Remote wireless vital signs monitoring on the ward for early detection of deteriorating patients: A case series.

INTRODUCTION: Remote wireless monitoring is a new technology that allows the continuous recording of ward patients' vital signs, supporting nurses by measuring vital signs frequently and accurately. A case series is presented to illustrate how these systems might contribute to improved patient surveillance. METHODS AND RESULTS: Five hospitals in three European countries installed a remote wireless vital signs monitoring system on medical or surgical wards. Heart rate, respiratory rate and temperature were measured by the system every 2 min. Four cases of (paroxysmal) atrial fibrillation are presented, two cases of sepsis and one case each of pyrexia, cardiogenic pulmonary edema and pulmonary embolisms. All cases show that the remote monitoring system revealed the first signs of ventilatory and circulatory deterioration before a change in the trends of the respective values became obvious by manual vital signs measurement. DISCUSSION: This case series illustrates that a wireless remote vital signs monitoring system on medical and surgical wards has the potential to reduce time to detect deteriorating patients.

Cytochrome P450 1D1: a novel CYP1A-related gene that is not transcriptionally activated by PCB126 or TCDD.

Enzymes in the cytochrome P450 1 family oxidize many common environmental toxicants. We identified a new CYP1, termed CYP1D1, in zebrafish. Phylogenetically, CYP1D1 is paralogous to CYP1A and the two share 45% amino acid identity and similar gene structure. In adult zebrafish, CYP1D1 is most highly expressed in liver and is relatively highly expressed in brain. CYP1D1 transcript levels were higher at 9h post-fertilization than at later developmental times. Treatment of zebrafish with potent aryl hydrocarbon receptor (AHR) agonists (3,3',4,4',5-pentachlorobiphenyl or 2,3,7,8-tetrachlorodibenzo-p-dioxin) did not induce CYP1D1 transcript expression. Morpholino oligonucleotide knockdown of AHR2, which mediates induction of other CYP1s, did not affect CYP1D1 expression. Zebrafish CYP1D1 heterologously expressed in yeast exhibited ethoxyresorufin- and methoxyresorufin-O-dealkylase activities. Antibodies against a CYP1D1 peptide specifically detected a single electrophoretically-resolved protein band in zebrafish liver microsomes, distinct from CYP1A. CYP1D1 in zebrafish is a CYP1A-like gene that could have metabolic functions targeting endogenous compounds.

Environmental sensing and response genes in cnidaria: the chemical defensome in the sea anemone Nematostella vectensis.

The starlet sea anemone Nematostella vectensis has been recently established as a new model system for the study of the evolution of developmental processes, as cnidaria occupy a key evolutionary position at the base of the bilateria. Cnidaria play important roles in estuarine and reef communities, but are exposed to many environmental stressors. Here, I describe the genetic components of a "chemical defensome" in the genome of N. vectensis and review cnidarian molecular toxicology. Gene families that defend against chemical stressors and the transcription factors that regulate these genes have been termed a chemical defensome and include the cytochromes P450 and other oxidases, various conjugating enyzymes, the ATP-dependent efflux transporters, oxidative detoxification proteins, as well as various transcription factors. These genes account for about 1% (266/27,200) of the predicted genes in the sea anemone genome, similar to the proportion observed in tunicates and humans, but lower than that observed in sea urchins. While there are comparable numbers of stress-response genes, the stress sensor genes appear to be reduced in N. vectensis relative to many model protostomes and deuterostomes. Cnidarian toxicology is understudied, especially given the important ecological roles of many cnidarian species. New genomic resources should stimulate the study of chemical stress sensing and response mechanisms in cnidaria and allow us to further illuminate the evolution of chemical defense gene networks.

The chemical defensome: environmental sensing and response genes in the Strongylocentrotus purpuratus genome.

