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Karolcik S, Manginas V, Chanh HQ, Daniels J, Giang NT, Huyen VNT, Hoang MTV, Phan Nguyen Quoc K, Hernandez B, Ming DK, Nguyen Van H, Phan TQ, Trieu HT, Luong Thi Hue T, Holmes AH, Thwaites L, Phan Vinh T, Yacoub S, Georgiou P. Towards a machine-learning assisted non-invasive classification of dengue severity using wearable PPG data: a prospective clinical study. EBioMedicine 2024; 104:105164. [PMID: 38815363 DOI: 10.1016/j.ebiom.2024.105164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 04/28/2024] [Accepted: 05/07/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Dengue epidemics impose considerable strain on healthcare resources. Real-time continuous and non-invasive monitoring of patients admitted to the hospital could lead to improved care and outcomes. We evaluated the performance of a commercially available wearable (SmartCare) utilising photoplethysmography (PPG) to stratify clinical risk for a cohort of hospitalised patients with dengue in Vietnam. METHODS We performed a prospective observational study for adult and paediatric patients with a clinical diagnosis of dengue at the Hospital for Tropical Disease, Ho Chi Minh City, Vietnam. Patients underwent PPG monitoring early during admission alongside standard clinical care. PPG waveforms were analysed using machine learning models. Adult patients were classified between 3 severity classes: i) uncomplicated (ward-based), ii) moderate-severe (emergency department-based), and iii) severe (ICU-based). Data from paediatric patients were split into 2 classes: i) severe (during ICU stay) and ii) follow-up (14-21 days after the illness onset). Model performances were evaluated using standard classification metrics and 5-fold stratified cross-validation. FINDINGS We included PPG and clinical data from 132 adults and 15 paediatric patients with a median age of 28 (IQR, 21-35) and 12 (IQR, 9-13) years respectively. 1781 h of PPG data were available for analysis. The best performing convolutional neural network models (CNN) achieved a precision of 0.785 and recall of 0.771 in classifying adult patients according to severity class and a precision of 0.891 and recall of 0.891 in classifying between disease and post-disease state in paediatric patients. INTERPRETATION We demonstrate that the use of a low-cost wearable provided clinically actionable data to differentiate between patients with dengue of varying severity. Continuous monitoring and connectivity to early warning systems could significantly benefit clinical care in dengue, particularly within an endemic setting. Work is currently underway to implement these models for dynamic risk predictions and assist in individualised patient care. FUNDING EPSRC Centre for Doctoral Training in High-Performance Embedded and Distributed Systems (HiPEDS) (Grant: EP/L016796/1) and the Wellcome Trust (Grants: 215010/Z/18/Z and 215688/Z/19/Z).
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Affiliation(s)
- Stefan Karolcik
- Centre for Bio-Inspired Technology, Imperial College London, South Kensington Campus, London, SW7 2AZ, United Kingdom.
| | - Vasileos Manginas
- Centre for Bio-Inspired Technology, Imperial College London, South Kensington Campus, London, SW7 2AZ, United Kingdom
| | - Ho Quang Chanh
- Oxford University Clinical Research Unit (OUCRU), Hospital for Tropical Diseases, Ho Chi Minh City, 700000, Viet Nam
| | - John Daniels
- Centre for Bio-Inspired Technology, Imperial College London, South Kensington Campus, London, SW7 2AZ, United Kingdom
| | - Nguyen Thi Giang
- Oxford University Clinical Research Unit (OUCRU), Hospital for Tropical Diseases, Ho Chi Minh City, 700000, Viet Nam
| | - Vu Ngo Thanh Huyen
- Oxford University Clinical Research Unit (OUCRU), Hospital for Tropical Diseases, Ho Chi Minh City, 700000, Viet Nam
| | - Minh Tu Van Hoang
- Oxford University Clinical Research Unit (OUCRU), Hospital for Tropical Diseases, Ho Chi Minh City, 700000, Viet Nam
| | - Khanh Phan Nguyen Quoc
- Oxford University Clinical Research Unit (OUCRU), Hospital for Tropical Diseases, Ho Chi Minh City, 700000, Viet Nam
| | - Bernard Hernandez
- Centre for Bio-Inspired Technology, Imperial College London, South Kensington Campus, London, SW7 2AZ, United Kingdom
| | - Damien K Ming
- Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Campus, London, W12 0NN, United Kingdom
| | - Hao Nguyen Van
- Oxford University Clinical Research Unit (OUCRU), Hospital for Tropical Diseases, Ho Chi Minh City, 700000, Viet Nam
| | - Tu Qui Phan
- Oxford University Clinical Research Unit (OUCRU), Hospital for Tropical Diseases, Ho Chi Minh City, 700000, Viet Nam
| | - Huynh Trung Trieu
- Oxford University Clinical Research Unit (OUCRU), Hospital for Tropical Diseases, Ho Chi Minh City, 700000, Viet Nam
| | - Tai Luong Thi Hue
- Oxford University Clinical Research Unit (OUCRU), Hospital for Tropical Diseases, Ho Chi Minh City, 700000, Viet Nam
| | - Alison H Holmes
- Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Campus, London, W12 0NN, United Kingdom
