Nucleic Acid-Sensing Receptors: Rheostats of Autoimmunity and Autoinflammation.

Distinct families of germline-encoded pattern recognition receptors can sense both microbial and endogenous nucleic acids. These DNA and RNA sensors include endosomal TLRs and cytosolic sensors upstream of stimulator of type I IFN genes (STING) and MAVS. The existence of overlapping specificities for both foreign and self nucleic acids suggests that, under optimal conditions, the activity of these receptors is finely tuned to effectively mediate host defense yet constrain pathogenic self-reactivity. This equilibrium becomes disrupted with the loss of either TLR9 or STING. To maintain immune protection, this loss can be counterbalanced by the elevated response of an alternative receptor(s). Unfortunately, this adjustment can lead to an increased risk for the development of systemic autoimmunity, as evidenced by the exacerbated clinical disease manifestations of TLR9-deficient and STING-deficient autoimmune-prone mice. These studies underscore the delicate balance normally maintained by tonic signals that prevent unchecked immune responses to nucleic acids released during infections and cellular duress or death.

Interest in the use of computerized patient portals: role of the provider-patient relationship.

BACKGROUND: Bioinformatics experts are developing interactive patient portals to help those living with diabetes and other chronic diseases to better manage their conditions. However, little is known about what influences patients' desires to use this technology. OBJECTIVE: To discern the impact of the provider-patient relationship on interest in using a web-based patient portal. DESIGN: Qualitative analysis of focus groups. PARTICIPANTS: Ten focus groups involving 39 patients (range 2-7) recruited from four primary care practices. APPROACH: A qualitative approach was used, which involved reading transcribed texts until a consensus was reached on data interpretation. An intercoder reliability kappa score (0.89) was determined by comparing the provider-patient relationship talk selected by the two coders. A conceptual framework was developed, which involved the development and refinement of a codebook and the application of it to the transcripts. RESULTS: Interest in the portal was linked to dissatisfaction with the provider-patient relationship, including dissatisfaction with provider communication/responsiveness, the inability to obtain medical information, and logistical problems with the office. Disinterest in the portal was linked to satisfaction with the provider-patient relationship, including provider communication/responsiveness, difficulty in using the portal, and fear of losing relationships and e-mail contact with the provider. No patient identified encrypted e-mail communication through the portal as an advantage. CONCLUSIONS: Promoting the use of computerized portals requires patient-based adaptations. These should include ease of use, direct provider e-mail, and reassurances that access and interpersonal relationships will not be lost. Education is needed about privacy concerns regarding traditional e-mail communication.

Value versus user fees: perspectives of patients before and after using a web-based portal for management of diabetes.

The objective of this work was to rate the potential or actual usefulness of 15 features of a Web-based portal for diabetes management and assess whether patients would be willing to pay user fees for portal access. We used a combination of qualitative methods (focus group discussions) and quantitative methods (survey responses) to examine patients' perspectives. We enrolled 21 patients before the diabetes-specific portal was released ("preportal" group) and 18 patients after it was released ("portal-users" group). The two groups were similar except that 67% of preportal patients and 100% of portal users were Internet users. Overall, portal features that were rated most favorably were the online calculator to estimate blood glucose control (characterized as "very useful" by 74% of patients), appointment reminder systems (74%), e-mail access to health team (74%), personal tracking logs (69%), and online scheduling (69%). More patients from the preportal group than the portal-users group favored personal logs (86% versus 50%; p = 0.015) and opportunities to form interest groups (62% versus 28%; p = 0.034). Of the 30 patients who assigned a dollar amount for 1 month of portal access, 20 assigned zero dollars. Discussions about payment focused on equity and access. Because fees are expected to discourage portal usage, many patients believed that the potential benefits associated with self-management would not be realized. Others felt that the health system would benefit financially from a portal and should therefore absorb the costs. Even if portals are valued, patients may be resistant to paying for them. This opposition stems from concerns about fairness and from the recognition that health systems may experience cost savings if patients manage their diabetes successfully.

Exploring challenges and potentials of personal health records in diabetes self-management: implementation and initial assessment.

The University of Pittsburgh Medical Center (UPMC) has implemented a personal health record grounded in the Chronic Care Model, UPMC HealthTrak, to assist patients with diabetes self-management. UPMC HealthTrak is based in the physician office and connects the patient, physician, and electronic medical record (EMR). Its functionalities include secure, electronic communication with the physician's office, along with preventive healthcare reminders, and disease-specific tools and information. In this paper, we describe challenges to office-based implementation of and initial patient reaction to the technology in the context of diabetes care. UPMC has deployed a secure Web-based patient portal, UPMC HealthTrak. We implemented UPMC HealthTrak in the ambulatory setting and assessed its impact on patient-practice communication. We conducted 10 90-minute focus groups (five pre- and five postimplementation) to assess patient reaction to UPMC HealthTrak. Focus groups were analyzed using grounded theory techniques. During the period September 2004-January 2007, there was no significant change in number of patient encounters or telephone calls received in our office, but the number of HealthTrak messages increased. Our 39 pre- and postimplementation focus group participants felt that the system would enhance communication with the office, and that the reminder system would be helpful. They also liked having access to laboratory tests remotely. They were frustrated when tests were not released and messages not answered. A Web-based patient portal can be integrated into a clinical office, although patients may not quickly change communication patterns. Patients are responsive to technology. Future work should focus on diabetes-related outcomes assessment and intensifying interventions.

Child passenger safety behaviors in Latino communities.

Booster seats protect child occupants between 4 and 8 years of age. The objective of this study was to determine barriers and facilitators for booster seat use among Latino families. We conducted one-to-one elicitation interviews with 56 mothers and 35 fathers of booster-eligible Latino children in an urban county and a rural county in Washington State. Half of the parents did not consistently use booster seats. Interviews were recorded, transcribed, translated, and coded. Statements expressed by at least one-third of respondents were entered into explanatory models. Motivators for booster use were child safety and concern about getting a ticket. Facilitators for booster use included affordability, ease of use, and children liking the seat. Barriers were the belief that the child was too big/old, perceived child resistance, and cost. Rural parents preferred radio to television messages. Campaign messages highlighting the risks to child safety and the risk of a citation are likely to motivate booster seat use among Latino families.