Mind the Gap! Working Toward Gender Equity in Pediatric and Congenital Heart Disease: Present and Future

Evidence from medicine and other fields has shown that gender diversity results in better decision making and outcomes. The incoming workforce of congenital heart specialists (especially in pediatric cardiology) appears to be more gender balanced, but past studies have shown many inequities. Gender-associated differences in leadership positions, opportunities presented for academic advancement, and recognition for academic contributions to the field persist. In addition, compensation packages remain disparate if evaluated based on gender with equivalent experience and expertise. This review explores these inequities and has suggested individual and institutional changes that could be made to recruit and retain women, monitor the climate of the institution, and identify and eliminate bias in areas like salary and promotions.

Toxicity of Patients with Ultra-Central Thoracic Tumors Treated with Stereotactic Body Radiotherapy (SBRT) with Dose of 50 Gy in 5 Fractions

PURPOSE/OBJECTIVE(S)

The ideal regimen for stereotactic body radiotherapy (SBRT) in ultra-central lung tumors is still to be defined, mostly due to the risk of unacceptable or fatal toxicity. There is not much information on outcomes after SBRT for this group of patients. We summarize here our experience with ultra-central lung cancer patients treated with the dose of 50 Gy delivered in 5 fractions.

MATERIALS/METHODS

This study is a retrospective review of all cases of ultra-central thoracic tumors treated with SBRT with the dose of 50 Gy in 5 fractions, delivered every other day, at our institution. In all cases, as we defined ultra-central lung tumor, the PTV overlapped or touched one or more of the following structures: bronchial tree, trachea, great vessels, heart, and esophagus. Metastatic and primary lung lesions were included. The volumes of treatment were defined by 4D-CT to consider breathing motion. Normal organs constraints followed the recommendations of the RTO 0813 trial as follows: Spinal cord: max 30 Gy. Lung right or lung left: V13 Gy[cc] < 1500. Esophagus: max 52 Gy and nonadjacent esophagus: V27.5 Gy[cc] < 5. Heart: V32 Gy[cc] < 15; max 52 Gy. Great vessels: max 52 Gy and non-adjacent great vessels V47 Gy[cc] < 10. Trachea plus bronchus: max 52 Gy and non-adjacent V18 Gy[cc] < 4. Follow-up, at the discretion of the treating MD, included periodic CT scans of the thorax after SBRT and assessment of radiation-induced toxicity scored with CTCv3.0.

RESULTS

Between December 2015 and February 2022, 86 patients were eligible for this review. Median follow-up was 17 months (range: 1-76 months); the median age was 74 years (range: 37-98 years). Histology was as follows: 50 patients had biopsy proved NSCLC, 16 had no biopsy, and 20 had metastatic non-lung primaries. Overlapped structures were as follows: with great vessels in 46 cases, heart in 20 cases, trachea/branchial tree in 18 cases, and esophagus in 2 cases. In 16 patients the overlap was present in more than one structure. Overall, 68.6% did not report acute toxicity. The most common acute side effects were fatigue (15.1%), coughing (8.1%), shortness of breath (6.9%), esophagitis (2.3%), and dysphagia (1.1%). No grade 3 or more significant toxicity was described. As acute side effects, many patients had exacerbations of the previous condition, such as shortness of breath (16 pts) or coughing (4 pts) during follow-up. Pneumonitis was found as a late side effect in four cases. One patient had empyema associated with a fistula in the non-irradiated lung, where the patient had previous surgery, but in the irradiated lung no severe complication was detected. There were no deaths attributed to the SBRT treatment. 67.5% of 86 patients were alive at the time of the review; 87.2% had local control, and 65.1% had metastases-free survival.

CONCLUSION

In this cohort of patients, no death or even severe acute or chronic toxicity was attributed to SBRT. SBRT seems safe for ultra-central lesions using the regimen of 50 Gy in 5 fractions with the constraints of the RTOG 0813 trial.

Preprocedural Anxiety in Adults With Congenital Heart Disease: The PANIC Study

Background

Preprocedural anxiety may have detrimental effects both cognitively and physiologically.

Objectives

The objective of this study was to determine the association between state (situational) and trait (persistent in everyday life) anxiety and differences between the adult congenital heart disease (ACHD) and acquired heart disease populations.

