Impact of remote vital sign monitoring on health outcomes in acute respiratory infection and exacerbation of chronic respiratory conditions: systematic review and meta-analysis

Background

Our aim was to investigate the effectiveness of virtual wards on health outcomes in patients with acute respiratory infection.

Methods

We searched four electronic databases from January 2000–March 2021 for randomised controlled trials (RCTs). We included studies in people with acute respiratory illness or an acute exacerbation of a chronic respiratory illness, where a patient or carer measured vital signs (oximetry, blood pressure, pulse) for initial diagnosis and/or asynchronous monitoring, in a person living in private housing or a care home. We performed random effects meta-analysis for mortality.

Results

We reviewed 5834 abstracts, 107 full texts, and judged nine RCTs relevant for inclusion in which sample sizes ranged from 37–389 (total=1627), mean ages between 61 and 77 years, and five judged to be at low risk of bias. Five RCTs had fewer hospital admissions in the intervention (monitoring) group, out of which two studies reported a significant difference. Two studies reported more admissions in the intervention group, with one reporting a significant difference. We were unable to perform a meta-analysis on healthcare utilisation and hospitalisation data due to lack of outcome definition in the primary studies and variable outcome measurements. We judged two studies to be at low risk of bias. The pooled summary risk ratio for mortality was 0.90 (95% CI 0.55 to 1.48).

Conclusion

The limited literature for remote monitoring of vital signs in acute respiratory illness provides weak evidence that these interventions have a variable impact on hospitalisations and healthcare utilisation, and may reduce mortality.

A Diagnostic Test Accuracy Study Investigating General Practitioner Clinical Impression and Brief Cognitive Assessments for Dementia in Primary Care, Compared to Specialized Assessment

BACKGROUND

Many health systems are interested in increasing the number of uncomplicated and typical dementia diagnoses that are made in primary care, but the comparative accuracy of tests is unknown.

OBJECTIVE

Calculate diagnostic accuracy of brief cognitive tests in primary care.

METHODS

We did a diagnostic test accuracy study in general practice, in people over 70 years who had consulted their GP with cognitive symptoms but had no prior diagnosis of dementia. The reference standard was specialist assessment, adjudicated for difficult cases, according to ICD-10. We assessed 16 index tests at a research clinic, and additionally analyzed referring GPs clinical judgement.

RESULTS

240 participants had a median age of 80 years, of whom 126 were men and 132 had dementia. Sensitivity of individual tests at the recommended thresholds ranged from 56% for GP judgement (specificity 89%) to 100% for MoCA (specificity 16%). Specificity of individual tests ranged from 4% for Sniffin' sticks (sensitivity 100%) to 91% for Timed Up and Go (sensitivity 23%). The 95% centile of test duration in people with dementia ranged from 3 minutes for 6CIT and Time and Change, to 16 minutes for MoCA. Combining tests with GP judgement increased test specificity and decreased sensitivity: e.g., MoCA with GP Judgement had specificity 87% and sensitivity 55%.

CONCLUSIONS

Using GP judgement to inform selection of tests was an efficient strategy. Using IQCODE in people who GPs judge as having dementia and 6CIT in people who GPs judge as having no dementia, would be a time-efficient and accurate diagnostic assessment.The original protocol for the study is available at https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-016-0475-2.

Clinical judgment of GPs for the diagnosis of dementia: a diagnostic test accuracy study

BACKGROUND

GPs often report using clinical judgment to diagnose dementia.

AIM

To investigate the accuracy of GPs' clinical judgment for the diagnosis of dementia.

DESIGN & SETTING

Diagnostic test accuracy study, recruiting from 21 practices around Bristol, UK.

METHOD

The clinical judgment of the treating GP (index test) was based on the information immediately available at their initial consultation with a person aged ≥70 years who had cognitive symptoms. The reference standard was an assessment by a specialist clinician, based on a standardised clinical examination and made according to the 10th revision of the International Classification of Diseases (ICD-10) criteria for dementia.

RESULTS

A total of 240 people were recruited, with a median age of 80 years (interquartile range [IQR] 75-84 years), of whom 126 (53%) were men and 132 (55%) had dementia. The median duration of symptoms was 24 months (IQR 12-36 months) and the median Addenbrooke's Cognitive Examination III (ACE-III) score was 75 (IQR 65-87). GP clinical judgment had sensitivity 56% (95% confidence interval [CI] = 47% to 65%) and specificity 89% (95% CI = 81% to 94%). Positive likelihood ratio was higher in people aged 70-79 years (6.5, 95% CI = 2.9 to 15) compared with people aged ≥80 years (3.6, 95% CI = 1.7 to 7.6), and in women (10.4, 95% CI = 3.4 to 31.7) compared with men (3.2, 95% CI = 1.7 to 6.2), whereas the negative likelihood ratio was similar in all groups.

CONCLUSION

A GP clinical judgment of dementia is specific, but confirmatory testing is needed to exclude dementia in symptomatic people whom GPs judge as not having dementia.

Carotid artery dissection presenting with isolated headache and Horner syndrome after minor head injury

A woman aged 31 years presented to the emergency department after a minor head injury. She reported mild headache and a metallic taste in her mouth. Full neurologic examination was remarkable only for left-sided Horner syndrome. Left internal carotid artery dissection was confirmed on magnetic resonance imaging. She was treated with aspirin. Symptoms and signs persisted 3 months later, but there was no additional neurologic deficit. We stress the importance of early detection of Horner syndrome to minimize the risk of disabling stroke.

High caloric intake, poor cognition and dementia: the Caerphilly Prospective Study

To examine the hypothesis that caloric intake in mid-life is associated with later dementia or cognitive impairment not dementia (CIND). A prospective cohort study was conducted in Caerphilly, South Wales, United Kingdom. Men aged 45-59 years were identified from the electoral roll and general practice. 2,512 men were examined between July 1979 until September 1983. Four follow-up examinations were conducted every 4-5 years until 2004. Participants were categorized on the basis of their average daily caloric intake over each of the first three phases. Outcomes were CIND and dementia ascertained at phase five (2004). 192 men (15% of 1,248 participants at phase five) had CIND and 100 (8%) dementia. Age adjusted odds ratios demonstrated strongest associations between average energy consumption and vascular CIND or dementia (OR 1.62 95% CI 1.25-2.10). Adjustment for nutritional factors, vascular disease, diabetes, smoking, BP and BMI if anything increased the association (OR 1.64, 95% CI 1.03-2.60). After adjusting for social class, associations were attenuated and consistent with chance (OR 1.48, 95% CI 0.92-2.38). When adjusted for social class, the previously observed association between caloric intake and cognitive outcomes is modest, consistent with chance, and may be due to residual confounding.

Orbital swelling: a simplified guide

Swelling in and around the orbit is common but many doctors may have difficulty forming a differential diagnosis for an orbital swelling. It is important to be able to differentiate the causes of orbital swelling either because they are common (e.g. thyroid eye disease) or because they are rare (e.g. mucormycosis) but may result in loss of vision or even death (Gamba et al, 1986; Rootman, 2001; Tanaka et al, 2004; Kanski, 2007; Lutt et al, 2008). This article outlines the assessment of orbital swelling.