Search

Computed tomography (CT) imaging has become a first line investigation for most cases of febrile neutropenia (FN) which can be the only sign of infection in oncology patients undergoing active chemotherapy and bone marrow transplants. The utility of routine non-targeted imaging remains unclear. To assess and compare the diagnostic rate between targeted, non-targeted and pan-scan CT in identifying an acute source of infection in adult oncology patients with FN. A retrospective observational study was conducted between February 2019 and March 2023 on 417 consecutive CT examinations for the clinical indication of source identification in FN. Scans were noted for the anatomical regions that were imaged and reports were classified as positive, negative or equivocal for infection. Pre-existing pathology was also noted. Results were tabulated and statistical analyses for comparison between groups of scans was performed using chi-square test. All targeted regional scans had statistically significant difference in positive rate compared to non-targeted scans of the respective region; chest (Χ ²(1)=18.11, P <.001); sinus (Χ ²(1)=15.36, P <.001); abdomen and pelvis (Χ ²(1)=5.95, P =.01). Pneumonia (41.3 %) was much more likely to be the diagnosis compared to sinusitis (16.2 %) in concomitant CT chest to sinus examinations (Χ ²(1)=45.3, P <.001). Pan-scans had a higher incidence of positive diagnosis compared to all-targeted scans (Χ ²(1)=4.91, P =.03) but when compared to higher yield targeted scans (abdomen and chest), there was no statistical difference (Χ ²(1)=2.43, P =.12). 20/54 patients had pan-scans despite having localising symptoms. Imaging guided by presenting signs and symptoms can help to reduce unnecessary imaging and promote more judicious use of non-targeted and pan-scan CT in current practices. [ABSTRACT FROM AUTHOR]

Abstract Iron oxides are promising thermoelectrics, but their high electrical resistivity impedes broader applications. In this work, we have studied Fe oxides with metallic contributions. Pt and Ir additions are also considered to enhance the valence electron concentration and further modify the transport properties. Based on density functional theory explorations, Fe based clusters (Fe 3 , Fe 4 , and Fe 3 Pt) are suggested to act as nucleation sites for metallic crystallites, while O leads to formation of an amorphous matrix. This has been validated by transmission electron microscopy and x-ray photoelectron spectroscopy of sputter-grown Fe-Pt-Ir-O thin films. Densely packed bcc Fe grains, approx. 2–3 nm in diameter, are embedded in an amorphous Fe-O matrix in the as-grown state. The Seebeck coefficient reaches even −411 μV K−1 and the electrical resistivity is up to 5 orders of magnitude lower than that of previously reported literature data on Fe oxides. We suggest that this peculiarity of our films is due to finite states localized at the Fermi level in these nanocomposites. Highlights • Iron oxides with metallic contributions were explored. • Iron based clusters act as nucleation sites for bcc nanograins. • Oxygen leads to formation of an amorphous matrix. • The Seebeck coefficient reaches even −411 μV K−1. • Electrical resistivity is 5 orders of magnitude lower than literature values. [ABSTRACT FROM AUTHOR]

