Is the digital divide an obstacle to e-health? An analysis of the situation in Europe and in Italy.

INTRODUCTION: The digital divide affecting elderly patients may compromise the diffusion of telemedicine systems for this age segment. It might be that the difficulties in the passage from trials to the effective distribution of telemedicine systems are also due to the awareness of a personal digital divide in the target population. MATERIALS AND METHODS: The analysis aims to estimate the number of people over the age of 50 years with potential cardiovascular problems able to access the Web. It made use of data from several sources (the Survey of Health, Ageing and Retirement in Europe and the Istituto Nazionale di Statistica Multiscopo Survey). Furthermore, with regard to Italy, the estimates obtained from official data were compared with those obtained in a survey investigating heart failure patients in Tuscany. RESULTS: In 2011, the percentage of people suffering from cardiovascular diseases and with Web access was 24% in Europe, with significant differences by country (ranging from 53% in Switzerland to below 20% in Italy, Spain, and Portugal). In Italy, however, the proportion of people with Web access increased from 2007 to 2011, and the survey in Tuscany showed that elderly people with limited information and communications technology skills overcame challenges and learned how to connect to the Web because they started to appreciate new technologies. CONCLUSIONS: The opportunity to use the Internet to monitor patients with chronic disease can serve as a challenge to reduce the digital divide gap and, furthermore, to increase their social and technological inclusion.

The informative contribution of the "virtual medical visit" in a new heart failure telemedicine integrated system.

INTRODUCTION: Telemedicine systems consist of collection, transmission, and analysis of biometric data essentially based on instrumental measures. Our goal was to evaluate if information collected from patients has an incremental informative value in automatically rating the patient's health status. MATERIALS AND METHODS: We present preliminary results of a new telemedicine system (ASCOLTA) obtained by observation of 12 heart failure patients (New York Heart Association Class IIb-III). Instrumental data (electrocardiogram, oxygen saturation level, and respiration rate) were wirelessly collected daily together with clinical data (weight, heart rate, and blood pressure values) and patients' information obtained through a Web-based questionnaire, simulating a virtual medical visit. Health status was independently judged by two blinded cardiologists and by the patient's cardiologist on the basis of 348 daily clinical reports. Random forest classification analysis was applied to 240 complete clinical report variables in order to estimate the judged health status. RESULTS: The use of "patient's information" led to a better predictive ability in comparison with using only physiological parameters assessed by instruments. The complete set of variables (Patient+Instrumental) achieved 84% concordance, compared with 72% for the instrumental-only variables and 69% for the patient-only variables. The receiver operator characteristics curves graphically confirmed the described results. CONCLUSIONS: Patients have an active role in home monitoring, and their information appears relevant for a new telemedicine approach integrating subjective and objective vital signs. Combining patient information with instrumental parameters, it is possible to achieve a more correct automatic classification of health status of heart failure patients.

Metabolic and cardiovascular effects of beta cell replacement in type 1 diabetes.

Type 1 diabetes is associated with high morbidity and mortality, mostly due to the acute and chronic complications of the disease. Restoration of the lost beta cell mass by pancreas transplantation is the treatment of choice in selected type 1 diabetic patients. Growing data show that successful pancreas transplantation normalizes the metabolic alterations of diabetes, and can slow the progression, stabilize, and even favor the regression of secondary complications of the disease, including those at the cardiovascular level.

Total thyroidectomy in patients with amiodarone-induced thyrotoxicosis and severe left ventricular systolic dysfunction.

