SDF4CHD: Generative modeling of cardiac anatomies with congenital heart defects

Congenital heart disease (CHD) encompasses a spectrum of cardiovascular structural abnormalities, often requiring customized treatment plans for individual patients. Computational modeling and analysis of these unique cardiac anatomies can improve diagnosis and treatment planning and may ultimately lead to improved outcomes. Deep learning (DL) methods have demonstrated the potential to enable efficient treatment planning by automating cardiac segmentation and mesh construction for patients with normal cardiac anatomies. However, CHDs are often rare, making it challenging to acquire sufficiently large patient cohorts for training such DL models. Generative modeling of cardiac anatomies has the potential to fill this gap via the generation of virtual cohorts; however, prior approaches were largely designed for normal anatomies and cannot readily capture the significant topological variations seen in CHD patients. Therefore, we propose a type- and shape-disentangled generative approach suitable to capture the wide spectrum of cardiac anatomies observed in different CHD types and synthesize differently shaped cardiac anatomies that preserve the unique topology for specific CHD types. Our DL approach represents generic whole heart anatomies with CHD type-specific abnormalities implicitly using signed distance fields (SDF) based on CHD type diagnosis. To capture the shape-specific variations, we then learn invertible deformations to morph the learned CHD type-specific anatomies and reconstruct patient-specific shapes. After training with a dataset containing the cardiac anatomies of 67 patients spanning 6 CHD types and 14 combinations of CHD types, our method successfully captures divergent anatomical variations across different types and the meaningful intermediate CHD states across the spectrum of related CHD diagnoses. Additionally, our method demonstrates superior performance in CHD anatomy generation in terms of CHD-type correctness and shape plausibility. It also exhibits comparable generalization performance when reconstructing unseen cardiac anatomies. Moreover, our approach shows potential in augmenting image-segmentation pairs for rarer CHD types to significantly enhance cardiac segmentation accuracy for CHDs. Furthermore, it enables the generation of CHD cardiac meshes for computational simulation, facilitating a systematic examination of the impact of CHDs on cardiac functions.

The utility of novel STE parameters in echocardiographic assessment of single ventricle after Fontan palliation

Background and aims of the study A functionally single ventricle (FSV) refers to a group of congenital heart defects that are not amenable for biventricular correction. The Fontan operation is utilized as surgical treatment for most of FSV patients. The evaluation of FSV function is extremely difficult due to its unique pathophysiology. This study aimed to explore the efficacy of speckle tracking echocardiography (STE) parameters measured at rest and during exercise for comprehensive assessment of univentricular heart.

METHODS

We enrolled 37 patients with a functionally single ventricle after the Fontan operation, hospitalized in the Department of Congenital Heart Defects between years 2019 and 2021.The echocardiographic stress tests were performed in the Echocardiography Laboratory of the Congenital Heart Defects Department. The study was conducted on a bicycle ergometer in a semi-recumbent position. The parameters obtained by speckle tracking echocardiography (STE): the longitudinal strain of the FSV free wall (Ɛ) and the longitudinal strain of myocardial layers: subendocardial, medial and subepicardial were analyzed. A transmural longitudinal strain gradient (TG) was calculated as the difference between longitudinal deformation of the subendocardial and subepicardial layers. Current results of cardiac magnetic resonance imaging (CMR) and cardio-pulmonary test (CPET) were also incorporated. Demographic data, past interventions, pharmacological treatment and comorbidities were extracted from medical records.

RESULTS

Ɛ at rest and during exercise were not related to the parameters of physical capacity obtained on CPET nor to the CMR results. The transmural strain gradient was dependent on physical performance parameter- peak oxygen uptake- and related to the FSV ejection fraction calculated by magnetic resonance imaging.

CONCLUSIONS

The transmural strain gradient and FSV free wall strain are readily measurable and suitable for evaluating single ventricle function. The TG is positively correlated with peak oxygen uptake during the cardiopulmonary test and with the ejection fraction derived from cardiac magnetic resonance imaging. The applicability of these findings in patients undergoing the Fontan procedure warrants further exploration.

Health-related quality of life among paediatric patients with coarctation of the aorta: an observational study

Advancements in early diagnosis and paediatric cardiac surgery have improved the long-term survival of patients with congenital heart disease, necessitating a thorough assessment of their health-related quality of life (HRQoL). This study aimed to assess HRQoL in paediatric patients with coarctation of the aorta (CoA) (both as reported by patients and caregivers), and to evaluate associated factors. Patients aged 5-18 years diagnosed with CoA and their parents were enrolled at Bambino Gesù Children's Hospital between September 2016 and December 2017. Socio-demographic characteristics were recorded using a family form, and the Pediatric Quality of Life Inventory (PedsQL) 3.0 cardiac module was used to evaluate HRQoL. Clinical data were retrieved from medical chart reviews. In this observational study, sixty-five pediatric patients (39 males, median [IQR] age 12 [9-14]) with CoA and their parents (65 mothers and 65 fathers) were enrolled. These patients exhibited overall good HRQoL. Mothers reported significantly lower total HRQoL scores compared to patient self-reports (p = .037), as well as treatment anxiety (p = .033), and cognitive problems (p = .021). Pediatric patients with CoA perceived their HRQoL better than their mothers did. Female sex and older age were associated with lower HRQoL scores.

Updates in Pediatric Sickle Cell Lung Disease

Sickle cell lung disease presents a challenging care paradigm involving acute and chronic lower airway disease, sleep-disordered breathing, pulmonary vascular disease, and modification by environmental factors. Understanding the presentation, pathophysiology, and diagnostic approaches is essential for accurate identification and management. While significant progress has been made, there remains a need for research to develop effective treatments and interventions to decrease disease burden in these children. Additionally, the long-term impact of interventions on cardiopulmonary outcomes is unknown. Collaborative efforts among health care providers, researchers, advocacy groups, and policy makers are crucial to improving the lives of children with SCD.

