RESUMEN
OBJECTIVE: Infants with single ventricle physiology have arterial oxygen saturations between 75 and 85%. Home monitoring with daily pulse oximetry is associated with improved interstage survival. They are typically sent home with expensive, bulky, hospital-grade pulse oximeters. This study evaluates the accuracy of both the currently used Masimo LNCS and a relatively inexpensive, portable, and equipped with Bluetooth technology study device, by comparing with the gold standard co-oximeter. DESIGN: Prospective, observational study. SETTING: Single institution, paediatric cardiac critical care unit, and neonatal ICU. INTERVENTIONS: none. PATIENTS: Twenty-four infants under 12 months of age with baseline oxygen saturation less than 90% due to cyanotic CHD. MEASUREMENTS AND RESULTS: Pulse oximetry with WristOx2 3150 with infant sensors 8008 J (study device) and Masimo LCNS saturation sensor connected to a Philips monitor (hospital device) were measured simultaneously and compared to arterial oxy-haemoglobin saturation measured by co-oximetry. Statistical analysis evaluated the performances of each and compared to co-oximetry with Schuirmann's TOST equivalence tests, with equivalence defined as an absolute difference of 5% saturation or less. Neither the study nor the hospital device met the predefined standard for equivalence when compared with co-oximetry. The study device reading was on average 4.0% higher than the co-oximeter, failing to show statistical equivalence (p = 0.16). The hospital device was 7.4% higher than the co-oximeter and also did not meet the predefined standard for equivalence (p = 0.97). CONCLUSION: Both devices tended to overestimate oxygen saturation in this patient population when compared to the gold standard, co-oximetry. The study device is at least as accurate as the hospital device and offers the advantage of being more portable with Bluetooth technology that allows reliable, efficient data transmission. Currently FDA-approved, smaller portable pulse oximeters can be considered for use in home monitoring programmes.
Asunto(s)
Cardiopatías Congénitas/sangre , Oximetría/instrumentación , Oxígeno/sangre , California , Femenino , Humanos , Lactante , Recién Nacido , Unidades de Cuidado Intensivo Neonatal , Unidades de Cuidado Intensivo Pediátrico , Masculino , Monitoreo Fisiológico/instrumentación , Estudios Prospectivos , Reproducibilidad de los ResultadosRESUMEN
RATIONALE: Asthma management depends on prompt identification of symptoms, which challenges both patients and providers. In asthma, a misapprehension of health between exacerbations can compromise compliance. Thus, there is a need for a tool that permits objective longitudinal monitoring without increasing the burden of patient compliance. OBJECTIVES: We sought to determine whether changes in nocturnal physiology are associated with asthma symptoms in pediatric patients. METHODS: Using a contactless bed sensor, nocturnal heart rate (HR), respiratory rate, relative stroke volume, and movement in children with asthma 5-18 years of age (n = 16) were recorded. Asthma symptoms and asthma control test (ACT) score were reported every 2 weeks. Random forest model was used to identify physiologic parameters associated with asthma symptoms. Elastic net regression was used to identify variables associated with ACT score. MEASUREMENTS AND MAIN RESULTS: The model on the full cohort performed with sensitivity of 47.2%, specificity of 96.3%, and accuracy of 87.4%; HR and respiratory parameters were the most important variables in this model. The model predicted asthma symptoms 35% of the time on the day before perception of symptoms, and 100% of the time for a select subject for which the model performed with greater sensitivity. Multivariable and bivariable analyses demonstrated significant association between HR and respiratory rate parameters and ACT score. CONCLUSIONS: Nocturnal physiologic changes correlate with asthma symptoms, supporting the notion that nocturnal physiologic monitoring represents an objective diagnostic tool capable of longitudinally assessing disease control and predicting asthma exacerbations in children with asthma at home.
