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Data-driven scheduling predicts patient no-shows

by System Administrator - Thursday, 11 September 2014, 2:55 PM
 

Data-driven scheduling predicts patient no-shows

By Michael B. Farrell

With all the advancements in health care, the medical profession still cannot get its appointment book in order.

Doctors are constantly overbooked. Patients constantly rescheduling. One day a waiting room is packed, the next it’s empty.

So when Gabriel Belfort attended a health care hackathon at the Massachusetts Institute of Technology in 2012, he challenged the coders, engineers, and clinicians there to fix that nagging issue.

“There’s a scheduling problem in medicine,” said Belfort, who at the time was a postdoctoral student studying brain science at MIT. “If you’ve had an appointment and you’ve showed up on time, you’ve probably had to wait.”

That dilemma posed by Belfort generated a very MIT proposal: What if you could use data science to determine which patients are likely to show up and which ones will be no-shows and manage office appointments around those tendencies?

“It was immediately clear to me that this is a problem that computers could solve,” Belfort said.

In short order, Belfort and an ad hoc team of nine people — students and health care professionals — at the hackathon built a prototype to prove out the concept. Then, so excited by the prospect that they could solve one of health care’s chronic pains, Belfort and three others who were strangers before that weekend launched a startup, aptly named Smart Scheduling Inc.

Here’s the gist: Smart Scheduling mines patient scheduling histories to determine who is more likely to cancel or miss an appointment. It then sends alerts to the scheduling programs that doctor offices use to book appointments.

If a patient is in a high-risk category, for instance, it prompts office schedulers to call with a reminder. If the patient cannot be reached, there is a good chance he will not show up at all. So, the doctors could then book another patient for that time slot, keeping the patient flow consistent throughout the day.

Within months of forming, Smart Scheduling attracted the interest of Healthbox, an accelerator program that invests $50,000 in promising startups and gives them free office space and mentoring. It also landed a meeting with executives at athenahealth Inc., which eventually resulted in Smart Scheduling’s becoming the first startup in the Watertown health information company’s new accelerator program. Athenahealth also made an undisclosed investment to help the company build out its marketing and sales efforts.

So far, Smart Scheduling has attracted some $500,000 in early-stage investment.

 

And already it has two large health systems signed up as customers: Martin’s Point Health Care, which runs health centers in Maine, and Steward Health Care System, one of the biggest hospital groups in Massachusetts, where the software is being used by about 40 of its doctors offices.

Dr. Michael Callum, president of Steward Medical Group, said Smart Scheduling helps take some of the ambiguity and guesswork out of making appointments; by eliminating unexpected down time, Steward doctors systemwide are able to see 100 more patients every week.

“When you leave it to the front-desk people in the office, they are not all that good of predicting flow in terms of when patients will show up,” Callum said. “It turns out that Smart Scheduling is much better at predicting that.”

Here is what Smart Scheduling has learned about us as patients: If we are single, or under 40, we are more likely to cancel an appointment than an older or married patient. New patients miss more appointments than regulars.

In general, expecting patients to show up for the 1 p.m. slot is a bad idea. On the other hand, Wednesdays are great, as patients are not likely to cancel on those days.

So far, Smart Scheduling has developed 722 variables that it uses to make predictions, based on an analysis of millions of data points about patients from athenahealth. And the more data Smart Scheduling can crunch, the better it gets at predicting behavior

The company says that, so far, its analysis has proven accurate 70 percent of the time when predicting cancellations.

“If everybody got a better schedule, we’d all be happier,” said Ateet Adhikari, director of the Healthbox accelerator program. “The patients benefit, the doctors benefit, and the insurer benefits. A more efficient system trickles down.”

Smart Scheduling was among the first companies that Healthbox invested in when it launched in Boston in 2012. Since then, it has backed 19 health-related startups.

Smart Scheduling exemplifies a new type of health care startup; instead of going after the big issues in health care — curing cancer, for instance — they are targeting more modest changes to improve the medical experience with technology.

“Companies like Smart Scheduling are dramatically improving health care not by producing a new drug,” said Bill Aulet, director of the Martin Trust Center For MIT Entrepreneurship. “It’s by streamlining the process and getting increased efficiencies.”

Belfort has since gone on to work at a local biotech company, although he remains an adviser to Smart Scheduling. Out of the group that came together to build the original product at the MIT hackathon in 2012, only Chris Moses has stuck around full time, and is now the company’s chief executive.

Improving patient flow in the doctor’s office is just the first step, Moses said. “The next step,” he added, “is to try to figure out who are the sickest patients and who the ones are that need to be seen first.”

Link: http://www.bostonglobe.com

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De-identification effective in maintaining patient privacy if done right

by System Administrator - Saturday, 9 August 2014, 1:28 AM
 

De-identification effective in maintaining patient privacy if done right

By Katie Dvorak

As hospitals and healthcare organizations adopt new ways to store and share data, privacy and security of the information is a top priority--and with that comes de-identification of data.

When it comes to HIPAA, there are two standards that allow for the sharing of data while maintaining privacy protections, according to privacy attorney Scot Ganow and Khaled El Emam, senior scientist at the Children's Hospital of Eastern Ontario Research Institute, both of whom spoke with HealthcareInfoSecurity.com.

The first HIPAA method for de-identifying data, according to Ganow, of Faruki Ireland & Cox, is to strip out the data and identifiable elements, though, he added that doing so doesn't offer a lot of value. The second, he said, is to de-identify data through the expert determination standard, which allows researchers to "retain a lot of the value of the info ... [while] at the same time carrying a very low risk of re-identification."

