[Cost analysis of telemedical treatment of stroke]. / Kostenanalyse telemedizinischer Schlaganfallbehandlung.

BACKGROUND: Telemedicine-enabled stroke networks increase the probability of a good clinical outcome. There is a shortage of evidence about the effects of this new approach on costs for inpatient care and nursing care. METHODS: We analysed health insurance and nursing care fund data of a statutory health insurance company (AOK Bayern). Data from stroke patients initially treated in a TeleStroke network (TEMPiS - telemedical project for integrative stroke care) between community hospitals and academic stroke centres were compared to data of matched hospitals without specialised stroke care and telemedical support. Costs for nursing care were obtained over a 30-month period after the initial stroke. To rule out pre-existing differences between network and control hospitals, costs of stroke care were also analysed during a time period before network implementation. FINDINGS: 1 277 patients (767 in intervention, 510 in control hospitals) were analysed in the post-implementation period. An increased proportion of patients treated in intervention hospitals had a favourable outcome concerning the level of required nursing care. Patients in intervention hospitals had higher costs for acute inpatient care (5 309 € vs. 4 901 €, p=0.04), but lower nursing care fund costs (3 946 € vs. 5 132 €; p=0.04). There was no difference in relation to absolute total costs obtained in the post-implementation period. However, nursing care costs per survived year were significantly lower in intervention hospitals (1 953 € vs. 2 635 €; p=0.005). No significant differences were found in the pre-implementation period. CONCLUSIONS: Considering both health insurance and nursing care fund costs, the incremental costs for TeleStroke network care in hospitals are compensated by savings in outpatient care.

Current management and risk of recurrent stroke in cerebrovascular patients with right-to-left cardiac shunt.

BACKGROUND: Right-to-left cardiac shunt (RLS) is considered a risk factor for stroke, especially in patients aged <55 years. We aimed to investigate the current management and prognosis in consecutive patients with RLS and otherwise cryptogenic cerebrovascular events. METHODS: In total, 1,126 patients with cryptogenic stroke or TIA were included from 17 German neurology departments. During a mean follow-up of 28.4 months, we assessed current antithrombotic medication, percutaneous device closure (PDC) and recurrent cerebrovascular events in 899 patients (79.8%). Stroke recurrence was compared between 548 patients without RLS and 351 patients with RLS under various prevention regimens. RESULTS: RLS was detected in 35.9% of cryptogenic cerebrovascular patients, but could not be evaluated as an independent predictor for recurrent stroke (adjusted HR 1.6, 95% CI: 0.9-2.7). In RLS-positive patients, the Kaplan-Meier estimate for stroke during the first year was 4.1% (95% CI: 1.9-6.3%) and 1.7% (95% CI: 0.9-2.4%) per year thereafter. At the last follow-up before recurrent stroke or end of study, 117 RLS-positive patients (33.3%) had received a PDC, 154 (43.9%) were receiving antiplatelets, 63 (17.9%) received anticoagulation, and 17 (4.8%) received none of the above. No association with recurrent stroke was found for the secondary preventive regime. CONCLUSION: Our multicenter hospital-based cohort study confirmed low recurrent event rates in RLS patients with otherwise cryptogenic stroke or TIA, as well as a great heterogeneity of current management. Despite the lack of scientific evidence, a substantial number of RLS-positive patients underwent PDC for secondary stroke prevention.

[Acceptance of telemedicine for acute stroke care. The German project TEMPiS]. / Akzeptanz der Telemedizin in der akuten Schlaganfallversorgung. Das bayerische Projekt TEMPiS.

