Telehealth and the diagnosis and management of cardiac disease

The financial and personal burden of chronic cardiac disease is high. Costs are likely to increase over the next few decades. Promising applications of telehealth have appeared in the diagnosis and management of cardiac disease and there are indications that telehealth services can improve the management of chronic cardiac disease as well as extend services to remote and rural populations. Telehealth has been applied to the capture of symptoms of cardiac disease with electrocardiography and echocardiography, to the management and rehabilitation of recently discharged patients, and in peer-to-peer consultation where remote expertise can facilitate diagnosis. Telehealth promises cost reductions in service delivery, although there is a need for properly controlled cost-effectiveness trials to underpin telehealth with a firm evidence base.

Advances in neurotrauma in Australia 1970-2000

The management of neurotrauma in Australia has been one of the significant public health triumphs during the last 30 years of the 20th century. State and national government agencies act in a coordinated fashion to collect data and to promote research on how to manage neurotrauma patients. Between 1970 and 1995, fatalities from road accidents decreased by 47%. Hospital admissions have decreased by 40% despite a 40% increase in the population and a 120% increase in registered vehicles. Fatalities per 10,000 registered vehicles were 8.05% in 1970 and they fell to 1.84% per vehicles in 1995, while fatalities per 10;000 population were 3 in 1970 falling to 1.11 in 1995. Hospitalization from road crashes decreased 23% between March 1988 and March 1997. Public education has steadily improved, backed by the state public health sources. A uniform code of road safety laws has been adopted, backed by legislation and legal penalties and increasing police enforcement. Clinical care of patients has improved as a result of faster communications, tele-medicine, trauma systems, the CT scanner; intensive care units, and improved monitoring. Patient rehabilitation and counseling are now carried out at units accredited by the Australian Council on Health Care Standards.

Brain natriuretic peptide: Disease marker or more in cardiovascular medicine?

Brain natriuretic peptide (BNP) is predominantly a cardiac ventricular hormone that promotes natriuresis and diuresis, inhibits the renin-anglotensin-aldosterone axis, and is a vasodilator. Plasma BNP levels are raised in essential hypertension, and more so in left ventricular (LV) hypertrophy and heart failure. Plasma BNP levels are also elevated in ischemic heart disease. Attempts have been made to use plasma BNP levels as a marker of LV dysfunction, but these have shown that plasma BNP levels are probably not sensitive enough to replace echocardiography in the diagnosis of LV dysfunction. Pericardial BNP or N-BNP may be more suitable markers of LV dysfunction. Plasma BNP levels are also elevated in right ventricular dysfunction, pregnancy-induced hypertension, aortic stenosis, age, subarachnoid hemorrhage, cardiac allograft rejection and cavopulmonary connection, and BNP may have an important pathophysiological role in some or all of these conditions. Clinical trials have demonstrated the natriuretic, diuretic and vasodilator effects, as well as inhibitory effects on renin and aldosterone of infused synthetic human BNP (nesiritide) in healthy humans. BNP infusion improves LV function in patients with congestive heart failure via a vasodilating and a prominent natriuretic effect. BNP infusion is useful for the treatment of decompensated congestive heart failure requiring hospitalization. The clinical potential of BNP is limited as it is a peptide and requires infusion. Drugs that modify the effects of BNP are furthering our understanding of the pathophysiological role and clinical potential of BNP. Increasing the effects of BNP may be a useful therapeutic approach in heart failure involving LV dysfunction. The levels of plasma BNP are increased by blockers, cardiac glycosides and vasopeptidase inhibitors, and this may contribute to the usefulness of these agents in heart failure. (C) 2001 Prous Science. All rights reserved.

Research into telehealth applications in speech-language pathology

A literature review was conducted to investigate the extent to which telehealth has been researched within the domain of speech-language pathology and the outcomes of this research. A total of 13 studies were identified. Three early studies demonstrated that telehealth was feasible, although there was no discussion of the cost-effectiveness of this process in terms of patient outcomes. The majority of the subsequent studies indicated positive or encouraging outcomes resulting from telehealth. However, there were a number of shortcomings in the research, including a lack of cost-benefit information, failure to evaluate the technology itself, an absence of studies of the educational and informational aspects of telehealth in relation to speech-language pathology, and the use of telehealth in a limited range of communication disorders. Future research into the application of telehealth to speech-language pathology services must adopt a scientific approach, and have a well defined development and evaluation framework that addresses the effectiveness of the technique, patient outcomes and satisfaction, and the cost-benefit relationship.

