MRI shows brain atrophy pattern that is predictive of Alzheimer’s

Using special MRI methods, researchers have identified a pattern of regional brain atrophy in patients with mild cognitive impairment (MCI) that indicates a greater likelihood of progression to Alzheimer’s disease. The findings are published in the online edition of Radiology. The study’s lead author, Linda K. McEvoy, Ph.D., assistant project scientist in the Department of Radiology at the University of California San Diego School of Medicine in La Jolla, USA said that previously this pattern had been observed only after a diagnosis of probable Alzheimer’s disease. The current results show that some individuals with MCI have the atrophy pattern characteristic of mild Alzheimer’s disease, and these people are at higher risk of experiencing a faster rate of brain degeneration and a faster decline to dementia than individuals with MCI who do not show that atrophy pattern.
For the study, Dr McEvoy and colleagues set out to determine if they could identify a pattern of regional atrophy characteristic of mild Alzheimer’s disease in order to aid in the prediction of cognitive decline in patients with MCI. The researchers analysed brain MR images from 84 patients with mild Alzheimer’s disease, 175 patients with MCI and 139 healthy controls, using semi-automated, individually specific quantitative MRI methods. The results showed widespread cortical atrophy in some patients with MCI, involving all cortical areas except those involved with processing of primary motor and sensory information. However, most indicative of future cognitive decline were atrophy in parts of the medial and lateral temporal lobes and in the frontal lobes. This pattern was also present in the patients with mild Alzheimer’s disease. Although these individuals were reporting problems mainly with memory, the atrophy involved more than just memory areas, extending into brain regions involved in planning, organisation, problem solving and language. Follow-up data were available for 160 patients with MCI. The patients exhibiting atrophy in the brain regions described above showed significant one-year clinical decline and structural brain loss and were more likely to progress to a probable diagnosis of Alzheimer’s disease. MCI patients without that pattern of atrophy remained stable after a year.
Dr McEvoy hopes that these findings will have an impact on the design of clinical trials to test medications that may slow or halt the progression of Alzheimer’s disease.

Fertility in developing countries: words into action

For almost 30 years - since the world’s first ‘test-tube’ baby was born in July 1978 - the benefits of modern infertility treatments have been largely confined to couples in developed countries. There, we have seen more than three million babies born as a result of in vitro fertilisation (IVF) and, in some countries, as many as four percent of all babies born are conceived by modern fertility techniques.
The plight of couples in developing countries, especially women, has been acknowledged, but rarely advanced from words into action. Now, a task force of ESHRE (the European Society of Human Reproduction and Embryology), the world’s leading professional organisation in reproductive medicine, has devised a programme of fertility treatment for developing countries which aims to integrate fertility clinics within broader family health services. Two pilot IVF services have already opened in Africa.
There are many reasons why infertility treatment has not been widely introduced in developing countries. The main explanations are poverty and limited health resources, but there is also the paradox that most of the countries where needs are greatest are also the countries where population growth is running out of control. Dr Willem Ombelet from the Institute for Fertility Technology in Genk, Belgium, and coordinator of the ESHRE task force, says that the ESHRE task force plans are to integrate infertility treatment within existing family planning and mother-care services. The most important goal is to provide treatment that is safe, affordable and culturally acceptable. The ESHRE programme proposes three levels of treatment, but its cornerstone is the provision of affordable IVF. Currently, one cycle of IVF treatment in Europe or the USA costs between US$ 5000 and 10,000. A system of low-cost IVF now being pilot-studied in Khartoum and Cape Town aims to provide one cycle of IVF for less than $200.
One of the instigators of the low-cost IVF scheme, Dr Luca Gianaroli from the SISMER Reproductive Medicine Unit in Bologna, Italy, says that the approach to IVF will be different. Every type of infertility will not be able to be treated, but many women with tubal damage as a result of infection can be helped. While the scheme has limited laboratory facilities for incubation, embryo selection and embryo freezing, triplets and high-order pregnancies will be avoided. The cornerstones in the treatment of infertility in low-resource settings are the simplification of techniques, minimising of complications, training for healthcare workers as well as and the incorporation of fertility treatments into existing healthcare programmes.

