Monitoring of Dynamic Plantar Foot Temperatures in Diabetes with Personalised 3D-Printed Wearables.

Diabetic foot ulcers (DFUs) are a life-changing complication of diabetes that can lead to amputation. There is increasing evidence that long-term management with wearables can reduce incidence and recurrence of this condition. Temperature asymmetry measurements can alert to DFU development, but measurements of dynamic information, such as rate of temperature change, are under investigated. We present a new wearable device for temperature monitoring at the foot that is personalised to account for anatomical variations at the foot. We validate this device on 13 participants with diabetes (no neuropathy) (group name D) and 12 control participants (group name C), during sitting and standing. We extract dynamic temperature parameters from four sites on each foot to compare the rate of temperature change. During sitting the time constant of temperature rise after shoe donning was significantly (p < 0.05) faster at the hallux (p = 0.032, 370.4 s (C), 279.1 s (D)) and 5th metatarsal head (p = 0.011, 481.9 s (C), 356.6 s (D)) in participants with diabetes compared to controls. No significant differences at the other sites or during standing were identified. These results suggest that temperature rise time is faster at parts of the foot in those who have developed diabetes. Elevated temperatures are known to be a risk factor of DFUs and measurement of time constants may provide information on their development. This work suggests that temperature rise time measured at the plantar surface may be an indicative biomarker for differences in soft tissue biomechanics and vascularisation during diabetes onset and progression.

Flexible 3D-Printed EEG Electrodes.

For electroencephalography (EEG) in haired regions of the head, finger-based electrodes have been proposed in order to part the hair and make a direct contact with the scalp. Previous work has demonstrated 3D-printed fingered electrodes to allow personalisation and different configurations of electrodes to be used for different people or for different parts of the head. This paper presents flexible 3D-printed EEG electrodes for the first time. A flexible 3D printing element is now used, with three different base mechanical structures giving differently-shaped electrodes. To obtain improved sensing performance, the silver coatings used previously have been replaced with a silver/silver-chloride coating. This results in reduced electrode contact impedance and reduced contact noise. Detailed electro-mechanical testing is presented to demonstrate the performance of the operation of the new electrodes, particularly with regards to changes in conductivity under compression, together with on-person tests to demonstrate the recording of EEG signals.

Chief complaint-based performance measures: a new focus for acute care quality measurement.

Performance measures are increasingly important to guide meaningful quality improvement efforts and value-based reimbursement. Populations included in most current hospital performance measures are defined by recorded diagnoses using International Classification of Diseases, Ninth Revision codes in administrative claims data. Although the diagnosis-centric approach allows the assessment of disease-specific quality, it fails to measure one of the primary functions of emergency department (ED) care, which involves diagnosing, risk stratifying, and treating patients' potentially life-threatening conditions according to symptoms (ie, chief complaints). In this article, we propose chief complaint-based quality measures as a means to enhance the evaluation of quality and value in emergency care. We discuss the potential benefits of chief complaint-based measures, describe opportunities to mitigate challenges, propose an example measure set, and present several recommendations to advance this paradigm in ED-based performance measurement.

Interunit handoffs of patients and transfers of information: a survey of current practices.

STUDY OBJECTIVE: We describe the current state of emergency department to inpatient handoffs and assess handoff best practices between emergency physicians and hospitalist medicine physicians. METHODS: A survey was distributed electronically to emergency medicine and internal medicine physicians at 10 hospitals across the United States. Descriptive and quantitative analysis was performed on survey results. Additionally, qualitative data were obtained from an expert focus group of both emergency medicine and hospital medicine clinicians. RESULTS: Seven hundred fifty of 1,799 physicians (42.2%) responded to our Web-based survey. Attending physicians (45%) described themselves as practicing emergency medicine (51%) or internal medicine (56%). Responding residents were 55% internal medicine, 43% emergency medicine, and 13% dual emergency medicine/internal medicine. Of the responding departments, use of standardized tools was reported by less than 20% and only one third of residents reported formal handoff training. Handoff factors identified as important include identifying "high-risk" patients, designating uninterrupted time to perform the handoff, and standardizing information provided during the handoff. Qualitative results mirrored these themes and acknowledged the importance of bedside handoffs. CONCLUSION: To our knowledge, this is the largest multispecialty survey to date, including both resident and attending physicians in emergency medicine and hospital medicine. Standardized tools are rarely used and training of residents in this critical task is uncommon. Physicians in both specialties agree on the important content and structure of handoff, including the ideal situation of face-to-face bedside discussion. A curriculum and assessment tool for this practice should be developed.

