Telemedicine in chronic disease management: a Public Health perspective

Introduction In 2014, the School of Hygiene of the University of Padua carried out an evaluation of home telemonitoring (HTM) programs for the management of chronic diseases. Our aims were to verify their efficacy, and to identify a model of care that could be integrated into the current health system. Our analysis addressed both organizational and clinical matters. Methods Our evaluation involved 19 reviews and 53 randomized controlled trials (RCT). Main selection criteria were: papers published over the last 15 years, HTM performed through a sensor system, data sent remotely to physicians, health out-comes and monitored parameters clearly stated. Included diseases were: heart failure, hypertension, COPD, asthma and diabetes. Results Several critical issues were highlighted. Due to the general tendency in the scientific literature to report HTM efficacy, there is a lack of conclusive evidence whether telemedicine actually improves both clinical (e.g. decreased disease/all-cause mortality, drop in disease/all-cause hospitalization rates, improvement in biological parameters and quality of life) and organizational (decreased length of hospital stay, decreased emergency room/other service use, decreased costs) outcomes or not. Discussion From a Public Health perspective, discrepancies and weaknesses may affect published results, since the best method for organizing and delivering telemedicine programs has not yet been identified. There is still no consensus on the following topics: setting: which context expresses the potential of technology best? No studies were found comparing, e.g., rural with urban communities. Within urban scenarios, samples do not discriminate users by their capability to access the healthcare network (e.g. residents in peripheral areas with limited transportation resources, rather than users with reduced mobility); target: it is unclear which demographic or socioeconomic characteristics users should possess to gain most benefit from HTM; duration and frequency: there are significant differences in RCT (and HTM program) duration. It has not been established whether HTM is more effective when permanently implemented, or only in the early stages of disease (i.e. until stabilization). There is no agreement on the optimal HTM implementation frequency, nor whether the patients should also receive traditional interventions (e.g. nurse home visits);scope: it has not been determined whether measurements should be disclosed to patients as educational means to improve disease management. However, past literature does include some indications that the effectiveness of HTM programs may be attributable to care intensification (or to a perceived intensification by the patient, as per the \u201cHawthorne effect\u201d described in sociology) or to the empowerment process. Conclusions HTM management of chronic diseases is a promising and remarkable strategy, still flawed by the lack of evidence. Reported efficacy, although modest, probably has a multifactorial origin. Our hypothesis is that it may not result from the technology itself, but from the impact of such process on multiple components of care, emphasizing patients' involvement and autonomy, and improving monitoring intensity. Further studies are needed to clarify the role played by the different HTM components (target, setting, etc.). The application of HTM as a tool for prevention, empowerment and reduction of healthcare access remains little explored

Is depression a real risk factor for acute myocardial infarction mortality? A retrospective cohort study

Background: Depression has been associated with a higher risk of cardiovascular events and a higher mortality in patients with one or more comorbidities. This study investigated whether continuative use of antidepressants (ADs), considered as a proxy of a state of depression, prior to acute myocardial infarction (AMI) is associated with a higher mortality afterwards. The outcome to assess was mortality by AD use. Methods: A retrospective cohort study was conducted in the Veneto Region on hospital discharge records with a primary diagnosis of AMI in 2002-2015. Subsequent deaths were ascertained from mortality records. Drug purchases were used to identify AD users. A descriptive analysis was conducted on patients' demographics and clinical data. Survival after discharge was assessed with a Kaplan-Meier survival analysis and Cox's multiple regression model. Results: Among 3985 hospital discharge records considered, 349 (8.8%) patients were classified as AD users'. The mean AMI-related hospitalization rate was 164.8/100,000 population/year, and declined significantly from 204.9 in 2002 to 130.0 in 2015, but only for AD users (-40.4%). The mean overall follow-up was 4.64.1years. Overall, 523 patients (13.1%) died within 30days of their AMI. The remainder survived a mean 5.3 +/- 4.0years. After adjusting for potential confounders, use of antidepressants was independently associated with mortality (adj OR=1.75, 95% CI: 1.40-2.19). Conclusions: Our findings show that AD users hospitalized for AMI have a worse prognosis in terms of mortality. The use of routinely-available records can prove an efficient way to monitor trends in the state of health of specific subpopulations, enabling the early identification of AMI survivors with a history of antidepressant use

Intrinsic electrochemical activity of single walled carbon nanotube–Nafion assemblies

