Telemedicine: Rx for the Future of Health Care

Quite simply, telemedicine symbolizes and catalyzes the clash between the reality of our legal and political approach to health care and the American dream of bringing health care to all patients. Telemedicine, like our health care delivery systems, is regulated by many layers of government. Unlike other issues, telemedicine cuts through and challenges the traditional controls of access and cost. As such, telemedicine is a microcosm of our health care delivery system and a lens through which one may analyze the obstacles to access in the current system. This article examines these issues, proposes that telemedicine\u27s goal should be to improve quality, access, and, costs for the American patient, and offers suggestions for obtaining these goals. In the past five years, professional, governmental, and private organizations\u27 interest in telemedicine has grown exponentially. Although telemedicine is still in its infancy, the technology driving telemedicine continues to advance more rapidly than the laws that apply to its use. Three main issues remain unresolved: (1) who controls quality; (2) how patients gain access; and, (3) who pays for that access? The combination of innovative application of technology and the regulated world of medicine, governed by our unique political landscape, compels us to examine and resolve issues relating to quality, access and costs. Over the next five years, we are poised to spend over $100 billion on telemedicine and other emerging information technologies. For this investment to pay off, the current framework for regulating telemedicine must be replaced with one that facilitates the delivery of these services. Those seeking to deliver telemedicine must contemplate cost, access and quality, and must pay particular attention to the best interests of the patient. Although telemedicine has been heralded, it has also been criticized, both for advancing too quickly and for moving too slowly, for taking on too much, for not taking on enough and for adding costs to health care. The telemedicine subject has raised a plethora of questions. This article will examine those questions in the context of our legal, regulatory and political/ethical framework. Part I defines telemedicine and telehealth, and explores current and future applications. Part II addresses regulation of quality and focuses on licensure, credentialing, and malpractice actions. Part III considers access and the regulatory monitors of telemedicine: the Federal Communications Commission ( FCC ), the Food Drug and Cosmetic Administration ( FD&CA ) and Health Care Financing Administration ( HCFA ). Part IV focuses on the cost of telemedicine, including funding and payment systems for telemedicine delivery services, and suggests guidelines that should provide fiscal support for telemedicine projects. Part V discusses current federal, state and private telemedicine proposals and suggests model approaches for achieving access, quality and cost objectives. Part VI suggests that telemedicine is a means to improving medical treatment. To that end, this article proposes solutions that will drive telemedicine toward improved quality and access for our entire health care delivery system

Candidate hypervelocity stars of spectral type G and K revisited

Hypervelocity stars (HVS) move so fast that they are unbound to the Galaxy. When they were first discovered in 2005, dynamical ejection from the supermassive black hole (SMBH) in the Galactic Centre (GC) was suggested as their origin. The two dozen HVSs known today are young massive B stars, mostly of 3-4 solar masses. Recently, 20 HVS candidates of low mass were discovered in the Segue G and K dwarf sample, but none of them originates from the GC. We embarked on a kinematic analysis of the Segue HVS candidate sample using the full 6D phase space information based on new proper motion measurements. Their orbital properties can then be derived by tracing back their trajectories in different mass models of our Galaxy. We present the results for 14 candidate HVSs, for which proper motion measurements were possible. Significantly lower proper motions than found in the previous study were derived. Considering three different Galactic mass models we find that all stars are bound to the Galaxy. We confirm that the stars do not originate from the GC. The distribution of their proper motions and radial velocities is consistent with predictions for runaway stars ejected from the Galactic disk by the binary supernova mechanism. However, their kinematics are also consistent with old disk membership. Moreover, most stars have rather low metallicities and strong $\alpha$-element enrichment as typical for thick disk and halo stars, whereas the metallicity of the three most metal-rich stars could possibly indicate that they are runaway stars from the thin disk. One star shows halo kinematics.Comment: A&A letter accepte

Gene expression profiling of microglia infected by a highly neurovirulent murine leukemia virus: implications for neuropathogenesis