Zusammenfassung Seit Mitte der 80er Jahre erlebt der Sport Snowboarden in Amerika und auch in Europa einen enormen Aufschwung. Auch wenn die Zahl der Snowboarder in den letzten Jahren von 2,2 Millionen in 2014 auf 1,98 Millionen in 2017 [9] zurückging, übt der Sport nach wie vor eine hohe Anziehungskraft vor allem auf junge Wintersportler aus [9]. Die ständige Weiterentwicklung der Sportart und des Materials führt auch zu einer Veränderung des Verletzungsmusters und zu speziellen Charakteristika von snowboard-spezifischen Verletzungen. Ein solches Verletzungsmuster konnte anhand von Studien nachgewiesen werden und lässt sich in ein Verletzungsprofil des Snowboardens zusammenfassen. In dem folgenden Review-Artikel wurde ein Verletzungsprofil der Sportart Snowboarden anhand einer systemischen Literaturrecherche erstellt. Zur Erstellung des Verletzungsprofils wurden verschiedene prospektive und retrospektive, klinische Studien der letzten 20 Jahre im Breitensport untersucht. Es wurden hauptsächlich Studien der Evidenzniveaus I und II untersucht. Aus den untersuchten Studien lässt sich ableiten, dass die Sportart Snowboarden eine höhere Prävalenz von Verletzungen als das alpine Skifahren zeigt. Die oberen Extremitäten sind dabei besonders verletzungsgefährdet. Die häufigste Verletzung stellt mit mehr als 50% aller erlittenen schweren Verletzungen der handgelenknahe Bruch speziell bei Anfängern dar [8]. Dem Einsatz von Helmen zur Prävention von Kopfverletzungen konnte ein positiver Einfluss nachgewiesen werden. Die Prävention umfasst auch die Möglichkeit, Verletzungen durch körperliche Vorbereitung und Snowboardschulung mit Sturztraining vorzubeugen oder Unfallrisiken durch intelligente Pisten-Strategien zu minimieren. Es ist wichtig, dass medizinische Versorger die Sportart Snowboarden und ihre Verletzungsmuster kennen und vorbereitet sind, Snowboard Verletzungen richtig zu bewerten und zu behandeln. Summary Since the 1980s snowboarding gained huge popularity in America as well as in Europe. Even though data show a slow decline of snowboarders in Germany from 2.2 million in 2014 to 1.98 million in 2017 [9], snowboarding still attracts a lot of young winter sport athletes [9]. The constant development of Snowboarding and the equipment leads to a changing injury pattern and distinct characteristics of snowboarding related injuries. Recent studies showed the existence of a distinct injury pattern which can be summarized in an injury profile of snowboarding. Specific injury patterns and characteristics of snowboard-related trauma were identified and are summarized in a snowboard-specific injury profile. The most affected body region reported in a lot of snowboard injury studies are the wrists more than 50% of severe injuries, especially for beginners [8]. Intelligent slope strategies and physical preparation can be realized to minimize the risk of injuries in snowboarding. It is important for medical providers to obtain knowledge about the snowboarding and to be prepared for evaluation and treatment of snowboard injuries. [ABSTRACT FROM AUTHOR]

The housing conditions and environments experienced during the rearing period can influence the development of feather pecking in chickens during this time and in the subsequent laying period. The aim of this study was to investigate the effect of a reduced stocking density and the provision of enrichment materials on the occurrence of feather pecking in hen chicks under commercial rearing conditions. Three groups, identical in age, laying strain, and management but kept with different stocking densities and varying availability of enrichment (pecking stone, pecking block, and lucerne bale), were observed. Group 1 had a high stocking density (22.9 animals per m 2 ) and no access to enrichment, group 2 had a lower stocking density (18.1 animals per m 2 ) plus enrichment, and group 3 had a high stocking density (22.9 animals per m 2 ) plus the same enrichment as group 2. Behavioral observations from video recordings were made on the occurrence of enrichment pecking, gentle feather pecking (GFP), severe feather pecking (SFP), and aggressive pecking. Furthermore, the influence of enrichment pecking on the occurrence of GFP, SFP, and aggressive pecking and the effect of SFP on the plumage condition were examined. The comparison of the 2 groups with enrichment demonstrated that the group with the higher stocking density showed a higher rate of SFP (95% confidence interval [CI] for the difference: [0.001-0.015]). The comparison of the 2 groups with and without enrichment but with equal stocking densities showed that the group with access to enrichment had significantly lower rates of GFP (95% CI: −0.019 to −0.006), SFP (95% CI: −0.036 to −0.020), and aggressive pecking (95% CI: −0.004 to −0.001). The group with a combination of a lower stocking density and enrichment had significantly lower rates of GFP (95% CI: −0.022 to −0.009), SFP (95% CI: −0.044 to −0.028), and aggressive pecking (95% CI: −0.004 to −0.001) compared to the group with a high stocking density without enrichment. Additionally, the occurrence of enrichment pecking had a significantly reducing effect on the occurrence of GFP (95% CI: −0.046 to −0.031), SFP (95% CI: −0.030 to −0.016), and aggressive pecking (95% CI: −0.003 to −0.0003). Finally, a high rate of SFP had a deteriorating effect on the plumage condition (95% CI: −0.859 to −0.084). Thus, we conclude that a lower stocking density and the provision of enrichment, such as pecking stones, pecking blocks, and lucerne bales, can reduce the prevalence of feather pecking and aggressive pecking in laying hen chicks. The evaluation of the plumage condition can be a valid indicator of feather pecking. [ABSTRACT FROM AUTHOR]

