F. Tost

Cohort Profile: The Study of Health in Pomerania

Henry Volzke, y Dietrich Alte,1y Carsten Oliver Schmidt, Dorte Radke, Roberto Lorbeer, Nele Friedrich, Nicole Aumann, Katharina Lau, Michael Piontek, Gabriele Born, Christoph Havemann, Till Ittermann, Sabine Schipf, Robin Haring, Sebastian E Baumeister, Henri Wallaschofski, Matthias Nauck, Stephanie Frick, Andreas Arnold, Michael Junger, Julia Mayerle, Matthias Kraft, Markus M Lerch, Marcus Dorr, Thorsten Reffelmann, Klaus Empen, Stephan B Felix, Anne Obst, Beate Koch, Sven Glaser, Ralf Ewert, Ingo Fietze, Thomas Penzel, Martina Doren, Wolfgang Rathmann, Johannes Haerting, Mario Hannemann, Jurgen Ropcke, Ulf Schminke, Clemens Jurgens, Frank Tost, Rainer Rettig, Jan A Kors, Saskia Ungerer, Katrin Hegenscheid, Jens-Peter Kuhn, Julia Kuhn, Norbert Hosten, Ralf Puls, Jorg Henke, Oliver Gloger, Alexander Teumer, Georg Homuth, Uwe Volker, Christian Schwahn, Birte Holtfreter, Ines Polzer, Thomas Kohlmann, Hans J Grabe, Dieter Rosskopf, Heyo K Kroemer, Thomas Kocher, Reiner Biffar,17,y Ulrich John20y and Wolfgang Hoffmann1y

[Diurnal variation of ocular pressure in open-angle glaucoma with telemonitoring].

BACKGROUND The aim of this study was to study and analyse distribution, range and intraday variation of ocular perfusion pressure (OPP) in patients with primary open-angle glaucoma (POAG) in the framework of telemedical home-monitoring. METHODS In the project Teletonometry Mecklenburg-Vorpommern (TTMV) patients were equipped with a home-monitoring system for self-measurement of intraocular pressure and blood pressure. All measurements were transmitted via telephone modem to an electronic patient record that automatically calculated OPP. We present the temporal characteristics of OPP in 70 patients with POAG. After the measurement of blood pressure and intraocular pressure was performed, the individual ocular perfusion pressure was calculated by the formula: (OPP=[2/3 x (2/3 x DBP + 1/3 x SBP)]-IOP). RESULTS In 3282 OPP measurements the percentage of values less than 50 mmHg was: left eye 2273/69.2%--right eye 2362/71.9 % and less than 40 mmHg: left eye 687/20.9 %--right eye 794/24.2%. 50/51 (left eye/right eye) patients had an individual OPP average of less than 50 mmHg and 10/10 (left eye/right eye) patients less than 40 mmHg. The diurnal OPP trend showed 4 phases (7-12, 12-18, 18-22, 22-7 hour). In the intervals from 22-7 hour and 7-12 hour ocular perfusion pressure values were low. Between 7-12 hour ocular perfusion pressure was significantly depressed as in the other phases (p<0.05). CONCLUSIONS Ocular perfusion pressure of glaucoma patients calculated using intraocular pressure (self-tonometry) and blood pressure demonstrates a feasible method to evaluate individual diurnal OPP fluctuations. However, this OPP could be described a bit more precisely as the really topical ocular perfusion. Many physiological conditions may not be included, e. g., autonomic circulation. Simultaneous measurement of blood pressure and intraocular pressure enable the detection and analysis of side effects and interactions between glaucoma and hypertension therapy. In clinical practice OPP telemonitoring presents a new way to examine ocular blood circulation in routine glaucoma work-up. The diurnal OPP variations were associated with the fluctuations of systemic blood pressure for the most of part.

[Home-monitoring in ophthalmology--prerequisites for an improvement in quality of life: conclusions from the management research study Teletonometry Mecklenburg-Vorpommern].

