Skin Pigmentation and Pulse Oximeter Accuracy in the Intensive Care Unit: a Pilot Prospective Study.

Rationale: Despite multiple reports of pulse oximeter inaccuracy among hospitalized Black individuals, regulatory testing of pulse oximeters is performed on healthy volunteers. Objective: Evaluate pulse oximeter accuracy among intensive care unit patients with diverse skin pigmentation. Methods: Skin pigmentation was measured using a chromameter in 12 patients and individual typology angle (ITA), a measure of constitutive pigmentation, calculated. Arterial blood gas (ABG) arterial oxygen saturation (SaO 2 ) sampling was precisely matched to pulse oximetry (SpO 2 ) using arterial line waveforms analysis. Error (SpO 2 -SaO 2 ), bias, and average root mean square error (A RMS ) were calculated. Multivariable linear mixed effects models evaluated the association of SpO 2 -SaO 2 with skin pigmentation. Measurements and Main Results: Sampling time was determined for 350 ABGs. Five participants (N=96 ABGs) were darkly pigmented (forehead ITA<-30°), and 7 lighter pigmented (N=254 ABGs). Darkly pigmented individuals had 1.05% bias and 4.15% A RMS compared to 0.34% bias and 1.97% A RMS among lighter pigmented individuals. After adjusting for SaO 2 , pH, heart rate, and mean arterial pressure, SpO 2 -SaO 2 was falsely elevated by 1.00% more among darkly pigmented individuals (95% confidence interval: 0.25-1.76%). SpO 2 significantly overestimated SaO 2 for dark, brown, and tan forehead or forearm pigmentation and brown and tan finger pad pigmentation compared to intermediate/light pigmentation. Conclusions: The pulse oximeter in clinical use at an academic medical center performed worse in darkly pigmented critically ill patients than established criteria for FDA clearance. Pulse oximeter testing in ICU settings is feasible, and could be required by regulators to ensure equivalent device performance by skin pigmentation among patients.

Decoding accelerometry for classification and prediction of critically ill patients with severe brain injury.

Our goal is to explore quantitative motor features in critically ill patients with severe brain injury (SBI). We hypothesized that computational decoding of these features would yield information on underlying neurological states and outcomes. Using wearable microsensors placed on all extremities, we recorded a median 24.1 (IQR: 22.8-25.1) hours of high-frequency accelerometry data per patient from a prospective cohort (n = 69) admitted to the ICU with SBI. Models were trained using time-, frequency-, and wavelet-domain features and levels of responsiveness and outcome as labels. The two primary tasks were detection of levels of responsiveness, assessed by motor sub-score of the Glasgow Coma Scale (GCSm), and prediction of functional outcome at discharge, measured with the Glasgow Outcome Scale-Extended (GOSE). Detection models achieved significant (AUC: 0.70 [95% CI: 0.53-0.85]) and consistent (observation windows: 12 min-9 h) discrimination of SBI patients capable of purposeful movement (GCSm > 4). Prediction models accurately discriminated patients of upper moderate disability or better (GOSE > 5) with 2-6 h of observation (AUC: 0.82 [95% CI: 0.75-0.90]). Results suggest that time series analysis of motor activity yields clinically relevant insights on underlying functional states and short-term outcomes in patients with SBI.

Assessing Sleep Concerns in Individuals With Acquired Brain Injury: The Feasibility of a Smartpad Sleep Tool.

OBJECTIVE: The investigators examined the presence of disrupted sleep in acquired brain injury (ABI) and the utility of a mobile health program, MySleepScript, as an effective clinical tool to detect sleep disturbances. METHODS: A cross-sectional pilot study of MySleepScript, a customizable electronic battery of validated sleep questionnaires, was conducted. Participants were recruited at the Acquired Brain Injury Clinic at Johns Hopkins Bayview Medical Center. RESULTS: Sixty-eight adults with ABI (mean age, 46.3 years [SD=14.8]) participated in the study, with a mean completion time of 16.6 minutes (SD=5.4). Time to completion did not differ on individual completion or staff assistance. The mean score on the Pittsburgh Sleep Quality Index was 9.2 (SD=4.7); 83.9% of individuals had poor sleep quality (defined as a score >5). Insomnia Severity Index scores indicated moderate to severe insomnia in 45% of participants; 36.5% of participants screened positive for symptoms concerning sleep apnea, while 39.3% of individuals screened positive for restless legs syndrome. CONCLUSIONS: Poor sleep quality was highly prevalent in this ABI cohort. MySleepScript may be an effective method of assessing for sleep disturbance in ABI. Further efforts to identify sleep disorders in this patient population should be pursued to optimize ABI management.

International Practice Variability in Treatment of Aneurysmal Subarachnoid Hemorrhage.

