Comparing Continuous with Periodic Vital Sign Scoring for Clinical Deterioration Using a Patient Data Model.

To evaluate a minute-by-minute monitoring algorithm against a periodic early warning score (EWS) in detecting clinical deterioration and workload. Periodic EWSs suffer from large measurement intervals, causing late detection of deterioration. This might be prevented by continuous vital sign monitoring with a real-time algorithm such as the Visensia Safety Index (VSI). This prospective comparative data modeling cohort study (NCT04189653) compares continuous algorithmic alerts against periodic EWS in continuous monitored medical and surgical inpatients. We evaluated sensitivity, frequency, number of warnings needed to evaluate (NNE) and time of initial alert till escalation of care (EOC): Rapid Response Team activation, unplanned ICU admission, emergency surgery, or death. Also, the percentage of VSI alerting minutes was compared between patients with or without EOC. In 1529 admissions continuous VSI warned for 55% of EOC (95% CI: 45-64%) versus 51% (95% CI: 41-61%) by periodic EWS. NNE for VSI was 152 alerts per detected EOC (95% CI: 114-190) compared to 21 (95% CI: 17-28). It generated 0.99 warnings per day per patient compared to 0.13. Time from detection score till escalation was 8.3 hours (IQR: 2.6-24.8) with VSI versus 5.2 (IQR: 2.7-12.3) hours with EWS (P=0.074). The percentage of warning VSI minutes was higher in patients with EOC than in stable patients (2.36% vs 0.81%, P<0.001). Although sensitivity of detection was not significantly improved continuous vital sign monitoring shows potential for earlier alerts for deterioration compared to periodic EWS. A higher percentage of alerting minutes may indicate risk for deterioration.

The Effect of Continuous Versus Periodic Vital Sign Monitoring on Disease Severity of Patients with an Unplanned ICU Transfer.

Continuous vital sign monitoring (CM) may detect ward patient's deterioration earlier than periodic monitoring. This could result in timely ICU transfers or in a transfer delay due to misperceived higher level of care on the ward. The primary objective of this study was to compare patient's disease severity upon unplanned ICU transfer, before and after CM implementation. We included a one-year period before and after CM implementation between August 1, 2017 - July 31, 2019. Before implementation, surgical and internal medicine patients' vital signs were periodically monitored, compared to continuous monitoring with wireless linkage to hospital systems after implementation. In both periods the same early warning score (EWS) protocol was in place. Primary outcome was disease severity scores upon ICU transfer. Secondary outcomes were ICU and hospital length of stay, incidence of mechanical ventilation and ICU mortality. In the two one-year periods 93 and 59 unplanned ICU transfer episodes were included, respectively. Median SOFA (3 (2-6) vs 4 (2-7), p = .574), APACHE II (17 (14-20) vs 16 (14-21), p = .824) and APACHE IV (59 (46-67) vs 50 (36-65), p = .187) were comparable between both periods, as were the median ICU LOS (3.0 (1.7-5.8) vs 3.1 (1.6-6.1), p.962), hospital LOS (23.6 (11.5-38.0) vs 19 (13.9-39.2), p = .880), incidence of mechanical ventilation (28 (47%) vs 22 (54%), p.490), and ICU mortality (11 (13%) vs 10 (19%), p.420). This study shows no difference in disease severity upon unplanned ICU transfer after CM implementation for patients who have deteriorated on the ward.

Effect of continuous wireless vital sign monitoring on unplanned ICU admissions and rapid response team calls: a before-and-after study.

BACKGROUND: Continuous vital sign monitoring may potentially be improved through the use of wearable monitors linked wirelessly to hospital electronic patient records. By improving early detection of physiological deterioration this approach may save lives. METHODS: We performed a single-centre before-and-after study including surgical and medical patients at a university hospital in The Netherlands. The study intervention was continuous vital sign monitoring using wearable monitors linked wirelessly to hospital systems. The co-primary outcomes were unplanned ICU admission and rapid response team calls. Secondary outcomes were length of hospital stay and in-patient death. RESULTS: Our baseline cohort included 2466 admissions and our intervention cohort included 2303 admissions recruited from August 2017 to July 2019. Patients in the intervention cohort experienced fewer unplanned ICU admissions (84 [3.4%] vs 54 [2.3%]; P=0.03) and fewer rapid response team calls (107 [4.3%] vs 71 [3.1%]; P=0.02). The number of rapid response team calls that did not result in ICU admission also declined (70 [2.8%] vs 45 [2.0%]; P=0.05). The number of rapid response team calls that did result in ICU admission was not significantly different (52 [2.1%] vs 36 [1.6%]; P=0.16). There were no differences in hospital stay or in-patient deaths between the two study periods. CONCLUSIONS: Continuous monitoring of patient vital signs using wearable monitoring technology linked wirelessly to hospital systems was associated with a reduction in unplanned ICU admissions and rapid response team calls. Further research is necessary to confirm the impact of this approach on patient survival.

