Validity of a Novel Research-Grade Physical Activity and Sleep Monitor for Continuous Remote Patient Monitoring

In the midst of the COVID-19 pandemic, Remote Patient Monitoring technologies are highly important for clinicians and researchers. These connected-health technologies enable monitoring of patients and facilitate remote clinical trial research while reducing the potential for the spread of the novel coronavirus. There is a growing requirement for monitoring of the full 24 h spectrum of behaviours with a single research-grade sensor. This research describes a free-living and supervised protocol comparison study of the Verisense inertial measurement unit to assess physical activity and sleep parameters and compares it with the Actiwatch 2 actigraph. Fifteen adults (11 males, 23.4 ± 3.4 years and 4 females, 29 ± 12.6 years) wore both monitors for 2 consecutive days and nights in the free-living study while twelve adults (11 males, 23.4 ± 3.4 years and 1 female, 22 ± 0 years) wore both monitors for the duration of a gym-based supervised protocol study. Agreement of physical activity epoch-by-epoch data with activity classification of sedentary, light and moderate-to-vigorous activity and sleep metrics were evaluated using Spearman's rank-order correlation coefficients and Bland-Altman plots. For all activity, Verisense showed high agreement for both free-living and supervised protocol of r = 0.85 and r = 0.78, respectively. For physical activity classification, Verisense showed high agreement of sedentary activity of r = 0.72 for free-living but low agreement of r = 0.36 for supervised protocol; low agreement of light activity of r = 0.42 for free-living and negligible agreement of r = -0.04 for supervised protocol; and moderate agreement of moderate-to-vigorous activity of r = 0.52 for free-living with low agreement of r = 0.49 for supervised protocol. For sleep metrics, Verisense showed moderate agreement for sleep time and total sleep time of r = 0.66 and 0.54, respectively, but demonstrated high agreement for determination of wake time of r = 0.83. Overall, our results showed moderate-high agreement of Verisense with Actiwatch 2 for assessing epoch-by-epoch physical activity and sleep, but a lack of agreement for activity classifications. Future validation work of Verisense for activity cut-point potentially holds promise for 24 h continuous remote patient monitoring.

Comparative investigation of different telemetric methods for measuring intracranial pressure: a prospective pilot study

OBJECTIVES

Measurement of intracranial pressure (ICP) plays an important role in long-term monitoring and neuro-intensive treatment of patients with a cerebral shunt. Currently, only two complete telemetric implants with different technical features are available worldwide. This prospective pilot study aims to examine patients who had both probes implanted at overlapping times for clinical reasons and represents the first in vivo comparison of both measurement methods.

MATERIALS AND METHODS

Patients with a primary subarachnoid hemorrhage or a spontaneous intracerebral hemorrhage with ventricular hemorrhage who had received a telemetric ICP probe (Raumedic® NEUROVENT®-P-tel) were included in the study. Conventional external ventricular drainages (EVD) and ventriculoperitoneal shunts with a telemetric ICP probe (Miethke Sensor Reservoir) were implanted in patients with hydrocephalus who required CSF (cerebrospinal fluid) drainage. Absolute ICP values from all systems were obtained. Due to the overlapping implantation time, parallel ICP measurements were performed via two devices simultaneously. ICP measurements via the sensor reservoir were repeated after 3 and 9 months. Differences between the absolute ICP values measured via the NEUROVENT®-P-tel probe, the Miethke sensor reservoir®, and the EVD were analyzed.

RESULTS

Seventeen patients were included in the present study between 2016 and 2018. 63% of all patients were male. In 11 patients the ICP measurements were followed up with both devices for 3 months. ICP measurements of the sensor reservoir showed corresponding trends in 9 cases compared to ICP measurement via the telemetry probe or EVD. Difference in absolute ICP values ranged between 14.5 mmHg and 0.0 mmHg. The average difference of the absolute ICP values in 8 cases was ≤ 3.5 mmHg.

CONCLUSION

ICP measurements with both systems continuously showed synchronous absolute ICP values, however absolute values of ICP measurement with the different systems did not match.

Patients' experiences of remote communication after pacemaker implant: The NORDLAND study

BACKGROUND

The concept of 'patient experience' has become central to how to improve healthcare. Remote communication with patients is today a frequent practice in healthcare services, showing similar outcomes to standard outpatient care while enabling cost reduction in both formal and informal care. The purpose of this study was to analyse the experiences of people with telemonitoring pacemakers.

METHODS

Patients were randomly allocated to either the telemonitoring or hospital monitoring follow-ups. Using the 'Generic Short Patient Experiences Questionnaire' (GS-PEQ), as well as an ad-hoc survey from the 'telehealth patient satisfaction survey' and 'costs survey', patients' experiences were measured six months after the pacemaker implant in a cohort of 50 consecutive patients. The mean age was 74.8 (± 11.75) years and 26 (52%) patients were male of which 1 was lost in follow-up. Finally, 24 patients were followed up with standard hospital monitoring, while 25 used the telemonitoring system. Differences in baseline characteristics between groups were not found.

