Use of Wearable and Wireless Technology in Real-World Clinical Settings to Improve Patient Outcomes in Chronic Kidney Disease: A Mixed Methods Pilot Prospective Trial

Background

During the 30-day period prior to initiating dialysis, there is a 10-fold rise in emergency department visits and hospitalizations related to kidney failure.

Objective

The Virtual Ward Incorporating Electronic Wearables (VIEWER) trial implemented a home telemonitoring system to track changes in patients' vitals and assess their adherence and the acceptability of telemonitoring in a chronic kidney disease (CKD) population.

Design

A pilot prospective clinical trial using a mixed methods approach was performed.

Setting

The research was conducted in Winnipeg, Manitoba.

Participants

There were 2 phases: Phase 1 was a 2-week-long pilot trial consisting of 10 participants. Phase 2 was a 3-month-long trial with a total of 26 participants. Patients with an estimated glomerular filtration rate <15 and a >40% risk of beginning dialysis in the next 2 years according to the kidney failure risk equation were eligible to participate in the study.

Methods

The primary quantitative outcome was adherence, defined as the proportion of daily self-assessments completed using VIEWER over the follow-up period. The usability and acceptability of VIEWER was assessed qualitatively at the end of the trial through structured questionnaires and focus groups.

Results

Phase 1 participants (n = 10) had a median adherence of 77.17% for the 2-week observation period. Phase 2 participants (n = 26) showed a lower median adherence of 36% for the 3-month period. Focus group participants (n = 11) identified many positive aspects of VIEWER, including increased awareness and empowerment over health, simplicity of the data platform, and the ability to show clinical staff their health trends. Some challenges identified with VIEWER were connectivity issues with the Bluetooth, perceived inconvenience, and negative thoughts toward their health.

Limitations

Limitations of the study include a small sample size, which limited our ability to measure quantitative outcomes. In addition, patients agreeing to participate in any trial are generally more highly motivated and engaged in their care than those declining participation. Therefore, our results may not be generalizable to individuals who are not interested in self-management of their health.

Conclusion

Our results suggest that home telemonitoring in patients with advanced CKD is feasible using a CKD-specific platform like VIEWER. We anticipate that improved functionality with incorporation of feedback from this study will result in greater long-term adherence. A future randomized clinical trial is planned.

Strategies to prevent hospital readmission and death in patients with chronic heart failure, chronic obstructive pulmonary disease, and chronic kidney disease: A systematic review and meta-analysis

BACKGROUND

Readmission following hospital discharge is common and is a major financial burden on healthcare systems.

OBJECTIVES

Our objectives were to 1) identify studies describing post-discharge interventions and their efficacy with respect to reducing risk of mortality and rate of hospital readmission; and 2) identify intervention characteristics associated with efficacy.

METHODS

A systematic review of the literature was performed. We searched MEDLINE, PubMed, Cochrane, EMBASE and CINAHL. Our selection criteria included randomized controlled trials comparing post-discharge interventions with usual care on rates of hospital readmission and mortality in high-risk chronic disease patient populations. We used random effects meta-analyses to estimate pooled risk ratios for all-cause and cause-specific mortality as well as all-cause and cause-specific hospitalization.

RESULTS

We included 31 randomized controlled trials encompassing 9654 patients (24 studies in CHF, 4 in COPD, 1 in both CHF and COPD, 1 in CKD and 1 in an undifferentiated population). Meta-analysis showed post-discharge interventions reduced cause-specific (RR = 0.71, 95% CI = 0.63-0.80) and all cause (RR = 0.90, 95% CI = 0.81-0.99) hospitalization, all-cause (RR = 0.73, 95% CI = 0.65-0.83) and cause-specific mortality (RR = 0.68, 95% CI = 0.54-0.84) in CHF studies, and all-cause hospitalization (RR = 0.52, 95% CI = 0.32-0.83) in COPD studies. The inclusion of a cardiac nurse in the multidisciplinary team was associated with greater efficacy in reducing all-cause mortality among patients discharged after heart failure admission (HR = 0.64, 95% CI = 0.54-0.75 vs. HR = 0.87, 95% CI = 0.73-1.03).

