Hard X-ray operation of X-ray gas monitors at the European XFEL.

X-ray gas monitors (XGMs) are operated at the European XFEL for non-invasive single-shot pulse energy measurements and average beam-position monitoring. The underlying measurement principle is the photo-ionization of rare gas atoms at low gas pressures and the detection of the photo-ions and photo-electrons created. These are essential for tuning and sustaining self-amplified spontaneous emission (SASE) operation, machine radiation safety, and sorting single-shot experimental data according to pulse energy. In this paper, the first results from XGM operation at photon energies up to 30 keV are presented, which are far beyond the original specification of this device. Here, the Huge Aperture MultiPlier (HAMP) is used for single-shot pulse energy measurements since the standard X-ray gas monitor detectors (XGMDs) do not provide a sufficient signal-to-noise ratio, even at the highest operating gas pressures. A single-shot correlation coefficient of 0.98 is measured between consecutive XGMs operated with HAMP, which is as good as measuring with the standard XGMD detectors. An intra-train non-linearity of the HAMP signal is discovered, and operation parameters to mitigate this effect are studied. The upper repetition rate limit of HAMP operation at 2.25 MHz is also determined. Finally, the possibilities and limits for future XGM operation at photon energies up to 50 keV are discussed.

Diabetes Technology in People with Type 2 Diabetes: Novel Indications.

PURPOSE OF REVIEW: Diabetes technology has been continuously evolving. Current versions of continuous glucose monitors (CGM) use minimally invasive designs, monitor glucose values with high accuracy, and can be used to guide insulin dosing. Extensive evidence supports the use of diabetes technology for monitoring and insulin administration in people with type 1 diabetes. However, there is emerging evidence for people with type 2 diabetes. In this review, we present the different technological devices used to monitor glucose and deliver insulin and the evidence supporting their use in people with type 2 diabetes. RECENT FINDINGS: The use of CGMs in people with type 2 diabetes treated with insulin or non-insulin therapies has been associated with improvements in glycemic control and time spent in hypoglycemia. Smart insulin pens and smart connected devices are options to track compliance and guide insulin delivery in people who do not require insulin pump therapy. Mechanical patch pumps can be used to reduce the burden of multiple daily insulin injections. Automated insulin delivery algorithms improve glycemic control without an increase in hypoglycemia. The use of technology in the management of type 2 diabetes generates glycemic data previously inaccessible, reduces barriers for insulin initiation, improves glycemic control, tracks adherence to therapy, and improves user satisfaction.

Systematic review of disparities in continuous glucose monitoring and insulin pump utilization in the United States: Key themes and evidentiary gaps.

AIM: This study aims to provide a comprehensive overview of real-world evidence pertaining to disparities in the utilization of continuous glucose monitors (CGMs)/insulin pumps to highlight potential evidentiary gaps and discern emerging themes from the literature. MATERIALS AND METHODS: A systematic review of published manuscripts and abstracts was conducted from: MEDLINE, EMBASE, Nursing and Allied Health, Web of Science and CINHAL. Attributes related to patients, outcomes, interventions (CGMs/pumps/both) and study type were captured. In addition, factors associated with disparities in device utilization were examined. RESULTS: Thirty-six studies were included in the final analysis; the studies predominantly focused on people living with type 1 diabetes. Only two studies included individuals with type 2 diabetes. Almost two-thirds of the studies reported outcomes associated with disparities (e.g. glycated haemoglobin, diabetic ketoacidosis, resource utilization). Most studies highlighted disparities across race, ethnicity and insurance type. Evidentiary gaps were identified, particularly in the evidence for people with type 2 diabetes, the continuation of CGM/pump use and limited studies addressing disparities among Native Americans/American Indians. CONCLUSION: This study reveals critical disparities in diabetes technology use across race, ethnicity and insurance type, particularly among people with type 1 diabetes. Evidentiary gaps assessing disparities in diabetes technology use persist, particularly concerning people with type 2 diabetes, Native American/American Indian and LGBTQ+ populations, and in outcomes related to continuation of use. Social and digital determinants of health, such as income, transportation, residential location and technological literacy, are crucial to achieving equitable access. Future research should focus on the patient journey to identify opportunities for equitable access to diabetes technology as its use grows.

Low-Cost Hourly Ambient Black Carbon Measurements at Multiple Cities in Africa.