Adverse Drug Reactions in Children with Congenital Heart Disease: A Scoping Review

BACKGROUND

Congenital heart disease (CHD) is one of the leading causes of death. Safe and timely medical interventions, especially in children, can prolong their survival. The drugs prescribed for children with CHD are mainly based on the outcomes of drug therapy in adults with cardiovascular diseases, and their adverse drug reactions (ADRs) might be different. Therefore, the aim of this study was to investigate ADRs in children with CHD.

METHODS

This was a scoping review conducted in 2023. PubMed, Web of Science, Scopus, the Cochrane Library, Ovid, ProQuest, and Google Scholar databases were searched. All studies that reported ADRs for children with CHD and were published in English by 1 November 2023 were included in this study. Finally, the results were reported using a content analysis method.

RESULTS

A total of 87 articles were included in the study. The results showed that symptoms/signs/clinical findings, and cardiovascular disorders were the most common ADRs reported in children with CHD. The results also showed that most of the ADRs were reported for prostaglandin E1, amiodarone, prostaglandin E2, dexmedetomidine, and captopril, respectively.

CONCLUSION

The review underscores the wide array of ADRs in children with CHD, particularly in antiarrhythmics, diuretics, beta-blockers, anticoagulants, and vasodilators, which affected cardiovascular, respiratory, endocrine, metabolic, genitourinary, gastrointestinal, and musculoskeletal systems. Tailored treatment is imperative, considering individual patient characteristics, especially in the vulnerable groups. Further research is essential for optimizing dosing, pharmacogenetics, and alternative therapies to enhance patient outcomes in CHD management.

Dosing, Monitoring, Blood Product Utilization, and Thromboembolic Complications of Four-Factor Prothrombin Complex Concentrate as Part of an Institutional Protocol in Pediatric Cardiac Surgery: A Retrospective Cohort Study

Pediatric cardiac surgery patients are predisposed to blood loss. Blood product administration can lead to complications. Prothrombin complex concentrates (PCCs) offer potential advantages of factor composition, small volume, decreased immunogenicity/infectious risks, and accessibility. The objective of this study was to describe dosing, monitoring, blood product utilization, and thromboembolic complications of administering four-factor PCC (4F-PCC) in pediatric cardiac surgery. We performed a retrospective review of patients aged <18 years undergoing cardiac surgery from June 2020 to May 2022 (inclusive) who received 4F-PCC. Outcomes of interest included 4F-PCC dosing (units/kg) and number of doses administered, chest tube output, blood product administration, donor exposure, length of stay, and thromboembolic events. Eighty-six patients met eligibility criteria. The median (range) age and weight were 0.37 (0.01-16.3) years and 5.3 (1.6-98) kg, respectively. Median (range) total 4F-PCC dose per patient was 25 (9.2-50) units/kg, with 6 patients (7%) receiving a total of two doses. Median (range) 24-hour postoperative packed red blood cells, platelet, plasma, and cryoprecipitate administration volumes were 0 (0-2.57) mL/kg/24 h, 0 (0-1.09), 0 (0-2.64), and 0 (0-0.28 mL/kg/24 h), respectively. Median (range) length of stay and 24-hour postoperative chest tube output were 10 (6-26) days and 1.1 (0.1-4.2) mL/kg/h, respectively. Two (2%) patients experienced a thromboembolic event within 30 days of 4F-PCC administration. These retrospective findings suggest no worsening of hemostatic parameters, a mild median improvement in fibrinogen, low blood product utilization, and low thromboembolism rates following 4F-PCC use in pediatric cardiac surgery.

Use of different debriefing methods after in situ simulation with intensive care unit nurses

BACKGROUND

The debriefing phase is the simulation phase where performance improves and learning occurs.

AIM

This study examined the effects of the learning conversation (LC)-based, 3D (defusing, discovering and deepening) model-based and unstructured debriefing methods on satisfaction and debriefing experience after in-situ simulation among intensive care unit (ICU) nurses.

STUDY DESIGN

In this randomized controlled experimental study, three debriefing methods were compared, according to which 119 ICU nurses were divided into the following groups: LC group (n = 38), 3D group (n = 40) and control group (n = 41). In- situ simulation was performed with an intensive care patient scenario. p < .05 was considered statistically significant.

RESULTS

The total Debriefing Experience Scale-Experience with Debriefing part scores were 89.76 ± 8.10 in the LC group, 88.90 ± 8.70 in the 3D group and 88.29 ± 7.28 in the control group. No significant difference was found in debriefing experience and satisfaction between the groups (p > .05), but a significant difference was observed in the LC group. The groups showed a homogeneous distribution regarding participant characteristics.

CONCLUSION

Debriefing experience and satisfaction do not differ between the methods.

RELEVANCE TO CLINICAL PRACTICE

Implementation of the simulation in the ICU in - situ with ICU nurses is beneficial in obtaining a fidelity experience. Performing the debriefing application after simulation in line with the model supports the International Nursing Association for Clinical Simulation and Learning (INACSL) debriefing standards.

