A New Day: The Role of Telemedicine in Reshaping Care for Persons With Movement Disorders.

The COVID-19 pandemic has demonstrated the fragility of clinic-based care for Parkinson's disease and other movement disorders. In response to the virus, many clinics across the world abruptly closed their doors to persons with Parkinson's disease. Fortunately, a niche care model, telemedicine-first described in this journal a generation ago-emerged as the dominant means of providing care. As we adjust to a new normal, we should focus future care not on clinics but on patients. Their needs, guided by clinicians, should determine how care is delivered, whether in the clinic, at home, remotely, or by some combination. Within this patient-centered approach, telemedicine is an attractive care option but not a complete replacement for in-person consultations, which are valuable for specific problems and for those who have access. Now that many clinicians and patients have gained exposure to telemedicine, we can better appreciate its advantages (eg, convenience) and disadvantages (eg, restricted examination). We can also create a new future that utilizes the Internet, video conferencing, smartphones, and sensors. This future will bring many clinicians to one patient, connect individual experts to countless patients, use widely available devices to facilitate diagnosis, and apply novel technologies to measure the disease in new ways. These approaches, which extend to education and research, enable a future where we can care for anyone anywhere and will help us stem the tide of Parkinson's disease. © 2020 International Parkinson and Movement Disorder Society.

Past, Present and Future of Home video-electroencephalographic telemetry: A review of the development of in-home video-electroencephalographic recordings.

Video-electroencephalographic (EEG) monitoring is an essential tool in epileptology, conventionally carried out in a hospital epilepsy monitoring unit. Due to high costs and long waiting times for hospital admission, coupled with technological advances, several centers have developed and implemented video-EEG monitoring in the patient's home (home video-EEG telemetry [HVET]). Here, we review the history and current status of three general approaches to HVET: (1) supervised HVET, which entails setting up video-EEG in the patient's home with daily visiting technologist support; (2) mobile HVET (also termed ambulatory video-EEG), which entails attaching electrodes in a health care facility, supplying the patient and carers with the hardware and instructions, and then asking the patient and carer to set up recording at home without technologist support; and (3) cloud-based HVET, which adds to either of the previous models continuous streaming of video-EEG from the home to the health care provider, with the option to review data in near real time, troubleshoot hardware remotely, and interact remotely with the patient. Our experience shows that HVET can be highly cost-effective and is well received by patients. We note limitations related to long-term electrode attachment and correct camera placing while the patient is unsupervised at home, and concerns related to regulations regarding data privacy for cloud services. We believe that HVET opens significant new opportunities for research, especially in the field of understanding the many influences in seizure occurrence. We speculate that in the future HVET may merge into innovative new multisensor approaches to continuously monitoring people with epilepsy.

Technological advances in home non-invasive ventilation monitoring: Reliability of data and effect on patient outcomes.

Home non-invasive mechanical ventilation (NIV) has become a well-established treatment for patients with chronic hypercapnic respiratory failure. NIV monitoring has been developed to evaluate the effectiveness of mechanical ventilation on patient outcomes, with built-in systems providing data on compliance, leaks and respiratory parameters. Although these data seem intuitively useful, two main concerns have been raised in the literature: (i) are they reliable and (ii) to what extent does their use improve patient outcomes. These two concerns are currently relevant since the very recent development of telemonitoring provides the possibility of adjusting ventilator settings remotely, based on the longitudinal assessment of NIV parameters and respiratory variables provided by the system. This may influence the future management strategies of health organizations for patients under home NIV. This narrative review describes technological advances in patient monitoring using home mechanical ventilation with a main focus on data provided by built-in NIV monitoring systems. The use of these systems is discussed, including their advantages and limitations in different clinical situations, and perspectives for long-term patient monitoring are discussed.

A Review of Implant Communication Technology in WBAN: Progress and Challenges.