There is a notable lack of continuous monitoring of air pollutants in the Global South, especially for measuring chemical composition, due to the high cost of regulatory monitors. Using our previously developed low-cost method to quantify black carbon (BC) in fine particulate matter (PM2.5) by analyzing reflected red light from ambient particle deposits on glass fiber filters, we estimated hourly ambient BC concentrations with filter tapes from beta attenuation monitors (BAMs). BC measurements obtained through this method were validated against a reference aethalometer between August 2 and 23, 2023 in Addis Ababa, Ethiopia, demonstrating a very strong agreement (R2 = 0.95 and slope = 0.97). We present hourly BC for three cities in sub-Saharan Africa (SSA) and one in North America: Abidjan (Côte d'Ivoire), Accra (Ghana), Addis Ababa (Ethiopia), and Pittsburgh (USA). The average BC concentrations for the measurement period at the Abidjan, Accra, Addis Ababa Central summer, Addis Ababa Central winter, Addis Ababa Jacros winter, and Pittsburgh sites were 3.85 µg/m3, 5.33 µg/m3, 5.63 µg/m3, 3.89 µg/m3, 9.14 µg/m3, and 0.52 µg/m3, respectively. BC made up 14-20% of PM2.5 mass in the SSA cities compared to only 5.6% in Pittsburgh. The hourly BC data at all sites (SSA and North America) show a pronounced diurnal pattern with prominent peaks during the morning and evening rush hours on workdays. A comparison between our measurements and the Goddard Earth Observing System Composition Forecast (GEOS-CF) estimates shows that the model performs well in predicting PM2.5 for most sites but struggles to predict BC at an hourly resolution. Adding more ground measurements could help evaluate and improve the performance of chemical transport models. Our method can potentially use existing BAM networks, such as BAMs at U.S. Embassies around the globe, to measure hourly BC concentrations. The PM2.5 composition data, thus acquired, can be crucial in identifying emission sources and help in effective policymaking in SSA.

Estrous activity in nulliparous heifers with divergent genetic merit for fertility traits.

This observational study determined the effect of genetic merit for fertility traits on estrous activity and duration and inter-estrous interval in nulliparous dairy heifers. We also compared estrous activity between estrous events with or without conception and determined the effect of genetic merit for fertility traits on age and body weight at time of first detected estrous activity event. Activity monitoring devices (Heatime, SCR Engineers) were fitted to 7-9-mo aged Holstein-Friesian heifers with positive or negative genetic merit for fertility traits (POS FertBV: average +5%, n = 275; NEG FertBV: average -5%, n = 249) and activity data was collected to the end of the first breeding period (15-17-mo). An estrous event was defined as when the activity change index exceeded 19.2 activity units (AU) for ≥6 consecutive h. In total, 2,434 estrous events were identified (POS FertBV: n = 1454; NEG FertBV: n = 980). Estrous event duration was defined as the period when the threshold was first exceeded and when activity dropped below threshold, without another event starting within 24 h of the end of the previous event. This definition included occurrences where activity crossed the threshold multiple times in a day; these were classified as a single estrous event. A second measure, high activity duration, was defined as the total time activity exceeded the threshold. To characterize estrous activity, baseline activity was determined from the previous 7 d of activity. Peak activity and total activity (area under the curve of activity above baseline) were calculated. A fifth variable, inter-estrous interval, was calculated as a proxy for estrous cycle length. Total activity and peak activity were greater in POS than NEG FertBV heifers (total activity: 548 vs 464 AU, SED = 19.6 AU; peak activity: 72 vs 65 AU, standard error of the difference (SED) = 1.5 AU). The POS FertBV group had a mean estrous event duration and high activity duration of 15.1 h and 15.0 h, compared with 14.1 and 14.1 h for the NEG FertBV group (SED = 0.30 and 0.29 h, respectively). Inter-estrous interval did not differ between POS and NEG FertBV heifers (19.5 vs 20.0 d, SED = 0.49). Estrous events associated with conception were shorter than those not associated with conception (mean ± standard error of the mean, high activity duration: 13.0 ± 0.25 h vs 13.9 ± 0.31 h, estrous event duration: 13.1 ± 0.25 h vs 14 ± 0.32 h) and had less total activity (408 ± 15.2 vs 487 ± 18.2 AU). The POS FertBV heifers were more likely to have their first estrous activity event than NEG FertBV heifers by a given age (HR = 1.26, 95% CI = 1.0 to 1.6) or body weight (HR = 1.35, 95% CI = 1.1 to 1.6). The outcomes of this study provide evidence that positive genetic merit for fertility traits is associated with more overt estrous expression. Therefore, estrous expression traits may have potential to be used as earlier-in-life predictors of genetic merit for fertility.