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Asma/diagnóstico , Asma/fisiopatología , Monitoreo Fisiológico/métodos , Adolescente , Niño , Preescolar , Ritmo Circadiano , Estudios de Cohortes , Progresión de la Enfermedad , Diagnóstico Precoz , Femenino , Frecuencia Cardíaca/fisiología , Humanos , Estudios Longitudinales , Masculino , Estudios Prospectivos , Reproducibilidad de los Resultados , Frecuencia Respiratoria/fisiología , Sensibilidad y Especificidad , Volumen Sistólico/fisiologíaRESUMEN
OBJECTIVES: Prior studies have shown inaccuracies in pulse oximetry readings at saturations less than 85%; however, no large studies have evaluated new sensors marketed for these low saturations. This study's purpose was to evaluate two sensors with claims of improved accuracy in children with saturations less than 85%. DESIGN: Prospective observational study. SETTING: Single institution; cardiac catheterization laboratory, and operating room. PATIENTS: Fifty patients weighing 3-20 kg with baseline saturations less than 90% undergoing surgical or catheterization procedure. MEASUREMENTS AND MAIN RESULTS: Data collected included demographics, diagnosis, continuous saturations from three different pulse oximeters (Masimo LNCS [Masimo, Irvine, CA], Masimo Blue [Masimo], and Nellcor Max-I [Medtronic, Dublin, Ireland]) and up to four blood samples for co-oximetry as the gold-standard arterial oxygen saturation. Analysis included scatter plots, smoothed regression estimates of mean continuous saturation levels plotted against corresponding arterial oxygen saturation values, and Bland-Altman plots. Bland-Altman analysis indicated increasing levels of bias and variability for decreasing arterial oxygen saturation levels for all three sensors, with a statistically significant increase in mean difference observed for decreasing arterial oxygen saturation level. The Masimo Blue sensor had the lowest mean difference, SD and Bland-Altman limits in patients with saturations less than or equal to 85%. At saturation range of less than or equal to 85% and greater than 75%, 14% of the samples obtained from Masimo Blue, 24% of the readings from the Nellcor, and 31% from the Masimo Standard sensors were greater than or equal to 5% points difference. All three sensors had a further increase in these differences for arterial oxygen saturation values less than 75%. CONCLUSIONS: The Masimo Blue sensor has improved accuracy at saturations 75-85% versus the Nellcor and Masimo Standard sensors. The accuracy of peripheral capillary oxygen saturation of the Masimo Blue sensor was within 5% points of the arterial oxygen saturation the majority of the time. Currently, at saturations less than or equal to 85%, pulse oximetry alone should not be relied on in making clinical decisions.
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Hipoxia/diagnóstico , Oximetría/instrumentación , Oxígeno/sangre , Niño , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Oximetría/normas , Estudios Prospectivos , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: Brugada syndrome (BrS) can be difficult to diagnose and treat, especially in the young patient. As there is currently no consensus on the evaluation and treatment of BrS in the pediatric population, we sought to describe the current practice for the diagnosis and treatment of BrS among pediatric electrophysiologists. METHODS: A web-based survey was distributed to 204 physician members (MDs) of The Pediatric and Adult Congenital Electrophysiology Society (PACES). Practice characteristics, BrS patient attributes, and diagnostic and therapeutic preferences were collected. RESULTS: Responses were obtained from 83 pediatric electrophysiologists. The most common initial presentation was family history. There is a large variation in testing, particularly in the use of electrophysiology (EP) studies, drug challenge testing, and genetic testing. Despite limited treatment options, there is only consensus in the therapeutic approach to the pediatric patient with symptomatic BrS with 97% of physicians recommending an implantable cardioverter defibrillator (ICD). In the asymptomatic patient, a wide variation in therapy was seen with only 27% of physicians recommending an ICD CONCLUSIONS: Significant practice variation exists among pediatric electrophysiologists with deviation from accepted diagnostic and therapeutic practices for adult BrS patients. Further studies are necessary to establish best practice guidelines for BrS in the pediatric EP community.