Exploring barriers to physical activity of patients at the internal medicine and surgical wards: a retrospective analysis of continuously collected data.

PURPOSE: To analyse physical activity of patients during their hospital stay and to explore the relationship between physical activity and barriers to physical activity. METHODS: This was a secondary analysis of physical activity data for patients admitted to the internal medicine and surgical wards. Physical activity data, collected with a wireless patch sensor, was operationalized as time spent lying, sitting/standing, and walking. Barriers to physical activity included patients' pain levels, the use of urinary catheters, intravenous tubing, oxygen lines, drains, and level of dependence. Regression analysis explored the relationship between physical activity and barriers to physical activity. RESULTS: Physical activity data were collected in 39 patients (aged 27-88, mean 54 years) during hospital stay. Patients were admitted for a median of 10 d (interquartile range [IQR]: 7-15 d). These patients were lying for a median of 12.1 h (7.6-17.7), sitting/standing 11.8 h (6.3-15.7), and walking 0.1 h (0-0.3) per day. Time lying during the day related to pain levels (ß = 0.4 h per unit increase in pain, p < 0.01) and drain use (ß = 3.1 h, p < 0.01). CONCLUSIONS: Patients spent the most time during the hospital stay lying in bed. Improved pain management and decreased drain use may be worth exploring to increase inpatient physical activity.Implications for rehabilitationContinuous monitoring of physical activity in patients during hospital stay is an important tool for health care professionals to improve multidisciplinary care and rehabilitation.Health care professionals should be aware of the necessity of adequate pain management and critically review the use of drains in order to improve physical activity of patients during hospital stay.Patients need extra support of health care professionals to increase physical activity during consecutive days of their hospital stay.

Identification of Cardiovascular Patient Groups at Risk for Poor Medication Adherence: A Cluster Analysis.

BACKGROUND: Poor medication adherence limits the secondary prevention of cardiovascular diseases (CVDs) and leads to increased morbidity, mortality, and costs. Identifying groups of patients at risk of poor adherence behavior could enable an intervention to be developed and target patients appropriately. OBJECTIVE: The first aim of this study was to identify homogeneous subgroups of cardiovascular outpatients based on their cardiovascular risk factors. Subsequently, differences in medication adherence between these groups were examined. METHODS: In this retrospective, observational study, patients with an established CVD were included. Well-known cardiovascular risk factors such as smoking, diet, exercise, blood lipid levels, blood pressure, and body mass index were collected. To identify patient subgroups, a 2-step cluster analytic procedure was performed. Differences between the groups on medication adherence were determined on the outcome of the Modified Morisky Scale. Data collection took place between October 2011 and January 2013. RESULTS: Cardiovascular risk factors of 530 patients were included in the cluster analysis. Three groups were identified. Compared with other clusters (clusters 1 and 2), cluster 3 contained significantly fewer patients who could be classified as highly adherent and more patients classified as medium adherent (23% and 57%, respectively; P = .024). This group was characterized by a younger age (53% were <55 years old) and using a relatively low number of different medications (41% used <4 different medications). Besides, in this subgroup the most smokers (37%), unhealthy alcohol users (27%), and patients with unhealthy eating habits (14%) were present. CONCLUSION: This study showed that cardiovascular patients who are relatively young and have an unhealthy lifestyle are at risk for nonadherent behavior.

Self-management support in cardiovascular consultations by advanced practice nurses trained in motivational interviewing: An observational study.