A Wrist-Worn Internet of Things Sensor Node for Wearable Equivalent Daylight Illuminance Monitoring.

Light exposure is a vital regulator of physiology and behavior in humans. However, monitoring of light exposure is not included in current wearable Internet of Things (IoT) devices, and only recently have international standards defined [Formula: see text] -optic equivalent daylight illuminance (EDI) measures for how the eye responds to light. This article reports a wearable light sensor node that can be incorporated into the IoT to provide monitoring of EDI exposure in real-world settings. We present the system design, electronic performance testing, and accuracy of EDI measurements when compared to a calibrated spectral source. This includes consideration of the directional response of the sensor, and a comparison of performance when placed on different parts of the body, and a demonstration of practical use over 7 days. Our device operates for 3.5 days between charges, with a sampling period of 30 s. It has 10 channels of measurement, over the range 415-910 nm, balancing accuracy and cost considerations. Measured [Formula: see text]-opic EDI results for 13 devices show a mean absolute error of less than 0.07 log lx, and a minimum between device correlation of 0.99. These findings demonstrate that accurate light sensing is feasible, including at wrist worn locations. We provide an experimental platform for use in future investigations in real-world light exposure monitoring and IoT-based lighting control.

Fully printed and multifunctional graphene-based wearable e-textiles for personalized healthcare applications.

Wearable e-textiles have gained huge tractions due to their potential for non-invasive health monitoring. However, manufacturing of multifunctional wearable e-textiles remains challenging, due to poor performance, comfortability, scalability, and cost. Here, we report a fully printed, highly conductive, flexible, and machine-washable e-textiles platform that stores energy and monitor physiological conditions including bio-signals. The approach includes highly scalable printing of graphene-based inks on a rough and flexible textile substrate, followed by a fine encapsulation to produce highly conductive machine-washable e-textiles platform. The produced e-textiles are extremely flexible, conformal, and can detect activities of various body parts. The printed in-plane supercapacitor provides an aerial capacitance of ∼3.2 mFcm-2 (stability ∼10,000 cycles). We demonstrate such e-textiles to record brain activity (an electroencephalogram, EEG) and find comparable to conventional rigid electrodes. This could potentially lead to a multifunctional garment of graphene-based e-textiles that can act as flexible and wearable sensors powered by the energy stored in graphene-based textile supercapacitors.

Impact of shift working on the potential for self-powering via kinetic energy harvesting in wearable devices.

Wearable devices are having a transformative impact on personalised monitoring and care. However, they frequently have limited battery life, requiring charging every few days; a major source of user frustration. Kinetic energy harvesting may help overcome this, collecting energy from the user's motion to allow the device to self-charge. While there are many works which have investigated wearable energy harvesting potential, none have incorporated socio-economic factors which affect activity, such as occupation type, on energy harvesting potential. We use the UK Biobank free-living accelerometer dataset to investigate the impact of occupational patterns on energy harvesting potential for the first time. We identify that those following shift patterns have a different distribution of when power is available, with those who work shifts having the most power intense period spread over a longer period of the day compared to controls. When stratifying into day or night shift work, we identify that those who work night shifts have a large variation between participants, as their most energy dense period is spread over the entire 24-hour period. This is compared to day shift workers who have the most power concentrated within a substantially smaller window, typically in the morning. Considering these socio-economic factors may affect system design of wearable energy harvesters.

Motion artefact removal in electroencephalography and electrocardiography by using multichannel inertial measurement units and adaptive filtering.

