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

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

A new interpolation method to measure delta evolution and sediment flux: Application to the late Holocene coastal plain of the Argens River in the western Mediterranean

Rapid environmental changes along the Mediterranean coasts influenced the sedimentary dynamics, shoreline position and human settlements in deltaic areas over the last millennia. An innovative and multiproxy approach using geostatistical modelling was developed to estimate geomorphic evolution and sediment fluxes in deltaic areas, while palaeoecological conditions and environmental changes were assessed from geochemistry and cluster analyses of molluscan fauna. This method was applied to the coastal plain of the Argens River in southern France. Depositional environments of prodelta, delta front, river channel, floodplain, marsh and abandoned channel were identified from the study of facies associations. The late Holocene sediment flux in the Argens River bayhead delta ranged from 15,800 ± 2300 to 52,000 ± 8500 m3·yr−1. The highest rate of sediment deposition between 2500 and 2000 cal yr BP was associated with increased river flooding in southeastern France. A general decrease in subaqueous sediment flux over the past 2500 years was primarily controlled by a decrease in accommodation space and delta slope. From 500 to 0 cal yr BP, a sharp increase in subaerial sediment flux probably due to hydroclimatic change was contemporaneous with a period of high flood frequency during the Little Ice Age. A southward shift of the North Atlantic westerlies combined with either a negative phase of the East Atlantic/West Russian pattern or a negative phase of the East Atlantic pattern coupled to a northward migration of the intertropical convergence zone could have led to increased fluvial activity in the lower Argens valley during the late Holocene

The importance of sex as a risk factor for hospital readmissions due to pulmonary diseases

BACKGROUND: Pulmonary diseases are a common and costly cause of 30-day readmissions. Few studies have focused on the difference in risk for rehospitalization between men and women in older patients. In this study we analyzed the association between sex and the risk of readmission in a cohort of patients admitted to the hospital for chronic obstructive pulmonary disease (COPD) exacerbation and other major pulmonary diseases. METHODS: This was a retrospective cohort study based on administrative data collected in the Veneto Region in 2016. We included 14,869 hospital admissions among residents aged 6565\u2009years for diagnosis related groups (DRGs) of the most common disorders of the respiratory system: bronchitis and asthma, pneumonia, pulmonary edema, respiratory failure, and COPD. Multilevel logistic regressions were performed to test the association between 30-day hospital readmission and sex, adjusting for confounding factors. RESULTS: For bronchitis and asthma, male patients had significantly higher odds of 30-day readmission than female patients (adjusted odds ratio (aOR), 2.07; 95% confidence interval (CI), 1.11-3.87). The odds of readmission for men were also significantly higher for pneumonia (aOR, 1.40; 95% CI, 1.13-1.72), for pulmonary edema and respiratory failure (aOR, 1.28; 95% CI, 1.05-1.55), and for COPD (aOR, 1.34; 95% CI, 1.00-1.81). CONCLUSIONS: This study found that male sex is a major risk factors for readmission in patients aged more than 65\u2009years with a primary pulmonary diagnosis. More studies are needed to understand the underlying determinants of this phenomena and to provide targets for future interventions

Estimativas de parâmetros genéticos em linhagens de feijão-caupi de porte prostrado avaliadas em Aquidauana, MS.

Foram avaliados 20 genótipos de feijão-caupi, provenientes da Embrapa Meio-Norte, em relação a seis características morfo-agronômicas. O experimento foi conduzido na Universidade Estadual de Mato Grosso do Sul, Unidade de Aquidauana, no delineamento de blocos casualizados, com quatro repetições. As estimativas de parâmetros genéticos demonstraram situação favorável ao melhoramento por seleção da característica peso de cem grãos, que apresentou elevado valor de herdabilidade e valor de índice de variação superior à unidade

Adaptabilidade e estabilidade de linhagens de feijão-caupi de porte ereto em Mato Grosso do Sul.

Este trabalho teve como objetivo estudar a adaptabilidade e estabilidade de 20 genótipos de feijão-caupi provenientes da Embrapa Meio-Norte, em três municípios de Mato Grosso do Sul (Chapadão do Sul, Dourados e Aquidauana), com relação à produção de grãos (kg ha-1). Os experimentos foram conduzidos no delineamento de blocos ao acaso, com quatro repetições. Para identificação de genótipos com boa adaptabilidade e estabilidade em relação aos locais estudados, aplicou-se a metodologia de Eberhart & Russell (1966). A linhagem MNC00-553D-8-1-2-3 foi a mais promissora, podendo vir a ser recomendada para cultivo em Chapadão do Sul, Dourados e Aquidauana, com grande chance de sucesso na produção de grãos de feijão-caupi