Predicting coronary heart disease after kidney transplantation: Patient Outcomes in Renal Transplantation (PORT) Study.

Traditional risk factors do not adequately explain coronary heart disease (CHD) risk after kidney transplantation. We used a large, multicenter database to compare traditional and nontraditional CHD risk factors, and to develop risk-prediction equations for kidney transplant patients in standard clinical practice. We retrospectively assessed risk factors for CHD (acute myocardial infarction, coronary artery revascularization or sudden death) in 23,575 adult kidney transplant patients from 14 transplant centers worldwide. The CHD cumulative incidence was 3.1%, 5.2% and 7.6%, at 1, 3 and 5 years posttransplant, respectively. In separate Cox proportional hazards analyses of CHD in the first posttransplant year (predicted at time of transplant), and predicted within 3 years after a clinic visit occurring in posttransplant years 1-5, important risk factors included pretransplant diabetes, new onset posttransplant diabetes, prior pre- and posttransplant cardiovascular disease events, estimated glomerular filtration rate, delayed graft function, acute rejection, age, sex, race and duration of pretransplant end-stage kidney disease. The risk-prediction equations performed well, with the time-dependent c-statistic greater than 0.75. Traditional risk factors (e.g. hypertension, dyslipidemia and cigarette smoking) added little additional predictive value. Thus, transplant-related risk factors, particularly those linked to graft function, explain much of the variation in CHD after kidney transplantation.

The geography of kidney transplantation in the United States.

The distance kidney transplant patients live from the centers where they undergo transplantation could affect long-term care and outcomes, but little is known about this distance and its associations. We used data from the United States Renal Data System to examine distance between home and transplant center for 92 224 adults undergoing kidney transplantation in 1995-2003. The 5th, 25th, 50th, 75th and 95th percentiles for distances were 2.4, 8.4, 23.0, 67.3 and 213.7 miles, respectively. Compared to whites (median distance 28.5 miles), African Americans (11.5 miles) and Asians (13.5 miles) lived closer to their centers, while Native Americans lived farther away (90.1 miles). Hispanics lived closer (14.7 miles) than non-Hispanics (24.3 miles). Even after adjusting for center density, we found substantial regional variability, with median distance of 15.1 miles for patients living in the Northeast and 40.6 miles for those in the Southeast. Distance was also associated with center size, median zip code income, listing on more than one deceased-donor waiting list and other factors, but greater distance (adjusted for these other factors) was not associated with worse patient or graft survival. The substantial variability in geographical access to kidney transplantation could have important implications for long-term care.

TELEMAM: a cluster randomised trial to assess the use of telemedicine in multi-disciplinary breast cancer decision making.

AIM: The TELEMAM trial aimed to assess the clinical effectiveness and costs of telemedicine in conducting breast cancer multi-disciplinary meetings (MDTs). METHODS: Over 12 months 473 MDT patient discussions in two district general hospitals (DGHs) were cluster randomised (2:1) to the intervention of telemedicine linkage to breast specialists in a cancer centre or to the control group of 'in-person' meetings. Primary endpoints were clinical effectiveness and costs. Economic analysis was based on a cost-minimisation approach. RESULTS: Levels of agreement of MDT members on a scale from 1 to 5 were high and similar in both the telemedicine and standard meetings for decision sharing (4.04 versus 4.17), consensus (4.06 versus 4.20) and confidence in the decision (4.16 versus 4.07). The threshold at which the telemedicine meetings became cheaper than standard MDTs was approximately 40 meetings per year. CONCLUSION: Telemedicine delivered breast cancer multi-disciplinary meetings have similar clinical effectiveness to standard 'in-person' meetings.

A comprehensive approach for evaluating telemedicine-delivered multidisciplinary breast cancer meetings in southern Scotland.

Multidisciplinary team (MDT) meetings for decisions on cancer management are a cornerstone of UK cancer policy. We have proposed a comprehensive methodology to assess the clinical and economic effectiveness of telemedicine in this setting, which is being tested in a randomized breast cancer trial. Pre- and post-telemedicine assessment includes attitudes to and expectations of telemedicine, based on semistructured interviews. The communication content of videotapes of the MDT meeting is being scored using Borgatta's revised Interaction Process Analysis System. The technical performance of the telemedicine equipment is reported on a standardized pro forma. A short questionnaire captures key elements of professional satisfaction for each patient discussion (consensus on future management, confidence in and sharing of decision), added value of linkage, group atmosphere, overall conduct of the meeting and compliance with SIGN guidelines. A cost-minimization analysis will be used for economic assessment.