OBJECTIVE: This observational study explores advanced practice nurses' (APN) performance in secondary prevention and self-management support in patients with cardiovascular disease. METHODS: Real-life consultations in three outpatient clinics were recorded on audio and analysed. First, discussed (sub)categories were determined using five categories of self-management: symptom management, treatment, biomedical cardiovascular risk factors, psychosocial consequences, and lifestyle changes. Second, the extent in which motivational interviewing aspects were applied was determined using the Behaviour Change Counselling Index (BECCI). RESULTS: In total, 49 consultations performed by five female APNs were analysed. Physical topics were discussed in 98% and psychological subthemes in 41% of the consultations. Although not all components of motivational interviewing were applied, talking about current behaviour and behaviours that should change were discussed, and information was provided. Especially setting targets and exchanging ideas on how to reach behavioural goals were applied to a small extent. CONCLUSION: Well-trained APNs in the current study do not carry out motivational interviewing in a structural and complete manner according to BECCI and do not discuss all self-management categories. PRACTICE IMPLICATIONS: Psychological topics should be more integrated in providing self-management support by APNs and the application of motivational interviewing should be enhanced by regularly and repeated training.

Social media monitoring on the perceived safety of medication use during pregnancy: A case study from the Netherlands.

AIMS: An increasing number of women trust the Internet for information about medication safety during pregnancy. This study aimed to evaluate the availability and accuracy of social media content on the perceived safety of medication use in pregnancy. METHODS: We performed a systematic search of posts related to medication safety during pregnancy in the Dutch language published on social media, blogs and forums between May 2011 and April 2016 using Coosto, a tool for social media monitoring. The perceived safety in the posts was compared with the Dutch Teratology Information Service (TIS) safety classifications. RESULTS: We included 1224 online posts, which described 1441 scenarios about medication safety in pregnancy. A total of 820 (57%) scenarios were in line with the TIS classification. Incorrect perception was higher for prescription medication compared to medication available over-the-counter (60 vs 25%). Furthermore, the safety classification of medications with a TIS classification on strict indication or second-line drugs (93%) and medications with insufficient knowledge on their safety during pregnancy (76%) was more likely to be incorrectly perceived by the public compared to medications with the TIS classification safe (24%). CONCLUSIONS: Social media monitoring may be useful for surveillance of potentially unsafe use of medications in pregnancy. Many social posts related to medication safety during pregnancy provide inaccurate information. As this information may affect women's perceptions and decisions, accurate communication between healthcare providers and pregnant women regarding the benefits and risks of medications is vital.

Google AdWords and Facebook Ads for Recruitment of Pregnant Women into a Prospective Cohort Study With Long-Term Follow-Up.

Objectives Several types of epidemiologic studies suffer from decreasing participation rates, resulting in potential selection bias and delay or termination of studies. We aimed to determine the feasibility of online methods for recruitment of pregnant women into a prospective cohort study. Methods In addition to traditional recruitment through prenatal care providers, we advertized participation in the PRegnancy and Infant DEvelopment (PRIDE) Study, an ongoing prospective cohort study with long-term follow-up in The Netherlands enrolling women in early pregnancy, through Google AdWords (30 days) and Facebook Ads (31 and 27 days) campaigns between September 2016 and January 2017. We calculated costs per eligible participant and compared demographics, health-related characteristics, and follow-up rates between participants recruited through online methods and prenatal care providers. Results During the study period, we recruited six women through AdWords (€54.28 per participant), 59 through Facebook (€10.17 per participant), and 327 through prenatal care providers (no valid cost estimate available). Facebook participants seemed to be younger (29.0 vs. 30.7 years), to have a higher body mass-index and/or low/intermediate education (27.0 vs. 24.0 kg/m2 and 41 vs. 25%, respectively), and to start prenatal care in secondary care more often (12 vs. 5%) than participants recruited through prenatal care providers. Item non-response and loss to follow-up rates were higher among women recruited online than among those recruited through prenatal care providers. Conclusion Google AdWords did not contribute substantially, but Facebook Ads may complement traditional recruitment methods of pregnant women into prospective cohort studies, despite challenges that may threaten internal validity.

Wireless and continuous monitoring of vital signs in patients at the general ward.

