Home telemonitoring of intracranial pressure

BACKGROUND

As technical progress advances, telemonitoring has become an important part of patient care in many areas of medical treatment. However, distanced surveillance of intracranial pressure (ICP) could not be established so far. With the recent introduction of a telemetric ICP measurement probe, new possibilities arise. Here, we report on a new home setup enabling home telemonitoring of intracranial pressure.

METHODS

Twenty patients suffering from disturbances of cerebrospinal fluid circulation, who underwent insertion of a telemetric ICP measurement probe, were provided with medical equipment to read ICP at home and save the data on an internet-enabled computer. Training in handling the equipment was performed during in-patient stay; recorded and uploaded ICP data was then analyzed online. Therefore, the treating medical team was able to access the ICP data via a secure internet connection while telephone conferencing with the patient.

RESULTS

Almost 7400 h of ICP data were recorded at home and evaluated via an internet connection according to the telemonitoring setup. This corresponds to an average record time of about 370 h per patient. ICP profiles were observed following endoscopic treatment, shunting procedures, or valve adjustments. The mean distance between the patients' residence and the consulting hospital was 172 km (range, 16-649 km).

CONCLUSIONS

ICP measurements have become accessible for telemonitoring purposes. This new management of hydrocephalus reflects an alternative method in patient care, especially for those who live far away from specialized centers.

SAFE@HOME - Feasibility study of a telemonitoring platform combining blood pressure and preeclampsia symptoms in pregnancy care

OBJECTIVE

To study the feasibility of a telemonitoring platform for hypertensive disease in pregnancy, consisting of a wireless blood pressure monitor and an app in combination with an integrated preeclampsia symptom checklist.

STUDY DESIGN

Prospective observational study with 14 pregnant women during a 15 weekday study period. For feasibility purposes, compliance was measured by evaluating the number of entered BP and symptom checklists. Comparing all the entered values with the threshold values checked the accuracy of the automatic alerts. Usability and patient satisfaction were measured using questionnaires.

RESULTS

Compliance rates for blood pressure and symptom checklist were 93% and 85% respectively. No false positive or missing alerts were found in the alarm system. The telemonitoring system alarmed 7 times for BP thresholds (3.8% of all received values), Of 167 returned symptom checklists, 93% of symptom alarms could be handled with expectant management because of concurrent normal blood pressure. The majority of participants were satisfied with the system.

CONCLUSIONS

This is the first feasibility study of a telemonitoring platform, combining remote monitoring of BP with preeclampsia symptoms in pregnancy care. Action from health care providers during telemonitoring is only needed in case of alarming combinations of results. This system is potentially very useful in care for women at risk for hypertensive disorders during pregnancy.

Predictive value of gamma-glutamyltransferase for ventricular arrhythmias and cardiovascular mortality in implantable cardioverter-defibrillator patients

Background

Gamma-glutamyltransferase (GGT) is a new predictor of cardiovascular diseases. In this study, we aimed to determine its association with ventricular arrhythmias (VAs) in implantable cardioverter-defibrillator (ICD) patients.

Methods

One hundred and forty patients implanted with ICD or cardiac resynchronization therapy defibrillator with home monitoring were studied retrospectively. The primary endpoint was appropriate ICD treatment of VAs, secondary endpoint was cardiac death.

Results

During a mean follow-up period of 44 ± 17 months, 78 patients (55.7%) experienced VAs, 50 patients (35.7%) were treated with appropriate ICD shocks and 16 patients (11.4%) died due to cardiovascular diseases. GGT was positively correlated with high sensitivity C reactive protein (r = 0.482, P < 0.001), left ventricular end-diastolic dimension (r = 0.175, P = 0.039), New York Heart Association class (r = 0.199, P = 0.018), fasting blood glucose (r = 0.233, P = 0.006) and negatively with left ventricular ejection fraction (r = − 0.181, P = 0.032) and high-density lipoprotein (r = − 0.313, P < 0.001). Based on receiver operating characteristics curve, the cut-off value of GGT = 56 U/L was identified to predict VAs. In Kaplan-Meier survival analysis, GGT ≥56 U/L was associated with increased VAs (P<0.001), ICD shock events (P = 0.006) and cardiovascular mortality (P = 0.003). In multivariate COX regression models, GGT ≥56 U/L was an independent risk factor for VAs (HR 2.253, 95%CI:1.383–3.671, P = 0.001), ICD shocks (HR 2.256, 95%CI:1.219–4.176, P = 0.010) and cardiac death (HR 3.555, 95%CI:1.215–10.404, P = 0.021).