Emam, who also serves as the director of the multidisciplinary Electronic Health Information Laboratory at the Children's Hospital institute, also emphasized using the expert determination method, saying it allows for more flexibility.

He told HealthcareInfoSecurity.com that not every organization uses the standards, and in those cases, the data won't be protected.

In addition to HIPAA, the Federal Trade Commission also has de-identification standards, including that an organization takes reasonable steps to de-identify protected data and announces that re-identification of data will not occur.

However, some are not sure that de-identification goes far enough in protecting patients.

Some studies have shown the possible ease with which de-identified data can be linked with a patient, including one by Harvard University researchers who were able to identify and link anonymous participants in a public DNA study with their personal data.

And while HIPAA specifies how data should be de-identified, a report by the Bipartisan Policy Center maintains that too much variability exists in the execution of anonymization.

Emam, though, said that if the process is done right, it is very difficult to re-identify data. He stressed that problems occur when organizations do a "lousy job" with de-identification, and that makes it easy for someone to reverse.

To learn more:
- listen to the HealthcareInfoSecurity.com interview

Related Articles:

Panel: Cloud's role in healthcare still up in the air
Anonymous research patients easily re-identified, Harvard researchers find
HIPAA burdensome to big data healthcare efforts, BPC says

Read more about: Federal Trade Commission, Deidentification

 

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Delivering Healthcare on an iPhone

by System Administrator - Tuesday, 16 September 2014, 9:05 PM
 

Delivering Healthcare on an iPhone

Joseph Kvedar at TEDxMidAtlantic

Joseph C. Kvedar, MD, is the Founder and Director of the Center for Connected Health, creating a new model of healthcare delivery, by developing innovative strategies to move care from the hospital or doctor's office into the day-to-day lives of patients. Dr. Kvedar is creating innovative programs to leverage information technology -- cell phones, computers, networked devices and simple remote health monitoring tools -- to help providers and patients manage chronic conditions, maintain health and wellness and improve adherence, engagement and clinical outcomes. Based on the technology platform developed at the Center, Healthrageous, a personalized health technology company, was launched in 2010, offering a range of health and wellness self-management programs to their clients.

In the spirit of ideas worth spreading, TEDx is a program of local, self-organized events that bring people together to share a TED-like experience. At a TEDx event, TEDTalks video and live speakers combine to spark deep discussion and connection in a small group. These local, self-organized events are branded TEDx, where x = independently organized TED event. The TED Conference provides general guidance for the TEDx program, but individual TEDx events are self-organized.* (*Subject to certain rules and regulations).

Top 10 Essential iPhone Apps for Doctors and Medical Students

by Giriraj Ranawat

 

#1. Heart Pro III

Paid – $2.99

This app, offered by 3D4 Medical in conjunction with Stanford University School of Medicine, allows users to rotate, cut, and label different components of a realistic 3D heart. This latest version contains many improvement which include, complete 360 degree 3D horizontal degree rotation of any body part with a swipe of your finger, 19 free & 51 paid animations, 2 types of Quiz, 62 images isolating elements of the heart.

#2. Epocrates

Free

This app is freely available across many mobile platforms including., Android, Blackberry and iPhone. Epocrates is a trusted clinical resource which helps in better patient care by delivering right information at the time it is required. More than 1 Million active members including 50 per cent US Physicians rely on this app to provide accurate and effective solution to there regular problems. It also perform dozens of calculations, such as BMI and GFR and timely medical news and research information.

#3. Medscape

Free

Medscape is used by more than 3 million healthcare professionals throughout the world and was the most downloaded app in Medical category in the year 2010. Developed by WebMD, Medscape provides Medical news and critical alerts in 34 specialty areas. It has a large pool of clinical resource which includes., 4,000+ evidence-based articles, 600+ step-by-step procedure videos, 100+ tables & protocols and Medical Calculators.

#4. Anesthesiology i-pocketcards

Paid – $3.99

Developed by Börm Bruckmeier Publishing, this app is a concise clinical reference guide with a compilation of scores, classifications, algorithms, and dosage information necessary for the anesthesiologist’s environment. It also contains an effective fluids and electrolytes management system, a table of anti-coagulation and neuraxial anesthesia, and special information about cardiothoracic and obstetric anesthesia.

#5. Eye Chart

Free

This is a great little app when you’re triaging, and can’t get the formal eyechart posted somewhere else in your department. Eye chart is used by eye care professionals and others to measure visual acuity. Snellen charts are named after the Dutch ophthalmologist Herman Snellen who developed the chart in 1862.

#6. Doximity

Free

Meant for US Physicians only, this app proves to be an effective and reliable medium to communicate and keep up with other medical peers. There are already 1 lac Doctors on this network and is considered as the most powerful medical directory and communication tool in the world. This app can really help you in building your Social and Professional Network if you are a newbie in Medical field.

#7. The ECG Guide

Paid – 55 INR

ECG Guide is a reservoir if around 200 examples of common and uncommon ECGs. It also incorporates ECG Interpreter which help sin stepwise assistance with ECG interpretation. You can also test your knowledge with 100 multiple-choice quiz questions updated regularly.

#8. MedCalc

Paid – 110 INR

This Medical Calculator helps to sort out complex medical calculations and problems using a simple UI. MedCalc continues to be the best and trusted medical calculator of all time for medical personnels providing easy access to complicated medical formulas, scores, scales and classifications. It features a Customizable list of favorite equations too.