BACKGROUND: Clinical deterioration regularly occurs in hospitalized patients potentially resulting in life threatening events. Early warning scores (EWS), like the Modified Early Warning Score (MEWS), assist care givers in assessing patients' clinical situation, but cannot alert for deterioration between measurements. New devices, like the ViSi Mobile (VM) and HealthPatch (HP) allow for continuous monitoring and can alert deterioration in an earlier phase. VM and HP were tested regarding MEWS calculation compared to nurse measurements, and detection of high MEWS in periods between nurse observations. METHODS: This quantitative study was part of a randomized controlled trial. Sixty patients of the surgical and internal medicine ward with a minimal expected hospitalization time of three days were randomized to VM or HP continuous monitoring in addition to regular nurse MEWS measurements for 24-72 h. RESULTS: Median VM and HP MEWS were higher than nurse measurements (2.7 vs. 1.9 and 1.9 vs. 1.3, respectively), predominantly due to respiratory rate measurement differences. During 1282 h VM and 1886 h HP monitoring, 71 (14 patients) and 32 (7 patients) high MEWS periods were detected during the non-observed periods. Time between VM or HP based high MEWS and next regular nurse measurement ranged from 0 to 9 (HP) and 10 (VM) hours. CONCLUSIONS: Both VM and HP are promising for continuous vital sign monitoring and may be more accurate than nurses. High MEWS can be detected in hospitalized patients around the clock and clinical deterioration at an earlier phase during unobserved periods.

A smart all-in-one device to measure vital signs in admitted patients.

BACKGROUND: Vital sign measurements in hospitalized patients by nurses are time consuming and prone to operational errors. The Checkme, a smart all-in-one device capable of measuring vital signs, could improve daily patient monitoring by reducing measurement time, inter-observer variability, and incorrect inputs in the Electronic Health Record (EHR). We evaluated the accuracy of self measurements by patient using the Checkme in comparison with gold standard and nurse measurements. METHODS AND FINDINGS: This prospective comparative study was conducted at the Internal Medicine ward of an academic hospital in the Netherlands. Fifty non-critically ill patients were enrolled in the study. Time-related measurement sessions were conducted on consecutive patients in a randomized order: vital sign measurement in duplicate by a well-trained investigator (gold standard), a Checkme measurement by the patient, and a routine vital sign measurement by a nurse. In 41 patients (82%), initial calibration of the Checkme was successful and results were eligible for analysis. In total, 69 sessions were conducted for these 41 patients. The temperature results recorded by the patient with the Checkme differed significantly from the gold standard core temperature measurements (mean difference 0.1 ± 0.3). Obtained differences in vital signs and calculated Modified Early Warning Score (MEWS) were small and were in range with predefined accepted discrepancies. CONCLUSIONS: Patient-calculated MEWS using the Checkme, nurse measurements, and gold standard measurements all correlated well, and the small differences observed between modalities would not have affected clinical decision making. Using the Checkme, patients in a general medical ward setting are able to measure their own vital signs easily and accurately by themselves. This could be time saving for nurses and prevent errors due to manually entering data in the EHR.

Stress measurement in surgeons and residents using a smart patch.

BACKGROUND: Stress may negatively affect surgeons' performance during surgical procedures, jeopardizing patient safety. For measuring stress, complex methods are used that cannot record stress real time. This study reports stress measurements in surgeons and residents using a novel patch sensor to identify activities and risk factors of stress. METHODS: In this explorative study, surgeons and residents wore the HealthPatch™ during all daily activities for 2-3 days. The patch recorded heart rate variability (HRV), and real time stress percentage using a validated algorithm of heart rate (HR) and HRV. The patch was compared with self perceived stress reporting using STAI. RESULTS: A significant increase in HRV and stress percentage was shown in twenty surgeons and residents during surgery in comparison with other activities. Consultants showed lower stress levels while operating compared to fellows and residents. Stress according to the patch did not correlate with STAI outcome. CONCLUSIONS: Continuous stress monitoring using a wearable sensor patch reveals relevant data on actual stress of surgeons and residents. Stress was highest performing an operation, particularly in fellows and residents.

Cytokine Inhibition in Patients With Chronic Fatigue Syndrome: A Randomized Trial.

