Medication safety messages for patients via the web portal: the MedCheck intervention.

OBJECTIVE: Communication failures account for many adverse drug events (ADEs) in adult primary care. Improving patient-physician communication may improve medication safety. Accordingly, the goal of this study was to learn whether electronic medication safety messages directed to patients can improve communication about medications and identify ADEs. DESIGN: We studied adult patients enrolled in a patient Internet portal at three primary care practices affiliated with a teaching hospital. MedCheck, a medication safety application, sent patients a secure electronic message 10 days after they received a new or changed prescription. MedCheck asked if the patient had filled the prescription or experienced medication-related problems, and then forwarded the patient's response to their primary care physician. MEASUREMENTS: We selected a stratified random sample of 267 subjects from 1821 patients who received and opened a MedCheck message from April 2001 to June 2002. We reviewed subjects' medical records for three months following their first MedCheck message. We analyzed patient and clinician response rates and times, examined patient-clinician communication about medications, and identified ADEs. RESULTS: Patients opened 79% of MedCheck messages and responded to 12%; 77% responded within 1 day. Patients often identified problems filling their prescriptions (48%), problems with drug effectiveness (12%), and medication symptoms (10%). Clinicians responded to 68% of patients' messages; 93% answered within 1 week. Clinicians often supplied or requested information (19%), or made multiple recommendations (15%). Patients experienced 21 total ADEs; they reported 17 electronically. CONCLUSION: Patients and physicians responded promptly to patient-directed electronic medication messages, identifying and addressing medication-related problems including ADEs.

ATM and ATR: sensing DNA damage.

Cellular response to genotoxic stress is a very complex process, and it usually starts with the "sensing" or "detection" of the DNA damage, followed by a series of events that include signal transduction and activation of transcription factors. The activated transcription factors induce expressions of many genes which are involved in cellular functions such as DNA repair, cell cycle arrest, and cell death. There have been extensive studies from multiple disciplines exploring the mechanisms of cellular genotoxic responses, which have resulted in the identification of many cellular components involved in this process, including the mitogen-activated protein kinases (MAPKs) cascade. Although the initial activation of protein kinase cascade is not fully understood, human protein kinases ATM (ataxia-telangiectasia, mutated) and ATR (ATM and Rad3-related) are emerging as potential sensors of DNA damage. Current progresses in ATM/ATR research and related signaling pathways are discussed in this review, in an effort to facilitate a better understanding of genotoxic stress response.

ATM, ATR and DNA-PK: initiators of the cellular genotoxic stress responses.

Exposure to genotoxic agents is a major cause of human cancer, and cellular responses to genotoxic stress are important defense mechanisms. These responses are very complex, involving many cellular factors that form an extensive signal transduction network. This network includes a protein kinase cascade that connects the detection of DNA damage to the activation of transcription factors, which in turn regulate the expression of genes involved in DNA repair, cell cycle arrest and programmed cell death (apoptosis). The mitogen-activated protein kinases are the best-studied members of the kinase cascade with an acknowledged role in the genotoxic stress response. However, the initial activation of the protein kinase cascade is not fully understood, although several protein kinases, such as ataxia telangiectasia, mutated (ATM), ATM- and Rad3-related (ATR), and DNA-dependent protein kinase (DNA-PK) in humans, are increasingly recognized for their potential roles in the sensing of DNA damage and initiating the subsequent protein kinase cascade. In this review, the properties of these three kinases are discussed and their functions in the initiation of the genotoxic stress response are explored.

Impact of population management with direct physician feedback on care of patients with type 2 diabetes.

OBJECTIVE: Population-level strategies may improve primary care for diabetes. We designed a controlled study to assess the impact of population management versus usual care on metabolic risk factor testing and management in patients with type 2 diabetes. We also identified potential patient-related barriers to effective diabetes management. RESEARCH DESIGN AND METHODS: We used novel clinical software to rank 910 patients in a diabetes registry at a single primary care clinic and thereby identify the 149 patients with the highest HbA(1c) and cholesterol levels. After review of the medical records of these 149 patients, evidence-based guideline recommendations regarding metabolic testing and management were sent via e-mail to each intervention patient's primary care provider (PCP). Over a 3-month follow-up period, we assessed changes in the evidence-based management of intervention patients compared with a matched cohort of control patients receiving usual care at a second primary care clinic affiliated with the same academic medical center. RESULTS: In the intervention cohort, PCPs followed testing recommendations more often (78%) than therapeutic change recommendations (36%, P = 0.001). Compared with the usual care control cohort, population management resulted in a greater overall proportion of evidence-based guideline practices being followed (59 vs. 45%, P = 0.02). Most intervention patients (62%) had potential barriers to effective care, including depression (35%), substance abuse (26%), and prior nonadherence to care plans (18%). CONCLUSIONS: Population management with clinical recommendations sent to PCPs had a modest but statistically significant impact on the evidence-based management of diabetes compared with usual care. Depression and substance abuse are prevalent patient-level adherence barriers in patients with poor metabolic control.