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Implementing early warning messages on emerging health technologies.

The purpose of this study was to determine how horizon-scanning organizations can encourage the implementation of recommendations contained in their early warning messages about emerging health technologies. We reviewed the conclusions of the EUR-ASSESS Project Subgroup report on dissemination and impact, an overview of systematic reviews of interventions to promote implementation of research findings by health care professionals, and various Cochrane Effective Practice and Organisation of Care Group protocols and reviews. The evidence on the effectiveness of different implementation strategies aimed at distinct target groups is of variable quality. There is some evidence from rigorous study designs on the effectiveness of strategies designed to influence the behavior of health care professionals; the quality of the evidence relating to policy makers and the general public is more limited. Horizon-scanning organizations can improve the likelihood of their recommendations being acted upon by developing active implementation strategies based on the best available evidence, establishing links with key groups, and directing early warning messages at specific target audiences. Given the relative lack of good quality evidence, it is important that implementation strategies be rigorously evaluated to determine their effectiveness.

Diffusion of Innovation↗

An analysis of an early-warning system to reduce abortions in dairy cattle in Denmark incorporating both financial and epidemiologic aspects.

Emergency preparedness relies on the ability to detect patterns in rare incidents in an early stage of an outbreak in order to implement relevant actions. Early warning of an abortion storm as a result of infection with a notifiable disease, e.g. brucellosis, bovine viral diarrhea (BVD) or infectious bovine rhinotracheitis (IBR), is a significant surveillance tool. This study used data from 507 large Danish dairy herds. A modified two-stage method for detecting an unusual increase in the abortion incidence was applied to the data. An alarm was considered true if an abortion were detected in the month following the alarm month, otherwise false. The total number of abortions that could potentially be avoided if effective action were taken ranged from 769 (22.9%) to 10 (0.3%), as the number of abortions required to set the alarm increased from 1 to 6. The vast majority of abortions could, however, not be predicted, much less prevented, given this early-warning system. The false to true alarm ratio was reduced when the number of abortions that set the alarm increased. The financial scenarios evaluated demonstrated that the value of an abortion, the cost of responding to an alarm and the efficiency of the actions are important for decision making when reporting an alarm. The presented model can readily be extended to other disease problems and multiple-time periods.

Abortion, Veterinary↗

The use of passive environmental TLDs in the operation of the Spanish early warning network 'REVIRA'.

As required by different international agreements, the regulatory body in Spain (Consejo de Seguridad Nuclear) implemented in 1992 a national automatic network (REVIRA) that continuously monitors radiation levels in order to give early warning of incidents having potential transboundary implications. The detector for environmental gamma-radiation dose rate is an active instrument based on a Geiger-Müller counter. However, the use of passive environmental dosemeters provides an additional low-cost dose estimate with an independent centralised calibration and even better basic features than active instruments. Since 1999, all 25 REVIRA stations have been monitored with passive TL environmental dosemeters based on LiF:Mg,Cu,P and operated according to the procedures established at Ciemat. This paper presents the obtained results and the further analysis considering differences in aspects such as photon energy response, inherent background or response to cosmic rays. The benefits of the use of passive environmental dosemeters in early warning networks are discussed.

Air Pollution, Radioactive↗

The CURB65 pneumonia severity score outperforms generic sepsis and early warning scores in predicting mortality in community-acquired pneumonia.

BACKGROUND: The performance of CURB65 in predicting mortality in community-acquired pneumonia (CAP) has been tested in two large observational studies. However, it has not been tested against generic sepsis and early warning scores, which are increasingly being advocated for identification of high-risk patients in acute medical wards. METHOD: A retrospective analysis was performed of data prospectively collected for a CAP quality improvement study. The ability to stratify mortality and performance characteristics (sensitivity, specificity, positive predictive value, negative predictive value and area under the receiver operating curve) were calculated for stratifications of CURB65, CRB65, the systemic inflammatory response syndrome (SIRS) criteria and the standardised early warning score (SEWS). RESULTS: 419 patients were included in the main analysis with a median age of 74 years (men = 47%). CURB65 and CRB65 stratified mortality in a more clinically useful way and had more favourable operating characteristics than SIRS or SEWS; for example, mortality in low-risk patients was 2% when defined by CURB65, but 9% when defined by SEWS and 11-17% when defined by variations of the SIRS criteria. The sensitivity, specificity, positive predictive value and negative predictive value of CURB65 was 71%, 69%, 35% and 91%, respectively, compared with 62%, 73%, 35% and 89% for the best performing version of SIRS and 52%, 67%, 27% and 86% for SEWS. CURB65 had the greatest area under the receiver operating curve (0.78 v 0.73 for CRB65, 0.68 for SIRS and 0.64 for SEWS). CONCLUSIONS: CURB65 should not be supplanted by SIRS or SEWS for initial prognostic assessment in CAP. Further research to identify better generic prognostic tools is required.

