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PubMed1991

Will knowing the variability of ambulatory blood pressure improve clinical outcome? An additional consideration in the critical evaluation of this technology.

The range through which blood pressure varies from moment to moment and from wakefulness to sleep confounds the assessment of the patient with suspected hypertension. The clinical application of this information depends upon the needs and resources available to the physician. Awareness of the variance between average clinic and average ambulatory blood pressures, acquired by ambulatory monitoring, may influence diagnostic and therapeutic decisions to the benefit of the patient. However, the hypothesis that those 20-30% of patients referred for management of mild to moderate hypertension after initial screening who are normotensive when remote from the clinic environment do not require treatment has not been tested prospectively. Two studies using intra-arterial recordings and one large study using a non-invasive device have demonstrated a relationship between ambulatory blood pressure variability and cardiovascular consequences of hypertension that is independent of the level of arterial pressure. Loss of information and problems with accuracy during activity preclude similar calculations of blood pressure variability by currently available portable non-invasive recorders. The hypothesis that actions based upon knowledge of blood pressure variability can improve clinical outcome is attractive, but waits, for its confirmation, large and rigorous trials based on advances in technologic capabilities that will permit accurate, continuous, yet non-invasive monitoring of ambulatory blood pressure.

Blood Pressure↗

PubMed2003

Doctors perceptions of the influences on their prescribing: a comparison of general practitioners based in rural and urban Australia.

OBJECTIVES: To compare and contrast the influences on prescribing perceived by general practitioners in an urban area of Queensland, Australia, to those perceived by general practitioners in rural Queensland. METHOD: An investigation was undertaken with a group of general practitioners in urban and rural locations of Australia. A self-administered questionnaire requested the doctors' demographic details and their opinions on statements about prescribing. They also reported their prescribing of six recently marketed drugs. RESULTS: One hundred and forty-two general practitioners from rural areas of Queensland (55% of the eligible population of these doctors) and one hundred and thirty-seven from the urban area (54% response) returned the surveys. The urban group were older and had more experience as general practitioners. Similarities and differences were detected between the two groups. The urban group considered that continuing medical education had a lesser influence on their prescribing than the rural group. The rural general practitioners were more likely than the urban doctors to agree that their information needs on prescribing were not being met in their practice, that their practice location had an effect on their prescribing (and also an effect on their prescribing of new drugs) as well as the remoteness of the patient's address having an effect. The rural doctors agreed more than the urban doctors that they try to avoid drugs requiring a significant amount of monitoring, reinforced by their agreement that they would be more likely to prescribe a newly marketed drug requiring less monitoring. When relating to whether the doctors in the two groups had reported initiating a supply of specific newly marketed drugs, independent of a specialist, rural general practitioners had initiated fewer of these selected new medicines. CONCLUSION: This study has highlighted some of the differences in perceptions of doctors on the influences on prescribing in rural relative to urban areas of Australia. An understanding of these perceptions will allow targeting and development of location-relevant prescribing interventions and messages.

Adult↗

PubMed1985

"Ischemia at a distance" during intermittent coronary artery occlusion: a coronary anatomic explanation.

The mechanism of electrocardiographic ST segment changes during acute coronary occlusion was evaluated in 28 consecutive patients with single vessel coronary artery disease undergoing coronary angioplasty. Patients were continuously monitored with a six lead electrocardiogram. Twenty-three patients showed ST changes in the primary zone of occlusion, and 13 of these had additional ST changes in a remote zone. Ten of these 13 had unusually extensive arteries supplying the remote zone. The balloon occluded two adjacent normal arteries in two patients, and no coronary anatomic explanation was evident in one patient. Ten patients with striking primary zone ST changes showed no remote change. Seven had nonextensive primary zone arteries, and three others had abundant collateral vessels. Five patients showed no electrocardiographic changes in primary or remote zones. Four had collateral vessels, and one had left ventricular hypertrophy on the baseline electrocardiogram. It was concluded that remote electrocardiographic changes are probably due to occlusion of unusually extensive coronary arteries and are not simply reciprocal.

