[Advancing therapy-oriented telemedicine- Does Europe have an answer?]. / Therapie-orientierte Telemedizin - hat Europa eine Antwort?

Despite a large number of existing telemedical applications as well as numerous issues in the current implementations, the desire for intensified integration of IT solutions for the health sector is unanimous amongst all actors involved (patients, practitioners, software and hardware developers, insurers, services, etc.). This reflects the state of digital systems in use in medicine today which have yet to arrive in the 21st century and operate well below the technologically possible. Telemedica/ methods remain mainly associated to flagship projects with often limited mid- or long termimpact on patient care practicesror scientific research. Supraregional or national standards are far from being defined. The register EUSTAR under patronage of the ESH is designed to fill gaps in the current IT solutions by utilization of the innovative software system SCITIM 0 to enable broad application of telemedicine and thereby provide evidence for its scientific and economical feasibility. For this the utilization of interventional decentralised telemonitoring (idTM 0 } is suitable as it preserves clear and direct patient practitioner bonds and communication. The fundamental measure of idTM 0 - to judge the quality of the te/emedica/ application by the medical quality of the consequent actions -is rarely considered by the majority of smaller projects where other tetemedical applications and methods are established.

Pharmacokinetics and antihypertensive effects of candesartan cilexetil in patients undergoing haemodialysis: an open-label, single-centre study.

BACKGROUND AND OBJECTIVE: In patients with endstage renal failure (ERF), activation of the renin-angiotensin-aldosterone system plays an important role in the onset and maintenance of arterial hypertension. This study aimed to elucidate the antihypertensive effect, pharmacokinetics and safety of candesartan cilexetil in patients with ERF undergoing haemodialysis. METHODS: In 14 anuric hypertensive patients undergoing haemodialysis (mean+/- SD 24-hour systolic [SBP]/diastolic [DBP] blood pressure [BP] 142.9 +/- 11.1/75.0 +/- 10.1 mmHg), 24-hour BP measurements on the second interdialysis day per week were performed at baseline and at weeks 4, 12 and 24. All patients started antihypertensive treatment with candesartan cilexetil 4 mg once daily immediately before the start of haemodialysis. Subsequently, the dose was titrated upward to 8 mg once daily until the patient's mean ambulatory BP measurement (ABPM) values were <130/80 mmHg. Plasma candesartan pharmacokinetics were investigated on days 7 and 14 after starting candesartan cilexetil treatment and after each titration step. RESULTS: After 6 months all patients demonstrated well controlled BP (ABPM mean +/- SD SBP 129.6 +/- 21.7/DBP 69.4 +/- 10.4 mmHg) and a significantly reduced pulse pressure (from a mean +/- SD 67.9 +/- 13.7 mmHg at baseline to a mean +/- SD 60.2 +/- 14.7 mmHg at 6 months), without any adverse events. Candesartan plasma concentrations increased over 3 hours followed by a continuous decline. Plasma concentrations remained stable after 7 and 14 days, independent of dosing. However, administration of candesartan cilexetil 8 mg (five patients) resulted in plasma concentrations about 1.4 times higher than those for candesartan cilexetil 4 mg. CONCLUSION: In this study with small number of patients with ERF undergoing haemodialysis, candesartan cilexetil was effective in lowering BP and pulse pressure without accumulation or associated adverse effects such as elevated potassium or symptomatic hypotension.

Impact of endothelin-1 Lys198Asn polymorphism on coronary artery disease and endorgan damage in hypertensives.

OBJECTIVE: Endothelin is the most potent endogenous vasoconstrictor and is involved in several vascular disorders such as arterial hypertension. Its intense interaction with other vasoactive hormone systems revealed the consideration about the endothelin gene as an interesting candidate for influencing the development of essential hypertension and hypertensive endorgan damage. The purpose of this study was to investigate the role of endothelin-1 Lys198Asn polymorphism in patients with severe arterial hypertension as well as associated endorgan damages. METHODS: In 400 hypertensive patients and 150 normotensive controls we examined the endothelin-1 Lys198Asn polymorphism by DNA sequencing and patients were divided according to their genotype (GG, GT, and TT). Moreover, the frequency of endothelin-1 Lys198Asn polymorphism was investigated with respect to the prevalence of several actual or historical endorgan damages (renal disorder, coronary artery disease, vascular events, vascular damage, and congestive heart failure) in hypertensive patients. RESULTS: Genotype distribution for endothelin-1 Lys198Asn polymorphism was 57.3% (GG), 41.3% (GT), and 1.43% (TT) in normotensive individuals; and in hypertensive individuals was 54.75% (GG), 43% (GT) and 2.25% (TT). Genotype distribution was unaffected in patients with severe hypertension, renal disorder, vascular events, vascular damage, and congestive heart failure. We, however, found a significant difference in hypertensive individuals with coronary artery disease and TT genotype (P=0.004). CONCLUSION: Homozygous TT carrier contributes to a higher prevalence of coronary artery disease, especially for three-vessel disease in hypertensive individuals. Thus, the polymorphism at position 198 could serve as a possibility to differentiate high-risk subgroups in the heterogeneous population of hypertensive patients.

Telemedicine: interventional decentralised blood pressure telemonitoring (idTBPM).