BACKGROUND: Telemedicine is increasingly used for acute stroke care, making neurological expertise available in nonspecialized hospitals. There are few data about telemedicine's acceptance by either medical staff or patients at treating hospitals. METHODS: Telemedicine's acceptance was evaluated in the Telemedical Project for Integrative Stroke Care (TEMPIS), a network of two stroke centers and 12 community hospitals in the German state of Bavaria; the grading of teleconsultation regarding video and audio quality, time consumption, and medical relevance was assessed in two periods, 2004 and 2007. Overall satisfaction with in-hospital treatment was compared between patients in telemedically-linked hospitals with specialized stroke care and patients treated in conventional community hospitals. With regard to sufficient follow-up rates, ratings were restricted to patients living at home without severe disability at 3 months after stroke. A second evaluation analyzed how the parameter "Telemedical assessment of patient" (36% of patients in TEMPIS hospitals) affected overall satisfaction. RESULTS: Respectively, 140 and 127 uses of telemedicine were assessed in the two evaluation periods. Video quality, time consumption, and medical relevance were graded "excellent" by over 50% in both periods. Audio quality was rated "excellent" by only 22% in the first period but 69% in the second. Excellent overall satisfaction was expressed significantly more frequently by patients at TEMPIS hospitals (total number 1044) than by those at control hospitals (total number 484; 56% vs 47% respectively, P<0.01). Patient consultation via telemedicine per se did not correlate with modified grading. CONCLUSIONS: Acceptance of telemedicine in acute stroke care was high and stable over a long period. This study suggests improved overall satisfaction with treatment in hospitals offering specialized care and linked via telemedicine. Clinical assessment via telemedicine had no major effect on satisfaction.

[Comparison of two coronary risk equivalents: diabetes mellitus and peripheral arterial disease]. / Risiken der Koronaräquivalente Diabetes mellitus und Periphere Arterielle Verschlusskrankheit im Vergleich.

BACKGROUND AND OBJECTIVE: Diabetes mellitus (DM) and peripheral arterial disease (PAD) are both coronary artery disease equivalents ("coronary equivalents"). It was the aim of this study to ascertain (1) to what extent each of these diseases differs from the other in respect of early death, (2) how frequently DM and PAD occur together in elderly patients seen in general practice and (3) what risk patients with DM and concomitant PAD carry. PATIENTS AND METHODS: In the prospective non-interventional study--"German Epidemiological Trial on Ankle Brachial Index"--6,880 unselected patients, aged 65 years or more, from 344 general medical practices were followed over five years and the incidence of deaths and of cardiovascular events recorded. DM was defined according to the medical diagnosis and/or if the HbA1c was > or = 6.5% and the ankle brachial index (ABI), determined by Doppler sonography. PAD was defined as an ABI of < 0.9 or the presence of intermittent claudication or state after peripheral revascularization/amputation. Survival rates were obtained using Kaplan-Meier estimate curves and Cox's proportional hazard model. 59 patients with an ABI > 1.5 were excluded from the study. Hazard ratios (HR with 95% confidence intervals [CI]) were adjusted according to known risk factors. RESULTS: The overall observation period for all the patients amounted to nearly 33000 patient-years (PY). The risk of death of patients with DM but no PAD (n = 1,220; 17.9%) was 1.5 times the risk of death (HR, 95% CI 1.2-1.8) of persons with neither disease (n = 4 172; 61.2%) and the risk of those with PAD but no DM (n = 918, 13;5%) was 1.7 times of those persons without either disease (HR, 95% CI 1.4-2.0). The risk for persons with DM and PAD (n = 511; 7.5%) was nearly 3 times that of persons without either disease, after adjustment for other cardiovascular risk factors (HR 2.8, 95% CI 2.3-3.4). The lower the ABI in persons with or without DM the greater the number of deaths per 1000 PY. CONCLUSIONS: These results confirm that diabetics and patients with PAD have a clearly increased risk of early death. These patients need intensive treatment of the risk factors. This is especially true for patients who have DM and PAD concomitantly.

Alpine infrastructure in Central Europe: integral evaluation of wastewater treatment systems at mountain refuges.

Planning, construction and operation of onsite wastewater treatment systems at mountain refuges is a challenge. Energy supply, costly transport, limited water resources, unfavourable climate and load variations are only some of the problems that have to be faced. Additionally, legal regulations are different between and even within countries of the Alps. To ensure sustainability, integrated management of the alpine infrastructure management is needed. The energy and water supply and the wastewater and waste disposal systems and the cross-relations between them were analysed for 100 mountain refuges. Wastewater treatment is a main part of the overall 'mountain refuge' system. The data survey and first analyses showed the complex interaction of the wastewater treatment with the other infrastructure. Main criteria for reliable and efficient operation are training, technical support, user friendly control and a relatively simple system set up. Wastewater temperature, alkalinity consumption and high peak loads have to be considered in the planning process. The availability of power in terms of duration and connexion is decisive for the choice of the system. Further, frequency fluctuations may lead to damages to the installed aerators. The type of water source and the type of sanitary equipment influence the wastewater quantity and quality. Biosolids are treated and disposed separately or together with primary or secondary sludge from wastewater treatment dependent on the legal requirements.

