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

Hamiltonian dynamics reveals the existence of quasi-stationary states for long-range systems in contact with a reservoir

We introduce a Hamiltonian dynamics for the description of long-range interacting systems in contact with a thermal bath (i.e., in the canonical ensemble). The dynamics confirms statistical mechanics equilibrium predictions for the Hamiltonian Mean Field model and the equilibrium ensemble equivalence. We find that long-lasting quasi-stationary states persist in presence of the interaction with the environment. Our results indicate that quasi-stationary states are indeed reproducible in real physical experiments.Comment: Title changed, throughout revision of the tex

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

A recent appreciation of the singular dynamics at the edge of chaos

We study the dynamics of iterates at the transition to chaos in the logistic map and find that it is constituted by an infinite family of Mori's $q$-phase transitions. Starting from Feigenbaum's $\sigma$ function for the diameters ratio, we determine the atypical weak sensitivity to initial conditions $\xi _{t}$ associated to each $q$-phase transition and find that it obeys the form suggested by the Tsallis statistics. The specific values of the variable $q$ at which the $q$-phase transitions take place are identified with the specific values for the Tsallis entropic index $q$ in the corresponding $\xi_{t}$. We describe too the bifurcation gap induced by external noise and show that its properties exhibit the characteristic elements of glassy dynamics close to vitrification in supercooled liquids, e.g. two-step relaxation, aging and a relationship between relaxation time and entropy.Comment: Proceedings of: Verhulst 200 on Chaos, Brussels 16-18 September 2004, Springer Verlag, in pres

Impact of pneumococcal conjugate vaccination: a retrospective study of hospitalization for pneumonia in North-East Italy

Introduction. Pneumonia remains a common reason for hospitalizing infants and the elderly worldwide, and streptococcal infection is often responsible. The aim of this study was to assess the burden of pneumonia in a large general population. Methods. All pneumonia-related hospitalizations from 2004 to 2013 in north-east Italy were identified from the hospital records with a first-listed diagnosis on discharge of bacterial pneumonia, or a first-listed diagnosis on discharge of meningitis, septicemia or empyema associated with a secondary diagnosis of bacterial pneumonia. We identified major comorbidities, calculated agespecific case-fatality rates (CFR), and estimated the related cost to the health care system. Results. Of the 125,722 hospitalizations identified, 96.9% were cases of pneumonia, 2.4% of septicemia, 0.4% of meningitis, and 0.3% of empyema; 75.3% of hospitalizations involved 65 65-yearolds. The overall CFR was 12.4%, and it increased with age, peaking in people over 80 (19.6%). The mean annual pneumonia-associated hospitalization rate was 204.6 per 100,000 population, and it peaked in 0- to 4-year-old children (325.6 per 100,000 in males, 288.9 per 100,000 in females), and adults over 65 (844.9 per 100,000 in males, 605.7 per 100,000 in females). Hospitalization rates dropped over the years for the 0-4 year-olds, and rose for people over 80. The estimated overall annual cost of these pneumonia-related hospitalizations was approximately \u20ac 41 million. Conclusions. This study shows that the burden on resources for pneumonia-related hospitalization is an important public health issue. Prevention remains the most valuable tool for containing pneumonia, and vaccination strategies can help in the primary prevention of infection, possibly reducing the number of cases in all age groups

Incomplete equilibrium in long-range interacting systems

We use a Hamiltonian dynamics to discuss the statistical mechanics of long-lasting quasi-stationary states particularly relevant for long-range interacting systems. Despite the presence of an anomalous single-particle velocity distribution, we find that the Central Limit Theorem implies the Boltzmann expression in Gibbs' $\Gamma$-space. We identify the nonequilibrium sub-manifold of $\Gamma$-space characterizing the anomalous behavior and show that by restricting the Boltzmann-Gibbs approach to this sub-manifold we obtain the statistical mechanics of the quasi-stationary states.Comment: Title changed, throughout revision of the tex

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

Connections between Tsallis' formalisms employing the standard linear average energy and ones employing the normalized qq-average energy

Tsallis' thermostatistics with the standard linear average energy is revisited by employing $S_{2-q}$, which is the Tsallis entropy with $q$ replaced by $2-q$. We explore the connections among the $S_{2-q}$ approach and the other different versions of Tsallis formalisms. It is shown that the normalized $q$-average energy and the standard linear average energy are related to each other. The relations among the Lagrange multipliers of the different versions are revealed. The relevant Legendre transform structures concerning the Lagrange multipliers associated with the normalization of probability are studied. It is shown that the generalized Massieu potential associated with $S_{2-q}$ and the linear average energy is related to one associated with the normalized Tsallis entropy and the normalized $q$-average energy.Comment: 16 pages, no figure, submitted to Physics Letter

On "Ergodicity and Central Limit Theorem in Systems with Long-Range Interactions" by Figueiredo et al

In the present paper we refute the criticism advanced in a recent preprint by Figueiredo et al [1] about the possible application of the $q$-generalized Central Limit Theorem (CLT) to a paradigmatic long-range-interacting many-body classical Hamiltonian system, the so-called Hamiltonian Mean Field (HMF) model. We exhibit that, contrary to what is claimed by these authors and in accordance with our previous results, $q$-Gaussian-like curves are possible and real attractors for a certain class of initial conditions, namely the one which produces nontrivial longstanding quasi-stationary states before the arrival, only for finite size, to the thermal equilibrium.Comment: 2 pages, 2 figures. Short version of the paper, accepted for publication in Europhysics Letters, (2009) in pres

Quasi-stationary chaotic states in multi-dimensional Hamiltonian systems

We study numerically statistical distributions of sums of chaotic orbit coordinates, viewed as independent random variables, in weakly chaotic regimes of three multi-dimensional Hamiltonian systems: Two Fermi-Pasta-Ulam (FPU-$\beta$) oscillator chains with different boundary conditions and numbers of particles and a microplasma of identical ions confined in a Penning trap and repelled by mutual Coulomb interactions. For the FPU systems we show that, when chaos is limited within "small size" phase space regions, statistical distributions of sums of chaotic variables are well approximated for surprisingly long times (typically up to $t\approx10^6$) by a $q$-Gaussian ($1<q<3$) distribution and tend to a Gaussian ($q=1$) for longer times, as the orbits eventually enter into "large size" chaotic domains. However, in agreement with other studies, we find in certain cases that the $q$-Gaussian is not the only possible distribution that can fit the data, as our sums may be better approximated by a different so-called "crossover" function attributed to finite-size effects. In the case of the microplasma Hamiltonian, we make use of these $q$-Gaussian distributions to identify two energy regimes of "weak chaos"-one where the system melts and one where it transforms from liquid to a gas state-by observing where the $q$-index of the distribution increases significantly above the $q=1$ value of strong chaos.Comment: 32 pages, 13 figures, Submitted for publication to Physica