RESULTS

Findings showed overall positive and similar experiences in patients living with telemonitoring and hospital monitoring pacemakers. Significant differences were found in GS-PEQ concerning how telemonitoring patients received less information about their diagnosis/afflictions (p = 0.046). We did not find significant differences in other items such as 'confidence in the clinicians' professional skills', 'treatment perception adapted to their situation', 'involvement in decisions regarding the treatment', 'perception of hospital organisation', 'waiting before admission', 'satisfaction of help and treatment received', 'benefit received', and 'incorrect treatment'.

CONCLUSIONS

The remote communication of pacemakers was met with positive levels of patients' experiences similarly to patients in the hospital monitoring follow-up. However, telemonitoring patients received less information. Thus, improving the quality and timing of information is required in telemonitoring patients in the planning and organisation of future remote communication healthcare services for people living with a pacemaker implant.

Appropriate utilisation of cardiac telemetry monitoring: a quality improvement project

For hospitals located in the United States, appropriate use of cardiac telemetry monitoring can be achieved resulting in cost savings to healthcare systems. Our institution has a limited number of telemetry beds, increasing the need for appropriate use of telemetry monitoring to minimise delays in patient care, reduce alarm fatigue, and decrease interruptions in patient care. This quality improvement project was conducted in a single academic medical centre in Kansas City, Kansas. The aim of the project was to reduce inappropriate cardiac telemetry monitoring on intermediate care units. Using the 2004 American Heart Association guidelines to guide appropriate telemetry utilisation, this project team sought to investigate the effects of two distinct interventions to reduce inappropriate telemetry monitoring, huddle intervention and mandatory order entry. Telemetry utilisation was followed prospectively for 2 years. During our initial intervention, we achieved a sharp decline in the number of patients on telemetry monitoring. However, over time the efficacy of the huddle intervention subsided, resulting in a need for a more sustained approach. By requiring physicians to input indication for telemetry monitoring, the second intervention increased adherence to practice guidelines and sustained reductions in inappropriate telemetry use.

Long-term Outcomes of the Effects of Home Blood Pressure Telemonitoring and Pharmacist Management on Blood Pressure Among Adults With Uncontrolled Hypertension: Follow-up of a Cluster Randomized Clinical Trial

IMPORTANCE

Hypertension is a leading cause of cardiovascular disease. The results were previously reported of a trial of home blood pressure (BP) telemonitoring and pharmacist management intervention in which the interventions stopped after 12 months. There were significantly greater reductions in systolic BP (SBP) in the intervention group than in the usual care group at 6, 12, and 18 months (-10.7, -9.7, and -6.6 mm Hg, respectively).

OBJECTIVES

To examine the durability of the intervention effect on BP through 54 months of follow-up and to compare BP measurements performed in the research clinic and in routine clinical care.

DESIGN, SETTING, AND PARTICIPANTS

Follow-up of a cluster randomized clinical trial among 16 primary care clinics and 450 patients with uncontrolled hypertension in a large health system from March 2009 to November 2015.

INTERVENTIONS

A home BP telemonitoring intervention with pharmacist management or usual care.

MAIN OUTCOMES AND MEASURES

Change from baseline to 54 months in SBP and diastolic BP (DBP) measured as the mean of 3 measurements obtained at each research clinic visit.

RESULTS

Among 450 patients, 228 (mean [SD] age, 62.0 [11.7] years; 54.8% male) were randomized to the telemonitoring intervention and 222 (mean [SD] age, 60.2 [12.2] years; 55.9% male) to usual care. Research clinic BP measurements were obtained from 326 of 450 (72.4%) study patients at the 54-month follow-up visit, including 162 (mean [SD] age, 62.0 [11.1] years; 54.9% male) randomized to the telemonitoring intervention and 164 (mean [SD] age, 60.0 [11.2] years; 57.3% male) to usual care. Routine clinical care BP measurements were obtained from 439 of 450 (97.6%) study patients at 6248 visits during the follow-up period. Based on research clinic measurements, baseline mean SBP was 148 mm Hg in both groups. In the intervention group, mean SBP at 6-, 12-, 18-, and 54-month follow-up was 126.7, 125.7, 126.9, and 130.6 mm Hg, respectively. In the usual care group, mean SBP at 6-, 12-, 18-, and 54-month follow-up was 136.9, 134.8, 133.0, and 132.6 mm Hg, respectively. The differential reduction by study group in SBP from baseline to 54 months was -2.5 mm Hg (95% CI, -6.3 to 1.2 mm Hg; P = .18). The DBP followed a similar pattern, with a differential reduction by study group from baseline to 54 months of -1.0 mm Hg (95% CI, -3.2 to 1.2 mm Hg; P = .37). The SBP and DBP results from routine clinical measurements suggested significantly lower BP in the intervention group for up to 24 months.

CONCLUSIONS AND RELEVANCE

This intensive intervention had sustained effects for up to 24 months (12 months after the intervention ended). Long-term maintenance of BP control is likely to require continued monitoring and resumption of the intervention if BP increases.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00781365.