#9. Psych Terms

Free

Verbal skills are must for any profession and the same goes for medical science too, with access to 1000+ frequently used psychiatric and mental health terms, phrases and definitions, Psych Terms continues to remain a quick and handy reference for both physicians and students. Surprisingly, these all words are available offline i.e., you don’t need a internet or Wi-Fi connection to access the resource.

#10. Pocket Lab Values

Paid – $2.99

Mathematical figures and values are quiet complicated and tedious to remember, so a ready reference to this stuff is necessary. Pocket Lab Values is the perfect companion for health professionals with access to over 320 common and uncommon lab values. Despite, of many apps providing the same feature, Pocket Lab Values contains more lab values than any other app on the store because of the consistent effort and feedback it takes from its users.

Does any of your favourite app made a miss from the list ?? It will be highly appreciated if you report the same to us and which will subsequently help us in mending the article too. 

 

Giriraj Ranawat

Giriraj Ranawat is a passionate tech blogger from Rajasthan, India. He is an avid traveler and love to explore new dimensions of technology. You can follow him at Twitter

 

 

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Demand for telehealth services causes price increase

by System Administrator - Thursday, 30 March 2017, 12:31 PM
 

Demand for telehealth services causes price increase

by Kristen Lee

The price of telehealth services may only continue to increase in the coming years as healthcare providers and businesses are using online consultations more and more. This has not only increased the demand for telehealth services during a three year period up to 2017, according to a market research report by IBISWorld, but also caused an increase in price. IBISWorld expects the price to only increase in the coming years through 2020.

However, telehealth market competition is helping keep price growth in check since the telehealth market is highly fragmented and competitive, the report said. Although, there are a few prominent players such as Teladoc and Doctor On Demand.

“IBISWorld estimates that there are about 640 firms currently operating in the US telehealth market. Moreover, most operators are small and midsize firms that are privately owned and operated. In the next three years, market share concentration is projected to remain low as new players enter the market, warranting strong price competition,” Anna Son, procurement research analyst at IBISWorld, said in a press release.

In 2017 alone, prices of telehealth services are expected to grow 3.5%, Son said in the release. This is because more and more employers are and will be offering more telehealth services to their employees. Son said in the release that this is “to help curb skyrocketing healthcare costs related to employee sickness and absenteeism.”

Regulations contribute to price increase

In the United States today 30 states and the District of Columbia require private health insurance carriers to provide the same coverage for telehealth services as they do for in-person visits over the next three years, the release said.

Furthermore, during the three year period in which the demand for telehealth services grew, there were also a number of regulatory changes as well with more to come, the release said. Currently, there are more pending legislations that are expected to help facilitate the adoption of telehealth in the future.

“A rising number of health insurance companies are planning on expanding their coverage for telehealth services. These regulatory changes will help accelerate the integration of telehealth services in healthcare settings, thus leading to anticipated double digit sales growth and rising service rates in the coming years,” Son said.

Link: http://searchhealthit.techtarget.com

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Depresión en el anciano

by System Administrator - Thursday, 9 October 2014, 10:55 AM
 

Un cuadro complejo, con comorbilidades y alto riesgo

Depresión en el anciano

La depresión en el anciano es frecuente y conlleva mayor riesgo de suicidio que en otros grupos etarios. Hay tratamientos eficaces, como los inhibidores selectivos de la recaptación de serotonina (ISRS) y la psicoterapia.

Audio

Resumen

La depresión en personas mayores de 60 años es frecuente y a menudo se asocia con enfermedades coexistentes, disfunción cognitiva o ambas. Los ancianos con depresión tienen mayor riesgo de suicidio.

La farmacoterapia o la psicoterapia se pueden emplear como tratamiento de primera línea. Los antidepresivos son eficaces para los ancianos, pero éstos pueden tener mayor riesgo de efectos colaterales. Los inhibidores selectivos de la recaptación de serotonina (ISRS) se consideran como tratamiento de primera línea.

La psicoterapia (conductual cognitiva o terapia de resolución de problemas) también es eficaz para la depresión en el anciano.

Cuadro clínico

La depresión en la vejez es la aparición de un trastorno depresivo mayor en adultos de 60 años o más. Se produce en hasta el 5% de los adultos mayores no institucionalizados y el 8 - 16% de los ancianos sufren síntomas depresivos clínicamente significativos. Las tasas de trastorno depresivo mayor aumentan cuando el paciente sufre otras enfermedades concomitante, hasta el 5-10% en atención primaria y hasta el 37% tras hospitalizaciones en cuidados intensivos.

En relación con los ancianos que refieren un episodio depresivo inicial en la juventud, aquéllos con depresión de inicio tardío son más proclives a sufrir trastornos neurológicos, entre ellos deficiencias en las pruebas neuropsicológicas y cambios relacionados con la edad mayores que lo normal en los estudios por imágenes; tienen también más riesgo de demencia ulterior. Estas observaciones generaron la hipótesis de que la enfermedad vascular puede contribuir a la depresión en algunos ancianos.

Tabla 1 Criterios Diagnósticos del DSM-5 para el trastorno depresivo mayor.
Deben estar presentes cinco o más de los siguientes síntomas casi todos los días durante dos semanas:

Síntomas principales (≥1 necesarios para el diagnóstico).

* El DSM-5 es el Manual Diagnóstico y Estadístico de Trastornos Mentales, Quinta edición.

