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Background: There are disparities in access to specialty care for chronic diseases in rural and minority populations. Telemedicine has been proposed to improve access. Introduction: The objective of this study was to identify predictors of telemedicine use for chronic disease specialty care in the Alaska Tribal Health System (ATHS) in the setting of usual care. Materials and Methods: We utilized data from the electronic health record (EHR) of patients from four regions in the ATHS. We queried the EHR to identify cases (ever users of telemedicine) and controls (never users), both of whom had chronic diseases requiring specialty care. Data were collected from 2015 through mid-2019. Results: We included 3,075 patients (799 ever users and 2,276 never users). In univariate analysis, ever users were older, more likely to be male, had more chronic conditions and higher encounter rates. There were differences by region, community, and type of specialty clinic. In our simple multivariate model, factors associated with telemedicine use included age, male gender, region, and outpatient visit rate per year. Having at least one cardiology clinic visit was also associated with telemedicine use, with the highest estimated odds ratio (5.27, p < 0.01). Discussion: This study describes factors associated with telemedicine use in the ATHS before the COVID-19 pandemic. We anticipate monitoring changes in these predictors over time, as we expect them to evolve. Conclusions: We found among factors associated with telemedicine use were age, gender, region, outpatient visit rate, and visits to a specific specialty clinic.

Objective High altitude headache (HAH) is the most common neurological complaint at altitude and the defining component of acute mountain sickness (AMS). However, there is a paucity of literature concerning its prevention. Toward this end, we initiated a prospective, double-blind, randomized, placebo-controlled trial in the Nepal Himalaya designed to compare the effectiveness of ibuprofen and acetazolamide for the prevention of HAH. Methods Three hundred forty-three healthy western trekkers were recruited at altitudes of 4280 m and 4358 m and assigned to receive ibuprofen 600 mg, acetazolamide 85 mg, or placebo 3 times daily before continued ascent to 4928 m. Outcome measures included headache incidence and severity, AMS incidence and severity on the Lake Louise AMS Questionnaire (LLQ), and visual analog scale (VAS). Results Two hundred sixty-five of 343 subjects completed the trial. HAH incidence was similar when treated with acetazolamide (27.1%) or ibuprofen (27.5%; P = .95), and both agents were significantly more effective than placebo (45.3%; P = .01). AMS incidence was similar when treated with acetazolamide (18.8%) or ibuprofen (13.7%; P = .34), and both agents were significantly more effective than placebo (28.6%; P = .03). In fully compliant participants, moderate or severe headache incidence was similar when treated with acetazolamide (3.8%) or ibuprofen (4.7%; P = .79), and both agents were significantly more effective than placebo (13.5%; P = .03). Conclusions Ibuprofen and acetazolamide were similarly effective in preventing HAH. Ibuprofen was similar to acetazolamide in preventing symptoms of AMS, an interesting finding that implies a potentially new approach to prevention of cerebral forms of acute altitude illness.

Objective To determine if video otoscope still images of the tympanic membrane taken in remote clinics are comparable to an in-person microscopic examination for follow-up care. Design Comparative concordance, diagnostic reliability. Methods Community health aide/practitioners in remote Alaska imaged 70 ears following tympanostomy tube placement. The patients were then examined in person by two otolaryngologists. Images were later reviewed at 8 and 14 weeks. Results Intraprovider concordance for physical examination findings was: “Tube in,” 94 percent –97 percent (κ = 0.89–0.94); “Tube patent,” 94 percent –97 percent (κ = 0.89–0.94); “Drainage,” 90 percent –96 percent (κ = −0.04–0.38); “Perforation,” 90 percent –96 percent (κ = 0.61–0.82); “Granulation,” 97 percent –100 percent (κ = 0.49–1.0); “Middle ear fluid,” 88 percent –96 percent (κ = 0.28–0.71); “Retracted,” 83 percent –91 percent (κ = 0.26–0.58). These agreement rates are similar to interprovider concordance when two otolaryngologists examine the same patient in person. Intraprovider concordance for diagnoses was 76 percent –80 percent (κ = 0.64–0.71) and 77 percent –88 percent (κ = 0.66–0.81) when poor images were excluded. Interprovider diagnostic concordance for the in-person exam was 89 percent (κ = 0.83). Conclusion Video-otoscopy images of the tympanic membrane are comparable to an in-person examination for assessment and treatment of patients following tympanostomy tubes. Store-and-forward telemedicine is an acceptable method of following patients post tympanostomy tube placement.