Methods

The State-Trait Anxiety Inventory and financial stress scale were administered to adults with acquired and CHD at 4 tertiary referral centers in the United States prior to cardiac catheterization. Student's t-test and least absolute shrinkage and selection operator regression analyses were used to assess differences in anxiety between groups and identify the optimal model of predictors of anxiety.

Results

Of the 291 patients enrolled, those with CHD (n = 91) were younger (age 41.3 ± 16.3 years vs 64.7 ± 11.3 years, P < 0.001), underwent more cardiac surgeries (P < 0.001), and had higher levels of trait anxiety (t[171] = 2.62, P = 0.001, d = 0.33). There was no difference in state anxiety between groups (t[158.65] = 1.37, P = 0.17, d = 0.18). State anxiety was singularly associated with trait anxiety. Trait anxiety was negatively associated with age and positively associated with state anxiety and financial stress. Patients with CHD of great complexity were more trait (F[2,88] = 4.21, P = 0.02) and state anxious (F[2,87] = 4.59, P = 0.01), though with relatively small effect size.

Conclusions

Trait anxiety levels are higher in the ACHD population and directly associated with state anxiety. Specialists caring for ACHD patients should not only recognize the frequency of trait anxiety but also high-risk subgroups that may benefit from psychological or social interventions to reduce preprocedural anxiety.

Electronic, electrical and thermoelectric properties of Ba0.95Ca0.05Ti0.95Y0.05O2.975 compound: Experimental study and DFT-mBJ calculation

This article explores the impact of co-doping BaTiO3 ceramics with Ca2+ and Y3+ using solid-state reactions to improve its dielectric constant and decrease losses. The oxide BCTYO (Ba0.95Ca0.05Ti0.95Y0.05O2.975) exhibits a tetragonal crystal structure, characterized by a space group of P4mm. By examining the behavior of the doped BaTiO3 sample and performing simulations, researchers can better understand the underlying mechanisms and optimize material properties for specific applications. DFT study shows a semiconductor behavior with an indirect gap (Eg = 2.5 eV). The partial DOS proves that the hybridization between the orbitals Ti 3d, Y 3d, and O 2p is responsible for the band gap and the hopping processes. The analysis of conductivity curves provides evidence for the semiconductor characteristics of the material under investigation. By determining the activation energy (Ea) through analyzing Ln(fmax) and conductivity as a function of 1000/T, the interconnection between conduction and relaxation phenomena is demonstrated. The study of the real part of the dielectric permittivity (ε') shows a transition at Tc = 380 K. The obtained results are promising and indicate that the studied material has the potential for various electronic applications (energy storage and diode fabrication …). Moreover, the thermal, electrical, and thermoelectric characteristics were examined utilizing the semi-classical Boltzmann theory. The findings revealed an intriguing result, suggesting that Ba0.95Ca0.05Ti0.95Y0.05O2.975 holds promise as a potential candidate for application in thermoelectric devices.

Effect of frequency on the classical and relaxor ferroelectric behavior of substituted titanate Ba0.7Er0.16Ca0.05Ti0.91Sn0.09O3

In the present work, we synthesized the perovskite Ba_0.70Er_0.16Ca_0.05Ti_0.91Sn_0.09O₃ compound (BECTSO) by a solid-state reaction and sintering at 1200 °C. The effects of doping on the structural, electrical, dielectric, and ferroelectric characteristics of the material are examined in this work. X-ray powder diffraction analysis shows that BECTSO crystallizes in a tetragonal structure with space group P4mm. A detailed study of the dielectric relaxation of the BECTSO compound has been reported for the first time. Classical low-frequency ferroelectric and high-frequency relaxor ferroelectric behaviors have been studied. The study of the real part of the permittivity (ε') as a function of temperature demonstrated a high dielectric constant and identified a phase transition from the ferroelectric phase to the paraelectric phase at T_c = 360 K. The analysis of conductivity curves shows two behaviors: semiconductor behavior for f < 10⁶ Hz and metallic behavior for f >10⁶ Hz. The relaxation phenomenon is dominated by the short-range motion of the charge carriers. The BECTSO sample could be considered as a potential lead-free material for next-generation non-volatile memory devices and wide-temperature range capacitor applications.