Conclusions

In this ICD population, GGT ≥56 U/L was independently associated with VAs and cardiac death.

Predictive value of rapid-rate non-sustained ventricular tachycardia in the occurrence of appropriate implantable cardioverter-defibrillator therapy

PURPOSE

Rapid-rate non-sustained ventricular tachycardia (RR-NSVT) that meets detection criteria but terminates itself before the delivery of implantable cardioverter-defibrillator (ICD) therapy is not rare in routine ICD interrogation. Whether sustained ventricular tachycardia/fibrillation will occur in a short time after RR-NSVT has not been fully elucidated.

METHODS

Clinical features and follow-up data of 828 ICD patients with home monitoring were retrospectively collected. RR-NSVT characteristics and time interval between the first episode of RR-NSVT and subsequent appropriate ICD therapy were analyzed.

RESULTS

During a mean follow-up of 44.75 ± 20.87 months, 335 episodes of RR-NSVT were documented in 145 patients. A total of 119 patients had both RR-NSVT and appropriate ICD therapy. In multivariate COX regression models, RR-NSVT was an independent predictor of appropriate ICD therapy (HR 7.599, 95%CI 5.926-9.745, P < 0.001), appropriate shock (HR 6.222, 95%CI 4.667-8.294, P < 0.001), and all-cause mortality (HR 2.156, 95%CI 1.499-3.099, P < 0.001). Appropriate ICD therapy was administered after the first RR-NSVT episode in 101 patients, with a median interval of 21 days. Compared to RR-NSVT with appropriate ICD therapy occurring beyond 21 days, RR-NSVT within 21 days prior to appropriate ICD therapy had a longer median duration time (14 s vs. 12 s, P = 0.013), but without significant difference in mean RR interval at initial detection and mean RR interval after episode termination.

CONCLUSIONS

Rapid-rate non-sustained VT was an independent predictor of appropriate ICD therapy and all-cause mortality. The presence of RR-NSVT should be considered a possible herald of more serious cardiac events in ICD patients.

Non-invasive home lung impedance monitoring in early post-acute heart failure discharge: Three case reports

BACKGROUND

Patients discharged after hospitalization for acute heart failure (AHF) are frequently readmitted due to an incomplete decongestion, which is difficult to assess clinically. Recently, it has been shown that the use of a highly sensitive, non-invasive device measuring lung impedance (LI) reduces hospitalizations for heart failure (HF); it has also been shown that this device reduces the cardiovascular and all-cause mortality of stable HF patients when used in long-term out-patient follow-ups. The aim of these case series is to demonstrate the potential additive role of non-invasive home LI monitoring in the early post-discharge period.

CASE SUMMARY

We present a case series of three patients who had performed daily LI measurements at home using the edema guard monitor (EGM) during 30 d after an episode of AHF. All patients had a history of chronic ischemic HF with a reduced ejection fraction and were hospitalized for 6–17 d. LI measurements were successfully made at home by patients with the help of their caregivers. The patients were carefully followed up by HF specialists who reacted to the values of LI measurements, blood pressure, heart rate and clinical symptoms. LI reduction was a more frequent trigger to medication adjustments compared to changes in symptoms or vital signs. Besides, LI dynamics closely tracked the use and dose of diuretics.

CONCLUSION

Our case series suggests non-invasive home LI monitoring with EGM to be a reliable and potentially useful tool for the early detection of congestion or dehydration and thus for the further successful stabilization of a HF patient after a worsening episode.

Information needs for designing a home monitoring system for children with medical complexity

