Search

Context: Congenital heart disease (CHD) is a common condition with high morbidity and mortality and is subject to racial and ethnic health disparities., Objective: To conduct a systematic review of the literature to identify differences in mortality in pediatric patients with CHD based on race and ethnicity., Data Sources: Legacy PubMed (MEDLINE), Embase (Elsevier), and Scopus (Elsevier) STUDY SELECTION: English language articles conducted in the USA focused on mortality based on race and ethnicity in pediatric patients with CHD., Data Extraction: Two independent reviewers assessed studies for inclusion and performed data extraction and quality assessment. Data extraction included mortality based on patient race and ethnicity., Results: There were 5094 articles identified. After de-duplication, 2971 were screened for title and abstract content, and 45 were selected for full-text assessment. Thirty studies were included for data extraction. An additional 8 articles were identified on reference review and included in data extraction for a total of 38 included studies. Eighteen of 26 studies showed increased risk of mortality in non-Hispanic Black patients. Results were heterogenous in Hispanic patients with eleven studies of 24 showing an increased risk of mortality. Results for other races demonstrated mixed outcomes., Limitations: Study cohorts and definitions of race and ethnicity were heterogenous, and there was some overlap in national datasets used., Conclusion: Overall, racial and ethnic disparities existed in the mortality of pediatric patients with CHD across a variety of mortality types, CHD lesions, and pediatric age ranges. Children of races and ethnicities other than non-Hispanic White generally had increased risk of mortality, with non-Hispanic Black children most consistently having the highest risk of mortality. Further investigation is needed into the underlying mechanisms of these disparities so interventions to reduce inequities in CHD outcomes can be implemented., (© 2023. W. Montague Cobb-NMA Health Institute.)

Arrhythmias are the leading cause of morbidity and mortality in repaired tetralogy of Fallot (TOF), and over 20% of these patients will develop a sustained atrial arrhythmia during their lifetimes. Cardiac magnetic resonance imaging (cMRI) is frequently performed in TOF, although its ability to identify patients at risk of atrial arrhythmias is uncertain. Adult TOF patients (n = 175) with no history of atrial arrhythmia who underwent cMRI between 2003 and 2020 at a single tertiary care center were identified. Clinical characteristics and imaging findings were evaluated to identify a predilection for atrial arrhythmias using Kaplan-Meier survival analysis and log-rank testing. Multivariable Cox regression was used to determine independent predictors of atrial arrhythmias. Over a median follow-up of 3.6 years, 29 patients (17%) developed atrial arrhythmias. Independent predictors of atrial arrhythmia included age (hazard ratio [HR] 1.06 per 1-year increase, 95% confidence interval [CI] 1.02 to 1.09, p = 0.002), diabetes mellitus (HR 4.26, 95% CI 1.26 to 14.41, p = 0.020), indexed right ventricular end-diastolic volume (RVEDVi), (HR 1.20 per 10-ml/m 2 increase, 95% CI 1.05 to 1.39, p = 0.010), and moderate or greater tricuspid regurgitation (TR) (HR 6.32, 95% CI 2.15 to 18.60, p = 0.001). Utilizing Kaplan-Meier analysis, patients with at least mild right ventricular dilation (RVEDVi >100 ml/m 2 , p = 0.047) and greater than or equal to moderate TR (p <0.001) were found to be significantly more likely to develop atrial arrhythmias. In conclusion, cMRI can help to identify TOF patients at increased risk for atrial arrhythmia beyond standard clinical and imaging data by better quantifying RVEDVi and degree of TR., Competing Interests: Disclosures Dr. Spector received consulting fees from Janssen Research and Development. Dr. Campbell receives consulting fees from Longeveron Inc. Dr. Krasuski receives consulting fees from Actelion Pharmaceuticals and Gore Medical, and research funding from the Adult Congenital Heart Association, Actelion Pharmaceuticals, Corvia, CryoLife, Edwards Lifesciences, and Medtronic. The remaining authors have no conflicts of interest to declare., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Children with medical complexity (CMC) have inter-related health and social needs; however, interventions to identify and respond to social needs have not been adapted for CMC. The objective of this study was to evaluate the feasibility of implementing social needs screening and assessment within pediatric complex care programs., Methods: We implemented systematic social needs assessment for CMC (SSNAC) at two tertiary care centers in three phases: (1) pre-implementation, (2) implementation, and (3) implementation monitoring. We utilized a multifaceted implementation package consisting of discrete implementation strategies within each phase. In phase 1, we adapted questions from evidence-informed screening tools into a 21-item SSNAC questionnaire, and we used published frameworks to inform implementation readiness and process. In phases 2-3, clinical staff deployed the SSNAC questionnaire to parents of CMC in-person or by phone as part of usual care and adapted to local clinical workflows. Staff used shared decision-making with parents and addressed identified needs by providing information about available resources, offering direct assistance, and making referrals to community agencies. Implementation outcomes included fidelity, feasibility, acceptability, and appropriateness., Results: Observations from clinical staff characterized fidelity to use of the SSNAC questionnaire, assessment template, and shared decision-making for follow-up on unmet social needs. Levels of agreement (5-point Likert scale; 1 = completely disagree; 5 = completely agree) rated by staff for key implementation outcomes were moderate to high for acceptability (mean = 4.7; range = 3-5), feasibility (mean = 4.2; range = 3-5), and appropriateness (mean = 4.6; range = 4-5). 49 SSNAC questionnaires were completed with a 91% response rate. Among participating parents, 37 (76%) reported ≥ 1 social need, including food/nutrition benefits (41%), housing (18%), and caregiver needs (29%). Staff responses included information provision (41%), direct assistance (30%), and agency referral (30%)., Conclusions: It was feasible for tertiary care center-based pediatric complex care programs to implement a standardized social needs assessment for CMC to identify and address parent-reported unmet social needs., (© 2021. The Author(s).)