Telemetry Monitor Watchers Reduce Bedside Nurses' Exposure to Alarms by Intercepting a High Number of Nonactionable Alarms

Cardiac telemetry, designed to monitor hospitalized patients with active cardiac conditions, is highly utilized outside the intensive care unit but is also resource-intensive and produces many nonactionable alarms. In a hospital setting in which dedicated monitor watchers are set up to be the first responders to system-generated alerts, we conducted a retrospective study of the alerts produced over a continuous 2-month period to evaluate how many were intercepted before nurse notification for being nonactionable, and how many resulted in code team activations. Over the 2-month period, the system generated 20,775 alerts (5.1/patient-day, on average), of which 87% were intercepted by monitor watchers. None of the alerts for asystole, ventricular fibrillation, or ventricular tachycardia resulted in a code team activation. Our results highlight the high burden of alerts, the large majority of which are nonactionable, as well as the role of monitor watchers in decreasing the alarm burden on nurses. Measures are needed to decrease telemetry-related alerts in order to reduce alarm-related harms, such as alarm fatigue. Journal of Hospital Medicine 2017;12:447-449.

Walking capacities in multiple sclerosis measured by global positioning system odometer

We used a global positioning satellite technology odometer to determine the maximum objective walking distance capacity (MOWD) of patients with multiple sclerosis (MS). The MOWD correlated with Expanded Disability Status Scale (EDSS) score (r2 =0.41; P < 0.0001), the MSWS-12 scale (r2 = 0.46; P < 0.0001), time to walk 10 m (r2 = 0.51; P < 0.02) and walking speed (r2 =0.75; P < 0.001). Limitation of walking capacities was measurable up to 4550 m, strikingly above the 500-m limit of the EDSS. This objective odometer is a promising tool for evaluation and follow-up of patients with MS. Multiple Sclerosis 2007; 13: 220–223. http://msj.sagepub.com

Teleconsultation in diagnostic pathology: experience from Iran and Germany with the use of two European telepathology servers

Eighty pathology cases were sent independently to each of two telepathology servers. Cases were submitted from the Department of Pathology at the University of Kerman in Iran (40 cases) and from the Institute of Pathology in Berlin, Germany (40 cases). The telepathology servers were located in Berlin (the UICC server) and Basel in Switzerland (the iPATH server). A scoring system was developed to quantify the differences between the diagnoses of the referring pathologist and the remote expert. Preparation of the cases, as well as the submission of images, took considerably longer from Kerman than from Berlin; this was independent of the server system. The Kerman delay was mainly associated with a slower transmission rate and longer image preparation. The diagnostic gap between referrers' and experts' diagnoses was greater with the iPATH system, but not significantly so. The experts' response time was considerably shorter for the iPATH system. The results showed that telepathology is feasible for requesting pathologists working in a developing country or in an industrialized country. The key factor in the quality of the service is the work of the experts: they should be selected according to their diagnostic expertise, and their commitment to the provision of telepathology services is critical.

Evaluating telemedicine systems and services

The evaluation of telemedicine involves attempts to answer a wide range of questions involved in making decisions about safety, about practicality and about utility. Roughly speaking, if we wish to provide a telemedicine service we should first establish that it is safe, next that it is practical and finally that it is worthwhile. In establishing safety, most laboratory studies of telemedicine have a common structure, and consist of the following steps: (1) selection of cases; (2) interpretation; (3) comparison with a gold standard; (4) statistical analyses. Most of the studies to establish the practicality of telemedicine have been carried out as demonstrations, to show that a proposed application can be implemented in a chosen setting. In terms of utility, telemedicine has been used to improve the efficiency of an existing service or to make an existing service available to a new community. One of the difficulties is that the vendors of relatively expensive telemedicine systems and services disseminate much of the information on the topic. We have to focus not on the glamorous technology but on the underlying issue of how the participants in health care (patients, general practitioners, specialists) can communicate more effectively, using the range of technological options open to them. Ensuring that the most appropriate technology is used in the most effective way should be the primary aim of telemedicine research. There is now sufficient evidence for us to be confident that telemedicine is a safe alternative to conventional care in a variety of situations and for a number of clinical conditions. Reliable evidence that it is a practical and cost-effective alternative is, at the time of writing, harder to find.

[The current tendencies and prospects of the neural response telemetry in the rehabilitation of the patients after cochlear implantation]

The objective of the present study was to estimate the potential of the modern technique for telemetry of the neural response during rehabilitation of the patients following cochlear implantation. The methods for the purpose included comparison of the results of intra- and postoperative registration on neural response telemetry (NRT) and evaluation of the influence of perimodiolar localization of electrodes of cochlear implants on the threshold level of stimulation and propagation of excitation inside the cochlea. The results of the study confirm the possibility of using the registration of the electrically evoked auditory nerve potential for fitting the speech processor of the cochlear implant. In addition, it was shown that the application of the perimodiolar electrode significantly narrows the intracochlear excitation distribution profile which enhances the rehabilitative effectiveness of cochlear implantation.

Effect of an electronic ordering system on adherence to the American College of Cardiology/American Heart Association guidelines for cardiac monitoring

INTRODUCTION

Telemetry monitoring is often overused in the inpatient setting. This has led to overcrowding of telemetry beds, increased wait times in the emergency department, and inefficient allocation of hospital resources. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines exist to guide appropriate utilization of cardiac monitoring. We sought to investigate the effect of the institution of an electronic ordering system (EOS) on adherence to guideline-based telemetry use.