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Antiarrítmicos/uso terapéutico , Síndrome de Brugada/diagnóstico , Síndrome de Brugada/terapia , Electrofisiología Cardíaca/estadística & datos numéricos , Desfibriladores Implantables/estadística & datos numéricos , Técnicas Electrofisiológicas Cardíacas/estadística & datos numéricos , Pediatría/estadística & datos numéricos , Niño , Femenino , Encuestas de Atención de la Salud , Humanos , Internacionalidad , Masculino , Pautas de la Práctica en Medicina/estadística & datos numéricosRESUMEN
Right ventricular failure is a significant complication following implantation of a left ventricular assist device (LVAD), which increases morbidity and mortality. Consequently, researchers have sought predictors that may identify patients at risk. However, they have lacked sensitivity and/or specificity. This study investigated the use of a decision tree technology to explore the preoperative data space for combinatorial relationships that may be more accurate and precise. We retrospectively analyzed the records of 183 patients with initial LVAD implantation at the Artificial Heart Program, University of Pittsburgh Medical Center, between May 1996 and October 2009. Among those patients, 27 later required a right ventricular assist device (RVAD+) and 156 remained on LVAD (RVAD-) until the time of transplantation or death. A synthetic minority oversampling technique (SMOTE) was applied to the RVAD+ group to compensate for the disparity of sample size. Twenty-one resampling levels were evaluated, with decision tree model built for each. Among these models, the top six predictors of the need for an RVAD were transpulmonary gradient (TPG), age, international normalized ratio (INR), heart rate (HR), aspartate aminotransferase (AST), prothrombin time, and right ventricular systolic pressure. TPG was identified to be the most predictive variable in 15 out of 21 models, and constituted the first splitting node with 7 mmHg as the breakpoint. Oversampling was shown to improve the senstivity of the models monotonically, although asymptotically, while the specificity was diminished to a lesser degree. The model built upon 5X synthetic RVAD+ oversampling was found to provide the best compromise between sensitivity and specificity, included TPG (layer 1), age (layer 2), right atrial pressure (layer 3), HR (layer 4,7), INR (layer 4, 9), alanine aminotransferase (layer 5), white blood cell count (layer 5,6, &7), the number of inotrope agents (layer 6), creatinine (layer 8), AST (layer 9, 10), and cardiac output (layer 9). It exhibited 85% sensitivity, 83% specificity, and 0.87 area under the receiver operating characteristic curve (RoC), which was found to be greatly improved compared to previously published studies.
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Insuficiencia Cardíaca/diagnóstico , Corazón Auxiliar , Disfunción Ventricular Izquierda/cirugía , Disfunción Ventricular Derecha/fisiopatología , Árboles de Decisión , Insuficiencia Cardíaca/fisiopatología , Humanos , Modelos Estadísticos , Pronóstico , Estudios RetrospectivosRESUMEN
BACKGROUND: Right ventricular (RV) failure is a significant complication after implantation of a left ventricular assist device (LVAD). It is therefore important to identify patients at risk a priori. However, prognostic models derived from multivariate analyses have had limited predictive power. METHODS: This study retrospectively analyzed the records of 183 LVAD recipients between May 1996 and October 2009; of these, 27 later required a RVAD (RVAD(+)) and 156 remained on LVAD only (RVAD(-)) until transplant or death. A decision tree model was constructed to represent combinatorial non-linear relationships of the pre-operative data that are predictive of the need for RVAD support. RESULTS: An optimal set of 8 pre-operative variables were identified: transpulmonary gradient, age, right atrial pressure, international normalized ratio, heart rate, white blood cell count, alanine aminotransferase, and the number of inotropic agents. The resultant decision tree, which consisted of 28 branches and 15 leaves, identified RVAD(+) patients with 85% sensitivity, RVAD(-) patients with 83% specificity, and exhibited an area under the receiver operating characteristic curve of 0.87. CONCLUSIONS: The decision tree model developed in this study exhibited several advantages compared with existing risk scores. Quantitatively, it provided improved prognosis of RV support by encoding the non-linear, synergic interactions among pre-operative variables. Because of its intuitive structure, it more closely mimics clinical reasoning and therefore can be more readily interpreted. Further development with additional multicenter, longitudinal data may provide a valuable prognostic tool for triage of LVAD therapy and, potentially, improve outcomes.