An integrated assessment of options for rural wastewater management in Austria.

This paper reports a recently finished, interdisciplinary project on rural wastewater management in Austria. The objective of the project was to study alternative wastewater management options based on separation of the wastewater into its constituent parts, and to compare them with conventional ones. Thereby, a feasibility study of both conventional and alternative options for wastewater management in six model regions was carried out. Life cycle costs and social acceptance were analysed by using a case study-based assessment approach. However, hygienic and environmental risks were evaluated on a more general level. In order to complement the findings, a survey on urine separation system users in the Solar City of Linz was conducted. Based on these assessments and empirical findings, the paper concludes that options using a full separation of all wastewater fractions should be considered with care. Options based on a separation of only grey water and black water or in the liquid/solid phase can offer ecological and financial advantages over conventional options. Further, options combining wastewater management and regional biogas plants were identified as an interesting solution. However, legal constraints restrict this option currently.

Removal efficiency of subsurface vertical flow constructed wetlands for different organic loads.

Using subsurface vertical flow constructed wetlands (SSVFCWs) with intermittent loading it is possible to fulfil the stringent Austrian effluent standards regarding nitrification. For small plants (less than 500 persons) standards for ammonia nitrogen concentration have to be met at water temperatures higher than 12 degrees C, effluent concentrations and treatment efficiencies for organic matter have to be met the whole year around. According to the Austrian design standards the required surface area for SSVFCWs treating wastewater was 5 m2 per person. Within the first part of an Austrian research project the goal was to optimise, i.e. minimise the surface area requirement of vertical flow beds. Therefore, three SSVFCWs with a surface area of 20 m2 each have been operated in parallel. The organic loads applied were 20, 27 and 40 g COD/m2/d, which corresponds to a specific surface area requirement of 4, 3 and 2 m2 per PE, respectively. The paper compares the effluent concentrations and elimination efficiencies of the three parallel operated beds. It could be shown that a specific area demand of 4 m2 per person is suitable to be included in the revision of the Austrian design standard. Additionally it could be shown that during the warmer seasons (May-October) when the temperature of the effluent is higher than 12 degrees C the specific surface area might be further reduced; even 2 m2 per person has been proven to be adequate.

Comparison of measured and simulated distribution of microbial biomass in subsurface vertical flow constructed wetlands.

The multi-component reactive transport module CW2D has been developed to model transport and reactions of the main constituents of municipal wastewater in subsurface flow constructed wetlands and is able to describe the biochemical elimination and transformation processes for organic matter, nitrogen and phosphorus. It has been shown that simulation results match the measured data when the flow model can be calibrated well. However, there is a need to develop experimental techniques for the measurement of CW2D model parameters to increase the quality of the simulation results. Over the last years methods to characterise the microbial biocoenosis in vertical subsurface flow constructed wetlands have been developed. The paper shows measured data for microbial biomass and their comparison with simulation results using different heterotrophic lysis rate constants.

Diversity of ammonia oxidising bacteria in a vertical flow constructed wetland.

Vertical flow constructed wetlands (VFCWs) with intermittent loading are very suitable for nitrification. Ammonia oxidising bacteria (AOB) are the limiting step of nitration. Therefore the AOB community of a full-scale VFCW, receiving municipal wastewater, was investigated within this study. The diversity of the functional gene encoding the alpha-subunit of the ammonia monooxygenase (amoA), present only in AOB, was assessed by denaturing gradient gel electrophoresis (DGGE). Only very few amoA sequence types dominated the wetland filter substrate; nevertheless a stable nitrification performance could be observed. During the cold season the nitrification was slightly reduced, but it has been shown that the same AOB could be identified. No spatial AOB pattern could be observed within the filter body of the VFCW. The most prominent bands were excised from DGGE gels and sequenced. Sequence analyses revealed two dominant AOB lineages: Nitrosomonas europaea/"Nitrosococcus mobilis" and Nitrosospira. Species of the Nitrosomonas lineage are commonly found in conventional wastewater treatment plants (WWTPs). In contrast, members of the Nitrosospira lineage are rarely present in WWTPs. Our observations indicate that the AOB community in this VFCW is similar to that found in horizontal flow constructed wetlands, but differs from common WWTPs regarding the presence of Nitrosospira.