METHODS

Telemetry bed utilization was followed prospectively before and after institution of the EOS. Patient records were reviewed and assessed for indication for telemetry monitoring at admission and at 48 hours, as well as telemetry events. The online order form was based on the ACC/AHA guidelines for in-hospital cardiac monitoring. The EOS mandates physicians to check the specific indication for monitoring. Initial telemetry order expires after 48 hours, and if continued monitoring is necessary, it must be reordered.

RESULTS

One hundred ninety-six patients before EOS and 156 patients after institution of EOS were assessed. Before EOS, 65% of patients placed on telemetry met guidelines for monitoring. Institution of EOS resulted in a significant improvement in compliance to 81% (P < 0.001). However, at 48 hours, compliance dropped with EOS from 31% to 13% (P < 0.001). All dysrhythmias observed occurred in patients who met guidelines for monitoring. There were no clinically significant events in patients who did not meet guidelines for telemetry monitoring.

CONCLUSION

The institution of an EOS significantly improved compliance with ACC/AHA guidelines for cardiac monitoring at the time of admission. However, compliance worsened after the initial 48 hours, which may have been due to the ease of online reordering with our EOS. Clinically significant events were only observed in patients who met criteria for monitoring. EOS can be a useful tool to improve adherence to guideline-based utilization of hospital resources.

Wireless physiological monitoring and ocular tracking: 3D calibration in a fully-immersive virtual health care environment

Wireless physiological/neurological monitoring in virtual reality (VR) offers a unique opportunity for unobtrusively quantifying human responses to precisely controlled and readily modulated VR representations of health care environments. Here we present such a wireless, light-weight head-mounted system for measuring electrooculogram (EOG) and electroencephalogram (EEG) activity in human subjects interacting with and navigating in the Calit2 StarCAVE, a five-sided immersive 3-D visualization VR environment. The system can be easily expanded to include other measurements, such as cardiac activity and galvanic skin responses. We demonstrate the capacity of the system to track focus of gaze in 3-D and report a novel calibration procedure for estimating eye movements from responses to the presentation of a set of dynamic visual cues in the StarCAVE. We discuss cyber and clinical applications that include a 3-D cursor for visual navigation in VR interactive environments, and the monitoring of neurological and ocular dysfunction in vision/attention disorders.

Telemetry monitoring guidelines for efficient and safe delivery of cardiac rhythm monitoring to noncritical hospital inpatients

Telemetry monitoring is a limited resource in most hospitals. Few clinical studies have established firm criteria for inpatient telemetry. At our urban institution, we have developed and incorporated guidelines to identify patients who benefit from cardiac rhythm monitoring. These guidelines serve to minimize inappropriate use of telemetry beds, thereby preventing emergency department overcrowding and ambulance diversion. This improvement in efficiency is achieved without compromising health care.

[Usefulness of home monitoring in patients with implantable cardioverter-defibrillators]

During the last years several remote monitoring systems have been introduced in everyday clinical practice, because of the development of new computer and information technologies. Therefore, clinical and technical data of implanted devices can be transmitted by patients directly to the cardiology department through a transtelephonic web-based connection, without undergoing traditional outpatient evaluation. Home monitoring systems are effective in identifying device malfunctioning and clinical instability in patients with implantable cardioverter-defibrillators. Their efficacy does not significantly differ from that of traditional outpatient device interrogation, but with significant advantages in terms of quality of life and reduction in clinic visits for device follow-up.

Evaluation of a wireless ingestible temperature probe in cardiac surgery

OBJECTIVES

CorTemp is a wireless intestinal temperature monitoring system in the form of an ingestible pill and an external receiver. The aim of the study was to evaluate the system's accuracy and practicality during cardiac surgery.

METHODS

A repeat measures design using simultaneous temperature readings from the pulmonary artery (T (pa)), a nasopharyngeal thermometer (T (np)), skin thermometers (T (sk)) and the CorTemp system (T (in)), was conducted in 15 patients undergoing elective cardiac surgery under hypothermic conditions.

RESULTS

Only 67 % of patients' data was analysed and the statistical analysis of a total of 264 sets of readings showed a clinically significant temperature difference of T (in) compared to the other thermometers with limits of agreement between T (in) and T (pa), T (np) and T (sk) (+/- 0.35 to +/- 1.53 degrees C), (+/- 0.72 to +/- 1.63 degrees C) (+/- 0.40 to +/- 1.84 degrees C), respectively. The T (in) bias was significantly different from that of T (pa) ( P = 0.0023), T (np) ( P = 0.018) and T (sk) ( P = 0.0005) during rewarming. The T (in) rate of temperature change was also found to be significantly slower during the rewarming period.

CONCLUSIONS

The significant temperature differences detected during rewarming urge caution regarding CorTemp use as an accurate estimator of brain temperature in cardiac surgery. Further studies are required to assess its potentially useful role as a body core and intestinal temperature monitoring system and as a useful adjunct in investigating bowel ischaemia aetiology in cardiac surgery.

Management of atrial fibrillation--what are the possibilities of early detection with home monitoring?