Optical brain imaging decodes preference

Researchers at Canada’s largest children’s rehabilitation hospital, namely Bloorview Kids Rehab, have developed a technique that uses infrared light brain imaging to decode preference, with the goal of ultimately opening the world of choice to children who can’t speak or move. In a study published this month in The Journal of Neural Engineering, Bloorview scientists demonstrate the ability to decode a person’s preference for one of two drinks with 80 per cent accuracy by measuring the intensity of near-infrared light absorbed in brain tissue.
Most brain-computer interfaces designed to read thoughts require training. For example, in order to indicate yes to a question, the subjects need to do an unrelated mental task, such as singing a song in their head. The nine adults in the study received no training. Prior to the study they rated eight drinks on a scale of one to five. Wearing a headband fitted with fibre-optics that emit light into the pre-frontal cortex of the brain, they were shown two drinks on a computer monitor, one after the other, and asked to make a mental decision about which they liked more. When the brain is active, the oxygen in the blood increases and, depending on the concentration, it absorbs more or less light. In some people the brain is more active when they don’t like something, and in some people it’s more active when they do like something. After allowing the computer to recognise the unique pattern of brain activity associated with preference for each subject in the study, the researchers accurately predicted which drink the participants liked best 80 per cent of the time. In future, a portable, near-infrared sensor that rests on the forehead and relies on wireless technology could be developed, opening up the world of choice to children who can’t speak or move.

www.iop.org/EJ/abstract/1741-2552/6/1/016003

Multivitamins have no impact on risk of cancer or heart disease in postmenopausal women

The largest study of its kind concludes that long-term multivitamin use has no impact on the risk of common cancers, cardiovascular disease or overall mortality in postmenopausal women. The results of the Women’s Health Initiative study, led by researchers at Fred Hutchinson Cancer Research Center, were published in the February issue of the Archives of Internal Medicine. The study focused on the effects of multivitamins because they are the most commonly used supplement. It assessed multivitamin use among nearly 162,000 women enrolled in the Women’s Health Initiative, one of the largest U.S. prevention studies of its kind and designed to address the most common causes of death, disability and impaired quality of life in postmenopausal women. The women were followed for about eight years. Nearly half of the study participants reported using multivitamins on a regular basis. Multivitamin users were more likely to be white, live in the western United States, have a lower body-mass index, be more physically active and have a college or higher degree as compared to non-users. Multivitamin users also were more likely to drink alcohol and less likely to smoke than non-users, and they reported eating more fruits and vegetables and consuming less fat than non-users. During the eight-year study period, 9,619 cases of breast, colorectal, endometrial, renal, bladder, stomach, lung or ovarian cancer were reported, as well as 8,751 cardiovascular events and 9,865 deaths. The study found no significant differences in either risk of cancer and heart disease or longevity between the multivitamin users and non-users.

Defibrillators may have little benefit for older heart failure patients with comorbidities

Defibrillators are commonly recommended to patients with heart failure to prevent sudden cardiac death, but there is a lack of criteria to identify the appropriate patients for this therapy beyond having heart failure due to systolic dysfunction. Researchers at Brigham and Women’s Hospital (BWH) found that older people with comorbidities and those with multiple hospital admissions related to heart failure are unlikely to receive a meaningful survival benefit from implanted defibrillators. Even if all out-of-hospital cardiac deaths were prevented by implanted defibrillators, the researchers found that survival was significantly lower in patients who were repeatedly hospitalised for heart failure. Similarly, survival was poor for older patients with comorbidities, such as cancer, dementia, and kidney disease. However, patients under 65 years of age and older patients without kidney disease, cancer or dementia would be most likely to benefit from defibrillators to prevent sudden death.

"Previous trials show significant benefits of defibrillators in patients with heart failure, but the study populations typically exclude elderly patients and those with comorbidities," said Soko Setoguchi, MD, of the Department of Medicine at Brigham and Women’s Hospital (BWH). However, information from the US National Cardiovascular Data Registry from 2006 through 2007 indicates that defibrillators are frequently implanted in patients with comorbidities, and 61 percent of implanted defibrillators go to people aged 65 or older.