Over the past six decades, there has been tremendous progress made in the field of medical implant communications. A comprehensive review of the progress, current state of the art, and future direction is presented in this paper. Implanted medical devices (IMDs) are designed mainly for the purpose of diagnostic, therapeutic, and assistive applications in heathcare, active living, and sports technology. The primary target of IMDs' design revolves around reliable communications, sustainable power sources, and a high degree of miniaturization while maintaining biocompatibility to surrounding tissues adhering to the human safety limits set by appropriate guidelines. The role of the Internet of Things and intelligent data analysis in implant device networks as future research is presented in this paper. Finally, in addition to reviewing the state of the art, a novel intuitive lower bound on implant size is presented.

Long-term reliability of the telemetric Neurovent-P-tel sensor: in vivo case report.

Intracranial pressure (ICP) measurements are imperative for the proper diagnosis and treatment of several neurological disorders. Telemetric sensors have shown their utility for ICP estimation in short-term monitoring in humans. However, their long-term reliability is uncertain. The authors present the case of a 37-year-old woman diagnosed with benign intracranial hypertension and obesity. The patient underwent gastric bypass surgery for ICP control. In order to monitor ICP before and after bariatric surgery, a Neurovent-P-tel sensor was implanted in the left frontal lobe. After gastric bypass, normal ICP values were recorded, and the patient's visual fields improved. However, the patient experienced incapacitating daily headaches. The authors decided to implant a Codman Microsensor ICP transducer in the right frontal lobe to assess the long-term reliability of the Neurovent-P-tel measurements. A comparison of the recordings at 24 and 48 hours showed good correlation and reliability during long-term monitoring with the Neurovent-P-tel, with minimal zero drift after 11 months of implantation.

Delayed pacemaker requirement after transcatheter aortic valve implantation with a new-generation balloon expandable valve: Should we monitor longer?

OBJECTIVES: To analyze the timing of appearance of conduction abnormalities (CAs) after transcatheter aortic valve implantation (TAVI), to identify predictors of delayed CAs requiring pacemaker (PM) implantation and to provide guidance regarding the duration of telemetry monitoring. BACKGROUND: How long patients remain at risk of development of CAs requiring PM implantation after TAVI and for how long they should be monitored remains unclear but is crucial when considering early discharge. METHODS: Development of CAs was studied in 701 consecutive patients treated with Edwards Sapien 3 valves and monitored with telemetry for 7 days in a single center. After excluding valve-in-valve procedures and patients with previous PM, 606 patients remained for analysis. Predictors of CAs requiring PM and the time of onset of CAs were analyzed. RESULTS: Of 606 patients 76 (12.5%) required a PM after TAVI. CAs requiring PM implantation occurred after 48 h in 22.4% (17 patients) and in 10.5% (8 patients) even after 5 days. Of the patients who developed high grade CAs requiring PM after 48 h, 47.1% had no CAs prior to TAVI, and 23.5% had neither pre-existing CAs nor new-developed CAs within the first 48 h after TAVI. CONCLUSION: After TAVI using a new-generation balloon-expandable valve, delayed development of CAs requiring PM implantation is not uncommon, even after 5 days. More importantly, 23.5% of patients eventually requiring a delayed PM implantation had still no CAs at 48 h after TAVI in this study. These results question the safety of early discharge and support ECG monitoring for a longer time period. The most optimal way to monitor these patients is yet to be determined.

Future of Smart Cardiovascular Implants.

Cardiovascular disease remains the leading cause of death in Western society. Recent technological advances have opened the opportunity of developing new and innovative smart stent devices that have advanced electrical properties that can improve diagnosis and even treatment of previously intractable conditions, such as central line access failure, atherosclerosis and reporting on vascular grafts for renal dialysis. Here we review the latest advances in the field of cardiovascular medical implants, providing a broad overview of the application of their use in the context of cardiovascular disease rather than an in-depth analysis of the current state of the art. We cover their powering, communication and the challenges faced in their fabrication. We focus specifically on those devices required to maintain vascular access such as ones used to treat arterial disease, a major source of heart attacks and strokes. We look forward to advances in these technologies in the future and their implementation to improve the human condition.

