Filed under: News, Telemedicine | Tags: acute stroke, AcuteCare Telemedicine, alabama, Atlanta, atlanta neurology, care, clinician, cutting edge, doctor shortage, efficient, emergency room, expert, Georgia, healthcare, healthcare reform, hospitals, investment, James Kiely, joint commission, Keith Sanders, Lisa Johnston, mandate, matthews gwynn, MD, medical news, Michael Woodcock, modern medicine, neurological emergency, news, nurses, patient satisfaction, press, primary stroke center, resources, rural hospitals, South Carolina, Southeast, staff, Stroke Belt, Technology, telehealth, telemedicine technology, teleneurology, telestroke
Following a third consecutive year of growth in 2012, AcuteCare Telemedicine (ACT), an Atlanta-based partnership of 4 board-certified neurologists, is expanding its efforts to become the leading provider expert neurological care to rural and underserved areas throughout the Southeastern United States via cutting edge telemedicine technology.
Telemedicine, once regarded as an exciting new frontier, has now been fully realized as a part of the mainstream lexicon of medicine as we enter 2013. For a large number of hospital systems, telemedicine programs are now becoming a mandate as the nation faces a growing shortage of specialized physicians.
ACT has established itself as an innovator on the forefront of the industry, taking a unique approach to telemedicine by leveraging new technologies and techniques to enable personal neurology consultation when doctor and patient are in different locations. ACT offers a broad range of customizable services including 24/7 emergency neurological consultation and support programs for facilities seeking Joint Commission accreditation as a Primary Stroke Center, but primarily specializes in telestroke: the application of telemedicine to the treatment of the acute stroke patient. With the help of ACT’s powerful and personalized services, patients throughout the ‘Stroke Belt’ states of the Southeast have drastically improved access to the care they deserve, and medical facilities increase efficiency while reducing the costs associated with maintaining a traditional emergency neurology staff.
Whereas many hospitals with existing neurology departments simply do not have the resources to maintain around-the-clock clinician capacity, ACT has managed to successfully disrupt the trend and bring patient and physician together, regardless of geographical boundaries. Achieving this goal requires a certain level of investment in technology and trust in the people behind it. ACT is truly technology-agnostic. This agility affords healthcare organizations with the ability to select the platform that meets budgetary and organizational parameters.
ACT provides access to the best 24X7 acute neurological care. Contact Michael Woodcock to hear how teleneurology can impact your business and patients in 2013.
Filed under: Stroke Prevention & Care | Tags: AcuteCare Telemedicine, andrew josephson, atlanta hospitals, atlanta neurology, cryptogenic stroke, device closure of PFOsatlanta healthcare, healthcare news, medical news, modern medicine, neurology, procedures, shunting, stroke care, stroke diagnosis, stroke prevention, techniques, telehealth, telemed, telemedicine, teleneurology, tPA
Sometimes, moving healthcare forward is achieved simply by looking back. The following article illustrates the latest example of the type of discoveries that fuel the constant evolution of medicine. Modern techniques, such as those utilized in telemedicine practices, often rely on the latest technical and innovative advances, but stepping back and evaluating standard procedures is a crucial step in ensuring the highest possible standards of care. As in the case of the findings featured here, discarding methods once thought to be best practices can improve both patient outcomes and cost-efficiency.
No Benefit to Patent Foramen Ovale (PFO) Closure in Ischemic Stroke or TIA
S. Andrew Josephson
M.D., Department of Neurology, University of California San Francisco, San Francisco, USA
Between 25% and 40% of ischemic strokes have no clear cause despite extensive investigation. These “cryptogenic” strokes may in some instances be due to an embolus traveling through a right-to-left shunt in the heart. A patent foramen ovale (PFO) is present in nearly one-quarter of patients in autopsy studies and is even more prevalent in young patients with cryptogenic stroke. Whether these PFOs should be treated with medical therapy or closure remains a point of much debate; Furlan and colleagues (2012) examined the benefit of a percutaneous closure device for preventing further cerebrovascular events in patients with cryptogenic stroke and transient ischemic attack (TIA).