Home-monitoring represents an innovative and growing health service area in which suitable conditions have to be created for the attending doctor and also for the patient. For this it is necessary to offer the technical supply and also to establish simultaneously organisational structures in the cooperation between the doctor and the patient based on prevalent experiences of general ambulant care. The medical care as a whole can be optimised to be more patient-orientated by integrating assistant medical staff and by establishing modern IT communication channels. The evolving home-monitoring in consideration of the doctor-patient experiences can contribute to an improvement in the patients quality of life.

[Fluctuation of intraocular pressure in 24-hour telemonitoring compared to tonometry during normal office hours].

BACKGROUND Elevated intraocular pressure (IOP) is a clinically relevant factor in glaucoma progression. As a dynamic parameter the IOP depends on various internal and exogenic influencing factors. Therefore, we analysed intraindividual IOD variations between ambulant care and 24-h home-monitoring using self-tonometry. PATIENTS AND METHODS This study is based on paper-based glaucoma cards of 25 patients with primary open angle glaucoma. Additionally, all patients participated in a telemedical home-monitoring study with self-measurements of IOP and blood pressure stored in an electronic patient record. The glaucoma cards contained a total number of 409 IOP values with documentation periods from 0.5 to 10 years. In the teletonometry project all 25 patients were observed for 6 months with 1490 recorded IOP values. Statistical analysis was performed with SPSS software. RESULTS Average IOP values for all 25 glaucoma patients were 16.3 +/- 2.9 mmHg for both eyes in glaucoma card documentation, whereas the electronic patient records showed IOP averages of 18.9 +/- 4.7 mmHg for right eyes and 18.2 +/- 4.4 mmHg for left eyes. Corresponding to the practice opening hours the glaucoma cards contained no IOP records from 12:00 pm to 01:30 pm as well as between 06:00 pm and 07:15 am. In these time periods 17 % of all IOP values recorded in 24-hour teletonometry were higher than 20 mmHg. However, statistical analysis and clinical evaluation of device parameters and measurement characteristics revealed sporadic measuring errors. CONCLUSIONS The additional involvement of self-tonometry in telemedical 24-h home-monitoring is a feasible method to record and detect intraday IOP fluctuations. Compared to single IOP measurements documented in common paper-based glaucoma cards, the 24-h electronic patient record showed more frequent circadian IOP variations. As a result, self-tonometry and home-monitoring can be a useful link to fill the gap between singular ambulant IOP measurement and hospitalisation with 24-hour IOP profiles.

Fortschritte in der geriatrischen Betreuung durch Telemedizin

ZusammenfassungIn der täglichen Praxis ist die Versorgung geriatrischer Patienten von wachsender Bedeutung, denn eine überalternde Bevölkerung führt zu einem Anstieg chronischer Krankheiten. Die besondere Gesundheits- und Lebenssituation dieser Patientengruppe erfordert intensive Betreuungskonzepte, die sich mit den bestehenden Mechanismen der Regelversorgung nur äußerst kosten- und zeitaufwändig umsetzen lassen. Durch den Einsatz der Telemedizin lassen sich neue Versorgungsformen realisieren, wenn sie in die bewährten Betreuungsstrukturen integriert werden. Der vorliegende Beitrag erläutert allgemeine Anwendungsmöglichkeiten und Vorteile der Gesundheitstelematik zur Betreuung geriatrischer Patienten sowie erste praktische Erfahrungen in einem Projekt zum telematikgestützten Glaukommanagement in Mecklenburg-Vorpommern.AbstractA constantly aging population leads to an increasing number of elderly patients. As a result, the treatment of chronic illnesses becomes a significant part of daily routine. Today’s concepts in social services and healthcare require time consuming and barely cost-effective efforts for the special needs of geriatric care. The use of telemedicine offers a possible solution, because telemedical methods may help to realize improved monitoring systems for optimized and effective patient management. This report provides an overview of the scenarios and advantages of telemedicine in general. In addition, we provide information on practical experiences in a project on telemedical glaucoma management in Mecklenburg-Vorpommern.