First-in-Human Study for Evaluating the Accuracy of Smart Ring Based Cuffless Blood Pressure Measurement.

BACKGROUND: Recently, a ring-type cuffless blood pressure (BP) measuring device has been developed. This study was a prospective, single arm, first-in-human pivotal trial to evaluate accuracy of BP measurement by the new device. METHODS: The ring-type smart wearable monitoring device measures photoplethysmography signals from the proximal phalanx and transmits the data wirelessly to a connected smartphone. For the BP comparison, a cuff was worn on the arm to check the reference BP by auscultatory method, while the test device was worn on the finger of the opposite arm to measure BP simultaneously. Measurements were repeated for up to three sets each on the left and right arms. The primary outcome measure was mean difference and standard deviation of BP differences between the test device and the reference readings. RESULTS: We obtained 526 sets of systolic BP (SBP) and 513 sets of diastolic BP (DBP) from 89 subjects, with ranges of 80 to 175 mmHg and 43 to 122 mmHg for SBP and DBP, respectively. In sample-wise comparison, the mean difference between the test device and the reference was 0.16 ± 5.90 mmHg (95% limits of agreement [LOA], -11.41, 11.72) in SBP and -0.07 ± 4.68 (95% LOA, -9.26, 9.10) in DBP. The test device showed a strong correlation with the reference for SBP (r = 0.94, P < 0.001) and DBP (r = 0.95, P < 0.001). There were consistent results in subject-wise comparison. CONCLUSION: The new ring-type BP measuring device showed a good correlation for SBP and DBP with minimal bias compared with an auscultatory method.

Evaluation of a Pharmacist-Led Personal Continuous Glucose Monitor Workflow to Improve Glycemic Management in an Internal Medicine Clinic.

The use of personal continuous glucose monitors (CGMs) in patients with diabetes has increased significantly and is expected to continue to increase as CGMs become more affordable and insurance plans improve coverage. The utilization of CGMs has improved diabetes management and reduced hypoglycemic events. A pharmacist-led personal CGM workflow was created to evaluate the impact on glycemic management in patients with diabetes. This was a prospective, investigator-initiated pilot study conducted at an Atrium Health Internal Medicine clinic over 28 weeks. In this pilot, 42 patients were qualifying candidates with diabetes and personal CGM use. Additionally, 30 patients were followed until study completion and included into final analysis. The average baseline A1c was reduced from 8.3% to 7.1% over a 3 - 6 month period. The pharmacist-led CGM workflow revealed a statistically significant reduction in A1c from baseline by an average of 1.2% (95% CI, -0.6 - -1.8; P = 0.0006). On average, patients were enrolled for 19.9 weeks and had an average of 5 visits during this time. During the study duration, 100 medications changes were implemented under the existing Clinical Pharmacist Practitioner (CPP) agreement between the pharmacists and the provider. The implementation of the CGM workflow led to one less diabetes related hospitalization. Overall, 58 CPT 95251 codes were billed yielding $7,052.00 in billed CGM services for the clinic. This project generated 40.6 provider relative value units (RVUs). The utilization of a pharmacist-led personal CGM workflow can improve diabetes outcomes.

Strategy and Metrological Support for Indoor Radon Measurements Using Popular Low-Cost Active Monitors with High and Low Sensitivity.

Traditionally, for indoor radon testing, predominantly passive measurements have been used, typically applying the solid-state alpha track-etch method for long-term and the charcoal method for short-term measurements. However, increasingly, affordable consumer-grade active monitors have become available in the last few years, which can generate a concentration time series of an almost arbitrary duration. Firstly, we argue that consumer-grade monitors can well be used for quality-assured indoor radon assessment and consequent reliable decisions. Secondly, we discuss the requirements of quality assurance, which actually allow for reliable decision-making. In particular, as part of a rational strategy, we discuss how to interpret measurement results from low-cost active monitors with high and low sensitivity with respect to deciding on conformity with reference levels that are the annual average concentration of indoor radon. Rigorous analysis shows that temporal variations in radon are a major component of the uncertainty in decision-making, the reliability of which is practically independent of monitor sensitivity. Manufacturers of low-cost radon monitors already provide sufficient reliability and quality of calibration for their devices, which can be used by both professional inspectors and the general public. Therefore, within the suggested measurement strategy and metrologically assured criteria, we only propose to clarify the set and values of the key metrological characteristics of radon monitors as well as to upgrade user-friendly online tools. By implementing clear metrological requirements as well as the rational measurement strategy for the reliable conformity assessment of a room (building) with radon safety requirements, we anticipate significant reductions in testing costs, increased accessibility, and enhanced quality assurance and control (QA/QC) in indoor radon measurements.