Online hospital management system and patient records system

Online hospital management
A fully integrated online hospital management system, which improves the day to day running of hospitals and the way patient information is stored and accessed, is now available. A revolutionary online medical records service, which allows patients to access their own medical records, dating back from the day they were born, is also available. Both systems, namely Medsystem Online (designed for healthcare professionals to run healthcare institutes) and Medrecord Online (the online health record designed for patients) work seamlessly together, offering a valuable online service and a unique way of accessing data.
Medsystems Online runs the functions of a hospital, including patient appointments, shift patterns, patient’s results such as blood tests, fully integrated PACS (X-rays, scans ultrasound), bed admissions, referrals to specialists and also telemedicine. The built-in referral system and messaging means that there is no chance of losing data; confidentiality is carefully respected. Medrecord Online is an online health record system, which stores people’s medical history, allowing individuals to access and control their own health records. Each person carries a Medcard; this is a ‘dumb card’ allocated to a person, which has a unique number on it as well as a bar code on the back. No data are stored on the card so any loss of the card is without consequence. The system is cheap to replace, easy to use and offers 100% data protection and security. All users have to do is log-in and access the information for which they are looking. Both systems use the latest cutting edge technology.

UV light cuts spread of TB

Ultraviolet lights could reduce the spread of tuberculosis in hospital wards and waiting rooms by 70 per cent, according to a new study involving researchers from the University of Leeds. The study explores the transmission of tuberculosis (TB) from infected patients, and suggests that installing simple ultraviolet C (UVC) lights in hospitals could help reduce the transmission of even drug-resistant strains.

Every year, more than nine million people are infected with tuberculosis and approximately two million people die from the disease, according to the World Health Organisation. Infection rates are particularly high in places where vulnerable people are crowded together, such as hospitals, homeless shelters and prisons.

When a tuberculosis patient coughs, bacteria are sprayed into the air in tiny droplets, floating around the room and infecting other patients, visitors and healthcare staff. These bacteria can be killed by hanging a shielded UVC light from the ceiling and ensuring an effective system to move and mix the air, say the researcher team, which includes the University of Leeds, Imperial College London, Hospital Nacional Dos de Mayo, Lima, Peru, and other international institutions.

UVC light kills tuberculosis bacteria, including drug-resistant strains, by damaging their DNA so they cannot infect people, grow or divide. It is already used at high intensity to disinfect empty ambulances and operating theatres.

The impact of UV lights is greatest when combined with careful management of the air flow on the wards, as Dr Cath Noakes from Leeds’ Faculty of Engineering explains: "The lights must be set high enough to ensure patients and health workers are not overexposed, but if the lights only treat air at that level, there will be little benefit. To be most effective, ventilation systems need to create a constant flow of treated air down to patient level, and potentially infected air up towards the lights."

Monitoring pain and activity in hip and knee replacement patients

The number of hip and knee replacements required is increasing due to ageing populations, and as governments seek to meet demand and contain costs, there is a need to take a fresh look at how costs can be reduced whilst improving patient care. Currently clinicians make treatment decisions on hip and knee replacement patients based on their physical activity and pain levels but without having good visibility of those two indicators of patient well-being. If clinicians are given remote and time aggregated access to that information along with clinical analysis of it, decisions all along the care pathway can be better informed with the result that patient outcomes are improved and cost savings are realised.
by D. Heaton, Dr I. Revie and Dr M. Slomczykowski

Clinical need
Each year there are approximately one million primary hip and knee replacements carried out in Europe, with the number growing at over 4% annually. North America, the Middle East and Pacific Rim also have a significant and growing number of replacements. With an ageing world population, it is likely that the demand for hip and knee replacements will continue to grow while the funds to resource them become more scarce.
With this in mind, Activ4Life Healthcare Technologies Ltd, initiated discussions with clinicians to determine where there were areas for improvement. What they found was that the two key reasons for carrying out hip and knee replacements were to increase patients’ mobility and reduce their pain, both parameters that are not currently economically measurable over time. In addition to being a key reason for joint replacement, activity is a vital part of the recovery and rehabilitation process, but again, this is currently not effectively measured in patients.

As the ability to walk is a frequent discharge criterion, it is important to ensure that this is maintained in the period early after discharge when hospital staff are no longer available to provide support. It is important to ensure that patients continue to increase activity over several weeks to re-establish mobility. If patients do not show a clearly increasing trend in activity levels post-operatively there may be additional complications which warrant attention. Without sufficient exercise muscles will weaken leading to a poor outcome and the real possibly of a negative effect on the stability of an operated joint. However, over- exercising a joint early post-operatively can also be a significant risk to recovery, potentially damaging the integrity of the joint, in which case the life of the joint will be compromised, and a revision will probably be required.