The purpose of this study is to assess the objective knowledge of mental health professionals in Hawaii related to evidence-based early psychological interventions for victims of mass trauma as well as their perceived response readiness to a bioterrorism associated event. During June and July 2004 an anonymous survey was mailed as many as three times to a random sample of licensed psychologists and social workers residing in Hawaii (n = 273). The response rate for deliverable surveys was 68 percent (176 of 257). Only 10 percent of respondents reported prior bioterrorism preparedness training. Less than 50 percent felt able to identify and manage populations exhibiting the normal range of stress reactions to a bioterrorist event, and only 19 percent felt able

750 mg per day of acetazolamide in the prevention of acute mountain sickness (AMS), as recommended in the meta-analysis published in 2000 in the British Medical Journal, may be excessive and is controversial. To determine if the efficacy of low-dose acetazolamide 125 mg bd (250 mg), as currently used in the Himalayas, is significantly different from 375 mg bd (750 mg) of acetazolamide in the prevention of AMS, we designed a prospective, double-blind, randomized, placebo-controlled trial. The participants were sampled from a diverse population of (non-Nepali) trekkers at Namche Bazaar (3440 m) in Nepal on the Everest trekking route as they ascended to study midpoints (4280 m/4358 m) and the endpoint, Lobuje (4928 m), where data were collected. Participants were randomly assigned to receive 375 mg bd of acetazolamide (82 participants), 125 mg bd of acetazolamide (74 participants), or a placebo (66 participants), beginning at 3440 m for up to 6 days as they ascended to 4928 m. The results revealed that composite AMS incidence for 125 mg bd was similar to the incidence for 375 mg bd (24% vs. 21%, 95% confidence interval, -12.6%, 19.8%), in contrast to significantly greater AMS (51%) observed in the placebo group (95% confidence interval for differences: 8%, 46%; 12%, 49% for low and high comparisons, respectively). Both doses of acetazolamide improved oxygenation equally (82.9% for 250 mg daily and 82.8% for 750 mg daily), while placebo endpoint oxygen saturation was significantly less at 80.7% (95% confidence interval for differences: 0.5%, 3.9% and 0.4%, 3.7% for low and high comparisons, respectively). There was also more paresthesia in the 375-mg bd group (p < 0.02). We conclude that 125 mg bd of acetazolamide is not significantly different from 375 mg bd in the prevention of AMS; 125 mg bd should be considered the preferred dosage when indicated for persons ascending to altitudes above 2500 m.

Background No cure for psoriasis exists for the 1–3% of the American population who suffer from it; however, anecdotal reports from patients with psoriasis visiting Hawaii who purchased kukui nut oil, claim it helped reduce the severity of their lesions. Objective This pilot study was a double-blind, placebo-controlled clinical trial to determine the effectiveness of kukui nut oil as a topical treatment for psoriasis. Methods Thirty adult subjects (18–78 year) were recruited from the community for a 12-week randomized, double-blind, placebo-controlled pilot study. Subjects were previously diagnosed with mild, stable plaque psoriasis (less than 15% of total body surface area [TBSA]) and agreed to abstain from other treatments during the course of the study. Following a 4-week washout period the subjects were randomized into a treatment group (15 subjects applying kukui nut oil) or a control group (15 applying the mineral oil placebo). Patients were seen every 2 weeks (seven visits at 0, 2, 4, 6, 8, 10, and 12 weeks) by a dermatological nurse practitioner under the general supervision of a board certified dermatologist. Measurable outcomes included evaluation of one targeted lesion and of the overall severity of their psoriasis using clinical evaluation, Psoriasis Area and Sensitivity Index (PASI), Global Severity of Psoriasis Scale, and photographs. Each patient also evaluated their own lesions daily using the Global Severity of Psoriasis Scale, and noted any side-effects or other treatments used. Results Although both groups improved, we found no significant difference between the treatment (kukui nut oil) and the placebo (mineral oil) among the 24 out of 30 subjects (80%) who completed the study. No side-effects or adverse events were reported. Conclusion Kukui nut oil did not significantly reduce symptoms of psoriasis; however, this was a small pilot study, and the use of this oil cannot be dismissed without using a larger study population of patients with psoriasis.

The authors and associates conducted a social norms-based intervention targeting high-risk sexual behaviors among undergraduate students at 4 college campuses. Social norms theory predicts that widely held misperceptions may encourage risky behavior in a misguided attempt to conform to perceived norms and that information correcting these misperceptions will lead to a decrease in such behaviors. Students overestimated their peers' levels of sexual activity, numbers of partners, incidence of sexually transmitted infections, and rates of unintended pregnancies, but underestimated rates of condom use. Rates of HIV test taking, however, were accurately estimated. Although some components of sexual risk behaviors lend themselves well to social norms-based interventions, others, specifically inconsistent condom use and avoiding HIV tests, do not. Although no changes in reported beliefs or practices were apparent at the end of a 9-month intervention period, longer or modified interventions may be needed to make a fair assessment of the efficacy of this approach.