| | - Louise Thwaites
- Oxford University Clinical Research Unit (OUCRU), Hospital for Tropical Diseases, Ho Chi Minh City, 700000, Viet Nam
| | - Tho Phan Vinh
- Oxford University Clinical Research Unit (OUCRU), Hospital for Tropical Diseases, Ho Chi Minh City, 700000, Viet Nam
| | - Sophie Yacoub
- Oxford University Clinical Research Unit (OUCRU), Hospital for Tropical Diseases, Ho Chi Minh City, 700000, Viet Nam
| | - Pantelis Georgiou
- Centre for Bio-Inspired Technology, Imperial College London, South Kensington Campus, London, SW7 2AZ, United Kingdom
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Loi MV, Wang QY, Lee JH. Fluid management in children with severe dengue: a narrative review. Minerva Pediatr (Torino) 2023; 75:49-61. [PMID: 36282485 DOI: 10.23736/s2724-5276.22.06935-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Dengue is a mosquito-borne arboviral infection of increasing public health importance. Globally, children account for a significant proportion of infections. No pathogen-specific treatment currently exists, and the current approach to reducing disease burden is focused on preventative strategies such as vector control, epidemiological interventions, and vaccination in selected populations. Once infected, the mainstay of treatment is supportive, of which appropriate fluid management is a cornerstone. The timely provision of fluid boluses has historically been central to the management of septic shock. However, in patients with dengue shock, particular emphasis is placed on judicious fluid administration. Certain colloids such as hydroxyethyl starches and dextran, despite no longer being used routinely in intensive care units due to concerns of acute kidney injury and impairment of coagulation, are still commonly used in dengue shock syndrome. Current guidelines recommend initial crystalloid therapy, with consideration of colloids for severe or recalcitrant shock in patients with dengue. In this review, we discuss the pathophysiology of septic shock, and consider whether any differences in dengue exist that may warrant a separate approach to fluid therapy. We critically review the available evidence for fluid management in dengue, including the role of colloids. In dengue, there is increasing recognition of the importance of tailoring fluid therapy to phases of disease, with attention to the need for fluid "deresuscitation" once the critical phase of vascular leak passes.
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Affiliation(s)
- Mervin V Loi
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore -
| | - Qi Y Wang
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Malaya, Kuala Lumpur, Malaysia
| | - Jan H Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
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3
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Trieu HT, Khanh LP, Ming DKY, Quang CH, Phan TQ, Van VCN, Deniz E, Mulligan J, Wills BA, Moulton S, Yacoub S. The compensatory reserve index predicts recurrent shock in patients with severe dengue. BMC Med 2022; 20:109. [PMID: 35387649 PMCID: PMC8986451 DOI: 10.1186/s12916-022-02311-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 02/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dengue shock syndrome (DSS) is one of the major clinical phenotypes of severe dengue. It is defined by significant plasma leak, leading to intravascular volume depletion and eventually cardiovascular collapse. The compensatory reserve Index (CRI) is a new physiological parameter, derived from feature analysis of the pulse arterial waveform that tracks real-time changes in central volume. We investigated the utility of CRI to predict recurrent shock in severe dengue patients admitted to the ICU. METHODS We performed a prospective observational study in the pediatric and adult intensive care units at the Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam. Patients were monitored with hourly clinical parameters and vital signs, in addition to continuous recording of the arterial waveform using pulse oximetry. The waveform data was wirelessly transmitted to a laptop where it was synchronized with the patient's clinical data. RESULTS One hundred three patients with suspected severe dengue were recruited to this study. Sixty-three patients had the minimum required dataset for analysis. Median age was 11 years (IQR 8-14 years). CRI had a negative correlation with heart rate and moderate negative association with blood pressure. CRI was found to predict recurrent shock within 12 h of being measured (OR 2.24, 95% CI 1.54-3.26), P < 0.001). The median duration from CRI measurement to the first recurrent shock was 5.4 h (IQR 2.9-6.8). A CRI cutoff of 0.4 provided the best combination of sensitivity and specificity for predicting recurrent shock (0.66 [95% CI 0.47-0.85] and 0.86 [95% CI 0.80-0.92] respectively). CONCLUSION CRI is a useful non-invasive method for monitoring intravascular volume status in patients with severe dengue.