Background: Assessment of emergent, rare or complex medical conditions in Endocrinology and Metabolism (E&M) is an integral component of training. However, data is lacking on how this could be best achieved. The purpose of this study was to develop and administer an Objective Structured Clinical Examination (OSCE) for E&M residents, and to gather validity evidence for its use., Methods: A needs assessment survey was distributed to all Canadian E&M Program Directors and recent graduates to determine which topics to include in the OSCE. The top 5 topics were selected using a modified Delphi technique. OSCE cases based on these topics were subsequently developed. Five E&M residents (PGY4-5) and five junior Internal Medicine (IM) residents participated in the OSCE. Performance of E&M and IM residents was compared and results were analyzed using a Generalizability study. Examiners and candidates completed a survey following the OSCE to evaluate their experiences., Results: The mean score of IM and E&M residents was 41.7 and 69.3 % (p < 0.001), respectively, with a large effect size (partial η 2  = 0.75). Overall reliability of the OSCE was 0.74. Standard setting using a borderline regression method resulted in a pass rate of 100 % of E&M residents and 0 % of IM residents. All residents felt the OSCE had high value for learning as a formative exam., Conclusions: The E&M OSCE is a feasible method for assessing emergent, rare and complex medical conditions and this study provides validity evidence to support its use in a competency-based curriculum.

Objective: Athletes with type 1 diabetes face unique challenges that make it difficult for health care providers to offer concise recommendations for diabetes management. Moreover, little is known about patient preferences for diabetes management during high-level and competitive exercise. We undertook a qualitative study to understand patient perspectives on managing type 1 diabetes during exercise., Methods: A qualitative design using focus groups was selected. Samples of 5-10 participants per group were recruited to participate in one of three 1.5-hour sessions focusing on experiences in managing diabetes, supports, and desired resources. Sessions were audiotaped and transcribed verbatim. Data were analyzed iteratively among team members., Results: The study included 21 participants (10 male and 11 female) with a mean age of 41 years. Most participants used trial and error to manage their blood glucose around exercise. Frequent monitoring of blood glucose was a common strategy and a challenge during exercise. Hypoglycemia after exercise and adrenaline-fueled hyperglycemia during exercise were the most prevalent concerns. Most participants relied on themselves, an endocrinologist, or the Internet for support but said they would prefer to rely more on peers with type 1 diabetes and mobile apps. Peer support or mentorship was strongly supported with recommendations for moving forward., Conclusion: This study highlights the individualized nature of balancing glycemic control in athletes and athletes' heavy self-reliance to develop strategies. Expanding the availability of resources such as peer mentoring and mobile apps could potentially support athletes with type 1 diabetes.

Objective: Determine how blood pressure differs in premature infants born small for gestational age (SGA)., Design: A retrospective study was conducted on inborn infants 24-32 weeks gestation. Mean arterial blood pressure (MAP) was collected and averaged every 12 h for the first 96 h of life. For each time point, the difference MAP in SGA vs. AGA infants was evaluated with t-testing. Linear mixed-effects modeling was performed to model MAP over time accounting for GA, BW, gender, and SGA status., Results: 356 subjects were evaluated. 52 (14.6%) were SGA. SGA infants were smaller, more likely male, exposed to maternal hypertension, born via caesarian section, and have chronic lung disease and retinopathy of prematurity. MAP in the SGA group more closely matched the MAP of AGA babies of similar GA for the first 24 h of life. Subsequently, SGA infants had lower MAPs more closely resembling their weight-matched counterparts. Mixed modeling showed GA to be significant, p < 0.0001 while BW though still marginally significant had less of an effect, p = 0.049., Conclusion: SGA infants have blood pressure that is strongly associated with GA in the first 24 hours of life, but then fails to increase at the same rate as their AGA counterparts.

Aims: The comparison of patients with long-standing implantable cardioverter-defibrillators (ICDs) who have had or never have had appropriate therapy for ventricular arrhythmias may offer insight into potential risk factors that may improve patient selection., Methods and Results: Records from patients in the Columbia Presbyterian device clinic whose original ICD was implanted before 31 December 2004 were analysed. The patients were divided into those who had never received appropriate therapy for ventricular arrhythmias (Group A, n = 188), and those who had received appropriate therapy (Group B, n = 173). The subset of patients with consistent follow-up greater than 5 years was then analysed (Group A, n = 140; Group B, n = 158). Demographic, clinical, echocardiographic, and electrocardiographic data were collected. There were no significant differences in age, sex, or type of heart disease between the groups. There were more patients in Group B vs. A who had ICDs implanted for secondary prevention (70.3 vs. 55.7%, P < 0.05). The mean QRS width was similar at implant but increased significantly in Group B vs. A on pre-ICD discharge electrocardiograms (134.1 ± 35.0 vs. 125.1 ± 36.2 ms, P < 0.05). Congestive heart failure class, comorbidities, use of antiarrhythmic agents, or left ventricular ejection fraction were not discriminators between Groups A and B., Conclusion: In this study of patients with long-standing ICDs, the only discriminating factors for appropriate shocks were implant for secondary prevention or increasing QRS width, suggesting electrical factors are the best predictors of ultimate ICD discharges.