Adolescent↗

Prodromal symptoms vs. early warning signs and clinical action in schizophrenia.

The term "prodromal symptoms" has traditionally referred to prepsychotic changes in thought, affect, and cognition that precede the initial onset of schizophrenia. Recently, however, the term has been extended into a clinical action context to refer to the early warning signs (EWS) of impending relapse in patients already diagnosed as having schizophrenia. However, recent reports reviewed by Norman and Malla (1995, this issue) use a narrow definition of prodromal symptoms and question their use in the clinical action context. We argue that the dual use of the term "prodromal symptoms" has led to conceptual confusion and to the impression that EWS cannot be used effectively for clinical action. The ability to base clinical action on EWS is central to schizophrenia therapeutics and is the cornerstone of pharmacological strategies based on early intervention. Our review of the evidence suggests that the effective clinical use of EWS depends on (1) the inclusion of both psychotic and nonpsychotic symptoms as EWS; (2) the use of clinician judgment in combination with predefined symptom changes to define the occurrence of EWS; (3) frequent clinical visits; and (4) the use of family or caregiver informants. We therefore suggest that, in the clinical action context, the terminology "early warning signs of impending relapse" should be used instead.

Anti-Anxiety Agents↗

Noninvasive hemodynamic monitoring for early warning of adult respiratory distress syndrome in trauma patients.

PURPOSE: Traditionally hemodynamic patterns after adult respiratory distress syndrome (ARDS) are described after appropriate diagnostic criteria have been met, but studies begun after the diagnosis of ARDS miss the antecedent circulatory influences that may contribute to its development. This study tests the hypothesis that noninvasive monitoring before the appearance of ARDS may reveal early circulatory deficiencies that lead to this disorder. The aims of this study are as follows: (1) to describe the time course of hemodynamic and tissue perfusion patterns in severely traumatized postoperative patients from the period immediately after admission and during surgical repair to the time that ARDS developed or to hospital discharge in patients who did not develop ARDS, (2) to compare the time course of these patterns in survivors and nonsurvivors of ARDS, and (3) to suggest that reduced flow and perfusion may be early warning signs of ARDS. Prospective descriptive study of severely injured trauma patients noninvasively monitored in the emergency department, operating room, and intensive care unit (ICU). Early hemodynamic pattems were described in the surviving and nonsurviving patients who subsequently developed ARDS. The study was performed in a University-affiliated Level I trauma center and ICU. PATIENTS AND METHODS: A consecutively monitored series of 60 severely injured patients were prospectively monitored by cardiac output, pulse oximetry (Sapo2), and transcutaneous O2 and co2 (Ptco2 and Ptc(co2)) sensors immediately after emergency admission. Twenty-nine patients developed ARDS in their ICU course, whereas 31 were discharged from the ICU and the hospital without developing ARDS. RESULTS: Patients who developed ARDS had significantly lower cardiac index and Ptco2 and higher Ptc(co2) values beginning with the early stage compared with those who did not develop ARDS. Nonsurvivors of ARDS had lower Ptco2 values than did the survivors. CONCLUSION: Early noninvasive monitoring in the emergency department, operating room, and ICU showed reduced cardiac and tissue perfusion functions in patients who subsequently developed ARDS. These patterns were more pronounced in the ARDS patients who died; these patterns may serve as early warning of ARDS.

Adult↗

Using higher organisms in biological early warning systems for real-time toxicity detection.