Attitudes of breast cancer professionals to conventional and telemedicine-delivered multidisciplinary breast meetings.

We surveyed the attitudes of breast cancer professionals to standard face-to-face and future telemedicine-delivered breast multidisciplinary team (MDT) meetings. Interviews, which included the Group Behaviour Inventory, were conducted face-to-face (n = 19) or by telephone (n = 26). The mean total score on the Group Behaviour Inventory was 96 (SD 19) for 33 respondents, which indicated satisfaction with standard MDT meetings, irrespective of role and base hospital. Positive attitudes to videoconferencing were more common among participants with previous experience of telemedicine (Spearman's rank correlation 0.26, P = 0.91). Common themes emerging from the interviews about telemedicine-delivered MDTs included group leadership, meeting efficiency, group interaction, group atmosphere and technical quality of communication. Most participants were satisfied with standard breast MDTs. Nurses and allied health professionals were least supportive of telemedicine.

Assessment of health-related quality of life.

In addition to mortality, morbidity, and patient satisfaction, health-related quality of life (HRQOL) is an outcome of health care as well as a consequence of illness or injury. Consequently, instruments to assess HRQOL have become important outcome measures for the evaluation of health care. The last 2 decades have seen the development of hundreds of HRQOL instruments, which are increasingly being incorporated in clinical trials. However, for HRQOL instruments to be valid outcome measures, a variety of factors must be addressed, including conceptual and methodological issues. In addition, there must be careful selection and thoughtful administration. The present report discusses these issues in addition to the scoring and interpretation considerations for the valid assessment of HRQOL. We provide an overview of generic, disease-specific, and utility measures. Using disease-specific instruments pertinent to respiratory care, we discuss their validity, reliability, responsiveness, and minimum clinically important difference. We conclude with recommendations regarding which HRQOL tools have documented evidence that they are psychometrically sound for application to research and clinical practice in respiratory care.

The diagnostic acceptability of low-bandwidth transmission for tele-ultrasound.

Ultrasound recordings were made of 100 consecutive patients attending for obstetric examination in Peterhead and 100 patients attending for non-obstetric examination in Aberdeen. Two identical video-conferencing machines were used to transmit and receive the original ultrasound images at data rates of 384 kbit/s and 128 kbit/s, thus producing a total of three tapes for each case. Four experienced observers, who were blinded to the transmission bandwidth, each viewed 300 examinations and decided whether the images were acceptable or not for diagnosis. Almost 100% of the obstetric ultrasound images on the original recordings were considered diagnostically acceptable, compared with 93% of the 384 kbit/s transmissions and 44% of the 128 kbit/s transmissions. Similarly, 99% of the non-obstetric ultrasound images were considered acceptable, compared with 87% of the 384 kbit/s transmissions and 21% of the 128 kbit/s transmissions. For the obstetric ultrasound images the intra-observer diagnostic agreement was 93% (kappa = 0.89) between the original and the 384 kbit/s transmissions, and 78% (kappa = 0.63) between the original and the 128 kbit/s transmissions. For the non-obstetric ultrasound images the respective intra-observer diagnostic agreements were 77% (kappa = 0.62) and 78% (kappa = 0.63). The quality of dynamic ultrasound images transmitted at 384 kbit/s was diagnostically acceptable, but was unsatisfactory at 128 kbit/s.

A healthy community through health system partnerships: the approach of Markham Stouffville Hospital.

The structure of the Canadian healthcare system, particularly in Ontario, has remained remarkably stable over the past 25 years. No other private sector industry employing hundreds of thousands of people, spending tens of billions of dollars annually and serving millions of consumers every day has survived for 30 years without the need to reinvent itself in quite fundamental ways. How then has the healthcare sector in Canada avoided the pressure to "reinvent itself?"

The diagnostic performance of a PC-based teleradiology link.