In modern meat production, broiler chickens are usually barn raised in deep litter where a special structured environment is typically not intended. Natural behaviors of the domestic fowl, such as running freely, pecking, scratching, flapping wings, grooming plumage, resting and sleeping undisturbed, can be restricted by lack of opportunities. Additional welfare concerns in industrial poultry farming are high stocking densities and genetic traits. Consumer surveys show an increasing public awareness of problems in livestock farming and the willingness to make a difference by spending more money on food coming from animal-friendly production. For this segment, the market offers organically produced products at higher costs, whereas the possibility for an intermediate product that meets animal welfare, consumer requirements, and economic aspects has barely been used. By increasing the environmental complexity with the provision of perches (15.9 m per 1000 birds), straw bales (1.7 per 1000 birds), pecking stones (1.1 per 1000 birds) and access to a roofed outside run (624 m 2 ) and by using a reduced stocking density (16 birds per m 2 ) and selecting Cobb Sasso 175 as a slower-growing broiler strain, we intended to improve bird welfare. We therefore established, tested, and scientifically evaluated an alternative rearing concept for broiler chickens on its way to market suitability. In addition, a conventional farm with Ross 308 broilers reared at a stocking density of 23 birds per m 2 was evaluated for comparison. The study included 6 rearing periods per concept and an additional 2 rearing periods with the broiler strain Ross 308 under the alternative concept. For the behavioral observations, video recordings were carried out simultaneously in both barns during all rearing periods in a weekly 24-hour interval. Results show that Cobb Sasso broilers reared with the alternative concept were more active during the observation intervals than conventionally reared Ross 308 broilers. The provided enrichment was well accepted and used. The straw bales were used as shelter for resting behavior during the early rearing phase and later as pecking objects and elevated resting areas. Perches were used as of day 9. The provision of environmental enrichment in broiler rearing can stimulate species-specific behaviors and therefore can increase animal welfare while meeting consumer requirements in an economic way. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate the activity patterns of American mink ( Neovison vison ). Twenty mink from a commercial mink farm were housed in a free-range enclosure (290 m 2 ) at the age of 13 weeks. In the enclosure, the mink were offered 20 nest boxes (animal-to-nest-box ratio: 1:1), food ad libitum , and 3 kinds of water basins. The activity rhythms and the use of the nest boxes were assessed by an automatic registration device that recorded the amount of time spent inside or outside the nest box or in the entrance tunnel for each individual mink over a period of 18 weeks between July and December. In addition to analyzing the mink's daily and seasonal activity patterns, we sought to detect any social preferences or preferences for individual nest boxes. Results showed that the mink had crepuscular activity patterns with 2 activity peaks during dusk and dawn and that the former shifted when the daylight period shortened. Throughout the experiment, the activity time spent outside the nest boxes declined with increasing age and decreasing ambient temperature. In addition, the mink showed a preference for nest boxes that faced the feeding lots and not the water basins. During sleep and rest periods, the mink spent high amounts of time using the nest boxes in company. Furthermore, the mink structured their own habitat by using certain nest boxes for sleeping and others as latrine boxes. Small differences between male and female mink existed in their activity (i.e., time spent inside or outside nest boxes) but not in their preference for certain nest boxes or other individuals. Based on our results, any environmental enrichment item should be presented all day long, so each mink has the opportunity to use them individually during their main activity times mostly at dusk and dawn, and their daily handling should be adjusted to this rhythm. A mink-to-nest-box ratio of 1:1 does not seem necessary as juvenile mink often slept in groups of 2 or more animals in 1 nest box. Furthermore, the animals should be given the opportunity to distinguish between a sleeping and a latrine area. [ABSTRACT FROM AUTHOR]