Clinical Diagnosis of Chronic Canaliculitis by 20-MHz Ultrasound

The practical value of high-resolution ultrasound (transducer frequency of 20 MHz) in the study of the lacrimal canaliculi has been proven. It can also be used in the clinical diagnosis of chronic canaliculitis. If the classic symptoms are absent, the clinical diagnosis is often inaccurate, and treatment is insufficient. Representative images of normal cases and of chronic canaliculitis illustrate the potential of high-resolution ultrasound. In our patient, 20-MHz scanner images revealed pathological findings which were invisible during slitlamp examination. Ultrasonic images of chronic canaliculitis showed ectasia of the canaliculus and sulfur grains. High-resolution ultrasonic examination of the lacrimal drainage system demonstrated that the 20-MHz scanner used was able to show concrements (sulfur grains), measuring 1–2 mm in diameter. Such more reflective structures (like sulfur grains) are a pathognomonic sign of chronic canaliculitis. Our report confirms the efficiency of 20-MHz sonography in the diagnosis of canaliculitis without any side effects.

20-MHz Ultrasound and Its Value in Imaging of Lacrimal Plugs

Background: High-frequency B scan ultrasonography is a proven method for the assessment of anterior segment diseases. Only few studies have used sonography to examine the lacrimal drainage system. We examined the proximal lacrimal drainage system by high-resolution 20-MHz ultrasound to verify the possibility to identify intracanalicular lacrimal plugs. Methods: Eight patients who had received 12 lacrimal plug implants were examined by high-resolution ultrasound. A 20-MHz sector scanner was used for detection and localization of 2 types of intracanalicular plugs (Herrick® lacrimal silicone plug, Smart™ acrylic polymer plug) and 1 punctum plug. Ultrasound examinations were performed 1–24 months after plug placement. Cross-sections of the lacrimal canaliculi were obtained. Results: The various intracanalicular implants were successfully viewed using the 20-MHz ultrasound sector scanner. Intracanalicular plugs were located at the appropriate position as intended. The silicone plugs could be seen as areas of higher reflectivity. In contrast, acrylic polymer plugs were seen as low-reflective inner structures. In a longitudinal echogram, the interface between the acrylic polymer plug and the lacrimal canaliculus produced a strong acoustic impedance. In patients with an intracanalicular acrylic polymer plug, the caliber of the plug could be ascertained and the diameter measured. Conclusion: High-resolution ultrasound with a 20-MHz sector scanner is helpful in detecting intracanalicular plugs and is a valuable tool to assess the migration of lacrimal plugs through lacrimal canaliculi. A 20-MHz sector scanner can be used to identify and locate lacrimal plugs in the proximal drainage system even if biomicroscopic signs or clinical data are absent.

Relationship of systemic blood pressure with ocular perfusion pressure and intraocular pressure of glaucoma patients in telemedical home monitoring

Summary Background We evaluated the relation of systemic blood pressure with intraday variations in ocular perfusion pressure and intraocular pressure in patients with primary open-angle glaucoma in a telemedical home monitoring scenario. Material/Methods In the project Teletonometry Mecklenburg-Vorpommern (TTMV) patients were equipped with a home monitoring system for 24-hour self-measurements of intraocular pressure and blood pressure for a period of six months. All measurements were transmitted via telephone modem to an electronic patient record. Ocular perfusion pressure (OPP) was automatically calculated from self-measurements of intraocular pressure (IOP), systolic (SBP) and diastolic blood pressure (DBP) using the equation: OPP=[2/3*(2/3*DBP+1/3*SBP)]–IOP. We present the temporal characteristics of 70 patients with primary open-angle glaucoma based on 3282 self-measurements. Results The diurnal ocular perfusion pressure trend showed four characteristic phases (7am – 12am, 12am – 6pm, 6pm – 10pm, and 10pm – 7am). Between 7am and 12am ocular perfusion pressure and simultaneously systolic and diastolic blood pressure were significantly depressed compared to all other phases (p<0.05) whereas intraocular pressure showed no significant shifting. Instead intraocular pressure was significantly depressed between 6pm and 10pm (p<0.05) where ocular perfusion pressure reached the highest intraday values. Conclusions We found that ocular perfusion pressure in patients with primary open-angle glaucoma showed remarkable circadian fluctuations. A significant decrease in the morning was associated with significantly depressed systolic and diastolic blood pressure levels. In addition we observed normal intraocular pressure values in the morning but a significant decrease in the evening which did not affect ocular perfusion pressure. These conclusions strengthen the evidence that systemic blood pressure fundamentally influences ocular circulation and consequently glaucoma progression.

