Can continuous remote vital sign monitoring reduce the number of room visits to patients suspected of COVID-19: A quasi-experimental study.

BACKGROUND: Continuous remote monitoring of vital signs on the hospital ward gained popularity during the Severe Acute Respiratory Syndrome coronavirus 2 pandemic due to its ability to support early detection of respiratory failure, and the possibility to do so without physical contact between patient and clinician. The effect of continuous monitoring on patient room visits has not been established yet. OBJECTIVES: To assess the impact of continuous monitoring on the number of patient room visits for patients suspected of Corona Virus Disease 2019 (COVID-19) and the use of personal protection equipment. DESIGN AND METHODS: We performed a before-after study at a ward with private rooms for patients suspected of COVID-19 at a tertiary hospital in Nijmegen, The Netherlands. Non-participant observers observed hospital staff during day, evening and night shifts to record patient room visits and personal protection equipment usage. After eleven days, wearable continuous vital sign monitoring was introduced. An interrupted time series analysis was applied to evaluate the effect of continuous monitoring on the number of patient room visits, visits for obtaining vital signs (Modified Early Warning Score visits) and the amount of personal protection equipment used. RESULTS: During the 45 day study period, 86 shifts were observed. During each shift, approximately six rooms were included. A total of 2347 patient room visits were recorded. The slope coefficient for the number of patient room visits did not change after introducing continuous vital sign monitoring (B -0.003, 95% confidence interval -0.022/0.016). The slope coefficients of the number of Modified Early Warning Score visits and the amount of personal protection equipment used did not change either (B -0.002, 95% confidence interval -0.021/0.017 and B 0.046, 95% confidence interval -0.008/0.099). The number of Modified Early Warning Score visits did show a decline over the entire study period, however this decline was not influenced by the intervention. Evening and night shifts were associated with fewer patient room visits compared to day shifts. CONCLUSION: Introduction of continuous vital sign monitoring at a general ward for patients with suspected COVID-19 did not reduce the number of patient room visits or the usage of personal protection equipment by hospital staff. The number of Modified Early Warning Score visits declined over time, but this was not related to the introduction of continuous monitoring. Detailed analysis of the influence of continuous monitoring on the workflow of hospital staff reveals key points to increase efficacy of this intervention.

[Early Warning Scores at the nursing ward: what do you really want to know?] / 'Early warning scores' op de verpleegafdeling.

Early Warning Scores (EWSs) are based on the assumption that critical illness is preceded by physical deterioration. The question is whether measuring 5 vital parameters several times a day can predict changes in a highly complex and dynamic clinical condition. Little evidence has yet been found for clinical superiority of current EWSs over good clinical assessment. If we want to predict better and act structurally proactively, the measurement frequency of vital parameters must increase and much more complex scores are needed to identify specific changes in individual patients at an early stage. It is plausible that the many innovative developments in this area are the stepping stone to an era in which care in regular nursing wards is increasingly directed in the right direction by predictive algorithms. Integration of such super EWSs in new working methods may contribute to continuously adaptive care that is ultimately better and more efficient and relieves the care provider.

Prior medication adherence of participants and non participants of a randomized controlled trial to improve patient adherence in cardiovascular risk management.

BACKGROUND: Poor medication adherence is a major factor in the secondary prevention of cardiovascular diseases (CVD) and contributes to increased morbidity, mortality, and costs. Interventions for improving medication adherence may have limited effects as a consequence of self selection of already highly adherent participants into clinical trials. METHODS: In this retrospective cohort study, existing levels of medication adherence were examined in self-decided participants and non-participants prior to inclusion in a randomized controlled study (RCT), evaluating the effect of an intervention to improve adherence. In addition, the non-participants were further divided into 'responders' and 'non responders'. All individuals had manifest cardiovascular disease and completed a questionnaire with baseline characteristics, the Beliefs about Medicines Questionnaire (BMQ) and the Modified Morisky Scale® (MMS®) as part of a regular screening program. A logistic regression was conducted to examine the relationship between study participation willingness, adherence level and the beliefs about medication. RESULTS: According to the MMS® the adherence level was comparable in all groups. In both (non)-participants groups, 36% was classified as high adherent; 46% participants versus 44% non-participants were classified as medium adherent and 19% of the participants versus 20% of the non-participants were low adherent (p = 0.91. The necessity concern differential (NCD) from the BMQ was 3.8 for participants and 3.4 for non-participants (p = 0.32). CONCLUSION: This study shows that adherence to medication and beliefs about medication do not differ between participants and non-participants before consenting to participate in an RCT. The study design seems not to have led to greater adherence in the study group.