CONCLUSIONS

Post-discharge interventions reduced all-cause mortality, cause-specific mortality, and cause-specific hospitalization in CHF patients and all-cause hospitalization in COPD patients. The presence of a cardiac nurse was associated with greater efficacy in included studies. Additional research is needed on the impact of post-discharge intervention strategies in COPD and CKD patients.

Association of Kawasaki disease and interstitial nephritis

Renal insufficiency is a rare manifestation of Kawasaki disease. We report a 2.5-year-old boy with Kawasaki disease who developed acute renal failure during the acute phase of his illness. A percutaneous renal biopsy revealed acute interstitial nephritis. No etiological agent could be identified and renal recovery occurred with supportive care alone.

Association of distal displacement of the left subclavian artery and coarctation of the aorta

Previously noted but undocumented observation of distal displacement of the left subclavian artery in patients with discrete coarctation of the aorta was verified by an objective two-dimensional echocardiographic method in 28 patients with aortic coarctation and in 43 control subjects. Relative position of brachiocephalic arteries to one another was evaluated by the ratio of the distance between the left common carotid and the left subclavian artery to the distance between the innominate and the left common carotid artery. Large distance between the left common carotid and the left subclavian artery was reflected by high value of the derived ratio. In neonates with aortic coarctation, the ratio was 1.69, SD +/- 0.66, compared to 1.04, SD +/- 0.40 in the control group. In older children this ratio was less discriminatory. We also observed that the left subclavian artery formed an acute angle (less than 90 degrees) with the proximal (upstream) segment of the aortic arch in infants with aortic coarctation. In all control infants, this angle was equal to or greater than 90 degrees. A corresponding necropsy study confirmed the echocardiographic findings. We conclude that distal displacement of the left subclavian artery is associated with coarctation of the aorta. It can be accurately visualized and objectively assessed by the two-dimensional echocardiographic technique proposed.

Long-term results after excision of fixed subaortic stenosis

Forty-nine patients underwent surgical excision of fixed subaortic stenosis (discrete fibrous ring and tunnel) between 1968 and 1984 and were followed up for 1 to 16 years (5.8 +/- 4). Twenty-six patients (Group I) had isolated subaortic stenosis and 23 (Group II) had subaortic stenosis and associated cardiac defects. Discrete fibrous ring was present in 46 and tunnel type of obstruction in three patients. For the discrete ring, excision alone was done in 32 patients (four recurrences) and excision with myotomy in 17 (three recurrences). In Group I, there were no operative deaths and one late death from a noncardiac cause. In Group II, one early and two late deaths occurred. The actuarial survival rate for 10 years is 88%. Reoperations were performed in 10 patients, seven for recurrence and three for aortic valve replacement for preexisting aortic regurgitation that had progressed since the primary operation. Cardioplegia was used in 28 patients (one recurrence) and was not used in 21 patients (six recurrences). An operative residual gradient of less than 15 mm Hg was achieved in 25 of 28 patients in whom cardioplegia was used compared to 12 of 21 patients in whom cardioplegia was not used (p = 0.017). These results indicate that complete excision of the ring with the aid of cardioplegia has significantly reduced the recurrence rate of subaortic stenosis (p = 0.033), elimination of the residual gradient at the initial operation has been a significant factor in reducing the recurrence rate (p = 0.017), and addition of myotomy in this series has not altered the outcome.

Congenital diverticulum of the heart of biventricular origin

An extremely rare diverticulum arising from both ventricles at the caudal end of the intraventricular septum was diagnosed in a 2.9 kg infant. The diverticulum was removed successfully while a coexisting ventricular septal defect was left open for further management. The types and complications of such diverticula are described and the need for early surgical intervention is stressed.

Solitary xanthoma of the limbus

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