Impact of malocclusion and orthognathic reconstruction surgery on resonance and articulatory function: an examination of variability in five cases

Articulatory patterns and nasal resonance were assessed before and 6 months after orthognathic reconstruction surgery in five patients with dentofacial deformities. Perceptual and physiological assessments showed disorders of nasality and articulatory function preoperatively, two patients being hyponasal, and one hypernasal. Four patients had mild articulatory deficits, and four had reduced maximal lip or tongue pressures. Operation resulted in different patterns of change. Nasality deteriorated in three patients and articulatory precision and intelligibility improved in only one patient and showed no change in the other four. Operation improved interlabial pressures in three patients, while its impact on tongue pressures varied, being improved in one case, deteriorating in one, and remaining unchanged in the other three. The variability in the results highlights the need for routine assessment of speech and resonance before and after orthognathic reconstruction. (C) 2002 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Science Ltd. All rights reserved.

Quality of care of patients hospitalized with acute coronary syndromes

Background: Measurement and improvement of quality of care is a priority issue in health care. Patients hospitalized with acute coronary syndromes (ACS) constitute a high-risk population whose care, if shown to be suboptimal on the basis of available research evidence, may benefit from quality improvement interventions. Aim: To evaluate the quality of in-hospital care for patients with ACS, using explicit quality indicators. Methods: Retrospective case note review was undertaken of 397 patients admitted to three teaching hospitals in Brisbane, Queensland, Australia, between 1 October 2000 and 17 April 2001. The main out-come measures were 12 process-of-care quality indicators, calculated as either: (i) the proportion of all patients who received specific interventions or (ii) the proportion of ideal patients who received -specific interventions (i.e. patients with clear indi-cations and lacking contraindications). Results: Quality indicators with values above 80% included: (i) patient selection for thrombolysis (100%) and discharge prescription of beta-blockers (84%), (ii) antiplatelet agents (94%) and (iii) lipid-lowering agents (82%). Indicators with values between 50% and 80% included: (i) timely per-formance of electrocardiogram (ECG) on admission (61%), (ii) early coronary angiography (75%), (iii) measurement of serum lipids (71%) and (iv) discharge prescription of angiotensin-converting-enzyme (ACE) inhibitors (73%). Indicators with values <50% included: (i) timely administration of thrombolysis (35%), (ii) non-invasive risk assessment (23%) and (ii) formal in-hospital and post-hospital cardiac rehabilitation (47% and 7%, respectively). Conclusion: There were delays in performing ECG and administering thrombolysis to patients who presented to emergency departments with ACS. Improvement is warranted in use of non-invasive procedures for identifying high-risk patients who may benefit from coronary revascularization as well as use of serum lipid measurements, ACE inhibitors and cardiac rehabilitation.

Whither our Art? Clinical Wisdom & Evidence-based Medicine

The relationship between evidence-based medicine (EBM) and clinical judgement is the subject of conceptual and practical dispute. For example, EBM and clinical guidelines are seen to increasingly dominate medical decision-making at the expense of other, human elements, and to threaten the art of medicine. Clinical wisdom always remains open to question. We want to know why particular beliefs are held, and the epistemological status of claims based in wisdom or experience. The paper critically appraises a number of claims and distinctions, and attempts to clarify the connections between EBM, clinical experience and judgement, and the objective and evaluative categories of medicine. I conclude that to demystify clinical wisdom is not to devalue it. EBM ought not be conceived as needing to be limited or balanced by clinical wisdom, since if its language is translatable into terms comprehensible and applicable to individuals, it helps constitute clinical wisdom. Failure to appreciate this constitutive relation will help perpetuate medical paternalism and delay the adoption of properly evidence-based practice, which would be both unethical and unwise.