Factors affecting maximal oxygen uptake in prepubertal children: a systematic review and meta-analysis

In pre-pubertal children the factors affecting maximal oxygen uptake have yet to be fully understood. Therefore, the purpose of this analysis is to present cardiorespiratory fitness in prepubertal boys and girls and to determine if there are any differences based on sex, exercise testing modality or if maximal or peak oxygen consumption metrics are used. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. For statistical analysis, multilevel models grounded in Bayesian principles were used. Selected studies obtained: maximal effort during the test, peak or maximal oxygen consumption (V̇O2) values, boys and girls (sex specific groups only) age under 11, cycle ergometry or treadmill, pre-intervention or no intervention data. In boys using cycle ergometry, 118 studies were included in the analysis, in boys using treadmill 115, in girls using cycle ergometry 83 and in girls using treadmill testing 95 study entries were included. As children get older, their cardiorespiratory fitness increases (P ≈ 100%). Studies with participants having smaller body mass have higher V̇O2 relative to body mass values (P ≈ 100%). Boys have higher V̇O2 values than girls (P ≈ 100%). Studies using treadmill reported higher values than those using cycle ergometer (P ≈ 100%). Regarding the influence of measurement method (max vs. peak) on V̇O2 values we did not find significant differences. In conclusion, we present reference values for cardiorespiratory fitness in prepubertal boys and girls using cycle ergometry or treadmill. Prepubertal boys have higher cardiorespiratory fitness than girls and using treadmill testing might be a preferred method to cycle ergometry, especially in older children. Maximal or peak oxygen consumption metrics might be used interchangeably in prepubertal children.

Corticosteroids for the treatment of Duchenne muscular dystrophy: a safety review

INTRODUCTION

Duchenne muscular dystrophy (DMD) is an X-linked genetic disorder characterized by progressive muscle degeneration and weakness, caused by mutations in the dystrophin gene. DMD has effects in early age with significantly shortened lifespan and deteriorated quality of life in the second decade, creating an urgent need to develop better therapeutic options. Corticosteroid medication therapy is an integral tool for the management of DMD and several therapeutic options have been recently approved for use.

AREAS COVERED

A comprehensive literature search was completed to examine efficacy and safety profiles of the three corticosteroid medications available for use in DMD patients. The review presents information about the three agents through clinical trials, significant preclinical trials, and comparative studies.

EXPERT OPINION

Managing DMD takes a multidisciplinary approach, although long-term corticosteroid therapy remains a significant therapeutic tool. Based on the available published studies, unequivocal comparison between the benefits of the three medications cannot yet be made. When selecting a medication for a patient, the decision-making process will most likely rely on the minor differences in the adverse effect profiles. Whichever medication is utilized will surely be a part of a larger regimen that includes other novel therapeutic agents.

Toward the latest advancements in cardiac regeneration using induced pluripotent stem cells (iPSCs) technology: approaches and challenges

A novel approach to treating heart failures was developed with the introduction of iPSC technology. Knowledge in regenerative medicine, developmental biology, and the identification of illnesses at the cellular level has exploded since the discovery of iPSCs. One of the most frequent causes of mortality associated with cardiovascular disease is the loss of cardiomyocytes (CMs), followed by heart failure. A possible treatment for heart failure involves restoring cardiac function and replacing damaged tissue with healthy, regenerated CMs. Significant strides in stem cell biology during the last ten years have transformed the in vitro study of human illness and enhanced our knowledge of the molecular pathways underlying human disease, regenerative medicine, and drug development. We seek to examine iPSC advancements in disease modeling, drug discovery, iPSC-Based cell treatments, and purification methods in this article.

Promotion of maturation of human pluripotent stem cell-derived cardiomyocytes via treatment with the peroxisome proliferator-activated receptor alpha agonist Fenofibrate

As research on in vitro cardiotoxicity assessment and cardiac disease modeling becomes more important, the demand for human pluripotent stem cell-derived cardiomyocytes (hPSC-CMs) is increasing. However, it has been reported that differentiated hPSC-CMs are in a physiologically immature state compared to in vivo adult CMs. Since immaturity of hPSC-CMs can lead to poor drug response and loss of acquired heart disease modeling, various approaches have been attempted to promote maturation of CMs. Here, we confirm that peroxisome proliferator-activated receptor alpha (PPARα), one of the representative mechanisms of CM metabolism and cardioprotective effect also affects maturation of CMs. To upregulate PPARα expression, we treated hPSC-CMs with fenofibrate (Feno), a PPARα agonist used in clinical hyperlipidemia treatment, and demonstrated that the structure, mitochondria-mediated metabolism, and electrophysiology-based functions of hPSC-CMs were all mature. Furthermore, as a result of multi electrode array (MEA)-based cardiotoxicity evaluation between control and Feno groups according to treatment with arrhythmia-inducing drugs, drug response was similar in a dose-dependent manner. However, main parameters such as field potential duration, beat period, and spike amplitude were different between the 2 groups. Overall, these results emphasize that applying matured hPSC-CMs to the field of preclinical cardiotoxicity evaluation, which has become an essential procedure for new drug development, is necessary.

Cancer mortality in children surviving congenital heart interventions: A study from the Pediatric Cardiac Care Consortium

INTRODUCTION

Children with congenital heart defects (CHD) have shorter life expectancy than the general population. Previous studies also suggest that patients with CHD have higher risk of cancer. This study aims to describe cancer-related mortality among patients with a history of CHD interventions using the Pediatric Cardiac Care Consortium (PCCC), a large US cohort of such patients.

METHODS

We performed a retrospective cohort study of individuals (<21 years) who underwent interventions for CHD in the PCCC from 1982 to 2003. Patients surviving their first intervention were linked to the National Death Index through 2020. Multivariable models assessed risk of cancer-related death, adjusting for age, sex, race, and ethnicity. Patients with/without genetic abnormalities (mostly Down syndrome [DS]) were considered separately, due to expected differential risk in cancer.