The authors enrolled patients between the ages of 18 and 60 who had experienced a cryptogenic stroke or TIA within the previous 6 months and who were found to have a PFO documented by transesophageal echocardiography (TEE) with bubble study. These patients were randomly assigned either to percutaneous closure with the STARFlex device plus antiplatelet therapy or to medical therapy alone. Those assigned to closure were treated with clopidogrel for 6 months and aspirin for 2 years, whereas those assigned to medical therapy were treated with warfarin, aspirin, or both at the discretion of the site investigator. The primary outcome examined was a composite 2-year rate of stroke or TIA, death from any cause in the first 30 days, or death from a neurologic cause from 31 days to 2 years.
The authors enrolled 909 patients in the trial, and there were no significant differences in the baseline characteristics of the two groups. At 6 months, effective closure was confirmed by TEE in 86% of the closure group. The primary endpoint was reached in 5.5% of the closure group and 6.8% of the medical group (hazard ratio, 0.78; 95% confidence interval, 0.45–1.35; p = .37). There were no significant differences in stroke or TIA rates between the two groups, although the latter TIA endpoint (a “softer” endpoint, subject to patient reporting) was numerically higher in the medical therapy group. There were no differences in adverse events between the two groups. Atrial fibrillation more frequently developed in the closure group compared with the medical group (5.7% vs 0.7%; p < .001). A variety of subgroups were examined, including sex, the presence of an atrial septal aneurysm, shunt size, entry event (stroke vs TIA), and baseline medication; none was found to significantly favor percutaneous closure.
This well-done negative trial definitively demonstrates no benefit to PFO closure in patients with cryptogenic stroke and argues strongly that these patients should either be treated with medical therapy or be invited to participate in ongoing randomized trials of different devices. The slow recruitment in this trial, which began enrolling in 2003, was likely due in part to the fact that the device was available for use outside of the trial and many patients and their physicians chose to close PFOs rather than enrolling in the study. One limitation of this study may therefore have been a bias toward patients with characteristics thought by their physicians to warrant randomization, perhaps those at perceived at lower risk for stroke. Ideally, the definitive results of this trial will mean that percutaneous PFO closure no longer is practiced outside of these trials.
– Josephson, SA. No Benefit to Patent Foramen Ovale (PFO) Closure in Ischemic Stroke or TIA. Harrison’s Online, April 23, 2012. http://www.accessmedicine.com
Related to Chapter 370 Cerebrovascular Diseases in Harrison’s Principles of Internal Medicine, 18thedition, Dan L. Longo, Dennis L. Kasper, J. Larry Jameson, Anthony S. Fauci, Stephen L. Hauser, Joseph Loscalzo, Eds. McGraw-Hill, New York, 2012.
Furlan AJ et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012;366:991.
Understanding that even the most accepted methods of diagnosis and treatment are subject to scrutiny is a key tenet of the relentless pursuit of a better standard of care. The partners of AcuteCare Telemedicine agree with Dr. Furlan’s recommendation that device closure of PFOs should now be limited to patients enrolled in one of the ongoing trials.
Filed under: Industry Standards, Telemedicine | Tags: acute care, AcuteCare Telemedicine, atlanta healthcare, Atlanta healthcare news, atlanta hospitals, atlanta telemedicine, cheaper healthcare, cleaner healthcare, cost effective healthcare, eco-friendly, energy usage, environment, environmentally friendly medicine, extend healthcare coverage, fuel costs, go green, healthcare costs, healthcare policy, hospital costs, hospitals, legislature, location, medical news, medicine, outpatient procedures, physicians, reducing emissions, rural hospitals, sustainability, telehealth, telemedicine, teleneurology, transportation
Telemedicine has leveraged technology to help hospitals overcome challenges associated with staffing and transportation extend higher quality healthcare to patients, regardless of their location, while simultaneously reducing costs. Now, we are beginning to understand that telemedicine not only helps hospital facilities run leaner; it may also help them be greener.