Background Children with medical complexity (CMC) are a growing population of medically fragile children with unique healthcare needs, who have recurrent emergency department (ED) and hospital admissions due to frequent acute escalations of their chronic conditions. Mobile health (mHealth) tools have been suggested to support CMC home monitoring and prevent admissions. No mHealth tool has ever been developed for CMC and challenges exist. Objective To: 1) assess information needs for operationalizing CMC home monitoring, and 2) determine technology design functionalities needed for building a mHealth application for CMC. Methods Qualitative descriptive study conducted at a tertiary care children's hospital with a purposive sample of English-speaking caregivers of CMC. We conducted 3 focus group sessions, using semi-structured, open-ended questions. We assessed caregiver's perceptions of early symptoms that commonly precede acute escalations of their child conditions, and explored caregiver's preferences on the design functionalities of a novel mHealth tool to support home monitoring of CMC. We used content analysis to assess caregivers' experience concerning CMC symptoms, their responses, effects on caregivers, and functionalities of a home monitoring tool. Results Overall, 13 caregivers of CMC (ages 18 months to 19 years, mean = 9 years) participated. Caregivers identified key symptoms in their children that commonly presented 1-3 days prior to an ED visit or hospitalization, including low oxygen saturations, fevers, rapid heart rates, seizures, agitation, feeding intolerance, pain, and a general feeling of uneasiness about their child's condition. They believed a home monitoring system for tracking these symptoms would be beneficial, providing a way to identify early changes in their child's health that could prompt a timely and appropriate intervention. Caregivers also reported their own symptoms and stress related to caregiving activities, but opposed monitoring them. They suggested an mHealth tool for CMC to include the following functionalities: 1) symptom tracking, targeting commonly reported drivers (symptoms) of ED/hospital admissions; 2) user friendly (ease of data entry), using voice, radio buttons, and drop down menus; 3) a free-text field for reporting child's other symptoms and interventions attempted at home; 4) ability to directly access a health care provider (HCP) via text/email messaging, and to allow real-time sharing of child data to facilitate care, and 5) option to upload and post a photo or video of the child to allow a visual recall by the HCP. Conclusions Caregivers deemed a mHealth tool beneficial and offered a set of key functionalities to meet information needs for monitoring CMC's symptoms. Our future efforts will consist of creating a prototype of the mHealth tool and testing it for usability among CMC caregivers.

Telemonitoring in asthma control: a randomized controlled trial

OBJECTIVE

Telemonitoring seems to be a useful tool for patients' management. The aim of our project was to test the applicability and potential effects of a 12-month telemonitoring of patients with asthma supported by information and communication technologies.

METHODS

We included 100 patients with asthma followed in the outpatient pulmonary clinic in a randomized controlled clinical trial. The patients' data were collected by study questionnaires and lung function tests at the inclusion and at the end of interventional period. In the interventional group, asthma control test (ACT) and peak expiratory flow measurements (PEF) were stimulated to be regularly reported by Short Message Service (SMS). As a response to reported values, the patients automatically received a preformed text or a call from a study nurse in case of detected predefined critical values.

RESULTS

The compliance of reporting PEF and ACT values was higher than 80% in 96% of patients. Although we did not detect significant differences in ACT score improvement between the two study groups, we found more prominent improvement of ACT score in the subgroup of patients with two or more exacerbations prior to inclusion in the interventional group, compared to the control group. 40 (78%) patients in the interventional group listed at least one positive effect of telemonitoring on management of asthma.

CONCLUSIONS

The developed program for home monitoring of patients with asthma was applicable and offered the patients support in managing their disease. Further studies with more selected patients are needed to confirm its usefulness in improving asthma control.

Prognostic significance of frequent premature ventricular complex early after implantation among patients with implantable cardioverter defibrillator

BACKGROUND

Premature ventricular complex (PVC) was mainly studied by 24-hour Holter in previous studies. However, the value of long-term Home Monitoring of PVC burden early after ICD implantation is unknown.

METHODS

The data of 416 patients with ICD were analyzed. The percentage of days with frequent PVC (≥10/h) within 30th-90th days was calculated as the continuous frequent PVC (CfPVC) percentage. ROC curve of CfPVC percentages was plotted. Kaplan-Meier survival and Cox regression were used to assess the cumulative risks.

RESULTS

Based on ROC curves, the cut-off value for the CfPVC percentage was 40%. According to Kaplan-Meier analysis and multivariate Cox regression analysis, CfPVC percentage ≥40% was an independent predictor of higher incidences of VAEs, appropriate ATP, appropriate shocks, and cardiac death.

CONCLUSION

A long-term continuous burden of frequent PVC with CfPVC percentage ≥40% can be a predictor of future VAEs, appropriate ATP, appropriate shocks and cardiac death in ICD recipients.

Sleep devices: wearables and nearables, informational and interventional, consumer and clinical

The field of sleep is in many ways ideally positioned to take full advantage of advancements in technology and analytics that is fueling the mobile health movement. Combining hardware and software advances with increasingly available big datasets that contain scored data obtained under gold standard sleep laboratory conditions completes the trifecta of this perfect storm. This review highlights recent developments in consumer and clinical devices for sleep, emphasizing the need for validation at multiple levels, with the ultimate goal of using personalized data and advanced algorithms to provide actionable information that will improve sleep health.

