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Russell MK, Horton JF, Clermont CA, Demarty JM, Transfiguracion LC, Worobets BR, Pineda ME, Santaniemi N, Stergiou P, Asmussen MJ, Day TA. Validation of Polar Elixir™ Pulse Oximeter against Arterial Blood Gases during Stepwise Steady-State Inspired Hypoxia. Med Sci Sports Exerc 2024; 56:1585-1594. [PMID: 38635406 DOI: 10.1249/mss.0000000000003460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
PURPOSE The purpose of this study was to evaluate the accuracy of peripheral oxygen saturation (SpO 2 ) measurements from Polar Elixir™ pulse oximetry technology compared with arterial oxygen saturation (SaO 2 ) measurements during acute stepwise steady-state inspired hypoxia at rest. A post hoc objective was to determine if SpO 2 measurements could be improved by recalibrating the Polar Elixir™ algorithm with SaO 2 values from a random subset of participants. METHODS The International Organization for Standardization (ISO) protocol (ISO 80601-2-61:2017) for evaluating the SpO 2 accuracy of pulse oximeter equipment was followed whereby five plateaus of SaO 2 between 70% and 100% were achieved using stepwise reductions in inspired O 2 during supine rest. Blood samples drawn through a radial arterial catheter from 25 participants were first used to compare SaO 2 with SpO 2 measurements from Polar Elixir™. Then the Polar Elixir™ algorithm was recalibrated using SaO 2 data from 13 random participants, and SpO 2 estimates were recalculated for the other 12 participants. For SaO 2 values between 70% and 100%, root mean square error, intraclass correlation coefficients (ICC), Pearson correlations, and Bland-Altman plots were used to assess the accuracy, agreement, and strength of relationship between SaO 2 values and SpO 2 values from Polar Elixir™. RESULTS The initial root mean square error for Polar Elixir™ was 4.13%. After recalibrating the algorithm, the RMSE was improved to 2.67%. The ICC revealed excellent levels of agreement between SaO 2 and Polar Elixir™ SpO 2 values both before (ICC(1,3) = 0.837, df = 574, P < 0.001) and after (ICC(1,3) = 0.942, df = 287, P < 0.001) recalibration. CONCLUSIONS Relative to ISO standards, Polar Elixir™ yielded accurate SpO 2 measurements during stepwise inspired hypoxia at rest when compared with SaO 2 values, which were improved by recalibrating the algorithm using a subset of the SaO 2 data.
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Affiliation(s)
- Monica K Russell
- Canadian Sport Institute Alberta-Sport Product Testing, Calgary, Alberta, CANADA
| | - John F Horton
- Canadian Sport Institute Alberta-Sport Product Testing, Calgary, Alberta, CANADA
| | | | | | | | - Breann R Worobets
- Canadian Sport Institute Alberta-Sport Product Testing, Calgary, Alberta, CANADA
| | - Mark E Pineda
- Canadian Sport Institute Alberta-Sport Product Testing, Calgary, Alberta, CANADA
| | | | - Pro Stergiou
- Canadian Sport Institute Alberta-Sport Product Testing, Calgary, Alberta, CANADA
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Marlar AI, Knabe BK, Taghikhan Y, Applegate RL, Fleming NW. Performance of pulse oximeters as a function of race compared to skin pigmentation: a single center retrospective study. J Clin Monit Comput 2024:10.1007/s10877-024-01211-9. [PMID: 39196478 DOI: 10.1007/s10877-024-01211-9] [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: 01/02/2024] [Accepted: 08/19/2024] [Indexed: 08/29/2024]
Abstract
Pulse oximetry (SpO2) is a critical monitor for assessing oxygenation status and guiding therapy in critically ill patients. Race has been identified as a potential source of SpO2 error, with consequent bias and inequities in healthcare. This study was designed to evaluate the incidence of occult hypoxemia and accuracy of pulse oximetry associated with the Massey-Martin scale and characterize the relationship between Massey scores and self-identified race. This retrospective single institute study utilized the Massey-Martin scale as a quantitative assessment of skin pigmentation. These values were recorded peri-operatively in patients enrolled in unrelated clinical trials. The electronic medical record was utilized to obtain demographics, arterial blood gas values, and time matched SpO2 values for each PaO2 ≤ 125 mmHg recorded throughout their hospitalizations. Differences between SaO2 and SpO2 were compared as a function of both Massey score and self-reported race. 4030 paired SaO2-SpO2 values were available from 579 patients. The average error (SaO2-SpO2) ± SD was 0.23 ± 2.6%. Statistically significant differences were observed within Massey scores and among races, with average errors that ranged from - 0.39 ± 2.3 to 0.53 ± 2.5 and - 0.55 ± 2.1 to 0.37 ± 2.7, respectively. Skin color varied widely within each self-identified race category. There was no clinically significant association between error rates and Massey-Martin scale grades and no clinically significant difference in accuracy observed between self-reported Black and White patients. In addition, self-reported race is not an appropriate surrogate for skin color.
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Affiliation(s)
- Audrey I Marlar
- Davis School of Medicine, University of California, Sacramento, CA, USA
| | - Bradley K Knabe
- Davis School of Medicine, University of California, Sacramento, CA, USA
| | - Yasamin Taghikhan
- Davis School of Medicine, University of California, Sacramento, CA, USA
| | | | - Neal W Fleming
- Department of Anesthesiology & Pain Medicine, Davis School of Medicine, University of California, Sacramento, CA, USA.
- Department of Anesthesiology & Pain Medicine, UC Davis Medical Center, 4150 V Street PSSB - Suite1200, Sacramento, CA, 95817-1460, USA.
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3
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Fawzy A, Ali H, Dziedzic PH, Potu N, Calvillo E, Golden SH, Iwashyna TJ, Suarez JI, Hager DN, Garibaldi BT. Skin Pigmentation and Pulse Oximeter Accuracy in the Intensive Care Unit: A Pilot Prospective Study. Am J Respir Crit Care Med 2024; 210:355-358. [PMID: 38820169 DOI: 10.1164/rccm.202401-0036le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/30/2024] [Indexed: 06/02/2024] Open
Affiliation(s)
| | | | | | | | | | - Sherita H Golden
- Division of Endocrinology, Diabetes, and Metabolism, and
- Office of Diversity, Inclusion, and Health Equity, Johns Hopkins Medicine, Baltimore, Maryland; and
| | - Theodore J Iwashyna
- Division of Pulmonary and Critical Care
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Jose I Suarez
- Department of Neurology
- Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine
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Mergler BD, Toles AO, Alexander A, Mosquera DC, Lane-Fall MB, Ejiogu NI. Racial and Ethnic Patient Care Disparities in Anesthesiology: History, Current State, and a Way Forward. Anesth Analg 2024; 139:420-431. [PMID: 38153872 DOI: 10.1213/ane.0000000000006716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
Disparities in patient care and outcomes are well-documented in medicine but have received comparatively less attention in anesthesiology. Those disparities linked to racial and ethnic identity are pervasive, with compelling evidence in operative anesthesiology, obstetric anesthesiology, pain medicine, and critical care. This narrative review presents an overview of disparities in perioperative patient care that is grounded in historical context followed by potential solutions for mitigating disparities and inequities.
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Affiliation(s)
- Blake D Mergler
- From the Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Allyn O Toles
- From the Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anthony Alexander
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Diana C Mosquera
- Department of Anesthesiology, Albany Medical Center, Albany, New York
| | - Meghan B Lane-Fall
- From the Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nwadiogo I Ejiogu
- From the Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Weir VR, Dempsey K, Gichoya JW, Rotemberg V, Wong AKI. A survey of skin tone assessment in prospective research. NPJ Digit Med 2024; 7:191. [PMID: 39014060 PMCID: PMC11252344 DOI: 10.1038/s41746-024-01176-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 06/21/2024] [Indexed: 07/18/2024] Open
Abstract
Increasing evidence supports reduced accuracy of noninvasive assessment tools, such as pulse oximetry, temperature probes, and AI skin diagnosis benchmarks, in patients with darker skin tones. The FDA is exploring potential strategies for device regulation to improve performance across diverse skin tones by including skin tone criteria. However, there is no consensus about how prospective studies should perform skin tone assessment in order to take this bias into account. There are several tools available to conduct skin tone assessments including administered visual scales (e.g., Fitzpatrick Skin Type, Pantone, Monk Skin Tone) and color measurement tools (e.g., reflectance colorimeters, reflectance spectrophotometers, cameras), although none are consistently used or validated across multiple medical domains. Accurate and consistent skin tone measurement depends on many factors including standardized environments, lighting, body parts assessed, patient conditions, and choice of skin tone assessment tool(s). As race and ethnicity are inadequate proxies for skin tone, these considerations can be helpful in standardizing the effect of skin tone on studies such as AI dermatology diagnoses, pulse oximetry, and temporal thermometers. Skin tone bias in medical devices is likely due to systemic factors that lead to inadequate validation across diverse skin tones. There is an opportunity for researchers to use skin tone assessment methods with standardized considerations in prospective studies of noninvasive tools that may be affected by skin tone. We propose considerations that researchers must take in order to improve device robustness to skin tone bias.
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Affiliation(s)
- Vanessa R Weir
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katelyn Dempsey
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University, Durham, NC, USA
| | - Judy Wawira Gichoya
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Veronica Rotemberg
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - An-Kwok Ian Wong
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University, Durham, NC, USA.
- Department of Biostatistics and Bioinformatics, Division of Translational Biomedical Informatics, Duke University, Durham, NC, USA.
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Vasudevan S, Vogt WC, Weininger S, Pfefer TJ. Melanometry for objective evaluation of skin pigmentation in pulse oximetry studies. COMMUNICATIONS MEDICINE 2024; 4:138. [PMID: 38992188 PMCID: PMC11239860 DOI: 10.1038/s43856-024-00550-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/11/2024] [Indexed: 07/13/2024] Open
Abstract
Pulse oximetry enables real-time, noninvasive monitoring of arterial blood oxygen levels. However, results can vary with skin color, thus detecting disparities during clinical validation studies requires an accurate measure of skin pigmentation. Recent clinical studies have used subjective methods such as self-reported color, race/ethnicity to categorize skin. Melanometers based on optical reflectance may offer a more effective, objective approach to assess pigmentation. Here, we review melanometry approaches and assess evidence supporting their use as clinical research tools. We compare performance data, including repeatability, robustness to confounders, and compare devices to each other, to subjective methods, and high-quality references. Finally, we propose best practices for evaluating melanometers and discuss alternate optical approaches that may improve accuracy. Whilst evidence indicates that melanometers can provide superior performance to subjective approaches, we encourage additional research and standardization efforts, as these are needed to ensure consistent and reliable results in clinical studies.
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Affiliation(s)
- Sandhya Vasudevan
- Center for Devices and Radiological Health, Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA.
| | - William C Vogt
- Center for Devices and Radiological Health, Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
| | - Sandy Weininger
- Center for Devices and Radiological Health, Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
| | - T Joshua Pfefer
- Center for Devices and Radiological Health, Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
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Tschopp S, Borner U, Caversaccio M, Tschopp K. Long-term night-to-night variability of sleep-disordered breathing using a radar-based home sleep apnea test: a prospective cohort study. J Clin Sleep Med 2024; 20:1079-1086. [PMID: 38415722 PMCID: PMC11217624 DOI: 10.5664/jcsm.11070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 02/04/2024] [Accepted: 02/07/2024] [Indexed: 02/29/2024]
Abstract
STUDY OBJECTIVES Night-to-night variability of sleep-disordered breathing limits the diagnostic accuracy of a single measurement. Multiple recordings using a reliable, affordable method could reduce the uncertainty and avoid misdiagnosis, which could be possible with radar-based home sleep apnea testing (HSAT). METHODS We recruited consecutive patients with suspected sleep-disordered breathing and performed contactless radar-based HSAT with automated scoring (Sleepiz One; Sleepiz AG, Zurich, Switzerland) over 10 nights. During the first night, patients were simultaneously measured with peripheral arterial tonometry. RESULTS Twenty-four of the 28 included patients could achieve a minimum of 4 measurements. The failure rate was 16% (37 of 238 measurements). The apnea-hypopnea index (AHI) and oxygen desaturation index were consistently lower with radar-based HSAT compared with peripheral arterial tonometry. The variability of the AHI was considerable, with a standard error of measurement of 5.2 events/h (95% confidence interval [CI]: 4.6-5.7 events/h) and a minimal detectable difference of 14.4 events/h (95% CI: 12.7-15.9 events/h). Alcohol consumption partially accounted for the variability, with an AHI increase of 1.7 events/h (95% CI: 0.6-2.8 events/h) for each standard drink. Based on a single measurement, 17% of patients were misdiagnosed and 32% were misclassified for sleep-disordered breathing severity. After 5 measurements, the mean AHI of the measured nights stabilized with no evidence of substantial changes with additional measurements. CONCLUSIONS Night-to-night variability is considerable and stable over 10 nights. HSAT using radar-based methods over multiple nights is feasible and well tolerated by patients. It could offer lower costs and allow for multiple-night testing to increase accuracy. However, validation and reducing the failure rate are necessary for implementation in the clinical routine. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Recording of Multiple Nights Using a New Contactless Device (Sleepiz One Connect) in Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/study/NCT05134402; Identifier: NCT05134402. CITATION Tschopp S, Borner U, Caversaccio M, Tschopp K. Long-term night-to-night variability of sleep-disordered breathing using a radar-based home sleep apnea test: a prospective cohort study. J Clin Sleep Med. 2024;20(7):1079-1086.