Angioplasty, Balloon↗

PubMed2005

New directions in the medical management of heart failure.

Like the introduction of digitalis more than 200 years ago, novel medical therapies today have the potential to significantly alter the course of heart failure (HF) and save thousands of lives. This review outlines new directions in HF medical management beyond the foundation of neurohormonal blockade. Furthermore, the role of novel risk factors in HF such as chronic renal insufficiency, anemia, and sleep apnea present tantalizing therapeutic targets to extend the morbidity and mortality benefits of current therapies. The course of time will tell which of these risk factors and therapies can hold promise, given the recent litany of negative trials in the HF arena. Advancements in molecular and genetic techniques have allowed us to begin to consider patient specific therapies and lay the groundwork for even further improvements in treatment of symptomatic HF. Finally, advances in telemedicine and device technology will allow the clinician to remotely monitor useful clinical parameters such as heart rate variability and pulmonary filling pressures to make more informed clinical decision-making and improve outcomes.

Adrenergic Antagonists↗

PubMed2000

Baby CareLink: using the internet and telemedicine to improve care for high-risk infants.

OBJECTIVE: To evaluate an Internet-based telemedicine program designed to reduce the costs of care, to provide enhanced medical, informational, and emotional support to families of very low birth weight (VLBW) infants during and after their neonatal intensive care unit (NICU) stay. BACKGROUND: Baby CareLink is a multifaceted telemedicine program that incorporates videoconferencing and World Wide Web (WWW) technologies to enhance interactions between families, staff, and community providers. The videoconferencing module allows virtual visits and distance learning from a family's home during an infant's hospitalization as well as virtual house calls and remote monitoring after discharge. Baby CareLink's WWW site contains information on issues that confront these families. In addition, its security architecture allows efficient and confidential sharing of patient-based data and communications among authorized hospital and community users. DESIGN/METHODS: A randomized trial of Baby CareLink was conducted in a cohort of VLBW infants born between November 1997 and April 1999. Eligible infants were randomized within 10 days of birth. Families of intervention group infants were given access to the Baby CareLink telemedicine application. A multimedia computer with WWW browser and videoconferencing equipment was installed in their home within 3 weeks of birth. The control group received care as usually practiced in this NICU. Quality of care was assessed using a standardized family satisfaction survey administered after discharge. In addition, the effect of Baby CareLink on hospital length of stay as well as family visitation and interactions with infant and staff were measured. RESULTS: Of the 176 VLBW infants admitted during the study period, 30 control and 26 study patients were enrolled. The groups were similar in patient and family characteristics as well as rates of inpatient morbidity. The CareLink group reported higher overall quality of care. Families in the CareLink group reported significantly fewer problems with the overall quality of care received by their family (mean problem score: 3% vs 13%). In addition, CareLink families also reported greater satisfaction with the unit's physical environment and visitation policies (mean problem score: 13% vs 50%). The frequency of family visits, telephone calls to the NICU, and holding of the infant did not differ between groups. The duration of hospitalization until ultimate discharge home was similar in the 2 groups (68.5 +/- 28.3 vs 70.6 +/- 35.6 days). Among infants born weighing <1000 g (n = 31) there was a tendency toward shorter lengths of stay (77.4 +/- 26.2 vs 93.1 +/- 35.6 days). All infants in the CareLink group were discharged directly to home whereas 6/30 (20%) of control infants were transferred to community hospitals before ultimate discharge home. CONCLUSIONS: CareLink significantly improves family satisfaction with inpatient VLBW care and definitively lowers costs associated with hospital to hospital transfer. Our data suggest the use of telemedicine and the Internet support the educational and emotional needs of families facilitating earlier discharge to home of VLBW infants. We believe that further extension of the Baby CareLink model to the postdischarge period will significantly improve the coordination and efficiency of care.

Aftercare↗

PubMed2000

[Telemedicine and lifestyle modifications in obstructive sleep apnea patients].

