Trial of Remote Continuous versus Intermittent NEWS monitoring after major surgery (TRaCINg): protocol for a feasibility randomised controlled trial

Background

Despite medical advances, major surgery remains high risk. Up to 44% of patients experience postoperative complications, which can have huge impacts for patients and the healthcare system. Early recognition of postoperative complications is crucial in reducing morbidity and preventing long-term disability. The current standard of care is intermittent manual vital signs monitoring, but new wearable remote monitors offer the benefits of continuous vital signs monitoring without limiting the patient's mobility. The aim of this study is to evaluate the feasibility, acceptability and clinical impacts of continuous remote monitoring after major surgery.

Methods

The study is a randomised, controlled, unblinded, parallel group, feasibility trial. Adult patients undergoing elective major surgery will be invited to participate if they have the capacity to provided informed, written consent and do not have a cardiac pacemaker or an allergy to adhesives. Participants will be randomly assigned to receive continuous remote monitoring and normal National Early Warning Score (NEWS) monitoring (intervention group) or normal NEWS monitoring alone (control group). Continuous remote monitoring will be achieved using the SensiumVitals® wireless patch which is worn on the patient's chest and monitors heart rate, respiratory rate and temperature continuously and alerts the nurse when there is deviation from pre-set physiological norms. Participants will be followed up throughout their hospital admission and for 30 days after discharge. Feasibility will be assessed by evaluating recruitment rate, adherence to protocol and randomisation, and the amount of missing data. The acceptability of the patch to nursing staff and patients will be assessed using questionnaires and interviews. Clinical outcomes will include time to antibiotics in cases of sepsis, length of hospital stay, number of critical care admissions and rate of readmission within 30 days of discharge.

Discussion

Early detection and treatment of complications minimises the need for critical care, improves patient outcomes, and produces significant cost savings for the healthcare system. Remote continuous monitoring systems have the potential to allow earlier detection of complications, but evidence from the literature is mixed. Demonstrating significant benefit over intermittent monitoring to offset the practical and economic implications of continuous monitoring requires well-controlled studies in high-risk populations to demonstrate significant differences in clinical outcomes; this feasibility trial seeks to provide evidence of how best to conduct such a confirmatory trial.

Trial registration

This study is listed on the ISRCTN registry with study ID ISRCTN16601772.

The impact of continuous versus intermittent vital signs monitoring in hospitals: A systematic review and narrative synthesis

BACKGROUND

Continuous vital signs monitoring on general hospital wards may allow earlier detection of patient deterioration and improve patient outcomes. This systematic review will assess if continuous monitoring is practical outside of the critical care setting, and whether it confers any clinical benefit to patients.

METHODS

MEDLINE^®, MEDLINE^® In-Process, EMBASE, CINAHL and The Cochrane Library were searched for articles that evaluated the clinical or non-clinical outcomes of continuous vital signs monitoring in adults outside of the critical care setting. The protocol was registered with PROSPERO (CRD42017058098).

FINDINGS

Twenty-four studies met the inclusion criteria and reported outcomes on a total of 40,274 patients and 59 ward staff in nine countries. The majority of studies showed benefits in terms of critical care use and length of hospital stay. Larger studies were more likely to demonstrate clinical benefit, particularly critical care use and length of hospital stay. Three studies showed cost-effectiveness. Barriers to implementation included nursing and patient satisfaction and the burden of false alerts.

CONCLUSIONS

Continuous vital signs monitoring outside the critical care setting is feasible and may provide a benefit in terms of improved patient outcomes and cost efficiency. Large, well-controlled studies in high-risk populations are required to evaluate the clinical benefit of continuous monitoring systems.

Patient attitudes towards remote continuous vital signs monitoring on general surgery wards: An interview study

BACKGROUND

Vital signs monitoring is used to identify deteriorating patients in hospital. The most common tool for vital signs monitoring is an early warning score, although emerging technologies allow for remote, continuous patient monitoring. A number of reviews have examined the impact of continuous monitoring on patient outcomes, but little is known about the patient experience. This study aims to discover what patients think of monitoring in hospital, with a particular emphasis on intermittent early warning scores versus remote continuous monitoring, in order to inform future implementations of continuous monitoring technology.

