A nutraceutical with Citrus bergamia and Cynara cardunculus improves endothelial function in adults with non-alcoholic fatty liver disease

OBJECTIVE

Polyphenol intake may prevent hepatic steatosis and cardiovascular disease by potentially improving endothelial function. The purposes of this study are to investigate the association between fatty liver disease and endothelial dysfunction and to test the effects of a nutraceutical containing extracts made from Citrus bergamia and Cynara cardunculus on peripheral vascular endothelial function in adults with liver steatosis.

METHODS

We analyzed data from 32 individuals with hepatic steatosis and endothelial dysfunction (reactive hyperemia index ≤ 1.67). Sixteen subjects took 1 capsule/d (300 mg/d) containing Cynara cardunculus extract and bergamot polyphenol fraction, while the other 16 subjects matched for age, sex, and body mass index took 1 capsule/d of placebo (maltodextrin) for 12 wk. All anthropometric parameters were assessed at baseline and after 12 wk as were lipids, glucose, and reactive hyperemia index using an EndoPAT 2000.

RESULTS

The mean age was 52 ± 9 y. The mean reactive hyperemia index was 1.15 ± 0.4. After 12 wk, we found a greater increase in reactive hyperemia index in the participants taking the nutraceutical rather than placebo (0.58 ± 0.5 versus 0.13 ± 0.5; P = 0.02, respectively). The stepwise multivariable analysis confirmed a positive association between reactive hyperemia index change and the nutraceutical treatment (B = 0.38; P = 0.025) and negative association with reactive hyperemia index values at baseline (B = -0.81; P < 0.001). No association was found between the reduction in the amount of intrahepatic fat and the improvement of endothelial function (B = 0.002; P = 0.56).

CONCLUSIONS

A nutraceutical containing bergamot and artichoke extracts improves peripheral vascular endothelial function in adults with hepatic steatosis and early phase of atherosclerosis.

The Italian investment in telemedicine: a breakthrough model of care in primary care

Issue/Problem

Aging populations, worsening burden of chronic disease and recent pandemic has accelerated awareness and the importance of telemedicine in providing continuity of healthcare.

Description of the problem

AGENAS is the public body responsible for the implementation of telemedicine investment (€1 billion) in the context of the NextGenerationEU plan. AGENAS has built up a working group expert panel to define the technical and informatics features of the investment. The project consists of the realization of the national telemedicine platform and the regional telemedicine services. Italian regions will implement telemedicine services based on the national guidelines defined by AGENAS, that will also monitor it through key performance indicators outlined on the basis of best practices and scientific evidence of multidimensional evaluation.

Results

National telemedicine platform will improve, optimise and standardise telemedicine services throughout the Country, considering what may already be available in regional and local healthcare contexts. Regarding telemedicine services in regional context, that will be implemented within the NextGenerationEU, they will be focused on the telemonitoring of high prevalence conditions (i.e. cardiological, respiratory, diabetes, neurological and oncological) as well as other services such as televisit, teleconsultation and teleassistance. Connecting patient's home with healthcare system provide benefits for patients and their families, who will be able to interact with healthcare professionals, obtaining consultation and monitoring of their health.

Lessons

The implementation of the investment, aiming at improving equity and integration of care, will contribute to provide real world evidence about usage, benefits and potential risk of the telemedicine in primary care for the management of chronic diseases.

Key messages

• The investment under the Next Generation EU plan it is the lifetime chance to transform Italian healthcare service and draw a new framework to cope with the high demand in telemedicine.

• Improving telemedicine services will determine a breakthrough in management of patient with chronic diseases in the Italian primary care sector.

The Contribution of Gut Microbiota and Endothelial Dysfunction in the Development of Arterial Hypertension in Animal Models and in Humans

The maintenance of the physiological values of blood pressure is closely related to unchangeable factors (genetic predisposition or pathological alterations) but also to modifiable factors (dietary fat and salt, sedentary lifestyle, overweight, inappropriate combinations of drugs, alcohol abuse, smoking and use of psychogenic substances). Hypertension is usually characterized by the presence of a chronic increase in systemic blood pressure above the threshold value and is an important risk factor for cardiovascular disease, including myocardial infarction, stroke, micro- and macro-vascular diseases. Hypertension is closely related to functional changes in the endothelium, such as an altered production of vasoconstrictive and vasodilator substances, which lead to an increase in vascular resistance. These alterations make the endothelial tissue unresponsive to autocrine and paracrine stimuli, initially determining an adaptive response, which over time lead to an increase in risk or disease. The gut microbiota is composed of a highly diverse bacterial population of approximately 10¹⁴ bacteria. A balanced intestinal microbiota preserves the digestive and absorbent functions of the intestine, protecting from pathogens and toxic metabolites in the circulation and reducing the onset of various diseases. The gut microbiota has been shown to produce unique metabolites potentially important in the generation of hypertension and endothelial dysfunction. This review highlights the close connection between hypertension, endothelial dysfunction and gut microbiota.