[Hypertension due to fibromuscular dysplasia: look for additional disease sites]. / Hypertensie door fibromusculaire dysplasie.

Fibromuscular dysplasia (FMD) is a non-inflammatory, non-atherosclerotic vasculopathy that can lead to arterial stenosis, occlusion, aneurysms, and dissection. FMD of the renal arteries can lead to renovascular hypertension. Percutaneous angioplasty of the renal arteries (PTRA) can lead to normalization of blood pressure in 45% of patients with renal artery stenosis caused by FMD, particularly in younger patients and patients with a short history of hypertension. A considerable number of the patients with renovascular FMD also have cervical FMD, which can lead to ischaemic or haemorrhagic stroke. In this article we discuss diagnostic and therapeutic options, illustrated by two cases of patients with renovascular and carotid FMD. Most of the recommendations are based on data from retrospective studies and expert opinion; prospective studies on the optimal diagnostic strategy and treatment are therefore, urgently required.

[Choosing wisely when prescribing statins]. / Verstandig kiezen bij het voorschrijven van statinen.

The Dutch campaign 'Verstandig kiezen', based on the American programme 'Choosing wisely', aims to improve quality in healthcare, with attention to cost control. The 'Choosing wisely'-based programme can be applied in the choice of a statin. Atorvastatin and rosuvastatin are regarded as equal choices in various guidelines regarding cardiovascular risk management. Generic atorvastatin is available, and is approximately 25 times cheaper than rosuvastatin in almost equipotent doses. Rosuvastatin provides a greater LDL reduction than atorvastatin. Patient LDL targets can usually be achieved with atorvastatin, and rosuvastatin is not needed. At group level, there are no relevant differences in adverse-events profile between both statins. Atorvastatin and rosuvastatin do have different pharmacokinetic interactions. When changing medication, good provision of information is a prerequisite for patient satisfaction and compliance. We advise use of atorvastatin instead of rosuvastatin as drug of choice when the LDL target is not reached using simvastatin. However, under specific conditions, rosuvastatin should be the treatment of choice. Efficacy and adverse effects should then be evaluated at individual patient level.

A nurse-led multidisciplinary intervention to improve cardiovascular disease profile of patients.

The aim of this study was to evaluate the impact of a structured screening and nurse-based intervention on cardiovascular risk factors. In patients with established cardiovascular disease, a cardiovascular risk profile was assessed, and lifestyle was evaluated by using an automated questionnaire. A multidisciplinary team proposed an integral individualized plan of care on the basis of these assessments. During follow-up, a nurse-led lifestyle intervention program and the best medical treatment were offered. A total of 328 outpatients were included. After screening, a follow-up term of at least 1 year was reached in 176 patients (59.9%). Low-density lipoprotein cholesterol and systolic blood pressure were significantly reduced. A reduction in the amount of smoking, alcohol consumption, and unhealthy eating habits was observed. However, the amount of physical activity was unaffected, and body mass was increased. A structural evaluation of cardiovascular risk factors and an integrated nurse-led approach can successfully reduce risk in cardiovascular patients.

[e-Health interventions and improvement in treatment adherence]. / E-healthinterventies en verbetering van therapietrouw.

Poor adherence to medication is one of the most important determinants in the treatment of patients with chronic disorders. e-Health-based interventions may be able to improve treatment adherence. This article gives an overview of the available e-Health interventions and the extent to which they can improve adherence. We searched in the PubMed, Cinahl, PsycInfo, and Embase databases for e-Health interventions that aimed at improving adherence to treatment. Of the 16 included studies, 15 used a website and one used an app. Ten studies showed a significant improvement in treatment adherence by using the intervention. e-Health interventions were generally complex. Simple interventions were the most successful in improving treatment adherence.