RESULTS

Among the 57,601 eligible patients in this study, cancer was the underlying or contributing cause of death for 208; with 20% among those with DS. Significantly increased risk of cancer-related death was apparent among patients with DS compared to the non-genetic group (aHR: 3.63, 95% confidence interval [CI]: 2.52-5.24, p < .001). For the group with non-genetic abnormalities, the highest association with cancer-related death compared to those with mild CHD was found among those with more severe CHD (severe two-ventricle aHR: 1.82, 95% CI: 1.04-3.20, p = .036, single-ventricle aHR: 4.68, 95% CI: 2.77-7.91, p < .001).

CONCLUSIONS

Patients with more severe forms of CHD are at increased risk for cancer-related death. Despite our findings, we are unable to distinguish whether having CHD raises the risk of cancer or reduces survival.

Evaluation of Point-of-Care-Directed Coagulation Management in Pediatric Cardiac Surgery

BACKGROUND

 Coagulatory alterations are common after pediatric cardiac surgery and can be addressed with point-of-care (POC) coagulation analysis. The aim of the present study is to evaluate a preventive POC-controlled coagulation algorithm in pediatric cardiac surgery.

METHODS

 This single-center, retrospective data analysis included patients younger than 18 years who underwent cardiac surgery with cardiopulmonary bypass (CPB) and received a coagulation therapy according to a predefined POC-controlled coagulation algorithm. Patients were divided into two groups (<10 and >10 kg body weight) because of different CPB priming strategies.

RESULTS

 In total, 173 surgeries with the use of the POC-guided hemostatic therapy were analyzed. In 71% of cases, target parameters were achieved and only in one case primary sternal closure was not possible. Children with a body weight ≤10 kg underwent surgical re-evaluation in 13.2% (15/113), and respectively 6.7% (4/60) in patients >10 kg. Hemorrhage in children ≤10 kg was associated with cyanotic heart defects, deeper intraoperative hypothermia, longer duration of CPB, more complex procedures (RACHS-1 score), and with more intraoperative platelets, and respectively red blood cell concentrate transfusions (all p-values < 0.05). In children ≤10 kg, fibrinogen levels were significantly lower over the 12-hour postoperative period (without revision: 3.1 [2.9-3.3] vs. with revision 2.8 [2.3-3.4]). Hemorrhage in children >10 kg was associated with a longer duration of CPB (p = 0.042), lower preoperative platelets (p = 0.026), and over the 12-hour postoperative period lower platelets (p = 0.002) and fibrinogen (p = 0.05).

CONCLUSION

 The use of a preventive, algorithm-based coagulation therapy with factor concentrates after CPB followed by POC created intraoperative clinical stable coagulation status with a subsequent executable thorax closure, although the presented algorithm in its current form is not superior in the reduction of the re-exploration rate compared to equivalent collectives. Reduced fibrinogen concentrations 12 hours after surgery may be associated with an increased incidence of surgical revisions.

Mitochondrial permeability transition dictates mitochondrial maturation upon switch in cellular identity of hematopoietic precursors

The mitochondrial permeability transition pore (mPTP) is a supramolecular channel that regulates exchange of solutes across cristae membranes, with executive roles in mitochondrial function and cell death. The contribution of the mPTP to normal physiology remains debated, although evidence implicates the mPTP in mitochondrial inner membrane remodeling in differentiating progenitor cells. Here, we demonstrate that strict control over mPTP conductance shapes metabolic machinery as cells transit toward hematopoietic identity. Cells undergoing the endothelial-to-hematopoietic transition (EHT) tightly control chief regulatory elements of the mPTP. During EHT, maturing arterial endothelium restricts mPTP activity just prior to hematopoietic commitment. After transition in cellular identity, mPTP conductance is restored. In utero treatment with NIM811, a molecule that blocks sensitization of the mPTP to opening by Cyclophilin D (CypD), amplifies oxidative phosphorylation (OXPHOS) in hematopoietic precursors and increases hematopoiesis in the embryo. Additionally, differentiating pluripotent stem cells (PSCs) acquire greater organization of mitochondrial cristae and hematopoietic activity following knockdown of the CypD gene, Ppif. Conversely, knockdown of Opa1, a GTPase critical for proper cristae architecture, induces cristae irregularity and impairs hematopoiesis. These data elucidate a mechanism that regulates mitochondrial maturation in hematopoietic precursors and underscore a role for the mPTP in the acquisition of hematopoietic fate.

Localization of EFA6A, an exchange factor for Arf6, in Z-lines and sarcoplasmic reticulum membranes in addition to myofilaments in I-domains of skeletal myofibers of peri-natal mice

Membrane trafficking and actin-remodeling are critical for well-maintained integrity of the cell organization and activity, and they require Arf6 (ADP ribosylation factor 6) activated by GEF (guanine nucleotide exchange factor) including EFA6 (exchange factor for Arf6). In the present immuno-electron microscopic study following previous immunohistochemical study by these authors (Chomphoo et al., 2020) of in situ skeletal myoblasts and myotubes of pre-and perinatal mice, the immunoreactivity for EFA6A was found to be localized at Z-bands and sarcoplasmic reticulum (SR) membranes in I-domains as well as I-domain myofilaments of skeletal myofibers of perinatal mice. Based on the previous finding that EFA6 anchored on the neuronal postsynaptic density via α-actinin which is known to be shared by muscular Z-bands, the present finding suggests that EFA6A is also anchored on Z-bands via α-actinin and involved in the membrane trafficking and actin-remodeling in skeletal myofibers. The localization of EFA6A-immunoreactivity in I-domain SR suggests a differential function in the membrane traffic between the I- and A-domain intracellular membranes in perinatal skeletal myofibers.

