Integrating telehealth technology into a clinical pharmacy telephonic diabetes management program

Background

Use of home monitoring technologies can enhance care coordination and improve clinical outcomes in patients with diabetes and other chronic diseases. This study was designed to explore the feasibility of incorporating a telehealth system into an existing telephonic diabetes management program utilizing clinical pharmacists.

Methods

This observational study was conducted at three Providence Medical Group primary care clinics. Adults with a diagnosis of diabetes and a recent hemoglobin A1c (HbA1c) >8% were referred by their primary care provider to participate in the study. Participants utilized the telehealth system developed by Intel Corporation and were followed by clinical pharmacists who provide telephonic diabetes management. The primary clinical outcome measure was change in mean HbA1c. Secondary outcomes included blood glucose levels, participant self-management knowledge, and the degree of participant engagement.

Results

Mean HbA1c level decreased by 1.3% at the study end (p = .001). Based on participant satisfaction surveys and qualitative responses, participants were satisfied with the telehealth system. Mean blood glucose values decreased significantly over the 16-week study period from 178 mg/dl [standard deviation (SD) 67] at week 1 to 163 mg/dl (SD 64) at week 16 (p = .0002). Participants entered the study with moderate to good knowledge about managing their diabetes based on three questions, and no statistically significant improvement in knowledge was found post-study.

Conclusion

Telehealth technology can be a positive adjunct to the primary care team in managing diabetes or other chronic conditions to improve clinical outcomes.     

Use of multi-modality intraoperative monitoring during carotid endarterectomy surgery: a case study

Carotid artery stenosis is a major risk factor leading to cerebral infarct, transient ischemic attack (TIA), and ischemic stroke in the United States. While carotid endarterectomy (CEA) surgery has been established as an effective treatment option for severe carotid artery stenosis, many risks remain inherent in performing this procedure. Surgeons will often utilize various intraoperative monitoring techniques in an effort to reduce surgical complications and morbidity. The usefulness of continuous EEG and somatosensory evoked potential (SSEP) monitoring during CEA surgery has been examined by many groups over the last couple decades. The following case review clearly proves that such monitoring is an effective tool in the detection of cerebral ischemic changes and is therefore feasible in CEA surgery.     

Anemia in frailty

Although anemia is regarded as a relatively common occurrence in older adults, the vigor with which the medical community should intervene to correct this common problem is disputed. Epidemiologic data clearly correlate anemia with functional decline, disability, and mortality. Anemia may contribute to functional decline by restricting oxygen delivery to muscle, or to cognitive decline by restricting oxygen delivery to the brain. On the other hand, the erythron may be a separate target of the same biologic mediators that influence deterioration of physiologic systems that contribute to weakness, functional and cognitive decline, and mortality. Clinical trials aimed at treating anemia in older adults could assess whether physical performance is improved or whether mortality risk declines with improved hemoglobin, but sufficient evidence from such trials is currently lacking. With few guidelines regarding treatment of older adults and significant risk for adverse events associated with transfusion and erythroid stimulating agents, anemia often goes untreated or ignored in geriatric clinics. This article reviews the problem of anemia in older adults, with a particular emphasis on the frail elderly. The gaps in the evidence base for the treatment of anemia in older adults are reviewed and the options for advancing the field are assessed.     

Comparison of epicardial potential maps derived from the 12-lead electrocardiograms with scintigraphic images during controlled myocardial ischemia

Our aim was to cross-validate electrocardiographic (ECG) and scintigraphic imaging of acute myocardial ischemia. The former method was based on inverse calculation of heart-surface potentials from the body-surface ECGs, and the latter, on a single photon emission computed tomography (SPECT). A boundary-element torso model with 352 body-surface and 202 heart-surface nodes was used to perform the ECG inverse solution. Potentials at 352 body-surface nodes were calculated from those acquired at 12-lead ECG measurement sites using regression coefficients developed from a design set (n = 892) of body-surface potential mapping (BSPM) data. The test set (n = 18) consisted of BSPM data from patients who underwent a balloon-inflation angioplasty of either the left anterior descending coronary artery (LAD) (n = 7), left circumflex coronary artery (LCx) (n = 2), or the right coronary artery (RCA) (n = 9). Body-surface potential mapping distributions at J point for 352 nodes were estimated from the 12-lead ECG, and an agreement with those estimated from 120 leads was assessed by a correlation coefficient (CC) (in percent). These estimates yielded very similar BSPM distributions, with a CC of 91.0% ± 8.1% (mean ± SD) for the entire test set and 94.1% ± 1.4%, 96.7% ± 0.8%, and 87.4% ± 10.3% for LAD, LCx, and RCA subgroups, respectively. Corresponding heart-surface potential distributions obtained by inverse solution correlated with a lower CC of 69.3% ± 18.0% overall and 73.7% ± 10.8%, 84.7% ± 1.1%, and 62.6% ± 21.8%, respectively, for subgroups. Bull's-eye displays of heart-surface potentials calculated from estimated BSPM distributions had an area of positive potentials that qualitatively corresponded, in general, with the underperfused territory suggested by SPECT images. For the LAD and LCx groups, all 9 ECG-derived bull's-eye images indicated the expected territory; for the RCA group, 6 of 9 ECG-derived images were as expected; 2 of 3 misclassified cases had very small ECG changes in response to coronary-artery occlusion, and their SPECT images showed indiscernible patterns. In conclusion, our findings demonstrate that noninvasive ECG imaging based on just the 12-lead ECG might provide useful estimates of the regions of myocardial ischemia that agree with those provided by scintigraphic techniques.