El problema clínico

El mal estado anímico puede ser menos frecuente en ancianos con depresión que en adultos más jóvenes deprimidos, mientras que la irritabilidad, la ansiedad y los síntomas somáticos suelen ser más frecuentes en ancianos. Los factores psicosociales estresantes, como la muerte de un ser querido, pueden desencadenar un episodio depresivo, aunque las reacciones transitorias a las pérdidas importantes pueden simular depresión.

Las personas con depresión en la vejez tienen mayores tasas de enfermedades concomitantes y por lo tanto de empleo de medicamentos, que los que no están deprimidos. La relación entre depresión y enfermedad coexistente puede ser bidireccional: problemas médicos como el dolor crónico pueden predisponer a la depresión y ésta a su vez se asocia con peor evolución de enfermedades como las cardiopatías. Las enfermedades concomitantes pueden generar polifarmacia, entre otros, los efectos de los psicotrópicos sobre algunas enfermedades y sobre el metabolismo de otros medicamentos.

El deterioro cognitivo es frecuente en ancianos con depresión. La depresión puede ser un factor de riesgo para el deterioro cognitivo y una manifestación del mismo: se asocia con el aumento a largo plazo de demencia. Las deficiencias cognitivas pueden ser signos de envejecimiento cerebral acelerado que predispone y perpetúa la depresión.

Estrategias y evidencia

Evaluación
La U.S. Preventive Services Task Force recomienda la detección sistemática de la depresión si se cuenta con apoyo para asegurar el diagnóstico preciso y el tratamiento y el seguimiento apropiados. Para evaluar la depresión se deben emplear mediciones validadas, como el Patient Health Questionnaire 9, que refleja los criterios diagnósticos (véase tabla 1). Debido a que las tasas de suicidio son altas en los ancianos, especialmente en los hombres, es necesario explorar cuidadosamente la existencia de pensamientos suicidas.

En la tabla 2 se resumen puntos importantes de los antecedentes

Son signos de alarma para la intervención urgente: síntomas graves o que empeoran, las tendencias suicidas y el deterioro del funcionamiento cotidiano.

Los exámenes complementarios recomendados son: hemograma para descartar anemia, glucemia, tirotrofina, ya que el hipotiroidismo puede imitar los síntomas depresivos. Se recomienda también medir las cifras de vitamina B12 y folato ya que la frecuencia de deficiencia de vitamina B12 aumenta con la edad y las cifras bajas de ésta y de folato pueden contribuir a la depresión.

La prueba cognitiva (e.g.,Mini–Mental State) se justifica para personas que refieren problemas de memoria y puede revelar deficiencias en el procesamiento visual espacial o la memoria, aún si la puntuación total está dentro de lo normal.

Tratamiento

Cambios en los hábitos de vida

Se debe estimular a los ancianos deprimidos a aumentar su actividad física en la medida de lo posible. En un metanálisis de siete estudios aleatorizados, controlados, el ejercicio de intensidad moderada redujo los síntomas depresivos. Otras recomendaciones son mejorar la alimentación y aumentar las actividades placenteras y las interacciones sociales. En general, debido a que la depresión aumenta la dificultad de iniciar cambios en los hábitos de vida, estas recomendaciones son insuficientes si no se efectúan farmacoterapia, psicoterapia o ambas.

Farmacoterapia

Debido a sus escasos efectos secundarios y su bajo costo, los inhibidores selectivos de la recaptación de serotonina (ISRS), son el tratamiento de primera línea para la depresión de la vejez. En algunos estudios aleatorizados, controlados, aunque no en todos, ISRS como la sertralina, la fluoxetina y la paroxetina fueron más eficaces que el placebo para disminuir los síntomas de depresión.

En general, los que mostraron un beneficio significativo en pacientes con depresión de la vejez fueron grandes estudios; por ejemplo, los estudios que mostraron que la sertralina es beneficiosa tuvieron más de 350 participantes en cada grupo. En los estudios más importantes, las tasas de respuesta a los ISRS (≥50% de reducción en la gravedad de la depresión) oscilaron entre el 35 y el 60%, mientras que la respuesta al placebo fue del 26 - 40%. Las tasas de remisión (síntomas depresivos mínimos) fueron del 32 -44% con los ISRS versus 19 - 26% con el placebo.

Los efectos adversos comunes de los ISRS, que suelen ser leves, son náuseas y cefalea. Pero preocupan informes que observan mayor riesgo de accidente cerebrovascular (ACV) entre personas que reciben ISRS que entre los que no los emplean. Se observó aumento similar del riesgo de ACV con otras clases de antidepresivos, para lo cual no hay una explicación evidente.

Los inhibidores de la recaptación de serotonina-norepinefrina (IRSN) se emplean como fármacos de segunda línea cuando no se logra remisión con los ISRS. Al igual que con estudios en adultos más jóvenes, los estudios aleatorizados con ancianos no mostraron diferencias significativas entre los beneficios de los ISRS y los de los IRSN, aunque los efectos adversos pueden ser más frecuentes con estos últimos.

Si los ISRS o los IRSN son ineficaces, se pueden considerar los antidepresivos tricíclicos, que tienen eficacia similar, si bien sus efectos colaterales son mayores. Los antidepresivos tricíclicos están incluidos en la lista de los Beers Criteria entre los medicamentos que pueden ser inapropiados por sus frecuentes efectos adversos en los ancianos.
Estudios abiertos y pequeños estudios controlados avalan el empleo de bupropión y mirtazapina en pacientes con depresión en la vejez, pero faltan estudios rigurosos controlados por placebo.