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Affiliation(s)
- Huynh Trung Trieu
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam. .,Oxford University Clinical Research Unit, 764 Vo Van Kiet, District 5, Ho Chi Minh City, Vietnam.
| | - Lam Phung Khanh
- Oxford University Clinical Research Unit, 764 Vo Van Kiet, District 5, Ho Chi Minh City, Vietnam.,University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | | | - Chanh Ho Quang
- Oxford University Clinical Research Unit, 764 Vo Van Kiet, District 5, Ho Chi Minh City, Vietnam
| | - Tu Qui Phan
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | | | | | - Bridget Ann Wills
- Oxford University Clinical Research Unit, 764 Vo Van Kiet, District 5, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK
| | - Steven Moulton
- Context Data Analytics Ltd, Longmont, CO, USA.,Department of Surgery, University of Colorado School of Medicine, CO, Aurora, USA
| | - Sophie Yacoub
- Oxford University Clinical Research Unit, 764 Vo Van Kiet, District 5, Ho Chi Minh City, Vietnam.,Centre for Antimicrobial Optimisation, Imperial College London, London, UK
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Rodriguez SA, Morgan GJ, Lara C, Zablah JE. Baseline Values of the Compensatory Reserve Index in a Healthy Pediatric Population. Pediatr Cardiol 2022; 43:344-349. [PMID: 34586457 DOI: 10.1007/s00246-021-02725-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
The objective of this study is to describe the compensatory reserve index (CRI) baseline values in a healthy cohort of healthy pediatric patients and evaluate the existing correlation with other physiological parameters that influence compensatory hemodynamic mechanisms. CRI is a computational algorithm that has been broadly applied to non-invasively estimate hemodynamic vascular adaptations during acute blood loss. So far, there is a lack of baseline values from healthy individuals, which complicates accurately estimating the severity of the hemodynamic compromise. Additionally, the application of this technology in pediatric populations is limited to a few reports, highlighting a marked variability by age, weight, and other physiological parameters. The CRI of 205 healthy subjects from 0 to 60 years of age were prospectively evaluated from January to February 2020 at several public outpatient clinics in El Salvador; vital signs and sociodemographic data were also collected during this period. After data collection, baseline values were classified for each age group. Multiple correlation models were tested between the CRI and the other physiological parameters. CRI value varies significantly for each age group, finding for patients under 18 years old a mean value lower than 0.6, which is currently considered the lower normal limit for adults. CRI presents strong correlations with other physiological variables such as age, weight, estimated blood volume, and heart rate (R > 0.8, R2 > 0.6, p < 0.0001). There is significant variability in the CRI normal values observed in healthy patients based on age, weight, estimated blood volume, and heart rate.
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Affiliation(s)
- Salvador A Rodriguez
- The Heart Institute, Children's Hospital Colorado, Box 100, 13123 East 16th Avenue, 80045, Aurora, CO, USA. .,School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.