METHODS

Semi-structured interviews were undertaken with 12 surgical inpatients as part of a study testing a remote continuous monitoring device. All patients were monitored with both an early warning score and the new device. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis.

FINDINGS

Patients can see the value in remote, continuous monitoring, particularly overnight. However, patients appreciate the face-to-face aspect of early warning score monitoring as it allows for reassurance, social interaction, and gives them further opportunity to ask questions about their medical care.

CONCLUSION

Early warning score systems are widely used to facilitate detection of the deteriorating patient. Continuous monitoring technologies may provide added reassurance. However, patients value personal contact with their healthcare professionals and remote monitoring should not replace this. We suggest that remote monitoring is best introduced in a phased manner, and initially as an adjunct to usual care, with careful consideration of the patient experience throughout.

Acute intravenous exposure to silver nanoparticles during pregnancy induces particle size and vehicle dependent changes in vascular tissue contractility in Sprague Dawley rats

The use of silver nanoparticles (AgNP) raises safety concerns during susceptible life stages such as pregnancy. We hypothesized that acute intravenous exposure to AgNP during late stages of pregnancy will increase vascular tissue contractility, potentially contributing to alterations in fetal growth. Sprague Dawley rats were exposed to a single dose of PVP or Citrate stabilized 20 or 110nm AgNP (700μg/kg). Differential vascular responses and EC50 values were observed in myographic studies in uterine, mesenteric arteries and thoracic aortic segments, 24h post-exposure. Reciprocal responses were observed in aortic and uterine vessels following PVP stabilized AgNP with an increased force of contraction in uterine artery and increased relaxation responses in aorta. Citrate stabilized AgNP exposure increased contractile force in both uterine and aortic vessels. Intravenous AgNP exposure during pregnancy displayed particle size and vehicle dependent moderate changes in vascular tissue contractility, potentially influencing fetal blood supply.

Mechanisms for C(sp2)-Si activation of aryltrimethylsilyl groups in palladium-catalysed couplings

Silyl-substituted aromatic compounds can participate as the electrophilic component in palladium-catalysed cross-couplings, and reactivity is enhanced by a neighbouring silyl-group. Products analogous to those obtained from C-H activation chemistry are accessible by this means with the additional benefit of regiochemistry defined by the site of silyl substitution. DFT studies described here show that the mechanism of C-Si cleavage is distinct from previously recognised mechanisms for C-H cleavage, with a cascade of silyl intermediates en route to a stable product. The amide directing-groups are involved only in the stabilisation of palladacyclic intermediates, and are never disposed to activate silicon directly. 5-Membered and 6-membered palladacycles are known to behave differently in coupling reactions and the calculations reveal underlying reasons in the cationic pathways studied here.

Water-carbon dioxide solid phase equilibria at pressures above 4 GPa

A solid phase in the mixed water-carbon dioxide system, previously identified as carbonic acid, was observed in the high-pressure diamond-anvil cell. The pressure-temperature paths of both its melting and peritectic curves were measured, beginning at 4.4 GPa and 165 °C (where it exists in a quadruple equilibrium, together with an aqueous fluid and the ices H₂O(VII) and CO₂(I)) and proceeding to higher pressures and temperatures. Single-crystal X-ray diffraction revealed a triclinic crystal with unit cell parameters (at 6.5 GPa and 20 °C) of a = 5.88 Å, b = 6.59 Å, c = 6.99 Å, α = 88.7°, β = 79.7°, and γ = 67.7°. Raman spectra exhibit a major line at ~1080 cm⁻¹ and lattice modes below 300 cm⁻¹.

Health Status After Transcatheter or Surgical Aortic Valve Replacement in Patients With Severe Aortic Stenosis at Increased Surgical Risk: Results From the CoreValve US Pivotal Trial

OBJECTIVES

This study sought to compare the health status outcomes for patients treated with either self-expanding transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (AVR).