Compliance with the prescribed exercise regime is important for patient outcomes and for reducing the costs associated with poor outcomes and/or revisions. Currently the only method of measuring compliance is by asking patients how much exercise they are taking. This is time consuming and unreliable, as it is subjective and reliant on the patient’s memory. Furthermore, patients who are not complying for whatever reason are unlikely to be detected until the damage is irreversible.

At present, clinicians have to make treatment decisions using minimal information based on ’snapshots’ of subjective measures of activity and pain provided by the patient from time to time, often at intervals of many weeks. What is considered very active by one patient may be considered inactive by another. Established scoring systems such as the Oxford Knee Score, Harris Hip Score and SF-12 are widely used and have some merit but they cannot provide quantitative trends that would show the rate at which a patient is declining pre-operatively, or if recovery is on track post-operatively. Moreover, there are very few published data on the activity characteristics of patients according to their different physical characteristics. For instance, what does the decline in mobility of a regular tennis player look like compared to the decline of someone who leads a more sedentary life, but is still in pain and frustrated by declining mobility? Obviously, there will be a broad spectrum of activity profiles for different patients. These need to be known and presented as a baseline for comparison as recovery progresses. Absolute measures of activity alone would be a step forward, but would not yield the ‘whole picture’ or maximum benefits. Clearly, more is needed.

If data on patients’ activity and pain levels were made visible to clinicians, and referenced to norms, treatment decisions would be better informed. This would improve many stages of overall patient care including triage of those presenting with joint pain; determination of optimal time for intervention; recovery prediction, appropriate exercise regime planning, exercise compliance monitoring, hospital planning and early detection of complications. Enhanced well as improved efficiency and cost savings.

The ProV3.8 monitoring system
Recognising these needs, the ProV3.8 system was developed to deliver effective reporting of patient activity and pain. Designed to be used on each patient for several months pre- and post-operatively, the system comprises three separate components:

• Patient hardware: a very user-friendly activity monitor and associated dock with a pain reporting facility
• Analysis against clinical “personas”: a comparison against a specific activity profile matched to the user
• Reporting: regular reports to the user and clinicians responsible for that user’s care

Patient hardware
At the start of each day the patient fixes the activity monitor to the waist, under clothing, using a double-sided medical grade adhesive patch. The activity monitor, about the size of a wrist watch and weighing only 15g, is unobtrusive and discreet. A 3-axis accelerometer and onboard processor are utilised to count steps and record each one against time. At the end of the day the patient removes the activity monitor and inserts it into the dock. This incorporates an integral mobile phone module that transmits the data to a secure server. At this point the patient is given the opportunity to record pain level for the day on a scale of 1 - 10 simply by pushing one of two buttons. There is no requirement for the patient to have an internet connection or any other equipment such as PC, PDA or mobile phone. The patient does not have to be familiar with modern communication technology demands on the user. All that is required is to wear the activity monitor during the day and place it in the dock overnight. Pain recording involves only the push of a single button.

Analysis against personas
Each patient’s data is compared against an assigned “persona”: a researched activity norm based on BMI, age, gender, operative state and lifestyle. This persona thus fits the patient’s characteristics, and is displayed with the patient’s activity data in the weekly reports. This persona profile is also used in setting patient activity targets, both pre- and post-operatively.

Reporting
Reports are generated from the analysis and show activity performance and trend lines against expected activity. These reports are delivered both to the decision-making clinicians and to the patient. Additionally, should activity levels fall outside predetermined boundaries, alerts can be generated to the clinician. Such alerts would allow an instruction to the patient to change their exercise behaviour appropriately. In the case of under-exercise this would improve outcomes; in the case of over-exercise a revision could be avoided in some patients.

