Patterns of Adherence to Oral Hypoglycemic Agents: Patterns, Correlates, and Outcomes

Despite the development of effective pharmacological therapy to prevent both macrovascular and microvascular complications and adverse events, diabetes control remains sub-optimal. Poor adherence to recommended regimens is a causal factor in preventable morbidity and mortality in diabetic patients. Sub-groups of patients with differing longitudinal profiles of adherence may yield differing treatment outcomes. Identifying characteristics associated with longitudinal profiles can potentially alert clinicians to patients at risk for poor clinical outcomes allowing for early intervention and follow-up. Furthermore, few studies have examined the role of adherence improvements as a mediator of intervention effect on glycemic control. In this work we sought to identify patterns, correlates and outcomes of adherence to oral hypoglycemic agents. We also assessed whether adherence improvements mediated a brief interventions effect on glycemic control. Longitudinal analysis via growth curve mixture modeling was carried out to classify 180 patients who participated in an adherence intervention according to patterns of adherence to oral hypoglycemic agents across 12 weeks. Adherence was assessed using the Medication Event Monitoring System. Hemoglobin A1c assays were used to measure glycemic control as the clinical outcome. Individual patient residential data was geo-coded at the tract level. Three patterns of adherence to oral hypoglycemic agents were identified: adherent, increasing adherence, and nonadherent. Both individual and neighborhood level factors were identified that were associated with patterns of adherence. Patients with an increasing adherence pattern were more likely to have a Hemoglobin A1c (HbA1c) \u3c 7% (adjusted odds ratio = 14.52, 95% CI [2.54, 82.99]) at 12 weeks in comparison with patients with the nonadherent pattern. Across the whole sample, longitudinal adherence profiles mediated 35.2 % (13.2, 81.0 %) of the effect of a brief adherence intervention on glycemic control [from odds ratio (OR) = 8.48, 95 % confidence interval (CI) (3.24, 22.2) to 4.00, 95 % CI (1.34, 11.93)]. These findings imply that the identification of patients with type 2 diabetes at risk of nonadherence is important for clinical prognosis and the development and delivery of interventions

On Estimating the High-Energy Cutoff in the X-ray Spectra of Black Holes via Reflection Spectroscopy

The fundamental parameters describing the coronal spectrum of an accreting black hole are the slope $\Gamma$ of the power-law continuum and the energy $E_{cut}$ at which it rolls over. Remarkably, this parameter can be accurately measured for values as high as 1 MeV by modeling the spectrum of X-rays reflected from a black hole accretion disk at energies below 100 keV. This is possible because the details in the reflection spectrum, rich in fluorescent lines and other atomic features, are very sensitive to the spectral shape of the hardest coronal radiation illuminating the disk. We show that fitting simultaneous NuSTAR (3-79 keV) and low-energy (e.g., Suzaku) data with the most recent version of our reflection model RELXILL, one can obtain reasonable constraints on $E_{cut}$ at energies from tens of keV up to 1 MeV, for a source as faint as 1 mCrab in a 100 ks observation.Comment: Accepted for publication in ApJL, 6 pages, 5 figure

X-ray Reflection Spectroscopy of the Black Hole GX 339-4: Exploring the Hard State with Unprecedented Sensitivity

We analyze {\it simultaneously} six composite {\it RXTE} spectra of GX 339--4 in the hard state comprising 77 million counts collected over 196 ks. The source spectra are ordered by luminosity and spanthe range 1.6\% to 17\% of the Eddington luminosity. Crucially, using our new tool {\tt pcacorr}, we re-calibrate the data to a precision of 0.1\%, an order of magnitude improvement over all earlier work. Using our advanced reflection model {\tt relxill}, we target the strong features in the component of emission reflected from the disk, namely, the relativistically-broadened Fe K emission line, the Fe K edge and the Compton hump. We report results for two joint fits to the six spectra: For the first fit, we fix the spin parameter to its maximal value ($a_*=0.998$) and allow the inner disk radius $R_{\rm in}$ to vary. Results include (i) precise measurements of $R_{\rm in}$, with evidence that the disk becomes slightly truncated at a few percent of Eddington; and (ii) an order-of-magnitude swing with luminosity in the high energy cutoff, which reaches $>890$ keV at our lowest luminosity. For the second fit, we make the standard assumption in estimating spin that the inner edge of the accretion disk is located at the innermost stable circular orbit ($R_\mathrm{in} = R_\mathrm{ISCO}$) and find $a_* = 0.95^{+0.03}_{-0.05}$ (90\% confidence, statistical). For both fits, and at the same level of statistical confidence, we estimate that the disk inclination is $i = 48\pm 1$ deg and that the Fe abundance is super-solar, $A_\mathrm{Fe} = 5\pm1$.Comment: Accepted for publication in ApJ, 20 pages, 13 figure