Tras ser autorizados para su empleo auxiliar en la depresión resistente al tratamiento, los antipsicóticos de segunda generación olanzapina y aripiprazol se emplean cada vez más para tratar la depresión no psicótica. Un análisis conjunto de subgrupos que incorporó datos de tres estudios controlados por placebo, la mayoría con adultos más jóvenes, mostró que entre pacientes de 50 - 67 años, las tasas de remisión con 6 semanas de refuerzo con aripiprazol fueron mayores que con refuerzo con placebo (32,5% vs. 17,1%). La acatisia fue el efecto colateral más común, en el 17% de los pacientes ancianos. Son necesarios datos a más largo plazo en estos pacientes.

Psicoterapia

La psicoterapia es eficaz para la depresión de la vejez y se la puede considerar como tratamiento de primera línea. Los enfoques terapéuticos son, entre otros, una fase de tratamiento breve, consistente en visitas semanales durante 8 - 12 semanas. Aunque otros tratamientos también pueden ser eficaces, la evidencia más fuerte a favor del tratamiento breve es la de la terapia conductual cognitiva y la terapia de resolución de problemas.

Poder generalizar, sin embargo, es difícil, porque la mayoría de los estudios de psicoterapia para la depresión de la vejez son en poblaciones geriátricas con cognición intacta, con buen nivel educativo, blancos y relativamente jóvenes.

La terapia conductual cognitiva se centra en identificar y reformular los pensamientos negativos, disfuncionales y al mismo tiempo aumentar la participación en tareas agradables y actividades sociales. Su efecto puede ser más débil en personas con enfermedades físicas o con deterioro cognitivo.

La terapia de resolución de problemas se centra sobre el desarrollo de aptitudes para mejorar la capacidad de afrontar los problemas. Estudios aleatorizados con ancianos mostraron que el tratamiento de resolución de problemas produce mayor mejoría de la depresión que la atención habitual o la terapia de reminiscencia, una psicoterapia centrada en la evaluación y la reformulación de episodios de la vida pasada.

La terapia de resolución de problemas es eficaz para tratar los síntomas depresivos en ancianos con deficiencias cognitivas (sobre todo disfunción ejecutiva), grupo que con frecuencia no responde bien a los antidepresivos. En un estudio de población con deficiencias cognitivas, la terapia de resolución de problemas produjo más remisiones que la terapia de apoyo (el 46% vs. el 28% a 12 semanas), así como también mayor mejoría de la discapacidad y mantuvo los beneficios durante por lo menos 24 semanas.

La terapia interpersonal para ancianos con depresión se centra en las transiciones de roles, la tristeza y las cuestiones interpersonales. En estudios aleatorizados esta terapia redujo mucho más los síntomas depresivos que el tratamiento habitual. Al igual que con la terapia cognitiva conductual, las personas con otras enfermedades concomitantes o con deficiencias cognitivas quizás no respondan bien a la terapia interpersonal.

Tratamiento de mantenimiento

Estudios longitudinales mostraron beneficios significativos del tratamiento continuo tras la remisión. Uno de ellos se efectuó con ancianos con depresión recurrente que tuvieron una remisión breve con nortriptilina y terapia interpersonal durante 16 semanas.

Se asignó aleatoriamente a los participantes a tratamiento de mantenimiento con nortriptilina o placebo y a una sesión mensual de psicoterapia (terapia interpersonal) o a ninguna psicoterapia. Tres años después, las tasas de recidiva fueron significativamente menores entre las personas asignadas a tratamiento continuo con nortriptilina sola (43%), nortriptilina y terapia interpersonal (20%), o terapia interpersonal sola (64%) que entre las que recibieron placebo sin terapia interpersonal (90%).

Sin embargo, en un estudio similar sobre pacientes con un primer episodio de depresión, el tratamiento de mantenimiento con paroxetina (sola o con terapia interpersonal), pero no con terapia interpersonal sola, disminuyó el riesgo de recidiva a 2 años, en relación con ningún tratamiento de mantenimiento. No hay datos de estudios aleatorizados a largo plazo para evaluar la eficacia del tratamiento de mantenimiento con terapia cognitiva conductual o terapia de resolución de problemas para la depresión del anciano.

Estimulación cerebral

El tratamiento electroconvulsivo (TEC) o electroshock es el tratamiento más eficaz para los pacientes con depresión intensa, incluidos los ancianos. Aunque los antidepresivos son el tratamiento de primera línea, el TEC se debe considerar si los pacientes son suicidas, no respondieron a los medicamentos antidepresivos, tienen un trastorno físico deteriorante o una discapacidad relacionada con la depresión que amenaza su posibilidad de vivir independientemente.

Datos de estudios abiertos, con pacientes que no respondieron a los antidepresivos, sugieren tasas de remisión del 70 - 90% con TEC. Faltan datos de estudios controlados de alta calidad con intervención simulada que empleen técnicas modernas de TEC. Estudios aleatorizados muestran altas tasas de recaída (40 - 50% en los 6 meses posteriores al tratamiento).

El TEC tiene pocas contraindicaciones. Los efectos colaterales más frecuentes son confusión con amnesia anterógrada y retrógrada; las técnicas actuales de administración disminuyen este riesgo y los síntomas cognitivos se resuelven tras finalizar el TEC. Las personas con enfermedad cardiovascular o neurológica tienen mayor riesgo de problemas de memoria relacionados con el TEC.