Many biological early warning systems (BEWS) have been developed in recent years that evaluate the physiological and behavioral responses of whole organisms to water quality. Using a fish ventilatory monitoring system developed at the US Army Centre for Environmental Health Research as an example, we illustrate the operation of a BEWS at a groundwater treatment facility. During a recent 12-month period, the fish ventilatory system was operational for 99% of the time that the treatment facility was on-line. Effluent-exposed fish responded as a group about 2.8% of the time. While some events were due to equipment problems or non-toxic water quality variations, the fish system did indicate effluent anomalies that were subsequently identified and corrected. The fish monitoring BEWS increased treatment facility engineers' awareness of effluent quality and provided an extra measure of assurance to regulators and the public. Many operational and practical considerations for whole organism BEWS are similar to those for cell- or tissue-based biosensors. An effective biomonitoring system may need to integrate the responses of several biological and chemical sensors to achieve desired operational goals. Future development of an 'electronic canary', analogous to the original canary in the coal mine, could draw upon advances in signal processing and communication to establish a network of sensors in a watershed and to provide useful real-time information on water quality.

Animals↗

Physiological abnormalities in early warning scores are related to mortality in adult inpatients.

BACKGROUND: Early warning scores using physiological measurements may help identify ward patients who are, or who may become, critically ill. We studied the value of abnormal physiology scores to identify high-risk hospital patients. METHODS: On a single day we recorded the following data from 433 adult non-obstetric inpatients: respiratory rate, heart rate, systolic pressure, temperature, oxygen saturation, level of consciousness, urine output for catheterized patients, age and inspired oxygen. We also noted the care required and given. RESULTS: Twenty-six patients (6%) died within 30 days. They were significantly older than survivors (P<0.001). Their median hospital stay was 26 days (interquartile range 16-39). Mortality increased with the number of physiological abnormalities (P<0.001), being 0.7% with no abnormalities, 4.4% with one, 9.2% with two and 21.3% with three or more. Patients receiving a lower level of care than desirable also had an increased mortality (P<0.01). Logistic regression modelling identified level of consciousness, heart rate, age, systolic pressure and respiratory rate as important variables in predicting outcome. CONCLUSIONS: Simple physiological observations identify high-risk hospital inpatients. Those who die are often inpatients for days or weeks before death, allowing time for clinicians to intervene and potentially change outcome. Access to critical care beds could decrease mortality.

Adult↗

Early warning system in the Czech Republic.

Since the 1950's early warning networks (EWN) for monitoring of the radiation situation on the state territory have been established in the most European countries. In the Czech republic the radiation monitoring network exists, but new requirements, especially after accident at the Chernobyl nuclear power plants, called for restructure of EWN so that be able of permanent and telemetrized measurements. Based on these requirements, the program of the EWN establishment in the Czech republic is prepared. The realization is planned in two phases--in the first one 40 telemetrized measuring places in professional observatories of the Czech Hydrometereological Institute and in the network of measuring points of air contamination will be established. In the second phase EWN will be supplemented with selected (about 30) measuring stations of Automatic Immission Monitoring and measuring points of the Czech Army.

Czech Republic↗

Extracellular sensing components and extracellular induction component alarmones give early warning against stress in Escherichia coli.

