Turning Data Into Information: Opportunities to Advance Rehabilitation Quality,Research, and Policy

Attention to health care quality and safety has increased dramatically. The internal focus of an organization is not without influence from external policy and research findings. Compared with other specialties, efforts to align and advance rehabilitation research, practice, and policy using electronic health record data are in the early stages. This special communication defines quality, applies the dimensions of quality to rehabilitation, and illustrates the feasibility and utility of electronic health record data for research on rehabilitation care quality and outcomes. Using data generated at the point of care provides the greatest opportunity for improving the quality of health care, producing generalizable evidence to inform policy and practice, and ultimately benefiting the health of the populations served.     

Myocardial scintigraphy correlates poorly with coronary angiography in the screening of transplant arteriosclerosis

BACKGROUND: Coronary angiography remains an important screening tool for transplant coronary arteriosclerosis (TxCAD) after heart transplantation despite criticism that it underestimates the incidence of TxCAD. In an effort to improve TxCAD incidence estimation, several methods of screening have been proposed. In the present study, the incidence of TxCAD assessed by both yearly coronary angiography and stress myocardial scintigraphy imaging was reviewed. PATIENTS AND METHODS: Ninety-nine consecutive primary heart transplantations were performed from 1988 to 1999. The standard immunosuppression protocol consisted of the introduction of antilymphocyte globulin and steroids, while maintenance therapy was with cyclosporine, imuran and steroids. Coronary angiography and a stress 2-methoxyisobutyl-isonitrile perfusion scan were performed yearly. TxCAD was defined by angiographic evidence of luminal abnormality by catheterization, or a perfusion abnormality at rest or after stress on myocardial scintigraphy. RESULTS: The mean recipient age was 49+/-12 years and the mean donor age was 33+/-13 years. The etiology of heart failure was ischemic cardiomyopathy (50%), dilated cardiomyopathy (41%) and congenital heart disease (9%). The freedom from angiographic TxCAD was 92% at one year, 64% at five years and 35% at eight years. The freedom from nuclear imaging TxCAD was 92% at one year, 69% at five years and 44% at eight years. However, a diagnosis of TxCAD by angiography only correlated with a diagnosis of TxCAD by nuclear imaging 52.8% of the time in the same patient, with a median time between studies of one month. CONCLUSION: The overall incidence of TxCAD diagnosed by angiography and nuclear imaging appears similar but correlates poorly in patients, casting doubt on the routine use of myocardial scintigraphy for screening TxCAD.     

The human JC polyomavirus (JCPyV): virological background and clinical implications

JC polyomavirus (JCPyV) was the first of now 12 PyVs detected in humans, when in 1964, PyV particles were revealed by electron microscopy in progressive multifocal leukoencephalopathy (PML) tissues. JCPyV infection is common in 35–70% of the general population, and the virus thereafter persists in the renourinary tract. One third of healthy adults asymptomatically shed JCPyV at approximately 50 000 copies/mL urine. PML is rare having an incidence of <0.3 per 100 000 person years in the general population. This increased to 2.4 per 1000 person years in HIV‐AIDS patients without combination antiretroviral therapy (cART). Recently, PML emerged in multiple sclerosis patients treated with natalizumab to 2.13 cases per 1000 patients. Natalizumab blocks α4‐integrin‐dependent lymphocyte homing to the brain suggesting that not the overall cellular immunodeficiency but local failure of brain immune surveillance is a pivotal factor for PML. Recovering JCPyV‐specific immune control, e.g., by starting cART or discontinuing natalizumab, significantly improves PML survival, but is challenged by the immune reconstitution inflammatory syndrome. Important steps of PML pathogenesis are undefined, and antiviral therapies are lacking. New clues might come from molecular and functional profiling of JCPyV and PML pathology and comparison with other replicative pathologies such as granule cell neuronopathy and (meningo‐)encephalitis, and non‐replicative JCPyV pathology possibly contributing to some malignancies. Given the increasing number of immunologically vulnerable patients, a critical reappraisal of JCPyV infection, replication and disease seems warranted.     

Potenzial und Wirksamkeit eines telemedizinischen Rettungsassistenzsystems

Background

The demographic change and an increasing multimorbidity of patients represent increasing challenges for the adequate prehospital treatment of emergency patients. The incorporation of supplementary telemedical concepts and systems can lead to an improved guideline-conform treatment. Beneficial evidence of telemedical procedures is only known for isolated disease patterns; however, no mobile telemedical concept exists which is suitable for use in the wide variety of different clinical situations.

Aim

This article presents a newly developed and evaluated total telemedical concept (TemRas) that encompasses organizational, medical and technical components. The use of intelligent and robust communication technology and the implementation of this add-on system allows the telemedical support of the rescue service for all emergencies.

Methods

After development of the telemedical rescue assistance system, which includes organizational, medical and technical components, a telemedical centre and six ambulances in five different districts in North-Rhine Westphalia were equipped with this new tool. During the evaluation phase of 1 year in the routine emergency medical service the rate of complications as well as differences between urban and rural areas were analyzed with respect to different target parameters.

Results

Between August 2012 and July 2013 a total of 401 teleconsultations were performed during emergency missions and 24 during secondary interhospital transfers. No complications due to teleconsultation were observed. The mean duration (±SD) of teleconsultations was longer in rural areas than in urban areas with 28.6±12.0?min vs. 25.5±11.1?min (p?<?0.0001). In 63.2?% of these missions administration of medications was delegated to the ambulance personnel (52.0?% urban vs. 73.6?% rural, p?<?0.0001). The severity of ailments corresponded to scores of III and VI in the National Advisory Committee for Aeronautics (NACA) classification.

Conclusion

Emergency medical care of patients with support by a telemedical system is technically feasible, safe for the patient and allows medical treatment independent of spatial availability of a physician in different emergency situations.