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Affiliation(s)
- Samuel Tschopp
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital and University of Bern, Bern, Switzerland
- Department of Otorhinolaryngology, Head and Neck Surgery, Kantonsspital Baselland, Liestal, Switzerland
| | - Urs Borner
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Marco Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Kurt Tschopp
- Department of Otorhinolaryngology, Head and Neck Surgery, Kantonsspital Baselland, Liestal, Switzerland
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8
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Henry KE, Giannini HM. Early Warning Systems for Critical Illness Outside the Intensive Care Unit. Crit Care Clin 2024; 40:561-581. [PMID: 38796228 DOI: 10.1016/j.ccc.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Early warning systems (EWSs) are designed and deployed to create a rapid assessment and response for patients with clinical deterioration outside the intensive care unit (ICU). These models incorporate patient-level data such as vital signs and laboratory values to detect or prevent adverse clinical events, such as vital signs and laboratories to allow detection and prevention of adverse clinical events such as cardiac arrest, intensive care transfer, or sepsis. The applicability, development, clinical utility, and general perception of EWS in clinical practice vary widely. Here, we review the field as it has grown from early vital sign-based scoring systems to contemporary multidimensional algorithms and predictive technologies for clinical decompensation outside the ICU.
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Affiliation(s)
- Katharine E Henry
- Department of Computer Science, Johns Hopkins University, Malone Hall, 3400 N Charles Street, Baltimore, MD 21218, USA
| | - Heather M Giannini
- Division of Pulmonary, Allergy and Critical Care, Hospital of the University of Pennsylvania, 5 West Gates Building, 5048, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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9
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Brookman S, Mukadam T, Owasil S, Thachettu A, Urquhart DS, Dhawan A, Gupta A. Pulse oximetry in patients with pigmented skin: What I should know. Paediatr Respir Rev 2024:S1526-0542(24)00050-2. [PMID: 38960816 DOI: 10.1016/j.prrv.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/03/2024] [Indexed: 07/05/2024]
Abstract
Pulse oximetry is widely used to non-invasively estimate the oxygen saturation of haemoglobin in arterial blood (SpO2). It is used widely throughout healthcare and was used extensively during the Covid-19 pandemic to detect and treat hypoxic patients. Research has suggested that pulse oximetry is less accurate in patients with darker skin. This led the US Food and Drug Administration agency (FDA) to issue a safety statement warning that pulse oximeters may be inaccurate when patients have pigmented skin. Evidence suggests that the oxygen saturation of arterial blood (SaO2) may be being overestimated by measuring SpO2 in those with pigmented skin. The degree of overestimation increases as SaO2 decreases especially when SpO2 reads below 80%. We review how pulse oximetry works and consider the implications for a patient's health when interpreting SpO2 in individuals with pigmented skin.
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Affiliation(s)
| | | | | | | | - Don S Urquhart
- Royal Hospital for Children and Young People, Edinburgh, United Kingdom
| | - Anil Dhawan
- Kings College Hospital, London, United Kingdom
| | - Atul Gupta
- Kings College Hospital, London, United Kingdom; Kings College Medical School, United Kingdom.
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10
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Sharma M, Brown AW, Powell NM, Rajaram N, Tong L, Mourani PM, Schootman M. Racial and skin color mediated disparities in pulse oximetry in infants and young children. Paediatr Respir Rev 2024; 50:62-72. [PMID: 38233229 PMCID: PMC11139570 DOI: 10.1016/j.prrv.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/19/2024]
Abstract
Race-based and skin pigmentation-related inaccuracies in pulse oximetry have recently been highlighted in several large electronic health record-based retrospective cohort studies across diverse patient populations and healthcare settings. Overestimation of oxygen saturation by pulse oximeters, particularly in hypoxic states, is disparately higher in Black compared to other racial groups. Compared to adult literature, pediatric studies are relatively few and mostly reliant on birth certificates or maternal race-based classification of comparison groups. Neonates, infants, and young children are particularly susceptible to the adverse life-long consequences of hypoxia and hyperoxia. Successful neonatal resuscitation, precise monitoring of preterm and term neonates with predominantly lung pathology, screening for congenital heart defects, and critical decisions on home oxygen, ventilator support and medication therapies, are only a few examples of situations that are highly reliant on the accuracy of pulse oximetry. Undetected hypoxia, especially if systematically different in certain racial groups may delay appropriate therapies and may further perpetuate health care disparities. The role of biological factors that may differ between racial groups, particularly skin pigmentation that may contribute to biased pulse oximeter readings needs further evaluation. Developmental and maturational changes in skin physiology and pigmentation, and its interaction with the operating principles of pulse oximetry need further study. Importantly, clinicians should recognize the limitations of pulse oximetry and use additional objective measures of oxygenation (like co-oximetry measured arterial oxygen saturation) where hypoxia is a concern.
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Affiliation(s)
- Megha Sharma
- Department of Pediatrics, Division of Neonatology, University of Arkansas for Medical Sciences, Little Rock, AR, United States; Arkansas Children's Research Institute, Little Rock, AR, United States.
| | - Andrew W Brown
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, United States; Arkansas Children's Research Institute, Little Rock, AR, United States
| | - Nicholas M Powell
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR, United States
| | - Narasimhan Rajaram
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR, United States; Winthrop P. Rockefeller Cancer Institute, Little Rock, AR, United States
| | - Lauren Tong
- Clinical Library Services, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Peter M Mourani
- Arkansas Children's Research Institute, Little Rock, AR, United States; Department of Pediatrics, Division of Pediatric Critical Care, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Mario Schootman
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
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11
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Westbrook JI, Wabe N, Raban MZ. Using AI to improve medication safety. Nat Med 2024; 30:1531-1532. [PMID: 38720001 DOI: 10.1038/s41591-024-02980-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Affiliation(s)
- Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.
| | - Nasir Wabe
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Magdalena Z Raban
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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12
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Lellouche F, Branson R. U.S. Food and Drug Administration Strategy to Evaluate Pulse Oximeters: The Same Cause Will Produce the Same Effects. Am J Respir Crit Care Med 2024; 209:1301-1303. [PMID: 38452248 PMCID: PMC11146577 DOI: 10.1164/rccm.202401-0243vp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/07/2024] [Indexed: 03/09/2024] Open
Affiliation(s)
- François Lellouche
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec, Canada; and
| | - Richard Branson
- Division of Trauma & Critical Care, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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Cruz S, Lu C, Ulloa M, Redding A, Hester J, Jacobs M. Perceptions of Wearable Health Tools Post the COVID-19 Emergency in Low-Income Latin Communities: Qualitative Study. JMIR Mhealth Uhealth 2024; 12:e50826. [PMID: 38717816 PMCID: PMC11112471 DOI: 10.2196/50826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 12/21/2023] [Accepted: 01/25/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Mobile health (mHealth) wearable devices are increasingly being adopted by individuals to help manage and monitor physiological signals. However, the current state of wearables does not consider the needs of racially minoritized low-socioeconomic status (SES) communities regarding usability, accessibility, and price. This is a critical issue that necessitates immediate attention and resolution. OBJECTIVE This study's aims were 3-fold, to (1) understand how members of minoritized low-SES communities perceive current mHealth wearable devices, (2) identify the barriers and facilitators toward adoption, and (3) articulate design requirements for future wearable devices to enable equitable access for these communities. METHODS We performed semistructured interviews with low-SES Hispanic or Latine adults (N=19) from 2 metropolitan cities in the Midwest and West Coast of the United States. Participants were asked questions about how they perceive wearables, what are the current benefits and barriers toward use, and what features they would like to see in future wearable devices. Common themes were identified and analyzed through an exploratory qualitative approach. RESULTS Through qualitative analysis, we identified 4 main themes. Participants' perceptions of wearable devices were strongly influenced by their COVID-19 experiences. Hence, the first theme was related to the impact of COVID-19 on the community, and how this resulted in a significant increase in interest in wearables. The second theme highlights the challenges faced in obtaining adequate health resources and how this further motivated participants' interest in health wearables. The third theme focuses on a general distrust in health care infrastructure and systems and how these challenges are motivating a need for wearables. Lastly, participants emphasized the pressing need for community-driven design of wearable technologies. CONCLUSIONS The findings from this study reveal that participants from underserved communities are showing emerging interest in using health wearables due to the COVID-19 pandemic and health care access issues. Yet, the needs of these individuals have been excluded from the design and development of current devices.
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Affiliation(s)
- Stefany Cruz
- Department of Electrical and Computer Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL, United States
| | - Claire Lu
- Department of Electrical and Computer Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL, United States
| | - Mara Ulloa
- Department of Computer Science, McCormick School of Engineering, Northwestern University, Evanston, IL, United States
| | - Alexander Redding
- Department of Computer Science and Engineering, Irwin & Joan Jacobs School of Engineering, University of California, San Diego, La Jolla, CA, United States
| | - Josiah Hester
- Interactive Computing and Computer Science, College of Computing, Georgia Institute of Technology, Atlanta, GA, United States
| | - Maia Jacobs
- Department of Computer Science, McCormick School of Engineering, Northwestern University, Evanston, IL, United States
- Department of Preventative Medicine, Feinberg School of Medicine, Northwestern University, Evanston, IL, United States
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14
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Tandon A, Avari Silva JN, Bhatt AB, Drummond CK, Hill AC, Paluch AE, Waits S, Zablah JE, Harris KC. Advancing Wearable Biosensors for Congenital Heart Disease: Patient and Clinician Perspectives: A Science Advisory From the American Heart Association. Circulation 2024; 149:e1134-e1142. [PMID: 38545775 DOI: 10.1161/cir.0000000000001225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Wearable biosensors (wearables) enable continual, noninvasive physiologic and behavioral monitoring at home for those with pediatric or congenital heart disease. Wearables allow patients to access their personal data and monitor their health. Despite substantial technologic advances in recent years, issues with hardware design, data analysis, and integration into the clinical workflow prevent wearables from reaching their potential in high-risk congenital heart disease populations. This science advisory reviews the use of wearables in patients with congenital heart disease, how to improve these technologies for clinicians and patients, and ethical and regulatory considerations. Challenges related to the use of wearables are common to every clinical setting, but specific topics for consideration in congenital heart disease are highlighted.
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15
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Greenhalgh T, Engebretsen E. Pragmatism and crisis: A response to three commentaries. Soc Sci Med 2024; 348:116782. [PMID: 38538379 DOI: 10.1016/j.socscimed.2024.116782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/11/2024] [Indexed: 04/29/2024]
Affiliation(s)
- Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK.
| | - Eivind Engebretsen
- Centre for Sustainable Healthcare Education, Faculty of Medicine, University of Oslo, Norway
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16
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Maher PJ, Goel NN, Horowitz CR, Rea M, Figueiro MG, Richardson LD. Survey in emergency medicine of skin pigmentation bias in pulse oximeters. Am J Emerg Med 2024; 79:209-211. [PMID: 38461101 PMCID: PMC11192040 DOI: 10.1016/j.ajem.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/29/2024] [Accepted: 03/03/2024] [Indexed: 03/11/2024] Open
Affiliation(s)
- Patrick J Maher
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - Neha N Goel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - Carol R Horowitz
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York NY, USA.
| | - Mark Rea
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Light and Health Research Center, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York NY, USA.
| | - Mariana G Figueiro
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Light and Health Research Center, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York NY, USA.
| | - Lynne D Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York NY, USA.
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17
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Martin D, Johns C, Sorrell L, Healy E, Phull M, Olusanya S, Peters M, Fabes J. Effect of skin tone on the accuracy of the estimation of arterial oxygen saturation by pulse oximetry: a systematic review. Br J Anaesth 2024; 132:945-956. [PMID: 38368234 PMCID: PMC11103098 DOI: 10.1016/j.bja.2024.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/10/2024] [Accepted: 01/19/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND Pulse oximetry-derived oxygen saturation (SpO2) is an estimate of true arterial oxygen saturation (SaO2). The aim of this review was to evaluate available evidence determining the effect of skin tone on the ability of pulse oximeters to accurately estimate SaO2. METHODS Published literature was screened to identify clinical and non-clinical studies enrolling adults and children when SpO2 was compared with a paired co-oximetry SaO2 value. We searched literature databases from their inception to March 20, 2023. Risk of bias (RoB) was assessed using the QUADAS-2 tool. Certainty of assessment was evaluated using the GRADE tool. RESULTS Forty-four studies were selected reporting on at least 222 644 participants (6121 of whom were children) and 733 722 paired SpO2-SaO2 measurements. Methodologies included laboratory studies, prospective clinical, and retrospective clinical studies. A high RoB was detected in 64% of studies and there was considerable heterogeneity in study design, data analysis, and reporting metrics. Only 11 (25%) studies measured skin tone in 2353 (1.1%) participants; the remainder reported participant ethnicity: 68 930 (31.0%) participants were of non-White ethnicity or had non-light skin tones. The majority of studies reported overestimation of SaO2 by pulse oximetry in participants with darker skin tones or from ethnicities assumed to have darker skin tones. Several studies reported no inaccuracy related to skin tone. Meta-analysis of the data was not possible. CONCLUSIONS Pulse oximetry can overestimate true SaO2 in people with darker skin tones. The clinical relevance of this bias remains unclear, but its magnitude is likely to be greater when SaO2 is lower. SYSTEMATIC REVIEW PROTOCOL International Prospective Register of Systematic Reviews (PROSPERO): CRD42023390723.
