064). Conclusions: Caspase-1 polymorphisms may play a role in Chagas cardiomyopathy development and could serve as markers to identify individuals at higher risk for priority treatment.

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The Indian Health Service (IHS) administers health care services to American Indians and Alaska Natives (AI/ANs) in the United States. The agency funds referral care services through the Purchased/Referred Care (PRC) Program, which prioritizes its budget to pay for emergent care. This commentary responds to a case about a physician's disappointment that a referral for nonemergent care is deferred for payment by the PRC Program. Jonsen et al's 4-quadrant approach (a microethical case analysis model) is applied to suggest that deferring referrals is just only when the PRC Program operates fairly. This model, however, might inadequately account for structural inequities underlying referral care rationing by the IHS, a federal entity that is legally and ethically obligated to care comprehensively for AI/AN patients. CaseAt an Indian Health Service (IHS) facility in Wyoming, a state in which Medicaid coverage has not been expanded under the Affordable Care Act, pediatric and gynecologic care is available inconsistently, and surgical and other subspecialty care is not offered. Dr R previously worked in the academic sector and was recently hired as a primary care physician at this IHS site. On his first day, he joins administrators and clinicians who meet regularly in the Purchased/Referred Care (PRC) Review Committee to review referral requests for health care services unavailable at the facility. In IHS sites without specialists, government funding can be directed to non-IHS public or private health care organizations to purchase needed specialty care for AI/AN patients. However, referral requests for nonemergent services are rarely approved at Dr R's and other IHS sites due to insufficient federal funding.During the meeting, a referral for Ms B is discussed. Ms B is a 55-year-old patient with bilateral knee osteoarthritis and disabling knee pain, and her IHS clinician placed a referral for an orthopedics consultation to assess her candidacy for surgical intervention. Ms B gets around with a wheelchair and manages her pain with opioids. She does not have private or public insurance. Dr R and his clinical colleagues agree that the referral is medically indicated, but authorization for payment of Ms B's referral

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Rural residents in the United States are less likely to have dental insurance and more likely to face environmental and geographic barriers to oral health and dental care. This article discusses oral health inequity, evidence of oral health's influence on overall health, and why the primary care workforce is well positioned to provide prevention, screening, and referrals for oral health and dental care. Six strategies by which oral health and dental care are integrated into primary care delivery streams can help mitigate rural health inequity.