A new telemetry-based system for assessing cardiovascular function in group-housed large animals. Taking the 3Rs to a new level with the evaluation of remote measurement via cloud data transmission.

INTRODUCTION: A newly developed total implant telemetry system for cardiovascular (CV), electrophysiological and body temperature measurement was evaluated. A cloud-based transmission of the physiological signals allowed an assessment of the quality of the physiological signals despite the physical separation between the instrumented animals and the evaluating home laboratory. The new system is intended to be used for safety pharmacological evaluations of drug candidates in various species. METHODS: Two female minipigs, 6 Labrador-mixed breed dogs and 4 female Cynomolgus monkeys were instrumented with a newly developed total implant system (TSE SYSTEMS). The implants feature a microprocessor, internal memory (1 GB), 2 solid state pressure-tipped catheters, amplifiers and a radio transmitter. Sampling rates for each measurement can be selected within a range between 0.1 and 1 kHz. Biological signals are selected in a programmable fashion on a session-by-session basis according to a user-defined protocol. The pressure sensors are at the tip of an electrical lead having a length customized to each species. Core temperature measurement and activity monitoring (3D accelerometer) are included in the system. Digital transmission range using a single antenna is 5 m with up to 16 animals held together and monitored simultaneously. The range can be expanded with more antennas in an array coupled to a single receiver. The antenna/receiver station consists of a single USB powered mobile unit connected to a PC or laptop. The battery life provides 110 days of continuous recording. The dogs and minipigs were instrumented and monitored in Germany. A novel cloud-based data transmission system was developed to monitor the physiological signals in real-time from the Cynomolgus monkeys, still kept in Mauritius, from the data evaluation laboratory in Germany. After recovery from the surgical implantation, aortic pressure (AP), left ventricular pressure (LVP), ECG and body temperature were recorded for 24 hr monitoring sessions in all animals. Additionally, moxifloxacin (10, 30 and 100 mg/kg) was tested in the dog model using a modified Latin square cross-over study design. RESULTS: The implant was well tolerated and the animals recovered rapidly from the implantation procedure. Excellent signal quality was obtained and stable hemodynamic and electrophysiological parameters could be measured, with little signal artefact or drop-out, over 24 h in each species. After oral dosing of moxifloxacin to the dogs, a substantial, dose-dependent increase in the QT-interval duration could be shown, as anticipated for this agent. Cloud-based data acquisition from the animals in Mauritius and the data evaluation lab in Germany worked well. CONCLUSION: This new CV telemetry system provides a novel alternative to fluid-filled catheter telemetry systems and the coupling to a cloud-based data transmission allows for flexibility in the location of the instrumented animals and data acquisition and the location of the site for data analysis. For the first time it is technically feasible to conduct a CV safety pharmacology study in Cynomolgus monkeys without having to ship them long distances to the home laboratory.

Adaptive quantization of local field potentials for wireless implants in freely moving animals: an open-source neural recording device.

OBJECTIVE: Modern neuroscience research requires electrophysiological recording of local field potentials (LFPs) in moving animals. Wireless transmission has the advantage of removing the wires between the animal and the recording equipment but is hampered by the large number of data to be sent at a relatively high rate. APPROACH: To reduce transmission bandwidth, we propose an encoder/decoder scheme based on adaptive non-uniform quantization. Our algorithm uses the current transmitted codeword to adapt the quantization intervals to changing statistics in LFP signals. It is thus backward adaptive and does not require the sending of side information. The computational complexity is low and similar at the encoder and decoder sides. These features allow for real-time signal recovery and facilitate hardware implementation with low-cost commercial microcontrollers. MAIN RESULTS: As proof-of-concept, we developed an open-source neural recording device called NeRD. The NeRD prototype digitally transmits eight channels encoded at 10 kHz with 2 bits per sample. It occupies a volume of 2 × 2 × 2 cm3 and weighs 8 g with a small battery allowing for 2 h 40 min of autonomy. The power dissipation is 59.4 mW for a communication range of 8 m and transmission losses below 0.1%. The small weight and low power consumption offer the possibility of mounting the entire device on the head of a rodent without resorting to a separate head-stage and battery backpack. The NeRD prototype is validated in recording LFPs in freely moving rats at 2 bits per sample while maintaining an acceptable signal-to-noise ratio (>30 dB) over a range of noisy channels. SIGNIFICANCE: Adaptive quantization in neural implants allows for lower transmission bandwidths while retaining high signal fidelity and preserving fundamental frequencies in LFPs.