BACKGROUND

In patients at increased surgical risk, TAVR with a self-expanding bioprosthesis is associated with improved 1-year survival compared with AVR. However, elderly patients may be just as concerned with quality-of-life improvement as with prolonged survival as a goal of treatment.

METHODS

Between 2011 and 2012, 795 patients with severe aortic stenosis at increased surgical risk were randomized to TAVR or AVR in the CoreValve US Pivotal Trial. Health status was assessed at baseline, 1 month, 6 months, and 1 year using the Kansas City Cardiomyopathy Questionnaire, Medical Outcomes Study Short-Form 12 Questionnaire, and EuroQOL 5-dimension questionnaire; growth curve models were used to examine changes over time.

RESULTS

Over the 1-year follow-up period, disease-specific and generic health status improved substantially for both treatment groups. At 1 month, there was a significant interaction between the benefit of TAVR over AVR and access site. Among surviving patients eligible for iliofemoral (IF) access, there was a clinically relevant early benefit with TAVR across all disease-specific and generic health status measures. Among the non-IF cohort, however, most health status measures were similar for TAVR and AVR, although there was a trend toward early benefit with TAVR on the Short-Form 12 Questionnaire's physical health scale. There were no consistent differences in health status between TAVR and AVR at the later time points.

CONCLUSIONS

Health status improved substantially in surviving patients with increased surgical risk who were treated with either self-expanding TAVR or AVR. TAVR via the IF route was associated with better early health status compared with AVR, but there was no early health status benefit with non-IF TAVR compared with AVR. (Safety and Efficacy Study of the Medtronic CoreValve® System in the Treatment of Symptomatic Severe Aortic Stenosis in High Risk and Very High Risk Subjects Who Need Aortic Valve Replacement; NCT01240902).

Carrier-wave shape effects in optical filamentation

Strong-field ionization in optical filaments created by ultrashort pulses with sub-cycle engineered waveforms is studied theoretically. To elucidate the physics of the recently demonstrated enhanced ionization yield and spatial control of the optical filament core in two color pulses, we employ two types of quantum models integrated into spatially resolved pulse-propagation simulations. We show that the dependence of the ionization on the shape of the excitation carrier is adiabatic in nature, and is driven by local temporal peaks of the electric field. Implications for the modeling of light-matter interactions in multicolor optical fields are also discussed.

Palladium-catalysed directed C–H activation by anilides and ureas; water participation in a general base mechanism

A general-base pathway for CH-activation in anilides and ureas en route to palladacycles was developed through DFT calculations and fits available evidence.

Mass-like peripheral zone enhancement on CT is predictive of higher-grade (Gleason 4 + 3 and higher) prostate cancer

PURPOSE

To determine whether focal peripheral zone enhancement on routine venous-phase CT is predictive of higher-grade (Gleason 4 + 3 and higher) prostate cancer.

MATERIALS AND METHODS

IRB approval was obtained and informed consent waived for this HIPAA-compliant retrospective study. Forty-three patients with higher-grade prostate cancer (≥Gleason 4 + 3) and 96 with histology-confirmed lower-grade (≤Gleason 3 + 4 [n = 47]) or absent (n = 49) prostate cancer imaged with venous-phase CT comprised the study population. CT images were reviewed by ten blinded radiologists (5 attendings, 5 residents) who scored peripheral zone enhancement on a scale of 1 (benign) to 5 (malignant). Mass-like peripheral zone enhancement was considered malignant. Likelihood ratios (LR) and specificities were calculated. Multivariate conditional logistic regression analyses were conducted.

RESULTS

Scores of "5" were strongly predictive of higher-grade prostate cancer (pooled LR+ 9.6 [95% CI 5.8-15.8]) with rare false positives (pooled specificity: 0.98 [942/960, 95% CI 0.98-0.99]; all 10 readers had specificity ≥95%). Attending scores of "5" were more predictive than resident scores of "5" (LR+: 14.7 [95% CI 5.8-37.2] vs. 7.6 [95% CI 4.2-13.7]) with similar specificity (0.99 [475/480, 95% CI 0.98-1.00] vs. 0.97 [467/480, 95% CI 0.96-0.99]). Significant predictors of an assigned score of "5" included presence of a peripheral zone mass (p < 0.0001), larger size (p < 0.0001), and less reader experience (p = 0.0008). Significant predictors of higher-grade prostate cancer included presence of a peripheral zone mass (p = 0.0002) and larger size (p < 0.0001).

