Pilot Study of Telehealth Evaluations in Patients Undergoing Hematopoietic Cell Transplantation

Telehealth involves the use of telecommunication and information technology for the delivery of clinical care and may be a mechanism to alleviate the burden of visits faced by patients undergoing hematopoietic cell transplantation (HCT). Few studies have evaluated the feasibility and acceptability of telehealth visits in the care of HCT patients. We conducted 27 telehealth visits with 25 patients undergoing HCT using a videoconferencing system that allows for real-time, 2-way interactions and administered satisfaction surveys to patients and providers. Of the 25 patients included in the study, 20 (80%) and 5 (20%) were undergoing autologous and allogeneic HCT, respectively. The telehealth visits were distributed as follows: 3 inpatient visits upon admission for HCT; 11 inpatient visits between 2 and 14 days post-HCT; 4 inpatient visits prior to discharge after HCT; 8 outpatient, post-HCT follow-up visits; and 1 handoff to a community oncologist. Out of a total of 54 provider assessments, 7 providers (13%) were unable to complete some part of the physical examination, but no provider reported being unable to manage patients’ symptoms through telehealth. Eighty-one percent of patients were either satisfied or very satisfied with the telemedicine session. Overall satisfaction was higher among patients than providers (mean scores 4.12 versus 2.64; scale 1 to 5, with 1 = very poor to 5 = excellent). Technological barriers resulting in delays and suboptimal physical examination were largely responsible for provider dissatisfaction. The use of telehealth to deliver comprehensive follow-up care to HCT patients is feasible across different HCT types but is dependent upon quality of data streaming and videoconferencing technologies.     

The untapped potential of Telehealth

The people of Malaysia generally enjoy a high standard of health. This is largely attributed to the comprehensive range of health services provided by the Government and the private sector at affordable costs. However, there are changing trends that now seriously challenge this status quo. The changing population structure, lifestyle, disease patterns and globalization are causing healthcare costs to rise. New and innovative ways will have to be devised to further improve the health status and at the same time contain costs. Information and Communication Technology (ICT) presents unprecedented opportunities to help the health sector in Malaysia reinvent itself and transform the way health and healthcare is managed and delivered in the future. Malaysia's Telehealth initiative under the Multimedia Super Corridor (MSC) project is designed to realize Malaysia's health vision and goals and meet future health challenges. Multimedia and Internet technology will be fully harnessed to deploy services that will shift the emphasis from episodic management of illness to proactive promotion of lifelong wellness and disease prevention. Health information content and interactive applications will engage the people to work as partners of health with healthcare professionals in maintaining their own health or managing their illnesses.     

Telehealth: the delayed revolution in health care.

It is recognized that health care in rural communities could be improved significantly with the assistance of telehealth, the term by which the combined application of computer and telecommunications technologies to health care has come to be known. Yet in spite of its obvious potential, the telehealth literature has shown a surprising lack of growth. This paper reports an analysis which revealed that, between 1975 and 1990, few telehealth articles were catalogued by the National Library of Medicine, and suggests why this might have been the case. Following a brief discussion of the origins of telehealth, terminology, and the rural health care crisis, this overview examines the status of telehealth in terms of its main applications: telemedicine and tele-education. An analysis of the pattern of publications between 1975 and 1990 is then used to suggest why telehealth has not fulfilled its potential. Corrective measures are proposed and the paper concludes with a summary of recent telehealth initiatives.     

Personalized Telehealth in the Future: A Global Research Agenda

As telehealth plays an even greater role in global health care delivery, it will be increasingly important to develop a strong evidence base of successful, innovative telehealth solutions that can lead to scalable and sustainable telehealth programs. This paper has two aims: (1) to describe the challenges of promoting telehealth implementation to advance adoption and (2) to present a global research agenda for personalized telehealth within chronic disease management. Using evidence from the United States and the European Union, this paper provides a global overview of the current state of telehealth services and benefits, presents fundamental principles that must be addressed to advance the status quo, and provides a framework for current and future research initiatives within telehealth for personalized care, treatment, and prevention. A broad, multinational research agenda can provide a uniform framework for identifying and rapidly replicating best practices, while concurrently fostering global collaboration in the development and rigorous testing of new and emerging telehealth technologies. In this paper, the members of the Transatlantic Telehealth Research Network offer a 12-point research agenda for future telehealth applications within chronic disease management.     