A home monitoring program including real-time wireless home spirometry in idiopathic pulmonary fibrosis: a pilot study on experiences and barriers

In idiopathic pulmonary fibrosis (IPF), home monitoring experiences are limited, not yet real-time available nor implemented in daily care. We evaluated feasibility and potential barriers of a new home monitoring program with real-time wireless home spirometry in IPF. Ten patients with IPF were asked to test this home monitoring program, including daily home spirometry, for four weeks. Measurements of home and hospital spirometry showed good agreement. All patients considered real-time wireless spirometry useful and highly feasible. Both patients and researchers suggested relatively easy solutions for the identified potential barriers regarding real-time home monitoring in IPF.

Diagnostic and therapeutic yield of a patient-controlled portable EEG device with dry electrodes for home-monitoring neurological outpatients-rationale and protocol of the HOMEONE pilot study

Background

The HOME^ONE study is part of the larger HOME project, which aims to provide evidence of diagnostic and therapeutic yield (“change of management”) of a patient-controlled portable EEG device with dry electrodes for the purposes of EEG home-monitoring neurological outpatients.

Methods

The HOME^ONE study is the first step in the process of investigating whether outpatient EEG home-monitoring changes the diagnosis and treatment of patients in comparison to conventional EEG (“change of management”). Both EEG devices (conventional and portable) will be systematically compared via a two-phase intra-individual assessment.

In the first phase (pilot study phase), both EEG devices will be used within neurologist practices (all other things being equal). This pilot study (involving 130 patients) will evaluate the technical usability and efficacy of the new portable dry electrode EEG recorder in comparison to conventional EEG devices. Judgements will be based on technical assessments and EEG record examinations of private practitioners and two experienced neurologists (percent of concordant readings and kappa values).

The second phase (feasibility study phase) aims to assess patients’ acceptability and feasibility of the EEG home-monitoring and will provide insights into the extent diagnostic and therapeutic yields can be expected.

For this purpose, a conventional EEG will be recorded in neurologist practices. Thereafter, the practice staff will instruct the patients on how the portable EEG device functions. The patients will subsequently use the devices in their home environment.

The evaluation will compare the before and after documented diagnostic findings and the therapeutic consequences of the private practitioners with those of two experienced neurologists.

Discussion

To the best of our knowledge, this will be the first study of its kind to examine new approaches to diagnosing unclear consciousness disorders or other disorders of the CNS or the cardiovascular system through the use of a patient-controlled portable EEG device with dry electrodes for the purpose of home-monitoring neurological outpatients. If the two phases of the HOME^ONE study provide sufficient evidence of diagnostic and therapeutic yields, this would justify (indication-specific) full-scale randomized controlled trials or observational studies.

Trial registration

DRKS DRKS00012685. Registered 9 August 2017, retrospectively registered.

An explorative study on the validity of various definitions of a 2·2°C temperature threshold as warning signal for impending diabetic foot ulceration

Home monitoring of skin temperature is effective to prevent diabetic foot ulceration. We explored the validity of various definitions for the >2·2°C left‐to‐right threshold used as a warning signal for impending ulceration. Twenty patients with diabetes and peripheral neuropathy monitored their skin temperature with an infrared thermometer at the plantar hallux, metatarsal heads, midfoot and heel four times a day for 6 consecutive days. Environmental temperature and walking activity were monitored and associated with foot temperature. The average temperature difference between feet was 0·65°C. At single locations, a left‐to‐right temperature difference of >2·2°C was found 245 times (8·5% of measurements). Confirmation of these above‐threshold readings on the following day was found seven times (0·3%). Corrected for individual left‐to‐right mean foot temperature differences, this reduced to four (0·2%). No ulcers developed in the week after monitoring. Left‐to‐right foot temperature differences were not significantly correlated with walking activity, environmental temperature or time of day. The >2·2°C left‐to‐right foot temperature threshold for impending ulceration is not valid as single measurement, but validity improves to acceptable levels when an above‐threshold temperature difference is confirmed the following day and further improves with individual correction. The threshold is independent of time of day, environmental temperature and walking activity.