Telemedicine comprises different methods of bridging a spatial distance between doctor, medical and care services and patients. These include mere data transmissions as well as alarm functionalities, consultations and therapy recommendations. A special form of telemedicine application is the interventional decentralised telemonitoring (idTM). Here the patient-practitioner relationship forms the basis for therapy control and optimisation using telemetrical medical data. To identify areas of indication of idTM, a detailed definition of transferred parameters, alarm conditions and intervention algorithms is required as a well as cost efficiency and feasibility studies. The quality of the telemedical application is determined by the medical quality of the derived actions.

[Interventional decentralized telemonitoring: possible indications and perspectives of a new method in telemedicine]. / Interventionelles dezentrales Telemonitoring: Mögliche Indikationen und Perspektiven einer neuen Methode in der Telemedizin.

Telemedicine comprises different concepts aiming to close a spatial distance between practitioner, medical staff and patient. Its functionality can include mere data transmission but extend as well to triggering alarms or enable consultation and therapy suggestions. A special form of telemedicinal application is interventional decentralized telemonitoring. Here practitioner-patient communication is characterized by telemedicinal data collection driven therapy-control and -optimization. To identify feasible indications for the employment of telemonitoring a detailed definition of communicated parameters, alarm rules and algorithms of intervention are required as well as a benefit-cost analysis. The quality of the telemedical application is determined by the medical quality of the resulting actions.

La télémédecine comprend différents concepts visant à supprimer la distance spatiale entre le praticien, le personnel médical et le patient. C'est une fonctionnalité qui peut inclure une simple transmission de données, mais s'étendre aussi bien au déclenchement d'alarmes ou permettre une consultation et des suggestions thérapeutiques. Une forme particulière d'application de la télémedicinal est la télésurveillance décentralisée interventionnelle. Ici, la communication médecin-patient est caractérisée par la collecte de données qui permettent du contrôler et d'optimiser le traitement. Pour identifier les indications possibles de la télésurveillance une définition détaillée des paramètres communiqués, les règles d'alarme et des algorithmes d'intervention sont nécessaires, ainsi qu'une analyse coûts-bénéfices. La qualité de l'application de la télémédecine est déterminée par la qualité médicale des actions qui en découlent.

Hemodynamic effects of peri-operative statin therapy in on-pump cardiac surgery patients.

BACKGROUND: Peri-operative statin therapy in cardiac surgery cases is reported to reduce the rate of mortality, stroke, postoperative atrial fibrillation, and systemic inflammation. Systemic inflammation could affect the hemodynamic parameters and stability. We set out to study the effect of statin therapy on perioperative hemodynamic parameters and its clinical outcome. METHODS: In a single center study from 2006 to 2007, peri-operative hemodynamic parameters of 478 patients, who underwent cardiac surgery with cardiopulmonary bypass, were measured. Patients were divided into those who received perioperative statin therapy (n = 276; statin group) and those who did not receive statin therapy (n = 202; no-statin group). The two groups were compared together using Kolmogorov-Smirnov-Test, Fisher's-Exact-Test, and Student's-T-test. A p value < 0.05 was considered as significant. RESULTS: There was no significant difference in the preoperative risk factors. Onset of postoperative atrial fibrillation was not affected by statin therapy. Extended hemodynamic measurements revealed no significant difference between the two groups, apart from Systemic Vascular Resistance Index (SVRI). The no-statin group had a significantly higher SVRI (882 ± 206 vs. 1050 ± 501 dyn s/cm5/m2, p = 0.022). Inotropic support was the same in both groups and no significant difference in the mortality rate was noticed. Also, hemodynamic parameters were not affected by different types and doses of statins. CONCLUSIONS: Perioperative statin therapy for patients undergoing on-pump coronary bypass grafting or valvular surgery, does not affect the hemodynamic parameters and its clinical outcome.

The eNOS 786C/T polymorphism in cardiac surgical patients with cardiopulmonary bypass is associated with renal dysfunction.

OBJECTIVE: Renal dysfunction is one of the most serious complications following cardiac surgery with cardiopulmonary bypass. The causes of renal dysfunction following cardiac surgery are poorly understood. We hypothesised that T-786C endothelial NO synthase (eNOS) polymorphism may lead to an increase in the occurrence of postoperative renal dysfunction following cardiac surgery with cardiopulmonary bypass. METHODS: A total of 497 patients undergoing cardiac surgery with cardiopulmonary bypass were included in the study. The T-786C eNOS polymorphism was detected by a polymerase chain reaction. The patients were grouped on the basis of whether they were homozygous or heterozygous for the C allele (TC+CC; n=289) or only homozygous for the T allele (TT; n=208). RESULTS: No significance was demonstrated in the preoperative risk factors, with the exclusion of smoking habits (p=0.04) for the C-allele carrier. The administration of anti-lipid agents (p=0.01) and anti-arrhythmics (p=0.01) was significantly lower in the TC/CC group. The TC+CC genotype group had a significantly greater decrease in creatine clearance (p=0.024), the lowest creatine clearance (p=0.004) and more C-allele carriers received acute renal replacement therapy (p=0.04). The usage of norepinephrine (p=0.02) and dobutamine (p=0.02) was significantly higher in C-allele carriers. In the TC+CC genotype group, cross-clamp time (p=0.02) and administration of red cell transfusion (p=0.04) achieved statistically significant difference. The overall in-hospital mortality rate was 8.2% for all patients and was not significant between genotypes. CONCLUSIONS: The present findings support the hypothesis that the T-786C eNOS polymorphism may play a role in the development of renal dysfunction and increase the occurrence of renal replacement therapy following cardiac surgery with cardiopulmonary bypass. This polymorphism may be useful in stratifying the risk for the development of postoperative renal dysfunction.