Enhanced interleukin-10 production by dendritic cells upon stimulation with Toll-like receptor 4 agonists in systemic sclerosis that is possibly implicated in CCL18 secretion.

BACKGROUND: It has been suggested that the T-cell attracting and profibrotic chemokine CCL18 might play a role in the pathogenesis of systemic sclerosis (SSc). However, it is unclear what underlies the higher CCL18 levels in SSc. The aim of our study was to determine whether Toll-like receptor (TLR)-mediated stimulation of monocytes and dendritic cells (DCs) contributes to the higher levels of CCL18 in SSc. METHODS: CCL18 levels were measured in 40 patients with SSc, primary Raynaud's phenomenon (RP) and healthy controls. The presence of TLR4 agonists in the circulation of SSc patients was investigated using TLR4 transgenic Chinese hamster ovary (CHO) cells. CCL18 and interleukin (IL)-10 secretion by monocytes/macrophages and monocyte-derived DCs (moDCs) was measured in the supernatant. The indirect effect of lipopolysaccharide (LPS)-stimulated moDCs on CCL18 secretion by monocytes/macrophages was investigated using a transwell system. RESULTS: CCL18 levels were significantly elevated in SSc patients compared to patients with RP and healthy controls. SSc sera strongly induced CD25 expression on CHO cells genetically modified to express TLR4 but not on those expressing CD14 only. By contrast, serum from systemic lupus erythematosus (SLE) patients or healthy individuals did not have an effect. Neither monocytes/macrophages nor moDCs from SSc patients secreted higher levels of CCL18 compared to healthy controls. However, moDCs matured with the TLR4 ligand LPS from patients with SSc did secrete significantly higher amounts of IL-10 compared to those from healthy counterparts, which were IL-10 dependent. CONCLUSIONS: Our results suggest that elevated CCL18 levels in SSc are not caused by an intrinsically enhanced CCL18 secretion by monocytes/macrophages but are, at least partly, orchestrated by an enhanced IL-10 secretion by TLR4-stimulated DCs. These observations suggest a role for TLR4 ligands and DCs in the pathogenesis of SSc, a topic that warrants further investigation.

Critical aneurysmal dilatation of the thoracic aorta in young adolescents with variant hyperimmunoglobulin E syndrome.

The autosomal-dominant (AD) form of the hyperimmunoglobulin E syndrome (HIES) has been described as a multisystem disorder including immune, skeletal and dental abnormalities. Recently, the evaluation of patients from families in which HIES was inherited in a manner more consistent with autosomal-recessive (AR) inheritance, showed that AR-HIES is a clinically distinct disease entity. In addition to classical immunologic findings of AD-HIES, the AR form presents with severe recurrent fungal and viral infections with herpes zoster, herpes simplex and characteristic mollusca contagiosa. Furthermore, cerebral vascular sequelae, including vasculitis, infarction and haemorrhage were noted. In this report, we describe the clinical picture of two patients who showed remarkable resemblance to the description of AR-HIES, but also developed fatal aneurysmal dilatation of the thoracic aorta in adolescence. This finding may further consummate the clinical picture of AR-HIES and emphasize the possibility to develop early aortitis, most likely preceding the critical aneurysm formation at older age. This process should be anticipated during childhood in cases with AR-HIES.

[Aortic involvement in patients with temporal arteritis and polymyalgia rheumatica]. / Ziekte van de aorta bij arteriitis temporalis en polymyalgia rheumatica.