Iron is a redox-activemetal required as a cofactor in multiple metalloproteins essential for a host of life processes. The metal is highly toxic when present in excess and must be strictly regulated to prevent tissue and organ damage. Hepcidin, amolecule first characterized as an antimicrobial peptide, plays a critical role in the regulation of iron homeostasis. Multiple stimuli positively influence the expression of hepcidin, including iron, inflammation, and infection by pathogens. In this Minireview, I will discuss how inflammation regulates hepcidin transcription, allowing for sufficient concentrations of iron for organismal needs while sequestering the metal from infectious pathogens. [ABSTRACT FROM AUTHOR]

Objective: Congenital heart valve disease is one of the most common abnormalities in children. There are limited technological solutions available for treating children with congenital heart valve diseases. The aim of this study is to provide the details of the consensus reached in terms of pediatric definitions, design approach, in vitro testing, and clinical trials, which may be used as guidance for developing prosthetic heart valves for the pediatric indication. Methods: In stark contrast to the various designs of adult-sized replacement valves available in the market, there are no Food and Drug Administration (FDA)–approved prosthetic heart valves available for use in the pediatric population. There is a pressing need for FDA-approved pediatric valve devices in the United States. The pediatric patient population has been typically excluded from replacement heart valve trials for several reasons. In January 2010, heart valve manufacturers and pediatric clinicians collaborated with academicians and FDA staff in a workshop to suggest ways to successfully evaluate pediatric prosthetic valves and conduct pediatric clinical trials to provide acceptable heart valve replacement options for this patient population. Results: Recommendations, derived from ISO 5840:2005 and the 2010 FDA Draft Replacement Heart Valve Guidance, are provided for hydrodynamic, durability, and fatigue testing. Conclusions: The article specifically addresses in vitro and premarket and postmarket approval clinical studies that should be considered by a heart valve manufacturer for obtaining regulatory approval of pediatric sizes of prosthetic heart valve designs that are already approved for adult clinical use. [Copyright &y& Elsevier]

Summary: Red blood cell production is a finely tuned process that requires coordinated oxygen- and iron-dependent regulation of cell differentiation and iron metabolism. Here, we show that translational regulation of hypoxia-inducible factor 2α (HIF-2α) synthesis by iron regulatory protein 1 (IRP1) is critical for controlling erythrocyte number. IRP1-null (Irp1 −/−) mice display a marked transient polycythemia. HIF-2α messenger RNA (mRNA) is derepressed in kidneys of Irp1 −/− mice but not in kidneys of Irp2 −/− mice, leading to increased renal erythropoietin (Epo) mRNA and inappropriately elevated serum Epo levels. Expression of the iron transport genes DCytb, Dmt1, and ferroportin, as well as other HIF-2α targets, is enhanced in Irp1 −/− duodenum. Analysis of mRNA translation state in the liver revealed IRP1-dependent dysregulation of HIF-2α mRNA translation, whereas IRP2 deficiency derepressed translation of all other known 5′ iron response element (IRE)-containing mRNAs expressed in the liver. These results uncover separable physiological roles of each IRP and identify IRP1 as a therapeutic target for manipulating HIF-2α action in hematologic, oncologic, and other disorders. [ABSTRACT FROM AUTHOR]

Summary: Adult humans have about 25 trillion red blood cells (RBCs), and each second we recycle about 5 million RBCs by erythrophagocytosis (EP) in macrophages of the reticuloendothelial system. Despite the central role for EP in mammalian iron metabolism, the molecules and pathways responsible for heme trafficking during EP remain unknown. Here, we show that the mammalian homolog of HRG1, a transmembrane heme permease in C. elegans, is essential for macrophage iron homeostasis and transports heme from the phagolysosome to the cytoplasm during EP. HRG1 is strongly expressed in macrophages of the reticuloendothelial system and specifically localizes to the phagolysosomal membranes during EP. Depletion of Hrg1 in mouse macrophages causes attenuation of heme transport from the phagolysosomal compartment. Importantly, missense polymorphisms in human HRG1 are defective in heme transport. Our results reveal HRG1 as the long-sought heme transporter for heme-iron recycling in macrophages and suggest that genetic variations in HRG1 could be modifiers of human iron metabolism. [ABSTRACT FROM AUTHOR]