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Affiliation(s)
- Daniel Martin
- Peninsula Medical School, University of Plymouth, John Bull Building, Plymouth, UK; Intensive Care Unit, University Hospitals Plymouth, Plymouth, UK.
| | - Chris Johns
- Library & Digital Support, University of Plymouth, Drake Circus, Plymouth, UK
| | - Lexy Sorrell
- Peninsula Medical School, University of Plymouth, John Bull Building, Plymouth, UK
| | - Eugene Healy
- Dermatopharmacology, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; Dermatology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mandeep Phull
- Barking, Havering and Redbridge University Trust, Romford, UK; William Harvey Research Institute, Queen Mary University London, London, UK
| | | | - Mark Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, UK; University College London Great Ormond St Institute of Child Health, London, UK
| | - Jeremy Fabes
- Peninsula Medical School, University of Plymouth, John Bull Building, Plymouth, UK; Anaesthetic Department, University Hospitals Plymouth, Plymouth, UK
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18
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Bierman A, Benner K, Rea MS. Melanin bias in pulse oximetry explained by light source spectral bandwidth. Br J Anaesth 2024; 132:957-963. [PMID: 38443287 PMCID: PMC11103167 DOI: 10.1016/j.bja.2024.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/02/2024] [Accepted: 01/18/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Pulse oximetry uses noninvasive optical measurements of light transmission from each of two sources through vascularised living tissue over the cardiac cycle (SpO2). From those measurements, the relative amount of oxygenated haemoglobin (SaO2) in circulating blood can be deduced. Recent reports have shown that, compared with SaO2 measurements from blood samples, SpO2 measurements are biased erroneously high for patients with dark skin. METHODS We developed a new method, spectrally resolved photoplethysmography (srPPG), to examine how spectral bandwidth affects the transmission of polychromatic light through the fingertip across the cardiac cycle. We measured and recorded the spectral transmission through the fingertip as the O2 concentration in inspired air was reduced. We applied digital spectral filters of two different bandwidths, narrow or broad, to the same srPPG recordings to determine whether SpO2 readings systematically varied for the two bandwidths. The srPPG method also allowed us to measure the fractional amount of melanin in the optical path. The effect of melanin content on the ratio of SpO2 readings for narrow and broad spectral bandwidths was analysed. RESULTS We hypothesised, based upon the Beer-Lambert law, and then showed experimentally, that the light emission spectra of light-emitting diode light sources, as used in commercial pulse oximeters, result in erroneously high SpO2 measurements for patients having greater melanin concentrations in their skin than those of the subject pool used for instrument calibration. CONCLUSIONS To eliminate melanin bias, pulse oximeters should use much narrower spectral bandwidths than those used in current models.
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Affiliation(s)
| | - Kevin Benner
- Light and Health Research Center, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mark S Rea
- Light and Health Research Center, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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19
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Lapum JL, Prendergast N, Istanboulian L. Anti-Racist Approach to Pulse Oximetry: A Nurse Educator's Guide. Nurse Educ 2024; 49:171-172. [PMID: 37782944 DOI: 10.1097/nne.0000000000001542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Affiliation(s)
- Jennifer L Lapum
- Author Affiliations: Professor (Dr Lapum) and Assistant Professor (Drs Prendergast and Istanboulian), Daphne Cockwell School of Nursing, Toronto Metropolitan University, Toronto, Ontario, Canada
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20
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Swamy SKN, He C, Hayes-Gill BR, Clark DJ, Green S, Morgan SP. Pulse oximeter bench tests under different simulated skin tones. Med Biol Eng Comput 2024:10.1007/s11517-024-03091-2. [PMID: 38653879 DOI: 10.1007/s11517-024-03091-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/06/2024] [Indexed: 04/25/2024]
Abstract
Pulse oximeters' (POs) varying performance based on skin tones has been highly publicised. Compared to arterial blood gas analysis, POs tend to overestimate oxygen saturation (SpO2) values for people with darker skin (occult hypoxemia). The objective is to develop a test bench for assessing commercial home and hospital-based POs in controlled laboratory conditions. A laboratory simulator was used to mimic different SpO2 values (~ 70 to 100%). Different neutral density and synthetic melanin filters were used to reproduce low signal and varying melanin attenuation levels. Six devices consisting of commercial home (Biolight, N = 13; ChoiceMMed, N = 18; MedLinket, N = 9) and hospital-based (Masimo Radical 7 with Neo L, N = 1; GE B450 Masimo SET with LNCS Neo L, N = 1; Nonin 9550 Onyx II™, N = 1) POs were reviewed and their response documented. Significant variations were observed in the recorded SpO2 values among different POs when exposed to identical simulated signals. Differences were greatest for lower SpO2 (< 80%) where empirical data is limited. All PO responses under low signal and melanin attenuation did not change across various simulated SpO2 values. The bench tests do not provide conclusive evidence that melanin does not affect in vivo SpO2 measurements. Research in the areas of instrument calibration, theory and design needs to be further developed.
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Affiliation(s)
- Suvvi K Narayana Swamy
- Optics and Photonics Research Group and Centre for Healthcare Technologies, University of Nottingham, University Park, Nottingham, UK
| | - Chenyang He
- Optics and Photonics Research Group and Centre for Healthcare Technologies, University of Nottingham, University Park, Nottingham, UK
| | - Barrie R Hayes-Gill
- Optics and Photonics Research Group and Centre for Healthcare Technologies, University of Nottingham, University Park, Nottingham, UK
| | - Daniel J Clark
- Clinical Engineering Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sarah Green
- Clinical Engineering Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Stephen P Morgan
- Optics and Photonics Research Group and Centre for Healthcare Technologies, University of Nottingham, University Park, Nottingham, UK.
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21
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Nguyen T, Park S, Park J, Sodager A, George T, Gandjbakhche A. Application of the Single Source-Detector Separation Algorithm in Wearable Neuroimaging Devices: A Step toward Miniaturized Biosensor for Hypoxia Detection. Bioengineering (Basel) 2024; 11:385. [PMID: 38671806 PMCID: PMC11048477 DOI: 10.3390/bioengineering11040385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 04/12/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024] Open
Abstract
Most currently available wearable devices to noninvasively detect hypoxia use the spatially resolved spectroscopy (SRS) method to calculate cerebral tissue oxygen saturation (StO2). This study applies the single source-detector separation (SSDS) algorithm to calculate StO2. Near-infrared spectroscopy (NIRS) data were collected from 26 healthy adult volunteers during a breath-holding task using a wearable NIRS device, which included two source-detector separations (SDSs). These data were used to derive oxyhemoglobin (HbO) change and StO2. In the group analysis, both HbO change and StO2 exhibited significant change during a breath-holding task. Specifically, they initially decreased to minimums at around 10 s and then steadily increased to maximums, which were significantly greater than baseline levels, at 25-30 s (p-HbO < 0.001 and p-StO2 < 0.05). However, at an individual level, the SRS method failed to detect changes in cerebral StO2 in response to a short breath-holding task. Furthermore, the SSDS algorithm is more robust than the SRS method in quantifying change in cerebral StO2 in response to a breath-holding task. In conclusion, these findings have demonstrated the potential use of the SSDS algorithm in developing a miniaturized wearable biosensor to monitor cerebral StO2 and detect cerebral hypoxia.
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Affiliation(s)
| | | | | | | | | | - Amir Gandjbakhche
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 49 Convent Drive, Bethesda, MD 20892-4480, USA; (T.N.); (S.P.); (J.P.); (A.S.); (T.G.)
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22
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Chen QC, Shen JJ, Huang YL, Kong R, Xie YM, Wang SS. Discrepancy between arterial oxygen saturation and pulse oximetry measurement in a Chinese pediatric patient cohort. Heliyon 2024; 10:e28336. [PMID: 38560171 PMCID: PMC10981058 DOI: 10.1016/j.heliyon.2024.e28336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 03/14/2024] [Accepted: 03/15/2024] [Indexed: 04/04/2024] Open
Abstract
Background Increasing evidence suggest a racial bias in pulse oximetry measurement, but this was under investigated in Asian pediatric populations. Methods Via the Pediatric Intensive Care database, this retrospective study included pediatric patient records of arterial oxygen saturation (SaO2) and oxygen saturation on pulse oximetry (SpO2) measured within 10 min. Discrepancy was examined, and potential predictors of occult hypoxemia (defined as SaO2 <88% with the paired SpO2 ≥92%) as well as its association with outcomes were explored by logistic regression. Results A total of 390 patients were included with 454 pairs of SaO2-SpO2 readings. The study population consisted of Han Chinese (99.0%) and 43.6% were female. Occult hypoxemia was observed in 20.0% of the patients, with a mean SaO2 of 71.4 ± 15.8%. Potential predictors of occult hypoxemia included female, being first admitted to cardiac ICU, congenital heart disease, increased heart rate, while patients with prior surgery records were less likely to experience occult hypoxemia. Patients with occult hypoxemia had numerically higher in-ICU mortality (16.7% versus 10.9%) and in-hospital mortality (17.9% versus 10.9%), but the associations were not statistically significant. Conclusions There was a substantial proportion of hypoxemia that was not detected by pulse oximetry in the Chinese pediatric patients, which might be predicted by several characteristics and seemed to associate with mortality.
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Affiliation(s)
| | | | | | - Ran Kong
- Department of Pediatric Cardiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510000, China
| | - Yu-mei Xie
- Department of Pediatric Cardiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510000, China
| | - Shu-shui Wang
- Department of Pediatric Cardiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510000, China
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23
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Lee SY(J, Alzeen M, Ahmed A. Estimation of racial and language disparities in pediatric emergency department triage using statistical modeling and natural language processing. J Am Med Inform Assoc 2024; 31:958-967. [PMID: 38349846 PMCID: PMC10990499 DOI: 10.1093/jamia/ocae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/16/2024] [Accepted: 01/19/2024] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVES The study aims to assess racial and language disparities in pediatric emergency department (ED) triage using analytical techniques and provide insights into the extent and nature of the disparities in the ED setting. MATERIALS AND METHODS The study analyzed a cross-sectional dataset encompassing ED visits from January 2019 to April 2021. The study utilized analytical techniques, including K-mean clustering (KNN), multivariate adaptive regression splines (MARS), and natural language processing (NLP) embedding. NLP embedding and KNN were employed to handle the chief complaints and categorize them into clusters, while the MARS was used to identify significant interactions among the clinical features. The study also explored important variables, including age-adjusted vital signs. Multiple logistic regression models with varying specifications were developed to assess the robustness of analysis results. RESULTS The study consistently found that non-White children, especially African American (AA) and Hispanic, were often under-triaged, with AA children having >2 times higher odds of receiving lower acuity scores compared to White children. While the results are generally consistent, incorporating relevant variables modified the results for specific patient groups (eg, Asians). DISCUSSION By employing a comprehensive analysis methodology, the study checked the robustness of the analysis results on racial and language disparities in pediatric ED triage. The study also recognized the significance of analytical techniques in assessing pediatric health conditions and analyzing disparities. CONCLUSION The study's findings highlight the significant need for equal and fair assessment and treatment in the pediatric ED, regardless of their patients' race and language.
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Affiliation(s)
- Seung-Yup (Joshua) Lee
- Department of Health Services Administration, School of Health Professions, The University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Mohammed Alzeen
- Department of Health Services Administration, School of Health Professions, The University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Abdulaziz Ahmed
- Department of Health Services Administration, School of Health Professions, The University of Alabama at Birmingham, Birmingham, AL 35233, United States
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24
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Sharma V, Barker SJ, Sorci R, Park L, Wilson WC. Racial effects on masimo pulse oximetry: impact of low perfusion index. J Clin Monit Comput 2024; 38:347-354. [PMID: 38238634 PMCID: PMC10995008 DOI: 10.1007/s10877-023-01113-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/21/2023] [Indexed: 04/06/2024]
Abstract
PURPOSE Evaluate the SpO2-SaO2 difference between Black and White volunteer subjects having a low perfusion index (Pi) compared to those having a normal Pi. METHODS The Pi data were abstracted from electronic files collected on 7183 paired SpO2-SaO2 samples (3201 Black and 3982 White) from a recently reported desaturation study of 75 subjects (39 Black and 36 White) where SaO2 values were sequentially decreased from 100 to 70%. The Pi values from that dataset were divided into two groups (Pi ≤ 1 or Pi > 1) for analysis. A Pi value ≤ 1 was considered "low perfusion" and a Pi value > 1 was considered "normal perfusion". Statistical calculations included values of bias (mean difference of SpO2-SaO2), precision (standard deviation of the difference), and accuracy (root-mean-square error [ARMS]). During conditions of low perfusion (Pi ≤ 1, range [0.1 to 1]), overall bias and precision were + 0.48% ± 1.59%, while bias and precision were + 0.19 ± 1.53%, and + 0.91 ± 1.57%, for Black and White subjects, respectively. RESULTS During normal perfusion (Pi > 1, range [1 to 12]), overall bias and precision were + 0.18% ± 1.34%, while bias and precision were -0.26 ± 1.37%, and - 0.12 ± 1.31%, for Black and White subjects, respectively. ARMS was 1.37% in all subjects with normal perfusion and 1.64% in all subjects with low perfusion. CONCLUSION Masimo SET® pulse oximeters with RD SET® sensors are accurate for individuals of both Black and White races when Pi is normal, as well as during conditions when Pi is low. The ARMS for all conditions studied is well within FDA standards. This study was conducted in healthy volunteers during well-controlled laboratory desaturations, and results could vary under certain challenging clinical conditions.
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Affiliation(s)
- Vikrant Sharma
- Vice President, Optical Sciences, Masimo Corp, Irvine, CA, USA
| | | | - Rebecca Sorci
- Director, Clinical Publication Review and Communications, Masimo Corp, Irvine, CA, USA
| | - Linus Park
- Vice President Regulatory Affairs, Masimo Corp, Irvine, CA, USA
| | - William C Wilson
- Executive Vice President, Clinical Research Operations and Medical Affairs, Masimo Corp, Irvine, CA, USA.