In 4 patients with temporal arteritis or polymyalgia rheumatica, women aged 60, 57, 83 and 73 years respectively, signs of aortic involvement were established. The first patient presented with signs of systemic inflammation without signs of temporal arteritis or aortitis. In the second, an acute symptomatic thoracoabdominal aneurysm developed. In the third, temporal arteritis was associated with chronic progressive dilatation ofthe thoracic aorta. The fourth developed signs of intermittent claudication of the extremities. The clinical manifestations in all patients were attributed to chronic inflammation of the aorta caused by giant cell arteritis. Aortic giant cell arteritis frequently accompanies temporal arteritis, but is rarely diagnosed. Up to 75% of patients with temporal arteritis may have some degree of aortic involvement. Thoracic aneurysms, complicated by rupture or dissection, are the most serious complications. Aortic disease associated with signs of systemic inflammation should trigger the suspicion of giant cell arteritis. Corticosteroids are the most important part of treatment. Three patients recovered following treatment; the first two received an endoprosthesis; in the woman aged 83 years, this was not technically possible; she died after 1.5 years.

[Therapeutic dilemmas in patients with a centrally-located pulmonary embolism confirmed by spiral CT-scan but with no cardiogenic shock]. / Dilemma's rond de behandeling van patiënten met een centrale longembolie op de spiraal-cT-scan zonder tekenen van cardiogene shock.

3 patients, 2 women aged 64 and 44 and 1 man aged 67, had severe dyspnoea and a large centrally-located pulmonary embolism (PE) without any accompanying arterial hypotension. They were all given conventional anticoagulation therapy, although thrombolytic therapy was also considered. The women recovered but the man eventually died of a second massive embolism. PE is a disease with a potentially high mortality. Patients with cardiogenic shock due to PE are candidates for thrombolytic therapy. A subset of patients with right-ventricular dysfunction (submassive PE) also have a poorer prognosis despite the absence ofarterial hypotension or shock. Spiral CT-scan is becoming the first-line imaging test of preference in patients with suspected PE. Spiral CT enables the accurate visualization ofthrombi. The value of risk management using cardial biomarkers, spiral CT and echocardiography is not yet clear. There is no evidence that thrombolytic therapy is beneficial in patients with acute PE and right-ventricular dysfunction without overt shock.

Pulmonary hypertension: its diagnosis and management, a multidisciplinary approach.

Pulmonary hypertension is a devastating complication of various, but rare diseases and can also occur as an isolated entity. It causes morbidity and mortality in all patients. Ongoing research has provided some insight into the pathophysiology and clinical manifestations, and new therapeutic options have recently become available for some types of pulmonary hypertension. In order to provide optimal care for an individual patient it is mandatory to establish the type and severity of the pulmonary hypertension in each patient. The diagnostic protocol used in our hospital is presented along with a description of two case histories. An algorithm of the different therapeutic strategies now available is given as well as recommendations for follow-up.

The StethoDop: a Doppler stethoscope attachment for investigation of arterial and venous insufficiency of the lower extremities.

BACKGROUND: The aim of the current study was to investigate whether the StethoDop can serve as a valid and reproducible instrument for measuring the ankle-brachial index (ABI) and assessing venous reflux, even when used by inexperienced investigators, in comparison with the classic Doppler. METHODS: I) During four weeks, four ankle-brachial index (ABI) measurements were performed on 44 patients: one measurement with the classic Doppler by an experienced investigator, one with the classic Doppler by an inexperienced investigator and two measurements with the StethoDop by the inexperienced investigator. II) 36 patients were screened for venous insufficiency by detecting venous reflux with the StethoDop and classic Doppler at the saphenofemoral and saphenopoplitial junctions by an inexperienced investigator. The results were compared with the results of the duplex as gold standard and with the results of the examination by an experienced dermatologist with the classic Doppler. RESULTS: I) The confidence interval of ABI measurement for both the classic Doppler and the StethoDop by the inexperienced investigator was within an acceptable +/- 0.21 interval of significant change. II) For venous reflux determination, the overall sensitivity and specificity of the StethoDop were comparable with the sensitivity and specificity of the classic Doppler: sensitivity 76.0 and 75.0%, specificity 94.8 and 94.2%, respectively. The positive predictive value of the StethoDop, compared with the duplex, was 87.5%; the negative predictive value was 90.0%. CONCLUSION: I) For ABI measurement, the StethoDop is a valid instrument with reproducible results, even when used by inexperienced investigators. II) For venous reflux determination, the StethoDop is a valid screening instrument for venous insufficiency. However, as with determination with the classic Doppler, the reflux assessment by StethoDop gives no information about the deep veins and may miss up to 24% of apparent reflux.