The recent advent of information technology(IT) has led to the application of telemedicine to the diagnosis of sleep-disordered breathing(SDB) such as obstructive sleep apnea(OSA). Trials with automatic SDB analyzers(Night Watch and Alice 4) are investigating the use of home SDB testing via telephone circuits or the internet, home continuous positive airway pressure(CPAP) titration via remote-control, and super-remote polysomnographic monitoring using the time difference between Japan and the United States. In 1994, we developed a computer-controlled lifestyle improvement support system(AILIFE) using a telephone circuit. The support system is expected to heighten the effectiveness of treatments for OSA with CPAP, prosthetic mandibular advancement, or uvulopalatopharyngoplasty by improving the lifestyle of OSA patients through the provision of home-based guidance on nutrition and exercise via telecare.

Home Care Services↗

PubMed1989

Neurophysiologic intraoperative monitoring: II. Facial nerve function.

Intraoperative facial nerve monitoring provides a potentially useful adjunct to recent surgical advances in neurotology and neurosurgery. These measures further aid the surgeon in preserving facial nerve function by enhancing visual identification with electrical monitoring of mechanically evoked facial muscle activation. Facial nerve monitoring in neurotologic surgery may achieve the following goals: (1) early recognition of surgical trauma to the facial nerve, with immediate feedback made available to the surgeon through monitoring of mechanical activation; (2) assistance in distinguishing the facial nerve from regional cranial nerves and from adjacent soft tissue and tumor with selective electrical stimulation; (3) facilitation of tumor excision by electrical mapping of portions of tumor that are remote from the facial nerve; (4) confirmation of nerve stimulability at the completion of surgery; and (5) identification of the site and degree of neural dysfunction in patients undergoing nerve exploration for suspected facial nerve neoplasm or undergoing decompression in acute facial palsy. This paper provides an overview of intraoperative facial nerve monitoring principles and methodology and reports a recent clinical investigation that demonstrates the utility of facial nerve monitoring in translabyrinthine acoustic neuroma surgery.

Electric Stimulation↗

PubMedDate not supplied

Evolution of neuronetworks.

Since the 1970s, the care of critically ill neurologic and neurosurgical patients has emerged as a developing subspecialty. Management of these patients involves an enormous amount of data generation and analysis. Review of the history of neuroepidemiology and neurocritical care demonstrates the inevitability of their present unwiedly burden of information. Compelling advantages of computerization in direct patient care include aid in data acquisition, analysis and remote access. Infrastructure and resources used to collect data on individual patients may be augmented to archive data in clinical databases. Several investigators have initiated information management projects including automation of beside clinical documentation, development of systems for remote access to information and patient registries to study the natural history and outcome of specific neurological conditions. These are steps toward the development of integrated systems to aid in patient monitoring, data management, continuous quality improvement and the generation of hypotheses for further clinical investigation. Improvements in information management technology will allow increased efficiency in an era where information generation continues to increase exponentially.

Critical Care↗

PubMed2001

An evaluation of a computer-based psychiatric assessment: evidence for expanded use.

The purpose of this study was to examine the psychiatric diagnoses of depression made using the structured interview, the Computer-Based Diagnostic Inventory Schedule for Children-Revised (CDISC-R) and diagnoses of depression made by pediatric psychiatrists. One hundred and twenty-two adolescents who were admitted to an inpatient psychiatric treatment unit agreed to participate in the study. All participants completed the CDISC-R structured diagnostic interview and independent measures reflecting depressive symptoms. The admitting pediatric psychiatrists' diagnoses were also recorded. Even though there were more females in the sample, males (n = 38) and females (n = 84) had similar results. The computer-based CDISC-R and physician diagnoses agreed in 76% of the cases. These results were confirmed by the independent measures of depressive symptoms, which were higher for those with diagnoses of depression and lower for those without depression. In the 24% of the cases, where the CDISC-R and physician diagnoses disagreed, the computer-based CDISC-R was more accurate in assigning a diagnosis of depression in terms of the independent measures of depressive symptoms. The CDISC-R, a computer-based diagnostic interview, efficiently and precisely diagnoses depression. This finding indicates that the use of computer-based diagnostic interviews in applied research will provide more objective and precise results, especially in clinical trials. It follows from these findings that computer-based diagnostic interviews could have important clinical applications and play a central role in web-based mental health and Telemedicine by facilitating triage, referral, and monitoring treatment outcomes through remote electronic assessment.