The Paradox of Self-Stigma and Mental Illness

Published narratives by persons with serious mental illness eloquently describe the harmful effects of stigma on self-esteem and self-efficacy. However, a more careful review of the research literature suggests a paradox; namely, personal reactions to the stigma of mental illness may result in significant loss in self-esteem for some, while others are energized by prejudice and express righteous anger. Added to this complexity is a third group: persons who neither lose self-esteem nor become righteously angry at stigma, instead seemingly ignoring the effects of public prejudice altogether. This article draws on research from social psychologists on self-stigma in other minority groups to explain this apparent paradox. We describe a situational model of the personal response to mental illness stigma based on the collective representations that are primed in that situation, the person's perception of the legitimacy of stigma in the situation, and the person's identification with the larger group of individuals with mental illness. Implications for a research program on the personal response to mental illness stigma are discussed.     

Immunologic Paradox in the Diagnosis of Tuberculous Meningitis

We report a patient with microbiologically documented tuberculous meningitis showing that the therapeutic paradox, a therapy-induced switch to a neutrophil-predominant situation in the differential cell counts of cerebrospinal fluid specimens, had a correlation with an immunologic paradox, an increased Mycobacterium tuberculosis-specific gamma interferon-producing T-cell response.     

Telehealth practice recommendations for diabetic retinopathy, second edition

Ocular telemedicine and telehealth have the potential to decrease vision loss from DR. Planning, execution, and follow-up are key factors for success. Telemedicine is complex, requiring the services of expert teams working collaboratively to provide care matching the quality of conventional clinical settings. Improving access and outcomes, however, makes telemedicine a valuable tool for our diabetic patients. Programs that focus on patient needs, consider available resources, define clear goals, promote informed expectations, appropriately train personnel, and adhere to regulatory and statutory requirements have the highest chance of achieving success.     

The Mediterranean Paradox for Susceptibility Factors in Coronary Heart Disease Extends to Genetics

The incidence of coronary heart disease (CHD) shows a North to South gradient in Europe. We tested whether that gradient could be accounted for by the distribution of putative susceptibility genotypes. We correlated the published frequencies of susceptibility genotypes for the genes most often associated with CHD ( ACE , AGT , APOE , F2 , F5 , MTHFR , PON1, and SERPINE1 ) with the incidence of the disease, controlling for the effects of smoking, systolic pressure, total cholesterol, and body-mass index. In three polymorphisms a negative correlation between the incidence of CHD and the frequency of a suceptibility genotype was observed. For ACE this correlation was significantly negative even when discounting classical susceptibility factors. This suggests that some alleles described as susceptibility factors cannot account for disease incidence at the population level. A genetic component must be added to the "Mediterranean paradox": genetic variants deemed to be risk factors for CHD show a geographical pattern uncorrelated with the disease incidence. This pattern can be understood from the history of populations which has shaped the genetic diversity of the European populations in North-South clines, similar to what is observed for CHD incidence, which will tend to create spurious correlations with polymorphisms related, or not related, to the disease.     