Quality of Life and Well-Being in Adults With Fontan Physiology: Findings From the Australian and New Zealand Fontan Registry Quality of Life Study

BACKGROUND

To characterize global and health-related quality of life (QOL) among adults with Fontan physiology enrolled in the Australian and New Zealand Fontan Registry (ANZFR), and identify sociodemographic, clinical, psychological, and relational factors associated with outcomes.

METHODS AND RESULTS

Using a cross-sectional survey design, 66 adults with Fontan physiology (58% women; mean age, 29.6±7.7 years; range, 18-50 years) completed validated self-report measures. Health-related QOL was assessed using the Pediatric Quality of Life Inventory, and global QOL was assessed using a visual analog scale (0-10). Participants reported lower total health-related QOL (P<0.001), as well as lower physical (P<0.001) and social (P=0.002) functioning compared with normative data. Median global QOL was 7.0 (interquartile range: 5.0-8.0) and most participants (71%) rated their QOL ≥6. For health-related QOL, age, sex, university education, and length of hospital stay in the past 12 months explained 27% of the variance in scores, while general psychological stress, medical traumatic stress, communication problems, and access to emotional support explained a further 44% of variance (final model: 71% of variance explained). For global QOL, sociodemographic and clinical factors explained 20% of the variance in scores, while psychological stress and sense of coherence explained a further 24% (final model: 44% of variance explained).

CONCLUSIONS

Adults with Fontan physiology reported lower overall health-related QOL compared with community-based norms. Variance in QOL outcomes were predominantly attributable to psychological and relational factors. Tailored screening and assessment to identify Fontan patients at greatest risk of lower QOL, and a proactive approach to supportive care, are needed.

Global and regional cardiac magnetic resonance feature tracking left ventricular strain analysis in assessing early myocardial disease in β thalassemia major patients

BACKGROUND

Cardiac magnetic resonance imaging (CMR) is the modality of choice for quantification of myocardial iron overload in β-thalassemia major patients using the T2* sequence. CMR feature tracking (FT) is a recent magnetic resonance imaging tool that gives an idea about myocardial fibers deformation; thus, it can detect early impairment in myocardial function even before the reduction in ejection fraction.

METHODS

This study aims to assess the ability of left ventricular CMR-FT in the early detection of systolic dysfunction in β thalassemia major patients and to correlate it with the degree of myocardial iron overload measured by CMR T2*. This prospective study enrolled 57 β thalassemia major patients who received long-term blood transfusion and 20 healthy controls. CMR was used to evaluate left ventricular volumes, ejection fraction, and the amount of myocardial T2*. A two-dimensional left ventricular FT analysis was performed. Both global and segmental left ventricular strain values were obtained.

RESULTS

The mean global circumferential strain (GCS) and global radial strain (GRS) values were significantly lower in patients compared to control (P = 0.002 and P = 0.006, respectively). No correlation was found between T2* values and ejection fraction; however, there was a significant correlation between T2* values and GCS and GRS (P = 0.012 and P = 0.025, respectively) in thalassemia patients. Regional strain revealed significantly lower values of GCS and GRS in basal regions compared to apical ones (P = 0.000).

CONCLUSIONS

Our study revealed that CMR-FT can play a role in the early detection of systolic impairment in thalassemia patients.

Validation of the Survey of Sleep Quality in the Pediatric Intensive Care Unit (SSqPICU)

STUDY OBJECTIVES

Observational data suggest pediatric intensive care unit-related sleep and circadian disruption (PICU-SCD) affects many critically ill children. Multicenter trials exploring PICU-SCD have been impractical because measuring sleep in this setting is challenging. This study validates a questionnaire for caregivers to describe children's sleep in the PICU.

METHODS

This prospective, multicenter, case-control study enrolled caregivers of children in 4 PICUs or in a hospital-based sleep laboratory (controls). Survey items were compiled from validated adult ICU and pediatric in- and outpatient sleep questionnaires. Control responses were compared to polysomnography to determine accuracy. A score was calculated by summing the level of disruption of sleep timing, duration, efficiency, quality, and daytime sleepiness and irritability.

RESULTS

In responses from 152 PICU and 61 sleep laboratory caregivers, sleep survey items had acceptable internal reliability (α = 0.75) and reproducibility on retest surveys (interclass correlation coefficient > 0.600). Caregivers could not assess sleep of sedated children. Factor analysis identified 3 subscales of PICU-SCD. Control parents had good agreement with polysomnography sleep onset time (κ = 0.823) and sleep onset latency (κ = 0.707). There was a strong correlation between sleep scores derived by parental reporting to those by polysomnography (r = .844, P < .001). Scores had a linear association with caregiver-reported child sleep quality. There were no site-specific differences in sleep quality. Nearly all respondents found the survey easy to understand and of appropriate length.

CONCLUSIONS

The Survey of Sleep Quality in the Pediatric Intensive Care Unit provides a reliable, accurate description of inpatient sleep disruption in nonsedated children, generalizable across PICUs. It offers practical means to quantify PICU-SCD daily in future investigations.

CITATION

Hassinger AB, Mody K, Gomez R, et al. Validation of the Survey of Sleep Quality in the Pediatric Intensive Care Unit (SSqPICU). J Clin Sleep Med. 2024;20(8):1251-1258.

The impact of simulation-based training on medical students' whole blood transfusion abilities

BACKGROUND

Whole blood transfusion has been found to increase the likelihood of patient survival within both military and civilian medicine contexts. However, no whole blood transfusion training curriculum currently exists within undergraduate or graduate medical education in the United States. The purpose of our study was to: (1) determine the impact of simulation-based training on medical students' abilities to conduct whole blood transfusions; and (2) determine the impact of simulation-based training on medical students' confidence in conducting whole blood transfusions.