A New Evolutionary Algorithm-Based Home Monitoring Device for Parkinson's Dyskinesia

Parkinson's disease (PD) is a neurodegenerative movement disorder. Although there is no cure, symptomatic treatments are available and can significantly improve quality of life. The motor, or movement, features of PD are caused by reduced production of the neurotransmitter dopamine. Dopamine deficiency is most often treated using dopamine replacement therapy. However, this therapy can itself lead to further motor abnormalities referred to as dyskinesia. Dyskinesia consists of involuntary jerking movements and muscle spasms, which can often be violent. To minimise dyskinesia, it is necessary to accurately titrate the amount of medication given and monitor a patient's movements. In this paper, we describe a new home monitoring device that allows dyskinesia to be measured as a patient goes about their daily activities, providing information that can assist clinicians when making changes to medication regimens. The device uses a predictive model of dyskinesia that was trained by an evolutionary algorithm, and achieves AUC>0.9 when discriminating clinically significant dyskinesia.

Impact of Infant-Polysomnography Studies on Discharge Management and Outcomes: A 5 Year Experience from a Tertiary Care Unit

OBJECTIVE

To evaluate the impact of infant-polysomnography studies performed in the NICU on management and outcomes.

STUDY DESIGN

Retrospective study to collect demographics and data on infant-polysomnography studies between Jan 2010 to Dec 2014.

RESULTS

110 premature neonates had polysomnography study performed at 36.9 ± 2.5 weeks post menstrual age. Almost all the studies were read as abnormal and 95% of the studied infants were discharged home on a cardiorespiratory monitor. 20% of the subjects had apnea >20 s, 18% had apnea of 15-20 s and 50% of infants had apnea of 10-15 s. 24.5% infants were discharged home on caffeine, 28% on metoclopramide and 24% on antacids. There were 11 readmissions for apparent life threatening events with no until 6 month-corrected age. There was no association between polysomnography results and readmission. There was a decline in polysomnography studies performed each year.

CONCLUSION

Cardiorespiratory monitoring, medications and polysomnography studies do not predict outcomes.

Assessing the usability by clinicians of VISION: A hierarchical display of patient-collected physiological information to clinicians

BACKGROUND

The inability of patients to accurately and completely recount their clinical status between clinic visits reduces the clinician's ability to properly manage their patients. One way to improve this situation is to collect objective patient information while the patients are at home and display the collected multi-day clinical information in parallel on a single screen, highlighting threshold violations for each channel, and allowing the viewer to drill down to any analog signal on the same screen, while maintaining the overall physiological context of the patient. All this would be accomplished in a way that was easy for the clinician to view and use.

METHODS

Patients used five mobile devices to collect six heart failure-related clinical variables: body weight, systolic and diastolic blood pressure, pulse rate, blood oxygen saturation, physical activity, and subjective input. Fourteen clinicians practicing in a heart failure clinic rated the display using the System Usability Scale that, for acceptability, had an expected mean of 68 (SD, 12.5). In addition, we calculated the Intraclass Correlation Coefficient of the clinician responses using a two-way, mixed effects model, ICC (3,1).

RESULTS

We developed a single-screen temporal hierarchical display (VISION) that summarizes the patient's home monitoring activities between clinic visits. The overall System Usability Scale score was 92 (95% CI, 87-97), p < 0.0001; the ICC was 0.89 (CI, 0.79-0.97), p < 0.0001.

CONCLUSION

Clinicians consistently found VISION to be highly usable. To our knowledge, this is the first single-screen, parallel variable, temporal hierarchical display of both continuous and discrete information acquired by patients at home between clinic visits that presents clinically significant information at the point of care in a manner that is usable by clinicians.

A prospective pilot study of home monitoring in adults with cystic fibrosis (HOME-CF): protocol for a randomised controlled trial

BACKGROUND

Home monitoring has the potential to detect early pulmonary exacerbations in people with cystic fibrosis (CF), with consequent improvements in health outcomes and healthcare associated costs. This study aims to assess the effects of home monitoring on hospital admissions, quality of life, antibiotic requirements, exacerbation frequency, lung function, nutritional outcomes, anxiety, depression, costs and health outcomes, as well as the qualitative effects on the patient experience.

