Early warning scores are widely used to identify deteriorating patients. Whilst their ability to predict clinical outcomes has been extensively reviewed, there has been no attempt to summarise the overall strengths and limitations of these scores for patients, staff and systems. This review aims to address this gap in the literature to guide improvements for the optimization of patient safety. A systematic review was conducted of MEDLINE®, PubMed, CINAHL and The Cochrane Library in September 2016. The citations and reference lists of selected studies were reviewed for completeness. Studies were included if they evaluated vital signs monitoring in adult human subjects. Studies regarding the paediatric population were excluded, as were studies describing the development or validation of monitoring models. A narrative synthesis of qualitative, quantitative and mixed- methods studies was undertaken. 232 studies met the inclusion criteria. Twelve themes were identified from synthesis of the data: Strengths of early warning scores included their prediction value, influence on clinical outcomes, cross-specialty application, international relevance, interaction with other variables, impact on communication and opportunity for automation. Limitations included their sensitivity, the need for practitioner engagement, the need for reaction to escalation and the need for clinical judgment, and the intermittent nature of recording. Early warning scores are known to have good predictive value for patient deterioration and have been shown to improve patient outcomes across a variety of specialties and international settings. This is partly due to their facilitation of communication between healthcare workers. There is evidence that the prediction value of generic early warning scores suffers in comparison to specialty-specific scores, and that their sensitivity can be improved by the addition of other variables. They are also prone to inaccurate recording and user error, which can be partly overcome by automation. Early warning scores provide the right language and environment for the timely escalation of patient care. They are limited by their intermittent and user-dependent nature, which can be partially overcome by automation and new continuous monitoring technologies, although clinical judgment remains paramount.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Vital signs monitoring is a universal tool for the detection of postoperative complications, but unwell patients can be missed in between traditional observation rounds. New remote monitoring technologies promise to convey the benefits of continuous monitoring to patients on general wards. Objective: The aim of this pilot study was to evaluate whether continuous remote vital signs monitoring is a practical and acceptable way of monitoring surgical patients, and to optimise the delivery of a definitive trial. Methods: A prospective, cluster-randomised, parallel-group, unblinded controlled pilot study was performed. Patients admitted to two surgical wards at a large tertiary hospital received either continuous and intermittent vital signs monitoring, or intermittent monitoring alone using an early warning score system. Continuous monitoring was provided by a wireless patch, worn on the patient’s chest, with data transmitted wirelessly every two minutes to a central monitoring station or a mobile device carried by the patient’s nurse. The primary outcome measure was time to administration of antibiotics in sepsis. Secondary outcome measures included length of hospital stay, 30-day readmission rate, mortality and patient acceptability. Results: 226 patients were randomised between January and June 2017. 140 patients were randomised to continuous remote monitoring; 86 patients were randomised to receive intermittent monitoring alone. On average, patients receiving continuous monitoring were administered antibiotics faster after evidence of sepsis (626 minutes, n=22, 95% CI 431.7-820.3 minutes, versus 1012.8 minutes, n=12, 95% CI 425.0-1600.6 minutes), had a shorter average length of hospital stay (13.3 days, 95% CI 11.3-15.3 days, versus 14.6 days, 95% CI 11.5-17.7 days) and were less likely to require readmission within 30 days of discharge (11.4%, 95% CI 6.16%-16.7%, versus 20.9%, 95% CI 12.3%-29.5%). Wide confidence intervals suggest these differences are not statistically significant. Patients found the monitoring device to be acceptable in terms of comfort and perceived an enhanced sense of safety, despite 34% discontinuing the intervention early. Conclusions: Remote continuous vital signs monitoring on surgical wards is practical and acceptable to patients. Large, well-controlled studies in high-risk populations are required to determine if the observed trends translate into a significant benefit for continuous over intermittent monitoring. Clinical Trial: The study was prospectively registered on the ISRCTN registry on 19th December 2016 under registry number ISRCTN60999823; URL: https://doi.org/10.1186/ISRCTN60999823.

Early detection of physiological deterioration has been shown to improve patient outcomes. Due to recent improvements in technology, comprehensive outpatient vital signs monitoring is now possible. This is the first review to collate information on all wearable devices on the market for outpatient physiological monitoring. A scoping review was undertaken. The monitors reviewed were limited to those that can function in the outpatient setting with minimal restrictions on the patient’s normal lifestyle, while measuring any or all of the vital signs: heart rate, ECG, oxygen saturation, respiration rate, blood pressure and temperature. A total of 270 papers were included in the review. Thirty wearable monitors were examined: 6 patches, 3 clothing-based monitors, 4 chest straps, 2 upper arm bands and 15 wristbands. The monitoring of vital signs in the outpatient setting is a developing field with differing levels of evidence for each monitor. The most common clinical application was heart rate monitoring. Blood pressure and oxygen saturation measurements were the least common applications. There is a need for clinical validation studies in the outpatient setting to prove the potential of many of the monitors identified. Research in this area is in its infancy. Future research should look at aggregating the results of validity and reliability and patient outcome studies for each monitor and between different devices. This would provide a more holistic overview of the potential for the clinical use of each device.

A high percentage of stroma predicts poor survival in triple-negative breast cancers but is diminished in studies of unselected cases. We determined the prognostic significance of tumour-stroma ratio (TSR) in oestrogen receptor (ER)-positive male and female breast carcinomas. TSR was measured in haematoxylin and eosin-stained tissue sections (118 female and 62 male). Relationship of TSR (cutoff 49%) to overall survival (OS) and relapse-free survival (RFS) was analysed. Tumours with ≥49% stroma were associated with better survival in female (OS P=0.008, HR=0.2-0.7; RFS P=0.006, HR=0.1-0.6) and male breast cancer (OS P=0.005, HR=0.05-0.6; RFS P=0.01, HR=0.87-5.6), confirmed in multivariate analysis. High stromal content was related to better survival in ER-positive breast cancers across both genders, contrasting data in triple-negative breast cancer and highlighting the importance of considering ER status when interpreting the prognostic value of TSR.