The Contribution of Endothelial Dysfunction in Systemic Injury Subsequent to SARS-Cov-2 Infection

SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) infection is associated, alongside with lung infection and respiratory disease, to cardiovascular dysfunction that occurs at any stage of the disease. This includes ischemic heart disease, arrhythmias, and cardiomyopathies. The common pathophysiological link between SARS-CoV-2 infection and the cardiovascular events is represented by coagulation abnormalities and disruption of factors released by endothelial cells, which contribute in maintaining the blood vessels into an anti-thrombotic state. Thus, early alteration of the functionality of endothelial cells, which may be found soon after SARS-CoV-2 infection, seems to represent the major target of a SARS CoV-2 disease state and accounts for the systemic vascular dysfunction that leads to a detrimental effect in terms of hospitalization and death accompanying the disease. In particular, the molecular interaction of SARS-CoV-2 with the ACE2 receptor located in the endothelial cell surface, either at the pulmonary and systemic level, leads to early impairment of endothelial function, which, in turn, is followed by vascular inflammation and thrombosis of peripheral blood vessels. This highlights systemic hypoxia and further aggravates the vicious circle that compromises the development of the disease, leading to irreversible tissue damage and death of people with SARS CoV-2 infection. The review aims to assess some recent advances to define the crucial role of endothelial dysfunction in the pathogenesis of vascular complications accompanying SARS-CoV-2 infection. In particular, the molecular mechanisms associated with the interaction of SARS CoV-2 with the ACE2 receptor located on the endothelial cells are highlighted to support its role in compromising endothelial cell functionality. Finally, the consequences of endothelial dysfunction in enhancing pro-inflammatory and pro-thrombotic effects of SARS-CoV-2 infection are assessed in order to identify early therapeutic interventions able to reduce the impact of the disease in high-risk patients.

A new breakfast brioche containing bergamot fiber prevents insulin and glucose increase in healthy volunteers: a pilot study

BACKGROUND

Despite the abundance of studies on the beneficial effects of a fiber rich diet as well as polyphenols deriving from Citrus fruits on postprandial serum glucose and insulin, clinical evidence on their synergic effects on healthy subjects have never been published. We aimed to investigate the feasibility of a new dietary approach in controlling glucose and insulin response at breakfast time by testing a brioche enriched with wheat bran and bergamot fiber.

METHODS

We enrolled 11 healthy volunteers in a cross-over study. Participants consumed a classic brioche at breakfast and our functional brioche, containing wheat bran and bergamot fiber, on another day. Vital functions, biochemical parameters (including glucose and insulin), anthropometric measurements as well as resting energy expenditure and fat oxidation were evaluated before and after the intake of both meals.

RESULTS

The mean age was ~25 years. The mean BMI was 23.5 kg/m². The consumption of the functional brioche reduced the glucose C<inf>max(0-120 min)</inf> by ~6% and prevented the insulin increase over time by 30%, finally demonstrating insulin C<inf>max(0-120 min)</inf> and iAUC<inf>(0-120 min)</inf> values significantly lower compared to classic brioche (respectively P value =0.04 and 0.03). The stepwise multivariable analysis confirmed the association between the consumption of the functional brioche containing bran and bergamot fiber and glucose C<inf>max(0-120 min)</inf> (B=-0.45; P=0.034), and insulin iAUC<inf>(0-120 min)</inf> (B=-764 P=0.036).

CONCLUSIONS

The association of wheat bran and bergamot fiber significantly influences glucose metabolism and may exert insulin-like effects on healthy volunteers. If confirmed, berga-brioche would be a useful tool in preventing diabetes and controlling the glycometabolic status of type 2 diabetic patients.

