Samuel S. Bruce

Smart wearable body sensors for patient self-assessment and monitoring

BackgroundInnovations in mobile and electronic healthcare are revolutionizing the involvement of both doctors and patients in the modern healthcare system by extending the capabilities of physiological monitoring devices. Despite significant progress within the monitoring device industry, the widespread integration of this technology into medical practice remains limited. The purpose of this review is to summarize the developments and clinical utility of smart wearable body sensors.MethodsWe reviewed the literature for connected device, sensor, trackers, telemonitoring, wireless technology and real time home tracking devices and their application for clinicians.ResultsSmart wearable sensors are effective and reliable for preventative methods in many different facets of medicine such as, cardiopulmonary, vascular, endocrine, neurological function and rehabilitation medicine. These sensors have also been shown to be accurate and useful for perioperative monitoring and rehabilitation medicine.ConclusionAlthough these devices have been shown to be accurate and have clinical utility, they continue to be underutilized in the healthcare industry. Incorporating smart wearable sensors into routine care of patients could augment physician-patient relationships, increase the autonomy and involvement of patients in regards to their healthcare and will provide for novel remote monitoring techniques which will revolutionize healthcare management and spending.

The promise of wearable activity sensors to define patient recovery

The recent emergence of mobile health--the use of mobile telecommunication and wireless devices to improve health outcomes, services, and research--has inspired a patient-centric approach to monitor health metrics. Sensors embedded in wearable devices are utilized to acquire greater self-knowledge by tracking basic parameters such as blood pressure, heart rate, and body temperature as well as data related to exercise, diet, and psychological state. To that end, recent studies on utilizing wireless fitness activity trackers to monitor and promote functional recovery in patients suggest that collecting up-to-date performance data could help patients regain functional independence and help hospitals determine the appropriate length of stay for a patient. This manuscript examines existing functional assessment scales, discusses the use of activity tracking sensors in evaluating functional independence, and explores the growing application of wireless technology in measuring and promoting functional recovery.

Hematoma volume as the major determinant of outcomes after intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a leading cause of morbidity and mortality, greatly linked to hematoma volume. Understanding the characteristics and size of hematoma is integral to evaluating severity and prognosis after ICH. Examination of the literature suggests that markers for hematoma size vary, but the key range between 20-30 mL is most widely used as the cut-off for classification of hematoma volume. The role of hematoma volume in episodes of hematoma expansion and re-bleeding further impact outcomes, with increased growth associated with larger hematoma volume. Additionally, many commonly used predictors of ICH outcomes are directly related to hematoma volume, implicating it as an important variable when determining outcomes. In conclusion, hematoma volume is likely the most significant determinant of outcomes in intracerebral hemorrhage.

Statins Reduce Neurologic Injury in Asymptomatic Carotid Endarterectomy Patients

Background and Purpose— Statins are neuroprotective in a variety of experimental models of cerebral injury. We sought to determine whether patients taking statins before asymptomatic carotid endarterectomy exhibit a lower incidence of neurological injury (clinical stroke and cognitive dysfunction). Methods— A total of 328 patients with asymptomatic carotid stenosis scheduled for elective carotid endarterectomy consented to participate in this observational study of perioperative neurological injury. Results— Patients taking statins had a lower incidence of clinical stroke (0.0% vs 3.1%; P=0.02) and cognitive dysfunction (11.0% vs 20.2%; P=0.03). In a multivariate regression model, statin use was significantly associated with decreased odds of cognitive dysfunction (odds ratio, 0.51 [95% CI, 0.27–0.96]; P=0.04). Conclusions— Preoperative statin use was associated with less neurological injury after asymptomatic carotid endarterectomy. These observations suggest that it may be possible to further reduce the perioperative morbidity of carotid endarterectomy. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00597883

Evaluation of intraventricular hemorrhage assessment methods for predicting outcome following intracerebral hemorrhage

