Health technology assessment review: Remote monitoring of vital signs - current status and future challenges

Recent developments in communications technologies and associated computing and digital electronics now permit patient data, including routine vital signs, to be surveyed at a distance. Remote monitoring, or telemonitoring, can be regarded as a subdivision of telemedicine - the use of electronic and telecommunications technologies to provide and support health care when distance separates the participants. Depending on environment and purpose, the patient and the carer/system surveying, analysing or interpreting the data could be separated by as little as a few feet or be on different continents. Most telemonitoring systems will incorporate five components: data acquisition using an appropriate sensor; transmission of data from patient to clinician; integration of data with other data describing the state of the patient; synthesis of an appropriate action, or response or escalation in the care of the patient, and associated decision support; and storage of data. Telemonitoring is currently being used in community-based healthcare, at the scene of medical emergencies, by ambulance services and in hospitals. Current challenges in telemonitoring include: the lack of a full range of appropriate sensors, the bulk weight and size of the whole system or its components, battery life, available bandwidth, network coverage, and the costs of data transmission via public networks. Telemonitoring also has the ability to produce a mass of data - but this requires interpretation to be of clinical use and much necessary research work remains to be done

Which is more useful in predicting hospital mortality - dichotomised blood test results or actual test values? A retrospective study in two hospitals

Routine blood tests are an integral part of clinical medicine and in interpreting blood test results clinicians have two broad options. (1) Dichotomise the blood tests into normal/abnormal or (2) use the actual values and overlook the reference values. We refer to these as the "binary" and the "non-binary" strategy respectively. We investigate which strategy is better at predicting the risk of death in hospital based on seven routinely undertaken blood tests (albumin, creatinine, haemoglobin, potassium, sodium, urea, and white blood cell count) using tree models to implement the two strategies

Human airway construct model is suitable for studying transcriptome changes associated with indoor air particulate matter toxicity

In vitro models mimicking the human respiratory system are essential when investigating the toxicological effects of inhaled indoor air particulate matter (PM). We present a pulmonary cell culture model for studying indoor air PM toxicity. We exposed normal human bronchial epithelial cells, grown on semi‐permeable cell culture membranes, to four doses of indoor air PM in the air‐liquid interface. We analyzed the chemokine interleukin‐8 concentration from the cell culture medium, protein concentration from the apical wash, measured tissue electrical resistance, and imaged airway constructs using light and transmission electron microscopy. We sequenced RNA using a targeted RNA toxicology panel for 386 genes associated with toxicological responses. PM was collected from a non‐complaint residential environment over 1 week. Sample collection was concomitant with monitoring size‐segregated PM counts and determination of microbial levels and diversity. PM exposure was not acutely toxic for the cells, and we observed up‐regulation of 34 genes and down‐regulation of 17 genes when compared to blank sampler control exposure. The five most up‐regulated genes were related to immunotoxicity. Despite indications of incomplete cell differentiation, this model enabled the comparison of a toxicological transcriptome associated with indoor air PM exposure

Quality Of Antenatal Care In Rural Southern Tanzania: A Reality Check.

Counselling on the danger signs of unpredictable obstetric complications and the appropriate management of such complications are crucial in reducing maternal mortality. The objectives of this study were to identify gaps in the provision of ANC services and knowledge of danger signs as well as the quality of care women receive in case of complications. The study took place in the Rufiji District of Tanzania in 2008 and was conducted in seven health facilities. The study used (1) observations from 63 antenatal care (ANC) sessions evaluated with an ANC checklist, (2) self-assessments of 11 Health workers, (3) interviews with 28 pregnant women and (4) follow-up of 12 women hospitalized for pregnancy-related conditions.Blood pressure measurements and abdominal examinations were common during ANC visits while urine testing for albumin or sugar or haemoglobin levels was rare which was often explained as due to a lack of supplies. The reasons for measuring blood pressure or abdominal examinations were usually not explained to the women. Only 15/28 (54%) women were able to mention at least one obstetric danger sign requiring medical attention. The outcomes of ten complicated cases were five stillbirths and three maternal complications. There was a considerable delay in first contact with a health professional or the start of timely interventions including checking vital signs, using a partograph, and detailed record keeping. Linking danger signs to clinical and laboratory examination results during ANC with the appropriate follow up and avoiding delays in emergency obstetric care are crucial to the delivery of coordinated, effective care interventions