Value of Information Analysis of a Web-Based Self-Management Intervention for Chronic Obstructive Pulmonary Disease.

Objective: Technology-based programs can be cost-effective in the management of chronic obstructive pulmonary disease (COPD). However, cost-effectiveness estimates always contain some uncertainty, and decisions based upon them carry some risk. We conducted a value of information (VOI) analysis to estimate the value of additional research of a web-based self-management intervention for COPD to reduce the costs associated with uncertainty. Methods: We used a 10,000-iteration cost-effectiveness model from the health care payer perspective to calculate the expected value of perfect information (EVPI) at the patient- and population-level. An opportunity loss was incurred when the web-based intervention did not produce a greater net monetary benefit than usual care in an iteration. We calculated the probability of opportunity loss and magnitude of opportunity costs as a function of baseline health utility. We aggregated opportunity costs over the projected incident population of inpatient COPD patients over 10 years and estimated it as a function of the willingness-to-pay (WTP) threshold. Costs are in 2022 U.S. Dollars. Results: Opportunity losses were found in 22.7% of the iterations. The EVPIpatient was $78 per patient (95% confidence interval: $75-$82). The probability that the intervention was the optimal strategy varied across baseline health utilities. The EVPIpopulation was $506,666,882 over 10 years for a WTP of $50,000. Conclusions: Research estimated to cost up to $500 million would be warranted to reduce uncertainty. Future research could focus on identifying the impact of baseline health utilities to maximize the cost savings of the intervention. Other considerations for future research priorities include implementation efforts for technology-based interventions.

Long-term comparison and performance study of consumer grade electronic radon integrating monitors.

This study reports the performance of 7 types of consumer grade passive Electronic Radon Integrating Monitors, ERIM (AlphaE, AER Plus, Canary, Corentium Pro, Radon Scout Home, Ramon and Wave) and passive etched track radon detectors. All monitors and passive radon detectors were exposed side by side for 2 periods of 3 months under controlled conditions in the UKHSA radon chamber and in a stainless steel container to an average radon concentration of 4781 Bq m-3and 166 Bq m-3, respectively. The performance of each individual monitor was compared with Atmos 12DPX and AlphaGUARD P30 reference instruments. The performance of the monitors was evaluated by estimating the biased, precision and measurement errors of each type. It was found that UKHSA passive radon detectors showed excellent performance (measurement error < 10%) at both higher and lower exposures. The AlphaE, Canary and Ramon showed excellent performance, with measurement error <10%, when they were exposed to radon concentrations between 4000 Bq m-3and 6000 Bq m-3in the UKHSA radon chamber. However, when the monitors were exposed to radon levels below the UK radon Action Level of 200 Bq m-3, the only ERIM which had a measurement error <10% was the Radon Scout Home. All other monitors showed a significant decrease in their performance with measurement errors ranging between 20% and 50%. The calibration factor, which is the ratio between the measured value (background is subtracted) and the reference value, was also studied. It was found that the calibration factors of individual monitors changed significantly. Calibration measurements in 2019 and in 2023 found that the percentage change varied between -46% and +63%. This shows the importance of initial and regular calibration, and maintenance of the monitors.

Novel algorithms improve arrhythmia detection accuracy in insertable cardiac monitors.