Paul Schmidt was born in 1925 into the Greatest Generation. Events during military service decided him on the study of medicine. Early research training in red cell preservation that continued during his medical studies opened a 20-year career at the National Institutes of Health (NIH). Beginning in 1954 at the Blood Bank of the NIH Clinical Center, he had exposure to the pioneers who had translated transfusion''s wartime beginnings into civilian applications. Work inside the unique NIH clinical research atmosphere together with many of his students provided a fertile field for the growth of what has become transfusion medicine. Topics described range from early studies on platelets and on hepatitis to the background in Washington health politics leading to the National Blood Policy. National and global organizational activity and a second career in community blood service added to his 65 years of experience. The story as transfusion history is presented as a template for future progress. [Copyright &y& Elsevier]

The politics of health were never tested more than when AIDS surfaced at the beginning of the 1980s in the industrialized nations. In those countries, it became the most important medical crisis of the last half of the 20th century. Today, the significance of AIDS remains as not only an unrelenting disease but also as a disease that continues to affect social and political life throughout the entire world. The connection between blood transfusion and AIDS is now under control in the industrialized countries but only because of lessons that took too long to learn over the past 25 years. That process had different roots and effects depending on the various national blood programs and policies in different countries. That is illustrated by comparing events in France, Japan, Canada, and the United States that differed in donor and patient populations and on decisions made and secrets kept. Some of the problems persist to this day in parts of the world. Overall, the lessons learned from what happened with blood early in the AIDS epidemic apply to other aspects of human disease and could help in facing the new problems that are sure to appear in the future. [Copyright &y& Elsevier]

Background & Aims: Abnormal hepcidin regulation is central to the pathogenesis of HFE hemochromatosis. Hepatic bone morphogenetic protein 6 (BMP6)–SMAD signaling is a main regulatory mechanism controlling hepcidin expression, and this pathway was recently shown to be impaired in Hfe knockout (Hfe −/− ) mice. To more definitively determine whether HFE regulates hepcidin expression through an interaction with the BMP6-SMAD signaling pathway, we investigated whether hepatic Hfe overexpression activates the BMP6-SMAD pathway to induce hepcidin expression. We then investigated whether excess exogenous BMP6 administration overcomes the BMP6-SMAD signaling impairment and ameliorates hemochromatosis in Hfe −/− mice. Methods: The BMP6-SMAD pathway and the effects of neutralizing BMP6 antibody were examined in Hfe transgenic mice (Hfe Tg) compared with wild-type (WT) mice. Hfe −/− and WT mice were treated with exogenous BMP6 and analyzed for hepcidin expression and iron parameters. Results: Hfe Tg mice exhibited hepcidin excess and iron deficiency anemia. Hfe Tg mice also exhibited increased hepatic BMP6-SMAD target gene expression compared with WT mice, whereas anti-BMP6 antibody administration to Hfe Tg mice improved the hepcidin excess and iron deficiency. In Hfe −/− mice, supraphysiologic doses of exogenous BMP6 improved hepcidin deficiency, reduced serum iron, and redistributed tissue iron to appropriate storage sites. Conclusions: HFE interacts with the BMP6-SMAD signaling pathway to regulate hepcidin expression, but HFE is not necessary for hepcidin induction by BMP6. Exogenous BMP6 treatment in mice compensates for the molecular defect underlying Hfe hemochromatosis, and BMP6-like agonists may have a role as an alternative therapeutic strategy for this disease. [ABSTRACT FROM AUTHOR]

Abstract: The ancient therapy of bloodletting that was universal in the West traveled to Japan 500years ago on the trading vessels that carried physicians and barber-surgeons to care for the body and Christian missionaries to care for the soul. Then bloodletting was replaced by blood transfusion in the 19th century, only to return less than 50years ago as apheresis. An understanding of those transitions can be gained from the story of the introduction of Western medicine to Japan and the events that have led to the practice of apheresis there today. [Copyright &y& Elsevier]