| | - Gareth J Morgan
- The Heart Institute, Children's Hospital Colorado, Box 100, 13123 East 16th Avenue, 80045, Aurora, CO, USA.,School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.,Department of Cardiology, University of Colorado Hospital, Aurora, CO, USA
| | - Claudia Lara
- Departamento de Pediatría, Universidad Dr. José Matías Delgado, Antiguo Cuscatlán, El Salvador
| | - Jenny E Zablah
- The Heart Institute, Children's Hospital Colorado, Box 100, 13123 East 16th Avenue, 80045, Aurora, CO, USA.,School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
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Ming DK, Hernandez B, Sangkaew S, Vuong NL, Lam PK, Nguyet NM, Tam DTH, Trung DT, Tien NTH, Tuan NM, Chau NVV, Tam CT, Chanh HQ, Trieu HT, Simmons CP, Wills B, Georgiou P, Holmes AH, Yacoub S. Applied machine learning for the risk-stratification and clinical decision support of hospitalised patients with dengue in Vietnam. PLOS DIGITAL HEALTH 2022; 1:e0000005. [PMID: 36812518 PMCID: PMC9931311 DOI: 10.1371/journal.pdig.0000005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/15/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Identifying patients at risk of dengue shock syndrome (DSS) is vital for effective healthcare delivery. This can be challenging in endemic settings because of high caseloads and limited resources. Machine learning models trained using clinical data could support decision-making in this context. METHODS We developed supervised machine learning prediction models using pooled data from adult and paediatric patients hospitalised with dengue. Individuals from 5 prospective clinical studies in Ho Chi Minh City, Vietnam conducted between 12th April 2001 and 30th January 2018 were included. The outcome was onset of dengue shock syndrome during hospitalisation. Data underwent random stratified splitting at 80:20 ratio with the former used only for model development. Ten-fold cross-validation was used for hyperparameter optimisation and confidence intervals derived from percentile bootstrapping. Optimised models were evaluated against the hold-out set. FINDINGS The final dataset included 4,131 patients (477 adults and 3,654 children). DSS was experienced by 222 (5.4%) of individuals. Predictors were age, sex, weight, day of illness at hospitalisation, indices of haematocrit and platelets over first 48 hours of admission and before the onset of DSS. An artificial neural network model (ANN) model had best performance with an area under receiver operator curve (AUROC) of 0.83 (95% confidence interval [CI], 0.76-0.85) in predicting DSS. When evaluated against the independent hold-out set this calibrated model exhibited an AUROC of 0.82, specificity of 0.84, sensitivity of 0.66, positive predictive value of 0.18 and negative predictive value of 0.98. INTERPRETATION The study demonstrates additional insights can be obtained from basic healthcare data, when applied through a machine learning framework. The high negative predictive value could support interventions such as early discharge or ambulatory patient management in this population. Work is underway to incorporate these findings into an electronic clinical decision support system to guide individual patient management.
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Affiliation(s)
- Damien K. Ming
- Department of Infectious Disease, Imperial College London, United Kingdom
- * E-mail:
| | - Bernard Hernandez
- Centre for Antimicrobial Optimisation, Imperial College London, United Kingdom
- Centre for BioInspired Technology, Imperial College London, United Kingdom
| | - Sorawat Sangkaew
- Centre for Antimicrobial Optimisation, Imperial College London, United Kingdom
| | - Nguyen Lam Vuong
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Phung Khanh Lam
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Nguyen Minh Nguyet
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Dong Thi Hoai Tam
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Dinh The Trung
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Nguyen Thi Hanh Tien
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Nguyen Minh Tuan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Children’s Hospital 1, Ho Chi Minh City, Vietnam
| | - Nguyen Van Vinh Chau
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Cao Thi Tam
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Ho Quang Chanh
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Huynh Trung Trieu
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Cameron P. Simmons
- Institute of Vector Borne Disease, Monash University, Clayton, Australia
| | - Bridget Wills
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Pantelis Georgiou
- Centre for Antimicrobial Optimisation, Imperial College London, United Kingdom
- Centre for BioInspired Technology, Imperial College London, United Kingdom
| | - Alison H. Holmes
- Centre for Antimicrobial Optimisation, Imperial College London, United Kingdom
| | - Sophie Yacoub
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
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Convertino VA, Koons NJ, Suresh MR. Physiology of Human Hemorrhage and Compensation. Compr Physiol 2021; 11:1531-1574. [PMID: 33577122 DOI: 10.1002/cphy.c200016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Hemorrhage is a leading cause of death following traumatic injuries in the United States. Much of the previous work in assessing the physiology and pathophysiology underlying blood loss has focused on descriptive measures of hemodynamic responses such as blood pressure, cardiac output, stroke volume, heart rate, and vascular resistance as indicators of changes in organ perfusion. More recent work has shifted the focus toward understanding mechanisms of compensation for reduced systemic delivery and cellular utilization of oxygen as a more comprehensive approach to understanding the complex physiologic changes that occur following and during blood loss. In this article, we begin with applying dimensional analysis for comparison of animal models, and progress to descriptions of various physiological consequences of hemorrhage. We then introduce the complementary side of compensation by detailing the complexity and integration of various compensatory mechanisms that are activated from the initiation of hemorrhage and serve to maintain adequate vital organ perfusion and hemodynamic stability in the scenario of reduced systemic delivery of oxygen until the onset of hemodynamic decompensation. New data are introduced that challenge legacy concepts related to mechanisms that underlie baroreflex functions and provide novel insights into the measurement of the integrated response of compensation to central hypovolemia known as the compensatory reserve. The impact of demographic and environmental factors on tolerance to hemorrhage is also reviewed. Finally, we describe how understanding the physiology of compensation can be translated to applications for early assessment of the clinical status and accurate triage of hypovolemic and hypotensive patients. © 2021 American Physiological Society. Compr Physiol 11:1531-1574, 2021.