Comparison of Two Non-mydriatic Fundus Cameras to Obtain Retinal Arterio-venous Ratio

Abstract Purpose: To analyze device-dependent variability of two non-mydriatic fundus cameras to obtain arterio-venous ratio (AVR), central retinal arteriolar equivalent (CRAE), and central retinal venular equivalent (CRVE) in static vessel analysis (SVA). Methods: We examined 53 participants (29 men, 24 women; median age 46 years) of the Study of Health in Pomerania (SHIP). We took 45° optic-disc-centered fundus images of the right eye with two different non-mydriatic fundus cameras. The first photograph was obtained from the TRC-NW 200, the second from the OCT 2000 (both Topcon Corporation, Tokyo, Japan). One experienced grader graded image quality from 1 “ideal quality” to 5 “not analyzable” and determined AVR, CRAE, and CRVE with the software Vesselmap3 (Imedos, Jena, Germany). Results: Average image quality was 1.8 for the TRC-NW 200 and 1.6 for the OCT 2000. AVR could not be determined in 5 images of the TRC-NW 200 due to low image quality, while six images of the OCT 2000 were not analyzable. The difference between AVR taken from two different non-mydriatic cameras was 0.01 ± 0.03 in Bland-Altman plots. The difference between CRAE was 0.17 ± 10.15 and between CRVE was −2.32 ± 11.76. Conclusions: The two different non-mydriatic cameras showed good agreement with respect to image quality. When using the same reading software, AVR, CRAE, and CRVE agreed well. Thus, funduscopy and SVA seem to be robust against inter-device variability. As a result, device dependency can remain unconsidered in follow-up examinations with different technical equipment. However, variability might impact more with devices from different manufacturers.