INTRODUCTION: Insertable cardiac monitors (ICMs) are commonly used to diagnose cardiac arrhythmias. False detections in the latest ICM systems remain an issue, primarily due to inaccurate R-wave sensing. New discrimination algorithms were developed and tested to reduce false detections of atrial fibrillation (AF), pause, and tachycardia episodes in ICMs. METHODS: Stored electrograms (EGMs) of AF, pause, and tachycardia episodes detected by Abbott Confirm Rx™ ICMs were extracted from the Merlin.net™ Patient Care Network, and manually adjudicated to establish independent training and testing datasets. New discrimination algorithms were developed to reject false episodes due to inaccurate R-wave sensing, P-wave identification, and R-R interval patterns. The performance of these new algorithms was quantified by false positive reduction (FPR) and true positive maintenance (TPM), relative to the existing algorithms. RESULTS: The new AF detection algorithm was trained on 5911 EGMs from 744 devices, resulting in 66.9% FPR and 97.8% TPM. In the testing data set of 1354 EGMs from 119 devices, this algorithm achieved 45.8% FPR and 97.0% TPM. The new pause algorithm was trained on 7178 EGMs from 1490 devices, resulting in 70.9% FPR and 98.7% TPM. In the testing data set of 1442 EGMs from 340 devices, this algorithm achieved 74.4% FPR and 99.3% TPM. The new tachycardia algorithm was trained on 520 EGMs from 204 devices, resulting in 57.0% FPR and 96.6% TPM. In the testing data set of 459 EGMs from 237 devices, this algorithm achieved 57.9% FPR and 96.5% TPM. CONCLUSION: The new algorithms substantially reduced false AF, pause, and tachycardia episodes while maintaining the majority of true arrhythmia episodes detected by the Abbott ICM algorithms that exist today. Implementing these algorithms in the next-generation ICM systems may lead to improved detection accuracy, in-clinic efficiency, and device battery longevity.

Biomarkers predictive of atrial fibrillation in patients with cryptogenic stroke. Insights from the Nordic Atrial Fibrillation and Stroke (NOR-FIB) study.

BACKGROUND AND PURPOSE: There are currently no biomarkers to select cryptogenic stroke (CS) patients for monitoring with insertable cardiac monitors (ICMs), the most effective tool for diagnosing atrial fibrillation (AF) in CS. The purpose of this study was to assess clinically available biomarkers as predictors of AF. METHODS: Eligible CS and cryptogenic transient ischaemic attack patients underwent 12-month monitoring with ICMs, clinical follow-up and biomarker sampling. Levels of cardiac and thromboembolic biomarkers, taken within 14 days from symptom onset, were compared between patients diagnosed with AF (n = 74) during monitoring and those without AF (n = 185). Receiver operating characteristic curves were created. Biomarkers reaching area under the receiver operating characteristic curve ≥ 0.7 were dichotomized by finding optimal cut-off values and were used in logistic regression establishing their predictive value for increased risk of AF in unadjusted and adjusted models. RESULTS: B-type natriuretic peptide (BNP), N-terminal pro-brain natriuretic peptide (NT-proBNP), creatine kinase, D-dimer and high-sensitivity cardiac troponin I and T were significantly higher in the AF than non-AF group. BNP and NT-proBNP reached the predefined area under the curve level, 0.755 and 0.725 respectively. Optimal cut-off values were 33.5 ng/l for BNP and 87 ng/l for NT-proBNP. Regression analysis showed that NT-proBNP was a predictor of AF in both unadjusted (odds ratio 7.72, 95% confidence interval 3.16-18.87) and age- and sex-adjusted models (odds ratio 4.82, 95% confidence interval 1.79-12.96). CONCLUSION: Several clinically established biomarkers were associated with AF. NT-proBNP performed best as AF predictor and could be used for selecting patients for long-term monitoring with ICMs.

Engagement, acceptability, usability and satisfaction with Active for Life, a computer-tailored web-based physical activity intervention using Fitbits in older adults.