CONTEXT: Patients with amiodarone-induced thyrotoxicosis (AIT) and left ventricular (LV) systolic dysfunction have a high mortality rate. Usually, medical therapy is the first choice for AIT patients, whereas the role of the thyroidectomy is unsettled. OBJECTIVE: The objective of the study was to evaluate the effect of a total thyroidectomy on cardiac function and survival of AIT patients with severe LV systolic dysfunction. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at a tertiary university center. PATIENTS: All AIT patients (n=24; nine patients with type 1 AIT, 15 patients with type 2 AIT) referred to the Department of Endocrinology and submitted to a total thyroidectomy at the Department of Surgery, both at the University of Pisa, during the years 1997-2010. INTERVENTION: The intervention was a total thyroidectomy. MAIN OUTCOME MEASURE: LV ejection fraction (EF) after the thyroidectomy and survival in December 2011 were measured. RESULTS: All enrolled patients had previously undergone to medical treatment for AIT, as appropriate, without achieving euthyroidism. Patients with moderate to severe LV systolic dysfunction (EF<40%, group 1, n=9) or with mild systolic dysfunction (40%≤EF≤50%, group 2, n=5) were compared with patients with normal systolic function (EF>50%, group 3, n=10). Two months after thyroidectomy, under levothyroxine replacement therapy, LVEF improved in patients with LV systolic dysfunction, particularly in those of group 1, in whom it increased from 28.2±7.2 to 38.3±6% (P=0.007). On the contrary, LVEF did not significantly change in group 3 (from 57.1±3.0 to 59.8±6.6%, P=0.242). The mean follow-up was 67±42 months. No death occurred during and 2 months after surgery. One death occurred in one patient of group 1, 30 months after the thyroidectomy, due to acute myocardial infarction. No patient had relevant complications of thyroidectomy. CONCLUSIONS: Total thyroidectomy, by rapidly restoring euthyroidism, may improve cardiac function and reduce the risk of mortality in AIT patients with severe LV dysfunction.

Long-term (5 years) efficacy and safety of pancreas transplantation alone in type 1 diabetic patients.

BACKGROUND: Although combined pancreas and kidney transplantation is an established procedure for the treatment of type 1 diabetes (T1D) in patients with end-stage renal disease, the role of pancreas transplant alone (PTA) in the therapy of T1D subjects with preserved kidney function is still matter of debate. METHODS: We report our single-center experience of PTA in 71 consecutive T1D patients all with a posttransplant follow-up of 5 years. Patient and pancreas (normoglycemia in the absence of any antidiabetic therapy) survivals were determined, and several clinical parameters (including risk factors for cardiovascular diseases) were assessed. Cardiac evaluation and Doppler echocardiographic examination were also performed, and renal function and proteinuria were evaluated. RESULTS: Actual patient and pancreas survivals at 5 years were 98.6% and 73.2%, respectively. Relaparotomy was needed in 18.3% of cases. Restoration of endogenous insulin secretion was accompanied by sustained normalization of fasting plasma glucose concentrations and HbA1c levels as well as significant improvement of total cholesterol, low-density lipoprotein-cholesterol, and blood pressure. An improvement of left ventricular ejection fraction was also observed. Proteinuria (24 hours) decreased significantly after transplantation. One patient developed end-stage renal disease. In the 51 patients with sustained pancreas graft function, kidney function (serum creatinine and glomerular filtration rate) decreased over time with a slower decline in recipients with pretransplant glomerular filtration rate less than 90 mL/min. CONCLUSIONS: PTA was an effective and reasonably safe procedure in this single-center cohort of T1D patients.

Myocardial delayed enhancement in paucisymptomatic nonischemic dilated cardiomyopathy.

OBJECTIVES: We investigated the prognostic role of myocardial fibrosis by delayed enhancement (DE) cardiovascular magnetic resonance (CMR) in nonischemic dilated cardiomyopathy (NICM) patients with no or mild symptoms of heart failure (HF). METHODS: A prospective cohort of 125 NICM patients (82 males, age 59±14years, mean±SD) with echocardiographic evidence of left ventricular (LV) systolic dysfunction (mean ejection-fraction 33±10%), without (stage B) or with history of mild HF symptoms (stage C, NYHA classes I-II) was enrolled. The end-point was a composite of cardiac death and HF hospitalization. RESULTS: Fifty (40%) patients showed myocardial DE, representing 12±7% of LV mass. During a median follow-up of 14.2months, 16 (32%) patients with DE experienced a composite event versus only 6 (8%) patients without DE (Kaplan-Meier survival curve, p=0.001). After correction for age, CMR-derived LV and right ventricular volumes, echocardiographic measurements of LV diastolic function and Doppler-estimated systolic pulmonary artery pressure, the presence of DE remained a strong and independent predictor of cardiac death or HF hospitalization (hazard ratio: 5.32, 95% confidence intervals 1.60 to 17.63, p=0.006). CONCLUSIONS: In NICM patients with no or mild HF symptoms, the presence of myocardial DE is a strong predictor of worse clinical outcome even after correction for other established prognostic determinants. Contrast-enhanced CMR may be useful in prognostic stratification from the early stages of NICM.