La estimulación magnética transcraneal (EMT) es un tratamiento más nuevo que emplea un campo electromagnético focal generado por una bobina situada sobre el cuero cabelludo, en general sobre la corteza prefrontal izquierda. Las sesiones se efectúan cinco veces a la semana durante 4 - 6 semanas.

Este tratamiento no tiene efectos secundarios cognitivos. Sin embargo, un metanálisis de seis estudios que compararon la EMT con el TEC mostraron que el TEC tiene mayores tasas de remisión. Algunos estudios sugieren que la respuesta en los ancianos deprimidos puede no ser tan positiva como la de los pacientes más jóvenes.

Dudas

Los datos sobre la eficacia y la seguridad de muchos antidepresivos en poblaciones ancianas son escasos o ausentes y quizás haya riesgos específicos para estas poblaciones. Los datos sobre la farmacoterapia prolongada y las estrategias de mantenimiento de la psicoterapia en poblaciones ancianas también son limitados.

No es evidente cuál es la mejor manera de tratar las deficiencias cognitivas en pacientes ancianos con depresión. Estas deficiencias son pronósticas de poca respuesta a los antidepresivos; aún con la remisión de la depresión, las deficiencias pueden persistir e indican un alto riesgo de demencia. Ni la memantina, autorizada para tratar la enfermedad de Alzheimer, ni los estimulantes como el metilfenidato mostraron beneficios cognitivos en pacientes ancianos con depresión.

Recomendaciones

Las recomendaciones de este trabajo coinciden con las de la American Psychiatric Association. Estas recomendaciones subrayan la necesidad de una cuidadosa evaluación del riesgo de suicidio y de las enfermedades concomitantes en esta población.

Conclusiones y recomendaciones

Para el primer episodio depresivo en un anciano el tratamiento de primera línea podría ser la farmacoterapia o la psicoterapia, según las preferencias del paciente y la disponibilidad de la psicoterapia. Si se emplean medicamentos, el tratamiento inicial recomendado es un ISRS, con una dosis baja al inicio (e.g., sertralina 25 mg/día) a fin de evaluar los efectos colaterales en el paciente y aumentar después a la dosis terapéutica mínima (50 mg/día).

Pueden ser necesarias dosis mayores para obtener la máxima eficacia (e.g., 100 mg o más de sertralina diariamente), con mucha atención a los efectos secundarios. Si los síntomas depresivos no disminuyen se podría considerara cambiar a un IRSN, como la venlafaxina. Se deben efectuar pruebas de detección para deficiencias cognitivas y considerar pruebas neuropsicológicas si los síntomas cognitivos persisten o empeoran a pesar del tratamiento antidepresivo.

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43. Reynolds CF III, Frank E, Perel JM, et al. Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years. JAMA 1999; 281:39-45.
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48. Lisanby SH, Husain MM, Rosenquist PB, et al. Daily left prefrontal repetitive transcranial magnetic stimulation in the acute treatment of major depression: clinical predictors of outcome in a multisite, randomized controlled clinical trial. Neuropsychopharmacology 2009; 34:522-34.
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Link: http://www.intramed.net

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DevOps strategy for health site fueled by flash, CDM

by System Administrator - Thursday, 16 March 2017, 11:26 PM
 

DevOps strategy for health site fueled by flash, CDM

by Dave Raffo

Women's health website Lifescript 'transformed into a DevOps' shop after implementing all-flash arrays from Pure Storage and Actifio CDM.

Flash storage and copy data management helped women's health website Lifescript adopt a DevOps strategy that is crucial to its revenue generation.

All-flash vendor Pure Storage Inc. and copy data management (CDM) pioneer Actifio Inc. last year launched the Actifio AppFlash DevOps Platform, which runs Actifio software on Pure arrays. Lifescript had already been using Actifio and Pure in combination for years as an early proponent of both technologies. That combo formed a storage foundation for a DevOps strategy.

"We've always been chasing performance," Lifescript's CTO Jack Hogan said of his company's move to flash.

Lifescript started using flash in Hewlett-Packard 3PAR StoreServ hybrid arrays in 2012. The hybrid 3PAR arrays improved IOPS performance, but latency remained an issue. Hogan looked at Pure Storage's FlashArray in the early days of the all-flash startup and became one of its first 100 customers in 2013.

He cited Pure's built-in data deduplication as a major selling point, especially after he tested it and it ran without a performance hit. He said the data reduction made Pure more cost-effective for Lifescript.

"It was hard to part with 3PAR because we had a long-term relationship with them," he said. "But it became a no-brainer once we determined there was no performance hit introducing [Pure's] dedupe and compression. We were always constrained by latency, and HP was still struggling to get its data reduction in place."

HP -- now Hewlett Packard Enterprise following the Hewlett-Packard company split -- introduced an all-flash version of 3PAR around the time Lifescript switched over, but Hogan said it would cost about eight times what the Pure array costs for usable capacity.

All-flash arrays reduce latency, bump IOPS

"We're making real-time business decisions based on our ability to process data. And now, we're processing it so much faster."
Jack Hogan | CTO, Lifescript

Hogan said Lifescript sends up to 30 million emails a day to subscribers. The website runs complex data analytics to find relevant information to send to users. He said the Pure arrays decreased latency from 60 milliseconds to five milliseconds while running analytics, helping Lifescript pump out relevant information faster.

"We're making real-time business decisions based on our ability to process data. And now, we're processing it so much faster," Hogan said.

Lifescript has Pure FlashArrays running in separate data centers for a total of 92 TB of raw capacity. Hogan said the arrays give him a 3 1/2:1 data reduction ratio.