A new breakfast brioche containing bergamot fiber prevents insulin and glucose increase in healthy volunteers: a pilot study

BACKGROUND

Despite the abundance of studies on the beneficial effects of a fiber rich diet as well as polyphenols deriving from Citrus fruits on postprandial serum glucose and insulin, clinical evidence on their synergic effects on healthy subjects have never been published. We aimed to investigate the feasibility of a new dietary approach in controlling glucose and insulin response at breakfast time by testing a brioche enriched with wheat bran and bergamot fiber.

METHODS

We enrolled 11 healthy volunteers in a cross-over study. Participants consumed a classic brioche at breakfast and our functional brioche, containing wheat bran and bergamot fiber, on another day. Vital functions, biochemical parameters (including glucose and insulin), anthropometric measurements as well as resting energy expenditure and fat oxidation were evaluated before and after the intake of both meals.

RESULTS

The mean age was ~25 years. The mean BMI was 23.5 kg/m². The consumption of the functional brioche reduced the glucose C<inf>max(0-120 min)</inf> by ~6% and prevented the insulin increase over time by 30%, finally demonstrating insulin C<inf>max(0-120 min)</inf> and iAUC<inf>(0-120 min)</inf> values significantly lower compared to classic brioche (respectively P value =0.04 and 0.03). The stepwise multivariable analysis confirmed the association between the consumption of the functional brioche containing bran and bergamot fiber and glucose C<inf>max(0-120 min)</inf> (B=-0.45; P=0.034), and insulin iAUC<inf>(0-120 min)</inf> (B=-764 P=0.036).

CONCLUSIONS

The association of wheat bran and bergamot fiber significantly influences glucose metabolism and may exert insulin-like effects on healthy volunteers. If confirmed, berga-brioche would be a useful tool in preventing diabetes and controlling the glycometabolic status of type 2 diabetic patients.

Percutaneous treatment of vascular access-site complications: a ten years' experience in two centres

Background

The spread of percutaneous arterial catheterization in diagnostic and therapeutic procedures has led to a parallel increase of vascular access site complications. The incidence of these events is between 0.2–1%. A detailed analysis of injuries by type of procedure shows a higher incidence of injuries after therapeutic procedures (3%) than those observed for diagnostic ones (1%), due to the greater size of the vascular devices used and the necessity to frequently administer anticoagulant and antiplatelet therapy during procedures. The iatrogenic arterial injuries requiring treatment are the pseudoaneurysm, arteriovenous fistula, arterial rupture and dissection. Less frequent complications include distal embolization of the limbs, nerve damage, abscess and lymphocele.

Moreover, the use of percutaneous vascular closure devices (VCD) has further expanded the types of complications, with an increased risk of stenosis, thrombosis, distal embolism and infection. Our work aims to bring the personal 10 years’ experience in the percutaneous treatment of vascular access-site complications.

Results

Ninety-two pseudoaneurysms (PSA), 12 arteriovenous fistulas (AVF), 15 retrograde dissections (RD) and 11 retroperitoneal bleedings (RB) have been selected and treated. In 120/130 cases there were no periprocedural complications with immediate technical success (92.3%). Nine femoral PSA, treated with percutaneous ultrasound-guided thrombin injection, showed a failure to close the sac and therefore they were treated by PTA balloon inflation with a contralateral approach and cross-over technique. Only one case of brachial dissection, in which the prolonged inflation of the balloon has not led to a full reimbursement of the dissection flap, was then surgically repaired. At the 7 days follow-up, complications were two abscesses in retroperitoneal bleedings, treated by percutaneous drainage. At 3 months, acute occlusion of 3 covered femoral stents occurred, then treated by loco-regional thrombolysis and PTA. A total of 18 major complications was recorded at 2 years, with a complication rate at 2 years of 13.8%.

Conclusions

The percutaneous treatment of vascular access-site complications is the first-choice treatment. It represents a safe and effective option, validated by a high technical success rate and a low long-term complication rate, that allows avoiding the surgical approach in most cases.