BACKGROUND: Interleukin-1 (IL-1), an important proinflammatory cytokine, is suspected to play a role in chronic fatigue syndrome (CFS). OBJECTIVE: To evaluate the effect of subcutaneous anakinra versus placebo on fatigue severity in female patients with CFS. DESIGN: Randomized, placebo-controlled trial from July 2014 to May 2016. Patients, providers, and researchers were blinded to treatment assignment. (ClinicalTrials.gov: NCT02108210). SETTING: University hospital in the Netherlands. PATIENTS: 50 women aged 18 to 59 years with CFS and severe fatigue leading to functional impairment. INTERVENTION: Participants were randomly assigned to daily subcutaneous anakinra, 100 mg (n = 25), or placebo (n = 25) for 4 weeks and were followed for an additional 20 weeks after treatment (n = 50). MEASUREMENTS: The primary outcome was fatigue severity, measured by the Checklist Individual Strength subscale (CIS-fatigue) at 4 weeks. Secondary outcomes were level of impairment, physical and social functioning, psychological distress, and pain severity at 4 and 24 weeks. RESULTS: At 4 weeks, 8% (2 of 25) of anakinra recipients and 20% (5 of 25) of placebo recipients reached a fatigue level within the range reported by healthy persons. There were no clinically important or statistically significant differences between groups in CIS-fatigue score at 4 weeks (mean difference, 1.5 points [95% CI, -4.1 to 7.2 points]) or the end of follow-up. No statistically significant between-group differences were seen for any secondary outcome at 4 weeks or the end of follow-up. One patient in the anakinra group discontinued treatment because of an adverse event. Patients in the anakinra group had more injection site reactions (68% [17 of 25] vs. 4% [1 of 25]). LIMITATION: Small sample size and wide variability in symptom duration; inclusion was not limited to patients with postinfectious symptoms. CONCLUSION: Peripheral IL-1 inhibition using anakinra for 4 weeks does not result in a clinically significant reduction in fatigue severity in women with CFS and severe fatigue. PRIMARY FUNDING SOURCE: Interleukin Foundation and an independent donor who wishes to remain anonymous.

Rheumatoid Arthritis Disadvantages Younger Patients for Cardiovascular Diseases: A Meta-Analysis.

INTRODUCTION: The incidence of cardiovascular diseases (CVD) is increased in rheumatoid arthritis (RA) patients. It remains unclear whether the load of RA increases cardiovascular (CV) risk especially in female and in younger RA patients. In the present study we aim to analyse the influence of age and gender on CV risk in RA relative to the general population, using meta-analysis of direct comparative studies. METHOD: Systematic literature search was performed in MEDLINE for studies reporting on occurrence of CV events in RA as compared to the general population, stratified for gender and/or age. Quality was appraised using the Newcastle-Ottawa scale. Meta-analysis was performed on rate ratios using inverse variance methods. RESULTS: There were 1372 records screened and 13 studies included. RA females and males have a similar higher risk (95%CI) to develop stroke with RR 1.35 (1.30-1.40) and RR 1.31 (1.21-1.43); coronary artery disease with RR 1.65 (1.54-1.76) versus RR 1.55 ((1.41-1.69) in men; cardiovascular disease with RR 1.56 (1.49-1.62) versus 1.50 (1.41-1.60). The highest incidence of CV events was observed in the youngest patients, RR 2.59 (1.77-3.79), whereas older patients had the lowest relative risk when compared to the general population, RR 1.27 (1.16-1.38). CONCLUSION: The relative risk of RA patients for CVD is age dependent, but does not depend on gender: the relative risk on CVD appears to be equally raised for males and females, while relatively young RA patients (<50 years) have the highest, and older patients the lowest relative risk.

A New Cuffless Device for Measuring Blood Pressure: A Real-Life Validation Study.