Flash, copy data management form DevOps strategy

Lifescript actually implemented Actifio before switching to all-flash. Lifescript started with an Actifio CDS data center appliance running at a managed third-party site. Now, it uses Actifio Sky virtual appliances to bridge primary and secondary data centers. Sky handles replication between Pure arrays, enabling disaster recovery for the company's VMware and Microsoft SQL Server applications.

"The primary reason [for going to Actifio]," Hogan said, "was the economies of copy data management, being able to spin up replicas, and move and replicate data easily."

Actifio's CDM fits into the DevOps strategy. Hogan said Actifio has made life easier on the six developers on Lifescript's 17-person IT team, allowing the team to quickly create copies of 10 TB-plus databases to use for development purposes.

"We've transformed into a DevOps shop," he said. "Our database group can quickly spin up copies of things, and our development group can run their new application against production-class platforms. We're not creating secondary block-level storage; we're just spinning up copies.

"That contention that used to exist between individual divisions in the IT group has gone away."

Next Steps

Link: http://searchstorage.techtarget.com

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Diagnósticos médicos a distancia

by System Administrator - Sunday, 19 October 2014, 1:44 PM
 

Diputados paraguayos aprueban ley de diagnósticos médicos a distancia

 

Los diputados aprobaron este jueves el proyecto de ley que "crea el Programa Nacional de Telesalud". | Foto: Archivo ÚH

La Cámara de Diputados aprobó este jueves el proyecto de ley que "crea el Programa Nacional de Telesalud", que da un marco legal a los diagnósticos médicos a distancia.

Este sistema permite que muestras médicas tomadas en cualquier punto del país puedan ser analizadas rápidamente por un equipo médico en Asunción. El documento pasa al Senado.

El diputado Carlos Núñez dijo que con este proyecto se establecerá un comité que trabajará para potenciar el sistema de telemedicina.

"El Ministerio de Salud aplica un sistema piloto con ecografías, electrocardiografía y otros estudios, en distintas ciudades. Actualmente unas 5 mil personas ya fueron atendidas con este sistema", explicó.

El diagnostico remoto es una herramienta que permitirá una mayor cobertura del sistema de salud en todo el país, con trasmisión de las pruebas a centros especializados que permitirán un pronto diagnóstico.

El documento fue propuesto en Diputados y pasa al Senado para su estudio.

El primer diagnóstico a distancia se realizó en Paraguay con un estudio remitido desde Fuerte Olimpo, Departamento de Alto Paraguay, y la recepción se hizo en el Instituto Nacional de Prevención Cardiovascular (Inpcard), se realizó en diciembre del 2013.

Link: http://www.ultimahora.com

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Digital Health Coaching

by System Administrator - Tuesday, 18 April 2017, 3:19 PM
 

Digital health coaching not here yet; human health coaches predominate

by Shaun Sutner

With corporate health coaching expanding fast, human coaches are dominating the field, and autonomous digital health coaching systems are a long way off, according to one expert.

 

Melinda Huffman

Melinda Huffman is co-founder of the National Society of Health Coaches and a principal of Miller and Huffman Outcome Architects, a health coaching consulting firm in Winchester, Tenn.

Health coaching is fast becoming popular in corporate America, and while digital health coaching technologies are available in some wellness and telemedicine platforms, Huffman's stance is that human health coaches still predominate.

In this Q&A with SearchFinancialApplications, Huffman asserts that live, trained coaches -- sometimes in conjunction with technologies such as connected health devices -- are best equipped to provide motivational coaching support.

How important is technology to corporate health coaching, and how fast is that technology evolving?

Melinda Huffman: Technology has become one of the go-to strategies in corporate wellness and health coaching initiatives. But health coaching is primarily about engaging an individual through conversational skills. The technology piece is an additional part of that. It's kind of a two-pronged approach.

The social context of one's life is how people make healthcare decisions, whether you're an employee, a client, a member or a patient. One of the most important things a health coach does is take what your concern is, and put that into perspective. Especially for chronic conditions, if you have a treatment plan, are you going to follow it? We know that up to 60% of patients don't follow their treatment plans, and up to 50% don't complete their medications. They may not even fill the prescription. They may fill the prescription and not take it.

In terms of how technology can assist the health coach, employers can provide employees with Fitbits or pedometers or apps to help us track progress, track what kind of intervention has happened and share that with each other in a kind of peer coaching to motivate each other. Technology is primarily used to help an individual track their own progress or compare their progress to others in their group, and they can do that anonymously and compare themselves to an aggregate.         

What's the status of specialized coaching apps that use software to perform the coaching function, or that work in conjunction with human coaches?

Huffman: It's still very, very early. We don't see much of that yet, and the reason for that is the scientific basis of motivational coaching is based on your responses to me as a coach. It's not a yes-no algorithm. Because how you respond to me is how I make my next comment.

There are several different responses I could make to you, the patient or the client, and it's based on what you're saying to me and what I know about you. So [digital health coaching] software that would be completely independent is a long way off.

How do health coaching programs work with corporate wellness and well-being programs, other benefits offerings and health insurance plans?

Huffman: We train a lot of Fortune 500 companies, and they have their coaching staff on site, or off site, and we see a lot of self-insured companies reach out to help their staff be prepared to engage employees, rather than having an MCO [managed care organization] or third-party provide coaching.

An MCO may simply call someone a health coach or put them in the role of a health coach, but what they're doing is health teaching, and health teaching is a very small part of health coaching.