STUDY DESIGN AND METHODS

We assessed 157 third-year military medical students' ability to conduct whole blood transfusion before and after Operation Gunpowder, a 2-day high-fidelity prolonged casualty care simulation. We conducted a paired samples t-test to compare the students' pre- and post-simulation performance scores as well as self-reported confidence and stress ratings.

RESULTS

There was a significant difference in students' scores at the beginning of the course (M = 20.469, SD 6.40675) compared to their scores at the end of the course (M = 30.361, SD = 2.10053); t(155) = -18.833, p < .001. The effect size for this analysis (d = 6.56) was large. There was a significant difference (p < .001) between the pre- and post-ratings for all self-reported confidence and stress survey items.

DISCUSSION

Our results suggest that simulation-based training is an effective means of training medical students to conduct whole blood transfusiontraining in a limited resource simulated environment where blood inventories may be limited.

Childhood growth hormone treatment: challenges, opportunities, and considerations

With long standing demand and popularity, growth hormone treatments continue to be a topic of interest for paediatric endocrinologists and general paediatricians due to ongoing issues regarding their long-term effects, the safety of childhood treatment, and the introduction of long-acting growth hormone preparations in the past decade. Moreover, uncertainty regarding how to approach individual patients and their treatment indications remains, particularly concerning tailored treatment goals and objectives; this uncertainty is further complicated by the multitude of approved indications that surpass substitution therapy. The paediatric endocrinologist thus grapples with pertinent questions, such as what defines reasonable treatment goals for each individual given their indications, and when (and how) to initiate the necessary discussions about risks and benefits with patients and their families. The aim of this Review is to offer advanced physiological concepts of growth hormone function, map out approved paediatric indications for treatment along with evidence on their effects and safety, highlight controversies and complexities surrounding childhood growth hormone treatment, and discuss the potential of long-acting growth hormone and future directions in the realm of childhood growth hormone treatment.

The Association of Race and Ethnicity with Mortality in Pediatric Patients with Congenital Heart Disease: a Systematic Review

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.

Defects in integrin complex formation promote CHKB-mediated muscular dystrophy

Phosphatidylcholine (PC) is the major membrane phospholipid in most eukaryotic cells. Bi-allelic loss of function variants in CHKB, encoding the first step in the synthesis of PC, is the cause of a rostrocaudal muscular dystrophy in both humans and mice. Loss of sarcolemma integrity is a hallmark of muscular dystrophies; however, how this occurs in the absence of choline kinase function is not known. We determine that in Chkb -/- mice there is a failure of the α7β1 integrin complex that is specific to affected muscle. We observed that in Chkb -/- hindlimb muscles there is a decrease in sarcolemma association/abundance of the PI(4,5)P2 binding integrin complex proteins vinculin, and α-actinin, and a decrease in actin association with the sarcolemma. In cells, pharmacological inhibition of choline kinase activity results in internalization of a fluorescent PI(4,5)P2 reporter from discrete plasma membrane clusters at the cell surface membrane to cytosol, this corresponds with a decreased vinculin localization at plasma membrane focal adhesions that was rescued by overexpression of CHKB.

Diuretics in neonatology: a narrative review and update

Diuretics are medications that promote the excretion of water and electrolytes. They are primarily used in the management and treatment of states of inappropriate salt and water retention. Diuretics represent one of the most common classes of drugs administered to sick neonates, the more so in very low birth weight infants. Diuretic drugs, especially loop diuretics, are often administered in the neonatal intensive care unit as off-label medications. This is the case for a variety of clinical situations, in which an increase in sodium excretion is not the primary goal of treatment (transitory tachypnoea of the newborn at term, hyaline membrane disease, patent ductus arteriosus of preterm infants). Thiazides and furosemide are widely used to treat preterm infants with oxygen-dependent chronic lung disease, despite a lack of data on beneficial effect of long-term therapy on pulmonary function or clinical outcome. This article reviews the mechanism of action, indications, administration, posology, adverse effects and contraindications of diuretics in newborn infants. Based on the most recent information available in the literature, we will discuss data supporting (or questioning) the use of diuretic in specific neonatal diseases. Research priorities over this issue will be briefly presented.

Parents' experience of children's transitions from intensive care unit after liver transplantation: A qualitative study

OBJECTIVE

The aim of this study was to understand parents' perspectives on caring for children who underwent liver transplantation in the intensive care unit transition period and to provide a reference for the development of targeted intervention strategies.

METHODS

Thirteen parents of children who underwent liver transplantation at a tertiary hospital in Hangzhou, Zhejiang Province were chosen for in-depth semi-structured interviews via purposive sampling. The interview data were analyzed and summarized via content analysis.

FINDINGS

Three themes were extracted, including a period of separation and suffering (being apart from child is tough, chilling atmosphere, and limited family access); being an overwhelming caregiver (hope coupled with worry, conflict of roles, and existential care dilemmas); and facing a new normal: searching for information and support (information on medical conditions, post-discharge care assistance, educational support, and peer support).

CONCLUSION

For parents whose child underwent liver transplantation, the transition period from the intensive care unit to the general ward is challenging. Parents are burdened with several caregiving responsibilities and require a variety of information and support. It is advised that nurses should offer sufficient information and suitable educational approaches to enhance these parents' capacity to care for their children and assist children and their parents in making a smooth transition.

IMPLICATIONS FOR CLINICAL PRACTICE

This study highlights parents' perspectives on caring for children with liver transplants transferred from the intensive care unit to a general ward. Transitional care is strenuous, evoking different feelings before and after transfer. The health care professionals should focus on the needs and challenges faced by parents who are caring for children with liver transplants during the intensive care unit transition period. To achieve this, it is critical to establish a supportive environment and provide suitable information and education for parents to enhance their caregiving abilities.