Adolescent↗

PubMedDate not supplied

[Monitoring of glycemic balance in diabetics living in Africa: a review of glycated hemoglobin measurement methods].

Diabetes has become a health care problem not only in the first world, but also in developing countries, where the majority of diabetics live. The development of a diabetes care system that can cater for the chronic management of diabetic patients is pivotal to an improvement of this situation. A lack of diagnostic facilities has often been made responsible for a lack in appropriate treatment and for the prevention of complications. However, while this is certainly the case in remote areas with health care available only at the primary or secondary level, preventing complications by securing a good diabetic control is possible now in many cities and/or highly populated regions in developing countries. A prerequisite for this is the ability to monitor retrospectively long-term glycemic control, specifically, measuring the level of glycated proteins or hemoglobins (HbA1c).

Africa↗

PubMed1999

Epilepsy syndromes in patients with childhood-onset seizures in Finland.

Childhood-onset epilepsy is a common disorder. There is insufficient data on the distribution of epilepsy syndromes in the population and their effect on long-term prognosis. This report presents the data on epilepsy syndromes in a childhood-onset epilepsy cohort. A population-based active-prevalence cohort of all children under 16 years of age residing in the catchment area of Turku University Hospital with active epilepsy between 1961 and 1964 was monitored prospectively until 1992. Etiology, seizure type, and epilepsy syndromes were classified according to the recent guidelines of the International League Against Epilepsy. The etiology of seizures was idiopathic in 28%, cryptogenic in 22%, and remote symptomatic in 50%. Seizures were classifiable in 235 patients (96%) and included 157 (64%) with partial seizures and 88 (36%) with generalized seizures. Epilepsy syndromes could be classified in 223 patients (91%) and included 152 (62%) localization-related syndromes, 61 (25%) generalized epilepsy syndromes, and 10 (4%) with syndromes not determined as being focal or generalized. Prognosis for both survival and remission was dependent on etiology and on the specific epilepsy syndrome. The authors conclude that the International League Against Epilepsy guidelines can be successfully applied to a population-based cohort with childhood-onset epilepsy. Accurate classification of syndromes is important because in many cases long-term outcome may be largely determined by the underlying epilepsy syndrome.

Adult↗

PubMed2006

Ellen R. Grass Lecture: Rapid EEG analysis for intensive care decisions in status epilepticus.

Nonconvulsive status epilepticus in intensive care units (ICUs) is common and increases the risk of death. Nonconvulsive status epilepticus treatment delays are associated with poor patient outcomes. Continuous EEG or EEG-video monitoring is used in ICU settings to diagnose subtle seizures and nonconvulsive status epilepticus among at-risk populations including patients with closed head injuries and altered consciousness, stroke, subarachnoid hemorrhage, neonates at-risk for sepsis or hypoxic-ischemic encephalopathy, and children who have undergone surgery for congenital heart disease. However expert EEG interpretation, currently required for accurate diagnosis, often lags behind the real-time recordings by hours or even longer. At most hospitals the numbers of at-risk patients in intensive care units far exceeds the capacity of the available EEG equipment and personnel to perform and interpret EEGs. Seizure-detection software, compressed EEG spectral arrays, and near real-time remote EEG interpretation have brought us closer to the goal of real-time analysis of EEG for intensive care decisions, but even at major tertiary referral centers the vast majority of at-risk ICU patients do not undergo EEG monitoring. Additional technological advances, innovative use of EEG technologists and ICU personnel, and clinical trials of new EEG monitoring technology and associated clinical outcomes are needed to achieve the goal of optimal use of EEG data for intensive care decisions.

Critical Care↗

PubMed2003

Telehealth: voice therapy using telecommunications technology.

