Telemedicine in integrated care (example: asthma treatment)

Purpose

Medical impact of telemetric management on patients with asthma.

Context

Sectoral boundaries still cause problems in supervising chronically Ill patients in Germany. Integrated care models by means of modern telemedicine can help.

Since the beginning of 2008, an agreement between the Techniker Krankenkasse (TK) and the German Foundation for the Chronically Ill has enabled a telemedical programme for asthma (see below).

Case description

Adult TK insured asthmatics are enrolled by participating doctors. Supervision by a telemedical support centre differs according to the severity of their condition and in coordination with participating doctors.

All patients receive electronic peak flow meters and training documents, and are phoned regularly by medically trained coaches. Major elements include information and training courses on asthma, self-management, target agreements, collection of medical data and regularly written reports to participants and doctors. High-risk patients also undergo telemonitoring of medical data via mobile phone. If values become critical, early intervention prevents escalation and medical emergencies.

Results and conclusions

Discussion

Integrated care models by means of modern telemedicine suitable for other chronic diseases and for multimorbid patients (whole patient management)?

[Telemonitoring in chronic heart failure patients. Which diagnostic finding prevents hospital readmission?]

Heart failure exhibits a significant clinical and health economic problem. The implementation of new therapeutic strategies favorably affecting the course of disease is still insufficient in day-to-day practice. Thus, the usage of telemedicine offers a central instrument for service and information, so that an optimized therapy can be achieved by consequent surveillance of the patient with chronic heart disease. Predefined vital parameters are automatically transmitted to the telemedicine center; if individually predefined limits are exceeded, therapeutic means are immediately initiated. For the patient, the center is attainable 24 h throughout the year in case he experiences cardio-pulmonary symptoms. This patient-oriented usage of technology should not replace the physician-patient relationship, but improves and supports the participation and self-management of patients. Furthermore, the results show that this technology can significantly reduce the amount of emergency physician services, hospital admissions and primary care physician visits, and displays for health economics purposes a clearly more cost-effective treatment strategy, while allowing for additional costs inherent to the system. The usage of telemonitoring in chronic heart failure patients may be a trendsetting form of care, which can be used to drastically optimize the information and data flow between patient, hospital and primary care physician individually and at any time.

Selected Soybean Plant Introductions with Partial Resistance to Sclerotinia sclerotiorum

Sclerotinia stem rot, caused by Sclerotinia sclerotiorum, is a major soybean (Glycine max) disease in north-central regions of the United States and throughout the world. Current sources of resistance to Sclerotinia stem rot express partial resistance, and are limited in number within soybean germ plasm. A total of 6,520 maturity group (MG) 0 to IV plant introductions (PIs) were evaluated for Sclerotinia stem rot resistance in the United States and Canada in small plots or in the greenhouse from 1995 to 1997. Selected PIs with the most resistance were evaluated for resistance in the United States and Canada in replicated large plots from 1998 to 2000. The PIs in the MG I to III tests in Urbana, IL were evaluated for agronomic traits from 1998 to 2000. The selected PIs also were evaluated with an excised leaf inoculation and petiole inoculation technique. After the 1995 to 1997 evaluations, all but 68 PIs were eliminated because of their susceptibility to Sclerotinia stem rot. In field tests in Urbana, higher disease severity in selected MG I to III PIs was significantly (P< 0.05) associated with taller plant heights and greater canopy closure. All other agronomic traits evaluated were not associated or were inconsistently associated with disease severity. MG I to III PIs 153.282, 189.931, 196.157, 398.637, 417.201, 423.818, and 561.331 had high levels of resistance and had canopies similar to the resistant checks. The resistance ratings from the petiole inoculation technique had a high and significant (P< 0.01) correlation with disease severity in the MG I and II field tests. The partially resistant PIs identified in this study can be valuable in incorporating Sclerotinia stem rot resistance into elite germ plasm.

Granzyme B ELISPOT assay for ex vivo measurements of T cell immunity

A major goal in immunodiagnostics has been the development of assay systems that can measure CD8(+) T cell immunity in humans, directly ex vivo, at high resolution, and with high throughput. We established granzyme B (grB) enzyme-linked immunospot assay (ELISPOT) in conjunction with image analysis to this end. Using grB transfected and untransfected Chinese hamster ovary (CHO) cells and T cell lines, we show that the antibody pair utilized was grB-specific and that only activated T cells secrete grB. GrB release began within 4 h after antigen stimulation and stopped within 40 h. Side-by-side comparison showed grB ELISPOT assays to have a higher resolution than classic chromium-release assays in terms of signal-to-noise ratio. The linearity of the relation of the number of CD8(+) effector T cells plated to grB spots detected suggests that grB ELISPOT assays measure the frequencies of grB-secreting cells directly. Reactivity to HIV peptides was seen in grB ELISPOT assays of freshly isolated PBMC from HIV patients, consistent with the detection of peptide-specific memory cells. The higher resolution and lower labor and material investment should make grB ELISPOT assays an attractive alternative to chromium-release assays in monitoring the clonal sizes of specific CD8 memory cells in vivo.

Direct visualization of cytokine-producing recall antigen-specific CD4 memory T cells in healthy individuals and HIV patients

We have used computer-assisted cytokine ELISA spot analysis to measure the frequencies, the type of cytokine, and the amount of cytokine produced by individual recall Ag-specific CD4 memory cells in freshly isolated blood. We studied the memory cells specific for tetanus toxoid and purified protein derivative in 18 healthy individuals and in 22 HIV-infected patients on highly active antiretroviral therapy (HAART). In healthy individuals, the frequency, cytokine signature, and cytokine production per cell of these memory cells were stable over time. Although it is presently unclear whether the maintenance of the memory T cell pool depends upon Ag persistence, cross-reactive Ag stimulation, or cytokine-driven bystander stimulations and expansions, our data strongly argue for a stable memory cell pool in healthy individuals. In HIV patients, however, the frequency of these memory cells was a function of the viral load. The decreased numbers of functional memory cells in patients with high viral loads might provide one mechanism behind the immunodeficient state. Although the cytokine output per cell was unaffected in most patients (20 of 24), in some patients (4 of 24) it was >100-fold reduced, which might provide an additional mechanism to account for the reduced immunocompetence of these patients. The ability to visualize directly and quantify the cytokine produced by the low frequency memory cells in freshly isolated blood that have been physiologically stimulated by Ag should aid comprehensive studies of the Ag-specific memory cell pool in vivo, in health and disease.

Genetic variance, coefficient of parentage, and genetic distance of six soybean populations

Plant breeders would like to predict which biparental populations will have the largest genetic variance. If the population genetic variance could be predicted using coefficient of parentage or genetic distance estimates based on molecular marker data, breeders could choose parents that produced segregating populations with a large genetic variance. Three biparental soybean Glycine max (L.) Merr. populations were developed by crossing parents that were closely related, based on pedigree relationships. Three additional biparental populations were developed by crossing parents that were assumed to be unrelated. The genetic variance of each population was estimated for yield, lodging, physiological maturity, and plant height. Coefficient of parentage was calculated for each pair of parents used to develop the segregating populations. Genetic distance was determined, based on the number of random amplified polymorphic markers (RAPD) that were polymorphic for each pair of parents. Genetic distance was not associated with the coefficient of parentage or the magnitude of the genetic variance. The genetic variance pooled across the three closely related populations was smaller than the genetic variance pooled across the three populations derived from crossing unrelated parents for all four traits that were evaluated.