Improved outcomes and cost savings
How the reports feed into the decision-making process along the care pathway can be illustrated by considering the different phases of the patient’s care in Figure 2. The green line shows a typical long-term activity profile for a patient having a primary hip replacement.
• Throughout the period of care, remote monitoring and visibility of the patient’s well-being can reduce the number of visits to clinicians: primary care doctors, surgeons and physiotherapists.
• It is well documented that delaying intervention for too long can result in a sub-optimal recovery; the patient takes longer to recover and the eventual plateau of activity level reached is lower than for earlier interventions. The red line illustrates the benefits of operating at the optimal time; a sustained higher level of activity more quickly. Conversely, an intervention before the optimal time is inefficient as it increases the likelihood of a revision later in life. In addition, the benefits, as perceived by the patient, are less. Enabling an informed decision on when to operate will, in some cases, allow the use of conservative, lower cost treatment options in the short term, thus allowing those with a more urgent need to be referred to secondary care earlier.
• Limited healthcare resources means that patients’ activity cannot be monitored as closely as would be ideal and thus discharge planning is often conservative. The instant availability of activity trends during the hospital post-operation period, together with increased patient confidence from knowing monitoring will continue at home, allows an earlier discharge from hospital with associated cost benefits.
• If activity levels are much lower than expected, or pain levels consistently higher, alerts that there may be a complication are generated to the clinicians. Such alerts also notify patients and their surgeons of inappropriate post-operative activity such as excessive or too demanding or too early exercise.
• Once patients are discharged from hospital and are back at home, monitoring and reporting results in increased se|f-awareness, encouraging self-management of care. In the longer term studies have shown that people who are able to quantify their activity levels tend to take more exercise, the obvious resulting health benefits.

Summary
The implementation of this system allows better clinical decision-making for hip and knee replacement patients, leading to improved outcomes and cost savings from:

• Triage of patients presenting with joint pain
• A reduction in incorrect referrals from primary to secondary care
• A reduction in unnecessary procedures
• Quicker discharge from hospital
• Fewer post-operative visits to clinicians
• Quicker recovery post-operatively
• Informed patient self management
• Recovery to a higher level of activity
• Early detection of complications allowing more conservative treatment options and less remedial work.
• Compliance with common government policies of patient self-management, improved quality at lower cost, measurement of quality, better use of ICT and data management.

Rapid neuroimaging of acute stroke patients

Stroke patients can respond well if rapid diagnosis is followed by prompt and appropriate therapy. For example in ischaemic stroke timely administration of thromobolytic or “clot-busting drugs” can prevent the progression of symptoms from transient to permanent. Delays in diagnosis can however lead to irreversible cerebral damage. The principal diagnostic challenge in overall stroke management is to differentiate brain ischaemic attacks from haemorrhages and stroke-like disorders. While timely non-contrast CT imaging distinguishes between haemorrhagic and ischaemic stroke, many hospitals cannot offer continuously available CT scanning in the radiology department. A dedicated, head/neck scanner in the ER facilitates rapid differential stroke diagnosis.
by Dr David B. Weinreb

Stroke is the third most frequent cause of mortality after ischaemic heart disease and cancer, and the primary cause of disability in adults worldwide. In 2005, there were an estimated 62 million stroke survivors. Over 15 million people suffer a stroke each year and of these, approximately five million will die as a result, and another five million will be permanently disabled. One of the most important challenge facing physicians globally is to reduce the unacceptable burden of stroke.

Prompt differential diagnosis is essential, but achieving rapid imaging in the Emergency Room (ER) is challenging, both for small community hospitals and large academic centres. There are numerous, frequently-encountered clinical scenarios for which there is an urgent need to briskly transport patients to the radiology suite: suspected intracranial haemorrhage, pulmonary emboli or ruptured aneurysms. Delays in obtaining the appropriate diagnostic imaging study create delays in correct management. This is particularly significant for patients presenting to the ER with signs of acute stroke.

Thrombolytic, or “clot-busting,” drugs offer tremendous hope to stroke patients, breaking apart the clots that deprive the brain of oxygen, preventing symptoms from progressing from transient to permanent. However, thrombolytic agents may be contraindicated in many patients. First and foremost, clinical guidelines dictate that thrombolytic drugs be administered within three hours of symptom onset. If administered after this three-hour window, the potential risks of bleeding complications tend to outweigh the benefits. For example, in about 83% of acute stroke patients their symptoms are secondary to a clot starving the brain of oxygen [1]. For the remaining 17% the stroke may be consequent to a site of haemorrhage in the brain [1]. In all such cases, administration of a clot-busting drug will exacerbate the hemorrhage. It is crucial to rapidly image such patients and “triage” them accordingly: those with oxygen-depriving clots may indeed be candidates for thrombolytic drugs; haemorrhage within the brain is an absolute
contraindication to such therapy.

