BACKGROUNDConsensus recommendations regarding the threshold levels of cardiac troponin elevations for the definition of perioperative myocardial infarction and clinically important periprocedural myocardial injury in patients undergoing cardiac surgery range widely (from >10 times to ≥70 times the upper reference limit for the assay). Limited evidence is available to support these recommendations. METHODS

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Objective To determine if virtual care with remote automated monitoring (RAM) technology versus standard care increases days alive at home among adults discharged after non-elective surgery during the covid-19 pandemic. Design Multicentre randomised controlled trial. Setting 8 acute care hospitals in Canada. Participants 905 adults (≥40 years) who resided in areas with mobile phone coverage and were to be discharged from hospital after non-elective surgery were randomised either to virtual care and RAM (n=451) or to standard care (n=454). 903 participants (99.8%) completed the 31 day follow-up. Intervention Participants in the experimental group received a tablet computer and RAM technology that measured blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, and body weight. For 30 days the participants took daily biophysical measurements and photographs of their wound and interacted with nurses virtually. Participants in the standard care group received post-hospital discharge management according to the centre’s usual care. Patients, healthcare providers, and data collectors were aware of patients’ group allocations. Outcome adjudicators were blinded to group allocation. Main outcome measures The primary outcome was days alive at home during 31 days of follow-up. The 12 secondary outcomes included acute hospital care, detection and correction of drug errors, and pain at 7, 15, and 30 days after randomisation. Results All 905 participants (mean age 63.1 years) were analysed in the groups to which they were randomised. Days alive at home during 31 days of follow-up were 29.7 in the virtual care group and 29.5 in the standard care group: relative risk 1.01 (95% confidence interval 0.99 to 1.02); absolute difference 0.2% (95% confidence interval −0.5% to 0.9%). 99 participants (22.0%) in the virtual care group and 124 (27.3%) in the standard care group required acute hospital care: relative risk 0.80 (0.64 to 1.01); absolute difference 5.3% (−0.3% to 10.9%). More participants in the virtual care group than standard care group had a drug error detected (134 (29.7%) v 25 (5.5%); absolute difference 24.2%, 19.5% to 28.9%) and a drug error corrected (absolute difference 24.4%, 19.9% to 28.9%). Fewer participants in the virtual care group than standard care group reported pain at 7, 15, and 30 days after randomisation: absolute differences 13.9% (7.4% to 20.4%), 11.9% (5.1% to 18.7%), and 9.6% (2.9% to 16.3%), respectively. Beneficial effects proved substantially larger in centres with a higher rate of care escalation. Conclusion Virtual care with RAM shows promise in improving outcomes important to patients and to optimal health system function. Trial registration ClinicalTrials.gov NCT04344665 .

Introduction The “gold standard” diagnostic test for assessing in vitro platelet function, light transmission aggregometry (LTA), has limitations to application because of sample requirements. Whole blood or multiple electrode aggregometry (MEA) using the Multiplate® analyzer (Roche Diagnostics) requires smaller blood volumes and less sample manipulation than LTA, making it an attractive clinical testing option. Direct comparisons of MEA with LTA for diagnosis of platelet aggregation abnormalities are few. Methods Ninety‐nine patients (66 F/33 M; median age 26 [range 2‐86] years), referred for initial laboratory evaluation of mucocutaneous bleeding, had parallel MEA/LTA testing. Concentrations of ADP, arachidonic acid (AA), collagen, and thrombin receptor‐activating peptide (TRAP) that produced threshold responses in normal controls were used for testing patients. Results Twenty‐nine of the 99 patients (30%) had at least one abnormal agonist response by LTA; 15 of these patients had >1 abnormal agonist response. Thirty‐six patients (36%) had at least one abnormal agonist response by MEA; 27 had >1 abnormal agonist response. Sensitivity/specificity of MEA relative to LTA: ADP, 0.70/0.72; AA, 0.71/0.85; collagen, 0.85/0.71; TRAP 0.25/0.84. Negative predictive values (NPVs) for MEA relative to LTA: ADP, 0.90; AA, 0.93; collagen, 0.97; TRAP, 0.96. Conclusions Specific abnormal results of MEA testing did not adequately predict specific abnormalities in LTA testing using threshold agonist concentrations. However, favorable NPVs suggest that MEA may be useful in screening patients for platelet aggregation abnormalities; those with normal MEA results not requiring further diagnostic testing by LTA.