The work reported here follows from the proposal that, for efficient induction of numerous extracellular stress responses, cultures contain extracellular stress-sensing molecules, termed extracellular sensing components (ESCs). These are directly converted to extracellular induction components (EICs) by stresses, thus providing an early warning system against stress, with very rapid responses occurring on exposure to increasing levels of stress. Although some stress responses appear to involve activation of intracellular sensors, the proposed ESCs and EICs function for many stress tolerance and sensitization responses and for several cross-tolerance and cross-sensitization responses. Because EICs can induce responses in unstressed cells, and because they are small molecules that can diffuse away from the site of formation, they can be considered to be 'alarmones', both warning unstressed organisms of future stress and preparing both stressed and unstressed ones to resist it. Therefore, EICs produced by one group of organisms could affect another group i.e. there could be 'cross-talk' (cell-to-cell communication) with other organisms in an area, to which the EICs diffuse, that has not yet faced the stress. In particular, stimuli that switch on acid tolerance, alkali tolerance, pH sensitization responses and alkylhydroperoxide tolerance are detected by ESCs; these molecules can give rise to EICs in the presence of the stress without organisms needing to be present. Not only does the ESC-EIC interconversion allow rapid switching on of responses, but for some responses it also allows rapid switching off. For some ESCs, the sensor can be modified by the culture conditions, modification leading to altered responsiveness to stress; such sensor changes appear to have evolved to allow the most efficient responses to stress to occur, under defined sets of conditions. In addition, the receptors on the organisms that interact with EICs are modified by culture conditions, so that extracellular components that function as ESCs for some cultures can act as EICs for others. In view of their role in early warning of stress, EICs and ESCs are likely to have important functions in the natural environment, especially in natural waters, in foods and food preparation and production, in hospital, domestic and commercial locations, and in the animal and human body. Findings of major importance relate to the extreme stress tolerance of some EICs. For example, because the acid-tolerance EIC formed at pH 5.0 is a heat-resistant molecule, heat-killed suspensions of acid-tolerant cultures can confer acid tolerance on living E. coli; cultures killed by extreme acidity and alkalinity and by exposure to high levels of UV irradiation or novobiocin are also able to confer acid tolerance on living E. coli. Extracellular components that inhibit induction of stress responses also occur in enterobacteria, since it has been found that AMP and HCO3-, which inhibit acid-tolerance induction, do so by forming extracellular agents that block the functioning of EICs. Similar agents to the above EICs and ESCs may occur in other non-stress-related processes. Systems using these extracellular components are quite distinct in their properties from quorum-sensing systems in Gram-negative bacteria and from those systems that use small peptides in intercellular communication and which induce virulence-related enzyme synthesis in Staphylococcus aureus and competence in streptococci and bacilli. Additionally, probably because the ESCs have evolved to become modified by cultural conditions, the components in the stress-related systems, although relatively small proteins, are much larger than the extracellular components used in the quorum-sensing processes and related systems. It is possible that the extracellular 'protectants' of Nikolaev, which protect E. coli from stress, act similarly to the EICs described here, e.g. by inducing stress tolerance. The antimutagenic factor of Vorobjeva may act similarly, although there is no evidence, so far, to suggest that it acts by inducing tolerance to mutagens.

Anti-Bacterial Agents↗

Automated DNA sequence-based early warning system for the detection of methicillin-resistant Staphylococcus aureus outbreaks.

BACKGROUND: The detection of methicillin-resistant Staphylococcus aureus (MRSA) usually requires the implementation of often rigorous infection-control measures. Prompt identification of an MRSA epidemic is crucial for the control of an outbreak. In this study we evaluated various early warning algorithms for the detection of an MRSA cluster. METHODS AND FINDINGS: Between 1998 and 2003, 557 non-replicate MRSA strains were collected from staff and patients admitted to a German tertiary-care university hospital. The repeat region of the S. aureus protein A (spa) gene in each of these strains was sequenced. Using epidemiological and typing information for the period 1998-2002 as reference data, clusters in 2003 were determined by temporal-scan test statistics. Various early warning algorithms (frequency, clonal, and infection control professionals [ICP] alerts) were tested in a prospective analysis for the year 2003. In addition, a newly implemented automated clonal alert system of the Ridom StaphType software was evaluated. A total of 549 of 557 MRSA were typeable using spa sequencing. When analyzed using scan test statistics, 42 out of 175 MRSA in 2003 formed 13 significant clusters (p < 0.05). These clusters were used as the "gold standard" to evaluate the various algorithms. Clonal alerts (spa typing and epidemiological data) were 100% sensitive and 95.2% specific. Frequency (epidemiological data only) and ICP alerts were 100% and 62.1% sensitive and 47.2% and 97.3% specific, respectively. The difference in specificity between clonal and ICP alerts was not significant. Both methods exhibited a positive predictive value above 80%. CONCLUSIONS: Rapid MRSA outbreak detection, based on epidemiological and spa typing data, is a suitable alternative for classical approaches and can assist in the identification of potential sources of infection.

Algorithms↗

RSV-prevention in children guided by a web-based early warning system.

BACKGROUND: Passive immunization with palivizumab is expensive and requires considerable logistic effort. So far 5 monthly injections from November to March are recommended. The RSV season onset and its duration, however, shows considerable variation. In many countries on the northern hemisphere a dual rhythm is described. METHOD: A web-based early warning system within the research network PID-ARI.net is in place since 2002. The surveillance data are published online weekly via www.pid-ari.net. This enables physicians to carry out interventions, like passive immunization for RSV, synchronously with the epidemiology of a given pathogen instead of a rigid schedule. The surveillance of PID-ARI.net is based on a 19 valent multiplex RT-PCR on naso-pharyngeal aspirates. The samples are provided by hospitals and offices in Freiburg, Mainz and Schleswig-Holstein (north, middle, south of Germany). Children with lower airway infections are prospectively enrolled. RESULTS: In the time period from July 1999 to June 2003 with 20 months of recommended palivizumab application, 5 months (25 %) would have been not on target. In two seasons the start of the vaccine campaign would have been too early (waste of two months). In one season the application would have started one month too late and in two seasons the vaccine campaign would have been stopped two months too early leaving the vaccinees on risk for acquiring RSV. CONCLUSIONS: The web-based early warning system of PID-ARI.net is the first, pathogen-specific, comprehensive and fast surveillance-system for airway pathogens in Europe. It facilitates the epidemic-synchronous use of the passive immunization with palivizumab and by this increases its efficiency and should safe costs.