A large number of patients implanted with dual-chamber pacemakers exhibit symptoms of recurrent or new atrial fibrillation. Scheduling follow-up visits for every 6-12 months in this setting may be disadvantageous on three grounds. First, delayed information about the onset of atrial fibrillation does not allow an immediate reaction with pharmacological or dedicated pacing therapy. Second, the efficacy of the chosen therapy cannot be evaluated until the next scheduled follow-up. Third, real-time awareness of a significant atrial fibrillation burden is critical to use appropriate anticoagulation therapy for the prevention of thromboembolic events. The new Home Monitoring technology (Biotronik, Berlin) offers real-time transmission of diagnostic data stored in the pacemaker memory to the physician. This may represent a useful tool for the detection and treatment of patients with atrial fibrillation. Daily documentation of atrial rhythm via Home Monitoring allows a quick reaction to the onset of atrial fibrillation and real-time control of the therapeutic efficacy. The ongoing, international, randomized Home-PAT clinical trial aims at defining and quantifying the importance of Home Monitoring for the diagnosis and treatment of atrial fibrillation in patients with dual-chamber pacemakers.

Diagnostic value and safety of long-term video-EEG monitoring

This paper aimed to assess the usefulness and safety of video-EEG (video-electroencephalography) monitoring in patients with refractory epilepsy. We analysed the video-EEG recordings of consecutive patients over a 3-year period from 2002 to 2005. The pre-admission diagnosis, demographic information, number of ictal episodes, adverse events, and final diagnosis were recorded in all patients. The diagnostic labels before and after monitoring were compared in order to assess whether it had led to a change in diagnosis and management. Of the 100 patients who underwent video-EEG, 227 clinical events were recorded in 62 cases. The most common events were complex partial seizures followed by non-epileptic attacks. Video-EEG allowed a diagnosis to be made in 81 patients and the diagnosis at discharge was altered in 19 cases. Major injuries and status epilepticus did not occur during monitoring. In our experience video-EEG is safe and provides important clinical information in over 80% of patients.

Performance of a wireless telemedicine system in a hospital accident and emergency department

We developed a mobile, wireless videoconferencing system suitable for use in a hospital accident and emergency (A&E) department. Four consultants, eight junior doctors and 11 nurses working in the A&E department tested the system. Transmission of three types of data (audio, still images and video) was tested. The audio for the breath and heart sounds was judged to have some disturbance. One consultant rated the diagnostic quality as good and one rated it as fair. The quality of the still images was judged to be from fair to excellent. The quality of the video was rated as good. Possible interference between the wireless local-area network and various medical devices in the A&E department were examined, but none was detected. The four consultants who tested the system were very positive in their initial comments. Eight of the 11 nurses remained sceptical about its use. Of a total of 20 patients who answered a survey, 13 were slightly anxious about the use of the system to transmit their data to a distant point. Overall, the performance of the system was satisfactory for use in the A&E role.

What lessons can be learned from telemedicine programmes in other countries?

Reviews of telemedicine literature have shown that about half of the published studies come from the USA. This suggests that there is a large potentially useful stock of research outside the USA that could be used to guide telemedicine decision-making in the USA. In the present study, a request was sent to eight international experts in telemedicine asking about successful telemedicine programmes that have been assessed and could potentially be implemented in the US health-care system. We also conducted a focused review of a few key publications in the field to identify examples of successful telemedicine programmes. The review found that in some specific areas, such as teleradiology, telemental health, telegeriatric applications, e-referrals and discharge letters, and integration of health-care organizations with telemedicine networks, applications successfully implemented in international settings would be suitable for implementation in the USA. If telemedicine programmes from other countries are disseminated to the USA, differences in health-care systems, and technological infrastructure will probably affect their chances of success.

Reliability of Estrous Detection in Holstein Heifers Using a Radiotelemetric Pedometer Located on the Neck or Legs Under Different Rearing Conditions

To evaluate the efficiency and accuracy of estrous detection using a new pedometry system that can measure the hourly activity of cattle, pedometers were attached to the neck and the hind legs of 15 Holstein heifers. Heifers were reared in pasture for grazing, an open paddock, or in a tie-stall barn (an additional pedometer was attached to a front leg of each of these heifers). The most recent 24 h-total number of steps was compared for each 1 h-interval with the mean value of the preceding days during the reference period (RP). The neck pedometer detected all 10 instances of estrous activity (100%) for the grazing heifers at 1.3 times the thresholds value for a 5-day RP but with only 32% accuracy. The hind leg pedometer, however, obtained 100% efficiency and 83% accuracy at 1.4 times the threshold value for a 7-day RP. The efficiencies and accuracies in detecting 12 instances of estrous activity under the paddock condition were 92 and 65% (neck, 1.3-fold, 7-day RP) and 92 and 100% (hind leg, 1.6- or 1.7-fold, 7-day RP), respectively. Under the tie stall condition, the neck pedometers detected 92% of 23 instances of estrous activity with 34% accuracy (1.2-fold, 3-day RP), and the efficiencies and accuracies of the leg pedometers were 78 and 78% (hind leg, 1.4-fold, 4- or 6-day RP) and 87 and 83% (front leg, 1.4-fold, 7-day RP), respectively. Prediction of ovulation time was more precisely with the leg pedometers than with those under the tie stall conditions. Our preliminary results indicate that this new pedometer system has practical value for estrous detection in heifers under different rearing conditions, which affect the criteria required for detection. Furthermore, they also indicate that a leg pedometer can reliably detect estrus and that a neck pedometer may only be capable of detecting estrus under paddock rearing conditions.

