Initial Experience with Telemedicine for Interstage Monitoring in Infants with Palliated Congenital Heart Disease.

Infants with staged surgical palliation for congenital heart disease are at high-risk for interstage morbidity and mortality; home monitoring programs have mitigated these risks. In 2019, we instituted telemedicine (TM) in our established Infant Single Ventricle Monitoring Program. All consecutive patients discharged following neonatal operation/intervention were monitored until subsequent stage 2 surgical palliation. We offered TM (synchronous video) visits as part of regularly scheduled follow-up, replacing at least one in-person primary care visit with a TM cardiologist visit. We tracked emergency department (ED) visits, hospitalizations, how TM identified clinical concerns, and whether use of TM prevented unnecessary ED visits or expedited in-person assessment. We assessed caregiver and clinician satisfaction. Between 8/2019 and 5/2020, we conducted 60 TM visits for 29 patients. Of 31 eligible patients, 2 families (6.9%) declined. Median monitoring time was 199 days (range 75-264) and median number of TM visits/patient was 2 (range 1-5). In 6 visits (10%), significant clinical findings were identified which avoided an ED visit. Five TM visits led to expedited outpatient assessments, of which 1 patient required hospitalization. There were no missed events or deaths. Median ED visits/patient/month were significantly lower compared to the same calendar period of the prior year (0.0 (0-2.5) vs. 0.4 (0-3.7), p = 0.0004). Caregivers and clinicians expressed high levels of satisfaction with TM. TM for this high-risk population is feasible and effective in identifying clinical concerns and preventing unnecessary ED visits. TM was particularly effective during the COVID-19 pandemic, allowing for easy adaptation of care to ensure patient safety in this fragile cohort.

Valuing Disease Prevention in a Vegetatively Propagated Annual Crop: Benefits From the Montana Seed Potato Certification Program.

We examine the economic costs of potato virus Y (PVY) and benefits to commercial potato growers from using screened seed. To do so, we use a quantile regression model to explore disease spread. We use this model to predict disease prevalence and corresponding losses in commercial potato operations with and without a screening and certification program in place. Our analysis suggests that this screening is very important; the amount of PVY in seed in the summer test is the strongest predictor of PVY in the winter test of the variables in our model. The amount of PVY in the seed can have major effects on commercial potato grower revenues and profitability. Using data and models from Idaho, a major purchaser of Montana seed, we estimate the annual benefit from Montana's program to Idaho to average $205 per acre or $22 million for the state.[Formula: see text] Copyright © 2020 The Author(s). This is an open access article distributed under the CC BY-NC-ND 4.0 International license.

Providing Early Attending Physician Expertise via Telemedicine to Improve Rapid Response Team Evaluations.

OBJECTIVES: To evaluate the effect of providing early attending physician involvement via telemedicine to improve the decision process of rapid response teams. DESIGN: Quasi-experimental; three pairs of control/intervention months: June/July; August/October; November/December. SETTING: Single-center, urban, quaternary academic children's hospital with three-member rapid response team: critical care fellow or nurse practitioner, nurse, respiratory therapist. Baseline practice: rapid response team leader reviewed each evaluation with an ICU attending physician within 2 hours after return to ICU. SUBJECTS: 1) Patients evaluated by rapid response team, 2) rapid response team members. INTERVENTIONS: Implementation of a smartphone-based telemedicine platform to facilitate early co-assessment and disposition planning between the rapid response team at the patient's bedside and the attending in the ICU. MEASUREMENTS AND MAIN RESULTS: As a marker of efficiency, the primary provider outcome was time the rapid response team spent per patient encounter outside the ICU prior to disposition determination. The primary patient outcome was percentage of patients requiring intubation or vasopressors within 60 minutes of ICU transfer. There were three pairs of intervention/removal months. In the first 2 pairs, the intervention was associated with the rapid response team spending less time on rapid response team calls (June/July: point estimate -5.24 min per call; p < 0.01; August/October: point estimate -3.34 min per call; p < 0.01). During the first of the three pairs, patients were significantly less likely to require intubation or vasopressors within 60 minutes of ICU transfer (adjusted odds ratio, 0.66; 95 CI, 0.51-0.84; p < 0.01). CONCLUSIONS: Early in the study, more rapid ICU attending involvement via telemedicine was associated with rapid response team providers spending less time outside the ICU, and among patients transferred to the ICU, a significant decrease in likelihood of patients requiring vasopressors or intubation within the first 60 minutes of transfer. These findings provide evidence that early ICU attending involvement via telemedicine can improve efficiency of rapid response team evaluations.

Software thresholds alter the bias of actigraphy for monitoring sleep in team-sport athletes.

OBJECTIVES: Actical® actigraphy is commonly used to monitor athlete sleep. The proprietary software, called Actiware®, processes data with three different sleep-wake thresholds (Low, Medium or High), but there is no standardisation regarding their use. The purpose of this study was to examine validity and bias of the sleep-wake thresholds for processing Actical® sleep data in team sport athletes. DESIGN: Validation study comparing actigraph against accepted gold standard polysomnography (PSG). METHODS: Sixty seven nights of sleep were recorded simultaneously with polysomnography and Actical® devices. Individual night data was compared across five sleep measures for each sleep-wake threshold using Actiware® software. Accuracy of each sleep-wake threshold compared with PSG was evaluated from mean bias with 95% confidence limits, Pearson moment-product correlation and associated standard error of estimate. RESULTS: The Medium threshold generated the smallest mean bias compared with polysomnography for total sleep time (8.5min), sleep efficiency (1.8%) and wake after sleep onset (-4.1min); whereas the Low threshold had the smallest bias (7.5min) for wake bouts. Bias in sleep onset latency was the same across thresholds (-9.5min). The standard error of the estimate was similar across all thresholds; total sleep time ∼25min, sleep efficiency ∼4.5%, wake after sleep onset ∼21min, and wake bouts ∼8 counts. CONCLUSIONS: Sleep parameters measured by the Actical® device are greatly influenced by the sleep-wake threshold applied. In the present study the Medium threshold produced the smallest bias for most parameters compared with PSG. Given the magnitude of measurement variability, confidence limits should be employed when interpreting changes in sleep parameters.