Although history states correctly that Bernard Fantus coined the name “blood bank” in Chicago in 1937, his was only one of many contributions of Midwest America to the new therapy of blood transfusion. Chicago was at the center of the movement before and after then, anticipating the modern era with the first practical method for direct donor-to-recipient transfusion and staging a secret clinical trial of cadaver blood. That successful trial of cadaver blood may have presaged the first functional cadaver kidney transplant, performed at the same hospital several years later. Modern-day technologies for blood collection, transfusion, and safety testing also have many roots in Chicago. [Copyright &y& Elsevier]

Summary: Hemochromatosis is caused by mutations in HFE, a protein that competes with transferrin (TF) for binding to transferrin receptor 1 (TFR1). We developed mutant mouse strains to gain insight into the role of the Hfe/Tfr1 complex in regulating iron homeostasis. We introduced mutations into a ubiquitously expressed Tfr1 transgene or the endogenous Tfr1 locus to promote or prevent the Hfe/Tfr1 interaction. Under conditions favoring a constitutive Hfe/Tfr1 interaction, mice developed iron overload attributable to inappropriately low expression of the hormone hepcidin. In contrast, mice carrying a mutation that interferes with the Hfe/Tfr1 interaction developed iron deficiency associated with inappropriately high hepcidin expression. High-level expression of a liver-specific Hfe transgene in Hfe−/− mice was also associated with increased hepcidin production and iron deficiency. Together, these models suggest that Hfe induces hepcidin expression when it is not in complex with Tfr1. [Copyright &y& Elsevier]

The first president of the Society for Cryobiology was a Roman Catholic priest born in a mountain village in Switzerland. Basile J. Luyet immigrated to the United States in 1929 with doctorates in biology and in physics and then devoted his life to studies described best by the title of his early monograph “Life and Death at Low Temperatures.” Established in the faculty at St. Louis University, he pursued studies on living matter in the cold that in midcareer led to efforts to vitrify red cells by ultrarapid cooling. As a purist who wanted to vitrify living matter without the assistance of cryoprotectant additives, he did not succeed with red cells. However, his 40 years of exploration of the biology of the cold joined physical chemistry with biology and made cryobiology into a new branch of scientific thought. A very formal man, he served both his God and his science with the dictum that “truth does not contradict truth.” His contributions are preserved in the knowledge and wisdom that he created and in the memory of the people of the Alpine village of his birth. [Copyright &y& Elsevier]

Background & Aims The National Early Warning Score (NEWS) is used to identify deteriorating adult hospital inpatients. However, it includes physiological parameters frequently altered in patients with cirrhosis. We aimed to assess the performance of the NEWS in acute and chronic liver diseases. Methods We collected vital signs, recorded in real time, from completed consecutive admissions of patients 16 years or older to a large acute-care hospital in Southern England, from January 1, 2010, through October 31, 2014. Using International Classification of Diseases, 10th revision, codes, we categorized patients as having primary liver disease, secondary liver disease, or none. For patients with liver disease, 2 analysis groups were developed: the first was based on clinical group (such as acute or chronic, alcohol-induced, or associated with portal hypertension), and the second was based on a summary of liver-related, hospital-level mortality indicator diagnoses. For each, we compared the abilities of the NEWS and 34 other early warning scores to discriminate 24-hour mortality, cardiac arrest, or unanticipated admission to the intensive care unit using the area under the receiver operating characteristic (AUROC) curve and early warning score efficiency curve analyses. Results The NEWS identified patients with primary, nonprimary, and no diagnoses of liver disease with AUROC values of 0.873 (95% CI, 0.860–0.886), 0.898 (95% CI, 0.891–0.905), and 0.879 (95% CI, 0.877–0.881), respectively. High AUROC values were also obtained for all clinical subgroups; the NEWS identified patients with alcohol-related liver disease with an AUROC value of 0.927 (95% CI, 0.912–0.941). The NEWS identified patients with liver diseases with higher AUROC values than other early warning scoring systems. Conclusions The NEWS accurately discriminates patients at risk of death, admission to the intensive care unit, or cardiac arrest within a 24-hour period for a range of liver-related diagnoses. Its widespread use provides a ready-made, easy-to-use option for identifying patients with liver disease who require early assessment and intervention, without the need to modify parameters, weightings, or escalation criteria. [ABSTRACT FROM AUTHOR]