The intrinsic electrochemical properties and activity of single walled carbon nanotube (SWNT) network electrodes modified by a drop-cast Nafion film have been determined using the one electron oxidation of ferrocene trimethyl ammonium (FcTMA+) as a model redox probe in the Nafion film. Facilitated by the very low transport coefficient of FcTMA+ in Nafion (apparent diffusion coefficient of 1.8 × 10−10 cm2 s−1), SWNTs in the 2-D network behave as individual elements, at short (practical) times, each with their own characteristic diffusion, independent of neighbouring sites, and the response is diagnostic of the proportion of SWNTs active in the composite. Data are analysed using candidate models for cases where: (i) electron transfer events only occur at discrete sites along the sidewall (with a defect density typical of chemical vapour deposition SWNTs); (ii) all of the SWNTs in a network are active. The first case predicts currents that are much smaller than seen experimentally, indicating that significant portions of SWNTs are active in the SWNT–Nafion composite. However, the predictions for a fully active SWNT result in higher currents than seen experimentally, indicating that a fraction of SWNTs are not connected and/or that not all SWNTs are wetted completely by the Nafion film to provide full access of the redox mediator to the SWNT surface

Turismo urbano en contexto metropolitano: Tigre como destino turístico en el Área Metropolitana de Buenos Aires (Argentina)

Este artículo aborda el tema de las ciudades como destino turístico, específicamente, en relación con las configuraciones y dinámicas metropolitanas. Se analiza el caso de la localidad de Tigre como destino turístico que, siendo parte constitutiva del Área Metropolitana de Buenos Aires, se oferta integrado al “destino turístico Buenos Aires”. El papel de la localidad turística en el contexto metropolitano es analizado a partir del reconocimiento de la escasez de estudios sobre el tema en esta escala. El análisis se enfoca en los procesos que desembocan en la configuración de la localidad como destino turístico, asumiendo que dicho carácter es resultado de acciones específicas, orientadas a adecuar el lugar a los requerimientos turísticos. Con esto, se cuestionan los difundidos enfoques que asumen, en forma naturalizada, la “vocación turística” de los lugares.This article addresses the issue of the city as tourist destination, specifically in relation to metropolitan configurations and dynamics. The article analyzes a tourist destination –the town of Tigreas part of the Metropolitan Area of Buenos Aires and its incorporation into the so called “Buenos Aires tourist destination”. The role of the tourist resort in the metropolitan context is analyzed beginning with the recognition of the paucity of studies on the subject at this scale. The article focuses on the analysis of the processes that lead to the establishing of the town as a tourist destination, assuming that this character is the result of specific actions to adapt the locality to tourist requirements. This focus questions the widespread approaches that assume the “tourist vocation” of localities as natural.O artigo discute o tema das cidades como destino turístico, especificamente com relação às configurações e dinâmicas metropolitanas. Analisa–se o caso da localidade de Tigre como destino turístico que, sendo parte integrante da Área Metropolitana de Buenos Aires, oferta–se integrado ao “destino turístico Buenos Aires”. O papel da localidade turística no contexto metropolitano é analisado a partir do reconhecimento da escassez de estudos sobre o assunto nessa escala. A análise enfoca–se nos processos que levam à configuração da localidade como destino turístico, assumindo que tal caráter é o resultado de ações específicas, orientadas a adequar o lugar às necessidades turísticas. Desse modo, questionam–se as generalizadas abordagens que assumem de modo naturalizado a “vocação turística” dos lugares

Turismo urbano en contexto metropolitano: Tigre como destino turístico en el Área Metropolitana de Buenos Aires (Argentina)

Este artículo aborda el tema de las ciudades como destino turístico, específicamente, en relación con las configuraciones y dinámicas metropolitanas. Se analiza el caso de la localidad de Tigre como destino turístico que, siendo parte constitutiva del Área Metropolitana de Buenos Aires, se oferta integrado al “destino turístico Buenos Aires”. El papel de la localidad turística en el contexto metropolitano es analizado a partir del reconocimiento de la escasez de estudios sobre el tema en esta escala. El análisis se enfoca en los procesos que desembocan en la configuración de la localidad como destino turístico, asumiendo que dicho carácter es resultado de acciones específicas, orientadas a adecuar el lugar a los requerimientos turísticos. Con esto, se cuestionan los difundidos enfoques que asumen, en forma naturalizada, la “vocación turística” de los lugares.This article addresses the issue of the city as tourist destination, specifically in relation to metropolitan configurations and dynamics. The article analyzes a tourist destination –the town of Tigreas part of the Metropolitan Area of Buenos Aires and its incorporation into the so called “Buenos Aires tourist destination”. The role of the tourist resort in the metropolitan context is analyzed beginning with the recognition of the paucity of studies on the subject at this scale. The article focuses on the analysis of the processes that lead to the establishing of the town as a tourist destination, assuming that this character is the result of specific actions to adapt the locality to tourist requirements. This focus questions the widespread approaches that assume the “tourist vocation” of localities as natural.O artigo discute o tema das cidades como destino turístico, especificamente com relação às configurações e dinâmicas metropolitanas. Analisa–se o caso da localidade de Tigre como destino turístico que, sendo parte integrante da Área Metropolitana de Buenos Aires, oferta–se integrado ao “destino turístico Buenos Aires”. O papel da localidade turística no contexto metropolitano é analisado a partir do reconhecimento da escassez de estudos sobre o assunto nessa escala. A análise enfoca–se nos processos que levam à configuração da localidade como destino turístico, assumindo que tal caráter é o resultado de ações específicas, orientadas a adequar o lugar às necessidades turísticas. Desse modo, questionam–se as generalizadas abordagens que assumem de modo naturalizado a “vocação turística” dos lugares