Metazoan genomes contain large numbers of genes that participate in responses to environmental stressors. We surveyed the sea urchin Strongylocentrotus purpuratus genome for homologs of gene families thought to protect against chemical stressors; these genes collectively comprise the 'chemical defensome.' Chemical defense genes include cytochromes P450 and other oxidases, various conjugating enzymes, ATP-dependent efflux transporters, oxidative detoxification proteins, and transcription factors that regulate these genes. Together such genes account for more than 400 genes in the sea urchin genome. The transcription factors include homologs of the aryl hydrocarbon receptor, hypoxia-inducible factor, nuclear factor erythroid-derived 2, heat shock factor, and nuclear hormone receptors, which regulate stress-response genes in vertebrates. Some defense gene families, including the ABCC, the UGT, and the CYP families, have undergone expansion in the urchin relative to other deuterostome genomes, whereas the stress sensor gene families do not show such expansion. More than half of the defense genes are expressed during embryonic or larval life stages, indicating their importance during development. This genome-wide survey of chemical defense genes in the sea urchin reveals evolutionary conservation of this network combined with lineage-specific diversification that together suggest the importance of these chemical stress sensing and response mechanisms in early deuterostomes. These results should facilitate future studies on the evolution of chemical defense gene networks and the role of these networks in protecting embryos from chemical stress during development.

The pulmonary physician in critical care. 10: difficult weaning.

The study of patients being weaned from mechanical ventilation has offered new insights into the physiology of respiratory failure. Assessment of the balance between respiratory muscle strength, work and central drive is essential if difficulty in weaning occurs, and optimisation of these elements may improve the success of weaning. Psychological support of patients and the creation of units specialising in weaning have also resulted in a higher success rate.

Reactions of hydroxyl radical with humic substances: bleaching, mineralization, and production of bioavailable carbon substrates.

In this study, we examine the role of the hydroxyl (OH*) radical as a mechanism for the photodecomposition of chromophoric dissolved organic matter (CDOM) in sunlit surface waters. Using gamma-radiolysis of water, OH* was generated in solutions of standard humic substances in quantities comparable to those produced on time scales of days in sunlit surface waters. The second-order rate coefficients of OH* reaction with Suwannee River fulvic (SRFA; 2.7 x 10(4) s(-1) (mg of C/L)(-1)) and humic acids (SRHA; 1.9 x 10(4) s(-1) (mg of C/L)(-1)) are comparable to those observed for DOM in natural water samples and DOM isolates from other sources but decrease slightly with increasing OH* doses. OH* reactions with humic substances produced dissolved inorganic carbon (DIC) with a high efficiency of approximately 0.3 mol of CO2/mol of OH*. This efficiency stayed approximately constant from early phases of oxidation until complete mineralization of the DOM. Production rates of low molecular weight (LMW) acids including acetic, formic, malonic, and oxalic acids by reaction of SRFA and SRHA with OH* were measured using HPLC. Ratios of production rates of these acids to rates of DIC production for SRHA and for SRFA were similar to those observed upon photolysis of natural water samples. Bioassays indicated that OH* reactions with humic substances do not result in measurable formation of bioavailable carbon substrates other than the LMW acids. Bleaching of humic chromophores by OH* was relatively slow. Our results indicate that OH* reactions with humic substances are not likely to contribute significantly to observed rates of DOM photomineralization and LMW acid production in sunlit waters. They are also not likely to be a significant mechanism of photobleaching except in waters with very high OH* photoformation rates.

Diagnosis and management of aortoenteric fistulas.

Development of an aortoenteric fistula (AEF) is a devastating and life-threatening condition, which is as difficult to diagnose as it is to treat. Fortunately, it is rare, most commonly seen as a delayed complication of aortic reconstruction. Two types are recognized: primary and secondary. Primary fistulas occur de novo between the aorta and bowel, most commonly duodenum. Secondary fistulas occur between an aortic graft and segment of bowel. Diagnosis of AEF requires a high index of suspicion in patients who present with either signs of infection or gastrointestinal hemorrhage. Early diagnosis is essential for a successful outcome because of the lethal nature of AEF. Symptomatology can be varied but most often includes signs of infection and of gastrointestinal bleeding. Esophagogastroduodenoscopy (EGD) and computed tomography (CT) scans are the most useful tests to diagnose AEF. Treatment almost always requires excision of the infected graft and revascularization. Placement of an extra anatomic bypass, followed by graft excision, has been the usual treatment. Recent experience with in situ revascularization has shown that a variety of materials can be use for in situ reconstruction with good results. Morbidity and mortality rates still are high even in contemporary series. The mortality rate still is approximately 33%, but amputation rates have been reduced to less then 10%. Care of patients with AEF requires timely control of bleeding and infection followed by vascular reconstruction performed in a manor to minimize physiological stress.