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25
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Leeb G, Auchus I, Law T, Bickler P, Feiner J, Hashi S, Monk E, Igaga E, Bernstein M, Chou YC, Hughes C, Schornack D, Lester J, Moore K, Okunlola O, Fernandez J, Shmuylovich L, Lipnick M. The performance of 11 fingertip pulse oximeters during hypoxemia in healthy human participants with varied, quantified skin pigment. EBioMedicine 2024; 102:105051. [PMID: 38458110 PMCID: PMC10943300 DOI: 10.1016/j.ebiom.2024.105051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 02/19/2024] [Accepted: 02/23/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Fingertip pulse oximeters are widely available, inexpensive, and commonly used to make clinical decisions in many settings. Device performance is largely unregulated and poorly characterised, especially in people with dark skin pigmentation. METHODS Eleven popular fingertip pulse oximeters were evaluated using the US Food and Drug Administration (FDA) Guidance (2013) and International Organization for Standardization Standards (ISO, 2017) in 34 healthy humans with diverse skin pigmentation utilising a controlled desaturation study with arterial oxygen saturation (SaO 2) plateaus between 70% and 100%. Skin pigmentation was assessed subjectively using a perceived Fitzpatrick Scale (pFP) and objectively using the individual typology angle (ITA) via spectrophotometry at nine anatomical sites. FINDINGS Five of 11 devices had a root mean square error (ARMS) > 3%, falling outside the acceptable FDA performance range. Nine devices demonstrated worse performance in participants in the darkest skin pigmentation category compared with those in the lightest category. A commonly used subjective skin colour scale frequently miscategorised participants as being darkly pigmented when compared to objective quantification of skin pigment by ITA. INTERPRETATION Fingertip pulse oximeters have variable performance, frequently not meeting regulatory requirements for clinical use, and occasionally contradicting claims made by manufacturers. Most devices showed a trend toward worse performance in participants with darker skin pigment. Regulatory standards do not adequately account for the impact of skin pigmentation on device performance. We recommend that the pFP and other non-standardised subjective skin colour scales should no longer be used for defining diversity of skin pigmentation. Reliable methods for characterising skin pigmentation to improve diversity and equitable performance of pulse oximeters are needed. FUNDING This study was conducted as part of the Open Oximetry Project funded by the Gordon and Betty Moore Foundation, Patrick J McGovern Foundation, and Robert Wood Johnson Foundation. The UCSF Hypoxia Research Laboratory receives funding from multiple industry sponsors to test the sponsors' devices for the purposes of product development and regulatory performance testing. Data in this paper do not include sponsor's study devices. All data were collected from devices procured by the Hypoxia Research Laboratory for the purposes of independent research. No company provided any direct funding for this study, participated in study design or analysis, or was involved in analysing data or writing the manuscript. None of the authors own stock or equity interests in any pulse oximeter companies. Dr Ellis Monk's time utilised for data analysis, reviewing and editing was funded by grant number: DP2MH132941.
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Affiliation(s)
- Gregory Leeb
- Department of Anesthesia, University of California, San Francisco, USA
| | - Isabella Auchus
- Department of Anesthesia, University of California, San Francisco, USA.
| | - Tyler Law
- Department of Anesthesia, University of California, San Francisco, USA
| | - Philip Bickler
- Department of Anesthesia, University of California, San Francisco, USA
| | - John Feiner
- Department of Anesthesia, University of California, San Francisco, USA
| | - Shamsudini Hashi
- Department of Anesthesia, University of California, San Francisco, USA
| | - Ellis Monk
- Department of Sociology, Harvard University, USA
| | - Elizabeth Igaga
- Department of Anesthesia, College of Health Sciences, Makerere University, Uganda
| | | | - Yu Celine Chou
- Department of Anesthesia, University of California, San Francisco, USA
| | - Caroline Hughes
- Department of Anesthesia, University of California, San Francisco, USA
| | - Deleree Schornack
- Department of Anesthesia, University of California, San Francisco, USA
| | - Jenna Lester
- Department of Dermatology, University of California, San Francisco, USA
| | - Kelvin Moore
- University of California, San Francisco School of Medicine, USA
| | - Olubunmi Okunlola
- Department of Anesthesia, New York University Langone Hospital Brooklyn, USA
| | - Jana Fernandez
- Department of Anesthesia, University of California, San Francisco, USA
| | | | - Michael Lipnick
- Department of Anesthesia, University of California, San Francisco, USA; University of California, San Francisco Institute for Global Health Sciences, USA
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26
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Trevino TN, Almousawi AA, Robinson KF, Fogel AB, Class J, Minshall RD, Tai LM, Richner JM, Lutz SE. Caveolin-1 mediates blood-brain barrier permeability, neuroinflammation, and cognitive impairment in SARS-CoV-2 infection. J Neuroimmunol 2024; 388:578309. [PMID: 38335781 PMCID: PMC11212674 DOI: 10.1016/j.jneuroim.2024.578309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/12/2024]
Abstract
Blood-brain barrier (BBB) permeability can cause neuroinflammation and cognitive impairment. Caveolin-1 (Cav-1) critically regulates BBB permeability, but its influence on the BBB and consequent neurological outcomes in respiratory viral infections is unknown. We used Cav-1-deficient mice with genetically encoded fluorescent endothelial tight junctions to determine how Cav-1 influences BBB permeability, neuroinflammation, and cognitive impairment following respiratory infection with mouse adapted (MA10) SARS-CoV-2 as a model for COVID-19. We found that SARS-CoV-2 infection increased brain endothelial Cav-1 and increased transcellular BBB permeability to albumin, decreased paracellular BBB Claudin-5 tight junctions, and caused T lymphocyte infiltration in the hippocampus, a region important for learning and memory. Concordantly, we observed learning and memory deficits in SARS-CoV-2 infected mice. Importantly, genetic deficiency in Cav-1 attenuated transcellular BBB permeability and paracellular BBB tight junction losses, T lymphocyte infiltration, and gliosis induced by SARS-CoV-2 infection. Moreover, Cav-1 KO mice were protected from the learning and memory deficits caused by SARS-CoV-2 infection. These results establish the contribution of Cav-1 to BBB permeability and behavioral dysfunction induced by SARS-CoV-2 neuroinflammation.
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Affiliation(s)
- Troy N Trevino
- Departments of Anatomy and Cell Biology, University of Illinois at Chicago College of Medicine, USA
| | - Ali A Almousawi
- Departments of Anatomy and Cell Biology, University of Illinois at Chicago College of Medicine, USA
| | - KaReisha F Robinson
- Departments of Anatomy and Cell Biology, University of Illinois at Chicago College of Medicine, USA
| | - Avital B Fogel
- Departments of Anatomy and Cell Biology, University of Illinois at Chicago College of Medicine, USA
| | - Jake Class
- Departments of Microbiology and Immunology, University of Illinois at Chicago College of Medicine, USA
| | - Richard D Minshall
- Departments of Anesthesiology, and Pharmacology and Regenerative Medicine, University of Illinois at Chicago College of Medicine, USA
| | - Leon M Tai
- Departments of Anatomy and Cell Biology, University of Illinois at Chicago College of Medicine, USA
| | - Justin M Richner
- Departments of Microbiology and Immunology, University of Illinois at Chicago College of Medicine, USA
| | - Sarah E Lutz
- Departments of Anatomy and Cell Biology, University of Illinois at Chicago College of Medicine, USA.
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Donaldson MA, Donohoe K, Assayag D, Durand C, Fisher JH, Johannson K, Kolb M, Lok SD, Manganas H, Marcoux V, Min B, Morisset J, Marinescu DC, Ryerson CJ. Characteristics of pulse oximetry and arterial blood gas in patients with fibrotic interstitial lung disease. BMJ Open Respir Res 2024; 11:e002250. [PMID: 38479819 PMCID: PMC10941153 DOI: 10.1136/bmjresp-2023-002250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/28/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Fibrotic interstitial lung disease (ILD) is frequently associated with abnormal oxygenation; however, little is known about the accuracy of oxygen saturation by pulse oximetry (SpO2) compared with arterial blood gas (ABG) saturation (SaO2), the factors that influence the partial pressure of carbon dioxide (PaCO2) and the impact of PaCO2 on outcomes in patients with fibrotic ILD. STUDY DESIGN AND METHODS Patients with fibrotic ILD enrolled in a large prospective registry with a room air ABG were included. Prespecified analyses included testing the correlation between SaO2 and SpO2, the difference between SaO2 and SpO2, the association of baseline characteristics with both the difference between SaO2 and SpO2 and the PaCO2, the association of baseline characteristics with acid-base category, and the association of PaCO2 and acid-base category with time to death or transplant. RESULTS A total of 532 patients with fibrotic ILD were included. Mean resting SaO2 was 92±4% and SpO2 was 95±3%. Mean PaCO2 was 38±6 mmHg, with 135 patients having PaCO2 <35 mmHg and 62 having PaCO2 >45 mmHg. Correlation between SaO2 and SpO2 was mild to moderate (r=0.39), with SpO2 on average 3.0% higher than SaO2. No baseline characteristics were associated with the difference in SaO2 and SpO2. Variables associated with either elevated or abnormal (elevated or low) PaCO2 included higher smoking pack-years and lower baseline forced vital capacity (FVC). Lower baseline lung function was associated with an increased risk of chronic respiratory acidosis. PaCO2 and acid-base status were not associated with time to death or transplant. INTERPRETATION SaO2 and SpO2 are weakly-to-moderately correlated in fibrotic ILD, with limited ability to accurately predict this difference. Abnormal PaCO2 was associated with baseline FVC but was not associated with outcomes.
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Affiliation(s)
- Mira A Donaldson
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Kathryn Donohoe
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Deborah Assayag
- Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Celine Durand
- Département de Médecine, Centre de Recherche du Centre Hospitalier de l'Universite de Montreal, Montreal, Québec, Canada
| | - Jolene H Fisher
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kerri Johannson
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Martin Kolb
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Stacey D Lok
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Hélène Manganas
- Département de Médecine, Centre de Recherche du Centre Hospitalier de l'Universite de Montreal, Montreal, Québec, Canada
| | - Veronica Marcoux
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Bohyung Min
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Julie Morisset
- Département de Médecine, Centre de Recherche du Centre Hospitalier de l'Universite de Montreal, Montreal, Québec, Canada
| | - Daniel-Costin Marinescu
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher J Ryerson
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
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Chen YY, Lai GH, Chen CT, Cheng HC, Tseng SH. Noninvasive hemoglobin quantification across different cohorts using a wearable diffuse reflectance spectroscopy system. BIOMEDICAL OPTICS EXPRESS 2024; 15:1739-1749. [PMID: 38495710 PMCID: PMC10942696 DOI: 10.1364/boe.517645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/09/2024] [Accepted: 02/09/2024] [Indexed: 03/19/2024]
Abstract
Quantifying hemoglobin is vital yet invasive through blood draws. We developed a wearable diffuse reflectance spectroscopy device comprising control and sensor boards with photodiodes and light-emitting diodes to noninvasively determine hemoglobin. Neural networks enabled recovery of optical parameters for chromophore fitting to calculate hemoglobin. Testing healthy and elderly subjects revealed strong correlation (r=0.9) between our system and invasive methods after data conversion. Bland-Altman analysis demonstrated tight 95% limits of agreement from -1.98 to 1.98 g/dL between the DRS and invasive hemoglobin concentrations. By spectroscopically isolating hemoglobin absorption, interference from melanin was overcome. Our device has the potential for future integration into wearable technology, enabling hemoglobin level tracking.
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Affiliation(s)
- Ying-Yu Chen
- Department of Photonics, National Cheng-Kung University, Tainan, Taiwan 701, Taiwan
| | - Guan-Hua Lai
- Department of Photonics, National Cheng-Kung University, Tainan, Taiwan 701, Taiwan
| | - Chia-Te Chen
- Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsiu-Chi Cheng
- Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Molecular Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan
| | - Sheng-Hao Tseng
- Department of Photonics, National Cheng-Kung University, Tainan, Taiwan 701, Taiwan
- School of Dentistry, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan 807, Taiwan
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Gudelunas MK, Lipnick M, Hendrickson C, Vanderburg S, Okunlola B, Auchus I, Feiner JR, Bickler PE. Low Perfusion and Missed Diagnosis of Hypoxemia by Pulse Oximetry in Darkly Pigmented Skin: A Prospective Study. Anesth Analg 2024; 138:552-561. [PMID: 38109495 DOI: 10.1213/ane.0000000000006755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
BACKGROUND Retrospective clinical trials of pulse oximeter accuracy report more frequent missed diagnoses of hypoxemia in hospitalized Black patients than White patients, differences that may contribute to racial disparities in health and health care. Retrospective studies have limitations including mistiming of blood samples and oximeter readings, inconsistent use of functional versus fractional saturation, and self-reported race used as a surrogate for skin color. Our objective was to prospectively measure the contributions of skin pigmentation, perfusion index (PI), sex, and age on pulse oximeter errors in a laboratory setting. METHODS We enrolled 146 healthy subjects, including 25 with light skin (Fitzpatrick class I and II), 78 with medium (class III and IV), and 43 with dark (class V and VI) skin. We studied 2 pulse oximeters (Nellcor N-595 and Masimo Radical 7) in prevalent clinical use. We analyzed 9763 matched pulse oximeter readings (pulse oximeter measured functional saturation [Sp o2 ]) and arterial oxygen saturation (hemoximetry arterial functional oxygen saturation [Sa o2 ]) during stable hypoxemia (Sa o2 68%-100%). PI was measured as percent infrared light modulation by the pulse detected by the pulse oximeter probe, with low perfusion categorized as PI < 1%. The primary analysis was to assess the relationship between pulse oximeter bias (difference between Sa o2 and Sp o2 ) by skin pigment category in a multivariable mixed-effects model incorporating repeated-measures and different levels of Sa o2 and perfusion. RESULTS Skin pigment, PI, and degree of hypoxemia significantly contributed to errors (bias) in both pulse oximeters. For PI values of 1.0% to 1.5%, 0.5% to 1.0%, and <0.5%, the P value of the relationship to mean bias or median absolute bias was <.00001. In lightly pigmented subjects, only PI was associated with positive bias, whereas in medium and dark subjects bias increased with both low perfusion and degree of hypoxemia. Sex and age was not related to pulse oximeter bias. The combined frequency of missed diagnosis of hypoxemia (pulse oximeter readings 92%-96% when arterial oxygen saturation was <88%) in low perfusion conditions was 1.1% for light, 8.2% for medium, and 21.1% for dark skin. CONCLUSIONS Low peripheral perfusion combined with darker skin pigmentation leads to clinically significant high-reading pulse oximeter errors and missed diagnoses of hypoxemia. Darkly pigmented skin and low perfusion states are likely the cause of racial differences in pulse oximeter performance in retrospective studies.