Prior research suggests substantial between-center differences in functional outcome following aneurysmal subarachnoid hemorrhage (aSAH). One hypothesis is that these differences are due to practice variability. To characterize practice variability, we sent a survey to 230 centers, of which 145 (63%) responded. Survey respondents indicated that an estimated 65% of ruptured aneurysms were treated endovascularly. Sixty-five percent of aneurysms were treated within 24 h of symptom onset, 18% within 24-48 h, and eight percent within 48-72 h. Centers in the United States (US) and Europe (EU) treat aneurysms more often endovascularly (72% and 70% vs. 51%, respectively, US vs. other p < 0.001, and EU vs. other p < 0.01) and more often within 24 h (77% and 64% vs. 46%, respectively, US vs. other p < 0.001, EU vs. other p < 0.01) compared to other centers. Most centers aim for euvolemia (96%) by administrating intravenous fluids to 0 (53%) or +500 mL/day (41%) net fluid balance. Induced hypertension is more often used in US centers (100%) than in EU (87%, p < 0.05) and other centers (81%, p < 0.05), and endovascular therapies for cerebral vasospasm are used more often in US centers than in other centers (91% and 60%, respectively, p < 0.05). We observed significant practice variability in aSAH treatment worldwide. Future comparative effectiveness research studies are needed to investigate how practice variation leads to differences in functional outcome.

The utility and feasibility of assessing sleep disruption in a men's health clinic using a mobile health platform device: A pilot study.

INTRODUCTION: Evidence linking sleep disruption and sexual dysfunction in men is mounting; yet the characterisation of sleep patterns and complaints utilising a clinically feasible method within this patient population remain largely under-reported. AIM: A pilot study aiming to demonstrate a clinically feasible method to characterise the sleep patterns and complaints in a representative sample of patients treated in a men's health clinic. METHODS: Male patients (n = 48) completed a battery of validated sleep questionnaires using an mHealth mobile platform, MySleepScript, at the Johns Hopkins Men's Health and Vitality Center. Metrics related to clinical feasibility such as completion time, ease of use, preference of electronic format, and patient satisfaction were also collected. MAIN OUTCOME MEASURES: Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Berlin Questionnaire, Patient Health Questionnaire (PHQ-9), and Primary Care PTSD Screen (PC-PTSD). RESULTS: Primary urological chief symptoms for this sample patient population were erectile dysfunction (ED; 80%), hypogonadism (40%), benign prostatic hyperplasia/lower urinary tract symptoms (BPH/LUTS; 40%) and Peyronie's disease (10%). Mean PSQI score was 7.8 [SD 4.2], with 67% of all patients falling within the "poor sleeper" range. At least mild symptoms of depression were noted in 40% and 43% were at risk for obstructive sleep apnea (OSA) on the Berlin Questionnaire. CONCLUSIONS: This pilot study demonstrated the feasibility and potential utility of an mHealth platform to assist clinicians, within a men's health clinic, in detecting sleep disturbances. Disrupted sleep was revealed in well over half of this sample of patients. As a result of the growing evidence linking poor sleep and sleep disorders (eg, OSA) to the conditions relevant to men's health (eg, erectile dysfunction, hypogonadism and BPH), further efforts beyond this pilot study are necessary to identify the aetiological processes underlying the association between specific disrupted sleep disorders and urological conditions.

Predicting Hemorrhagic Transformation of Acute Ischemic Stroke: Prospective Validation of the HeRS Score.

Hemorrhagic transformation (HT) increases the morbidity and mortality of ischemic stroke. Anticoagulation is often indicated in patients with atrial fibrillation, low ejection fraction, or mechanical valves who are hospitalized with acute stroke, but increases the risk of HT. Risk quantification would be useful. Prior studies have investigated risk of systemic hemorrhage in anticoagulated patients, but none looked specifically at HT. In our previously published work, age, infarct volume, and estimated glomerular filtration rate (eGFR) significantly predicted HT. We created the hemorrhage risk stratification (HeRS) score based on regression coefficients in multivariable modeling and now determine its validity in a prospectively followed inpatient cohort.A total of 241 consecutive patients presenting to 2 academic stroke centers with acute ischemic stroke and an indication for anticoagulation over a 2.75-year period were included. Neuroimaging was evaluated for infarct volume and HT. Hemorrhages were classified as symptomatic versus asymptomatic, and by severity. HeRS scores were calculated for each patient and compared to actual hemorrhage status using receiver operating curve analysis.Area under the curve (AUC) comparing predicted odds of hemorrhage (HeRS score) to actual hemorrhage status was 0.701. Serum glucose (P < 0.001), white blood cell count (P < 0.001), and warfarin use prior to admission (P = 0.002) were also associated with HT in the validation cohort. With these variables, AUC improved to 0.854. Anticoagulation did not significantly increase HT; but with higher intensity anticoagulation, hemorrhages were more likely to be symptomatic and more severe.The HeRS score is a valid predictor of HT in patients with ischemic stroke and indication for anticoagulation.