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Affiliation(s)
- Victor A Convertino
- Battlefield Healthy & Trauma Center for Human Integrative Physiology, United States Army Institute of Surgical Research, JBSA San Antonio, Texas, USA
| | - Natalie J Koons
- Battlefield Healthy & Trauma Center for Human Integrative Physiology, United States Army Institute of Surgical Research, JBSA San Antonio, Texas, USA
| | - Mithun R Suresh
- Battlefield Healthy & Trauma Center for Human Integrative Physiology, United States Army Institute of Surgical Research, JBSA San Antonio, Texas, USA
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Ming DK, Sangkaew S, Chanh HQ, Nhat PTH, Yacoub S, Georgiou P, Holmes AH. Continuous physiological monitoring using wearable technology to inform individual management of infectious diseases, public health and outbreak responses. Int J Infect Dis 2020; 96:648-654. [PMID: 32497806 PMCID: PMC7263257 DOI: 10.1016/j.ijid.2020.05.086] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 05/15/2020] [Accepted: 05/23/2020] [Indexed: 01/12/2023] Open
Abstract
Optimal management of infectious diseases is guided by up-to-date information at the individual and public health levels. For infections of global importance, including emerging pandemics such as COVID-19 or prevalent endemic diseases such as dengue, identifying patients at risk of severe disease and clinical deterioration can be challenging, considering that the majority present with a mild illness. In our article, we describe the use of wearable technology for continuous physiological monitoring in healthcare settings. Deployment of wearables in hospital settings for the management of infectious diseases, or in the community to support syndromic surveillance during outbreaks, could provide significant, cost-effective advantages and improve healthcare delivery. We highlight a range of promising technologies employed by wearable devices and discuss the technical and ethical issues relating to implementation in the clinic, focusing on low- and middle- income countries. Finally, we propose a set of essential criteria for the rollout of wearable technology for clinical use.
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Affiliation(s)
- Damien K Ming
- NIHR-Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK; Centre for Antimicrobial Optimisation (CAMO), Imperial College London, UK.
| | - Sorawat Sangkaew
- NIHR-Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK; Department of Family Medicine, Hat Yai Regional Hospital, Thailand
| | - Ho Q Chanh
- Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Viet Nam
| | - Phung T H Nhat
- Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Viet Nam
| | - Sophie Yacoub
- Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Viet Nam; Centre for Tropical Medicine and Global Health, University of Oxford, UK
| | | | - Alison H Holmes
- NIHR-Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK; Centre for Antimicrobial Optimisation (CAMO), Imperial College London, UK
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8
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Convertino VA, Koons NJ. The compensatory reserve: potential for accurate individualized goal-directed whole blood resuscitation. Transfusion 2020; 60 Suppl 3:S150-S157. [PMID: 32478902 DOI: 10.1111/trf.15632] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 11/29/2022]
Abstract
Hemorrhagic shock can be mitigated by timely and accurate resuscitation designed to restore adequate delivery of oxygen (DO2 ). Current doctrine of using systolic blood pressure (SBP) as a guide for resuscitation can be associated with increased morbidity. The compensatory reserve measurement (CRM) is a novel vital sign based on the recognition that the sum of all mechanisms that contribute to the compensatory response to hemorrhage reside in features of the arterial pulse waveform. CRM can be assessed continuously and non-invasively in real time. Compared to standard vital signs, CRM provides an early, as well as more sensitive and specific, indicator of patient hemorrhagic status since the activation of compensatory mechanisms occurs immediately at the onset of blood loss. Recent data obtained from our laboratory experiments on non-human primates have demonstrated that CRM is linearly related to DO2 during controlled progressive hemorrhage and subsequent whole blood resuscitation. We used this relationship to determine that the time of hemodynamic decompensation (i.e., CRM = 0%) is defined by a critical DO2 at approximately 5.3 mL O2 ∙kg-1 ∙min-1 . We also demonstrated that a target CRM of 35% during whole blood resuscitation only required replacement of 40% of the total blood volume loss to adequately sustain a DO2 more than 50% (i.e., 8.1 mL O2 ∙kg-1 ∙min-1 ) above critical DO2 (i.e., threshold for decompensated shock) while maintaining hypotensive resuscitation (i.e., SBP at ~90 mmHg). Consistent with our hypothesis, specific values of CRM can be used to accurately maintain DO2 thresholds above critical DO2 , avoiding the onset of hemorrhagic shock with whole blood resuscitation.