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Affiliation(s)
- M Koa Gudelunas
- From the Hypoxia Research Laboratory, Department of Anesthesia and Perioperative Care
| | - Michael Lipnick
- From the Hypoxia Research Laboratory, Department of Anesthesia and Perioperative Care
- Division of Critical Care Medicine, Zuckerberg San Francisco General Hospital
- School of Medicine
- UCSF Center for Health Equity in Surgery and Anesthesia (CHESA), University of California San Francisco, San Francisco, California
| | - Carolyn Hendrickson
- From the Hypoxia Research Laboratory, Department of Anesthesia and Perioperative Care
- Division of Critical Care Medicine, Zuckerberg San Francisco General Hospital
| | - Sky Vanderburg
- From the Hypoxia Research Laboratory, Department of Anesthesia and Perioperative Care
- Division of Critical Care Medicine, Zuckerberg San Francisco General Hospital
| | - Bunmi Okunlola
- From the Hypoxia Research Laboratory, Department of Anesthesia and Perioperative Care
- Division of Critical Care Medicine, Zuckerberg San Francisco General Hospital
- Department of Anesthesiology and Critical Care, New York University School of Medicine, New York, New York
| | - Isabella Auchus
- From the Hypoxia Research Laboratory, Department of Anesthesia and Perioperative Care
- School of Medicine
- UCSF Center for Health Equity in Surgery and Anesthesia (CHESA), University of California San Francisco, San Francisco, California
| | - John R Feiner
- From the Hypoxia Research Laboratory, Department of Anesthesia and Perioperative Care
| | - Philip E Bickler
- From the Hypoxia Research Laboratory, Department of Anesthesia and Perioperative Care
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Hao S, Dempsey K, Matos J, Cox CE, Rotemberg V, Gichoya JW, Kibbe W, Hong C, Wong I. Utility of skin tone on pulse oximetry in critically ill patients: a prospective cohort study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.24.24303291. [PMID: 38464170 PMCID: PMC10925348 DOI: 10.1101/2024.02.24.24303291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Importance Pulse oximetry, a ubiquitous vital sign in modern medicine, has inequitable accuracy that disproportionately affects Black and Hispanic patients, with associated increases in mortality, organ dysfunction, and oxygen therapy. Although the root cause of these clinical performance discrepancies is believed to be skin tone, previous retrospective studies used self-reported race or ethnicity as a surrogate for skin tone. Objective To determine the utility of objectively measured skin tone in explaining pulse oximetry discrepancies. Design Setting and Participants Admitted hospital patients at Duke University Hospital were eligible for this prospective cohort study if they had pulse oximetry recorded up to 5 minutes prior to arterial blood gas (ABG) measurements. Skin tone was measured across sixteen body locations using administered visual scales (Fitzpatrick Skin Type, Monk Skin Tone, and Von Luschan), reflectance colorimetry (Delfin SkinColorCatch [L*, individual typology angle {ITA}, Melanin Index {MI}]), and reflectance spectrophotometry (Konica Minolta CM-700D [L*], Variable Spectro 1 [L*]). Main Outcomes and Measures Mean directional bias, variability of bias, and accuracy root mean square (ARMS), comparing pulse oximetry and ABG measurements. Linear mixed-effects models were fitted to estimate mean directional bias while accounting for clinical confounders. Results 128 patients (57 Black, 56 White) with 521 ABG-pulse oximetry pairs were recruited, none with hidden hypoxemia. Skin tone data was prospectively collected using 6 measurement methods, generating 8 measurements. The collected skin tone measurements were shown to yield differences among each other and overlap with self-reported racial groups, suggesting that skin tone could potentially provide information beyond self-reported race. Among the eight skin tone measurements in this study, and compared to self-reported race, the Monk Scale had the best relationship with differences in pulse oximetry bias (point estimate: -2.40%; 95% CI: -4.32%, -0.48%; p=0.01) when comparing patients with lighter and dark skin tones. Conclusions and relevance We found clinical performance differences in pulse oximetry, especially in darker skin tones. Additional studies are needed to determine the relative contributions of skin tone measures and other potential factors on pulse oximetry discrepancies.
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Affiliation(s)
- Sicheng Hao
- Duke University, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Durham, NC, USA
| | - Katelyn Dempsey
- Duke University, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Durham, NC, USA
| | - João Matos
- Duke University, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Durham, NC, USA
| | - Christopher E. Cox
- Duke University, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Durham, NC, USA
| | | | - Judy W. Gichoya
- Emory University School of Medicine, Department of Radiology, Atlanta, USA
| | - Warren Kibbe
- Duke University, Department of Biostatistics and Bioinformatics, Division of Translational Biomedical Informatics, Durham, NC, USA
| | - Chuan Hong
- Duke University, Department of Biostatistics and Bioinformatics, Division of Translational Biomedical Informatics, Durham, NC, USA
| | - Ian Wong
- Duke University, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Durham, NC, USA
- Duke University, Department of Biostatistics and Bioinformatics, Division of Translational Biomedical Informatics, Durham, NC, USA
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Khanna AK, Beard J, Lamminmäki S, Närväinen J, Antaki N, Yapici HO. Assessment of skin pigmentation-related bias in pulse oximetry readings among adults. J Clin Monit Comput 2024; 38:113-120. [PMID: 37882880 PMCID: PMC10879215 DOI: 10.1007/s10877-023-01095-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 10/09/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE Recent reports that pulse oximeters may overestimate oxygen saturation in individuals with darker skin pigmentation have prompted concerns from regulatory authorities regarding racial bias. We investigated the performance of TruSignal SpO2 sensors (GE Healthcare, Helsinki, Finland) in adults with varying skin pigmentation. METHODS A retrospective study was conducted using a set of pooled assessments of SpO2/SaO2 measurements from nine studies to assess bias, accuracy (Arms), and precision of TruSignal sensors in healthy adults under induced hypoxia. Subgroup analyses were performed based on oxygen saturation levels (band 1, ≥ 70 and ≤ 80%; band 2, > 80 and ≤ 90%; band 3, > 90 and ≤ 100%). RESULTS Of the 10,800 data points from 131 individuals, 8,202 (75.9%) and 2,598 (24.1%) were assigned to the light and dark pigment groups, respectively. Bias was 0.14% overall and less than 1% across oxygenation bands. The difference in bias between dark and light pigment groups was statistically significant at the low oxygenation band with SpO2 ≥ 70 and ≤ 80% (+ 0.58% and + 0.30% respectively; p = 0.0035). Throughout the saturation range, Arms was 1.64% in the light and 1.71% in the dark pigment group, within device specifications and regulatory requirements. Oxygenation was the dominating factor in stepwise ANOVA modeling. The mixed model also showed that bias was strongly affected by the oxygenation range. CONCLUSION TruSignal sensors demonstrated higher bias at lower oxygen saturation, with less than 0.5% difference between pigment groups. These findings raise new questions, such as ways to improve pulse oximetry measurements during challenging clinical conditions, including low perfusion.
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Affiliation(s)
- Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA.
- Outcomes Research Consortium, Cleveland, OH, USA.
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA.
| | - John Beard
- GE HealthCare - Patient Care Solutions, Milwaukee, WI, USA
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32
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Saleem F, Ryerson CJ, Sarma N, Johannson K, Marcoux V, Fisher J, Assayag D, Manganas H, Khalil N, Morisset J, Glaspole IN, Goh N, Oldham JM, Cox G, Fell C, Gershon AS, Halayko A, Hambly N, Lok SD, Shapera S, To T, Wilcox PG, Wong AW, Kolb M, Khor YH. Predicting New-onset Exertional and Resting Hypoxemia in Fibrotic Interstitial Lung Disease. Ann Am Thorac Soc 2023; 20:1726-1734. [PMID: 37676933 DOI: 10.1513/annalsats.202303-208oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/07/2023] [Indexed: 09/09/2023] Open
Abstract
Rationale: Hypoxemia in fibrotic interstitial lung disease (ILD) indicates disease progression and is of prognostic significance. The onset of hypoxemia signifies disease progression and predicts mortality in fibrotic ILD. Accurately predicting new-onset exertional and resting hypoxemia prompts appropriate patient discussion and timely consideration of home oxygen. Objectives: We derived and externally validated a risk prediction tool for both new-onset exertional and new-onset resting hypoxemia. Methods: This study used ILD registries from Canada for the derivation cohort and from Australia and the United States for the validation cohort. New-onset exertional and resting hypoxemia were defined as nadir oxyhemoglobin saturation < 88% during 6-minute-walk tests, resting oxyhemoglobin saturation < 88%, or the initiation of ambulatory or continuous oxygen. Candidate predictors included patient demographics, ILD subtypes, and pulmonary function. Time-varying Cox regression was used to identify the top-performing prediction model according to Akaike information criterion and clinical usability. Model performance was assessed using Harrell's C-index and goodness-of-fit (GoF) likelihood ratio test. A categorized risk prediction tool was developed. Results: The best-performing prediction model for both new-onset exertional and new-onset resting hypoxemia included age, body mass index, a diagnosis of idiopathic pulmonary fibrosis, and percent predicted forced vital capacity and diffusing capacity of carbon monoxide. The risk prediction tool exhibited good performance for exertional hypoxemia (C-index, 0.70; GoF, P = 0.85) and resting hypoxemia (C-index, 0.77; GoF, P = 0.27) in the derivation cohort, with similar performance in the validation cohort except calibration for resting hypoxemia (GoF, P = 0.001). Conclusions: This clinically applicable risk prediction tool predicted new-onset exertional and resting hypoxemia at 6 months in the derivation cohort and a diverse validation cohort. Suboptimal GoF in the validation cohort likely reflected overestimation of hypoxemia risk and indicated that the model is not flawed because of underestimation of hypoxemia.
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Affiliation(s)
- Ferhan Saleem
- Department of Medicine and
- Department of Medicine, St. Martinus University, Willemstad, Curaçao, Netherlands Antilles
| | - Christopher J Ryerson
- Department of Medicine and
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nandini Sarma
- Department of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon
| | - Kerri Johannson
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Veronica Marcoux
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Deborah Assayag
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Helene Manganas
- Département de Médecine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | | | - Julie Morisset
- Département de Médecine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Ian N Glaspole
- Department of Respiratory Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Nicole Goh
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Justin M Oldham
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan
| | - Gerard Cox
- Firestone Institute for Respiratory Health, McMaster University, Hamilton, Ontario, Canada
| | - Charlene Fell
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrea S Gershon
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Halayko
- Departmentof Physiology and Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nathan Hambly
- Firestone Institute for Respiratory Health, McMaster University, Hamilton, Ontario, Canada
| | - Stacey D Lok
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Teresa To
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Alyson W Wong
- Department of Medicine and
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Martin Kolb
- Firestone Institute for Respiratory Health, McMaster University, Hamilton, Ontario, Canada
| | - Yet H Khor
- Department of Respiratory Medicine, Alfred Health, Melbourne, Victoria, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
- Respiratory Research@Alfred, Central Clinical School, Monash University, Melbourne, Victoria, Australia; and
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
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Pal AD. Limitations in the Use of Pulse Oximetry in Patients of Color. J Perianesth Nurs 2023; 38:943-944. [PMID: 37865906 DOI: 10.1016/j.jopan.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 08/25/2023] [Indexed: 10/23/2023]
Affiliation(s)
- Angela D Pal
- Division of Adult and Senior Health, University of Colorado Anschutz Medical Campus College of Nursing, Aurora, CO.
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Charlton PH, Allen J, Bailón R, Baker S, Behar JA, Chen F, Clifford GD, Clifton DA, Davies HJ, Ding C, Ding X, Dunn J, Elgendi M, Ferdoushi M, Franklin D, Gil E, Hassan MF, Hernesniemi J, Hu X, Ji N, Khan Y, Kontaxis S, Korhonen I, Kyriacou PA, Laguna P, Lázaro J, Lee C, Levy J, Li Y, Liu C, Liu J, Lu L, Mandic DP, Marozas V, Mejía-Mejía E, Mukkamala R, Nitzan M, Pereira T, Poon CCY, Ramella-Roman JC, Saarinen H, Shandhi MMH, Shin H, Stansby G, Tamura T, Vehkaoja A, Wang WK, Zhang YT, Zhao N, Zheng D, Zhu T. The 2023 wearable photoplethysmography roadmap. Physiol Meas 2023; 44:111001. [PMID: 37494945 PMCID: PMC10686289 DOI: 10.1088/1361-6579/acead2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 04/04/2023] [Accepted: 07/26/2023] [Indexed: 07/28/2023]
Abstract
Photoplethysmography is a key sensing technology which is used in wearable devices such as smartwatches and fitness trackers. Currently, photoplethysmography sensors are used to monitor physiological parameters including heart rate and heart rhythm, and to track activities like sleep and exercise. Yet, wearable photoplethysmography has potential to provide much more information on health and wellbeing, which could inform clinical decision making. This Roadmap outlines directions for research and development to realise the full potential of wearable photoplethysmography. Experts discuss key topics within the areas of sensor design, signal processing, clinical applications, and research directions. Their perspectives provide valuable guidance to researchers developing wearable photoplethysmography technology.