Non-contrast CT imaging
The first step in the evaluation of acute stroke patients is to distinguish between patients whose symptoms are due to bleeding (haemorrhagic stroke) and those patients presenting with stroke due to clots (ischaemic stroke). This can be achieved with non-contrast CT imaging [Figure 1a and 1b]. Within the few hours of the onset of a haemorrhagic stroke, the non-contrast CT scan will identify the presence of haemorrhage. These patients require close neurological monitoring and possible neurovascular/neurosurgical interventions to control the bleeding.
By comparison, within the first hours of an ischaemic stroke, non-contrast CT imaging may likely be completely normal: the clot is barricading the flow of oxygen-rich blood to the brain, but it is too early to see any changes in the brain apparent on CT imaging. Generally, greater than 24 hours after the onset of symptoms, repeat CT imaging will demonstrate areas of low attenuation, corresponding to brain territory that has been deprived of blood flow.

Non-contrast CT imaging should therefore be performed as briskly as possible in patients with suspected acute stroke. The National Institute of Neurological Disorders and Stroke (NINDS) urges that CT imaging be completed within 25 minutes of the patient arriving in the ER; the images should be interpreted within 45 minutes [2]. For various reasons, compliance with these time guidelines may be more easily attained in large academic centres. Specifically, these larger institutions may have a stroke team consisting a specialised nurse and stroke neurologist on-call to evaluate patients in the ER. Additionally, the radiology department may have continuously available CT scanning in the ER, staffed around the clock by teams of technologists.
However, the situation may be quite different in smaller community hospitals, and such differences have constructed barriers to ideal care. First, many community hospitals may not have a CT scanner in the ER; their imaging facilities may be located in another building and, in many cases, off-site. Additionally, the CT department may not be staffed 24 hours a day. These obstacles to the “25-minutes to CT” guideline represents challenges facing smaller community hospitals. This is particularly and painfully relevant given that the overwhelming majority of stroke patients initially present to community hospital ERs.

Use of a dedicated head/neck CT scanner
First, one creative solution is a dedicated head/neck CT scanner, stationed in the ER, ready at a moment’s notice for an arriving stroke patient. One manufacturer, NeuroLogica Corporation in Massachusetts, has developed a light-weight (700-lb), portable 8-slice scanner [Figure 2]. Designed specifically for head imaging, this scanner is stored in the ER, eliminating the need for stroke patients to be transported to the radiology suite. In many of the community hospitals where this novel scanner is currently operating, it has helped clinicians achieve the “25-minute” guideline [3].

A recent investigation has explored the clinical utility of the portable CT scanner for ER patients [3]. The study was conducted in the 16-bed ER of Salem Hospital/North Shore Medical Center (Salem, Massachusetts). At Salem Hospital, it typically took 25-35 minutes from the time of initial arrival at the ER door until the CT scan was completed. This delay in transporting the patient to the radiology suite for CT imaging was one of the several factors that slowed the entire process of clinically assessing patients presenting with an acute ischaemic stroke. Thus, interventions were necessary to provide more rapid diagnostic imaging for ER patients.
Following the implementation of a dedicated scanner in the ER, these times was drastically reduced to less than 17 minutes; a large percent of ER stroke patients were imaged fewer than 12 minutes [Figure 3]. These preliminary results suggest that increasing the availability of CT in community or rural hospitals may have a tremendously positive impact on the ability to these hospitals to more effectively care for acute stroke patients.

In summary, providing rapid diagnostic imaging when and where it is needed the most is an enormous challenge. Nowhere is this challenge more apparent than in community hospitals, faced with the arrival of a stroke patient within the three hour period for thrombolytic interventions. The emergence of new technologies is helping to surmount this challenge, though new approaches and strategies at the community level are still needed.