OBJECT Intraventricular hemorrhage (IVH) associated with intracerebral hemorrhage (ICH) is an independent predictor of poor outcome. Clinical methods for evaluating IVH, however, are not well established. This study sought to determine the best IVH grading scale by evaluating the predictive accuracies of IVH, Graeb, and LeRoux scores in an independent cohort of ICH patients with IVH. Subacute IVH dynamics as well as the impact of external ventricular drain (EVD) placement on IVH and outcome were also investigated. METHODS A consecutive cohort of 142 primary ICH patients with IVH was admitted to Columbia University Medical Center between February 2009 and February 2011. Baseline demographics, clinical presentation, and hospital course were prospectively recorded. Admission CT scans performed within 24 hours of onset were reviewed for ICH location, hematoma volume, and presence of IVH. Intraventricular hemorrhage was categorized according to IVH, Graeb, and LeRoux scores. For each patient, the last scan performed within 6 days of ictus was similarly evaluated. Outcomes at discharge were assessed using the modified Rankin Scale (mRS). Receiver operating characteristic analysis was used to determine the predictive accuracies of the grading scales for poor outcome (mRS score ≥ 3). RESULTS Seventy-three primary ICH patients (51%) had IVH. Median admission IVH, Graeb, and LeRoux scores were 13, 6, and 8, respectively. Median IVH, Graeb and LeRoux scores decreased to 9 (p = 0.005), 4 (p = 0.002), and 4 (p = 0.003), respectively, within 6 days of ictus. Poor outcome was noted in 55 patients (75%). Areas under the receiver operating characteristic curve were similar among the IVH, Graeb, and LeRoux scores (0.745, 0.743, and 0.744, respectively) and within 6 days postictus (0.765, 0.722, 0.723, respectively). Moreover, the IVH, Graeb, and LeRoux scores had similar maximum Youden Indices both at admission (0.515 vs 0.477 vs 0.440, respectively) and within 6 days postictus (0.515 vs 0.339 vs 0.365, respectively). Patients who received EVDs had higher mean IVH volumes (23 ± 26 ml vs 9 ± 11 ml, p = 0.003) and increased incidence of Glasgow Coma Scale scores < 8 (67% vs 38%, p = 0.015) and hydrocephalus (82% vs 50%, p = 0.004) at admission but had similar outcome as those who did not receive an EVD. CONCLUSIONS The IVH, Graeb, and LeRoux scores predict outcome well with similarly good accuracy in ICH patients with IVH when assessed at admission and within 6 days after hemorrhage. Therefore, any of one of the scores would be equally useful for assessing IVH severity and risk-stratifying ICH patients with regard to outcome. These results suggest that EVD placement may be beneficial for patients with severe IVH, who have particularly poor prognosis at admission, but a randomized clinical trial is needed to conclusively demonstrate its therapeutic value.

Incidence, treatment and survival of patients with craniopharyngioma in the surveillance, epidemiology and end results program

Craniopharyngioma is a rare primary central nervous system neoplasm. Our objective was to determine factors associated with incidence, treatment, and survival of craniopharyngiomas in the United States. We used the surveillance, epidemiology and end results program (SEER) database to identify patients who received a diagnosis of craniopharyngioma during 2004-2008. We analyzed clinical and demographic information, including age, race, sex, tumor histology, and treatment. Age-adjusted incidence rates and age, sex, and race-adjusted expected survival rates were calculated. We used Cox proportional hazards models to determine the association between covariates and overall survival. We identified 644 patients with a diagnosis of craniopharyngioma. Black race was associated with an age-adjusted relative risk for craniopharyngioma of 1.26 (95% confidence interval [CI], 0.98-1.59), compared with white race. One- and 3-year survival rates of 91.5% (95% CI, 88.9%-93.5%), and 86.2% (95% CI, 82.7%-89.0%) were observed for the cohort; relative survival rates were 92.1% (95% CI, 89.5%-94.0%) and 87.6% (95% CI, 84.1%-90.4%) for 1- and 3-years, respectively. In the multivariable model, factors associated with prolonged survival included younger age, smaller tumor size, subtotal resection, and radiation therapy. Black race, on the other hand, was associated with worse overall survival in the final model. We demonstrated that >85% of patients survived 3 years after diagnosis and that subtotal resection and radiation therapy were associated with prolonged survival. We also noted a higher incidence rate and worse 1- and 3-year survival rates in the black population. Future investigations should examine these racial disparities and focus on evaluating the efficacy of emerging treatment paradigms.