METHODS

This randomised controlled mixed-methods trial aims to recruit 100 adults with CF cared for in one large regional CF centre. Participants are randomly allocated 1:1 to the intervention group (twice-weekly home monitoring of symptoms measured by the Cystic Fibrosis Respiratory Symptom Diary - Chronic Respiratory Infection Symptom Score (CFRSD-CRISS) and Forced Expiratory Volume in one second (FEV1)) or a control group (routine clinical care) for the 12-month study period. Measurements are recorded at study visits at baseline, 3, 6, 9 and 12 months. Spirometry, body weight, co-morbidities, medications, hospital inpatient days, courses of antibiotics (oral and intravenous), pulmonary exacerbations (defined by the modified Fuchs criteria) are recorded at each study visit. Health status, capability and health economics are measured at each study visit by the Hospital Anxiety and Depression Scale (HADS), the ICEpop CAPability measure for Adults (ICECAP-A), EuroQol 5 dimensions (EQ-5D-5L) questionnaire and an adapted resource use questionnaire. The patient experience is assessed by semi-structured qualitative interviews at baseline and 12 months.

DISCUSSION

Results from this study will help to determine the effect of home monitoring on inpatient bed days and quality of life in adults with CF, as well as other relevant health and health economic outcomes.

TRIAL REGISTRATION

This study protocol is registered with Clinicaltrials.gov ( NCT02994706 ), date registered 16th July 2014.

Exploring the feasibility and acceptability of sensor monitoring of gait and falls in the homes of persons with multiple sclerosis

Gait parameters variability and falls are problems for persons with MS and have not been adequately captured in the home. Our goal was to explore the feasibility and acceptability of monitoring of gait and falls in the homes of persons with MS over a period of 30 days. To test the feasibility of measuring gait and falls for 30days in the home of persons with MS, spatiotemporal gait parameters stride length, stride time, and gait speed were compared. A 3D infrared depth imaging system has been developed to objectively measure gait and falls in the home environment. Participants also completed a 16-foot GaitRite electronic pathway walk to validate spatiotemporal parameters of gait (gait speed (cm/s), stride length (cm), and gait cycle time(s)) during the timed 25 foot walking test (T25FWT). We also documented barriers to feasibility of installing the in-home sensors for these participants. The results of the study suggest that the Kinect sensor may be used as an alternative device to measure gait for persons with MS, depending on the desired accuracy level. Ultimately, using in-home sensors to analyze gait parameters in real time is feasible and could lead to better analysis of gait in persons with MS.

Long-term integrated telerehabilitation of COPD Patients: a multicentre randomised controlled trial (iTrain)

BACKGROUND

Pulmonary rehabilitation (PR) is an effective intervention for the management of people with chronic obstructive pulmonary disease (COPD). However, available resources are often limited, and many patients bear with poor availability of programmes. Sustaining PR benefits and regular exercise over the long term is difficult without any exercise maintenance strategy. In contrast to traditional centre-based PR programmes, telerehabilitation may promote more effective integration of exercise routines into daily life over the longer term and broaden its applicability and availability. A few studies showed promising results for telerehabilitation, but mostly with short-term interventions. The aim of this study is to compare long-term telerehabilitation with unsupervised exercise training at home and with standard care.

METHODS/DESIGN

An international multicentre randomised controlled trial conducted across sites in three countries will recruit 120 patients with COPD. Participants will be randomly assigned to telerehabilitation, treadmill and control, and followed up for 2 years. The telerehabilitation intervention consists of individualised exercise training at home on a treadmill, telemonitoring by a physiotherapist via videoconferencing using a tablet computer, and self-management via a customised website. Patients in the treadmill arm are provided with a treadmill only to perform unsupervised exercise training at home. Patients in the control arm are offered standard care. The primary outcome is the combined number of hospitalisations and emergency department presentations. Secondary outcomes include changes in health status, quality of life, anxiety and depression, self-efficacy, subjective impression of change, physical performance, level of physical activity, and personal experiences in telerehabilitation.

DISCUSSION

This trial will provide evidence on whether long-term telerehabilitation represents a cost-effective strategy for the follow-up of patients with COPD. The delivery of telerehabilitation services will also broaden the availability of PR and maintenance strategies, especially to those living in remote areas and with no access to centre-based exercise programmes.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02258646 .

Daily life negative mood and exhaled nitric oxide in asthma

BACKGROUND

Psychosocial stress and negative affect have been linked to asthma exacerbations, but longitudinal studies demonstrating a daily life association between negative affect and airway nitric oxide are missing.

OBJECTIVE

The longitudinal association between negative mood fluctuations, exhaled nitric oxide, and lung function in asthma was examined.