[Alteration of pulmonary epithelial permeability by cathepsin S in chronic obstructive pulmonary disease]

Smoking is accountable for most of the chronic obstructive pulmonary disease (COPD) cases. COPD, which is characterized by the development of chronic bronchitis, could be associated with emphysema. In active smokers, there is an overexpression of cathepsin S, a cysteine protease, which participates in the development of emphysema via its elastinolytic activity. Likewise, we demonstrated that cathepsin S could degrade one or more protein constituents of cell junctions. This deleterious proteolytic activity leads to an alteration of the integrity of the lung epithelial barrier, which in turn could aggravate chronic inflammation and promote the exacerbation phases associated with infections.

Assessment of parental decision making in congenital heart disease, cardiomyopathy and heart transplantation: an observational study analysing decisional characteristics and preferences

OBJECTIVE

We explore shared decision making (DM) in guardians of children with heart disease by assessing the desired weight of influence on DM and factors that may alter the relative weight of parent or medical team influence.

METHODS

Guardians of patients <21 years and admitted >1 week in the paediatric cardiac intensive care unit (PCICU) were recruited. Twelve vignettes were designed including technical (antibiotic selection, intubation, peripherally inserted central catheter placement, ventricular assist device placement, heart transplant, organ rejection, heart rhythm abnormalities and resuscitation effort) and non-technical vignettes (cessation of life-sustaining therapies, depression treatment, obesity and palliative care referral). Participants responded to questions on DM characteristics and one question querying preference for relative weight of parent or medical team influence on DM.

RESULTS

Of 209 participants approached, 183 were included. Most responded with equal desire of medical team and parental influence on DM in all vignettes (range 41.0%-66.7%). Technical scenarios formed one cluster based on DM characteristics, compared with non-technical scenarios. Factors that increase the relative weight of parental influence on DM include desired input and involvement in big-picture goals (OR 0.274, CI [0.217 to 0.346]; OR 0.794, CI [0.640 to 0.986]). Factors that increase the relative weight of medical team influence on DM include perception of medical expertise needed (OR 1.949 [1.630 to 2.330]), urgency (OR 1.373 [1.138 to 1.658]), benefit (OR 1.415 [1.172 to 1.710]), number of PCICU admissions (OR 1.134 [1.024 to 1.256]) and private insurance (OR 1.921 [1.144 to 3.226]).

CONCLUSION

Although factors may alter the weight of influence on DM, most parents desire equal parental and medical team influence on DM.

Artificial Intelligence in Congenital Heart Disease: Current State and Prospects

The current era of big data offers a wealth of new opportunities for clinicians to leverage artificial intelligence to optimize care for pediatric and adult patients with a congenital heart disease. At present, there is a significant underutilization of artificial intelligence in the clinical setting for the diagnosis, prognosis, and management of congenital heart disease patients. This document is a call to action and will describe the current state of artificial intelligence in congenital heart disease, review challenges, discuss opportunities, and focus on the top priorities of artificial intelligence-based deployment in congenital heart disease.

Rationale, design and methodology of APPROACH-IS II: International study of patient-reported outcomes and frailty phenotyping in adults with congenital heart disease

BACKGROUND

In recent years, patient-reported outcomes (PROs) have received increasing prominence in cardiovascular research and clinical care. An understanding of the variability and global experience of PROs in adults with congenital heart disease (CHD), however, is still lacking. Moreover, information on epidemiological characteristics and the frailty phenotype of older adults with CHD is minimal. The APPROACH-IS II study was established to address these knowledge gaps. This paper presents the design and methodology of APPROACH-IS II.

METHODS/DESIGN

APPROACH-IS II is a cross-sectional global multicentric study that includes Part 1 (assessing PROs) and Part 2 (investigating the frailty phenotype of older adults). With 53 participating centers, located in 32 countries across six continents, the aim is to enroll 8000 patients with CHD. In Part 1, self-report surveys are used to collect data on PROs (e.g., quality of life, perceived health, depressive symptoms, autonomy support), and explanatory variables (e.g., social support, stigma, illness identity, empowerment). In Part 2, the cognitive functioning and frailty phenotype of older adults are measured using validated assessments.