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Affiliation(s)
- Victor A Convertino
- Battlefield Health & Trauma Center for Human Integrative Physiology, United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Natalie J Koons
- Battlefield Health & Trauma Center for Human Integrative Physiology, United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
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Leopold DK, Phillips RC, Shahi N, Gien J, Marwan AI, Kinsella JP, Mulligan J, Liechty KW, Moulton SL. Low postnatal CRI values are associated with the need for ECMO in newborns with CDH. J Pediatr Surg 2020; 55:39-44. [PMID: 31679772 DOI: 10.1016/j.jpedsurg.2019.09.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 09/29/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Accurate, real-time technology is needed to predict which newborns with congenital diaphragmatic hernia (CDH) will require ECMO. The Compensatory Reserve Index (CRI) is a noninvasive monitoring technology that continuously trends an individual's capacity to compensate from normovolemia (CRI = 1) to decompensation (CRI = 0). We hypothesized that postnatal CRI values would be lower in CDH newborns that required ECMO than those who did not require ECMO. METHODS Newborns with a CDH were prospectively monitored with a CipherOx® CRI M1 device. We compared CRI values from delivery to ECMO (ECMO group) versus delivery to clinical stabilization (non-ECMO group). RESULTS Postnatal CRI values were available from 26 newborns. Eight underwent ECMO within 33 h of delivery, and median CRI prior to ECMO was 0.068 (IQR: 0.057, 0.078). Eighteen did not require ECMO. Median CRI from birth to 48 h was 0.112 (IQR: 0.082, 0.15). CRI values were significantly lower in newborns that required ECMO versus those who did not (p = 0.0035). Postnatal CRI had the highest AUC (0.85) compared to other prenatal prognostic measures. CONCLUSION Humans from newborns to adults share elemental features of the pulsatile waveform that are associated with progression to decompensation. CRI may be helpful when deciding when to initiate ECMO. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Diagnostic test.
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Affiliation(s)
- David K Leopold
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO.
| | - Ryan C Phillips
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Niti Shahi
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Jason Gien
- Department of Pediatrics, Division of Neonatology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Ahmed I Marwan
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - John P Kinsella
- Department of Pediatrics, Division of Neonatology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | | | - Kenneth W Liechty
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Steven L Moulton
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO; Flashback Technologies Inc., Louisville, CO
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10
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Schlotman TE, Lehnhardt KR, Abercromby AF, Easter BD, Downs ME, Akers LTCKS, Convertino VA. Bridging the gap between military prolonged field care monitoring and exploration spaceflight: the compensatory reserve. NPJ Microgravity 2019; 5:29. [PMID: 31815179 PMCID: PMC6893012 DOI: 10.1038/s41526-019-0089-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 10/31/2019] [Indexed: 01/03/2023] Open
Abstract
The concept of prolonged field care (PFC), or medical care applied beyond doctrinal planning timelines, is the top priority capability gap across the US Army. PFC is the idea that combat medics must be prepared to provide medical care to serious casualties in the field without the support of robust medical infrastructure or resources in the event of delayed medical evacuation. With limited resources, significant distances to travel before definitive care, and an inability to evacuate in a timely fashion, medical care during exploration spaceflight constitutes the ultimate example PFC. One of the main capability gaps for PFC in both military and spaceflight settings is the need for technologies for individualized monitoring of a patient's physiological status. A monitoring capability known as the compensatory reserve measurement (CRM) meets such a requirement. CRM is a small, portable, wearable technology that uses a machine learning and feature extraction-based algorithm to assess real-time changes in hundreds of specific features of arterial waveforms. Future development and advancement of CRM still faces engineering challenges to develop ruggedized wearable sensors that can measure waveforms for determining CRM from multiple sites on the body and account for less than optimal conditions (sweat, water, dirt, blood, movement, etc.). We show here the utility of a military wearable technology, CRM, which can be translated to space exploration.