Results of pancreas transplantation alone with special attention to native kidney function and proteinuria in type 1 diabetes patients.

We report on our single-center experience with pancreas transplantation alone (PTA) in 71 patients with type 1 diabetes, and a 4-year follow-up. Portal insulin delivery was used in 73.2% of cases and enteric drainage of exocrine secretion in 100%. Immunosuppression consisted of basiliximab (76%), or thymoglobulin (24%), followed by mycophenolate mofetil, tacrolimus, and low-dose steroids. Actuarial patient and pancreas survival at 4 years were 98.4% and 76.7%, respectively. Relaparatomy was needed in 18.3% of patients. Restored endogenous insulin secretion resulted in sustained normalization of fasting plasma glucose levels and HbA1c concentration in all technically successful transplantations. Protenuria (24-hour) improved significantly after PTA. Renal function declined only in recipients with pretransplant glomerular filtration rate (GFR) greater than 90 ml/min, possibly as a result of correction of hyperfiltration following normalization of glucose metabolism. Further improvements were recorded in several cardiovascular risk factors, retinopathy, and neuropathy. We conclude that PTA was an effective and reasonably safe procedure in this single-center experience.

Weight loss and quality of life in chronic heart failure patients.

OBJECTIVES: To evaluate the impact of a planned body weight reduction on quality of life (QoL) in obese/overweight chronic heart failure (CHF) patients. METHODS: Thirty-four obese/overweight chronic heart failure patients (24 men, mean age 67.8 +/- 9.4 years) underwent a 6-month dietary programme. An assessment of clinical and biochemical parameters was executed before and after dietary programme. The QoL was judged by means of the Kansas City Cardiomyopathy Questionnaire (KCCQ) at baseline and at the end of the programme. RESULTS: End-study BMI (P < 0.005) and body weight (P < 0.04) values were significantly reduced. We observed a significant improvement in the mean New York Heart Association (NYHA) functional class value (P < 0.02) and in the left ventricle ejection fraction (LVEF) (P < 0.05). The end-study KCCQ scores were significantly increased in seven out of eight domains. We identified a cut-off value of body weight loss of 3 kg to separate responder patients from the nonresponder ones. Only responder group patients showed a significant variation in BMI (P < 0.04), body weight (P < 0.03), mean NYHA class value (P < 0.05), LVEF (P < 0.05). Moreover, all KCCQ domain scores significantly increased in the responder group only. CONCLUSION: A diet-based body weight reduction improved the quality of life and, perhaps, the cardiac function. Benefits are already evident with a small reduction in body weight.

Survival and hospitalization in a nurse-led domiciliary intervention for elderly heart failure patients.