Meteorological and cloud conditions during the Arctic Ocean 2018 expedition

The Arctic Ocean 2018 (AO2018) took place in the central Arctic Ocean in August and September 2018 on the Swedish icebreaker Oden. An extensive suite of instrumentation provided detailed measurements of surface water chemistry and biology, sea ice and ocean physical and biogeochemical properties, surface exchange processes, aerosols, clouds, and the state of the atmosphere. The measurements provide important information on the coupling of the ocean and ice surface to the atmosphere and in particular to clouds. This paper provides (i) an overview of the synoptic-scale atmospheric conditions and their climatological anomaly to help interpret the process studies and put the detailed observations from AO2018 into a larger context, both spatially and temporally; (ii) a statistical analysis of the thermodynamic and near-surface meteorological conditions, boundary layer, cloud, and fog characteristics; and (iii) a comparison of the results to observations from earlier Arctic Ocean expeditions – in particular AOE1996 (Arctic Ocean Expedition 1996), SHEBA (Surface Heat Budget of the Arctic Ocean), AOE2001 (Arctic Ocean Experiment 2001), ASCOS (Arctic Summer Cloud Ocean Study), ACSE (Arctic Clouds in Summer Experiment), and AO2016 (Arctic Ocean 2016) – to provide an assessment of the representativeness of the measurements. The results show that near-surface conditions were broadly comparable to earlier experiments; however the thermodynamic vertical structure was quite different. An unusually high frequency of well-mixed boundary layers up to about 1 km depth occurred, and only a few cases of the “prototypical” Arctic summer single-layer stratocumulus deck were observed. Instead, an unexpectedly high amount of multiple cloud layers and mid-level clouds were present throughout the campaign. These differences from previous studies are related to the high frequency of cyclonic activity in the central Arctic in 2018

Evaluating Arctic clouds modelled with the Unified Model and Integrated Forecasting System

By synthesising remote-sensing measurements made in the central Arctic into a model-gridded Cloudnet cloud product, we evaluate how well the Met Office Unified Model (UM) and the European Centre for Medium-Range Weather Forecasting (ECMWF) Integrated Forecasting System (IFS) capture Arctic clouds and their associated interactions with the surface energy balance and the thermodynamic structure of the lower troposphere. This evaluation was conducted using a 4-week observation period from the Arctic Ocean 2018 expedition, where the transition from sea ice melting to freezing conditions was measured. Three different cloud schemes were tested within a nested limited-area model (LAM) configuration of the UM – two regionally operational single-moment schemes (UM_RA2M and UM_RA2T) and one novel double-moment scheme (UM_CASIM-100) – while one global simulation was conducted with the IFS, utilising its default cloud scheme (ECMWF_IFS). Consistent weaknesses were identified across both models, with both the UM and IFS overestimating cloud occurrence below 3 km. This overestimation was also consistent across the three cloud configurations used within the UM framework, with >90 % mean cloud occurrence simulated between 0.15 and 1 km in all the model simulations. However, the cloud microphysical structure, on average, was modelled reasonably well in each simulation, with the cloud liquid water content (LWC) and ice water content (IWC) comparing well with observations over much of the vertical profile. The key microphysical discrepancy between the models and observations was in the LWC between 1 and 3 km, where most simulations (all except UM_RA2T) overestimated the observed LWC. Despite this reasonable performance in cloud physical structure, both models failed to adequately capture cloud-free episodes: this consistency in cloud cover likely contributes to the ever-present near-surface temperature bias in every simulation. Both models also consistently exhibited temperature and moisture biases below 3 km, with particularly strong cold biases coinciding with the overabundant modelled cloud layers. These biases are likely due to too much cloud-top radiative cooling from these persistent modelled cloud layers and were consistent across the three UM configurations tested, despite differences in their parameterisations of cloud on a sub-grid scale. Alarmingly, our findings suggest that these biases in the regional model were inherited from the global model, driving a cause–effect relationship between the excessive low-altitude cloudiness and the coincident cold bias. Using representative cloud condensation nuclei concentrations in our double-moment UM configuration while improving cloud microphysical structure does little to alleviate these biases; therefore, no matter how comprehensive we make the cloud physics in the nested LAM configuration used here, its cloud and thermodynamic structure will continue to be overwhelmingly biased by the meteorological conditions of its driving model

Comparison of the National Early Warning Score in non-elective medical and surgical patients.

BACKGROUND: The National Early Warning Score (NEWS) is used to identify deteriorating patients in hospital. NEWS is a better discriminator of outcomes than other early warning scores in acute medical admissions, but it has not been evaluated in a surgical population. The study aims were to evaluate the ability of NEWS to discriminate cardiac arrest, death and unanticipated ICU admission in patients admitted to surgical specialties, and to compare the performance of NEWS in admissions to medical and surgical specialties. METHODS: Hospitalwide data over 31 months, from adult inpatients who stayed at least one night or died on the day of admission, were analysed. The data were categorized as elective or non-elective surgical or medical admissions. The ability of NEWS to discriminate the outcomes above in these different groups was assessed using the area under the receiver operating characteristic curve (AUROC). RESULTS: There were too few outcomes to permit meaningful comparison of elective admissions, so the analysis was constrained to comparison of non-elective admissions. NEWS performed equally well, or better, for surgical as for medical patients. For death within 24 h the AUROC for surgical admissions was 0·914 (95 per cent c.i. 0·907 to 0·922), compared with 0·902 (0·898 to 0·905) for medical admissions. For the combined outcome of any of death, cardiac arrest or unanticipated ICU admission, the AUROC was 0·874 (0·868 to 0·880) for surgical admissions and 0·874 (0·871 to 0·877) for medical admissions. CONCLUSION: NEWS discriminated deterioration in non-elective surgical patients at least as well as in non-elective medical patients