Computergestützte Erstellung grafischer Netzhautbefunde

ZusammenfassungZielDie grafische Dokumentation von Netzhautbefunden wird im klinischen Alltag häufig mit Hilfe von Freihandzeichnungen und handschriftlichen Textbausteinen durchgeführt. Der Funktionsumfang bekannter Softwareprodukte zur Befundung retinaler Veränderungen geht nicht über die Funktionalität eines Zeichenprogramms hinaus, das ein Platzieren, Skalieren und Färben von Grafikprimitiven (Kreis, Rechteck, Pfeil, Textfeld usw.) erlaubt. Eine schnelle und einheitlich standardisierte Befunderstellung mit grafischer Dokumentation ist so nur schwer zu realisieren, was durch die Entwicklung und den Einsatz moderner Softwaretools ermöglicht werden soll.MethodeEs wurde ein Softwarepaket entwickelt, das ein schnelles und intuitives Erstellen eines Fundusschemas zum digitalen Archivieren oder Ausdrucken ermöglicht. Eigens für den klinisch-augenärztlichen Nutzen wurden standardisierte Symbole zur Netzhautbefundung digital umgesetzt und in einer grafischen Symbolbibliothek integriert, die sich in folgende Kategorien gliedert: präoperativ, postoperativ, Gefäßneubildungen und Tumoren, Frühgeborenenretinopathie. Das benötigte Symbol wird einfach mit einem Mausklick ausgewählt und per drag-and-drop auf dem Augenhintergrund platziert.ErgebnisseDie bisherigen Möglichkeiten der grafischen Dokumentation von Netzhautbefunden sind unbefriedigend, weil sie zeitlich zu aufwändig sind und handschriftliche Interindividualabweichungen eine eindeutige Interpretation erschweren bzw. im Einzelfall unmöglich machen. Die Computergestützte Erstellung einer Skizze des Augenhintergrunds ist schneller durchführbar als die Freihandzeichnung und erhöht gleichzeitig die Qualität der medizinischen Dokumentation durch die Verwendung standardisierter Symbole, die zudem fachlich kategorisiert sind.SchlussfolgerungenGrafische Symbole zur Dokumentation von Netzhautbefunden gehören zum klinischen Allgemeingut von Augenärzten, das durch die Auswahlmöglichkeit aus einer vorgegebenen standardisierten Symbolbibliothek praktikabler als bisher in der klinischen Routine verfügbar gemacht wird.AbstractAimTo develop a software package that improves the standardized clinical documentation of retinal findings. In the clinical routine, retinal findings are usually documented with sketchy freehand drawings and supplementary handwritten remarks. Documentation features of common ophthalmologic software products include only simple sketching functions, which are limited to a change in location, size, or color of graphic primitives (e.g., ovals, rectangles, lines, textboxes). As a result, a feasible creation of standardized graphic documentation in retinal imaging is almost impossible.MethodsWe developed a Java-based software tool that features quick and intuitive generation of fundus schemes, which can be printed as a findings sheet or digitally archived. Particularly for clinical ophthalmologists, we created a set of standardized symbols that can be digitally rendered for graphic documentation. All symbols were integrated into a graphics library and separated in specific categories: preoperative, postoperative, angiomas and tumors, and retinopathy of prematurity. The user can simply choose the required symbol from the library and place it onto the retina scheme using drag-and-drop functionality.ResultsThe practicability of existing features for graphic documentation of retinal findings is not sufficient because freehand drawings are too time-consuming and also share the risk of false interpretation due to individual handwriting. In contrast to freehand sketching, our software tool not only allows faster graphic creation but also improves medical documentation using a standardized symbol library, which is also specifically categorized.ConclusionsGraphic symbols for retinal documentation have found universal acceptance by ophthalmologists for a long time, but their practical use is still not efficient in clinical routine. This report shows how the appropriate use of software technology can contribute to documentation quality and clinical practice.AIM To develop a software package that improves the standardized clinical documentation of retinal findings. In the clinical routine, retinal findings are usually documented with sketchy freehand drawings and supplementary handwritten remarks. Documentation features of common ophthalmologic software products include only simple sketching functions, which are limited to a change in location, size, or color of graphic primitives (e.g., ovals, rectangles, lines, textboxes). As a result, a feasible creation of standardized graphic documentation in retinal imaging is almost impossible. METHODS We developed a Java-based software tool that features quick and intuitive generation of fundus schemes, which can be printed as a findings sheet or digitally archived. Particularly for clinical ophthalmologists, we created a set of standardized symbols that can be digitally rendered for graphic documentation. All symbols were integrated into a graphics library and separated in specific categories: preoperative, postoperative, angiomas and tumors, and retinopathy of prematurity. The user can simply choose the required symbol from the library and place it onto the retina scheme using drag-and-drop functionality. RESULTS The practicability of existing features for graphic documentation of retinal findings is not sufficient because freehand drawings are too time-consuming and also share the risk of false interpretation due to individual handwriting. In contrast to freehand sketching, our software tool not only allows faster graphic creation but also improves medical documentation using a standardized symbol library, which is also specifically categorized. CONCLUSIONS Graphic symbols for retinal documentation have found universal acceptance by ophthalmologists for a long time, but their practical use is still not efficient in clinical routine. This report shows how the appropriate use of software technology can contribute to documentation quality and clinical practice.