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Affiliation(s)
- Peter H Charlton
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB1 8RN, United Kingdom
- Research Centre for Biomedical Engineering, City, University of London, London, EC1V 0HB, United Kingdom
| | - John Allen
- Research Centre for Intelligent Healthcare, Coventry University, Coventry, CV1 5RW, United Kingdom
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, United Kingdom
| | - Raquel Bailón
- Biomedical Signal Interpretation and Computational Simulation (BSICoS) Group, Aragon Institute of Engineering Research (I3A), IIS Aragon, University of Zaragoza, E-50018 Zaragoza, Spain
- CIBER-BBN, Instituto de Salud Carlos III, C/Monforte de Lemos 3-5, E-28029 Madrid, Spain
| | - Stephanie Baker
- College of Science and Engineering, James Cook University, Cairns, 4878 Queensland, Australia
| | - Joachim A Behar
- Faculty of Biomedical Engineering, Technion Israel Institute of Technology, Haifa, 3200003, Israel
| | - Fei Chen
- Department of Electrical and Electronic Engineering, Southern University of Science and Technology, Shenzhen, 518055 Guandong, People’s Republic of China
| | - Gari D Clifford
- Department of Biomedical Informatics, Emory University, Atlanta, GA 30322, United States of America
- Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA 30332, United States of America
| | - David A Clifton
- Department of Engineering Science, University of Oxford, Oxford, OX3 7DQ, United Kingdom
| | - Harry J Davies
- Department of Electrical and Electronic Engineering, Imperial College London, London, SW7 2AZ, United Kingdom
| | - Cheng Ding
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA 30332, United States of America
- Department of Biomedical Engineering, Emory University, Atlanta, GA 30322, United States of America
| | - Xiaorong Ding
- School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, 611731, People’s Republic of China
| | - Jessilyn Dunn
- Department of Biomedical Engineering, Duke University, Durham, NC 27708-0187, United States of America
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC 27708-0187, United States of America
- Duke Clinical Research Institute, Durham, NC 27705-3976, United States of America
| | - Mohamed Elgendi
- Biomedical and Mobile Health Technology Laboratory, Department of Health Sciences and Technology, ETH Zurich, Zurich, 8008, Switzerland
| | - Munia Ferdoushi
- Department of Electrical and Computer Engineering, University of Southern California, 90089, Los Angeles, California, United States of America
- The Institute for Technology and Medical Systems (ITEMS), Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, United States of America
| | - Daniel Franklin
- Institute of Biomedical Engineering, Translational Biology & Engineering Program, Ted Rogers Centre for Heart Research, University of Toronto, Toronto, M5G 1M1, Canada
| | - Eduardo Gil
- Biomedical Signal Interpretation and Computational Simulation (BSICoS) Group, Aragon Institute of Engineering Research (I3A), IIS Aragon, University of Zaragoza, E-50018 Zaragoza, Spain
- CIBER-BBN, Instituto de Salud Carlos III, C/Monforte de Lemos 3-5, E-28029 Madrid, Spain
| | - Md Farhad Hassan
- Department of Electrical and Computer Engineering, University of Southern California, 90089, Los Angeles, California, United States of America
- The Institute for Technology and Medical Systems (ITEMS), Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, United States of America
| | - Jussi Hernesniemi
- Finnish Cardiovascular Research Center Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, 33720, Finland
- Tampere Heart Hospital, Wellbeing Services County of Pirkanmaa, Tampere, 33520, Finland
| | - Xiao Hu
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, 30322, Georgia, United States of America
- Department of Biomedical Informatics, School of Medicine, Emory University, Atlanta, 30322, Georgia, United States of America
- Department of Computer Sciences, College of Arts and Sciences, Emory University, Atlanta, GA 30322, United States of America
| | - Nan Ji
- Hong Kong Center for Cerebrocardiovascular Health Engineering (COCHE), Hong Kong Science and Technology Park, Hong Kong, 999077, People’s Republic of China
| | - Yasser Khan
- Department of Electrical and Computer Engineering, University of Southern California, 90089, Los Angeles, California, United States of America
- The Institute for Technology and Medical Systems (ITEMS), Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, United States of America
| | - Spyridon Kontaxis
- Biomedical Signal Interpretation and Computational Simulation (BSICoS) Group, Aragon Institute of Engineering Research (I3A), IIS Aragon, University of Zaragoza, E-50018 Zaragoza, Spain
- CIBER-BBN, Instituto de Salud Carlos III, C/Monforte de Lemos 3-5, E-28029 Madrid, Spain
| | - Ilkka Korhonen
- Finnish Cardiovascular Research Center Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, 33720, Finland
| | - Panicos A Kyriacou
- Research Centre for Biomedical Engineering, City, University of London, London, EC1V 0HB, United Kingdom
| | - Pablo Laguna
- Biomedical Signal Interpretation and Computational Simulation (BSICoS) Group, Aragon Institute of Engineering Research (I3A), IIS Aragon, University of Zaragoza, E-50018 Zaragoza, Spain
- CIBER-BBN, Instituto de Salud Carlos III, C/Monforte de Lemos 3-5, E-28029 Madrid, Spain
| | - Jesús Lázaro
- Biomedical Signal Interpretation and Computational Simulation (BSICoS) Group, Aragon Institute of Engineering Research (I3A), IIS Aragon, University of Zaragoza, E-50018 Zaragoza, Spain
- CIBER-BBN, Instituto de Salud Carlos III, C/Monforte de Lemos 3-5, E-28029 Madrid, Spain
| | - Chungkeun Lee
- Digital Health Devices Division, Medical Device Evaluation Department, National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Cheongju, 28159, Republic of Korea
| | - Jeremy Levy
- Faculty of Biomedical Engineering, Technion Israel Institute of Technology, Haifa, 3200003, Israel
- Faculty of Electrical and Computer Engineering, Technion Institute of Technology, Haifa, 3200003, Israel
| | - Yumin Li
- State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing 210096, People’s Republic of China
| | - Chengyu Liu
- State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing 210096, People’s Republic of China
| | - Jing Liu
- Analog Devices Inc, San Jose, CA 95124, United States of America
| | - Lei Lu
- Department of Engineering Science, University of Oxford, Oxford, OX3 7DQ, United Kingdom
| | - Danilo P Mandic
- Department of Electrical and Electronic Engineering, Imperial College London, London, SW7 2AZ, United Kingdom
| | - Vaidotas Marozas
- Department of Electronics Engineering, Kaunas University of Technology, 44249 Kaunas, Lithuania
- Biomedical Engineering Institute, Kaunas University of Technology, 44249 Kaunas, Lithuania
| | - Elisa Mejía-Mejía
- Research Centre for Biomedical Engineering, City, University of London, London, EC1V 0HB, United Kingdom
| | - Ramakrishna Mukkamala
- Department of Bioengineering and Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Meir Nitzan
- Department of Physics/Electro-Optic Engineering, Lev Academic Center, 91160 Jerusalem, Israel
| | - Tania Pereira
- INESC TEC—Institute for Systems and Computer Engineering, Technology and Science, Porto, 4200-465, Portugal
- Faculty of Engineering, University of Porto, Porto, 4200-465, Portugal
| | | | - Jessica C Ramella-Roman
- Department of Biomedical Engineering and Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33174, United States of America
| | - Harri Saarinen
- Tampere Heart Hospital, Wellbeing Services County of Pirkanmaa, Tampere, 33520, Finland
| | - Md Mobashir Hasan Shandhi
- Department of Biomedical Engineering, Duke University, Durham, NC 27708-0187, United States of America
| | - Hangsik Shin
- Department of Digital Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, Republic of Korea
| | - Gerard Stansby
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, United Kingdom
- Northern Vascular Centre, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, United Kingdom
| | - Toshiyo Tamura
- Future Robotics Organization, Waseda University, Tokyo, 1698050, Japan
| | - Antti Vehkaoja
- Finnish Cardiovascular Research Center Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, 33720, Finland
- PulseOn Ltd, Espoo, 02150, Finland
| | - Will Ke Wang
- Department of Biomedical Engineering, Duke University, Durham, NC 27708-0187, United States of America
| | - Yuan-Ting Zhang
- Hong Kong Center for Cerebrocardiovascular Health Engineering (COCHE), Hong Kong Science and Technology Park, Hong Kong, 999077, People’s Republic of China
- Department of Biomedical Engineering, City University of Hong Kong, Hong Kong, 999077, People’s Republic of China
| | - Ni Zhao
- Department of Electronic Engineering, The Chinese University of Hong Kong, Hong Kong
| | - Dingchang Zheng
- Research Centre for Intelligent Healthcare, Coventry University, Coventry, CV1 5RW, United Kingdom
| | - Tingting Zhu
- Department of Engineering Science, University of Oxford, Oxford, OX3 7DQ, United Kingdom
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Fawzy A, Ali H, Dziedzic PH, Potu N, Calvillo E, Golden SH, Iwashyna TJ, Suarez JI, Hager DN, Garibaldi BT. Skin Pigmentation and Pulse Oximeter Accuracy in the Intensive Care Unit: a Pilot Prospective Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.11.16.23298645. [PMID: 38014046 PMCID: PMC10680877 DOI: 10.1101/2023.11.16.23298645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
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.
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Vogt WC, Wear KA, Pfefer TJ. Phantoms for evaluating the impact of skin pigmentation on photoacoustic imaging and oximetry performance. BIOMEDICAL OPTICS EXPRESS 2023; 14:5735-5748. [PMID: 38021140 PMCID: PMC10659791 DOI: 10.1364/boe.501950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/25/2023] [Accepted: 09/11/2023] [Indexed: 12/01/2023]
Abstract
Recent reports have raised concerns of potential racial disparities in performance of optical oximetry technologies. To investigate how variable epidermal melanin content affects performance of photoacoustic imaging (PAI) devices, we developed plastisol phantoms combining swappable skin-mimicking layers with a breast phantom containing either India ink or blood adjusted to 50-100% SO2 using sodium dithionite. Increasing skin pigmentation decreased maximum imaging depth by up to 25%, enhanced image clutter, and increased root-mean-square error in SO2 from 8.0 to 17.6% due to signal attenuation and spectral coloring effects. This phantom tool can aid in evaluating PAI device robustness to ensure high performance in all patients.
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Affiliation(s)
- William C. Vogt
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD 20993, USA
| | - Keith A. Wear
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD 20993, USA
| | - T. Joshua Pfefer
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD 20993, USA
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Fawzy A, Wise RA. Pulse Oximetry Misclassifies Need for Long-Term Oxygen Therapy in Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2023; 20:1556-1557. [PMID: 37909796 PMCID: PMC10632928 DOI: 10.1513/annalsats.202309-754ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Affiliation(s)
- Ashraf Fawzy
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert A Wise
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Dcosta JV, Ochoa D, Sanaur S. Recent Progress in Flexible and Wearable All Organic Photoplethysmography Sensors for SpO 2 Monitoring. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2023; 10:e2302752. [PMID: 37740697 PMCID: PMC10625116 DOI: 10.1002/advs.202302752] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 07/09/2023] [Indexed: 09/25/2023]
Abstract
Flexible and wearable biosensors are the next-generation healthcare devices that can efficiently monitor human health conditions in day-to-day life. Moreover, the rapid growth and technological advancements in wearable optoelectronics have promoted the development of flexible organic photoplethysmography (PPG) biosensor systems that can be implanted directly onto the human body without any additional interface for efficient bio-signal monitoring. As an example, the pulse oximeter utilizes PPG signals to monitor the oxygen saturation (SpO2 ) in the blood volume using two distinct wavelengths with organic light emitting diode (OLED) as light source and an organic photodiode (OPD) as light sensor. Utilizing the flexible and soft properties of organic semiconductors, pulse oximeter can be both flexible and conformal when fabricated on thin polymeric substrates. It can also provide highly efficient human-machine interface systems that can allow for long-time biological integration and flawless measurement of signal data. In this work, a clear and systematic overview of the latest progress and updates in flexible and wearable all-organic pulse oximetry sensors for SpO2 monitoring, including design and geometry, processing techniques and materials, encapsulation and various factors affecting the device performance, and limitations are provided. Finally, some of the research challenges and future opportunities in the field are mentioned.
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Affiliation(s)
- Jostin Vinroy Dcosta
- Mines Saint‐ÉtienneCentre Microélectronique de ProvenceDepartment of Flexible Electronics880, Avenue de MimetGardanne13541France
| | - Daniel Ochoa
- Mines Saint‐ÉtienneCentre Microélectronique de ProvenceDepartment of Flexible Electronics880, Avenue de MimetGardanne13541France
| | - Sébastien Sanaur
- Mines Saint‐ÉtienneCentre Microélectronique de ProvenceDepartment of Flexible Electronics880, Avenue de MimetGardanne13541France
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Pusey-Reid E, Quinn LW, Wong J, Wucherpfennig A. Representation of dark skin tones in foundational nursing textbooks: An image analysis. NURSE EDUCATION TODAY 2023; 130:105927. [PMID: 37556863 DOI: 10.1016/j.nedt.2023.105927] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/11/2023] [Accepted: 08/02/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE This study aimed to analyze and quantify the representation of dark skin tones (DST) images/graphics across fifteen foundational and clinical nursing textbooks to understand the degree of portrayed diversity in current nursing texts. BACKGROUND The United States (U.S.) population is becoming more ethnically and racially diverse. There is a scarcity of nursing literature, studies, and educational materials on the assessment and early recognition of common skin assessment in patients with dark skin tones (DST). The underrepresentation of people with DST images in didactic material suggests that omissions of these images in educational resources may introduce bias in health care provider education and practice. METHODS Fifteen popular foundational and clinical nursing textbooks were selected and analyzed. All the photo images and drawn graphics in these textbooks were coded according to Fitzpatrick's skin phototype (FSP) scale, which categorizes skin tone as (a) "Light" or Fitzpatrick scale I or II, (b) "Medium" or Fitzpatrick scale III or IV, and (c) "Dark" or Fitzpatrick scale V or VI. The training was provided for data collectors before analysis to ascertain good inter-rater reliability (Cohen's kappa = 0.960 for light skin tone, Cohen's kappa = 0.899 for medium skin tone, and Cohen's kappa = 0.913 for dark skin tone). RESULTS Analysis of 14,192 photo images and drawn graphics depicting skin tone was completed across 15 foundational and clinical nursing textbooks. 12.3 % of photo images and 2.4 % of drawn graphics depicted dark skin tones, compared to 60.9 % of photo images and 82.8 % of drawn graphics that displayed light skin tones in these textbooks. CONCLUSIONS Nursing textbooks overrepresent light skin tones and underrepresent dark skin tones. While the approximate racial distribution of the U.S. population is 59.3 % non-Hispanic-White, 13.6 % Black/African American, and 26.6 % Person of Color, the images and graphics of skin tones represented 68 % light, 15 % medium, and 9.4 % dark. RELEVANCE TO CLINICAL PRACTICE All healthcare providers are expected and required to deliver competent clinical care to an increasingly diverse population. For teaching-learning, more visual representations of DST and comparative images between what to expect in dark, medium, and light skin tones can help improve knowledge deficits and increase health equity.