Wearable technology for cardiology: An update and framework for the future.

The field of cardiology has long used wearable medical devices to monitor heart rate and rhythm. The past decade has seen the emergence of many new wearable devices, including several that have been widely adopted by both physicians and consumers. In this review, we discuss existing and forthcoming devices designed to measure activity, heart rate, heart rhythm, and thoracic fluid. We also offer several frameworks to classify and better understand wearable devices, such that we may weigh their potential benefit in improving healthcare with the many challenges that must be addressed to reap these benefits.

Diagnostic yield of asymptomatic arrhythmias detected by mobile cardiac outpatient telemetry and autotrigger looping event cardiac monitors.

INTRODUCTION: Asymptomatic arrhythmias can have important therapeutic implications in certain patient populations, for example, atrial fibrillation in patients with prior ischemic stroke. We sought to compare the diagnostic yield of two commercially available monitoring systems with automated arrhythmia detection algorithms. METHODS: We queried a large, proprietary database containing rhythm data for patients receiving ambulatory EKG monitoring (BioTelemetry, Malvern, PA, USA). We compared all patients prescribed mobile cardiac outpatient telemetry (MCOT™, Braemar Manufacturing, LLC, Eagan, MN, USA) versus autotrigger looping event recorder (AT-LER) devices over a consecutive 8-month period. Data from both device types were analyzed for diagnostic yields in detecting asymptomatic (device-triggered) arrhythmias consisting of atrial fibrillation (of any detected duration), bradycardia (ventricular rate ≤ 40 bpm), ventricular pause (≥ 3 seconds), supraventricular tachycardia (≥ 6 consecutive supraventricular beats), and ventricular tachycardia (≥ 4 consecutive premature ventricular contractions). The mean time to first diagnosis of each arrhythmia for each device was determined. Physician-designated diagnostic codes for patients prescribed each device were also determined from the database. RESULTS: The MCOT™ device had significantly higher diagnostic yields of all evaluated asymptomatic arrhythmias than the AT-LER. The MCOT™ device also produced an earlier mean time to diagnosis for all evaluated asymptomatic arrhythmias. These findings were noted despite a shorter average prescription length for MCOT™ monitored patients. CONCLUSIONS: In patients with conventional diagnostic monitoring indications, MCOT™ had significantly higher diagnostic yields for five asymptomatic arrhythmias compared to the AT-LER.

[Active cardiac implantable electronic devices: What is possible in ambulatory health care in 2017?] / Aktive kardiale Rhythmusimplantate: Was ist 2017 in der Praxis möglich?

Telemonitoring (TM) features are implemented in nearly all cardiac implantable electronic devices (CIEDs) that have recently been released to the market. In combination with pacemakers, defibrillators and systems for cardiac resynchronization it is a safe and efficient method for routine technical aftercare of the devices as well as for monitoring heart failure and arrhythmias. Using TM has the potential to optimize patient care with regard to economic, clinical and safety aspects. Despite the good availability of existing data and clear recommendations of the responsible scientific societies, it is often seen as an isolated solution which is not fully integrated into standard care, although it has its own EBM number for implantable cardioverter-defibrillators and cardiac resynchronization therapy systems. The reasons are not only the unsatisfactory reimbursement of costs, different IT structures and the borders between clinics and medical practices, but also acceptance problems of physicians and legal aspects. The compensation of cardiac pacemakers and 'event recorders' is unsolved. TM provides the prospect for optimal and cross-sectoral patient care. Furthermore it has the potential to become the standard method for the care for patients with a CIED.

