Quality assessment and cataloguing of telemedicine applications

We created a Web catalogue of approved telemedicine systems that authoritative Italian research bodies had made available for more general use. The evaluation process was divided into two stages: (1) classification of the telemedicine systems and rough preliminary evaluation; (2) assessment of the telemedicine products and services. The scoring method was applied to four well-known telemedicine systems that had been tested in health-care settings: an echocardiology teleconsulting and analysis system; a ward nursing management system; a virtual cooperative system for the management of oncology patients and a telepathology system based on remotely controlled microscopy. After technical revision during the standardization/qualification process, the applications were transferred successfully to eight new health-care facilities. The methodology achieved the main goal of providing effective tools, such as a set of quality control procedures for telemedicine and telehealth projects and a Web catalogue of telemedicine applications with a standardized level of quality, available to all interested parties.

Cardiac function during breath-hold diving in humans: an echocardiographic study

Breath-hold diving induces, in marine mammals, a reduction of cardiac output due to a decrease of both heart rate and stroke volume. Cardiovascular changes in humans during breath-hold diving are only partially known due to the technical difficulty of studying fully immersed subjects. Recently, a submersible echocardiograph has been developed, allowing a feasible assessment of cardiac anatomy and function of subjects during diving. Aim of the study was to evaluate, by Doppler-echocardiography, the cardiovascular changes inducedby breath-hold diving in humans. Ten male subjects were studied by Doppler echocardiography in dry conditions and during breath-hold diving at 3 m depth. In addition 14 male subjects were studied, using the same protocol, before and during breath-hold diving at 10 m depth. At 3 m depth significant reductions in heart rate (-17%), stroke volume (-17%), cardiac output (-29%), left atrial dimensions, and deceleration time of early diastolic transmitral flow (DTE) were observed. At 10 m depth similar but more pronounced changes occurred. In particular, increase in early transmitral flow velocity became significant (+33%), while DTE decreased by 34%. At both depths dimensions of right cardiac chambers remained unchanged. Breath-hold diving at shallow depth induced, in humans, cardiovascular changes qualitatively similar to those observed in natural divers such as seals. The reduced dimensions of left atrium associated to a left ventricular diastolic pattern resembling that of restrictive/constrictive heart disease, suggest that the hemodynamic effects of diving could be explained, at least in part, by a constriction exerted on the heart by the reduced chest volume and the increased blood content of the lungs. Finally, the absence of dimensional changes in the right chambers suggests that most of the pulmonary blood shift occurred before cardiac imaging.

An effective algorithm for quick fractal analysis of movement biosignals

The problem of numerically classifying patterns, of crucial importance in the biomedical field, is here faced by means of their fractal dimension. A new simple algorithm was developed to characterize biomedical mono-dimensional signals avoiding computationally expensive methods, generally required by the classical approach of the fractal theory. The algorithm produces a number related to the geometric behaviour of the pattern providing information on the studied phenomenon. The results are independent of the signal amplitude and exhibit a fractal measure ranging from 1 to 2 for monotonically going-forwards monodimensional curves, in accordance with theory. Accurate calibration and qualification were accomplished by analysing basic waveforms. Further studies concerned the biomedical field with special reference to gait analysis: so far, well controlled movements such as walking, going up and downstairs and running, have been investigated. Controlled conditions of the test environment guaranteed the necessary repeatability and the accuracy of the practical experiments in setting up the methodology. The algorithm showed good performance in classifying the considered simple movements in the selected sample of normal subjects. The results obtained encourage us to use this technique for an effective on-line movement correlation with other long-term monitored variables such as blood pressure, ECG, etc.

High-dose busulfan and cyclophosphamide are an effective conditioning regimen for allogeneic bone marrow transplantation in chemosensitive multiple myeloma