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Affiliation(s)
- Eleonor Pusey-Reid
- MGH Institute of Health Professions, School of Nursing, Charlestown Navy Yard, 36 1st Avenue, Boston, MA 02129, United States of America.
| | - Lisa W Quinn
- MGH Institute of Health Professions, School of Nursing, Charlestown Navy Yard, 36 1st Avenue, Boston, MA 02129, United States of America.
| | - John Wong
- MGH Institute of Health Professions, School of Nursing and Department of Occupational Therapy, Charlestown Navy Yard, 36 1st Avenue, Boston, MA 02129, United States of America.
| | - Andrea Wucherpfennig
- MGH Institute of Health Professions, School of Nursing, Charlestown Navy Yard, 36 1st Avenue, Boston, MA 02129, United States of America.
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White M, Pizzetta C, Davidson E, Hines A, Azevedo M, Ikem F, Jones LM, Malone S, Berhie G. Mississippi church leaders' perceptions of challenges and barriers to the use of consumer wearables among community members. AIMS Public Health 2023; 10:775-790. [PMID: 38187904 PMCID: PMC10764966 DOI: 10.3934/publichealth.2023052] [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: 06/14/2023] [Revised: 07/25/2023] [Accepted: 08/09/2023] [Indexed: 01/09/2024] Open
Abstract
Background Wearables have begun to play a transformative role in health management and disease prevention. Objective This study examined the use of wearable devices in African American communities in Mississippi, USA, through the lens of church leaders. Methods We conducted focus groups with church leaders to record their perceptions about the use of wearables of their community members. We conducted six focus groups with a total of 89 church leaders from across the state of Mississippi. The focus groups were designed to contextualize and explain the socio-cognitive processes that provided an understanding of wearable device adoption practices among community members. Participants were male and female church leaders who were recruited from the three Mississippi Districts. The church leaders' perceptions of barriers and challenges to the adoption of consumer wearables in their communities were thoroughly analyzed using thematic analysis. Results There was great apprehension on the part of community members about the security of the information they entered into the wearable devices and about how that information could be used by other parties. Many community members who understood the value of proactive health behaviors could not afford the high cost of purchasing wearable devices, while others displayed a low level of comfort with technology, believing that wearable use was for younger people. Conclusion More expansive adoption of wearable devices in Mississippi will depend on the ability of the public health professionals, policy-makers and manufacturers to address the barriers that were identified by this study, thereby enabling the community to have full access to the potential benefits of these technologies.
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Affiliation(s)
- Monique White
- Public Health, Informatics, and Technology, College of Health Sciences, Jackson State University, Jackson, MS, USA
| | - Candis Pizzetta
- Department of English, Foreign Languages, and Speech Communication, College of Liberal Arts, Jackson State University, Jackson, MS, USA
| | - Edith Davidson
- Department of Business Administration, College of Business Administration, Jackson State University, Jackson, MS, USA
| | - Andre Hines
- Department of Public Policy & Administration, College of Liberal Arts, Jackson State University, Jackson, MS, USA
| | - Mario Azevedo
- Department of History and Philosophy, College of Liberal Arts, Jackson State University, Jackson, MS, USA
| | - Fidelis Ikem
- Department of Business Administration, College of Business Administration, Jackson State University, Jackson, MS, USA
| | - Lena M. Jones
- Department of Public Policy & Administration, College of Liberal Arts, Jackson State University, Jackson, MS, USA
| | - Shelia Malone
- Department of Epidemiology and Biostatistics, College of Health Sciences, Jackson State University, Jackson, MS, USA
| | - Girmay Berhie
- Public Health, Informatics, and Technology, College of Health Sciences, Jackson State University, Jackson, MS, USA
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Blank JA, Armstrong-Hough M, Valley TS. Disparities among patients with respiratory failure. Curr Opin Crit Care 2023; 29:493-504. [PMID: 37641499 PMCID: PMC10599128 DOI: 10.1097/mcc.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW Disparities are common within healthcare, and critical illness is no exception. This review summarizes recent literature on health disparities within respiratory failure, focusing on race, ethnicity, socioeconomic status, and sex. RECENT FINDINGS Current evidence indicates that Black patients have higher incidence of respiratory failure, while the relationships among race, ethnicity, and mortality remains unclear. There has been renewed interest in medical device bias, specifically pulse oximetry, for which data demonstrate patients with darker skin tones may be at risk for undetected hypoxemia and worse outcomes. Lower socioeconomic status is associated with higher mortality, and respiratory failure can potentiate socioeconomic inequities via illness-related financial toxicity. Literature on sex-based disparities is limited; however, evidence suggests males receive more invasive care, including mechanical ventilation. SUMMARY Most studies focused on disparities in incidence and mortality associated with respiratory failure, but few relied on granular clinical data of patients from diverse backgrounds. Future studies should evaluate processes of care for respiratory failure that may mechanistically contribute to disparities in order to develop interventions that improve outcomes.
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Affiliation(s)
| | - Mari Armstrong-Hough
- New York University School of Global Public Health, Department of Social & Behavioral Sciences, Department of Epidemiology
| | - Thomas S. Valley
- University of Michigan, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine
- VA Center for Clinical Management Research, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan
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Charpignon ML, Carrel A, Jiang Y, Kwaga T, Cantada B, Hyslop T, Cox CE, Haines K, Koomson V, Dumas G, Morley M, Dunn J, Ian Wong AK. Going beyond the means: Exploring the role of bias from digital determinants of health in technologies. PLOS DIGITAL HEALTH 2023; 2:e0000244. [PMID: 37824494 PMCID: PMC10569586 DOI: 10.1371/journal.pdig.0000244] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
BACKGROUND In light of recent retrospective studies revealing evidence of disparities in access to medical technology and of bias in measurements, this narrative review assesses digital determinants of health (DDoH) in both technologies and medical formulae that demonstrate either evidence of bias or suboptimal performance, identifies potential mechanisms behind such bias, and proposes potential methods or avenues that can guide future efforts to address these disparities. APPROACH Mechanisms are broadly grouped into physical and biological biases (e.g., pulse oximetry, non-contact infrared thermometry [NCIT]), interaction of human factors and cultural practices (e.g., electroencephalography [EEG]), and interpretation bias (e.g, pulmonary function tests [PFT], optical coherence tomography [OCT], and Humphrey visual field [HVF] testing). This review scope specifically excludes technologies incorporating artificial intelligence and machine learning. For each technology, we identify both clinical and research recommendations. CONCLUSIONS Many of the DDoH mechanisms encountered in medical technologies and formulae result in lower accuracy or lower validity when applied to patients outside the initial scope of development or validation. Our clinical recommendations caution clinical users in completely trusting result validity and suggest correlating with other measurement modalities robust to the DDoH mechanism (e.g., arterial blood gas for pulse oximetry, core temperatures for NCIT). Our research recommendations suggest not only increasing diversity in development and validation, but also awareness in the modalities of diversity required (e.g., skin pigmentation for pulse oximetry but skin pigmentation and sex/hormonal variation for NCIT). By increasing diversity that better reflects patients in all scenarios of use, we can mitigate DDoH mechanisms and increase trust and validity in clinical practice and research.
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Affiliation(s)
- Marie-Laure Charpignon
- Massachusetts Institute of Technology; Institute for Data, Systems, and Society; Laboratory for Information and Decision Systems, Boston, Massachusetts, United States of America
| | - Adrien Carrel
- CentraleSupélec, Université Paris-Saclay, Gif-sur-Yvette, France
- Imperial College London, London, United Kingdom
| | - Yihang Jiang
- Duke University, Pratt School of Engineering, Department of Biomedical Engineering, Durham, North Carolina, United States of America
| | - Teddy Kwaga
- Mbarara University of Science and Technology, Department of Ophthalmology, Mbarara, Uganda
| | - Beatriz Cantada
- Massachusetts Institute of Technology; Institute Community and Equity Office, Boston, Massachusetts, United States of America
| | - Terry Hyslop
- Duke University, Department of Biostatistics and Bioinformatics, Durham, North Carolina, United States of America
| | - Christopher E. Cox
- Duke University, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Durham, North Carolina, United States of America
| | - Krista Haines
- Duke University, Department of Surgery, Durham, North Carolina, United States of America
| | - Valencia Koomson
- Tufts University, Department of Electrical and Computer Engineering, Boston, Massachusetts, United States of America
| | - Guillaume Dumas
- CHU Sainte-Justine Research Center, Department of Psychiatry, Université de Montréal, Montréal, Quebec, Canada
- Mila–Quebec AI Institute, University of Montreal, Montréal, Quebec, Canada
| | - Michael Morley
- Ophthalmic Consultants of Boston, Boston, Massachusetts, United States of America
- Assistant Clinical Professor of Ophthalmology, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Jessilyn Dunn
- Duke University, Pratt School of Engineering, Department of Biomedical Engineering, Durham, North Carolina, United States of America
- Duke University, Department of Biostatistics and Bioinformatics, Durham, North Carolina, United States of America
| | - An-Kwok Ian Wong
- Duke University, Department of Biostatistics and Bioinformatics, Durham, North Carolina, United States of America
- Duke University, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Durham, North Carolina, United States of America
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Rea MS, Bierman A. Light source spectra are the likely cause of systematic bias in pulse oximeter readings for individuals with darker skin pigmentation. Br J Anaesth 2023; 131:e101-e103. [PMID: 37188559 DOI: 10.1016/j.bja.2023.04.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/11/2023] [Accepted: 04/15/2023] [Indexed: 05/17/2023] Open
Affiliation(s)
- Mark S Rea
- Light and Health Research Center, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Quijano T, Crowell J, Eggert K, Clark K, Alexander M, Grau L, Heimer R. Xylazine in the drug supply: Emerging threats and lessons learned in areas with high levels of adulteration. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 120:104154. [PMID: 37574646 DOI: 10.1016/j.drugpo.2023.104154] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/22/2023] [Accepted: 07/29/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Xylazine, a sedative analgesic drug approved as an animal tranquilizer but not for human use, has become an adulterant in the illicit opioid marketplace in North America. Recently declared an emerging health threat in the U.S., the prevalence of xylazine in overdose deaths increased 5.5-fold between 2019 and 2021. More information is needed about the impact of xylazine on opioid users and harm reduction service providers. METHODS The impact of xylazine adulteration was triangulated through examination of (1) opioid overdose fatalities in Connecticut between 2017 and 2021 reported by the Office of the Chief Medical Examiner data, (2) a convenience survey of people in Connecticut who use drugs (PWUD) regarding their knowledge of and attitude about the local illicit drug supply, and (3) semi-structured interviews of harm reduction service providers in Connecticut and Philadelphia in response to prompts on the impacts of and responses to xylazine adulteration. RESULTS The presence of fentanyl or its analogues in fatal opioid overdoses was a statistically significant predictor of xylazine presence [OR = 25.0, 95%CI (10.7,81.1)] as was being Hispanic [OR = 1.36, 95%CI (1.03,1.77)]. A survey of people who used drugs revealed that 43% (n = 286) were concerned that the drug supply was always unpredictable. Three-quarters of respondents were aware of xylazine and two-thirds would use a xylazine test strip if one was available. Respondents who identified as White, Hispanic were most likely to be aware of xylazine, to have used a fentanyl test strip, and to be interested in a xylazine test strip. Respondents who injected drugs were 3.6-fold more likely than those who did not inject to endorse an interest in a xylazine test strip. Harm reduction service providers were cognizant of a range of problems surrounding the use and injection of xylazine. Although they reported implementing practices to better respond to xylazine harms, they recognized the absence of solutions to many of the problems encountered. CONCLUSION The prevalence of xylazine has expanded, especially in combination with fentanyl. Harm reduction education efforts with fidelity to best practices have emerged, but the harms persist and community prevention needs are largely unmet.
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Affiliation(s)
- Thomas Quijano
- Yale School of Public Health, New Haven, CT, United States.
| | - Jason Crowell
- Sex Workers and Allies Network, New Haven, CT, United States
| | - Kathryn Eggert
- APT Foundation, New Haven, CT, United States; Antioch University Graduate School of Leadership and Change, Yellow Springs, OH, United States
| | - Katie Clark
- Clark Health Education and Research Solutions, Branford, CT, United States
| | - Marcus Alexander
- Yale Institute for Network Science, New Haven, CT, United States
| | - Lauretta Grau
- Yale School of Public Health, New Haven, CT, United States
| | - Robert Heimer
- Yale School of Public Health, New Haven, CT, United States
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Paik KE, Hicklen R, Kaggwa F, Puyat CV, Nakayama LF, Ong BA, Shropshire JNI, Villanueva C. Digital Determinants of Health: Health data poverty amplifies existing health disparities-A scoping review. PLOS DIGITAL HEALTH 2023; 2:e0000313. [PMID: 37824445 PMCID: PMC10569513 DOI: 10.1371/journal.pdig.0000313] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 07/02/2023] [Indexed: 10/14/2023]
Abstract
Artificial intelligence (AI) and machine learning (ML) have an immense potential to transform healthcare as already demonstrated in various medical specialties. This scoping review focuses on the factors that influence health data poverty, by conducting a literature review, analysis, and appraisal of results. Health data poverty is often an unseen factor which leads to perpetuating or exacerbating health disparities. Improvements or failures in addressing health data poverty will directly impact the effectiveness of AI/ML systems. The potential causes are complex and may enter anywhere along the development process. The initial results highlighted studies with common themes of health disparities (72%), AL/ML bias (28%) and biases in input data (18%). To properly evaluate disparities that exist we recommend a strengthened effort to generate unbiased equitable data, improved understanding of the limitations of AI/ML tools, and rigorous regulation with continuous monitoring of the clinical outcomes of deployed tools.