RFID tags make hospital equipment management easier

From the organisational and management point of view, a modern hospital is an extremely complex system. Efficient running of a hospital can therefore be a daunting task but is nevertheless called for more and more since increased efficiency in the management of hospital facilities can not only result in significant savings but also in improvement in patient outcomes. One of the most difficult aspects of modern hospital management is keeping track of the many portable and movable pieces of equipment, whose physical location in the hospital can vary enormously, depending on the use the patient is making of the equipment.Items such as IV pumps, specialised mattresses or even apparently mundane pieces of equipment such as wheelchairs can at any one time be located almost anywhere in the hospital. Frequently, hospitals are required to compensate for their ignorance of the precise whereabouts of their own property by purchasing more items than would otherwise be necessary. The use of modern Radio Frequency Identification (RFID) systems is a cost-effective method of managing such movable but important equipment. Here we look at how two Belgian hospitals have implemented their RFID systems.

St Trudo Regional Hospital, Sint Truiden, Belgium
Located in the Flemish-speaking part of Belgium in the town of Sint Truiden, the St. Trudo Regional Hospital is a 310-bed hospital that serves the Limburg and Vlaams-Brabant regions of the country. Its 700 employees and 80 doctors care for more than 11,000 patients admitted to the hospital annually. The hospital recently installed a wireless network and uses this infrastructure to support Wi-Fi-based active radio-frequency identification (RFID) tags, in particular to track and manage expensive specialty mattresses, IV pumps and wheelchairs that are required throughout the facility. St. Trudo also uses the wireless network to accurately monitor the temperature inside the hospital’s data centre.The specialty mattresses, known as anti-decubitus mattresses, help prevent pressure sores in patients who must remain in the hospital for extended periods. The hospital’s mattresses, as well as the IV pumps and wheelchairs are in constant use and continual movement throughout the facility. Before installing the new asset tracking solution, staff often had to manually search the entire facility to locate needed equipment, which wasted a substantial amount of time and reduced overall utilisation of the patient care equipment. Moreover, when the required equipment wasn’t readily available, the hospital often had to rent others, incurring significant expenses and delays.To solve this problem, St. Trudo implemented Wi-Fi-based RFID tags and AeroScout’s MobileView software. The tags are attached to the specialty mattresses, IV pumps and wheelchairs, enabling accurate, real-time visibility and management of those assets. The system is also set up to alert hospital personnel when the number of wheelchairs available for use reaches a critically low level, or whenever a wheelchair is inactive for two hours so that it can be returned to the reception area. In addition, Wi-Fi-based temperature-monitoring application is installed in St. Trudo’s server room (see technology primer opposite). The application also uses the wireless infrastructure to transport information — in this case, temperature readings — to the network. This enables the hospital’s IT department to remotely monitor the temperature of the room from anywhere in the hospital, or even to transmit alerts to the home of the appropriate facilities engineer. “The new system has made a significant improvement in the way we operate,” said Daniel Loos, manager, information technology, at St. Trudo. “The staff are more satisfied and much more efficient with their time. With the new system, we have been able to increase the utilisation of expensive mattresses, IV pumps and wheelchairs, as well as reduce expenses related to renting extra equipment. Best of all, we can improve service and care for patients who require the use of the tracked equipment.”

Jan Yperman Hospital, Ypres, Belgium
Housed in a brand new building inaugurated in 2007 and featuring state-of-the-art telecommunications systems, the Jan Yperman hospital in Ypres, Belgium, has about 550 beds, 1,000 employees and 100 doctors. Each year, the hospital accepts 15,000 patient admissions and 18,000 one-day hospitalisations. The hospital has opted for for a “Wi-Fi–Based Active RFID solution”, based on a Telindus LAN and WiFi system for tracking patients and medical equipment in real time. Approximately 1,000 pieces of equipment (infusion pumps, wheelchairs, beds, patient monitors, etc.) were fitted with Aeroscout Active RFID tags, not only saving medical staff precious time in locating these assets, but also making it easier for managers to maintain them, establish an inventory and reduce the risk of theft. Temperature-monitoring tags are used for refrigerators containing lab specimens, blood bags and other temperature-sensitive items. Such continuous monitoring ensures safe operation and correct temperatures. Approximately 400 tags with call buttons ensure better protection for medical staff, who are sometimes confronted with aggressive patients. The tags are also a useful tool for keeping track of disoriented patients such as those suffering from Alzheimer’s disease.