The present clinical trial was undertaken to investigate the toxicity and antimyeloma activity of busulfan (BU) and cyclophosphamide (CY) at the maximum tolerated doses of, respectively, 16 mg/kg and 200 mg/kg (BU-CY 4) as conditioning therapy for allogeneic bone marrow transplantation (BMT) in 19 consecutive patients with multiple myeloma (MM). Twelve (63%) had failed to respond to prior chemotherapy, while the remaining 37% had chemosensitive disease. No life-threatening or fatal regimen-related complications were observed. The incidence of veno-occlusive disease of the liver was zero according to Jones' criteria and 21% according to McDonald's system. Transplant-related mortality was 37%. Using stringent criteria, the frequency of complete remission (CR) was 42% among all patients and 53% among those who could be evaluated. With a median follow-up of 21 months for all patients and 66 months for survivors, the actuarial probability of survival and event-free survival at 4 years from BMT was 26% (95% CI: 7-46) and 21% (95% CI: 3-39), respectively. A more favorable outcome of transplantation was observed in the subgroup of patients with chemosensitive disease who had a transplant-related mortality of 14%, an overall CR rate of 86% (95% CI: 49-97) and a 4-year projected probability of event-free survival of 57% (95% CI: 20-93). Four of these patients are currently alive in continuous CR after 54, 66, 80 and 94 months, respectively. It is concluded that BU-CY 4 as conditioning for allogeneic transplantation for MM is associated with acceptable morbidity and relatively low mortality. This regimen exerts substantial antimyeloma activity, resulting in a high CR rate and durable responses, especially in patients with chemosensitive disease. Long-lasting remission and probable cure is possible following allogeneic stem cell transplantation for MM.

On the contribution of biomedical engineering and technology to the understanding and the management of arterial hypertension

There are several reasons why arterial blood pressure, i.e. the pressure within the large arterial vessels, is out of the physical parameters of the human body, one of the most frequently measured. Firstly, arterial blood pressure is a physiologically meaningful parameter, since it represents the driving pressure generated by the heart which maintains blood perfusion in the periphery. Secondly, it is a clinically important parameter: a decline of arterial blood pressure (e.g. in shock) may represent a life-threatening emergency which requires prompt recognition and correction; elevated blood pressure (hypertension) on the other hand is a very common condition, which bears a high risk of cardiovascular mortality and morbidity and can be controlled with appropriate pharmacological means. Thirdly, but not lastly, arterial blood pressure is easily measurable with a fair degree of accuracy by the standard manual sphygmomanometric method and, more recently, by non-invasive automatic techniques. This paper discusses some of the aspects related to arterial blood pressure measurement, in which, in the author's opinion, medical engineering and technology are expected to provide useful advancements. Two major areas will be considered. The first regards the methodologies for arterial blood pressure assessment; the second the identification and acquisition of information additional to blood pressure which would be helpful for a better understanding of blood pressure measurements and/or of risk profiling. For the purpose of this brief paper, we shall mainly use examples and reasonings from our own experience.

Autologous bone marrow transplantation in late first complete remission improves outcome in acute myelogenous leukemia

We evaluated the role of ABMT in late 1st CR AML adult patients using busulfan plus cyclophosphamide as preparative regimen. Fifty-one adult patients (mean age 36 years, range 15-59) with AML underwent ABMT in 1st CR. Three of them had a prior diagnosis of myelodysplastic syndrome; one patient had a secondary leukemia. The median interval between CR and ABMT was 8 months (range 4-20). Patients received busulfan, 4 mg/kg/day for 4 days plus cyclophosphamide 50 mg/kg/day for 4 days or 60 mg/kg/day for 2 days. No maintenance chemotherapy was administered after ABMT. Median days to reach 0.5 x 10(9)/I PMN and 20 x 10(9)/I platelets were 26 (range 12-250) and 74 (range 16-740), respectively. No transplant-related deaths were observed. Five-year actuarial overall survival rate is 76.9%; actuarial leukemia-free survival rate is 70.6%. Mean follow-up from ABMT is 35 months. Leukemia-free survival of this group was compared with that of 38 non-transplanted patients younger than 60 years, who maintained a CR longer than 8 months in the same period. This analysis shows a statistically significant difference in favor of ABMT patients. These results suggest that, even if performed late after 1st CR as post-remission intensification, ABMT can improve the outcome of AML patients.

Toxicity of high-dose busulphan and cyclophosphamide as conditioning therapy for allogeneic bone marrow transplantation in adults with haematological malignancies

The toxicity of the conditioning regimen high-dose busulfan (BU) 16 mg/kg followed by cyclophosphamide (CY) 200 mg/kg has been analysed in 60 adult patients (mean age 36 +/- 9 years) with haematological malignancies, a third of whom had advanced disease, all received the graft from fully HLA-identical siblings. Significant nausea and vomiting were rare during BU administration but occurred in 44% of the patients with CY. Severe mucositis occurred in 30% of patients. Haemorrhagic cystitis occurred in 16% of patients; interstitial pneumonia occurred in 3 patients and was fatal in one. Veno-occlusive disease of the liver occurred in 2 patients and was fatal in one: however, increase of bilirubin of at least twice the baseline value and/or isolated weight gain > 5% of pre-transplant value occurred in 28% of patients. These signs of liver toxicity disappeared in all patients after appropriate therapy. Normalisation of bilirubin levels took twice as long as normalisation of body weight: median 35 and 18 days, respectively. Hyperpigmentation of the skin, mainly involving flexural and pressure areas, occurred in 47% of patients and was manageable topically. Eight patients died of relapsed disease; 15 died of transplant complications but in six the original malignancy persisted or had recurred at the time of death. Overall transplant-related mortality was 15%. We conclude that the toxicity of this regimen has not been high, with the liver being the most seriously affected organ. A longer follow-up is necessary to assess long-term consequences.