CONCLUSION

Focal mass-like peripheral zone enhancement on routine venous-phase CT is specific and predictive of higher-grade (Gleason 4 + 3 and higher) prostate cancer.

Origins of observed reactivity and specificity in the addition of B2Cl4 and analogues to unsaturated compounds

In 1954 Schlesinger and co-workers observed the direct reaction of diboron tetrachloride with simple organic compounds under mild conditions, the 1,2 addition product being formed with either ethylene or acetylene. In the following 25 years a series of addition reactions to simple alkenes, alkynes and dienes was demonstrated. B2F4 was shown to react in similar manner, albeit under more forcing conditions. Crucially, it was demonstrated that the addition to (E)- or (Z)-but-2-ene occurred with cis-stereospecificity. Only sporadic interest was shown in this field thereafter until catalysed addition reactions of diboron reagents were realized. Encouraged by this revival of interest through the discovery of transition-metal and nucleophilic catalysis of diboryl additions, DFT analysis of uncatalysed additions of B2X4 has been carried out and interpreted. This includes the relative reactivity of several B-B reagents with ethene, and that of B2Cl4vs. B2F4 additions, including benzene, naphthalene and C60 as reactants. This allows the analysis of relative reactivity vis-à-vis substitution on boron, and also direct comparison with hydroboration by HBCl2. [4 + 2] Addition of diboron reagents to dienes with B-B cleavage competes with direct [2 + 2] addition, favourably so for B2F4. The computational results demonstrate that the stereospecific addition to isomeric but-2-enes is a rare concerted [2σs + 2πs] process.

Assessment of the metastable electronic state approach as a microscopically self-consistent description for the nonlinear response of atoms

This Letter presents the first quantitative assessment of the recently proposed metastable electronic state approach (MESA) for calculation of the nonlinear optical response of noble gas atoms. Based on the single active electron potentials for several atomic species, Stark resonant states are used to extract the nonlinear polarization and ionization rates free of any additional fitting parameters. It is shown that even the simplest version of the method provides a viable, first-principle-based, and self-consistent alternative to the standard model commonly used for simulations in the field of extreme nonlinear optics.

Cardiac Ischemia Reperfusion Injury Following Instillation of 20 nm Citrate-capped Nanosilver

BACKGROUND

Silver nanoparticles (AgNP) have garnered much interest due to their antimicrobial properties, becoming one of the most utilized nano-scale materials. However, any potential evocable cardiovascular injury associated with exposure has not been reported to date. We have previously demonstrated expansion of myocardial infarction after intratracheal (IT) instillation of carbon-based nanomaterials. We hypothesized pulmonary exposure to Ag core AgNP induces a measureable increase in circulating cytokines, expansion of cardiac ischemia-reperfusion (I/R) injury and is associated with depressed coronary constrictor and relaxation responses. Secondarily, we addressed the potential contribution of silver ion release on AgNP toxicity.

METHODS

Male Sprague-Dawley rats were exposed to 200 μl of 1 mg/ml of 20 nm citrate-capped Ag core AgNP, 0.01, 0.1, 1 mg/ml Silver Acetate (AgAc), or a citrate vehicle by intratracheal (IT) instillation. One and 7 days following IT instillation the lungs were evaluated for inflammation and the presence of silver; serum was analyzed for concentrations of selected cytokines; cardiac I/R injury and coronary artery reactivity were assessed.

RESULTS

AgNP instillation resulted in modest pulmonary inflammation with detection of silver in lung tissue and alveolar macrophages, elevation of serum cytokines: G-CSF, MIP-1α, IL-1β, IL-2, IL-6, IL-13, IL-10, IL-18, IL-17α, TNFα, and RANTES, expansion of I/R injury and depression of the coronary vessel reactivity at 1 day post IT compared to vehicle treated rats. Silver within lung tissue was persistent at 7 days post IT instillation and was associated with an elevation in cytokines: IL-2, IL-13, and TNFα and expansion of I/R injury. AgAc resulted in a concentration dependent infarct expansion and depressed vascular reactivity without marked pulmonary inflammation or serum cytokine response.