Hospital facilities are traditionally located in areas of higher population, often far away from patients living in rural communities. The transfer of these remote patients to hospitals for inpatient treatment demands relatively high energy consumption. With a foreseeable increase in numbers of patients requiring care in the future, these costs can be expected to rise if left unaddressed.
Within the context of changing environmental policy, increased focus must be placed on reducing emissions and energy usage in healthcare policy. Telemedicine has demonstrated positive effects, creating a more environmentally sustainable process by improving inpatient treatment in local community hospitals and improving monitoring of complex diseases in outpatient settings, avoiding unnecessary hospital admissions.
Physicians have traditionally placed a priority patient care over any environmental responsibility, but telemedicine offers opportunities to minimize environmental impact while developing a higher standard of care across the country. By combating energy consumption, telemedicine is improving not only the health of patients, but also the planet.
Filed under: Stroke Prevention & Care | Tags: AcuteCare Telemedicine, atlanta hospital news, atlanta medical news, atlanta medical research, atlanta medicine, atlanta sleep lab, atlanta stroke care, cognition, dementia, Dr. Lisa Johnston, lisa johnston sleep, medical news, medical research, new york times medicine, OSA, OSA cognition, risk factors for stroke, sleep apnea, sleep disorders, stroke prevention, telemedicine atlanta, telemedicine news
Awareness of sleep disorders has increased over the past several years, leading more physicians to appreciate that Obstructive Sleep Apnea (OSA) is an independent risk factor for hypertension, cardiovascular disease and stroke. Although seemingly overlooked, studies as far back as 15 years have also suggested that OSA may be a risk factor for cognitive dysfunction.
When patients present to a neurologist with complaints of cognitive dysfunction, most are screened for potentially reversible causes such as vitamin B12 deficiency, hypothyroidism, undiagnosed/untreated syphilis, or normal pressure hydrocephalus. If all laboratory and imaging studies are normal, these patients are often started on acetylcholinesterase inhibitors, in hopes of slowing down the rate of cognitive decline. Screening for sleep apnea, however, is often times not performed. As a result, the opportunity to treat an otherwise harmful disorder and potentially reverse cognitive impairment is forfeited.
In 2010, an article was published in the New York Times entitled “When Sleep Apnea Masquerades as Dementia.” A case study was reported: “The woman was only in her 60s but complained that she was having trouble concentrating.” She couldn’t follow a television program or stay focused during a conversation. As he evaluated the woman, the physician asked, as he usually does, how she was sleeping. The woman, who lived alone, hadn’t noticed any problems. Her son, however, had stayed with her the previous night to drive her to the appointment. “She was snoring like a freight train,” he reported. Overnight sleep testing determined that the woman had obstructive sleep apnea – nightlong interruptions in breathing that reduce oxygen flow to the brain and prevent deep sleep. The interruptions are quite common in older adults, exacerbating – or sometimes mimicking – dementia symptoms. Treated with a CPAP (continuous positive airway pressure) machine her scores on neuropsychological tests eventually climbed back into normal range.
Another recent study published in JAMA, also showed that sleep disordered breathing may contribute to the development of dementia. 298 women 65 years or older and without dementia were enrolled in this study, undergoing overnight polysomnography testing. Those who were found to have sleep disordered breathing were more likely to have developed cognitive impairment or dementia on follow up testing. It is thought that hypoxemia resulting from sleep disordered breathing is responsible. Dr Michael J. Thorpy, director of the Sleep-Wake Disorders Center at the Montefiore Medical Center in the Bronx, NY stated “We used to think that impaired sleep caused cognitive impairment, but this shows that nocturnal hypoxemia plays an important role and this suggests that the cognitive impairment might be partially reversible in some cases.
Although further studies are needed, these findings do stress the importance of screening patients with complaints of cognitive dysfunction for sleep apnea. Because the large majority of people who develop dementia do so after the age of 65, it would seem imperative to screen younger patients with cognitive complaints for sleep disordered breathing.