Telehealth offers the potential to meet the needs of underserved populations in remote regions. The purpose of this study was a proof-of-concept to determine whether voice therapy can be delivered effectively remotely. Treatment outcomes were evaluated for a vocal rehabilitation protocol delivered under 2 conditions: with the patient and clinician interacting within the same room (conventional group) and with the patient and clinician in separate rooms, interacting in real time via a hard-wired video camera and monitor (video teleconference group). Seventy-two patients with voice disorders served as participants. Based on evaluation by otolaryngologists, 31 participants were diagnosed with vocal nodules, 29 were diagnosed with edema, 9 were diagnosed with unilateral vocal fold paralysis, and 3 presented with vocal hyperfunction with no laryngeal pathology. Fifty-one participants (71%) completed the vocal rehabilitation protocol. Outcome measures included perceptual judgments of voice quality, acoustic analyses of voice, patient satisfaction ratings, and fiber-optic laryngoscopy. There were no differences in outcome measures between the conventional group and the remote video teleconference group. Participants in both groups showed positive changes on all outcome measures after completing the vocal rehabilitation protocol. Reasons for participants discontinuing therapy prematurely provided support for the telehealth model of service delivery.

Adolescent↗

PubMed2005

Morbidity and mortality related to anesthesia outside the operating room.

Morbidity and mortality related to sedation or anesthesia outside the operating room has not been investigated so far, but it is assumed to be a relevant problem because the increasing needs for sedation/analgesia in remote locations for a wide range of diagnostic and operative procedures (endoscopy, radiology, magnetic resonance...) and the lack of monitoring, inadequate training of personnel,insufficient staffing. Many complications could occur to patients, like anaphylactic shock,accidental hypothermia,difficult airway maintenance, aspiration,nausea and vomiting, and anesthesiologists, like exposure to pollution, radiation, electromagnetic fields, falls and trauma. Recent guidelines and personal experience are presented and discussed.

Ambulatory Surgical Procedures↗

PubMed1989

Hypertensive disorders in pregnancy: analysis of 110 cases.

One hundred and ten cases of hypertensive disorders in pregnancy were analyzed retrospectively. There were 16 cases of gestational hypertension, 36 cases of mild preeclampsia, 43 cases of severe preeclampsia, 6 cases of eclampsia, and 9 cases of chronic hypertension with superimposed severe preeclampsia. The principle of management was conservative in order to prolong pregnancy for patients remote from term. Corticosteroids were used to accelerate fetal lung maturity for patients with gestations of less than 36 weeks and magnesium sulfate was administered to prevent seizures. Fetal heart rate monitoring was done routinely and doppler blood flow velocity time wave form study of uterine and umbilical arteries was also performed in the latter part of the study. The cesarean section rate in gestational hypertension and mild preeclampsia was comparable to the general obstetric population in our institute (26.9% vs. 21.2%), but the rate of severe forms of the disease including severe preeclampsia, eclampsia, and chronic hypertension with superimposed severe preeclampsia was as high as 77.6%. Fetal distress was the main indication of section. There were 2 cases (6.9%) of mild respiratory distress syndrome, and all recovered uneventfully. The patients with severe forms of the disease had a higher incidence of small infants for gestational age (72%) and delivery at less than 36 weeks' gestation (48.2%). The corrected perinatal mortality rate was 5.4%. No maternal death was encountered. It was concluded that pregnancy could be prolonged in the interest of fetal lung maturity under meticulous maternal-fetal monitoring without endangering the mother.

Adolescent↗

PubMed1997

Sustainability of pyrethroid-impregnated bednets for malaria control in Afghan communities.