BACKGROUND: Cuffless blood pressure (BP) monitoring devices, based on pulse transit time, are being developed as an easy-to-use, more convenient, fast, and relatively cheap alternative to conventional BP measuring devices based on cuff occlusion. Thereby they may provide a great alternative to BP self-measurement. OBJECTIVE: The objective of our study was to evaluate the performance of the first release of the Checkme Health Monitor (Viatom Technology), a cuffless BP monitor, in a real-life setting. Furthermore, we wanted to investigate whether the posture of the volunteer and the position of the device relative to the heart level would influence its outcomes. METHODS: Study volunteers fell into 3 BP ranges: high (>160 mmHg), normal (130-160 mmHg), and low (<130 mmHg). All requirements for test environment, observer qualification, volunteer recruitment, and BP measurements were met according to the European Society of Hypertension International Protocol (ESH-IP) for the validation of BP measurement devices. After calibrating the Checkme device, we measured systolic BP with Checkme and a validated, oscillometric reference BP monitor (RM). Measurements were performed in randomized order both in supine and in sitting position, and with Checkme at and above heart level. RESULTS: We recruited 52 volunteers, of whom we excluded 15 (12 due to calibration failure with Checkme, 3 due to a variety of reasons). The remaining 37 volunteers were divided into low (n=14), medium (n=13), and high (n=10) BP ranges. There were 18 men and 19 women, with a mean age of 54.1 (SD 14.5) years, and mean recruitment systolic BP of 141.7 (SD 24.7) mmHg. BP results obtained by RM and Checkme correlated well. In the supine position, the difference between the RM and Checkme was >5 mmHg in 17 of 37 volunteers (46%), of whom 9 of 37 (24%) had a difference >10 mmHg and 5 of 37 (14%) had a difference >15 mmHg. CONCLUSIONS: BP obtained with Checkme correlated well with RM BP, particularly in the position (supine) in which the device was calibrated. These preliminary results are promising for conducting further research on cuffless BP measurement in the clinical and outpatient settings.

Cytokine inhibition in chronic fatigue syndrome patients: study protocol for a randomized controlled trial.

BACKGROUND: Chronic fatigue syndrome (CFS) is a medically unexplained syndrome for which no somatic or pharmacological treatment has been proven effective. Dysfunction of the cytokine network has been suspected to play a role in the pathophysiology of CFS. The disturbances of the cytokine network detected in CFS patients are highly variable, in part due to the lack of adequate controls in many studies. Furthermore, all studies have been performed on peripheral venous blood of patients. As cytokines mainly act in tissues, for example, the brain, the information that can be derived from peripheral blood cells is limited. The information regarding the possible role of cytokines in the pathophysiology could come from intervention studies in which the activities of relevant cytokines are reduced, for example, reducing interleukin-1, interleukin-6 or tumor necrosis factor. In this study, the clinical usefulness of anakinra, an IL-1 antagonist, will be assessed in patients with CFS. METHODS/DESIGN: A randomized placebo-controlled, double-blind trial will be conducted. Fifty adult female patients meeting the Centers for Disease Control (CDC) criteria for CFS and without psychiatric co-morbidity will be included. After inclusion, patients will be randomized between treatment with anakinra (recombinant human interleukin-1 receptor antagonist) or placebo. Each group will be treated for 4 weeks. Outcome measures will be assessed at baseline, after 4 weeks of intervention, and 6 months after baseline assessment. The primary outcome measure will be fatigue severity at 4 weeks, measured with the validated Checklist of Individual Strength (CIS). Secondary outcome measures are functional impairment, physical and social functioning, psychological distress, pain severity, presence of accompanying symptoms, and cytokine and cortisol concentrations. DISCUSSION: This is the first randomized placebo-controlled trial that will evaluate the effect of interference with IL-1 on the experience of fatigue in patients with CFS. The results of this study may expand treatment options for patients with CFS, for whom graded exercise therapy and cognitive behavioral therapy are the only evidence-based interventions that exist at this moment. TRIAL REGISTRATION: Clinicaltrials.gov: NCT02108210 . Clinicaltrials.gov registration date: 8 April 2014. EudraCT: 2013-005466-19.

The CareWell in Hospital program to improve the quality of care for frail elderly inpatients: results of a before-after study with focus on surgical patients.

BACKGROUND: The objective of this study was to evaluate implementation of an innovative intervention designed to prevent complications and stimulate early rehabilitation among frail elderly inpatients. METHODS: The program was implemented in April 2011. A mixed-methods process evaluation and before-after study were performed. Primary effect outcomes included incidence of hospital-acquired delirium, cognitive decline, and decline in activities of daily living (ADL) during hospital stay. Secondary endpoints included ADL performance 3 months postdischarge, readmission, and caregiver burden. RESULTS: One hundred ninety-one preintervention and 195 postintervention patients aged 70 years or older were included. Overall, no significant differences in primary endpoints were found. Mean ADL between discharge and follow-up improved (3.2 vs 5.7, P = .058). Caregivers rated burden of care lower at 3 months postdischarge (.5 vs -.6, P = .049). CONCLUSIONS: The CareWell in Hospital program was implemented satisfactorily. Although the low baseline delirium incidence (11%), higher comorbidity, and an increasing learning curve during a restricted implementation period potentially influenced the overall effects, this integrated care program may have beneficial effects on outcomes among frail elderly surgical patients.