Reliability and accuracy of six hand-held blood lactate analysers.

The reliability and accuracy of five portable blood lactate (BLa) analysers (Lactate Pro, Lactate Pro2, Lactate Scout+, Xpress™, and Edge) and one handheld point-of-care analyser (i-STAT) were compared to a criterion (Radiometer ABL90). Two devices of each brand of analyser were assessed using 22 x 6 mL blood samples taken from five subjects at rest and during exercise who generated lactate ranging ~1-23 mM. Each sample was measured simultaneously ~6 times on each device. Reliability was assessed as the within-sample standard deviation (wsSD) of the six replicates; accuracy as the bias compared with the ABL90; and overall error (the root mean squared error (√MSE)) was calculated as the square root of (wsSD(2) and bias(2)). The √MSE indicated that both the Edge and Xpress had low total error (~0-2 mM) for lactate concentrations <15 mM, whereas the Edge and Lactate Pro2 were the better of the portable analysers for concentrations >15 mM. In all cases, bias (negative) was the major contribution to the √MSE. In conclusion, in a clinical setting where BLa is generally <15 mM the Edge and Xpress devices are relevant, but for athlete testing where peak BLa is important for training prescription the Edge and Lactate Pro2 are preferred. Key pointsThe reliability of five common portable blood lactate analysers were generally <0.5 mM for concentrations in the range of ~1.0-10 mM.For all five portable analysers, the analytical error within a brand was much smaller than the biological variation in blood lactate (BLa).Compared with a criterion blood lactate analyser, there was a tendency for all portable analysers to under-read (i.e. a negative bias), which was particularly evident at the highest concentrations (BLa ~15-23 mM).The practical application of these negative biases would overestimate the ability of the athlete and prescribe a training intensity that would be too high.

Evaluation of three portable blood lactate analysers: Lactate Pro, Lactate Scout and Lactate Plus.

Three portable blood lactate analysers, Lactate Pro (LP), Lactate Scout (LS) and Lactate Plus (L(+)), were evaluated. Analyser reliability and accuracy was assessed. For reliability, intra- and inter-analyser comparisons demonstrated that the LP (intra-TE = 0.5 mM, inter-TE = 0.4 mM) and L(+) (intra-TE = 0.4, inter-TE = 0.4 mM) displayed greater overall reliability than the LS (intra-TE = 1.0, inter-TE = 0.8 mM). At BLa < 4.0 mM, the LP (intra-TE = 0.1 mM) demonstrated greater reliability than the LS (intra-TE = 0.5 mM) and L(+) (intra-TE = 0.4 mM). At BLa > 8.0 mM, the LP (intra-TE = 0.5 mM, inter-TE = 0.4 mM) and L(+) (intra- and inter-TE = 0.4 mM) displayed greater reliability than the LS (intra-TE = 1.1 mM, inter-TE = 0.9 mM). For accuracy, the L(+) (SEE = 0.6 mM) compared more favourably to the LP than the LS (SEE = 1.1 mM). At BLa approximately 1.0-18.0 mM, the LS produced values that were up to 0.9 mM higher than the LP; the L(+) produced BLa that were within +/-0.1 mM. All portable analysers tended to under-read the ABL 700 analyser. The suitability of the LP and L(+) as accurate analysers is supported by strong correlations (r = 0.91 and r = 0.94) and limits of agreement

National Stroke Association guidelines for the management of transient ischemic attacks.

OBJECTIVE: Transient ischemic attacks are common and important harbingers of subsequent stroke. Management varies widely, and most published guidelines have not been updated in several years. We sought to create comprehensive, unbiased, evidence-based guidelines for the management of patients with transient ischemic attacks. METHODS: Fifteen expert panelists were selected based on objective criteria, using publication metrics that predicted nomination by practitioners in the field. Prior published guidelines were identified through systematic review, and recommendations derived from them were rated independently for quality by the experts. Highest quality recommendations were selected and subsequently edited by the panelists using a modified Delphi approach with multiple iterations of questionnaires to reach consensus on new changes. Experts were provided systematic reviews of recent clinical studies and were asked to justify wording changes based on new evidence and to rate the final recommendations based on level of evidence and quality. No expert was allowed to contribute to recommendations on a topic for which there could be any perception of a conflict of interest. RESULTS: Of 257 guidelines documents identified by systematic review, 13 documents containing 137 recommendations met all entry criteria. Six iterations of questionnaires were required to reach consensus on wording of 53 final recommendations. Final recommendations covered initial management, evaluation, medical treatment, surgical treatment, and risk factor management. INTERPRETATION: The final recommendations on the care of patients with transient ischemic attacks emphasize the importance of urgent evaluation and treatment. The novel approach used to develop these guidelines is feasible, allows for rapid updating, and may reduce bias.