The Protective Effect of Cynara Cardunculus Extract in Diet-Induced NAFLD: Involvement of OCTN1 and OCTN2 Transporter Subfamily

Hyperlipidemia and insulin-resistance are often associated with Non-Alcoholic Fatty Liver Disease (NAFLD) thereby representing a true issue worldwide due to increased risk of developing cardiovascular and systemic disorders. Although clear evidence suggests that circulating fatty acids contribute to pathophysiological mechanisms underlying NAFLD and hyperlipidemia, further studies are required to better identify potential beneficial approaches for counteracting such a disease. Recently, several artichoke extracts have been used for both reducing hyperlipidemia, insulin-resistance and NAFLD, though the mechanism is unclear. Here we used a wild type of Cynara Cardunculus extract (CyC), rich in sesquiterpens and antioxidant active ingredients, in rats fed a High Fat Diet (HFD) compared to a Normal Fat Diet (NFD). In particular, in rats fed HFD for four consecutive weeks, we found a significant increase of serum cholesterol, triglyceride and serum glucose. This effect was accompanied by increased body weight and by histopathological features of liver steatosis. The alterations of metabolic parameters found in HFDs were antagonised dose-dependently by daily oral supplementation of rats with CyC 10 and 20 mg/kg over four weeks, an effect associated to significant improvement of liver steatosis. The effect of CyC (20 mg/kg) was also associated to enhanced expression of both OCTN1 and OCTN2 carnitine-linked transporters. Thus, present data suggest a contribution of carnitine system in the protective effect of CyC in diet-induced hyperlipidemia, insulin-resistance and NAFLD.

The synergistic effect of Citrus bergamia and Cynara cardunculus extracts on vascular inflammation and oxidative stress in non-alcoholic fatty liver disease

BACKGROUND AND AIM

Non-Alcoholic Fatty Liver Disease (NAFLD) represents a risk factor for cardiovascular diseases. NAFLD is worsened by the simultaneous occurrence of type 2 diabetes mellitus (T2DM) causing an enhancement of inflammatory and fibrotic processes. Although insulin resistance appears the link between NAFLD and T2DM, current pharmacological treatments of T2DM failed to produce relevant benefits in preventing T2DM-related liver dysfunction. In this randomized, double blind, placebo-controlled clinical study, we evaluated the effect of Bergacyn, an innovative formulation originating from the combination of Bergamot Polyphenolic Fraction (BPF) and Cynara cardunculus (CyC).

EXPERIMENTAL PROCEDURE

80 adult patients with a history of at least 12 months of T2DM and NAFLD received orally BPF (300 mg/daily) Cyc (300 mg/daily), separately or formulated in combination 50/50% (Bergacyn; 300 mg/daily), or placebo all containing 300 mg of bergamot albedo fibers micronized and co-grinded as excipients.

RESULTS AND CONCLUSION

Serum measurements and liver ultrasound analyses showed that concomitant administration of BPF and CyC produced significant improvement of NAFLD biomarkers in patients with T2DM. This effect was associated with a substantial reduction of oxidative stress/inflammatory biomarkers, thus contributing to a significant improvement of NO-mediated reactive vasodilation. Furthermore, the effect of Bergacyn showed a synergistic effect of both extracts, thus suggesting that this peculiar formulation represents a novel therapeutic strategy to counteract vascular inflammation and endothelial dysfunction in patients suffering from T2DM and NAFLD. Further studies in larger cohort of diabetic patients are required to better identify the potential of Bergacyn on metabolic disorders accompanying T2DM and NAFLD.

Randomized Clinical Trial: Bergamot Citrus and Wild Cardoon Reduce Liver Steatosis and Body Weight in Non-diabetic Individuals Aged Over 50 Years

Background: Non-alcoholic fatty liver disease is the most common cause of liver-related morbidity and mortality in the world. However, no effective pharmacological treatment for this condition has been found. Purpose: This study evaluated the effect of a nutraceutical containing bioactive components from Bergamot citrus and wild cardoon as a treatment for individuals with fatty liver disease. The primary outcome measure was the change in liver fat content. Methods: A total of 102 patients with liver steatosis were enrolled in a double-blind placebo controlled clinical trial. The intervention group received a nutraceutical containing a Bergamot polyphenol fraction and Cynara Cardunculus extract, 300 mg/day for 12 weeks. The control group received a placebo daily. Liver fat content, by transient elastography, serum transaminases, lipids and glucose were measured at the baseline and the end of the study. Results: We found a greater liver fat content reduction in the participants taking the nutraceutical rather than placebo (-48.2 ± 39 vs. -26.9 ± 43 dB/m, p = 0.02); The percentage CAP score reduction was statistically significant in those with android obesity, overweight/obesity as well as in women. However, after adjustment for weight change, the percentage CAP score reduction was statistically significant only in those over 50 years (44 vs. 78% in placebo and nutraceutical, respectively, p = 0.007). Conclusions: This specific nutraceutical containing bioactive components from Bergamot and wild cardoon reduced the liver fat content during 12 weeks in individuals with liver steatosis over 50 years. If confirmed, this nutraceutical could become the cornerstone treatment of patients affected by liver steatosis. Clinical Trial Registration: www.isrctn.com, identifier ISRCTN12833814.