[Branch retinal vein occlusion: high time for cardiovascular risk management]. / Retinale venetakocclusie: de hoogste tijd voor cardiovasculair risicomanagement.

Cardiovascular risk management is common in patients suffering from manifest cardiovascular disease, hypertension, hyperlipidaemia and diabetes mellitus. It is generally accepted that medication is the most effective treatment for reducing cardiovascular morbidity and mortality in these patients. Remarkably, cardiovascular risk management is rare in patients suffering from branch retinal vein occlusion. This common retinal vascular disorder in middle aged and elderly people occurs where a thickened retinal artery compresses the affected vein. Although thrombosis is involved, procoagulant disorders are only present in selected cases. On the other hand, prior diabetes, hypertension, and peripheral artery disease are associated with an increased risk of developing branch retinal vein occlusion up to a decade later, and retinal vascular disorder is associated with an increased risk of subsequently developing hypertension, diabetes, congestive heart failure, and cerebrovascular disease later on. Therefore, branch retinal vein occlusion is a marker of developing cardiovascular disease and warrants adequate cardiovascular risk management.

A high prevalence of carotid artery stenosis in male patients older than 65 years, irrespective of presenting clinical manifestation of atherosclerotic diseases.

This study investigated the prevalence of carotid artery stenosis (CS) and the association with various risk factors in male patients (>65 years) diagnosed with cardiovascular diseases. Duplex sonography of the carotid arteries was performed in 434 of 473 eligible patients of whom 118 (27.8%) patients had significant CS ≥50%. The prevalence and severity of CS did not differ between patients who presented with neurological symptoms or acute coronary syndrome/peripheral artery disease (30.8% vs 25.9%, respectively). Among patients with CS, a higher rate of current smoking, a higher systolic blood pressure, and a lower glomerular filtration rate were observed compared with patients without CS. A history of coronary artery bypass graft was a significant predictor of the presence of CS (P = .003, odds ratio [OR] = 2.70 [1.40-5.19]). The prevalence of CS in elderly males with manifest atherosclerotic disease is high, irrespective of presenting clinical manifestation.

No significant effect of ginkgo biloba special extract EGb 761 in the treatment of primary Raynaud phenomenon: a randomized controlled trial.

BACKGROUND: Medicinal treatment of vasospastic Raynaud phenomenon is limited to primarily vasodilator medicines. OBJECTIVE: To explore the possible beneficial effects and tolerability of 120 mg two times a day of Ginkgo Biloba special extract EGb 761 in patients suffering from Raynaud disease (RD) (primary Raynaud phenomenon). METHODS: In a placebo-controlled, double-blind, pilot study, 41 patients with RD were randomized to either the active treatment group (EGb 761, n = 21) or placebo group for 10 weeks, after an initial 2-week run-in phase. The primary efficacy variables were self-reported changes of the frequency, duration, and severity of vasospastic attacks between the placebo-controlled run-in phase and the end of the study. RESULTS: Most of the patients were female, and both groups were perfectly matched with respect to demographic characteristics. The frequency of daily attacks reduced from 3.6 ± 2.3 to 2.4 ± 2.6 (-33%) in the EGb 761 group and from 2.9 ± 2.0 to 2.0 ± 1.8 (-31%) in the placebo group with no significant difference according to the ordinary least squares test (P = 0.3564). Furthermore, no significant differences were found with respect to the duration and severity of vasospastic attacks between the EGb 761 and placebo groups (P = 0.4392 and P = 0.7187, respectively). In all, 17 adverse events (AEs) were reported, 6 AEs from 5 patients in the EGb 761 group and 11 AEs from 8 patients in the placebo group. Serious AEs did not occur. CONCLUSION: EGb 761 treatment showed an excellent safety profile in patients with RD but could not demonstrate a statistically significant reduction in clinically relevant symptoms compared with placebo.