DISCUSSION

APPROACH-IS II will generate a rich dataset representing the international experience of individuals in adult CHD care. The results of this project will provide a global view of PROs and the frailty phenotype of adults with CHD and will thereby address important knowledge gaps. Undoubtedly, the project will contribute to the overarching aim of improving optimal living and care provision for adults with CHD.

Lodewyk H.S. van Mierop (March 31, 1927-October 17, 2021): a true giant

We honour a great man and a true giant. Lodewyk H.S. van Mierop (March 31, 1927 - October 17, 2021), known as Bob, was not only a Paediatric Cardiologist but also a dedicated Scientist. He made many significant and ground-breaking contributions to the fields of cardiac anatomy and embryology. He was devoted as a teacher, spending many hours with medical students, Residents, and Fellows, all of whom appreciated his regularly scheduled educational sessions. Those of us who were fortunate to know and spend time with him will always remember his great mind, his willingness to share his knowledge, and his ability to encourage spirited and fruitful discussions. His life was most productive, and he will long be remembered by many through his awesome and exemplary scientific contributions.His legacy continues to influence the current and future generations of surgeons and all providers of paediatric and congenital cardiac care through the invaluable archive he established at University of Florida in Gainesville: The University of Florida van Mierop Heart Archive. Undoubtedly, with these extraordinary contributions to the fields of cardiac anatomy and embryology, which were way ahead of his time, Professor van Mierop was a true giant in Paediatric Cardiology. The invaluable archive he established at University of Florida in Gainesville, The University of Florida van Mierop Heart Archive, has been instrumental in teaching medical students, Residents, Medical Fellows, and Surgical Fellows. Only a handful of similar archives exist across the globe, and these archives are the true legacy of giants such as Dr. van Mierop. We have an important obligation to leave no stone unturned to continue to preserve these archives for the future generations of surgeons, physicians, all providers of paediatric and congenital cardiac care, and, most importantly, our patients.

DiGeorge syndrome: consider the diagnosis

DiGeorge syndrome (DGS) is caused by a chromosomal microdeletion at 22q11.2 that results in impaired development of the pharyngeal pouch system. Patients with DGS may have developmental abnormalities of craniofacial structures, parathyroid glands, thymus and cardiac outflow tract. Doctors have been routinely testing for DGS in newborns with conotruncal cardiac anomalies since the late 1990s; before then, however, they relied on complex diagnostic criteria and the disease was often missed. Adults born with conotruncal defects before the late 1990s may have undiagnosed DGS. We present one such case: a 35-year-old woman with a cardiac diagnosis of tetralogy of Fallot and unilateral absence of a pulmonary arter who was found to have DGS. Identifying DGS in adults is important both for disease management and genetic counselling. Our case emphasises the importance of screening for DGS in adults who were born with conotruncal cardiac abnormalities before widespread neonatal testing became common.

Drivers of fish choice: an exploratory analysis in Mediterranean countries

Fish is an important source of healthy proteins and an important economic sector in Mediterranean countries. Despite the wealth of knowledge acquired in Western countries, a gap has been found in studies in developing countries, as in the Mediterranean southern shore. Therefore, we aimed to investigate consumers' perceptions of finfish attributes, with qualitative tools as focus groups, given the exploratory nature of the research. The focus groups have been held in Italy, Lebanon, Spain, and Tunisia; in each country, one was held in seaside areas and one in inland areas, in order to control for the availability of fish that shapes consumers' evaluations and expectations. The focus groups have been analysed through content and semantic analyses. Results of the study yielded main themes recurring in the discussions that have been categorized along such dimensions: (1) definition of fish products; (2) context; (3) search attributes; (4) experience attributes; and (5) credence attributes. Among attributes, the ones mostly guiding consumers' choices seem to be freshness and fish species, which are used as proxies for quality and sensory attributes. Most of the respondents preferred delicate white fish, while some exceptions were found in Tunisian respondents preferring blue fish and they also were the only ones who were not looking for convenient and already cleaned products. Trust also represented a critical element in guiding the decisions of consumers: with a lack of trust, consumers deviate from preferring local products, as noticeable especially in Lebanese respondents' opinions. Credence attributes such as animal welfare and sustainability received a minor attention from all the respondents.