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Affiliation(s)
- Taylor E. Schlotman
- United States Army Institute of Surgical Research 3698 Chambers Pass, Bldg. 3611 JBSA Fort Sam, Houston, TX 78234 USA
| | | | | | | | - Meghan E. Downs
- NASA Johnson Space Center, 2101 E NASA Pkwy, Houston, TX 77058 USA
| | - L. T. C. Kevin S. Akers
- United States Army Institute of Surgical Research 3698 Chambers Pass, Bldg. 3611 JBSA Fort Sam, Houston, TX 78234 USA
| | - Victor A. Convertino
- United States Army Institute of Surgical Research 3698 Chambers Pass, Bldg. 3611 JBSA Fort Sam, Houston, TX 78234 USA
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Suresh MR, Chung KK, Schiller AM, Holley AB, Howard JT, Convertino VA. Unmasking the Hypovolemic Shock Continuum: The Compensatory Reserve. J Intensive Care Med 2018; 34:696-706. [PMID: 30068251 DOI: 10.1177/0885066618790537] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Hypovolemic shock exists as a spectrum, with its early stages characterized by subtle pathophysiologic tissue insults and its late stages defined by multi-system organ dysfunction. The importance of timely detection of shock is well known, as early interventions improve mortality, while delays render these same interventions ineffective. However, detection is limited by the monitors, parameters, and vital signs that are traditionally used in the intensive care unit (ICU). Many parameters change minimally during the early stages, and when they finally become abnormal, hypovolemic shock has already occurred. The compensatory reserve (CR) is a parameter that represents a new paradigm for assessing physiologic status, as it comprises the sum total of compensatory mechanisms that maintain adequate perfusion to vital organs during hypovolemia. When these mechanisms are overwhelmed, hemodynamic instability and circulatory collapse will follow. Previous studies involving CR measurements demonstrated their utility in detecting central blood volume loss before hemodynamic parameters and vital signs changed. Measurements of the CR have also been used in clinical studies involving patients with traumatic injuries or bleeding, and the results from these studies have been promising. Moreover, these measurements can be made at the bedside, and they provide a real-time assessment of hemodynamic stability. Given the need for rapid diagnostics when treating critically ill patients, CR measurements would complement parameters that are currently being used. Consequently, the purpose of this article is to introduce a conceptual framework where the CR represents a new approach to monitoring critically ill patients. Within this framework, we present evidence to support the notion that the use of the CR could potentially improve the outcomes of ICU patients by alerting intensivists to impending hypovolemic shock before its onset.