BACKGROUND: Preliminary evidence suggests that web-based physical activity interventions with tailored advice and Fitbit integration are effective and may be well suited to older adults. Therefore, this study aimed to examine the engagement, acceptability, usability, and satisfaction with 'Active for Life,' a web-based physical activity intervention providing computer-tailored physical activity advice to older adults. METHODS: Inactive older adults (n = 243) were randomly assigned into 3 groups: 1) tailoring + Fitbit, 2) tailoring only, or 3) a wait-list control. The tailoring + Fitbit group and the tailoring-only group received 6 modules of computer-tailored physical activity advice over 12 weeks. The advice was informed by objective Fitbit data in the tailoring + Fitbit group and self-reported physical activity in the tailoring-only group. This study examined the engagement, acceptability, usability, and satisfaction of Active for Life in intervention participants (tailoring + Fitbit n = 78, tailoring only n = 96). Wait-list participants were not included. Engagement (Module completion, time on site) were objectively recorded through the intervention website. Acceptability (7-point Likert scale), usability (System Usability Scale), and satisfaction (open-ended questions) were assessed using an online survey at post intervention. ANOVA and Chi square analyses were conducted to compare outcomes between intervention groups and content analysis was used to analyse program satisfaction. RESULTS: At post-intervention (week 12), study attrition was 28% (22/78) in the Fitbit + tailoring group and 39% (37/96) in the tailoring-only group. Engagement and acceptability were good in both groups, however there were no group differences (module completions: tailoring + Fitbit: 4.72 ± 2.04, Tailoring-only: 4.23 ± 2.25 out of 6 modules, p = .14, time on site: tailoring + Fitbit: 103.46 ± 70.63, Tailoring-only: 96.90 ± 76.37 min in total, p = .56, and acceptability of the advice: tailoring + Fitbit: 5.62 ± 0.89, Tailoring-only: 5.75 ± 0.75 out of 7, p = .41). Intervention usability was modest but significantly higher in the tailoring + Fitbit group (tailoring + Fitbit: 64.55 ± 13.59, Tailoring-only: 57.04 ± 2.58 out of 100, p = .003). Participants reported that Active for Life helped motivate them, held them accountable, improved their awareness of how active they were and helped them to become more active. Conversely, many participants felt as though they would prefer personal contact, more detailed tailoring and more survey response options. CONCLUSIONS: This study supports web-based physical activity interventions with computer-tailored advice and Fitbit integration as engaging and acceptable in older adults. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry: ACTRN12618000646246. Registered April 23 2018, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374901.

Estimation of adherence to medication treatment in presence of censoring.

AIMS: The purpose of this study is to provide a theoretical framework for the analysis of medication adherence based on longitudinal data from electronic medication monitors and to suggest methods for unbiased estimation of the effect of time and covariates on adherence. METHODS: After defining the statistical summaries involved in adherence analyses and the assumptions necessary for their estimation, we address the issue of bias encountered when adherence is estimated on censored data. We suggest 2 unbiased methods to estimate adherence: (i) indirect combining implementation and persistence; and (ii) based on weights, allowing estimation of the effect of time and covariates on adherence via generalized estimating equations models. RESULTS: We applied the proposed methods to investigate the effect of sex on adherence in a sample of 43 oncology patients followed 1 year. Implementation was higher for men than for women at baseline (98.8 vs. 97.5%, odds ratio [OR] 2.08, 95% confidence interval [CI]: 1.00-4.35), whereas the relationship was reversed at 1 year (94.5 vs. 96.4%, OR 0.65, 95%CI: 0.28-1.52). Adherence declined faster in men, with year-end values of 46.3% for men and 92.2% for women (OR 0.07, 95%CI: 0.02-0.26). CONCLUSION: Estimation of adherence is a complex statistical issue with longitudinal and duration data, possibly censored, interleaving. This study provides a theoretical framework and suggests methods for unbiased estimation of adherence as a function of time and covariates. This allows the effect of an intervention to be estimated in clinical trials, and helps healthcare providers reframe adherence programmes to address covariates such as sex.

Insertable cardiac monitoring results in higher rates of atrial fibrillation diagnosis and oral anticoagulation prescription after ischaemic stroke.

AIMS: After an ischaemic stroke, atrial fibrillation (AF) detection allows for improved secondary prevention strategies. This study aimed to compare AF detection and oral anticoagulant (OAC) initiation in patients with an insertable cardiac monitor (ICM) vs. external cardiac monitor (ECM) after ischaemic stroke. METHODS AND RESULTS: Medicare Fee-for-Service (FFS) insurance claims and Abbott Labs device registration data were used to identify patients hospitalized with an ischaemic stroke in 2017-2019 who received an ICM or ECM within 3 months. Patients with continuous Medicare FFS insurance and prescription drug enrolment in the prior year were included. Patients with prior AF, atrial flutter, cardiac devices, or OAC were excluded. Insertable cardiac monitor and ECM patients were propensity score matched 1:4 on demographics, comorbidities, and stroke hospitalization characteristics. The outcomes of interest were AF detection and OAC initiation evaluated with Kaplan-Meier and Cox proportional hazard regression analyses. A total of 5702 Medicare beneficiaries (ICM, n = 444; ECM, n = 5258) met inclusion criteria. The matched cohort consisted of 2210 Medicare beneficiaries (ICM, n = 442; ECM, n = 1768) with 53% female, mean age 75 years, and mean CHA2DS2-VASc score 4.6 (1.6). Insertable cardiac monitor use was associated with a higher probability of AF detection [(hazard ratio (HR) 2.88, 95% confidence interval (CI) (2.31, 3.59)] and OAC initiation [HR 2.91, CI (2.28, 3.72)] compared to patients monitored only with ECM. CONCLUSION: Patients with an ischaemic stroke monitored with an ICM were almost three times more likely to be diagnosed with AF and to be prescribed OAC compared to patients who received ECM only.