Antibodies, Monoclonal↗

Promoting care for acutely ill children-development and evaluation of a paediatric early warning tool.

The primary purpose of this paper was to develop and evaluate a physiologically based system for the identification of acutely ill children in hospital environments. The dependency of children in hospital is increasing and ensuring the appropriate and timely intervention by a team of health personnel experienced in the care of these children is paramount to ensure their optimal outcome. A paediatric early warning (PEW) tool was designed and demographic and physiological data collected on all children (n = 360) who triggered the tool over a 6-month period, between September 2003 and February 2004. Analysis of the data was undertaken on each criterion within the tool and by reviewing it against patient outcome, the decision for its retention or removal was made. The modified tool showed a 99% sensitivity and a 66% specificity. The resultant Paediatric Early Warning Tool has been validated for use in a tertiary children's hospital in the United Kingdom (UK). The use of such a tool by all staff caring for acutely ill children in hospital environments can help to ensure their early recognition and timely treatment. The tool together with an action plan must, however, be appropriate for use in individual ward or hospital areas.

Child↗

The critical care outreach service and the early warning system on surgical wards.

The implementation and evaluation of a modified early warning system (MEWS) on surgical wards are described. The MEWS was found to be a useful adjunct to the outreach service. Early data have shown that MEWS can help direct critical intervention. Ward staff have benefit from both the MEWS and the outreach service.

Critical Care↗

[Detection of early warning signs in schizophrenic patients. Possible applications in prevention of recurrence].

In the treatment of schizophrenia, two new strategies have been developed with the aim of adequate relapse prevention accompanied by lowest possible risk of side-effects. One strategy is to have the patient continue to take medication at a highly reduced dosage (10-20% of the standard dose). The other is to gradually stop neuroleptic medication after remission and to reinstitute medication only in the case of prodromal symptoms (termed targeted or intermittent treatment). According to Herz and Melville [13] many schizophrenic patients show signs of relapse well before recurrence of overt psychotic features. Monitoring to detect prodromal symptoms is especially important in targeted treatment because, otherwise, neuroleptic medication often cannot be initiated in time. In the present study of 51 schizophrenic patients we were able to replicate the results of Herz & Melville in the German-speaking countries. Prior to acute exacerbation of psychosis, most patients experience alterations of feelings and behaviour. These alterations may also be recognized by family members. Such early warning signs of relapse mainly consist of non-specific, non-psychotic symptoms: tenseness and nervousness, eating less, trouble concentrating and sleeping, depressive mood and seeing friends less. Furthermore, the regular monitoring and use of early warning signs specific to each patient in the aftercare of schizophrenic patients seems to be practicable, especially in psychoeducative family therapy.

Adult↗

Transcutaneous oxygen and CO2 as early warning of tissue hypoxia and hemodynamic shock in critically ill emergency patients.