BACKGROUND: Certain murine leukemia viruses (MLVs) are capable of inducing progressive spongiform motor neuron disease in susceptible mice upon infection of the central nervous system (CNS). The major CNS parenchymal target of these neurovirulent retroviruses (NVs) are the microglia, whose infection is largely coincident with neuropathological changes. Despite this close association, the role of microglial infection in disease induction is still unknown. In this paper, we investigate the interaction of the highly virulent MLV, FrCasE, with microglia ex vivo to evaluate whether infection induces specific changes that could account for neurodegeneration. Specifically, we compared microglia infected with FrCasE, a related non-neurovirulent virus (NN) F43/Fr57E, or mock-infected, both at a basic virological level, and at the level of cellular gene expression using quantitative real time RT-PCR (qRT-PCR) and Afffymetrix 430A mouse gene chips. RESULTS: Basic virological comparison of NN, NV, and mock-infected microglia in culture did not reveal differences in virus expression that provided insight into neuropathogenesis. Therefore, microglial analysis was extended to ER stress gene induction based on previous experiments demonstrating ER stress induction in NV-infected mouse brains and cultured fibroblasts. Analysis of message levels for the ER stress genes BiP (grp78), CHOP (Gadd153), calreticulin, and grp58 in cultured microglia, and BiP and CHOP in microglia enriched fractions from infected mouse brains, indicated that FrCasE infection did not induce these ER stress genes either in vitro or in vivo. To broadly identify physiological changes resulting from NV infection of microglia in vitro, we undertook a gene array screen of more than 14,000 well-characterized murine genes and expressed sequence tags (ESTs). This analysis revealed only a small set of gene expression changes between infected and uninfected cells (<18). Remarkably, gene array comparison of NN- and NV-infected microglia revealed only 3 apparent gene expression differences. Validation experiments for these genes by Taqman real-time RT-PCR indicated that only single Ig IL-1 receptor related protein (SIGIRR) transcript was consistently altered in culture; however, SIGIRR changes were not observed in enriched microglial fractions from infected brains. CONCLUSION: The results from this study indicate that infection of microglia by the highly neurovirulent virus, FrCasE, does not induce overt physiological changes in this cell type when assessed ex vivo. In particular, NV does not induce microglial ER stress and thus, FrCasE-associated CNS ER stress likely results from NV interactions with another cell type or from neurodegeneration directly. The lack of NV-induced microglial gene expression changes suggests that FrCasE either affects properties unique to microglia in situ, alters the expression of microglial genes not represented in this survey, or affects microglial cellular processes at a post-transcriptional level. Alternatively, NV-infected microglia may simply serve as an unaffected conduit for persistent dissemination of virus to other neural cells where they produce acute neuropathogenic effects

The development of a nursing subset of patient problems to support interoperability

Since the emergence of electronic health records, nursing information is increasingly being recorded and stored digitally. Several studies have shown that a wide range of nursing information is not interoperable and cannot be re-used in different health contexts. Difficulties arise when nurses share information with others involved in the delivery of nursing care. The aim of this study is to develop a nursing subset of patient problems that are prevalent in nursing practice, based on the SNOMED CT terminology to assist in the exchange and comparability of nursing information. Explorative qualitative focus groups were used to collect data. Mixed focus groups were defined. Additionally, a nursing researcher and a nursing expert with knowledge of terminologies and a terminologist participated in each focus group. The participants, who work in a range of practical contexts, discussed and reviewed patient problems from various perspectives. Sixty-seven participants divided over seven focus groups selected and defined 119 patient problems. Each patient problem could be documented and coded with a current status or an at-risk status. Sixty-six percent of the patient problems included are covered by the definitions established by the International Classification of Nursing Practice, the reference terminology for nursing practice. For the remainder, definitions from either an official national guideline or a classification were used. Each of the 119 patient problems has a unique SNOMED CT identifier. To support the interoperability of nursing information, a national nursing subset of patient problems based on a terminology (SNOMED CT) has been developed. Using unambiguously defined patient problems is beneficial for clinical nursing practice, because nurses can then compare and exchange information from different settings. A key strength of this study is that nurses were extensively involved in the development process. Further research is required to link or associate nursing patient problems to concepts from a nursing classification with the same meaning

Urinary albumin and 8-oxo-7,8-dihydroguanosine as markers of mortality and cardiovascular disease during 19 years after diagnosis of type 2 diabetes:A comparative study of two markers to identify high risk patients

Urinary albumin is an important biomarker used to identify high risk patients with diabetes, but there is a need for new biomarkers that alone or in combination with urinary albumin could give an even better prediction of clinical patient outcomes. One promising biomarker is 8-oxo-7,8-dihydroguanosine (8-oxoGuo) that represents intracellular oxidative stress. We investigated the ability of microalbuminuria (MA) and urinary 8-oxoGuo, alone and in combination, to predict mortality and cardiovascular disease (CVD) in patients with type 2 diabetes. We used data from 1381 newly diagnosed diabetes patients, and urinary albumin and 8-oxoGuo were assessed in morning urine collected at the time of diabetes diagnosis and at a follow-up visit 6 years later. Associations between the urinary markers and mortality and CVD were assessed in Cox proportional hazards regression models. Test performance was assessed using sensitivity, specificity, positive predictive value and negative predictive value for 10-year mortality and 10-year incidence of CVD. Both 8-oxoGuo and urinary albumin were statistically significantly associated with all-cause mortality at diagnosis as well as at 6-year follow-up. At diagnosis only urinary albumin was associated with CVD. In contrast, only 8-oxoGuo was associated with CVD at 6-year follow-up. When investigating test performance, we found that by combining information from MA and 8-oxoGuo the ability to correctly identify patients at risk could be improved. The findings suggest that measurement of urinary 8-oxoGuo provides additional information about risk to that obtained from urinary albumin, and that the combined use of 8-oxoGuo and urinary albumin could be useful for a better identification of patients at risk of CVD and death