Hematological recovery after autologous bone marrow transplantation for high-grade non Hodgkin's lymphomas: a single center experience

BACKGROUND

Both rhGM-CSF and rhG-CSF can accelerate hematological recovery after high-dose therapy and autologous bone marrow transplantation in patients with high grade non Hodgkin's lymphoma and reduce transplant-related morbidity after ABMT.

METHODS

The clinical course of 23 non randomized patients was analyzed and compared with a historical control group of 10 patients. Ten patients received GM-CSF at a dose of 10 micrograms/kg in a 6-h IV infusion, and 13 received G-CSF at a dose of 5 micrograms/kg subcutaneously. Control patients received no GFs.

RESULTS

Mean granulocytic recovery to 0.5 x 10(9)/L was obtained 13.1 +/- 3.2 days after marrow reinfusion in the G-CSF arm vs 16 +/- 2.7 in GM-CSF pts (p = 0.03) and vs 19.6 +/- 7.6 in controls (p < 0.01); this reduction led to a statistically significant shorter duration of fever and parenteral antibiotic therapy. Platelet recovery to 20 x 10(9)/L was not significantly influenced by GFs.

CONCLUSIONS

These results indicate that only G-CSF accelerates hematological recovery after high-dose chemotherapy and autologous bone marrow transplantation and induces a significant decrease in terms of infection morbidity and duration of hospital stay.

In vitro amplification of hypervariable DNA regions for the evaluation of chimerism after allogeneic BMT

The role of mixed hematopoietic chimerism in engraftment and relapse after allogeneic BMT remains unclear. To better evaluate post-transplant chimerism we used polymerase chain reaction (PCR) in vitro amplification of four single locus simple repetitive DNA sequences, all of which vary extensively in their repeat number among different individuals: variable number of tandem repeats D1S80, APOB and D17S5, and the tetranucleotide repeat F8VWF. We tested 13 cases of CML, four of multiple myeloma (MM), three of ANLL and one of B-CLL. In a sequential analysis protocol with the different loci, the donor could be distinguished from the recipient in 14 of 20 (70%) pairs with the first marker used (D1S80). When a donor of opposite sex was involved, karyotyping and Y chromosome-specific PCR were also used. With the use of the four markers, chimerism was identified in all the pairs. Mixed chimerism was present in 5 patients, and complete chimerism in 15. No patients relapsed. The application of PCR for documenting post-transplant chimerism has several advantages over Southern blotting: increased sensitivity, use of small amounts of sample, ease of preparation of DNA, elimination of restriction enzyme analysis and of radioisotopes, and speed.

Ticlopidine in the treatment of thrombotic thrombocytopenic purpura: report of two cases

The observation of two clinical cases make possible an evaluation of the potential therapeutic activity of platelet function inhibitors in thrombotic thrombocytopenic purpura (TTP). In particular, the clinical and hematological effects of ticlopidine (TC), employed alone in two TTP patients, are reported. The mechanism of action of this peculiar antiplatelet drug is mainly represented by the inhibition of fibrinogen binding on the platelet surface. In the first patient, a 45-year-old female in whom plasma-exchange (PE) and corticosteroids (C) led to a partial remission (platelets 80 x 10(9)/l), treatment with TC at a dose of 750 mg/day was carried out, and after 6 weeks a normal platelet count was observed. A complete remission was maintained for 31+ months, even after reduction of the TC dose to 250 mg/day. In the second patient, an 18-year-old female affected by relapsing TTP, a complete remission obtained with PE and C was maintained for 19 months in concomitance with TC treatment, started at a dose of 750 mg/day and lowered to 250 mg/day. After 11 months of treatment at this low dosage there was a relapse (platelets 20 x 10(9)/l), but the increase of the TC dose to 750 mg/day in a few weeks induced a complete remission again. These data, in accord with a few other recent preliminary reports, suggest that TC, even alone, may play an interesting role in the management of TTP patients.