The Role of Endothelial Dysfunction in Peripheral Blood Nerve Barrier: Molecular Mechanisms and Pathophysiological Implications

The exchange of solutes between the blood and the nerve tissue is mediated by specific and high selective barriers in order to ensure the integrity of the different compartments of the nervous system. At peripheral level, this function is maintained by the Blood Nerve Barrier (BNB) that, in the presence, of specific stressor stimuli can be damaged causing the onset of neurodegenerative processes. An essential component of BNB is represented by the endothelial cells surrounding the sub-structures of peripheral nerves and increasing evidence suggests that endothelial dysfunction can be considered a leading cause of the nerve degeneration. The purpose of this review is to highlight the main mechanisms involved in the impairment of endothelial cells in specific diseases associated with peripheral nerve damage, such as diabetic neuropathy, erectile dysfunction and inflammation of the sciatic nerve.

Hypoglycemic and Hypolipemic Effects of a New Lecithin Formulation of Bergamot Polyphenolic Fraction: A Double Blind, Randomized, Placebo- Controlled Study

OBJECTIVE

Hyperlipemia represents an independent risk factor in the development of atherosclerosis in patients undergoing type 2 diabetes mellitus (DM). Moreover, the pharmacological treatment of dyslipemia in patients undergoing type 2 DM (e.g. by means of statins), is accompanied by relevant side effects and oral supplementation with natural antioxidants, such as Citrus polyphenols, has recently been suggested to improve cardioprotection in such patients. However, due to the poor gastrointestinal absorption of polyphenols, novel formulations have recently been developed for getting a better bioavailability of polyphenolic rich fractions of citrus species extract rich in polyphenols.

METHODS

Here, we investigated the effect of standard bergamot polyphenolic fraction (BPF®) as well as of its phytosomal formulation (BPF Phyto), in patients with type 2 DM and hyperlipemia. A randomized, double blind, placebo-controlled study was carried out in 60 patients suffering from type 2 DM and mixed hyperlipemia. Patients were divided into three groups: one receiving placebo, the second receiving standard BPF and the third BPF Phyto.

RESULTS

In the groups receiving BPF and BPF Phyto, a significant reduction of fasting plasma glucose, serum LDL cholesterol and triglycerides accompanied by increased HDL cholesterol was observed. This effect was associated with significant reduction of small dense atherogenic LDL particles, as detected by means of proton NMR Spectroscopy, thus confirming the hypolipemic and hypoglycemic effect of bergamot extract both when using standard formulation as well as BPF Phyto. No differences were seen in the therapeutic response among groups receiving BPF and BPF Phyto, thus suggesting a substantial bioequivalence in their hypoglycemic and hypolipemic profile. However, when comparing the pharmacokinetic profile of naringin (the major component of BPF) and its metabolites, in patients treated with BPF Phyto, an at least 2,5 fold increase in its absorption was found, confirming in human studies the better profile of BPF Phyto compared to standard BPF.

CONCLUSION

These data suggest that better absorption and tissue distribution of BPF Phyto formulation represents an innovative approach in supplementation treatments of cardiometabolic disorders.

The effect of bergamot polyphenolic fraction on lipid transfer protein system and vascular oxidative stress in a rat model of hyperlipemia

Background

Experimental and epidemiological studies show that bergamot polyphenolic fraction (BPF) ameliorates the serum lipemic profile, normalizes blood pressure and improves non alcoholic fatty liver disease in patients suffering from metabolic syndrome. Despite this evidence, the molecular mechanisms responsible for these beneficial effects remain unclear. The aim of our study is to clarify the effects of BPF on the lipoprotein assembly and to identify oxidative stress biomarkers correlating hyperlipidaemia and BPF-induced metabolic changes.