Optimization of subsurface vertical flow constructed wetlands for wastewater treatment.

Constructed wetlands (CWs) use the same processes that occur in natural wetlands to improve water quality and are used worldwide to treat different qualities of water. This paper shows the results of an Austrian research project having the main goals to optimize vertical flow beds in terms of surface area requirement and nutrient removal, respectively. It could be shown that a subsurface vertical flow constructed wetland (SSVFCW) operated with an organic load of 20 g COD x m(-2) x d(-1) (corresponding to a specific surface area demand of 4 m2 per person) can fulfil the requirements of the Austrian standard regarding effluent concentrations and removal efficiencies. During the warmer months (May - October), when the temperature of the effluent is higher than 12 degrees C, the specific surface area might be further reduced. Even 2 m2 per person have been proven to be adequate. Enhanced nitrogen removal of 58% could be achieved with a two-stage system (first stage: grain size for main layer 1-4 mm, saturated drainage layer; and second stage: grain size for main layer 0.06-4 mm, free drainage) that was operated with an organic load of 80 g COD x m(-2) x d(-1) for the first stage (1 m2 per person), i.e. 40 g COD x m(-2) x d(-1) for the two-stage system (2 m2 per person). Although the two-stage system was operated with higher organic loads a higher effluent quality compared to a single-stage SSVFCW (grain size for main layer 0.06-4 mm, free drainage, organic load 20 g COD x m(-2) x d(-1)) could be reached.

[Metabolic syndrome and peripheral arterial occlusive disease as indicators for increased cardiovascular risk]. / Metabolisches Syndrom und periphere arterielle Verschlusskrankeit als Indikatoren für erhöhtes kardiovaskuläres Risiko.

BACKGROUND AND AIMS: The usefulness of the metabolic syndrome (MetS) or a low ankle brachial index (ABI), respectively, to identify patients with high risk for cardiovascular events has repeatedly been postulated. However, robust data on the prevalence and prognosis of such patients are missing in the primary care setting. PATIENTS AND METHODS: In the prospective, non-interventional "German epidemiological trial on Ankle Brachial Index (getABI) at total of 6880 unselected patients > or = 65 years were observed by their General Practitioners over 3 years. Death and cardiovascular events were recorded. The definition of MetS was similar to the one of NCEP ATP III (National Cholesterol Education Program--Adult Treatment Panel III). ABI (ratio of the systolic blood pressures measured at the distal part of the calf and at the upper arm) was measured with Doppler sonography. Peripheral arterial disease (PAD) was defined as ABI <0.9 or peripheral revascularization/amputation owing to PAD. Survival analyses were conducted with a Cox proportional hazard model. Hazard rate ratios (HRR, 95 % confidence intervals, CI) were multvariate adjusted. RESULTS: The observation time for the total cohort was more than 20,000 patient years (PY). Cardiovascular mortality in patients with MetS (n = 3040, 44 %) compared to patients without MetS (n = 3795; 55 %) was doubled (8.5 vs. 4.0 per 1,000 PY; HRR: 2.0; CI 1.3 - 2.9). Concomitant presence of MetS and PAD (n = 651; 9.5 %) increased the mortality risk compared to patients without both conditions (n = 3194; 46.4 %) drastically (21.1 vs. 3.0 per 1000 PY; HRR: 5.7; CI: 3.5 - 9.4). Similar significant risk increases also were noted for all-cause mortality or a combined endpoint of mortality and vascular morbidity. Further, in lower ABI categories cardiovascular event rates increased. CONCLUSIONS: Patients with MetS carry a substantially increased risk of premature death, especially cardiovascular death, and therefore require intensive treatment of their risk factors. This holds especially true if concomitant PAD is present.