AIM: Heart failure in the elderly population represents a complex clinical situation associated with frequent hospitalizations and numerous comorbidities. The present study aimed to evaluate the impact of a domiciliary-based nurse-led strategy in a group of very elderly patients affected by heart failure who were regularly seen at an outpatient heart failure clinic (HFC). METHODS: Patients were periodically assessed in their homes by two trained nurses under supervision of the cardiologists of the HFC. During each visit, the nurses examined clinical status and adherence to medication. When necessary, they also gathered venous blood samples for laboratory analysis and recorded an electrocardiogram. In addition, they provided key information regarding disease management to patients as well as to their care givers. During the baseline visit and, subsequently, every 6 months, an echocardiogram was performed at the HFC. RESULTS: Forty-four patients (52.4% male, median age 82 years) were followed up for a mean of 25 +/- 12 months. Compared to an equally long time period before randomization, during follow-up, a significant reduction in cardiac hospitalizations (from 1.83 +/- 1.54 to 1.07 +/- 1.39, P = 0.004), total hospitalizations (from 2.09 +/- 1.71 to 1.52 +/- 1.68, P = 0.003), HFC visits (from 3.31 +/- 2.33 to 2.24 +/- 1.38, P = 0.03) and New York Heart Association (NYHA) class (from 2.74 +/- 0.70 to 2.49 +/- 0.61, P = 0.04) was observed. Total 1-year mortality was 25% and was predicted by several clinical (weight loss, NYHA class), laboratory (hyperuricaemia, anaemia, renal failure, hyposodiemia) and echocardiographic (end-systolic diameter, ejection fraction, systolic pulmonary artery pressure) parameters. Multivariate analysis revealed that hyperuricaemia was as an independent predictor of mortality (odds ratio = 1.53, P = 0.038). CONCLUSIONS: The present study demonstrates that a domiciliary-based strategy in elderly patients affected by heart failure guarantees clinical stability and reduces hospitalizations as well as outpatient visits.

Acute effects of triiodothyronine (T3) replacement therapy in patients with chronic heart failure and low-T3 syndrome: a randomized, placebo-controlled study.

CONTEXT: Low-T(3) syndrome is a predictor of poor outcome in patients with cardiac dysfunction. The study aimed to assess the short-term effects of synthetic L-T(3) replacement therapy in patients with low-T(3) syndrome and ischemic or nonischemic dilated cardiomyopathy (DC). DESIGN: A total of 20 clinically stable patients with ischemic (n = 12) or nonischemic (n = 8) DC were enrolled. There were 10 patients (average age 72 yr, range 66-77; median, 25-75th percentile) who underwent 3-d synthetic L-T(3) infusion (study group); the other 10 patients (average age 68 yr, range 64-71) underwent placebo infusion (control group). Clinical examination, electrocardiography, cardiac magnetic resonance, and bio-humoral profile (free thyroid hormones, TSH, plasma renin activity, aldosterone, noradrenaline, N-terminal-pro-B-Type natriuretic peptide, and IL-6) were assessed at baseline and after 3-d synthetic L-T(3) (initial dose: 20 microg/m(2) body surface.d) or placebo infusion. RESULTS: After T(3) administration, free T(3) concentrations increased until reaching a plateau at 24-48 h (3.43, 3.20-3.84 vs. 1.74, 1.62-1.93 pg/ml; P = 0.03) without side effects. Heart rate decreased significantly after T(3) infusion (63, 60-66 vs. 69, 60-76 beats per minute; P = 0.008). Plasma noradrenaline (347; 270-740 vs. 717, 413-808 pg/ml; P = 0.009), N-terminal pro-B-Type natriuretic peptide (3000, 438-4005 vs. 3940, 528-5628 pg/ml; P = 0.02), and aldosterone (175, 152-229 vs. 231, 154-324 pg/ml; P = 0.047) significantly decreased after T(3) administration. Neurohormonal profile did not change after placebo infusion in the control group. After synthetic L-T(3) administration, left-ventricular end-diastolic volume (142, 132-161 vs. 133, 114-158 ml/m(2) body surface; P = 0.02) and stroke volume (40, 34-44 vs. 35, 28-39 ml/m(2) body surface; P = 0.01) increased, whereas external and intracardiac workload did not change. CONCLUSIONS: In DC patients, short-term synthetic L-T(3) replacement therapy significantly improved neuroendocrine profile and ventricular performance. These data encourage further controlled trials with more patients and longer periods of synthetic L-T(3) administration.

Admission C-reactive protein serum levels and survival in patients with acute myocardial infarction with persistent ST elevation.