Abstract: Aim of study: To develop a validated, paper-based, aggregate weighted track and trigger system (AWTTS) that could serve as a template for a national early warning score (EWS) for the detection of patient deterioration. Materials and methods: Using existing knowledge of the relationship between physiological data and adverse clinical outcomes, a thorough review of the literature surrounding EWS and physiology, and a previous detailed analysis of published EWSs, we developed a new paper-based EWS – VitalPAC™ EWS (ViEWS). We applied ViEWS to a large vital signs database (n =198,755 observation sets) collected from 35,585 consecutive, completed acute medical admissions, and also evaluated the comparative performance of 33 other AWTTSs, for a range of outcomes using the area under the receiver-operating characteristics (AUROC) curve. Results: The AUROC (95% CI) for ViEWS using in-hospital mortality with 24h of the observation set was 0.888 (0.880–0.895). The AUROCs (95% CI) for the 33 other AWTTSs tested using the same outcome ranged from 0.803 (0.792–0.815) to 0.850 (0.841–0.859). ViEWS performed better than the 33 other AWTTSs for all outcomes tested. Conclusions: We have developed a simple AWTTS – ViEWS – designed for paper-based application and demonstrated that its performance for predicting mortality (within a range of timescales) is superior to all other published AWTTSs that we tested. We have also developed a tool to provide a relative measure of the number of “triggers” that would be generated at different values of EWS and permits the comparison of the workload generated by different AWTTSs. [Copyright &y& Elsevier]

Summary: Objectives: There is no up-to-date literature review of physiologically-based, single-parameter weighted “track and trigger” systems (SPTTS) and little data on their sensitivity and specificity to predict adverse outcomes. The aim of this study was to describe the SPTTS in clinical use and measure their sensitivity and specificity when using admission vital signs data for predicting in-hospital mortality. Materials and methods: We performed a systematic review of the literature to describe the SPTTS, their components and their differences. We measured their sensitivity and specificity for predicting in-hospital mortality when using a database of 9987 admission vital signs datasets. Results: We identified 39 unique classes of SPTTS, of which 30 were evaluated. There was considerable variation in the physiological variables used, together with significant variation in the physiological values used to trigger a medical emergency or critical care outreach team. There was marked variation in sensitivity (7.3–52.8%), specificity (69.1–98.1%), positive predictive values (13.5–26.1%), negative predictive values (92.1–94.2%) and the potential number of calls triggered (234–3271). Conclusions: There is a wide range of unique, but very similar, SPTTS in clinical use. Although specificities were high, sensitivities were too low to provide institutions with confidence that these SPTTS could identify patients at risk of in-hospital death using admission vital signs. Institutions may wish to consider these data when selecting which, if any, single-parameter track and trigger systems to introduce. [Copyright &y& Elsevier]

Summary: Aim of study: Few published “track and trigger systems” used to identify sick adult patients incorporate patient age as a variable. We investigated the relationship between vital signs, patient age and in-hospital mortality and investigated the impact of patient age on the function as predictors of in-hospital mortality of the two most commonly used track and trigger systems. Materials and methods: Using a database of 9987 vital signs datasets, we studied the relationship between admission vital signs and in-hospital mortality for a range of selected vital signs, grouped by patient age. We also used the vital signs data set to study the impact of patient age on the relationship between patient triggers using the “MET criteria” and “MEWS”, and in-hospital mortality. Results: At hospital discharge, there were 9152 (91.6%) survivors and 835 (8.4%) non-survivors. As admission vital signs worsened, mortality increased for each age range. Where groups of patients had triggered a certain MET criterion, mortality was higher as patient age increased. Mortality varied significantly with age (p <0.05; Fishers exact test) for breathing rate >36breathsmin−1, systolic BP<90mmHg and decreased conscious level. For each age group, mortality also increased as total MEWS score increased. As the number of simultaneously occurring MEWS abnormalities, or simultaneously occurring MET criteria, increased, mortality increased for each age range. Conclusions: Age has a significant impact on in-hospital mortality. Our data suggest that the inclusion of age as a component of these systems could be advantageous in improving their function. [Copyright &y& Elsevier]