METHODS

Self-assessments of the fraction of exhaled nitric oxide (FeNO), spirometry (forced expiratory volume in the first second, FEV1), negative mood, and daily activities were obtained from 20 patients with asthma for 2 months, resulting in 1108 assessments for the analyses (approximately 55 per patient). Concurrent and prospective associations between FeNO, FEV1, and negative mood were analyzed using mixed effects regression models for longitudinal data.

RESULTS

Negative mood was positively associated with changes in FeNO during the same day, and to a stronger extent when prior day negative mood was included in the prediction. FeNO and negative mood were positively associated with same-day FEV1, with the latter relation being partially mediated by changes in FeNO. Associations between FeNO and FEV1 were stronger in younger patients, with earlier onset of asthma, or with lower asthma control. Findings were not changed when controlling for physical activity, medication, cold symptoms, air pollution, and hours spent outside.

CONCLUSION

Daily life changes of negative mood in asthma are positively associated with FeNO changes and FeNO increases are associated with a mild bronchodilation. These findings indicate that psychological influences need to be considered when using FeNO as indicator of airway inflammation and guide for treatment decisions.

Digital monitoring and care: Virtual medicine

Remote digital health monitoring technologies can be synergistically organized to create a virtual medical system providing more continuous care centered on the patient rather than the bricks and mortar medical complex. Utilization of the digitalized patient health monitoring can facilitate diagnosis, treatment plans, physician-patient interaction, and accelerate the progress of medical research, education, and training. The field of cardiac electrophysiology has been an early adopter of this shift in care and serves as a paradigm applicable to all areas of medicine. The overall impact of this remote virtual care model on the quality of medical care and patient experience requires greater study, as well as vigilance as to the differences between technology and care in order to preserve the intangible and immeasurable factors that bring humanity to the art and science of medicine.

Hemodynamic monitoring in the era of digital health

Digital innovations are changing medicine, and hemodynamic monitoring will not be an exception. Five to ten years from now, we can envision a world where clinicians will learn hemodynamics with simulators and serious games, will monitor patients with wearable or implantable sensors in the hospital and after discharge, will use medical devices able to communicate and integrate the historical, clinical, physiologic and biological information necessary to predict adverse events, propose the most rationale therapy and ensure it is delivered properly. Considerable intellectual and financial investments are currently made to ensure some of these new ideas and products soon become a reality.

The role of variability in night-time mean heart rate on the prediction of ventricular arrhythmias and all-cause mortality in implantable cardioverter defibrillator patients

AIMS

This study was to use implantable cardioverter defibrillator (ICD) home monitoring (HM) feature to evaluate the role of mean night-time heart rate (MNHR) in the occurrence of ventricular arrhythmias (VAs) and mortality.

METHODS AND RESULTS

This study retrospectively analysed clinical and ICD device data in 318 ICD patients. Data of the first 30-day MNHR (recorded 02:00-06:00 am) by HM were collected. The average and standard deviation of 30-day MNHR (AVHR and SDHR, respectively) were then determined in each patient. The primary endpoint was appropriate ICD treatment of VAs. The secondary endpoint was all-cause mortality. During a mean follow-up period of 32 ± 10 months, 179 of the 318 patients (56.3%) experienced VAs, 123 patients (38.7%) were treated by ICD shocks, and 37 patients (11.6%) died. The overall SDHR in this study cohort was 4.5 ± 3.0 bpm. Based on the receiver operating characteristic curve, the cut-off value of SDHR = 3.685 bpm was identified to predict VAs. In the Kaplan-Meier survival, SDHR ≥ 3.685 bpm was associated with increased VAs [hazard ratio (HR) = 1.885; 95% confidence interval (CI) = 1.362-2.609; P < 0.001], shock events (HR = 1.637; 95% CI = 1.11-2.414; P = 0.013), all-cause mortality (HR = 2.42; 95% CI = 1.266-4.627; P = 0.008), and the combined endpoints (HR = 1.872; 95% CI = 1.365-2.567; P < 0.001). In univariate and multivariate Cox models (adjusting for clinical factors), SDHR ≥ 3.685 bpm was still an independent predictor for all endpoints.

CONCLUSION

In ICD population, SDHR ≥ 3.685 bpm was an independent predictor for VAs and all-cause mortality.