A tele-ultrasound needs analysis in Queensland

A tele-ultrasound survey was distributed to clinicians and sonographers in regional and rural sites throughout Queensland. In all, 28 centres were invited to complete a profile questionnaire, and 27 centres were invited to complete a case-log. Twenty-five of the 28 questionnaires were returned (89% response rate). Twenty-two of the 27 case-logs were returned (81% response rate). Obstetric ultrasound was the most frequently performed ultrasound examination, accounting for 846 (35%) of the 2,410 recorded during the two-week survey period. The respondents considered that 182 cases would have benefited from further consultation: 79% for diagnostic advice, 13% for patient management advice and 8% for advice on examination technique. Six hospitals appeared to have the greatest need for a tele-ultrasound service. There was a strong preference for the store-and-forward transmission of static images: 70% preferred this modality, in comparison with 19% who preferred realtime transmission and 11% who preferred store-and-forward transmission of video clips.

Telephonic transmission of 12-lead electrocardiograms during acute myocardial infarction

To test the feasibility of a small and simple system for telephonic transmission of 12-lead electrocardiograms (ECGs), 70 patients with acute coronary syndrome admitted to the cardiac care unit (CCU) were included in a feasibility study. The transmission system consisted of a belt with multiple electrodes, which was positioned around the chest. The ECG signal was sent to a call centre via a standard telephone line. In parallel, a standard 12-lead ECG was recorded on site. In a retrospective analysis, each lead of the transmitted ECG was compared with the on-site 12-lead ECG with regard to ST-segment changes and final diagnosis. In all 37 patients with acute ST-elevation myocardial infarction, the diagnosis was correctly established on the basis of telephone-transmitted ECGs. In 96% of limb and 88% of chest leads, ST elevations which were visible in standard ECGs were correctly displayed on telephonically transmitted ECGs. In the remaining 33 patients no false-positive diagnosis was made using transtelephonic ECG analysis. A control group of 31 patients without apparent heart disease showed high concordance between standard ECGs and telephonically transmitted ECGs. Telephonically transmitted 12-lead ECGs interpreted by a hospital-based internist/cardiologist might allow a rapid and accurate diagnosis of ST-elevation myocardial infarction and may increase diagnostic safety for the emergency staff during prehospital decision making and treatment of acute myocardial infarction.

A pooled analysis to evaluate results of capsule endoscopy trials

BACKGROUND AND STUDY AIM

Capsule endoscopy is a new tool in the evaluation of the small intestine. To speed evaluation and acceptance of this technology, the manufacturer (Given Imaging Ltd, Yoqneam, Israel) funded several trials. The data from these trials were collected at a central repository using a standardized reporting tool. Presentation of this data to the US Food and Drug Administration (FDA) in July 2003 led to the removal of the adjunctive term with regard to indication for capsule endoscopy, recognizing that the method is of independent importance for evaluating the small bowel. The aim of the present study was to combine the data from several capsule trials to help determine the yield and miss rate of capsule endoscopy for different diseases, compared with alternative diagnostic modalities.

METHODS

Capsule studies were identified from a master database of funded studies. Studies were included in the pooled analysis if they reported a prospective comparison with another modality for evaluation of the small intestine.

RESULTS

32 studies with a total of 691 patients were found in the master database, of which 24 studies, representing 530 patients, met inclusion criteria and were entered into the pooled analysis. Prior to study entry, patients had undergone a mean of 6.77 diagnostic procedures, without findings. Of these 24 studies, 14 (involving 310 patients) were categorized as "bleeding" studies, and 10 studies (220 patients) as "nonbleeding small-bowel disorders" studies. The comparison procedure was push enteroscopy in 300 patients (in 45 for nonbleeding disorders), small-bowel series in 140 patients (in 125 for non-bleeding disorders), and colonoscopy with ileoscopy in 90 patients (50 for nonbleeding disorders). Overall analysis per patient showed new findings from capsule endoscopy in 50 % of patients; 17 % had new findings from the comparison method; in 22 % there were similar findings; and in 11 % there were no findings. A total of 1349 instances of disease were identified in the 530 examinations. Capsule endoscopy solely detected 87 % of the disease instances, while the comparison method solely detected 13 %. The yield for push enteroscopy alone was 14.8 %, for small-bowel series it was 9.9 %, and for colonoscopy it was 13.2 %. Capsule endoscopy missed 146 disease instances for a miss rate of 10 %; 989 were missed by the comparison methods for a miss rate of 73 %; and 214 were detected by both methods.

CONCLUSION

Capsule endoscopy is the state of the art method for noninvasive detection of small-bowel disease.

Inpatient Telemetry Does Not Need To Be Used in the Management of Older Patients Hospitalized With Chest Pain at Low Risk for In-Hospital Coronary Events and Mortality

BACKGROUND

Little is known about patients admitted with chest pain to inpatient telemetry units directly from an emergency department.