Between 1992 and 1995 a series of studies was undertaken to assess the long-term suitability of pyrethroid-impregnated bednets (PIBs) for malaria control in Afghan refugee communities in two villages in North-West Frontier Province, Pakistan. During 1992, 86% of bednet owners volunteered to have their bednets re-impregnated, and a further 15% of families purchased nets at two-thirds of cost price. From 1992 onwards, 27% of the villagers returned to Afghanistan, and annual house spraying campaigns were introduced to protect those still resident but sleeping without bednets. Within 3 years, these campaigns, together with PIBs, reduced the annual incidence of malaria by 87%, from 597 to 78 cases per 1000 population. Nevertheless, 65% of resident families continued to re-impregnate their nets annually with permethrin. To assess whether PIBs were still being used and were still protective, in view of these reduced transmission rates, we carried out a case--control study in 1994 on febrile or otherwise symptomatic patients presenting at village health centres. Comparison of the slide-positivity rates of PIB users and those without bednets showed that regular usage reduced the odds of contracting falciparum and vivax malaria to 0.22 (95% confidence interval (CI): 0.09-0.55) and 0.31 (95% CI: 0.19-0.51), respectively. There was no evidence of a sex- or age-bias in bednet use or in protective effect. The results indicate that a community-based PIB programme is an appropriate malaria control measure in areas where management or security problems make traditional house-spraying campaigns impossible. A relevant finding for those involved in the monitoring of bednet distribution projects is that the local coverage of bednets and the local impact on malaria, even when introduced to remote areas, can be estimated very cheaply by health centre microscopists who simply catalogue blood film diagnoses according to patients' bednet use practices.

Afghanistan↗

PubMedDate not supplied

[Percutaneous treatment of hilar cholangiocarcinoma completed by high-dose rate brachytherapy. Experience in the first 5 cases].

Cholangiocarcinoma at the confluence of the hepatic ducts (Klatskin tumor) is a slowly growing malignancy with early onset of symptoms and poor outcome since surgery allows radical resection in only a minority of cases. Percutaneously placed biliary stents offer a good palliation, but tend to obstruct after 6-8 months; then, retreatment requires exchange of the endoprosthesis or establishment of a permanent external-internal biliary drainage which offers, in some patients, a relatively long survival. Percutaneous intraluminal HDR brachytherapy might be a valid alternative as a definitive therapy or as a method to keep metallic stents patent for a long time. Five patients with hilar cholangiocarcinoma, diagnosed by means of ultrasound, Computed Tomography, percutaneous transhepatic cholangiography and transluminal biopsy, underwent double percutaneous external-internal biliary drainage. Dummy sources were introduced into the drainage catheters to allow dose distribution planning. The stepwise progression of the miniaturized high activity Iridium source inside the applicators, introduced into the drainage catheters, was controlled and monitored by a computer equipped with dedicated software. In the radiotherapy bunker, using the remote loading technique, percutaneous intracavitary high dose rate brachytherapy was delivered at the rate of 750 cGy per fraction, prescribed at 1 cm from the center of the catheter, once a week, for 4 weeks. Nevertheless, only 4 of 5 patients underwent the complete treatment. In one case, radiation treatment was discontinued after the first session because of digestive bleeding from a duodenal ulcer, supposingly as a consequence of the decubitus of a catheter tip. CT demonstrated rapid progression of the disease with neoplastic spread to the omentum and gallbladder wall thickening; a gallbladder malignancy was then suspected and the patient was no more eligibile for brachytherapy. Subsequently, Carey-Coons endoprostheses were inserted to prevent post-actinic strictures and removed after three months. After completing radiation therapy, control cholangiograms demonstrated in all cases improvement of neoplastic strictures. The first two patients we treated show no signs of tumor recurrence at 4 and 1 months, respectively, after endoscopic removal of the stents. The third patient is still bearing 2 Carey-Coons endoprostheses to be removed after 3 months. The last patient with supposingly partial success of bracytherapy, was treated with two Strecker nitinol stents.

Aged↗

PubMed1998

The next-generation emergency department.

The greatest advances in medicine over the next two decades will result from application of the tools and principles of informatics to the problems of clinical medicine. New developments in medical informatics will drive advances in clinical care administration, research, and education. Information flow in the emergency department a decade hence will be characterized by a transformation from a "hunter-gatherer" information model to a "publisher-subscriber" model in which the right information will always be available at the right time. In large part, information will be gathered automatically rather than manually. Computers will be ubiquitous and almost invisible. Invasive and attached monitoring and testing will yield to new remote and noninvasive technologies. Information will be shared and modified as needed, rather than recreated and reentered by each caregiver. Eventually, the use of information technologies in the emergency medicine workplace will enhance our traditional role as hands-on providers of direct patient care.

Emergency Service, Hospital↗