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Affiliation(s)
- Kenneth Eugene Paik
- MIT Critical Data, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
| | - Rachel Hicklen
- Research Medical Library, MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Fred Kaggwa
- Department of Computer Science, Mbarara University of Science & Technology, Mbarara, Uganda
| | | | - Luis Filipe Nakayama
- MIT Critical Data, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- Department of Ophthalmology, São Paulo Federal University, São Paulo, Brazil
| | - Bradley Ashley Ong
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | | | - Cleva Villanueva
- Instituto Politécnico Nacional, Escuela Superior de Medicina, Mexico City, Mexico
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Aoki KC, Barrant M, Gai MJ, Handal M, Xu V, Mayrovitz HN. Impacts of Skin Color and Hypoxemia on Noninvasive Assessment of Peripheral Blood Oxygen Saturation: A Scoping Review. Cureus 2023; 15:e46078. [PMID: 37900526 PMCID: PMC10610303 DOI: 10.7759/cureus.46078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/26/2023] [Indexed: 10/31/2023] Open
Abstract
Standard pulse oximeters estimate arterial blood saturation (SaO2) non-invasively by emitting and detecting light of a specific wavelength through a cutaneous vascular bed, such as a digit or the ear lobe. The quantity measured at these peripheral sites is designated as oxygen saturation (SpO2). Most reliable pulse oximeters are calibrated from measurements of healthy volunteers using some form of oxygen desaturation method. As the degree of inducible hypoxemia is limited, the calibration below achievable desaturation levels is usually extrapolated, leading to potential measurement error at low SaO2 values, especially in highly pigmented skin. Such skin color-related errors (SCRE) are the topic of this scoping review. Specifically, this study aimed to identify the combined impact of skin color and reduced SaO2 on the non-invasive assessment of SpO2 and report the consequences of potential inaccuracies. Three databases were searched (Cumulated Index to Nursing and Allied Health Literature (CINAHL), PubMed, and Web of Science) for peer-reviewed prospective and retrospective studies published in English between 2000 and 2022 involving human patients with hypoxemia that included a measure of skin color (Fitzpatrick scale or race/ethnicity). Ten studies met the criteria and were included in the final review. Eight of these studies reported statistically significant higher pulse oximeter readings in darker-skinned patients with hypoxia compared to their arterial blood gas measurements. Occult hypoxia was more prevalent in Black and Hispanic patients than in White patients. Minority patients overall (Black, Asian, and American Indian) were more likely to have a SaO2 < 88% that was not detected by pulse oximetry (occult hypoxemia) during hospitalization. With greater levels of hypoxemia, the differences between SpO2 and SaO2 were greater. If SaO2 was < 90%, then SpO2 was overestimated in all ethnicities but worse in minorities. In conclusion, the bias found in pulse oximeter readings in the skin of color broadly impacts patients with hypoxemia. The failure of SpO2 measuring devices to detect occult hypoxemia can delay the delivery of life-saving treatment to critically ill patients requiring respiratory rehabilitation and supplemental oxygen therapy. This may lead to adverse health outcomes, increased in-hospital mortality, and complications such as organ dysfunction. An improvement in pulse oximeter detection mechanisms that would include all skin pigmentations is therefore much desired to optimize individual healthcare status and minimize disparities in treatment.
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Affiliation(s)
- Kawaiola C Aoki
- Medical School, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Maya Barrant
- Medical School, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Mam Jarra Gai
- Medical School, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Marina Handal
- Medical School, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Vivian Xu
- Medical School, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Harvey N Mayrovitz
- Medical Education and Simulation, Cardiopulmonary Physiology, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
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DeBolt CL, Rheuban KS, Harris D. Telehealth Services: Improving Equity in Pulmonary Health Outcomes. Clin Chest Med 2023; 44:651-660. [PMID: 37517842 DOI: 10.1016/j.ccm.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
Expansion of telehealth services has the potential to attenuate health inequities in pulmonary medicine, by improving access to care and health outcomes in patients with lung disease. These telehealth services include remote patient monitoring, synchronous telemedicine, and remote pulmonary rehabilitation. Currently, patients who are White, well-educated, wealthy, and from urban areas are the most likely to benefit from telehealth services. Without clear policy decisions and planning to overcome the "Digital Divide," telehealth services will only exacerbate existing disparities within the pulmonary disease. We describe the benefits and limitations of these new technologies and their impact on improving equity in pulmonary medicine.
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Affiliation(s)
| | - Karen S Rheuban
- Department of Pediatrics, University of Virginia, Center for Telehealth, Charlottesville, VA, USA
| | - Drew Harris
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
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Fawzy A, Wu TD, Wang K, Sands KE, Fisher AM, Arnold Egloff SA, DellaVolpe JD, Iwashyna TJ, Xu Y, Garibaldi BT. Clinical Outcomes Associated With Overestimation of Oxygen Saturation by Pulse Oximetry in Patients Hospitalized With COVID-19. JAMA Netw Open 2023; 6:e2330856. [PMID: 37615985 PMCID: PMC10450566 DOI: 10.1001/jamanetworkopen.2023.30856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 07/19/2023] [Indexed: 08/25/2023] Open
Abstract
Importance Many pulse oximeters have been shown to overestimate oxygen saturation in persons of color, and this phenomenon has potential clinical implications. The relationship between overestimation of oxygen saturation with timing of COVID-19 medication delivery and clinical outcomes remains unknown. Objective To investigate the association between overestimation of oxygen saturation by pulse oximetry and delay in administration of COVID-19 therapy, hospital length of stay, risk of hospital readmission, and in-hospital mortality. Design, Setting, and Participants This cohort study included patients hospitalized for COVID-19 at 186 acute care facilities in the US with at least 1 functional arterial oxygen saturation (SaO2) measurement between March 2020 and October 2021. A subset of patients were admitted after July 1, 2020, without immediate need for COVID-19 therapy based on pulse oximeter saturation (SpO2 levels of 94% or higher without supplemental oxygen). Exposures Self-reported race and ethnicity, difference between concurrent SaO2 and pulse oximeter saturation (SpO2) within 10 minutes, and initially unrecognized need for COVID-19 therapy (first SaO2 reading below 94% despite SpO2 levels of 94% or above). Main Outcome and Measures The association of race and ethnicity with degree of pulse oximeter measurement error (SpO2 - SaO2) and odds of unrecognized need for COVID-19 therapy were determined using linear mixed-effects models. Associations of initially unrecognized need for treatment with time to receipt of therapy (remdesivir or dexamethasone), in-hospital mortality, 30-day hospital readmission, and length of stay were evaluated using mixed-effects models. All models accounted for demographics, clinical characteristics, and hospital site. Effect modification by race and ethnicity was evaluated using interaction terms. Results Among 24 504 patients with concurrent SpO2 and SaO2 measurements (mean [SD] age, 63.9 [15.8] years; 10 263 female [41.9%]; 3922 Black [16.0%], 7895 Hispanic [32.2%], 2554 Asian, Native American or Alaskan Native, Hawaiian or Pacific Islander, or another race or ethnicity [10.4%], and 10 133 White [41.4%]), pulse oximetry overestimated SaO2 for Black (adjusted mean difference, 0.93 [95% CI, 0.74-1.12] percentage points), Hispanic (0.49 [95% CI, 0.34-0.63] percentage points), and other (0.53 [95% CI, 0.35-0.72] percentage points) patients compared with White patients. In a subset of 8635 patients with a concurrent SpO2 - SaO2 pair without immediate need for COVID-19 therapy, Black patients were significantly more likely to have pulse oximetry values that masked an indication for COVID-19 therapy compared with White patients (adjusted odds ratio [aOR], 1.65; 95% CI, 1.33-2.03). Patients with an unrecognized need for COVID-19 therapy were 10% less likely to receive COVID-19 therapy (adjusted hazard ratio, 0.90; 95% CI, 0.83-0.97) and higher odds of readmission (aOR, 2.41; 95% CI, 1.39-4.18) regardless of race (P for interaction = .45 and P = .14, respectively). There was no association of unrecognized need for COVID-19 therapy with in-hospital mortality (aOR, 0.84; 95% CI, 0.71-1.01) or length of stay (mean difference, -1.4 days; 95% CI, -3.1 to 0.2 days). Conclusions and Relevance In this cohort study, overestimation of oxygen saturation by pulse oximetry led to delayed delivery of COVID-19 therapy and higher probability of readmission regardless of race. Black patients were more likely to have unrecognized need for therapy with potential implications for population-level health disparities.
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Affiliation(s)
- Ashraf Fawzy
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tianshi David Wu
- Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston, Texas
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Administration Medical Center, Houston, Texas
| | - Kunbo Wang
- Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, Maryland
| | - Kenneth E. Sands
- HCA Healthcare, HCA Healthcare Research Institute (HRI), Nashville, Tennessee
| | | | | | | | - Theodore J. Iwashyna
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Yanxun Xu
- Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, Maryland
| | - Brian T. Garibaldi
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Gary CS, Iskandarova A, Abadeer AI, Yohe GJ, Giladi AM. Performance of Near-Infrared Spectroscopy in Detecting Acute Tourniquet-Induced Upper-Extremity Ischemia Across Different Skin Phenotypes. J Hand Surg Am 2023:S0363-5023(23)00326-X. [PMID: 37498271 DOI: 10.1016/j.jhsa.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 05/30/2023] [Accepted: 06/21/2023] [Indexed: 07/28/2023]
Abstract
PURPOSE Diagnosing acute tissue ischemia is challenging, particularly in patients with higher skin melanin content. We investigated whether near-infrared spectroscopy (NIRS) is effective and consistent in detecting upper extremity ischemia across various skin phenotypes. METHODS Volunteers underwent tourniquet-induced upper extremity ischemia. Skin color was evaluated by the Fitzpatrick scale (FP, range: I-VI) and the Von Luschan scale (vL, range: 1-36). A NIRS probe was placed on one finger. The tourniquet was inflated to 250 mmHg and perfusion was restricted for 7 minutes, followed by a 10-minute monitored reperfusion period. The percent tissue oxygenation (StO2) was recorded. RESULTS A total of 55 volunteers were enrolled (22 self-identified as Caucasian, 21 African American, 7 Asian, 2 Latinx, and 2 Biracial). Average starting and ending StO2 for the cohort was 72.2% and 45.9%, respectively. However, there was variability based on skin melanin content. Increasing vL correlated with lower starting StO2, smaller StO2 decrease, and shorter time to reach ischemic steady state. High skin melanin (FP scale IV-VI) was associated with significantly lower starting StO2 (-7.1%) and shorter time to reach ischemic steady state (-0.3 mins). African Americans had lower starting StO2 (-8.6%) and 7.8% lesser total StO2 decrease than other groups. CONCLUSIONS NIRS can rapidly detect acute onset tissue ischemia in the upper extremity. However, given the lower starting StO2 and smaller total StO2 decrease after tourniquet-induced ischemia for patients with higher skin melanin, using NIRS for clinical detection of acute ischemia may be more challenging in these patients. These inconsistencies may limit use of NIRS clinically for spot identification of ischemia. CLINICAL RELEVANCE Although NIRS has utility in tracking tissue oxygenation, variable performance with different skin melanin content raises concerns as to whether different cutoff/threshold levels are needed for different groups, and whether NIRS is reliable for spot checks in acute events.
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Affiliation(s)
- Cyril S Gary
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Aygul Iskandarova
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Andrew I Abadeer
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Gabriel J Yohe
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; MedStar Health Research Institute, Hyattsville, MD
| | - Aviram M Giladi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
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Bermond M, Davies HJ, Occhipinti E, Nassibi A, Mandic DP. Reducing racial bias in SpO 2 estimation: The effects of skin pigmentation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023; 2023:1-5. [PMID: 38083781 DOI: 10.1109/embc40787.2023.10341069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Accurate pulse-oximeter readings are critical for clinical decisions, especially when arterial blood-gas tests - the gold standard for determining oxygen saturation levels - are not available, such as when determining COVID-19 severity. Several studies demonstrate that pulse oxygen saturation estimated from photoplethysmography (PPG) introduces a racial bias due to the more profound scattering of light in subjects with darker skin due to the increased presence of melanin. This leads to an overestimation of blood oxygen saturation in those with darker skin that is increased for low blood oxygen levels and can result in a patient not receiving potentially life-saving supplemental oxygen. This racial bias has been comprehensively studied in conventional finger pulse oximetry but in other less commonly used measurement sites, such as in-ear pulse oximetry, it remains unexplored. Different measurement sites can have thinner epidermis compared with the finger and lower exposure to sunlight (such as is the case with the ear canal), and we hypothesise that this could reduce the bias introduced by skin tone on pulse oximetry. To this end, we compute SpO2 in different body locations, during rest and breath-holds, and compare with the index finger. The study involves a participant pool covering 6-pigmentation categories from Fitzpatrick's Skin Pigmentation scale. These preliminary results indicate that locations characterized by cartilaginous highly vascularized tissues may be less prone to the influence of melanin and pigmentation in the estimation of SpO2, paving the way for the development of non-discriminatory pulse oximetry devices.
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