METHODS

We analyzed data from 105 consecutive patients who presented with chest pain to an emergency department and who were hospitalized in an inpatient telemetry unit but who were at low risk for a coronary event.

RESULTS

Telemetry yielded no information which was used to manage any patient. None of the 105 patients (0%) developed a myocardial infarction or died during hospitalization. At 4.8-year follow-up, 8 of 105 patients (8%) died. Significant risk factors for long-term mortality were age (p < .001), prior coronary artery disease (p < .05), and diabetes (p < .02).

CONCLUSIONS

Inpatient telemetry was of no value in predicting short-term coronary events or mortality or long-term mortality in low-risk patients hospitalized with chest pain.

A self-calibrating telemetry system for measurement of ventricular pressure-volume relations in conscious, freely moving rats

Using Bluetooth wireless technology, we developed an implantable telemetry system for measurement of the left ventricular pressure-volume relation in conscious, freely moving rats. The telemetry system consisted of a pressure-conductance catheter (1.8-Fr) connected to a small (14-g) fully implantable signal transmitter. To make the system fully telemetric, calibrations such as blood resistivity and parallel conductance were also conducted telemetrically. To estimate blood resistivity, we used four electrodes arranged 0.2 mm apart on the pressure-conductance catheter. To estimate parallel conductance, we used a dual-frequency method. We examined the accuracy of calibrations, stroke volume (SV) measurements, and the reproducibility of the telemetry. The blood resistivity estimated telemetrically agreed with that measured using an ex vivo cuvette method (y=1.09x - 11.9, r2= 0.88, n=10). Parallel conductance estimated by the dual-frequency (2 and 20 kHz) method correlated well with that measured by a conventional saline injection method (y=1.59x - 1.77, r2= 0.87, n=13). The telemetric SV closely correlated with the flowmetric SV during inferior vena cava occlusions (y=0.96x + 7.5, r2=0.96, n=4). In six conscious rats, differences between the repeated telemetries on different days (3 days apart on average) were reasonably small: 13% for end-diastolic volume, 20% for end-systolic volume, 28% for end-diastolic pressure, and 6% for end-systolic pressure. We conclude that the developed telemetry system enables us to estimate the pressure-volume relation with reasonable accuracy and reproducibility in conscious, untethered rats.

Cardiorespiratory requirements and reproducibility of the six-minute walk test in elderly patients with coronary artery disease

OBJECTIVES

To measure the cardiorespiratory requirements of the six-minute walk test (6MWT), to compare this demand with the symptom-limited exercise test (SLET) at ventilatory threshold and at maximal level in elderly patients with coronary artery disease (CAD), and to assess the reproducibility of the 6MWT in cardiorespiratory exchanges in those patients.

DESIGN

Comparative and reproducibility sample.

SETTING

Cardiac rehabilitation service.

PARTICIPANTS

Twenty-five people with CAD.

INTERVENTIONS

Subjects performed an SLET and a 6MWT. To test 6MWT reproducibility, 9 patients performed 2 repeated 6MWTs.

MAIN OUTCOME MEASURES

The 6MWT cardiorespiratory values, measured with a portable gas analyzer, were compared with the SLET data and with the data from the 2 repeated 6MWTs.

RESULTS

The 6MWT peak oxygen uptake (VO2peak, 14.27+/-2.94 mL.min(-1).kg(-1)) and heart rate (94+/-14 beats/min) did not differ from the SLET values at ventilatory threshold (VO2, 13.4+/-2.65 mL.min(-1).kg(-1); heart rate, 91+/-17 beats/min), whereas the 6MWT ventilation (VEpeak, 36.72+/-10.03 L/min) was higher than the SLET at ventilatory threshold (Ve, 31.54+/-8.93 L/min, P<.03). Maximal 6MWT cardiorespiratory data were lower than the SLET maximal values. Cardiorespiratory values did not differ between the 2 repeated 6MWT (VO2peak, 15.33+/-3.52 mL.min(-1).kg(-1) vs 15.11+/-2.65 mL.min(-1).kg(-1); VEpeak, 39.07+/-12.33 L/min vs 39.07+/-12.13 L/min; heart rate, 95+/-21 beats/min vs 89+/-15 beats/min).

CONCLUSIONS

The 6MWT cardiorespiratory requirement values did not differ from SLET values at ventilatory threshold except for ventilation, and 6MWT values are reproducible in elderly patients with CAD.

Home informatics in healthcare: assessment guidelines to keep up quality of care and avoid adverse effects

Due to an ageing population and improved treatment possibilities, a shortage in hospital beds is a fact in many countries. Home healthcare schemes using information technology (IT) are under development as a response to this and with the intention to produce a more cost-effective care. So far it has been shown that home healthcare is beneficial to certain patient groups. The trend is a widening of the criteria for admission to home healthcare, which means treatment in the home of more severe conditions that otherwise would require in-hospital care. Home informatics has the potential to become a means of providing good care at home. In this process, it is important to consider what new risks will be encountered when placing electronic equipment in the home care environment. Continuous assessment and guidance is important in order to achieve a safe and effective care. Based on a review of current knowledge this paper presents an inventory of risks and adverse events specific to this area. It was found that risks and adverse events could stem from technology in itself, from human-technology interaction conditions or from the environment in which the technology is placed. As a result from the risk inventory, this paper proposes guidelines for the planning and assessment of IT-based hospital-at-home schemes. These assessment guidelines are specifically aimed at performance improvement and thus to be considered a complement to the more general guidelines on telehomecare adopted by the American Telemedicine Association (ATA) in October 2002.