How B-Type Natriuretic Peptide (BNP) and Body Weight Changes Vary in Heart Failure With Preserved Ejection Fraction Compared With Reduced Ejection Fraction: Secondary Results of the HABIT (HF Assessment With BNP in the Home) Trial

BACKGROUND

Heart failure is a common cause of hospitalization and can be divided into types with preserved and reduced ejection fraction (HFpEF and HFrEF, respectively). In this subanalysis of the HABIT (Heart Failure Assessment With BNP in the Home) trial, we examined the differences between home B-type natriuretic peptide (BNP) testing and weight monitoring in patients with HFpEF and with HFrEF before decompensation.

METHODS AND RESULTS

This was a retrospective review of patients with HFpEF and HFrEF from the HABIT trial. The HFpEF patients compared with HFrEF patients were older and more obese and had lower baseline BNP values. Intra-individual BNP dispersion (spread of distribution over time) was greater in HFpEF than in HFrEF owing to rapid fluctuations (within 3 days). Slowly varying changes in BNP (estimated by a moving average) were equally predictive of ADHF risk in both HFpEF and HFrEF. However, in HFpEF, a rapid rise in BNP >200 pg/mL within 3 days was associated with an increased risk of acute decompensated heart failure (ADHF; hazard ratio 4.0), whereas a similar association was not observed in HFrEF. Weight gain ≥5 lb in 3 days had a high specificity but low sensitivity for ADHF in both HFpEF and HFrEF, whereas a lower threshold of ≥2 lb weight gain over 3 days in patients with HFpEF (but not HFrEF) was a moderately sensitive cutoff associated with decompensation (60% sensitivity).

CONCLUSIONS

Patients with HFpEF and HFrEF have variations in their BNP and weight before decompensation. The rapid time scale behaves differently between the groups. In those with HFpEF, a 3-day period characterized by ≥2 lb weight gain and/or >200 pg/mL BNP rise was significantly associated with decompensation. Future prospective studies investigating different weight and BNP cutoffs for home monitoring of HFpEF and HFrEF patients should be performed to fully learn the value of BNP changes before clinical deompensation.

Markers for upper limb dysfunction in Amyotrophic Lateral Sclerosis using analysis of typing activity

OBJECTIVE

Assistive devices based on keyboard access support communication and control tools for patients with Amyotrophic Lateral Sclerosis (ALS). The aim of this work was to explore movement activity in the use of keyboards and identify markers for upper limb (UL) dysfunction.

METHODS

We present a longitudinal study including 19 ALS patients, followed for 2-20 months. Typing activity was recorded with an accelerometer placed on the posterior part of patients' index finger. Participants performed the same 10-word typing task (2-6 assessments). Time and acceleration during keystroke were the main outcomes of this study. Patients were compared with 20 healthy subjects and 6 patients with other neuromuscular disorders.

RESULTS

During disease progression, mean time in holding down a key increased and was longer than in control subjects. Acceleration at key press and key release decreased with progression of UL dysfunction. Delay between tapping and pressing down each key increased with UL dysfunction.

CONCLUSIONS

Delay in pressing and releasing keys are markers of UL dysfunction in ALS. The decrease in the acceleration of movements related to keystroke can contribute to monitor disease progression.

SIGNIFICANCE

Typing activity can be explored to access remotely and continuously to ALS progression by patients who use assistive communication devices.

Heuristic evaluation of a telehealth system from the Danish TeleCare North Trial

OBJECTIVE

The aim was to evaluate the usability of the design of the telehealth system, named Telekit, developed for the Danish TeleCare North Trial, early into the design process in order to assess potential problems and limitations which could hinder its successful implementation.

METHODS

Five experts, including one who pilot-tested the Telekit system, individually evaluated its usability and its compliance with Jakob Nielsen's ten usability heuristics for interaction design. Usability problems were categorised according to Rolf Molich's severity classification.

RESULTS

The five experts identified a total of 152 problems in the Telekit system, each identifying 22-40 problems. 86 (57%) out of the 152 problems were identified only once. All heuristics were used, but the three most frequently used were: "Match between system and the real world" (32%), "Consistency and standards" (13%) and "Aesthetic and minimalist design" (13%). The most widely used classifications were: "Improvement" (40%) and "Minor problem" (43%).

CONCLUSION

Heuristic evaluation was an effective method for uncovering and identifying problems with the system. The consistent finding of particular usability problems confirms that the development of a telehealth system should pay particular attention to user aspects. The most serious problem was the inability of the system to inform users of how to perform measurements correctly and to "speak the users' language". The problems found in the heuristic evaluation have led to several significant changes in the telehealth system. We suggest that heuristic evaluation always be followed by user tests to evaluate the design of telehealth systems.