Methods

Male Wistar rats (180–200 g) were randomly assigned to receive a standard diet, a hypercholesterolemic diet or a hypercholesterolemic diet+BPF (20 mg/Kg/rat daily, gavage), respectively, for 90 days. Total cholesterol (tChol), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), triglycerides (TG) and fasting plasma glucose were evaluated at the baseline as well as at the end of the treatment. To assess the effect of BPF on the Lipid Transfer Protein System, detection of ACAT, LCAT, CETP, PON1, Apo A1 and Apo B have also been carried out. Finally, the lipid peroxidation biomarker (TBARS) and oxyLDL were also measured.

Results

BPF prevented tChol, LDL-C, TG and fasting plasma glucose enhancement and improved HDL-C. Treatment of hyperlipæmic rats with BPF significantly restored altered the serum concentration of lipemic biomarkers and the activity of ACAT, LCAT, CETP and PON1, an effect accompanied by the concomitant normalization of Apo A1 and APO B levels. In addition, TBARS levels were reduced significantly by the treatment with BPF.

Conclusions

BPF prevents diet-induced alteration of the lipid profile in rats, counteracting oxidative stress and improving the dysregulation of the Lipid Transfer Protein System. These data add new insights into the molecular mechanisms underlying the beneficial role of BPF in the therapy of hyperlipidaemia, thus suggesting a novel approach in the prevention of cardiovascular disease.

Occurrence of enteropathogenic bacteria in birds of prey in Italy

The importance of wild birds as potential vectors of disease has received recent renewed empirical interest, especially regarding human health although information regarding the enteropathogenic bacteria in birds of prey continue to be scant. This study was performed with the aim to evaluate the occurrence of enteropathogenic bacteria (i.e. Campylobacter spp. Escherichia coli, Salmonella spp.) in birds of prey carcasses in Southern Italy. The results of the present study showed a prevalence of 33·1% (49/148) for Campylobacter spp. where all positive isolates (49/49) were identified as Campylobacter jejuni, and among these positive 12/49 were also identified as Campylobacter coli. Thus, 12/49 birds of prey showed mixed infections for both Campylobacter species. Differences in Campylobacter spp. prevalence between diurnal and nocturnal birds were statistically significant (P = 0·016). Escherichia coli showed a prevalence of 6·8% (10/148) and were serogrouped as O26 (n = 3), O55 (n = 2), O145 (n = 5). Salmonella spp. showed a prevalence of 6·8% (10/148) and were serotyped as S. Napoli (n = 4), Salmonella salamae (n = 3) and S. Typhimurium (n = 3). Although wildlife disease outbreaks have often been underreported in the broader context of global epidemiology, results of the present study suggest that birds of prey may serve as a reservoir of pathogens for livestock and human health, acting at the animal-human-ecosystem interface.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study confirms the role of birds of prey as a reservoir of enteropathogenic bacteria (i.e. Campylobacter spp., Escherichia coli, Salmonella spp.). Wild birds can contaminate environment with their faeces and play a crucial role in the transmission of pathogens to poultry and livestock farms and aquifers supplying water to humans. Furthermore, wild birds could disseminate pathogens within rescue and rehabilitation centres where they are admitted.

Who are portal users vs. early e-Visit adopters? A preliminary analysis

Patient portals and eVisits are gaining momentum due to increasing consumer demand for improved access to clinical information and services, availability of new technologies to deploy them and development of reimbursement initiatives by major payers. Despite increasing interest in online health consultation by consumers, adoption has been slow and little is known about the users of such services. In this study, we analyze the key features that distinguish early adopters of eVisits from portal consumers, in aggregate and in four distinct ambulatory practices, using data from a major healthcare provider in Western Pennsylvania. Preliminary results indicate that out of 10,532 portal users, the 336 patients who submitted 446 eVisits between April 1, 2009 and May 31, 2010 are younger on average, predominantly female, not retired, but in poorer health condition. They access the portal more frequently, indicating that they are potentially more involved in managing their health. Using fixed-effects logistic regression models to compare across practices, we note that practice indicator is a significant predictor of eVisit usage, perhaps due to the varying strategies used to build awareness and encourage adoption. Despite the small difference in out-of-pocket payment for eVisits covered by insurance vs. otherwise, insurance coverage for eVisits significantly contributes to increased usage. In ongoing work, additional characteristics of patients and practices that have access to the patient portal will be used to better delineate patients' choice of eVisit vs. the traditional office visit.