Evaluation and applications of radiotelemetry in small laboratory animals

Radiotelemetry is the "state of the art" for monitoring physiological functions in awake and freely moving laboratory animals, while minimizing stress artifacts. For researchers, especially those in the fields of pharmacology and toxicology, the technique provides a valuable tool for defining the physiological and pathophysiological consequences derived from advances molecular, cellular, and tissue biology and in predicting the effectiveness and safety of new compounds in humans. There is ample evidence that radiotelemetry systems for measuring physiological functions has been sufficiently validated. Today, the technology is an important tool for collection of a growing number of physiological parameters, for contributing to animal welfare (reduction and refinement alternatives), and for reducing overall animal research costs.

A nurse practitioner intervention model to maximize efficient use of telemetry resources

BACKGROUND

Telemetry monitoring is widely used in hospitals; the importance of being able to monitor and examine dysrhythmias has been universally accepted. Yet it is often used for patients who do not actually require this technology. A model to improve the efficiency of telemetry use entailed the use of an advanced practice nurse (APN; identical to a nurse practitioner) to provide concurrent review and intervention of floating telemetry, which is available for patients independently of the floor location and who do not need an intensive care unit bed. ADDRESSING OVERUSE: The demand for floating telemetry at Hackensack University Medical Center had equaled or exceeded the telemetry availability virtually 100% of the time, even after local guidelines had been disseminated in 1998. The APN carried out concurrent monitoring and intervened with the attending physician when patients were on telemetry for longer than 48 hours and did not meet the local telemetry guidelines.

RESULTS

The mean number (standard error [SE]) of hours per patient declined from 65.2 +/- 0.7 hours (95% confidence interval, 63.8 to 66.6 hours) for the 11 months before the intervention to a mean of 49.6 +/- 0.4 hours (95% confidence interval, 48.7 to 50.2 hours) for the 29 months after intervention--representing a decrease of 34% (p < 0.0001). This decrease led to an increase in the number of patients per month put on telemetry.

DISCUSSION

The APN model, an aggressive approach that induced change almost immediately, was then applied to other quality improvement projects.

A health monitoring system for elderly people living alone

We have developed a health monitoring system for elderly people living alone. We monitored the in-house movements of eight subjects (average age 81 years) by placing infrared sensors in each room of their homes. Because their movements were unrestricted, monitoring could last longer than other forms of monitoring. Continuous monitoring was performed for 80 months in total. We found that each subject had a specific pattern of movements. We estimated their health condition by comparing the duration of stays in specific rooms, such as the lavatory, with previously recorded data. If after analysis an unusual state was detected, we informed the family of the incident. Final decisions should be made by the family members, not automatically by computer software. For example, after contacting the subject or a neighbour by telephone, family members could call for an ambulance or arrange a visit by a doctor or home help. Thus, this system reduced anxiety for both the elderly subjects living alone and their family members.

A method for QT correction based on beat-to-beat analysis of the QT/RR interval relationship in conscious telemetred beagle dogs

INTRODUCTION

Drug-induced QT prolongation is a major clinical risk factor for arrhythmia induction, particularly torsades de pointes. QT interval is rate dependent, and many formulae exist that attempt to correct QT for changes in heart rate. Most correction factors are acknowledged to overcorrect at high heart rates, undercorrect at low heart rates, and tend to be species specific. Data collected from computerised data acquisition systems are normally reported as means over a given logging period, and so extremes of heart rate are averaged out. Therefore, the aim of this study was to develop a technique for assessing drug-induced changes in the QT/RR relationship, which is simple, suitable for small group sizes, and better able to determine rate-dependent effects of drugs.

METHODS

Telemetred beagle dogs (n=4) instrumented for the measurement of electrocardiogram (ECG) were monitored for four separate 20-h periods to define the control QT/RR relationship. Data were binned by RR interval, in 10 ms bins, to produce a control curve. Each dog was treated with vehicle and sotalol (4, 8, 32 mg/kg) in a crossover design to determine whether drug-induced changes in the QT/RR relationship could be detected using the data binning technique.

RESULTS

The control QT/RR relationship was curvilinear with a steep section for RR intervals below 580 ms, and was much less steep after this point. Sotalol produced QT prolongation and bradycardia-Fridericia's correction (QTf) reduced the magnitude of this prolongation. The data analysed by the binning technique showed a larger prolongation in QT than was suggested by QTf, and an inverse frequency-dependent response.

DISCUSSION

Beat-to-beat analysis and binning allows accurate determination of the QT/RR relationship and assessment of QT prolongation without recourse to mathematical modelling. It also highlights the importance of assessing QT effects in well-trained animals over a range of heart rates.