BACKGROUND: Although cardiac and pulmonary function can be measured precisely, evaluation of tissue perfusion remains elusive because it usually is inferred from subjective symptoms and imprecise signs of shock. The latter are indirect criteria used to assess the overall circulatory status as well as tissue perfusion but are not direct quantitative measures of perfusion. However, noninvasive transcutaneous oxygen (PtcO2) and carbon dioxide (PtcCO2) tensions, which directly measure skin oxygenation and CO2 retention, may be used to objectively evaluate skin oxygenation and perfusion in emergency patients beginning with resuscitation immediately after hospital admission. OBJECTIVE: This study was a preliminary evaluation of tissue oxygenation and perfusion by objective PtcO2 and PtcCO2 patterns in severely injured surviving and nonsurviving patients; specifically, the aim was to describe time patterns that may be used as early warning signs of circulatory dysfunction and death. DESIGN: Prospective descriptive study of a consecutive series of severely injured emergency patients. SETTING: University-affiliated Level I trauma center and intensive care unit. PATIENTS AND METHODS: Forty-eight consecutive severely injured patients were prospectively monitored by PtcO2 and PtcCO2 sensors immediately after emergency admission. RESULTS: Compared with survivors, patients who died had significantly lower PtcO2 and higher PtcCO2 values beginning with the early stage of resuscitation. All patients who maintained PtcO2 >150 torr (19.99 kPa) throughout monitoring survived. Periods of PtcO2 <50 torr (6.66 kPa) for >60 mins or PtcCO2 >60 torr (8.00 kPa) for >30 mins were associated with 90% mortality and 100% morbidity. CONCLUSION: PtcO2 and PtcCO2 monitoring continuously evaluate tissue perfusion and serve as early warning in critically injured patients during resuscitation immediately after hospital admission.

Adult↗

[The motility test, an early warning system for biological water control].

A satisfying continuous control of waters on toxicants by chemical and physical analysis is not possible, and therefore biological methods must be used in addition. Hereby the fish test obtained special importance. To perform this test qualified experimental fish are put into the water, which should be controlled, and the effect of the water upon the fish is observed. As is known fish react to every small change of the quality of water by changing their motility behaviour. Consequently, the most sensitive fish test method is a Motility Test, then with it toxicants appearing in waters can be registered already in such low concentrations, by which the test fish feel disturbed first only in their well-being. Thus, the Motility Test can be used as "early warning system" in the biological control of waters. The prior condition to perform the Motility Test is a reliable technique for registrating the body movements if fish. Well qualified is the principle of magnet induction. Hereto the test fish is marked by a small permanent magnet and kept in the sensitive area of a wire coil. If the fish moves, voltage impulses are induced in the coil, which are registered as measure of the animal moving activity. In this work the practicability of the Motility Test by means of magnet marked trouts (Salmo gairdneri, 260-320 g) was checked: In the first series of tests the "normal" motility of trouts in freshwater was registered. Thereby, the influence of feeding, of a hiding shelter, of holding in groups, and of the water temperature upon the spontaneous activity of the fish was studied. In the second series of tests the chemo-physical quality of the water was modified (O2-decrease, CO2-increase, pH-change), and the changes of the motility of the test trouts effected thereby were registered. In the third series of tests there was measured the motor reaction of trouts upon some toxicants (ammonia, nitrite, phenol, detergents, zinc) given into the water. The results are shown by some representative actograms. In addition "reaction values" (toxicant concentration in the water) determined in the tests at the beginning of the motor unrest of the fish were listed in a table. According to the positive results obtained in all these tests the Motility Test by means of magnet marked trouts can be recommended as an useful early warning system for the biological control of waters.

Animals↗

Brood indicators are an early warning signal of honey bee colony loss-a simulation-based study.

Honey bees (Apis mellifera) are exposed to multiple stressors such as pesticides, lack of forage, and diseases. It is therefore a long-standing aim to develop robust and meaningful indicators of bee vitality to assist beekeepers While established indicators often focus on expected colony winter mortality based on adult bee abundance and honey reserves at the beginning of the winter, it would be useful to have indicators that allow detection of stress effects earlier in the year to allow for adaptive management. We used the established honey bee simulation model BEEHAVE to explore the potential of different indicators such as population size, number of capped brood cells, flight activity, abundance of Varroa mites, honey stores and a brood-bee ratio. We implemented two types of stressors in our simulations: 1) parasite pressure, i.e. sub-optimal Varroa treatment by the beekeeper (hereafter referred as Biotic stress) and 2) temporal forage gaps in spring and autumn (hereafter referred as Environmental stress). Neither stressor type could be detected by bee abundance or honey reserves at the end of the first year. However, all response variables used in this study did reveal early warning signals during the course of the year. The most reliable and useful measures seem to be related to brood and the abundance of Varroa mites at the end of the year. However, while in the model we have full access to time series of variables from stressed and unstressed colonies, knowledge of these variables in the field is challenging. We discuss how our findings can nevertheless be used to develop practical early warning indicators. As a next step in the interactive development of such indicators we suggest empirical studies on the importance of the number of capped brood cells at certain times of the year on bee population vitality.

Bees↗