AIM: Evaluation of the diagnostic performance of a personal computer based teleradiology link. MATERIALS AND METHODS: Two experienced radiologists assessed 100 cases, all based on chest and skeletal films using teleradiology for 50. These assessments were compared with the consensus of a panel of three independent radiologists. RESULTS: Diagnostic performance of teleradiology and conventional film was similar (sensitivity 88 vs. 90%; specificity 96 vs. 90%; accuracy 91 vs. 90%; not significant). However, the quality of teleradiology images was rated poorer, and the confidence in diagnosis was lower with teleradiology. ROC curve analysis, taking into account diagnostic confidence, showed significantly poorer performance for teleradiology at all thresholds when chest X-rays only were considered. There was no significant difference for skeletal images, although the two smooth curves crossed, suggesting teleradiology might be better when the specificity is high. CONCLUSION: These findings suggest that when this type of teleradiology system is used, the value of rapid reporting must be balanced against poorer image quality, particularly for chest X-rays.

Low-bandwidth tele-ultrasound.

We examined the acceptability and diagnostic accuracy of dynamic ultrasound images transmitted at 128 kbit/s and 384 kbit/s. The gold standard was the direct recording of 200 ultrasound examinations on video-tape. The taped images were later transmitted at both 128 kbit/s and 384 kbit/s and recorded, resulting in three tapes for each case. Four observers viewed each tape individually. Ninety per cent of images transmitted at 384 kbit/s were rated as diagnostically acceptable compared with 32% of images transmitted at 128 kbit/s. Diagnostic agreement between tapes transmitted at 384 kbit/s and the gold standard was 85%, compared with 78% for 128 kbit/s transmissions. Observers were not satisfied with low-bandwidth transmission of ultrasound images despite adequate diagnostic accuracy. Dynamic ultrasound images transmitted at 384 kbit/s were viewed as both diagnostically acceptable and accurate.

Factors that may influence the implementation of nurse-centred telemedicine services.

A qualitative study of four UK telemedicine sites was carried out to explore reactions to nurse-centred telemedicine services and their possible implications. Using semistructured schedules, 36 people directly involved in these services were interviewed--25 nurses, four general practitioners, two advising medical consultants, three service managers and two researchers. Factors identified which may influence successful implementation included: early involvement of all groups affected, prior consideration of the practical implications, thorough initial equipment testing, good technical support, imaginative training and clarity of the purpose of the service. The study showed that all those involved must be prepared for the rapid learning that is implicit in the implementation of change. The challenge is to maximize the potential for the primary operator to use new techniques. In respect of nurse-centred services, the nurse must not be viewed as a technician, nor should telemedicine be seen as a substitute for an available doctor.

A review of Scottish telemedicine.

Telemedicine services have been provided from Scotland for many years. Initial activities centred on the provision of health care to workers on the oil installations in the North Sea, to mixed-gas divers supporting the oil industry, and to scientific staff in British Antarctic Territory. Other Scottish research work has contributed to space medicine. The remote location of much of the Scottish population is currently the reason for much telemedicine research. This paper reviews the past quarter of a century of telemedicine in Scotland and identifies the principles that have led to success in some challenging locations. The same principles can be expected to apply when telemedicine services are provided more generally.

Design of a clinical data-collection form for remote health care.

A clinical data-collection form was designed for use in the consultation process between an astronaut and Earth. It can also be applied in most remote health-care settings. The form was tested by non-medically trained individuals in 101 simulated and 19 real cases. A completion rate of 88% was achieved, with a diagnostic accuracy of 85%. This compares favourably with studies by other workers in the field of medical decision support. Space telemedicine research will contribute to developments that will benefit not only space activities but also terrestrial applications.

The Grant syndrome. Persistent Wormian bones, blue sclerae, mandibular hypoplasia, shallow glenoid fossae and campomelia--an autosomal dominant trait.

A father and daughter with apparently unique clinical findings are described. The findings include persistent Wormian bones, blue sclerae, mandibular hypoplasia, shallow glenoid fossae and campomelia. Apparently it is an autosomal dominant trait. Although the disorder is in the osteogenesis imperfecta group, nevertheless it appears to be different and until the basic defect is found we have named it "The Grant Syndrome".