[Improvement in stroke care in a non-urban community hospital--quality of procedures before and after participating in a telemedical stroke network]. / Verbesserung der Schlaganfall-Behandlung in einem regionalen Versorgungskrankenhaus--Prozessqualität vor und nach Einbindung in ein telemedizinisch unterstütztes Schlaganfall-Netzwerk.

BACKGROUND: Although treatment in a stroke unit has been proven to be effective, most stroke patients in rural areas have no access to it. The community hospital of Ebersberg (Bavaria/Germany) joined the Telemedic Project for Integrative Stroke Care (TEMPiS) in order to optimize the quality of stroke care. This analysis focuses on changes in stroke management using generally accepted indicators for quality of acute stroke treatment. METHODS: The core elements consisted of the setting up of a stroke ward in the community hospital, continual stroke education and a 24-hour telemedical consultation service offered by stroke centers. Treatment of stroke patients was documented during two 12-months periods before the project was started start (i.e. retrospectively) and during the course of the project (prospectively). In addition, data on fatal outcome and institutionalization of patients who had lived at home before the qualifying event were collected 12 months after stroke onset. RESULTS: There were 299 admissions for stroke or transient ischemic attacks between 1 Nov 2001 and 31 Oct 2002, and 305 between 7 July 2003 and 6 June 2004. Length of in-hospital stay decreased from 12.1 to 9.2 days. More patients (10.3 vs. 1.3%) were transferred to other acute hospitals during the later period. Indicators for stroke care quality improved: numbers of cerebral imaging rose from 56.5% to 96.4%, of duplex sonography of cervical arteries from 43.5 to 72.8 %, of speech therapy from 0% to 50.8% and of occupational therapy from 0 to 33.4%. One year after admission, 18.9% and 17.2%, respectively, of the patients had died, while 10.2% and 6.1% were living in institutions. CONCLUSION: Participation in the TEMPiS network substantially improved stroke care quality according to national and international guidelines. These improvements may lead to a better prognosis after a stroke.

[Problems of emergency transfers of patients after a stroke. Results of a telemedicine pilot project for integrated stroke accommodation in southeast Bavaria (TEMPiS)]. / Problemfeld der Notfallverlegungen beim Schlaganfall. Ergebnisse des telemedizinischen Pilotprojekts zur integrierten Schlaganfallversorgung in Südostbayern (TEMPiS).

BACKGROUND: Specific stroke subtypes like subarachnoid hemorrhages or malignant brain infarcts require immediate interventions, but treatment options are offered mainly in specialized centers. For this reason, interhospital transfers from primary hospitals need to be done without delay. METHODS: The telemedic pilot project for integrative stroke care (TEMPiS) connects 2 stroke centers and 12 regional hospitals in Bavaria (Germany). Core elements are the implementation of stroke wards, telemedic consultation and improvement of emergency interhospital transfers. Organization of patient transports is offered by the central telemedic service. During the first 12 months of the continuing project all interhospital transfers initiated by the central telemedic service were prospectively documented. Emergency transports were analysed according to diagnosis, type of transport, distance and time delays. RESULTS: A total of 252 interhospital transfers were recommended in teleconsultations; finally 221 transports took place. Median total duration of transfers (including the necessary arrangements) was 134 min (interquartile range: 105-219) for intracerebral hemorrhages (N = 58), 138 min (95-157) for subarachnoid hemorrhages (N = 31), 161 min (100-230) for malignant infarcts (N = 22) and 147 min (109-180) for suspected basilar artery occlusion (N = 28). Time from admission in the primary hospital to initiation of interhospital transfer was 135 min (median; interquartile range: 86-172), transport time was 81 min (60-116). Helicopter transport did not save time for transfer distances up to 50 kilometres, compared to transport via ambulance (including assistance of hospital physicians). Transport using a special intensive care vehicle was much more time consuming because of the longer transport preparation time. CONCLUSION: Emergency transfers of stroke patients are time consuming. This may contribute to additional harm being done to severely ill patients. Faster organization and conduct of transports is required.