Myasthenia Gravis: Paradox versus paradigm in autoimmunity

Myasthenia Gravis (MG) is a paradigm of organ-specific autoimmune disease (AID). It is mediated by antibodies that target the neuromuscular junction. The purpose of this review is to place MG in the general context of autoimmunity, to summarize the common mechanisms between MG and other AIDs, and to describe the specific mechanisms of MG. We have chosen the most common organ-specific AIDs to compare with MG: type 1 diabetes mellitus (T1DM), autoimmune thyroid diseases (AITD), multiple sclerosis (MS), some systemic AIDs (systemic lupus erythematous (SLE), rheumatoid arthritis (RA), Sjogren's syndrome (SS)), as well as inflammatory diseases of the gut and liver (celiac disease (CeD), Crohn's disease (CD), and primary biliary cirrhosis (PBC)).Several features are similar between all AIDs, suggesting that common pathogenic mechanisms lead to their development. In this review, we address the predisposing factors (genetic, epigenetic, hormones, vitamin D, microbiota), the triggering components (infections, drugs) and their interactions with the immune system [1], [2]. The dysregulation of the immune system is detailed and includes the role of B cells, Treg cells, Th17 and cytokines. We particularly focused on the role of TNF-α and interferon type I whose role in MG is very analogous to that in several other AIDS. The implication of AIRE, a key factor in central tolerance is also discussed.Finally, if MG is a prototype of AIDS, it has a clear specificity compared to the other AIDS, by the fact that the target organ, the muscle, is not the site of immune infiltration and B cell expansion, but exclusively that of antibody-mediated pathogenic mechanisms. By contrast, the thymus in the early onset subtype frequently undergoes tissue remodeling, resulting in the development of ectopic germinal centers surrounded by high endothelial venules (HEV), as observed in the target organs of many other AIDs.     

Overcoming the Heme Paradox: Heme Toxicity and Tolerance in Bacterial Pathogens

Virtually all bacterial pathogens require iron to infect vertebrates. The most abundant source of iron within vertebrates is in the form of heme as a cofactor of hemoproteins. Many bacterial pathogens have elegant systems dedicated to the acquisition of heme from host hemoproteins. Once internalized, heme is either degraded to release free iron or used intact as a cofactor in catalases, cytochromes, and other bacterial hemoproteins. Paradoxically, the high redox potential of heme makes it a liability, as heme is toxic at high concentrations. Although a variety of mechanisms have been proposed to explain heme toxicity, the mechanisms by which heme kills bacteria are not well understood. Nonetheless, bacteria employ various strategies to protect against and eliminate heme toxicity. Factors involved in heme acquisition and detoxification have been found to contribute to virulence, underscoring the physiological relevance of heme stress during pathogenesis. Herein we describe the current understanding of the mechanisms of heme toxicity and how bacterial pathogens overcome the heme paradox during infection.Iron is an essential cofactor for many enzymes found within all kingdoms of life. Bacterial pathogens are no exception to this rule, and therefore, they must acquire iron from their hosts in order to cause disease. Iron is a transition metal that can cycle between redox states, making it a valuable cofactor for biological processes. Ferric iron is water insoluble, and as such, it requires specialized proteins to facilitate its mobilization and to maintain intracellular reservoirs. In mammalian species, lactoferrin and transferrin transport iron, while ferritin stores iron. The most abundant form of iron in vertebrates, however, is bound within a porphyrin ring as ferriprotoporphyrin IX (heme). Heme solubilizes iron and enhances its catalytic ability by 5 to 10 orders of magnitude (14, 111). This catalytic activity is harnessed by hemoproteins involved in oxygenation reactions, oxidative stress responses, electron transport, oxygen transport, oxygen sensing, and oxygen storage. While heme is a necessary prosthetic group for many proteins, it also has the potential to cause toxicity at high concentrations. This property of heme requires that the intracellular pool of heme be tightly regulated.Intracellular heme concentrations within vertebrates are tightly controlled by balancing the rates of heme biosynthesis and catabolism (87). Free heme released into the plasma by the dissolution of hemoproteins from lysed erythrocytes is quickly scavenged by albumin, hemopexin, and the serum lipocalin α₁-microglobulin (13, 23, 44, 75). Any hemoglobin released into the serum is tightly bound by haptoglobin and subsequently cleared by tissue macrophages (51). It is evident that the vital yet reactive nature of heme requires that its production, degradation, and availability be carefully controlled in metazoans. Meeting these demands reduces heme-mediated toxicity and minimizes surplus free heme. Most bacterial pathogens that infect vertebrate tissues have systems dedicated to the acquisition of heme for use as a nutrient iron source. However, the toxicity of heme presents a paradox for microorganisms that satisfy their nutrient iron requirement through heme acquisition. This heme paradox is resolved through tightly regulated systems dedicated to balancing the acquisition of heme with the prevention of heme-mediated toxicity.