Uncompleted Emergency Department Care (UEDC): A 5-year population-based study in the Veneto Region, Italy

Introduction: Uncompleted visits to emergency departments (UEDC) are a patient safety concern. The purpose of this study was to investigate risk factors for UEDC, describing not only the sociodemographic characteristics of patients who left against medical advice (AMA) and those who left without being seen (LWBS), but also the characteristics of their access to the emergency department (ED) and of the hospital structure. Methods: This was a cross sectional study on anonymized administrative data in a population-based ED database. Results: A total of 9,147,415 patients attended EDs in the Veneto Region from 2011 to 2015. The UEDC rate was 28.7\u2030, with a slightly higher rate of AMA than of LWBS (15.3\u2030 vs 13.4\u2030). Age, sex, citizenship, and residence were sociodemographic factors associated with UEDC, and so were certain characteristics of access, such as mode of admission, type of referral, emergency level, waiting time before being seen, and type of medical issue (trauma or other). Some characteristics of the hospital structure, such as the type of hospital and the volume of patients managed, could also be associated with UEDC. Conclusion: Cases of UEDC, which may involve patients who leave AMA and those who LWBS, differ considerably from other cases managed at the ED. The present findings are important for the purpose of planning and staffing health services. Decision-makers should identify and target the factors associated with UEDC to minimize walkouts from public hospital EDs

May car washing represent a risk for Legionella infection?

Background. Legionella is a ubiquitous Gram-negative bacterium naturally found in aquatic environments. It can pose a health problem when it grows and spreads in man-made water systems. Legionella pneumophila is the most common cause of Legionnaires\u2019 disease nowadays, a community-acquired pneumonia with pulmonary symptoms and chest radiography no different from any other form of infectious pneumonia. Legionella monitoring is important for public health reasons, including the identification of unusual environmental sources of Legionella. Methods. We report two cases of Legionnaires\u2019 disease associated with two different car wash installations in the province of Vicenza, in the Veneto region, northeastern Italy. Patients were not employees of the car wash installations, but users of the service. In both cases, Legionella antigen was detected in urine using the Alere BinaxNOW\uae Legionella Urinary Antigen, and Legionella antibodies were detected in serum using SERION ELISA classic Legionella pneumophila 1-7 IgG and IgM. Water samples were also analyzed as part of the surveillance program for Legionella prevention and control in compliance with the Italian guidelines. Results. Both patients had clinical symptoms and chest radiography compatible with pneumonia, and only one of them had diabetes as a risk factor. Legionella urinary antigen and serological test on serum samples were positive for Legionella in both patients, even if much slighter in the case A due to the retrospective serological investigation performed a year later the episode and after the second clinical case occurred in the same district. The environmental investigations highlighted two different car wash plants as potential source of infection. A certified company using shock hyperchlorination was asked to disinfect the two plants and, subsequently, control samples resulted negative for Legionella pneumophila. Conclusions. Any water source producing aerosols should be considered at risk for the transmission of Legionella bacteria, including car wash installations frequently used by a large number of customers and where poor maintenance probably creates favorable conditions for Legionella overgrowth and spreading. Additional research is needed to ascertain optimal strategies for Legionella monitoring and control, but environmental surveillance, paying careful attention to possible unconventional sources, should remain an important component of any Legionnaires\u2019 disease prevention program. Additionally, all available diagnostic methods would be recommended for the confirmation of all cases even in the event of non-serogroup 1 Legionella pneumophila infection, probably underestimated at this time