Dynamic Failure in Amorphous Solids via a Cavitation Instability

The understanding of dynamic failure in amorphous materials via the propagation of free boundaries like cracks and voids must go beyond elasticity theory, since plasticity intervenes in a crucial and poorly understood manner near the moving free boundary. In this Letter we focus on failure via a cavitation instability in a radially-symmetric stressed material, set up the free boundary dynamics taking both elasticity and visco-plasticity into account, using the recently proposed athermal Shear Transformation Zone theory. We demonstrate the existence (in amorphous systems) of fast cavitation modes accompanied by extensive plastic deformations and discuss the revealed physics.Comment: 4 pages, 4 figure

Hearing Loss: Applying the Social-Ecological Model for Change

Introduction: The proportion of Ohioans experiencing deafness or serious difficulty hearing is higher than national estimates and is increasing over time. Purpose: The purpose of this study is to describe the burden, risk factors, comorbidities, and financial implications of hearing loss in Ohio as well as discuss approaches to reduce the burden of hearing loss in Ohio applying the Social-Ecological Model Methods: A narrative review was completed to summarize peer-reviewed literature on hearing loss in Ohio. The Social-Ecological Model was applied to identify approaches to reduce the burden of hearing loss in Ohio. Results: The burden of hearing loss on health and economic well-being is substantial in Ohio. While initiatives have sought to reduce costs and increase access, barriers continue to persist impeding people’s ability to obtain needed services in Ohio. Approaches were identified on all levels of the Social-Ecological Model to address the burden of hearing loss in Ohio such as creating interventions for prevention, improving access to hearing tests and hearing aids, and changing policies that expand insurance coverage for hearing aids. Conclusion: There is a critical need for public health-initiated programs and policies that reduce barriers and increase access to hearing related services that can be implemented on all levels of the Social-Ecological Model

A Parallax Distance to the Microquasar GRS 1915+105 and a Revised Estimate of its Black Hole Mass

Using the Very Long Baseline Array, we have measured a trigonometric parallax for the micro quasar GRS 1915+105, which contains a black hole and a K-giant companion. This yields a direct distance estimate of 8.6 (+2.0,-1.6) kpc and a revised estimate for the mass of the black hole of 12.4 (+2.0,-1.8) Msun. GRS 1915+105 is at about the same distance as some HII regions and water masers associated with high-mass star formation in the Sagittarius spiral arm of the Galaxy. The absolute proper motion of GRS 1915+105 is -3.19 +/- 0.03 mas/y and -6.24 +/- 0.05 mas/y toward the east and north, respectively, which corresponds to a modest peculiar speed of 22 +/-24 km/s at the parallax distance, suggesting that the binary did not receive a large velocity kick when the black hole formed. On one observational epoch, GRS 1915+105 displayed superluminal motion along the direction of its approaching jet. Considering previous observations of jet motions, the jet in GRS 1915+105 can be modeled with a jet inclination to the line of sight of 60 +/- 5 deg and a variable flow speed between 0.65c and 0.81c, which possibly indicates deceleration of the jet at distances from the black hole >2000 AU. Finally, using our measurements of distance and estimates of black hole mass and inclination, we provisionally confirm our earlier result that the black hole is spinning very rapidly.Comment: 20 pages; 2 tables; 6 figure

The Low-Spin Black Hole in LMC X-3

Building upon a new dynamical model for the X-ray binary LMC X-3, we measure the spin of its black hole primary via the continuum-fitting method. We consider over one thousand thermal-state RXTE X-ray spectra of LMC X-3. Using a large subset of these spectra, we constrain the spin parameter of the black hole to be spin = 0.21(+0.18,-0.22), 90% confidence. Our estimate of the uncertainty in spin takes into account a wide range of systematic errors. We discuss evidence for a correlation between a black hole's spin and the complexity of its X-ray spectrum.Comment: Submitted to ApJL, 5 pages emulateapj, 2 figures and 1 tabl