Effects of Indole-3-Butyric Acid (IBA) and rooting media on rooting and survival of air layered wax apple (Syzygium samarangense) CV Jambu Madu

Abstract The wax apple or jambu madu, is a non-climacteric tropical fruit from Myrtaceae family and widely cultivated in South East Asia. The limited availability of good quality seedlings of wax apple is the main problem to development of flourish it’s market share in the current fruit industry. Therefore, in order to produce good quality planting materials, a study aimed at optimizing propagation and adventitious rooting technique and survivability of wax apple air layer was conducted. In this study, four different levels of Indole-3-Butyric Acid (IBA) concentration (0, 1000, 1500 and 2000 mg L-1) and three rooting media (sphagnum moss, vermicompost and garden soil) were applied after removal of bark (phloem) on the shoot to determine the effect on rooting and survivability of the wax apple air layer under field conditions. The results showed that the wax apple shoots treated with 2000 mg L-1 IBA produced the significantly higher number of roots, increased length of root, diameter of branch, length of branch, number of leaf and leaf area of air layers. In addition, the highest chlorophyll content and stomatal aperture were recorded in 2000 mg L-1 IBA treatment compared to other treatments including control. Vermicompost medium was better than garden soil and sphagnum moss in respect of rooting and survivability of air layers. The results showed that the combination of 2000 mg L-1 IBA and vermicompost as rooting media give the best combination to root initiation, root number, root length and survival rate (100%) of wax apple air layers. From this study, it can be concluded that 2000 mg L-1 IBA and vermicompost treatment enhance the root initiation, early establishment and survivability of wax apple air layered under field conditions.

Health Care Policy and Congenital Heart Disease: 2020 Focus on Our 2030 Future

The congenital heart care community faces a myriad of public health issues that act as barriers toward optimum patient outcomes. In this article, we attempt to define advocacy and policy initiatives meant to spotlight and potentially address these challenges. Issues are organized into the following 3 key facets of our community: patient population, health care delivery, and workforce. We discuss the social determinants of health and health care disparities that affect patients in the community that require the attention of policy makers. Furthermore, we highlight the many needs of the growing adults with congenital heart disease and those with comorbidities, highlighting concerns regarding the inequities in access to cardiac care and the need for multidisciplinary care. We also recognize the problems of transparency in outcomes reporting and the promising application of telehealth. Finally, we highlight the training of providers, measures of productivity, diversity in the workforce, and the importance of patient-family centered organizations in advocating for patients. Although all of these issues remain relevant to many subspecialties in medicine, this article attempts to illustrate the unique needs of this population and highlight ways in which to work together to address important opportunities for change in the cardiac care community and beyond. This article provides a framework for policy and advocacy efforts for the next decade.

In vivo investigation of antidiabetic, hepatoprotective, anti-inflammatory and antipyretic activities of Centaurea tougourensis Boiss. & Reut

Centaurea species are widely used in traditional medicine to treat several illnesses, especially by Mediterranean populations due to their pharmacological properties. The present study aimed to evaluate for the first time some in vivo activities of n-butanol (n-BuOH) extract of the aerial part of Centaurea tougourensis. For this approach; the antidiabetic (streptozotocin-induced diabetes), hepatoprotective (paracetamol induced hepatotoxicity), anti-inflammatory (croton oil induced ear edema assay) and antipyretic activities of this plant extract were tested. The pharmacological results suggest that C. tougourensis has a non-negligible anti-inflammatory effect on the formation of ear edema with a maximum inhibition percentage of (39.58%) for the highest tested concentration of 400 mg/kg. However, the antipyretic activity of the plant was remarkable for both tested concentrations (200 and 400 mg/kg) 5 h after treatment with a significant (P < 0.05) reduction of rectal temperature to (32.88 ± 0.23°C) and (32.36 ± 0.18°C) which correspond to a pyrexia inhibition of (78.9%) and (90.18%) respectively. C. tougourensis exhibited also a good anti-hyperglycemic effect which reached an inhibition percentage of (68.29%) at the end of the 3rd week of treatment for the tested concentration of 400 mg/kg and was considered almost similar to those of standard value (71.83%) at the same time. The n-BuOH extract C. tougourensis showed also a remarkable hepatoprotective effect which was confirmed by biochemical and histological approaches of note is that natural silymarin was also used as reference drug and showed a remarkable hepatoprotective effect. These encouraging results demonstrated once again the pharmacological potential of Centaurea species.