Vascular graft infection in aortoiliac and aortofemoral bypass surgery: clinical presentation, diagnostic strategies and results of surgical treatment.

OBJECTIVES: Evaluation of the prevalence, diagnostic procedures and clinical outcome of infections of aortoiliac and aortofemoral vascular grafts presented in our centre. DESIGN: Retrospective study. MATERIALS: All patients who underwent a surgical aortoiliac or aortofemoral revascularisation between 1991 and 2001. METHODS: Evaluation of several hospital databases. RESULTS: 32 cases of aortoiliac and aortofemoral vascular graft infection with varied clinical presentation were found. Enteral bleeding was the first clinical manifestation in 31% of the cases, inguinal swelling, wound, or fistula in 59% and fever or sepsis in 6.3%. In 3% the cause was unknown. The vast majority (84.5%) of the infections presented three or more months after surgery (late infections). In cases of enteral bleeding, endoscopy procedures only revealed the diagnosis in 55%. Diagnostic algorithms including an abdominal CT scan appeared to have a sensitivity of 94% for establishing an accurate diagnosis. Remarkably, no specific risk factors for graft infection could be demonstrated. Furthermore, a 30-day survival of 20% or less was observed in early graft infections, whereas late infections managed with extra-anatomical bypasses appeared to have a better survival rate of up to 70%. CONCLUSION: Endoscopy in cases of enteral bleeding and CT scanning overall were shown to be very useful for establishing the diagnosis. Clinical outcome and survival after treatment remain poor.

F-18-fluorodeoxyglucose positron emission tomography in diagnosis and follow-up of patients with different types of vasculitis.

BACKGROUND: F-18-fluorodeoxyglucose (FDG) accumulates in inflammatory cells due to an increased metabolic rate. Therefore, FDG positron emission tomography (PET) represents a promising imaging technique in patients with vasculitis. The aim of this study was to assess the value of FDG PET in the diagnosis of different types of vasculitis. METHODS: The results of FDG PET performed because of suspected vasculitis or fever of unknown origin with results indicating vasculitis were reviewed. These results were compared with the final diagnosis, based on the American College of Rheumatology 1990 criteria. RESULTS: FDG PET was ordered because of suspected vasculitis in 20 patients, because of fever of unknown origin in two patients, and for follow-up of vasculitis in five patients. Fourteen patients were diagnosed with vasculitis (giant cell arteritis n = 5, polymyalgia rheumatica n = 2, polyarteritis nodosa n = 3, Takayasu n = 1, Churge-Strauss n = 1, Wegener's granulomatosis n = 1, vasculitis skin n = 1), two patients were diagnosed with fibromuscular dysplasia and one patient had media necrosis of the aorta. In five patients no diagnosis could be reached. FDG PET results were considered to be true-positive in ten patients, true-negative in 14 patients and false-negative in three patients resulting in a positive predictive value of 100% and a negative predictive value of 82%. CONCLUSIONS: FDG PET appears to be a promising new imaging technique in diagnosing and determining the extent of various forms of vasculitis. Furthermore, FDG PET may become a useful tool for evaluating the effect of treatment of vasculitis.

[The added value of a structured evaluation of patients with vascular disease]. / De meerwaarde van een gestructureerde benadering bij vaatpatiënten.

In 3 patients, 2 women aged 21 and 34 years and a man aged 56 years, with complaints related to wide-ranging and extensive vascular conditions, an organ-specific diagnostic approach and treatment did not lead to the correct diagnosis of the underlying clinical condition. Hereafter a structured, partly protocol-based approach was started which considered the entire vascular system and risk factors for vascular disease. The youngest women died a few years later due to ventricular fibrillation, while the two other patients were assisted in reducing those risk factors that could be influenced. As a result, the planned bypass operation was no longer necessary for the male patient. A structured evaluation by a multidisciplinary team can optimise the care of these patients. The basis of such a team consists of a vascular specialist and vascular nurse-practitioner, both of whom should have specific knowledge of risk factors, aetiology, life style intervention and treatment of these disorders.