[Current status and future of telemonitoring : Scenarios for telemedical care in 2025]. / Aktueller Stand und Zukunft des Telemonitoring : Szenarien für die telemedizinische Versorgung im Jahr 2025.

Telemonitoring is an already realized implementation of digital transformation in the healthcare system. It has the potential to support and secure a sustainable and comprehensive provision of healthcare for a rising number of chronically ill patients, e. g. patients with chronic heart failure. Remote regions in particular can profit from the benefits of telemonitoring; however, so far telemonitoring services have not become truly established in the German healthcare market. Together with experts from politics, science and practice, a scenario analysis "Health Care System 2025 - A Place for Telemonitoring?" was carried out with the aim to examine the future development of the healthcare market and to draw conclusions for providers of telemonitoring services or devices. The scenario analysis contained two workshops and an expert survey and was supported by a scenario software. The current drivers and barriers of the diffusion of telemonitoring were identified and the most relevant factors that influence the future development of the healthcare market were discussed. Based on those influencing factors, three different scenarios were determined: (1) administrating rather than shaping, (2) safely into the future and (3) interconnected and digital world. In the subsequent consequence analysis activities were defined, which describe the necessary infrastructure, software instruments, organizational structures and provision of services and discuss possible activities, which prepare telemonitoring solutions for the future.

Pretreatment with indomethacin results in increased heat stroke severity during recovery in a rodent model of heat stroke.

It has been suggested that medications can increase heat stroke (HS) susceptibility/severity. We investigated whether the nonsteroidal anti-inflammatory drug (NSAID) indomethacin (INDO) increases HS severity in a rodent model. Core temperature (Tc) of male, C57BL/6J mice (n = 45) was monitored continuously, and mice were given a dose of INDO [low dose (LO) 1 mg/kg or high dose (HI) 5 mg/kg in flavored treat] or vehicle (flavored treat) before heating. HS animals were heated to 42.4°C and euthanized at three time points for histological, molecular, and metabolic analysis: onset of HS [maximal core temperature (Tc,Max)], 3 h of recovery [minimal core temperature or hypothermia depth (HYPO)], and 24 h of recovery (24 h). Nonheated (control) animals underwent identical treatment in the absence of heat. INDO (LO or HI) had no effect on physiological indicators of performance (e.g., time to Tc,Max, thermal area, or cooling time) during heating or recovery. HI INDO resulted in 45% mortality rate by 24 h (HI INDO + HS group). The gut showed dramatic increases in gross morphological hemorrhage in HI INDO + HS in both survivors and nonsurvivors. HI INDO + HS survivors had significantly lower red blood cell counts and hematocrit suggesting significant hemorrhage. In the liver, HS induced cell death at HYPO and increased inflammation at Tc,Max, HYPO, and 24 h; however, there was additional effect with INDO + HS group. Furthermore, the metabolic profile of the liver was disturbed by heat, but there was no additive effect of INDO + HS. This suggests that there is an increase in morbidity risk with INDO + HS, likely resulting from significant gut injury.NEW & NOTEWORTHY This paper suggests that in a translational mouse model, NSAIDs may be counterindicated in situations that put an individual at risk of heat injury. We show here that a small, single dose of the NSAID indomethacin before heat stroke has a dramatic and highly damaging effect on the gut, which ultimately leads to increased systemic morbidity.

Guideline-based intervention to reduce telemetry rates in a large tertiary centre.

