Endothelin-1 Predicts Hemodynamically Assessed Pulmonary Arterial Hypertension in HIV Infection.

BackgroundHIV infection is an independent risk factor for PAH, but the underlying pathogenesis remains unclear. ET-1 is a robust vasoconstrictor and key mediator of pulmonary vascular homeostasis. Higher levels of ET-1 predict disease severity and mortality in other forms of PAH, and endothelin receptor antagonists are central to treatment, including in HIV-associated PAH. The direct relationship between ET-1 and PAH in HIV-infected individuals is not well described.MethodsWe measured ET-1 and estimated pulmonary artery systolic pressure (PASP) with transthoracic echocardiography (TTE) in 106 HIV-infected individuals. Participants with a PASP ≥ 30 mmHg (n = 65) underwent right heart catheterization (RHC) to definitively diagnose PAH. We conducted multivariable analysis to identify factors associated with PAH.ResultsAmong 106 HIV-infected participants, 80% were male, the median age was 52 years and 77% were on antiretroviral therapy. ET-1 was significantly associated with higher values of PASP [14% per 0.1 pg/mL increase in ET-1, p = 0.05] and PASP ≥ 30 mmHg [PR (prevalence ratio) = 1.24, p = 0.012] on TTE after multivariable adjustment for PAH risk factors. Similarly, among the 65 individuals who underwent RHC, ET-1 was significantly associated with higher values of mean pulmonary artery pressure and PAH (34%, p = 0.003 and PR = 2.43, p = 0.032, respectively) in the multivariable analyses.ConclusionsHigher levels of ET-1 are independently associated with HIV-associated PAH as hemodynamically assessed by RHC. Our findings suggest that excessive ET-1 production in the setting of HIV infection impairs pulmonary endothelial function and contributes to the development of PAH

Will Americans Embrace Single-Payer Health Insurance: The Intractable Barriers of Inertia, Free Market and Culture

In a country that prides itself on equality of opportunity, why is there so little equality when it comes to healthcare? Why does the value of equality of opportunity not translate into social solidarity? This Article seeks answers to these questions. Risking the label of socialist, I posit that the most cost-effective, efficacious, and efficient solution to the health care mess that the United States is in is universal single-payer reform with the federal government as that payer. Part I examines the United States\u27 current climate as it affects health care reform. In Part II, this Article scrutinizes recent state health care reform legislation, specifically in California and Massachusetts. Part III evaluates current national reform efforts, while Part IV argues that though the barriers to implementing single-payer health insurance may be insurmountable at this time, it is the best answer to our health care crisis

The ACA, Provider Mergers and Hospital Pricing: Experimenting with Smart, Lower-Cost Health Insurance Options

This paper addresses the issue of whether the recent significant uptick in provider mergers and the implementation of the Affordable Care Act have a particularly adverse effect on provider pricing in the commercial insurance market. Uncompetitive provider markets exacerbate already existing high cost issues such as lack of transparency in provider pricing, patient behavior that conflates reputation and quality, and payers’ inability, or at least reluctance, to exclude high-price providers from their networks. The ACA’s incentives for providers to coordinate patient care and hospitals’ revenue losses from reductions in Medicare reimbursement create further rationales for consolidation. The burden of finding solutions to high non-transparent provider pricing is on all stakeholders who should be experimenting in earnest with remedies for the harms that high health care costs create for patients. But no stakeholders have more incentive to find solutions than those who ultimately pay for health care: the insurers, the employers, governments and individuals. The recent literature is replete with payer experiments in insurance design that are intended to provide smart, lower-cost options for consumers and may influence provider behavior as well. More experimentation with remedial measures is warranted and appears to be ongoing even among providers who also see the proverbial handwriting on the wall. The ACA promises health care security by creating near universal, affordable, adequate health care. The work continues to achieve these goals

Can State Health Reform Initiatives Achieve Universal Coverage: Lessons from California’s Recent Failed Experiment

This article is about the struggle toward health care reform. It looks at the mandated health care insurance model as well as the experiences of Massachusetts and California