This paper presents a new active electrode design for electroencephalogram (EEG) and electrocardiogram (ECG) sensors based on inertial measurement units to remove motion artefacts during signal acquisition. Rather than measuring motion data from a single source for the entire recording unit, inertial measurement units are attached to each individual EEG or ECG electrode to collect local movement data. This data is then used to remove the motion artefact by using normalised least mean square adaptive filtering. Results show that the proposed active electrode design can reduce motion contamination from EEG and ECG signals in chest movement and head swinging motion scenarios. However, it is found that the performance varies, necessitating the need for the algorithm to be paired with more sophisticated signal processing to identify scenarios where it is beneficial in terms of improving signal quality. The new instrumentation hardware allows data driven artefact removal to be performed, providing a new data driven approach compared to widely used blind-source separation methods, and helps enable in the wild EEG recordings to be performed.

Improving handoffs in the emergency department.

Patient handoffs at shift change are a ubiquitous and potentially hazardous process in emergency care. As crowding and lengthy evaluations become the standard for an increasing proportion of emergency departments (EDs), the number of patients handed off will likely increase. It is critical now more than ever before to ensure that handoffs supply valid and useful shared understandings between providers at transitions of care. The purpose of this article is to provide the most up-to-date evidence and collective thinking about the process and safety of handoffs between physicians in the ED. It offers perspectives from other disciplines, provides a conceptual framework for handoffs, and categorizes models of existing practices. Legal and risk management issues are also addressed. A proposal for the development of handoff quality measures is outlined. Practical strategies are suggested to improve ED handoffs. Finally, a research agenda is proposed to provide a roadmap to future work that may increase knowledge in this area.

A Graphene-Based Sleep Mask for Comfortable Wearable Eye Tracking.

We present a new wearable electrooculogram (EOG) monitor for measuring eye movements. We fabricated conductive and flexible graphene-based textiles from nylon to use as a sensing electrode, which we then integrated into a commercially available eye mask held in place only with the standard elastic strap. We tested this mask on 4 participants to quantify the noise floor and show that we can detect eye blinks to a high SNR of over 16 dB. We also identify that the material can detect other eye movements in cases when the noise floor is low. As our system is held in place with only an elastic strap it offers the same level of comfort as when wearing a normal eye mask. Our sensors offer an increased level of comfort over conventional gelled electrodes traditionally used in EOG monitoring and may be of use for comfortable eye movement experiments. This is particularly important during sleep studies where the EOG is routinely monitored, but using bulky instrumentation.

Performance of graphene ECG electrodes under varying conditions.

Smart garments for invisible health sensing have been available for a number of years, with heart sensing typically performed using silver loaded conductive threads integrated into the fabric to pick up the electrocardiogram. Recent work has investigated printed graphene textiles as an alternative to this, which are potentially more environmentally friendly, cost-effective, and can be performed after garment manufacturing. This paper presents an exploration of second order factors on the performance of graphene textile electrodes for electrocardiogram measurements. We prepare graphenebased textile electrodes using a simple and highly scalable continuous padding method. We then analyze two metrics: the change in heart rate estimation error, and the changes in signal-to-noise ratio; under two separate conditions: an extended record length, and varying temperatures; to recreate the some of the conditions the material would experience when being worn in real-life. We report that neither the heart rate estimation error or the signal-to-noise ratio are significantly affected after a long record or with varying temperature. These tests indicate that graphene electrodes are suitable for electrocardiogram measurements in a wearable that will be subjected to these conditions.

Optimizing Energy Harvesting for Foot Based Wearable Sensors.

Wearable devices have the potential to improve healthcare, but suffer from significant barriers to adoption, including the need for constant recharging. Harvesting energy from the ambient environment to top-up batteries can overcome this, but the actual energy available is very small, and hence it is critical that the whole system is highly optimized. This paper presents an investigation into the optimization of inertial energy harvesters for placement at the human foot. Lower body locations have previously been shown to be very energy dense, however previous energy harvester modeling has focused on the lower leg rather than the foot itself for ease of device placement. We show that the typical energy density can be almost double at the foot compared with lower leg positions, with substantially more energy concentrated in a smaller bandwidth. There is thus a dual benefit of placing a harvester at the foot: there is more energy due to the larger movement of the foot, and more efficient (higher Q) harvesters can be used to increase the collected energy. We place these results in context by analyzing the power demands of a typical wearable, and identify that with appropriate harvester tuning the peak current requirements of the electronics can be fitted into the energy peaks generated from each footstep.

Left Ventricular Assist Device Management in the Emergency Department.