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Affiliation(s)
- Mithun R Suresh
- 1 Battlefield Health & Trauma Center for Human Integrative Physiology, US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | - Kevin K Chung
- 2 Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,3 Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Alicia M Schiller
- 4 Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Aaron B Holley
- 2 Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,3 Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jeffrey T Howard
- 1 Battlefield Health & Trauma Center for Human Integrative Physiology, US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | - Victor A Convertino
- 1 Battlefield Health & Trauma Center for Human Integrative Physiology, US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
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Platelet Count, D-Dimer, Component Therapy and Dengue Hemorrhagic Fever. Indian J Hematol Blood Transfus 2018; 34:370-371. [DOI: 10.1007/s12288-017-0861-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/04/2017] [Indexed: 10/18/2022] Open
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Choi YM, Leopold D, Campbell K, Mulligan J, Grudic GZ, Moulton SL. Noninvasive monitoring of physiologic compromise in acute appendicitis: New insight into an old disease. J Pediatr Surg 2018; 53:241-246. [PMID: 29217323 DOI: 10.1016/j.jpedsurg.2017.11.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 11/08/2017] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Physiologic compromise in children with acute appendicitis has heretofore been difficult to measure. We hypothesized that the Compensatory Reserve Index (CRI), a novel adjunctive cardiovascular status indicator, would be low for children presenting with acute appendicitis in proportion to their physiological compromise, and that CRI would rise with fluid resuscitation and surgical management of their disease. METHODS Ninety-four children diagnosed with acute appendicitis were monitored with a CipherOx CRI™ M1 pulse oximeter (Flashback Technologies Inc., Boulder, CO). For clarity, CRI=1 indicates supine normovolemia, CRI=0 indicates hemodynamic decompensation (systolic blood pressure<80mmHg), and CRI values between 1 and 0 indicate the proportion of volume reserve remaining before collapse. Results are presented as counts with proportion (%), or mean with 95% confidence interval (CI). RESULTS Mean age was 11years old (95% CI: 10-12), and 49 (52%) of the children were male. Fifty-four (57%) had nonperforated appendicitis and 40 (43%) had perforated appendicitis. Mean initial CRI was significantly higher in those with nonperforated appendicitis compared to those with perforated appendicitis (0.57, 95% CI: 0.52-0.63 vs. 0.36, 95% CI: 0.29-0.43; P<0.001). The significant differences in mean CRI values between the two groups remained throughout the course of treatment, but lost its significance at 2h after surgery (0.63, 95% CI: 0.57-0.70 vs. 0.53, 95% CI: 0.46-0.61; P=0.05). CONCLUSION Low CRI values in children with perforated appendicitis are indicative of their lower reserve capacity owing to peritonitis and hypovolemia. CRI offers a real-time, noninvasive adjunctive tool to monitor tolerance to volume loss in children. LEVEL OF EVIDENCE Study of diagnostic test; Level of evidence: Level III.
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Affiliation(s)
- Young Mee Choi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - David Leopold
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Kristen Campbell
- Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | - Steven L Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Flashback Technologies, Inc., Boulder, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
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Ahmed A, Tanveer M, Khan GM, Imran M. Dengue fever again in Pakistan: are we going in the right direction? Public Health 2017; 152:153-156. [PMID: 28892674 DOI: 10.1016/j.puhe.2017.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 06/18/2017] [Accepted: 07/25/2017] [Indexed: 10/18/2022]
Affiliation(s)
- A Ahmed
- Department of Pharmacy, Quaid I Azam University, Islamabad, Pakistan
| | - M Tanveer
- Department of Pharmacy, Quaid I Azam University, Islamabad, Pakistan
| | - G M Khan
- Department of Pharmacy, Quaid I Azam University, Islamabad, Pakistan.
| | - M Imran
- University College of Pharmacy, Punjab University, Lahore, Pakistan
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Convertino VA, Sawka MN. Wearable technology for compensatory reserve to sense hypovolemia. J Appl Physiol (1985) 2017; 124:442-451. [PMID: 28751369 DOI: 10.1152/japplphysiol.00264.2017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Traditional monitoring technologies fail to provide accurate or early indications of hypovolemia-mediated extremis because physiological systems (as measured by vital signs) effectively compensate until circulatory failure occurs. Hypovolemia is the most life-threatening physiological condition associated with circulatory shock in hemorrhage or sepsis, and it impairs one's ability to sustain physical exertion during heat stress. This review focuses on the physiology underlying the development of a novel noninvasive wearable technology that allows for real-time evaluation of the cardiovascular system's ability to compensate to hypovolemia, or its compensatory reserve, which provides an individualized estimate of impending circulatory collapse. Compensatory reserve is assessed by real-time changes (sampled millions of times per second) in specific features (hundreds of features) of arterial waveform analog signals that can be obtained from photoplethysmography using machine learning and feature extraction techniques. Extensive experimental evidence employing acute reductions in central blood volume (using lower-body negative pressure, blood withdrawal, heat stress, dehydration) demonstrate that compensatory reserve provides the best indicator for early and accurate assessment for compromises in blood pressure, tissue perfusion, and oxygenation in resting human subjects. Engineering challenges exist for the development of a ruggedized wearable system that can measure signals from multiple sites, improve signal-to-noise ratios, be customized for use in austere conditions (e.g., battlefield, patient transport), and be worn during strenuous physical activity.
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Affiliation(s)
- Victor A Convertino
- Battlefield Health & Trauma Center for Human Integrative Physiology, U. S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, Texas
| | - Michael N Sawka
- School of Biological Sciences, Georgia Institute of Technology , Atlanta, Georgia
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