OBJECTIVE: To evaluate the prognostic value of a single and early determination of high sensitivity C-reactive protein levels at admittance in patients with acute myocardial infarction with persistent ST elevation. PATIENTS AND METHODS: We evaluated high-sensitivity C-reactive protein levels in 247 consecutive acute myocardial infarction with persistent ST elevation patients at admittance. Patients were monitored for the occurrence of major adverse cardiovascular events. RESULTS: Mean follow-up was 26 months. High C-reactive protein levels were principally associated with age > or = 65 years (P=0.01), diabetes (P=0.03) and reduced left ventricle ejection fraction (P=0.048). We observed a significant C-reactive protein level difference between the major adverse cardiovascular event-free group and the major adverse cardiovascular event group (28.2+/-21.9 vs. 47.7+/-31.9 mg/l, P=0.03), between deceased patients group (vs. 81.5+/-51.8 mg/l, P<0.001) and early deaths (vs. 129.5+/-71.9 mg/l, P<0.001). Kaplan-Meier plots for survival and major adverse cardiovascular event occurrence showed a significant separation (P=0.01 and 0.002 by log-rank test, respectively) between high and low C-reactive protein level groups. C-reactive protein levels were independent risk predictors of major adverse cardiovascular events (odds ratio 2.931, 95% confidence interval 1.512-5.893; P=0.046) and death (odds ratio 5.068, 95% confidence interval 2.056-20.195; P=0.04). Patients with high C-reactive protein levels and age > or = 65 years were at highest risk for major adverse cardiovascular event occurrence (odds ratio 5.658, 95% confidence interval 2.898-6.249; P=0.022) and death (odds ratio 8.120, 95% confidence interval 5.656-22.729; P=0.03). CONCLUSIONS: High C-reactive protein levels identify patients with a worse prognosis after acute myocardial infarction with persistent ST elevation. The evaluation of C-reactive protein and age may provide a tool to select high-risk patients.

[Clinical features and diagnostic evaluation of heart failure in the elderly]. / Manifestazioni cliniche e valutazione diagnostica dello scompenso cardiaco nell'anziano.

The diagnosis of heart failure in the elderly frequently represents a clinical challenge. Atypical symptoms and signs and confounding comorbid conditions are common situations in old patients with heart failure and may obscure the clinical picture, complicating the diagnostic evaluation. Furthermore in the elderly, especially in female gender with a long-lasting history of hypertension, heart failure commonly may ensue as a consequence of a predominating impairment of the diastolic function with normal or near-normal preserved systolic function. Echocardiography represents the gold standard for the confirmation of the clinical suspicion of heart failure and may provide detailed information about left and right ventricular dimensions and function, atrial dimensions, valvular function and pericardium. For this reason it is recommended as part of initial diagnostic evaluation in almost all cases of heart failure. However, the low diagnostic accuracy of the clinical picture in elderly patients with suspected heart failure, as suggested by the international guidelines, requires the corroboration of the clinical suspicion with the help of "first-line" traditional investigations like ECG and chest X-ray. Recently natriuretic peptides (B-type natriuretic peptide [BNP] and NT-proBNP) have emerged as an attracting "tool" to support the clinical signs in patients with suspected heart failure. In this review we discuss about the opportunity that BNP and NT-proBNP would be relevant in the diagnostic process of elderly patients with suspected heart failure.

Pancreas transplant alone determines early improvement of cardiovascular risk factors and cardiac function in type 1 diabetic patients.

BACKGROUND: The effects of pancreas transplant alone (PTA) on cardiovascular risk factors (CRF) and cardiac function in type 1 diabetes mellitus (T1DM) patients are still unsettled. METHODS: We studied 13 T1DM patients who received PTA with portal drainage and 11 matched control patients. Parameters of glucose and lipid metabolism and several additional classic CRF were assessed before and up to 6 months posttransplant. Cardiac morphology and function were assessed by Doppler echocardiographic examination. RESULTS: Insulin independence was promptly achieved and then maintained after PTA. Total and low-density lipoprotein cholesterol levels were significantly lower after transplantation, whereas high-density lipoprotein cholesterol and triglyceride concentrations did not change. Both systolic and diastolic blood pressure values and fibrinogen levels improved significantly. In addition, PTA determined a significant amelioration of several morphologic and functional cardiac indices. None of the measured parameters changed in the control patients. CONCLUSIONS: PTA with portal drainage induces an early improvement of CRF and ameliorates cardiac function in patients with T1DM.