CONCLUSIONS

Based on these data, IT instillation of AgNP increases circulating levels of several key cytokines, which may contribute to persistent expansion of I/R injury possibly through an impaired vascular responsiveness.

Coordination diversity in hydrogen-bonded homoleptic fluoride-alcohol complexes modulates reactivity

The nucleophilic reactivity of fluoride ion is altered in the presence of hydrogen-bond donors, including alcohols. Relatively little is known about the coordination involved; to rectify this, the X-ray structures of fourteen novel fluoride-alcohol complexes with tetrabutylammonium as the counterion have been determined. The coordination number varies from two to four depending on the steric bulk of the alcohol and is closely linked to trends in reactivity. This diversity in coordination stoichiometry is unprecedented but significant, as it implies differences in the ability of the fluoride-alcohol complexes to dissociate in solution with release of a more active and/or selective fluoride source.

Pattern of association between endemic Hawaiian fruit flies (Diptera, Tephritidae) and their symbiotic bacteria: Evidence of cospeciation events and proposal of "Candidatus Stammerula trupaneae"

Several insect lineages have evolved mutualistic association with symbiotic bacteria. This is the case of some species of mealybugs, whiteflies, weevils, tsetse flies, cockroaches, termites, carpenter ants, aphids and fruit flies. Some species of Tephritinae, the most specialized subfamily of fruit flies (Diptera: Tephritidae), harbour co-evolved vertically transmitted, bacterial symbionts in their midgut, known as "Candidatus Stammerula spp.". The 25 described endemic species of Hawaiian tephritids, plus at least three undescribed species, are taxonomically distributed among three genera: the cosmopolitan genus Trupanea (21 described spp.), the endemic genus Phaeogramma (2 spp.) and the Nearctic genus Neotephritis (2 spp.). We examined the presence of symbiotic bacteria in the endemic tephritids of the Hawaiian Islands, which represent a spectacular example of adaptive radiation, and tested the concordant evolution between host and symbiont phylogenies. We detected through PCR assays the presence of specific symbiotic bacteria, designated as "Candidatus Stammerula trupaneae", from 35 individuals of 15 species. The phylogeny of the insect host was reconstructed based on two regions of the mitochondrial DNA (16S rDNA and COI-tRNALeu-COII), while the bacterial 16S rRNA was used for the symbiont analysis. Host and symbiont phylogenies were then compared and evaluated for patterns of cophylogeny and strict cospeciation. Topological congruence between Hawaiian Tephritinae and their symbiotic bacteria phylogenies suggests a limited, but significant degree of host-symbiont cospeciation. We also explored the character reconstruction of three host traits, as island location, host lineage, and host tissue attacked, based on the symbiont phylogenies under the hypothesis of cospeciation.

Demonstration of the need for cardiovascular and pulmonary normative data for cancer survivors

Despite evidence that cancer and its treatments severely reduce cardiorespiratory fitness (CRF), normative data for cancer survivors do not exist. The present study identifies age and gender-specific CRF distributions in a cancer population. The use of cancer-specific normative CRF data may help stratify initial fitness status and assess improvements in response to exercise interventions in cancer survivors. Data from 703 cancer survivors were analyzed for this study. Quintiles were compiled for peak oxygen consumption (VO2peak), forced vital capacity (FVC), and forced expiratory volume (FEV1) for males and females in 5 age groups (19-39, 40-49, 50-59, 60-69, and ≥70 years of age). VO2peak values for the cancer population were significantly lower than the general US population. The cancer population average in each age group fell within the "very poor" classification of VO2peak values for the general population. FVC values in the cancer population were similar to the general population. Cancer survivors had very low age group-specific VO2peak values compared to the apparently healthy general US population. Previously, CRF values of cancer survivors were compared to normative values for the apparently healthy general population, which yielded imprecise classifications of initial fitness and changes in fitness, resulting in patient discouragement.