The objective of this study was to determine if video otoscope still images (640 x 480 pixel resolution) of the tympanic membrane following surgical placement of tympanostomy tubes are comparable to an in-person microscopic examination. Forty patients having undergone tympanostomy tube placement in both ears were independently examined in-person by two otolaryngologists and imaged using a video otoscope and telemedicine software package. The two physicians later reviewed images at 6 and 12 weeks. Physical examination findings and diagnosis were documented and compared for their concordance using kappa statistics. For both physicians, the intraprovider concordance between the in-person examination and the corresponding image review was high for each of the physical examination findings: Tube In 93-94% (K 0.85-0.87), Tube Patent 86-93% (K 0.74-0.85), Drainage 94-98% (K 0.42-0.66), Perforation 85-98% (K 0.40-0.84), Granulation 95-99% (K -0.01 to 0.00), Middle Ear Fluid 89-91% (K -0.03 to 0.50), and Retracted 89-94% (K 0.13-0.43). These agreement rates are similar to the normal interprovider concordance observed when two physicians independently examined the same patient in-person for physical exam findings: Tube In 96% (K 0.93), Tube Patent 94% (K 0.88), Drainage 96% (K 0.56), Perforation 90% (K 0.60), Granulation 96% (K 0.39), Middle Ear Fluid 88% (K 0.14), and Retracted 91% (K 0.43). For both physicians, the intraprovider diagnostic concordance between the in-person examination and the corresponding image review was high 79-85% (K 0.67-0.76). The interprovider diagnostic concordance for the in-person exam was 88% (K 0.81). The interprovider diagnostic concordance when two physicians independently reviewed all images was 84% (K 0.74), and 89% (K 0.80) when poor images were excluded. This study demonstrates that physician review of video otoscope images is comparable to an in-person microscopic examination. Store-and-forward video otoscopy may be an acceptable method of following patients post-tympanostomy tube placement.

Hypothesis Treatment of hepatocellular carcinoma before liver transplantation can curb local tumor progression and thereby prolong patients' transplantation eligibility. Design Retrospective case-control pilot study. Twelve of 39 patients receiving liver transplantation for hepatocellular carcinoma had treatment before transplantation. Pretreatment included radiofrequency ablation (n = 8), percutaneous ethanol injection (n = 2), both modalities (n = 1), and tumor resection (n = 1). Twelve control subjects without pretreatment who were age-, sex-, and score-matched on the Model for End-stage Liver Disease and Child-Turcotte-Pugh classification were selected. The primary outcome measure was the waiting period for transplantation. Results Patients with pretreatment waited on the transplant list significantly longer than their counterparts without pretreatment (median, 484 vs 253 days;P= .03). Conclusions Treatment before transplantation with tumor ablation or resection is associated with a longer waiting period on the transplant list. This enables patients who might otherwise be removed from the list because of tumor progression to receive transplantation.

Although historically Alaska Native women have had a relatively low incidence of cardiovascular disease (CVD), this pattern has changed dramatically in recent years. Alaska Native leaders have identified decreasing cardiovascular risk as an intervention priority.From October 2000 to April 2001, Southcentral Foundation, an Alaska Native-owned and managed health corporation in Anchorage, conducted a pilot randomized controlled trial of a heart disease prevention program tailored for Alaska Native women. The aim was to assess feasibility and cultural acceptability and to develop enrollment procedures. Of 76 women who enrolled, 44 were randomized to the intervention group. Thirty-seven of 44 attended at least two intervention sessions, 23 completed prequestionnaires and postquestionnaires, and 27 returned for 12-month follow-up screening. Thirty of 32 control group participants returned for 12-month follow-up screening. The intervention included 12 weekly sessions on lifestyle change and goal setting. At baseline and 12 months, participants' height, weight, resting blood pressure, fasting lipid levels, and blood glucose were measured. At sessions 1 and 12, participants completed assessments regarding diet, physical activity, tobacco use, and psychosocial status.At 12 weeks, significant improvements were noted in moderate walking and physical activity self-efficacy. Also observed was substantial movement from the contemplation and preparation stages to the action stage regarding physical activity and heart-healthy eating.Although the small sample size precludes drawing conclusions about the intervention's effect, participants reported lifestyle and psychosocial changes. The pilot study resulted in protocol changes that improved the design and implementation of a subsequent large-scale study.