Volume-dependent effect of perihaematomal oedema on outcome for spontaneous intracerebral haemorrhages

Introduction It is still unknown whether subsequent perihaematomal oedema (PHE) formation further increases the odds of an unfavourable outcome. Methods Demographic, clinical, radiographic and outcome data were prospectively collected in a single large academic centre. A multiple logistic regression model was then developed to determine the effect of admission oedema volume on outcome. Results 133 patients were analysed in this study. While there was no significant association between relative PHE volume and discharge outcome (p=0.713), a strong relationship was observed between absolute PHE volume and discharge outcome (p=0.009). In a multivariate model incorporating known predictors of outcome, as well as other factors found to be significant in our univariate analysis, absolute PHE volume remained a significant predictor of poor outcome only in patients with intracerebral haemorrhage (ICH) volumes ≤30 cm3 (OR 1.123, 95% CI 1.021 to 1.273, p=0.034). An increase in absolute PHE volume of 10 cm3 in these patients was found to increase the odds of poor outcome on discharge by a factor of 3.19. Conclusions Our findings suggest that the effect of absolute PHE volume on functional outcome following ICH is dependent on haematoma size, with only patients with smaller haemorrhages exhibiting poorer outcome with worse PHE. Further studies are needed to define the precise role of PHE in driving outcome following ICH.

Disparities in Access to Deep Brain Stimulation Surgery for Parkinson Disease Interaction Between African American Race and Medicaid Use

IMPORTANCE African American individuals experience barriers to accessing many types of health care in the United States, resulting in substantial health care disparities. To improve health care in this patient population, it is important to recognize and study the potential factors limiting access to care. OBJECTIVE To examine deep brain stimulation (DBS) use in Parkinson disease (PD) to determine which factors, among a variety of demographic, clinical, and socioeconomic variables, drive DBS use in the United States. DESIGN, SETTING, AND PARTICIPANTS We queried the Nationwide Inpatient Sample in combination with neurologist and neurological surgeon countywide density data from the Area Resource File. We used International Classification of Diseases, Ninth Revision codes to identify discharges of patients at multicenter, all-payer, nonfederal hospitals in the United States diagnosed with PD (code 332.0) who were admitted for implantation of intracranial neurostimulator lead(s) (code 02.39), DBS. MAIN OUTCOMES AND MEASURES We analyzed factors predicting DBS use in PD using a hierarchical logistic regression analysis including patient and hospital characteristics. Patient characteristics included age, sex, comorbidity score, race, income quartile of zip code, and insurance type. Hospital characteristics included teaching status, size, regional location, urban vs rural setting, experience with DBS discharges, year, and countywide density of neurologists and neurological surgeons. RESULTS Query of the Nationwide Inpatient Sample yielded 2,408,302 PD discharges from 2002 to 2009; 18,312 of these discharges were for DBS. Notably, 4.7% of all PD discharges were African American, while only 0.1% of DBS for PD discharges were African American. A number of factors in the hierarchical multivariate analysis predicted DBS use including younger age, male sex, increasing income quartile of patient zip code, large hospitals, teaching hospitals, urban setting, hospitals with higher number of annual discharges for PD, and increased countywide density of neurologists (P < .05). Predictors of nonuse included African American race (P < .001), Medicaid use (P < .001), and increasing comorbidity score (P < .001). Countywide density of neurological surgeons and Hispanic ethnicity were not significant predictors. CONCLUSIONS AND RELEVANCE: Despite the fact that African American patients are more often discharged from hospitals with characteristics predicting DBS use (ie, urban teaching hospitals in areas with a higher than average density of neurologists), these patients received disproportionately fewer DBS procedures compared with their non-African American counterparts. Increased reliance on Medicaid in the African American population may predispose to the DBS use disparity. Various other factors may be responsible, including disparities in access to care, cultural biases or beliefs, and/or socioeconomic status.