Psychometric adaptation of the Spanish version of the Brief Pittsburgh Sleep Quality Index in adolescents

OBJECTIVE

Good sleep quality is essential for adolescent health, yet sleep difficulties persist in this age group. The 6-item Brief Pittsburgh Sleep Quality Index (B-PSQI) was recently developed to improve sleep quality assessment, however, its validity in adolescents remains unexplored. This study examined the B-PSQI's psychometric properties in Spanish adolescents and adapted the scoring method to age-specific sleep recommendations.

METHODS

A cross-sectional study involving 1,065 adolescents (15-17 years; 56.8% female) was conducted in public high schools. Sleep quality was measured using the B-PSQI, the Insomnia Severity Index (ISI), the short Patient-Reported Outcomes Measurement Information System (PROMIS), and the Epworth Sleepiness Scale (ESS). Additionally, depression and anxiety were assessed using the Depression, Anxiety, and Stress Scales. Reliability, validity, and measurement invariance were analyzed.

RESULTS

The B-PSQI global scores were 4.5 (SD = 1.9) for the original scoring method and 5.4 (SD = 2.8) for the age-adjusted. The age-adjusted B-PSQI showed satisfactory reliability (ω = 0.84) and concurrent, convergent, and discriminant validity (ISI rS = 0.67; PROMIS rS = 0.71; anxiety rS = 0.40; depression rS = 0.42; ESS rS = 0.29). Adequacy for one-factor structure (χ2(4) = 53.9; CFI = 0.97; TLI = 0.92; RMSEA = 0.108; SRMR = 0.05) and invariance across sexes were supported. Both B-PSQI scoring methods showed similar psychometric properties, but the original yielded a higher percentage of poor sleepers (43.1%; cutoff ≥5) than the age-adjusted version (41.9%; cutoff ≥6).

CONCLUSIONS

Findings suggest that the B-PSQI is a valid and reliable measure to assess adolescent sleep quality. Its scoring can be adjusted to provide age-specific criteria for good sleep. The B-PSQI has potential utility for screening sleep problems and facilitating overall health promotion in adolescents.

Cardiac function in congenital diaphragmatic hernia

Cardiac function is known to play critical role in the pathophysiological progression and ultimate clinical outcome of patients with congenital diaphragmatic hernia (CDH). While often anatomically normal, the fetal and neonatal heart in CDH can suffer from both right and left ventricular dysfunction. Here we explore the abnormal fetal heart, early postnatal right and left ventricular dysfunction, the interplay between cardiac dysfunction and pulmonary hypertension, evaluation and echocardiographic assessment of the heart, and therapeutic strategies for managing and supporting the pathophysiologic heart and CDH. Further, we take a common clinical scenario and provide clinically relevant guidance for the diagnosis and management of this complex process.

Diagnostic value of D-dimer in differentiating multisystem inflammatory syndrome in Children (MIS-C) from Kawasaki disease: systematic literature review and meta-analysis

Coronavirus disease 2019 (COVID-19) is frequently associated with thrombo inflammation, which can predispose to developing of life-threatening conditions in children such as the multisystem inflammatory syndrome (MIS-C) and Kawasaki disease. Because of the consistent overlap in pathogenesis and symptoms, identifying laboratory tests that may aid in the differential diagnosis of these pathologies becomes crucial. We performed an electronic search in PubMed, Web of Science and Scopus, without date or language restrictions, to identify all possible studies reporting D-dimer values in separate cohorts of children with MIS-C or Kawasaki disease. Three multicenter cohort studies were included in our analysis, totaling 487 patients (270 with MIS-C and 217 with Kawasaki disease). In this meta-analysis, significantly higher D-dimer values were found in MIS-C compared to Kawasaki disease in all three studies, yielding an SMD of 1.5 (95 % CI, 1.3-1.7) mg/L. Thus, very high D-dimer values early in the course of disease should raise the clinical suspicion of MIS-C rather than Kawasaki disease. Further studies should be planned to identify harmonized D-dimer diagnostic thresholds that may help discriminate these conditions.

Systemic hemodynamics and pediatric lung disease: mechanistic links and therapeutic relevance

Chronic lung disease, also known as bronchopulmonary dysplasia, affects thousands of infants worldwide each year. The impact on resources is second only to bronchial asthma, with lung function affected well into adolescence. Diagnostic and therapeutic constructs have almost exclusively focused on pulmonary architecture (alveoli/airways) and pulmonary hypertension. Information on systemic hemodynamics indicates major artery thickness/stiffness, elevated systemic afterload, and/or primary left ventricular dysfunction may play a part in a subset of infants with severe neonatal-pediatric lung disease. Understanding the underlying principles with attendant effectors would aid in identifying the pathophysiological course where systemic afterload reduction with angiotensin-converting enzyme inhibitors could become the preferred treatment strategy over conventional pulmonary artery vasodilatation.NEW & NOTEWORTHY Extremely preterm infants are at a higher risk of developing severe bronchopulmonary dysplasia. In a subset of infants, diuretic and pulmonary vasodilator therapy is ineffective. Recent information points toward systemic hemodynamic disease (systemic arterial stiffness and left ventricular dysfunction) as a contributor via back-pressure changes. Mechanistic links include heightened renin angiotensin aldosterone system activity, inflammation, and oxygen toxicity. Angiotensin-converting enzyme inhibition may be operationally more suited compared with induced pulmonary artery vasodilatation.