Medical repatriation via fixed-wing air ambulance: a review of patient characteristics and adverse events.

Anaesthetists are often employed as medical escorts for patients undergoing international transfer by air ambulance. There is little published data on the types of patients being transferred and on the incidence of adverse events. We performed a retrospective review of the documentation of all air ambulance transfers performed by a single company over a 2-year period followed by a prospective assessment of all high-risk patients transferred over a 1-year period. Of 483 transfers identified, 47% were defined as high-risk and 20% were of patients receiving mechanical ventilation. In the prospective group, 28% of patients required pretransfer optimisation, 7% required a major therapeutic intervention during transfer and there was a major adverse event in 12% of transfers. There were two deaths during transport. These data support the recommendation that escorting personnel should be from an appropriate speciality, have reasonable seniority and be adequately trained and supervised.

A quantum adiabatic evolution algorithm applied to random instances of an NP-complete problem.

A quantum system will stay near its instantaneous ground state if the Hamiltonian that governs its evolution varies slowly enough. This quantum adiabatic behavior is the basis of a new class of algorithms for quantum computing. We tested one such algorithm by applying it to randomly generated hard instances of an NP-complete problem. For the small examples that we could simulate, the quantum adiabatic algorithm worked well, providing evidence that quantum computers (if large ones can be built) may be able to outperform ordinary computers on hard sets of instances of NP-complete problems.

Aortic aneurysm resulting from umbilical artery catheterization: case report, literature review, and management algorithm.

Aortic aneurysms in infants and children are quite rare. The use of umbilical artery catheters in the management of critically ill neonates has been associated with infection and subsequent aneurysm formation. There have been 46 cases reported (including our own); most of the aneurysms have been located in the abdominal aorta and have displayed saccular morphology. Through an analysis of the literature, we identified two factors that had significant correlation with improved survival: diagnosis before surgery and surgical repair (P <.05). This report presents the case of a 23-day-old neonate with an abdominal aortic aneurysm and hypertension. On the basis of our literature review, we offer a management algorithm for this rare but very serious complication of umbilical artery catheterization.

Changes in cerebral blood volume with changes in position in awake and anesthetized subjects.

UNLABELLED: Changes in posture affect cerebral blood volume (CBV), and moderate head-up tilt is used as a therapeutic maneuver to reduce CBV and intracranial pressure. However, CBV is rarely measured in the clinical setting. Near-infrared spectroscopy allows real-time bedside monitoring of cerebral hemodynamics, and we have used this technique to measure changes in CBV with changes in posture in 10 normal subjects and 10 propofol-anesthetized patients. In the awake subjects, changes in CBV were correlated with the degree of table tilt. CBV decreased with 18 degrees head-up tilt and increased with 18 degrees head-down tilt (P < 0.0001, r = -0.924). In anesthetized patients, there were differences between head-up and head-down tilt. In the head-down position, CBV was also correlated with the degree of table tilt (P < 0.001, r = -0.782), whereas there was a clinically insignificant reduction in CBV in the head-up position. Near-infrared spectroscopy allows continuous, real time measurement of changes in CBV at the bedside. IMPLICATIONS: Near-infrared spectroscopy, a bedside technique, has been used to measure changes in cerebral blood volume in normal subjects. We have used the same technique in anesthetized patients and have shown that, when a patient is placed in the head up position, the decrease in cerebral blood volume is attenuated, relative to normal subjects.

An in vivo comparison of a catheter mounted pressure transducer system with conventional balloon catheters.