BACKGROUND: Inappropriate cardiac telemetry use is associated with reduced patient flow and increased healthcare costs. AIM: To evaluate the outcomes of guideline-based application of cardiac telemetry. METHODS: Phase I involved a prospective audit (March to August 2011) of telemetry use at a tertiary hospital. Data were collected on indication for telemetry and clinical outcomes. Phase II prospectively included patients more than 18 years under general medicine requiring ward-based telemetry. As phase II occurred at a time remotely from phase I, an audit similar to phase I (phase II - baseline) was completed prior to a 3-month intervention (May to August 2015). The intervention consisted of a daily telemetry ward round and an admission form based on the American Heart Association guidelines (class I, telemetry indicated; class II, telemetry maybe indicated; class III, telemetry not indicated). Patient demographics, telemetry data, and clinical outcomes were studied. Primary endpoint was the percentage reduction of class III indications, while secondary endpoint included telemetry duration. RESULTS: In phase I (n = 200), 38% were admitted with a class III indication resulting in no change in clinical management. A total of 74 patients was included in phase II baseline (mean ± standard deviation (SD) age 73 years ± 14.9, 57% male), whilst 65 patients were included in the intervention (mean ± SD age 71 years ± 18.4, 35% male). Both groups had similar baseline characteristics. There was a reduction in class III admissions post-intervention from 38% to 11%, P < 0.001. Intervention was associated with a reduction in median telemetry duration (1.8 ± 1.8 vs 2.4 ± 2.5 days, P = 0.047); however, length of stay was similar in both groups (P > 0.05). CONCLUSION: Guideline-based telemetry admissions and a regular telemetry ward round are associated with a reduction in inappropriate telemetry use.

Long-term blood glucose monitoring with implanted telemetry device in conscious and stress-free cynomolgus monkeys.

AIMS: Continuous blood glucose monitoring, especially long-term and remote, in diabetic patients or research is very challenging. Nonhuman primate (NHP) is an excellent model for metabolic research, because NHPs can naturally develop Type 2 diabetes mellitus (T2DM) similarly to humans. This study was to investigate blood glucose changes in conscious, moving-free cynomolgus monkeys (Macaca fascicularis) during circadian, meal, stress and drug exposure. MATERIALS AND METHODS: Blood glucose, body temperature and physical activities were continuously and simultaneously recorded by implanted HD-XG telemetry device for up to 10 weeks. RESULTS AND DISCUSSION: Blood glucose circadian changes in normoglycemic monkeys significantly differed from that in diabetic animals. Postprandial glucose increase was more obvious after afternoon feeding. Moving a monkey from its housing cage to monkey chair increased blood glucose by 30% in both normoglycemic and diabetic monkeys. Such increase in blood glucose declined to the pre-procedure level in 30 min in normoglycemic animals and >2 h in diabetic monkeys. Oral gavage procedure alone caused hyperglycemia in both normoglycemic and diabetic monkeys. Intravenous injection with the stress hormones, angiotensin II (2 µg/kg) or norepinephrine (0.4 µg/kg), also increased blood glucose level by 30%. The glucose levels measured by the telemetry system correlated significantly well with glucometer readings during glucose tolerance tests (ivGTT or oGTT), insulin tolerance test (ITT), graded glucose infusion (GGI) and clamp. CONCLUSION: Our data demonstrate that the real-time telemetry method is reliable for monitoring blood glucose remotely and continuously in conscious, stress-free, and moving-free NHPs with the advantages highly valuable to diabetes research and drug discovery.

Current rare indications and future directions for implantable loop recorders.

The scope of application for implantable loop recorders has shifted away from the evaluation of unclear palpitations and syncope episodes to more complex conditions. This article focuses on rare indications of growing importance such as rhythm monitoring after ablation of atrial fibrillation or after cryptogenic stroke. Furthermore, forthcoming applications in various clinical settings are described, e. g., arrhythmia detection after myocardial infarction, after catheter-based valve interventions, in heart failure, and in cardiomyopathies. Enhancement of the capabilities of implantable loop recorders could broaden their fields of use.