Outcomes after suboccipital decompression without dural opening in children with Chiari malformation Type I.

OBJECT Symptomatic pediatric Chiari malformation Type I (CM-I) is most often treated with posterior fossa decompression (PFD), but controversy exists over whether the dura needs to be opened during PFD. While dural opening as a part of PFD has been suggested to result in a higher rate of resolution of CM symptoms, it has also been shown to lead to more frequent complications. In this paper, the authors present the largest reported series of outcomes after PFD without dural opening surgery, as well as identify risk factors for recurrence. METHODS The authors performed a retrospective review of 156 consecutive pediatric patients in whom the senior authors performed PFD without dural opening from 2003 to 2013. Patient demographics, clinical symptoms and signs, radiographic findings, intraoperative ultrasound results, and neuromonitoring findings were reviewed. Univariate and multivariate regression analyses were performed to determine risk factors for recurrence of symptoms and the need for reoperation. RESULTS Over 90% of patients had a good clinical outcome, with improvement or resolution of their symptoms at last follow-up (mean 32 months). There were no major complications. The mean length of hospital stay was 2.0 days. In a multivariate regression model, partial C-2 laminectomy was an independent risk factor associated with reoperation (p = 0.037). Motor weakness on presentation was also associated with reoperation but only with trend-level significance (p = 0.075). No patient with < 8 mm of tonsillar herniation required reoperation. CONCLUSIONS The vast majority (> 90%) of children with symptomatic CM-I will have improvement or resolution of symptoms after a PFD without dural opening. A non-dural opening approach avoids major complications. While no patient with tonsillar herniation < 8 mm required reoperation, children with tonsillar herniation at or below C-2 have a higher risk for failure when this approach is used.

The role for adjuvant radiotherapy in the treatment of hemangiopericytoma: a Surveillance, Epidemiology, and End Results analysis

OBJECT Central nervous system (CNS) hemangiopericytomas are relatively uncommon and unique among CNS tumors as they can originate from or develop metastases outside of the CNS. Significant difference of opinion exists in the management of these lesions, as current treatment paradigms are based on limited clinical experience and single-institution series. Given these limitations and the absence of prospective clinical trials within the literature, nationwide registries have the potential to provide unique insight into the efficacy of various therapies. METHODS The authors queried the Surveillance Epidemiology and End Results (SEER) database to investigate the clinical behavior and prognostic factors for hemangiopericytomas originating within the CNS during the years 2000-2009. The SEER survival data were adjusted for demographic factors including age, sex, and race. Univariate and multivariate analyses were performed to identify characteristics associated with overall survival. RESULTS The authors identified 227 patients with a diagnosis of CNS hemangiopericytoma. The median length of follow-up was 34 months (interquartile range 11-63 months). Median survival was not reached, but the 5-year survival rate was 83%. Univariate analysis showed that age and radiation therapy were significantly associated with survival. Moreover, young age and supratentorial location were significantly associated with survival on multivariate analysis. Most importantly, multivariate analysis using the Cox proportional hazards model showed a statistically significant survival benefit for patients treated with gross-total resection (GTR) in combination with adjuvant radiation treatment (HR 0.31 [95% CI 0.01-0.95], p = 0.04), an effect not appreciated with GTR alone. CONCLUSIONS The authors describe the epidemiology of CNS hemangiopericytomas in a large, national cancer database, evaluating the effectiveness of various treatment paradigms used in clinical practice. In this study, an overall survival benefit was found when GTR was accomplished and combined with radiation therapy. This finding has not been appreciated in previous series of patients with CNS hemangiopericytoma and warrants future investigations into the role of upfront adjuvant radiation therapy.