In the assessment of respiratory muscle function balloon catheters have been widely used for pressure measurements. However, this type of investigation is poorly tolerated by acutely ill patients. This study assessed the performance of a possible alternative, a catheter-mounted miniature pressure transducer (CMT). The assessment consisted of a laboratory study of the linearity, frequency response, and stability of gain and baseline of the CMT system, and an in vivo study directly comparing the CMT and balloon catheter systems in seven normal subjects for a range of respiratory manoeuvres. These were: 1) maximal inspiratory and expiratory pressures against a closed airway, 2) twitch transdiaphragmatic pressure elicited by cervical magnetic phrenic nerve stimulation, and 3) tidal breathing, sniffs and coughs in five body positions. The agreement of the two systems was analysed for measurements of 1) absolute pressures, 2) magnitude of changes in pressure, and 3) rate of change of pressure (maximum relaxation rate after sniff manoeuvres). The CMT system was linear, with a high frequency response and stable gain, but showed baseline drift. The two systems agreed well for measurements of change and rate of change of pressure, but less well for measurements of absolute pressure. The CMT system tested is potentially useful for studies of acute changes in respiratory pressures, or studies of respiratory muscle strength, but would be less useful where accurate measurements of absolute pressures are required.

Continuous measurement of cerebral oxygenation by near infrared spectroscopy during induction of anesthesia.

UNLABELLED: Near infrared spectroscopy (NIRS) measures tissue oxygenation continuously at the bedside. Major disturbances of cerebral oxygenation can be detected by using NIRS, but the ability to observe smaller changes is poorly documented. Although anesthetics generally depress cerebral metabolism and enhance oxygen delivery, the administration of etomidate has been associated with cerebral desaturation. We used this difference to study the ability of NIRS to detect the small changes associated with the onset of anesthesia. Thirty-six healthy patients were randomly allocated to have anesthesia induced with either etomidate, propofol, or thiopental. We found that there was a temporal association between the onset of anesthesia and NIRS-derived indices of cerebral oxygenation. Etomidate was associated with a decrease in cerebral oxygenation, whereas propofol and thiopental were associated with an increase in cerebral oxygenation. We conclude that NIRS is capable of detecting the small changes in cerebral oxygenation associated with the induction of general anesthesia and shows promise as a bedside investigational tool for the noninvasive assessment of cerebral oxygenation. IMPLICATIONS: We conclude that near infrared spectroscopy is capable of detecting the small changes in cerebral oxygenation associated with the induction of general anesthesia and shows promise as a bedside investigational tool for the noninvasive assessment of cerebral oxygenation.

Esophageal-directed pressure support ventilation in normal volunteers.

STUDY OBJECTIVES: To ascertain whether inspiratory pressure support (IPS) can be triggered reliably from and targeted at esophageal pressures (Pes), and to compare the work of breathing and time delay to initiation of inspiratory flow between conventional pressure support and esophageal-directed pressure support (EDPS). DESIGN: Prospective laboratory study. SETTING: University medical school. PATIENTS OR PARTICIPANTS: Five normal volunteers. INTERVENTIONS: IPS at a level to achieve tidal volume of 10 mL/kg, and EDPS with a target Pes of 0 cm H2O via full facemask. MEASUREMENTS AND RESULTS: Pes, airway pressure, and inspiratory flow were measured during spontaneous breathing. Peak Pes and pressure time product (PTP) of Pes were calculated during spontaneous breathing and through linear resistances. Measurements were repeated during IPS and EDPS ventilation. At rest, PTP was 7.56 (+/- 3.6) and peak Pes was -5.8 cm H2O (+/- 1.44). When subjects were breathing through the resistors, PTP increased to 12.4 (+/- 8.1) and 30.3 (+/- 8.9) and peak Pes decreased to -7.2 and -15.3 cm H2O respectively. With facemask IPS, unloaded PTP fell to 1.7 (+/- 1.3) and peak Pes fell to -3.3 cm H2O (+/- 1.3). When ventilated through the highest resistance with IPS, mean PTP increased to 21.9 and peak Pes increased to -11.9 (+/- 4.2) cm H2O relative to baseline. During EDPS with the resistor, PTP fell to 1.5+/-1.1 (p < 0.007) and peak Pes fell to -1.9+/-1.1 cm H2O (p < 0.0001). CONCLUSIONS: It was possible to initiate supported breathing from Pes values. The work performed, as measured by PTP, was lower during EDPS than during either unsupported breathing or conventional IPS.