Intraoperative management of pediatric renal transplant recipients: An opportunity for improvement.

BACKGROUND: Optimal organ perfusion at the time of pediatric renal transplantation is a commonly agreed upon goal. Intraoperative conditions such as fluid balance and arterial pressure determine the success of this goal. Sparse literature guides the anesthesiologist in accomplishing this. We, therefore, hypothesized that significant variability exists in the methods used to optimize renal perfusion during transplantation. METHODS: A literature search was performed to assess what guidelines currently exist to optimize intraoperative renal perfusion. The intraoperative practice pathways of six large children's hospitals in North America were obtained to compare suggested guidelines. A retrospective chart review of anesthesia records was performed of all pediatric renal transplants over 7 years at the University of North Carolina. RESULTS: There did not appear to be agreement between the various publications in terms of standard intraoperative monitoring, specific blood pressure or central venous pressure goals, and fluid management. The practice pathways of six children's hospitals showed significant variation and lack of a consensus-driven approach. The chart review demonstrated significant variation between anesthesiologists in terms of invasive monitoring, fluid management, hemodynamic goals, vasopressor use, and analgesic choices. However, children <30 kg were significantly more likely to have arterial lines and epidural catheters placed prior to surgery. CONCLUSION: Significant variation exists across centers of expertise and even within centers of expertise with regard to the intraoperative management of pediatric kidney transplant recipients. In the era of enhanced recovery after surgery, this presents an opportunity to develop consensus on an evidence-based approach to optimize initial organ perfusion during surgery.

Effect of sugammadex on processed EEG parameters in patients undergoing robot-assisted radical prostatectomy.

BACKGROUND: Sugammadex has been associated with increases in the bispectral index (BIS). We evaluated the effects of sugammadex administration on quantitative electroencephalographic (EEG) and electromyographic (EMG) measures. METHODS: We performed a prospective observational study of adult male patients undergoing robot-assisted radical prostatectomy. All patients received a sevoflurane-based general anaesthetic and a continuous infusion of rocuronium, which was reversed with 2 mg kg-1 of sugammadex i.v. BIS, EEG, and EMG measures were captured with the BIS Vista™ monitor. RESULTS: Twenty-five patients were included in this study. Compared with baseline, BIS increased at 4-6 min (ß coefficient: 3.63; 95% confidence interval [CI]: 2.22-5.04; P<0.001), spectral edge frequency 95 (SEF95) increased at 2-4 min (ß coefficient: 0.29; 95% CI: 0.05-0.52; P=0.016) and 4-6 min (ß coefficient: 0.71; 95% CI: 0.47-0.94; P<0.001), and EMG increased at 4-6 min (ß coefficient: 1.91; 95% CI: 1.00-2.81; P<0.001) after sugammadex administration. Compared with baseline, increased beta power was observed at 2-4 min (ß coefficient: 93; 95% CI: 1-185; P=0.046) and 4-6 min (ß coefficient: 208; 95% CI: 116-300; P<0.001), and decreased delta power was observed at 4-6 min (ß coefficient: -526.72; 95% CI: -778 to -276; P<0.001) after sugammadex administration. Neither SEF95 nor frequency band data analysis adjusted for EMG showed substantial differences. None of the patients showed clinical signs of awakening. CONCLUSIONS: After neuromuscular block reversal with 2 mg kg-1 sugammadex, BIS, SEF95, EMG, and beta power showed small but statistically significant increases over time, while delta power decreased.

Effectiveness of Wearable Activity Monitors on Metabolic Outcomes in Patients With Type 2 Diabetes: A Systematic Review and Meta-Analysis.