The prevalence of patients living with a left ventricular assist device (LVAD) is rapidly increasing due to improvements in pump technology, limiting the adverse event profile, and to expanding device indications. To date, over 22,000 patients have been implanted with LVADs either as destination therapy or as a bridge to transplant. It is critical for emergency physicians to be knowledgeable of current ventricular assist devices (VAD), and to be able to troubleshoot associated complications and optimally treat patients with emergent pathology. Special consideration must be taken when managing patients with VADs including device inspection, alarm interpretation, and blood pressure measurement. The emergency physician should be prepared to evaluate these patients for cerebral vascular accidents, gastrointestinal bleeds, pump failure or thrombosis, right ventricular failure, and VAD driveline infections. Early communication with the VAD team and appropriate consultants is essential for emergent care for patients with VADs.

Profiles in patient safety: emergency care transitions.

A 59-year-old man presented to the emergency department (ED) with the chief complaint of "panic attacks." In total, he was evaluated by 14 faculty physicians, 2 fellows, and 16 residents from emergency medicine, cardiology, neurology, psychiatry, and internal medicine. These multiple transitions were responsible, in part, for the perpetuation of a failure to accurately diagnose the patient's underlying medical illness. The case illustrates the discontinuity of care that occurs at transitions, which may threaten the safety and quality of patient care. Considerable effort must be directed at making transitions effective and safe. Recommendations to improve transitions include a heightened awareness of cognitive biases operating at these vulnerable times, improving team situational awareness and communication, and exploring systems to facilitate effective transfer of relevant data.

Clinical operations in academic emergency medicine.

The operations of an emergency department are increasingly being recognized as vital to the provision of safe, efficient, quality care. The numerous and highly variable processes that characterize our system must be closely examined and investigated to identify those which are effective and those which are not. Original research in this field should be promoted and embraced by our society for both our patients and our profession. Effective operational processes should ultimately be seen as those which preserve and enhance the patient-physician relationship.

Emergency department digital radiology: moving from photos to pixels.

Emergency department (ED) patient care relies heavily on radiologic imaging. As advances in technologic innovation continue to present opportunities to streamline and simplify the delivery of care, emergency medicine (EM) practitioners face the challenge of transitioning from a system of primarily film-based radiography to one that utilizes digitized images. The move to digital radiology can result in enhanced quality of patient care, reduction of errors, and increased ED efficiency; however, making this transition will necessarily involve changes in EM practice. As the technology evolves, digital radiology will gradually become ingrained into everyday practice because of these and other notable benefits; however, EM practitioners will need to overcome several challenges to make the transition smoothly and consider the potential impacts that this change will have on ED workflow. The authors discuss the benefits, challenges, and other operational considerations involved with the ED implementation of digital radiology and close by presenting guiding principles for current and future users. Despite the unresolved issues, digital radiology will mature as a technology and improve EM practice, making it one of the great information technology advances in EM.

Improving interunit transitions of care between emergency physicians and hospital medicine physicians: a conceptual approach.

Patient care transitions across specialties involve more complexity than those within the same specialty, yet the unique social and technical features remain underexplored. Further, little consensus exists among researchers and practitioners about strategies to improve interspecialty communication. This concept article addresses these gaps by focusing on the hand-off process between emergency and hospital medicine physicians. Sensitivity to cultural and operational differences and a common set of expectations pertaining to hand-off content will more effectively prepare the next provider to act safely and efficiently when caring for the patient. Through a consensus decision-making process of experienced and published authorities in health care transitions, including physicians in both specialties as well as in communication studies, the authors propose content and style principles clinicians may use to improve transition communication. With representation from both community and academic settings, similarities and differences between emergency medicine and internal medicine are highlighted to heighten appreciation of the values, attitudes, and goals of each specialty, particularly pertaining to communication. The authors also examine different communication media, social and cultural behaviors, and tools that practitioners use to share patient care information. Quality measures are proposed within the structure, process, and outcome framework for institutions seeking to evaluate and monitor improvement strategies in hand-off performance. Validation studies to determine if these suggested improvements in transition communication will result in improved patient outcomes will be necessary. By exploring the dynamics of transition communication between specialties and suggesting best practices, the authors hope to strengthen hand-off skills and contribute to improved continuity of care.