Publications

BACKGROUND

Interactive health information technology (HIT) can support the complex self-management tasks for diabetes. However, less is known about between-visit interactions and patient safety among chronic illness patients treated in the outpatient setting.

METHODS

We classified 13 categories for safety events and potential safety events within a larger trial evaluating a multilingual automated telephone self-management support system for diabetes using interactive voice response. Participants could trigger safety concerns by reporting hyperglycemia or hypoglycemia, inability to obtain medications, medication nonadherence and side effects, and needing appointments and/or supplies. We then examined these triggers across patient demographic and health characteristics to determine which patients were most likely to experience safety events.

RESULTS

Overall, there were 360 safety triggers that occurred among 155 participants, which represented 53% of individuals and 7.6% of all automated calls over the 27-week intervention. The most common triggers were for pain or medication side effects (22%) and not checking blood sugars (13%). In adjusted models, race/ethnicity and language were related to safety triggers; Spanish-speaking participants were significantly (p = .02) more likely than English-speaking participants to experience a safety trigger, and black participants were marginally more likely (p = .09) than white participants to experience a safety trigger.

CONCLUSION

About half of patients enrolled in a self-management technology intervention triggered at least one potential safety event over the course of the trial, and this was more frequent among some patients. Systems implementing HIT strategies to improve self-care and remote monitoring should consider specific program design elements to address these potential safety events.

AIMS

The tobacco and alcohol industries share common policy goals when facing regulation, opposing policies such as tax increases and advertising restrictions. The collaboration between these two industries in the tobacco policy arena is unknown. This study explored if tobacco and alcohol companies built alliances to influence tobacco legislation and, if so, how those alliances worked.

METHODS

Analysis of previously secret tobacco industry documents.

FINDINGS

In the early 1980s, tobacco companies started efforts to build coalitions with alcohol and other industries to oppose cigarette excise taxes, clean indoor air policies and tobacco advertising and promotion constraints. Alcohol companies were often identified as a key partner and source of financial support for the coalitions. These coalitions had variable success interfering with tobacco control policy-making.

CONCLUSIONS

The combined resources of tobacco and alcohol companies may have affected tobacco control legislation. These alliances helped to create the perception that there is a broader base of opposition to tobacco control. Advocates should be aware of the covert alliances between tobacco, alcohol and other industries and expose them to correct this misperception.

BACKGROUND

Guidelines advise testing for ischemia, such as with stress testing, before elective percutaneous coronary intervention (PCI). However, pre-PCI stress testing is not always done; the implications of this practice are not known. Our objective was to evaluate whether receipt of stress testing before elective PCI predicts mortality.

METHODS AND RESULTS

Using claims data from a 20% random sample of Medicare beneficiaries, we identified patients who had elective PCI in 2004 and followed them for a median of 3.4 years (n=23 887). Cox proportional hazards models were used to test the relationship of pre-PCI stress testing to survival. Population-based rates of elective PCI and stress testing were calculated for 306 hospital referral regions and categorized into 4 groups: high stress test/high PCI, low stress test/low PCI, low stress test/high PCI, and high stress/low PCI regions. Cox modeling was used to test whether category of hospital referral regions is related to survival. Patients who underwent pre-PCI stress testing had a 13% lower risk of mortality than those who did not (adjusted hazard ratio, 0.87; 95% confidence interval, 0.81-0.92) after median follow-up of 3.4 years. Patients in low stress test/high PCI regions had a 14% higher risk of mortality than those in high stress test/high PCI regions (adjusted hazard ratio, 1.14; 95% confidence interval, 1.03-1.26).

CONCLUSIONS

Pre-PCI stress testing is associated with lower mortality in patients undergoing elective PCI. Greater adherence to guidelines with respect to documenting ischemia before elective PCI may result in improved outcomes for patients.

We studied mice with or without heterozygous deletion of the Casr in the parathyroid gland (PTG) [(PTG) CaSR(+/-)] to delineate effects of age and sex on manifestations of hyperparathyroidism (HPT). In control mice, aging induced a left-shift in the Ca(2+) /parathyroid hormone (PTH) set point accompanied by increased PTG CaSR expression along with lowered serum Ca(2+) and mildly increased PTH levels, suggesting adaptive responses of PTGs to aging-induced changes in mineral homeostasis. The aging effects on Ca(2+) /PTH set point and CaSR expression were significantly blunted in (PTG) CaSR(+/-) mice, who showed instead progressively elevated PTH levels with age, especially in 12-month-old females. These 12-month-old knockout mice demonstrated resistance to their high PTH levels in that serum 1,25-dihydroxyvitamin D (1,25-D) levels and RNA expression of renal Cyp27b1 and expression of genes involved in Ca(2+) transport in kidney and intestine were unresponsive to the rising PTH levels. Such changes may promote negative Ca(2+) balance, which further exacerbate the HPT. Skeletal responses to HPT were age-, sex-, and site-dependent. In control mice of either sex, trabecular bone in the distal femur decreased whereas cortical bone in the tibiofibular junction increased with age. In male (PTG) CaSR(+/-) mice, anabolic actions of the elevated PTH levels seemed to protect against trabecular bone loss at ≥ 3 months of age at the expense of cortical bone loss. In contrast, HPT produced catabolic effects on trabecular bone and anabolic effects on cortical bone in 3-month-old females; but these effects reversed by 12 months, preserving trabecular bone in aging mice. We demonstrate that the CaSR plays a central role in the adaptive responses of parathyroid function to age-induced changes in mineral metabolism and in target organ responses to calciotropic hormones. Restraining the ability of the PTG to upregulate CaSRs by heterozygous gene deletion contributes to biochemical and skeletal manifestations of HPT, especially in aging females.

OBJECTIVE

We describe a young woman with previously undiagnosed thyrotoxicosis who presented with acute liver failure (ALF).

METHODS

We present a case report and review the relevant literature.

RESULTS

An extensive evaluation excluded possible causes of ALF other than thyrotoxicosis. The management of thyrotoxicosis posed several unique challenges in the setting of ALF, particularly because we did not want to use potentially hepatotoxic thionamides. The patient was treated with prednisone and propranolol and was started on potassium iodide when she was listed for liver transplantation. She underwent an uncomplicated liver transplant and subsequent thyroidectomy and is doing well.

CONCLUSION

This well-characterized case describes thyrotoxicosis as a possible cause of ALF after thoroughly excluding other possible causes and illustrates the challenges of simultaneously managing both disorders. To our knowledge, this is the first report of ALF possibly resulting from untreated thyrotoxicosis that was successfully treated with liver transplantation.

Transient low-level viremia (TLLV) of 50-400 HIV RNA copies per milliliter is common during antiretroviral therapy, but its pathogenesis, consequences, and optimal management are unclear. Heightened immune activation is associated with detrimental outcomes, including impaired CD4 T-cell reconstitution. Using CD38/HLA-DR expression on CD8 T cells measured in 2 large studies, we determined associations between TLLV and immune activation levels before, during, and after TLLV. We found that TLLV does not significantly change CD8 T-cell activation and that higher CD8 T-cell activation during viral suppression <50 copies per milliliter is associated with a modest increase in the risk of a subsequent TLLV.