OBJECTIVE: Wearable activity monitors are promising tools for improving metabolic outcomes in patients with type 2 diabetes mellitus (T2DM); however, no uniform conclusive evidence is available. This study aimed to evaluate the effects of the intervention using wearable activity monitors on blood glucose, blood pressure, blood lipid, weight, waist circumference, and body mass index (BMI) in individuals with T2DM. METHODS: Two independent reviewers searched 4 online databases (PubMed, Cochrane Library, Web of Science, and Embase) to identify relevant studies published from January 2000 to October 2022. The primary outcome indicator was hemoglobin A1c (HbA1c), and the secondary outcome indicators included physical activity (steps per day), fasting blood glucose, triglyceride, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, total cholesterol, systolic blood pressure, diastolic blood pressure, BMI, waist circumference, and weight. RESULTS: A total of 25 studies were included. The HbA1c level (standardized mean difference [SMD], -0.14; 95% confidence interval [CI], -0.27 to -0.02; P = .02; I2 = 48%), BMI (SMD, -0.16; 95% CI, -0.26 to -0.05; P = .002; I2 = 0), waist circumference (SMD, -0.21; 95% CI, -0.34 to -0.09; P < .001; I2 = 0), and steps/day (SMD, 0.55; 95% CI, 0.36-0.94; P < .001; I2 = 77%) significantly improved. CONCLUSION: Wearable activity monitor-based interventions could facilitate the improvement of the HbA1c level, BMI, and waist circumference and increase in physical activity in individuals with T2DM. Wearable technology appeared to be an effective tool for the self-management of T2DM; however, there is insufficient evidence about its long-term effect.

Innovations in Diabetes Device Training: A Scoping Review.

OBJECTIVE: The coronavirus disease 2019 pandemic highlighted a pre-existing need for alternatives to traditional in-person diabetes device trainings. Barriers to care, which include the heavy burden of training, pose a threat to optimal adoption and utilization of these devices. We searched the literature for alternative methods of training, evaluated user satisfaction, and compared short-term clinical outcomes with guideline-based glucometric targets and historical training results. METHODS: A scoping review of Embase articles from 2019 to 2021 was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines using key words relevant to diabetes technologies. Original full-text articles investigating training of new users on devices were included. Titles and abstracts were screened for eligibility by 2 independent reviewers, and results were summarized. RESULTS: Of 25 articles retrieved from the database, 11 met the criteria. Alternative training strategies included video conferencing, phone calls, mobile applications, and hybrids with traditional trainings. Overall, there was a high degree of user satisfaction with virtual visits, with a preference for hybrid approaches (6 articles). Although glucometrics varied between articles, short-term glucometrics were satisfactory overall (8 articles), including improved glycated hemoglobin measurements and time in range. Two articles compared time in range over various time points after traditional and remote training. One found equivalency, and the other identified a 5% improvement with remote training. CONCLUSION: Alternative training approaches are a viable option to reduce the barriers to care and to alleviate training burden. Intentional implementation of alternatives should be considered a solution to address current barriers.

Comparison of invasive and non-invasive measurements of cardiac index and systemic vascular resistance in living-donor liver transplantation: a prospective, observational study.

BACKGROUND: Based on the controversy surrounding pulmonary artery catheterization (PAC) in surgical patients, we investigated the interchangeability of cardiac index (CI) and systemic vascular resistance (SVR) measurements between ClearSight™ and PAC during living-donor liver transplantation (LDLT). METHODS: This prospective study included consecutively selected LDLT patients. ClearSight™-based CI and SVR measurements were compared with those from PAC at seven LDLT-stage time points. ClearSight™-based systolic (SAP), mean (MAP), and diastolic (DAP) arterial pressures were also compared with those from femoral arterial catheterization (FAC). For the comparison and analysis of ClearSight™ and the reference method, Bland-Altman analysis was used to analyze accuracy while polar and four-quadrant plots were used to analyze the trending ability. RESULTS: From 27 patients, 189 pairs of ClearSight™ and reference values were analyzed. The CI and SVR performance errors (PEs) exhibited poor accuracy between the two methods (51.52 and 51.73%, respectively) in the Bland-Altman analysis. CI and SVR also exhibited unacceptable trending abilities in both the polar and four-quadrant plot analyses. SAP, MAP, and DAP PEs between the two methods displayed favorable accuracy (24.28, 21.18, and 26.26%, respectively). SAP and MAP exhibited acceptable trending ability in the four-quadrant plot between the two methods, but not in the polar plot analyses. CONCLUSIONS: During LDLT, CI and SVR demonstrated poor interchangeability, while SAP and MAP exhibited acceptable interchangeability between ClearSight™ and FAC.