How do real-life coaches work with tracking devices, whether they are step counters, connected scales, blood pressure cuffs or glucometers?

Huffman: Individuals will either call in, text or go online to enter that information. Some of those [devices] can be connected via your smartphone. For example, you can directly download your glucometer readings to your phone, and the company can do whatever it chooses with that information, such as trend outcomes, aggregate outcomes or give you feedback on how you fit in relation to others your age and with the same condition.

In health coaching, as the National Society of Health Coaching defines it, there must be somebody else to engage you. The bottom line of health coaching is tapping into [the patient's] own self-motivation. [With connected devices] your doctor is just depending on you to have enough motivation to do what you're supposed to do and share the information with them.

With all these devices, and getting the data from point A to point B, whether it's a software interface or platform, that's only a part. That's just the data. That itself is not health coaching. There has to be someone there to do the coaching, whether it's over FaceTime or Skype or email or texting. But there's got to be someone there who has been trained in the skill of motivational interviewing.

"With all these devices, and getting the data from point A to point B, whether it's a software interface or platform, that's only a part. That's just the data. That itself is not health coaching."

Melinda Huffman | health coach

 

Next Steps

 

Link: http://searchfinancialapplications.techtarget.com

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Digital Pathology Repository

by System Administrator - Wednesday, 8 July 2015, 10:05 PM
 

Philips, Mount Sinai To Create Digital Pathology Repository

by

Today, Philips announced a joint development agreement with the Mount Sinai Health System to create a digital image pathology repository containing the digital scans of patient tissue slides and data analytics to pursue the discovery of new tissue-based tests and unlock pathology data. The collaboration aims to advance clinical research and ultimately enable better care for complex diseases, including cancer. Terms of this collaboration agreement were managed by Mount Sinai Innovation Partners, the technology development and commercialization group for the Mount Sinai Health System.

Collaboration Details

Together, Philips and Mount Sinai will create a comprehensive digital image repository containing the digital scans of all these patient glass tissue slides that will be made accessible to researchers. By integrating, analyzing and presenting the data available from whole slide pathology images, clinical laboratory services, genetic analysis, radiology, and surgical and molecular pathology, the data analytics obtained will enable the development of predictive analytics to help personalize patient care. Currently, Mount Sinai Health System comprises seven hospital campuses serving approximately 170,000 inpatients and 2.6 million outpatients annually.

“This collaboration with Philips has the potential to help drive a new paradigm in healthcare that includes the optimization of treatment efficacy and superior clinical outcomes,” said Dr. Carlos Cordon-Cardo M.D., Ph.D., Chairman of the Department of Pathology at the Mount Sinai Health System. “Our ultimate goal with this initiative is to translate data into knowledge to maximize personalized patient management.”

Link: http://hitconsultant.net

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Digitizing Surgery: How New Technologies Will Transform Old Medical Practices [Video]

by System Administrator - Sunday, 5 July 2015, 11:55 PM
 

Digitizing Surgery: How New Technologies Will Transform Old Medical Practices [Video]

By David J. Hill

From one point of view, surgery is a fairly barbaric means of improving your health. After all, your body is cut open, organs are moved around or removed, and doctors probe with their fingers and use instruments to repair damaged tissues. But these practices are in the midst of significant change.

At last year's Exponential Medicine conference in San Diego, Dr. Catherine Mohr, Vice President of Medical Research at Intuitive Surgical, took the stage to address how emerging technologies are reshaping medical practice. "We're talking about the future of intervention. When we look at where things are going in the future, it's always a good idea to understand what we're doing now and where we've come from."

Mohr provided a historical walkthrough of the advances that have increased longevity."We have been intervening with our health care for a very, very long time," she said. "Surgery has been going on for tens of thousands of years. We see evidence from archaeology of surgical procedures that were done on patients and they've lived afterwards."

Beginning with Egyptian surgical methods, Mohr proceeded from improvements in public health such as sanitation and access to clean water, through the age of antibiotics, and into the era of modern medicine, highlighting an amazing achievement in public health: Within a century, a life expectancy of over 50 years progressed from just a few countries to almost every country in the world.

She added, "In this last 50 years or so, we have been making huge strides in both the kinds of surgical therapies we can provide and the imaging that we can do to support it." Essential to surgery will be the ability to analyze the streams of data that will increasingly be available and make data-driven decisions for care.

 Video

Mohr outlined three pillars of medical care that technologies are improving:

  1. Prevention — enhancing wellness with the goal of reducing intervention
  2. Diagnostics — improving detection so that actions can be taken earlier and often
  3. Intervention — reducing the scale of need by providing care earlier and more precisely

One disease that Mohr expects new technologies to drastically disrupt our approach to care is cancer. She explained that because of improved methods of detection and imaging, cancerous tissue will be identified when it's the size of a pea. The impact on surgery will be the elimination of "big reconstructive surgeries."


Within a century, a life expectancy of over 50 years progressed from just a few countries to almost every country in the world.


So what is the future of medicine? What will digitizing surgery actually mean?

Mohr says that doctors will be "shifting more into the spare parts business." She continued, "As we get rid of cancer, we unmask the issues causing our bodies to sag and tear and wear out. The replacement of these parts is maintenance." Additionally, she noted that in the near term, advances with new instruments and the ability to insert robotic instruments through a very small opening in the body, the future of intervention will be defined by diagnostics driven by regenerative medicine and high-tech implants coupled with artificial intelligence and big data.

To learn more about Singularity University's Exponential Medicine conference, click here.

Link: http://singularityhub.com


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