Summary: Objectives: There is no up-to-date literature review of physiologically based, aggregate weighted ‘track and trigger’ systems (AWTTS) and few data on their predictive ability for serious adverse outcomes. The aim of this study was to describe the AWTTS in clinical use and assess their ability to discriminate between survivors and non-survivors of hospital admission, based on an initial set of vital signs. Materials and methods: A systematic review of the literature was performed, to describe the AWTTS, their components and their differences. Their ability to discriminate between survivors and non-survivors was evaluated using the area under the receiver-operating characteristics (AUROC) curve, and a database of 9987 vital signs datasets. Results: A total of 33 unique AWTTS were identified with AUROC (±95% CI) ranging from 0.657 (0.636–0.678) to 0.782 (0.767–0.797). 12 AWTTS (36%) discriminated reasonably well between survivors and non-survivors, the top four performing AWTTS incorporated age as a component (AUROCs ranging from 0.722 to 0.782). The top two systems also incorporated temperature. Conclusions: There is a wide range of unique, but very similar, AWTTS in clinical use. There is no consistency regarding their physiological components, but the majority differ only in minor variations in the weightings for physiological derangement and/or the cut-off points between physiological weighting bands. The performance of most systems tested was poor when used to discriminate between survivors and non-survivors, although 36% discriminated reasonably well. Our results suggest that physiology can be used to predict outcome, but that further work is required to improve the AWTTS models. [Copyright &y& Elsevier]

Summary: Hospitalised patients, who suffer cardiac arrest and require unanticipated intensive care unit (ICU) admission or die, often exhibit premonitory abnormalities in vital signs. Sometimes, the deterioration is well documented, though there is little discernable evidence of intervention. In other cases, monitoring and recording of vital signs is infrequent or incomplete. Healthcare providers have introduced “track and trigger” systems to allow early identification of patients with physiological abnormalities, and rapid response teams to facilitate rapid and appropriate management. However, even when “track and trigger” systems are used, the recording of vital signs, patient chart completion and team activation remain sub-optimal. We have developed a system for collecting routine vital signs data at the bedside using standard personal digital assistants (PDA). The PDAs act as “thin clients” linked by a wireless local area network (W-LAN) to the hospital''s intranet system, where raw and derived data are integrated with other patient information, e.g., name, hospital number, laboratory results. It is possible for raw physiology data, early warning scores (EWS), vital signs charts and oxygen therapy records to be made instantaneously available to any member of the hospital healthcare team via the W-LAN or hospital intranet. Early and direct contact with members of the patient''s primary clinical team or rapid response team can be made through an automated alerting system, triggered by the EWS data. The ability to capture physiological data at the bedside, and to make these available to anyone with appropriate access rights at any time and in any place, should provide previously unattainable, clinical and administrative benefits. Analysis of the raw physiological data and patient outcomes will also make it possible to validate existing and future “track and trigger” systems. [Copyright &y& Elsevier]

Summary: To assist in the early detection of critical illness, many hospitals now use a “track and trigger” system that allocates points to routine vital signs measurements on the basis of their derangement from an arbitrarily agreed “normal” range. These points are summed to provide an early warning score (EWS). Little is known about the accuracy with which EWS are calculated and charted. We compared the speed and accuracy of charting the weighted value attributed to each vital sign, and of calculating the EWS, using the traditional pen and paper method with that using a specially programmed, personal digital assistant (VitalPAC™). Incorrect entries or omissions occurred in 24 (29%) of 84 EWS computed using pen/paper compared to 8 (10%) computed using the VitalPAC™ method. Fewer incorrect clinical actions were indicated using EWS derived via the VitalPAC™ method (4/84, 5%) than from those calculated using pen/paper (12/84, 14%). The mean time (±S.D.) taken for participants to calculate and chart a set of weighted values and EWS using the pen/paper method was 67.6±35.3s (n =84). The corresponding time taken to enter a set of physiological data using the VitalPAC™ was 43.0±23.5s (n =84). By comparison with the conventional pen/paper method, the use of VitalPAC™ was on average 1.6-times faster. The use of a device such as VitalPAC™ offers significant advantages both in speed and accuracy of recording of EWS. [Copyright &y& Elsevier]