The pros and cons for having medical emergency teams (METs) in hospitals

Typically composed of an ICU doctor, nurse and other appropriate personnel, Medical Emergency Teams (METs) were first introduced in certain hospitals in the 1990s. Since then METs have been widely implemented; their mission is to provide a medically-based critical care resource to critically ill patients wherever in the hospital it is needed. METs should be able to be summoned to a medical emergency in a similar manner and with comparable urgency as a traditional cardiac arrest team. Although METs seem on the surface to make intuitive common-sense, the data regarding their benefits are not clear-cut, and can even show them to be inefficacious. A recent paper by Price and Cuthbertson evaluated the cases for and against METs [1]; this article presents their principal conclusions.

The basic rationale for the creation of dedicated Medical Emergency Teams (METs) is to address the situation that can occur if a patient on a general ward develops critical illness and there are insufficient resources (both in terms of personnel and equipment) to meet the clinical need. In response to these considerations, the concept of a Rapid Response System (RRS) has emerged. In addition to being known as MET, the responding team can also be known as a rapid response team (RRT) or critical care outreach (CCO) but whatever the name, all are designed to provide early intervention by individuals with critical care competencies. The recommendations of an international consensus conference on METs were that hospitals should implement a rapid response system, consisting of four elements [2]. These are an afferent, “crisis detection” and “response triggering” mechanism; an efferent, predetermined rapid response team; a governance/administrative structure to supply and organise resources; and a mechanism to evaluate crisis antecedents and promote hospital process improvement to prevent future events.

The case for METS
The rationale for a MET is both obvious and intuitive: the provision of a rapidly responding team should overcome the situation in many hospitals, where there are inevitable delays within a hierarchical structure that consists of individuals who may not possess the appropriate skills for the treatment of deteriorating patients. With a MET, costs may thus be saved via a reduction in the length of ICU and hospital stays. Many studies have been set up to try to quantitate the benefits of the implementation of METs and some have demonstrated a positive effect. However, from an evidence-based medicine point of view the level of evidence is frequently weak and most of these studies can be considered as Level 2 evidence at best, with a significant likelihood of bias. At least there does not seem to be any suggestion within the literature that METs are actually harmful in some way.

The case against METs
One of the most fundamental arguments against METs is that surprisingly there is no clear-cut evidence in favour of cardiac arrest team systems, which have served as the model on which most METs have been designed. The more detailed evidence against METs comes from a rigorous analysis of the studies that on the face of it purported to show benefits. The question being raised is simply this: are the data in such studies flawed to the extent that they cannot be trusted. For example, some studies involved the comparison of hospitals using the MET system with others that didn’t. Clearly differences between the basic case composition of the different hospitals could bias the results. A priori, the use of studies in the same hospital before and after the introduction of METs should minimise this problem, but even here problems still exist, such as seasonal variations, differences in case mix and general changes with time of the overall health care provision.

Accepting the limitations of such “before and after studies”, two studies have shown that there is no demonstrable benefits to the introduction of METs. In a UK study, Kenward et al [3] looked at the effect of the introduction of a MET on the incidence of cardiac arrest and in-hospital death. The study was carried out over a period of one year before and one year after the introduction of MET. For both outcome parameters, no benefit was shown for the existence of METs.

The MERIT study (Medical Early Response. Intervention and Therapy) is the largest and most robust study of METS and involved 23 hospitals in a prospective cluster-randomised trial [4], with the primary outcome being the composite of unexpected death, cardiac arrest and unplanned ICU admission. The studies were designed such that for each hospital there was a baseline period of two months prior to the introduction of METs in the test group of hospitals. Of course, in the control group of hospitals, no METs were set up after the baseline period. It was found that a significant improvement in the outcomes between the baseline period and test only occurred in the control group of hospitals (i.e. those with no METs)! Direct comparison of the test and control hospitals showed no statistically significant improvement in those hospitals using METs. Various theories have been advanced to explain the apparent lack of efficacy in the MERIT studies. One is that the triggers used to call the MET [Table 1} were not specific or sensitive enough. Likewise the use of a composite outcome criterion of unexpected death, cardiac arrest and unplanned ICU admission may have been inappropriate. Other explanations could be inappropriate staffing or inappropriate or inadequate interventions. However until clear evidence for the benefits of METs is presented, the case for their implementation remains seriously flawed.