Educational Needs of the Adolescent Transplant Recipient: A Developmental Approach to Understanding Transplant

BACKGROUND

As pediatric transplant patients reach adolescence, care teams must prepare them for an eventual transition to adult-oriented care. Care teams must provide patients with the necessary knowledge and skills to manage their medical needs independently, but the level of learning required to successfully self-manage a transplant is substantial. Furthermore, adolescence is also a dynamic developmental period that includes significant cognitive development and changes in social motivations.

METHODS

Within this report, we offer insights into some of the key developmental mechanisms of adolescence that may influence their learning in a medical context. We also review key concepts that should be included in patient education across a range of domains. Finally, we consider how patients with comorbid developmental disorders may require tailored education.

RESULTS

Key domains for education include (1) personal health history, (2) medication knowledge/adherence, (3) navigation of the healthcare system, and (4) communication with others about their health. Teams should intentionally track patient progress in their education, although few formalized tools are currently available to support tracking. Accommodations to learning for patients with developmental needs include varied instructional modalities (e.g., verbal, written, and modeling), opportunities to practice skills in a controlled manner, and establishment of family/community support that can persist into adulthood.

CONCLUSIONS

Education of transplant patients is a critical but long-term process that supports the successful transition to adulthood. Care teams should develop intentional plans to transfer knowledge and build skills across adolescence, while remaining open to adaptive approaches to support the learning of all patients.

Transcatheter and Surgical Ductus Arteriosus Closure in Very Low Birth Weight Infants: 2018-2022

BACKGROUND AND OBJECTIVE

The optimal patent ductus arteriosus (PDA) closure method in very low birth weight (VLBW) infants is uncertain. In 2019, the first transcatheter occlusion device was approved in the United States for infants ≥700 g. We described survival and short-term outcomes among VLBW infants who underwent transcatheter or surgical PDA closure (2018-2022).

METHODS

Vermont Oxford Network members submitted data on infants born from 401 to 1500 g or 22 to 29 weeks' gestational age. Adjusted risk ratios (aRR) for survival, length of stay (LOS), prematurity complications, and discharge support were used to compare transcatheter versus surgical closure. Subgroup analyses were conducted for infants with birth weight ≥700 g and born in 2020-2022.

RESULTS

Overall, 6410 of 216 267 infants at 726 hospitals received invasive PDA treatment. Transcatheter closure increased from 29.8% in 2018 to 71.7% in 2022. VLBW infants undergoing transcatheter closure had higher survival (adjusted rate ratio [aRR] 1.03; 1.02-1.04) with similar LOS (aRR 1.00; 0.97-1.03), neonatal complications (aRR 1.00; 0.98-1.01), and receipt of discharge support (aRR 0.94; 0.89-1.01). In subgroup analyses, survival (aRR 1.02; 1.00-1.04) and discharge support (aRR 0.90; 0.81-1.01) were similar between groups, whereas selected neonatal complications (aRR 0.95; 0.93-0.98) and LOS (aRR 0.95; 0.90-0.99) were lower after transcatheter closure.

CONCLUSIONS

Transcatheter PDA closure in VLBW infants was increasingly used after 2018. Selected short-term outcomes for infants receiving transcatheter closure may be more favorable, compared with surgical, and warrants further clinical investigation.

Health-related quality of life outcomes in children after congenital heart disease surgery in low-middle-income countries: a systematic review and meta-analysis

Introduction

Improved treatments for children with congenital heart disease (CHD) have led to a growing interest in long-term functional outcomes such as health-related quality of life (HRQOL). Studies on HRQOL in children with CHD have yielded contradictory results. In this study, we aimed to perform a systematic review and meta-analysis to analyze the effect of surgery on HRQOL outcomes in children with CHD in low-income and middle-income countries.

Methods

A comprehensive search for articles was performed using the Medline (PubMed), Scopus, and Embase databases from their inception to September 5, 2023. Studies reporting QOL outcomes in children <18 years and published in English were included.

Results

Of the 1239 records screened, 10 studies, including 1721 participants, were included in the study. The overall QOL was significantly better in the control group than in the children who underwent surgery for CHD (P=0.04, standard mean difference of -0.62, 95% CI: -1.2 to -0.04), and the overall QOL was significantly better in the children with CHD after surgery than before surgery (P=0.05, standard mean difference of -0.56, 95% CI: -1.11 to -0.01).

Conclusion

The QOL of children from low-income and middle-income countries who undergo surgery for CHD is significantly poorer than that of controls in all dimensions except the emotional domain. Meanwhile, surgery has the greatest impact on improving the physical domain in children with CHD after surgery. Strategies to improve HRQOL in this subgroup of patients should be further investigated.

Alarm fatigue and sleep quality in medical staff-a Polish-Czech-Slovak study on workplace ergonomics

Background

Alarms are crucial in informing Healthcare Workers (HCWs) about critical patient needs, but unmanaged frequency and noise of alarms can de-sensitize medical staff and compromise patient safety. Alarm fatigue is identified as the major cause of the clinical alarm management problem. It occurs when the medical staff is overwhelmed by the number of clinical alarms.

Methods

The survey was conducted online using Google's form-making tools from June to July 2023. There were three parts to the survey used in the study: a socio-demographic metric, the Alarm Fatigue Assessment Questionnaire (AFAQ), and The Pittsburgh Sleep Quality Index (PSQI). A significance level of 0.05 was used in the analysis.

Results

The survey included 756 medical professionals from three European countries (Slovakia, the Czech Republic and Poland). The participants in the study were 42 years old on average, and they had 12 years of work experience. 603 out of 756 survey participants had poor sleep quality, 147 had good sleep quality, and 6 did not provide an answer. This study analyzed the alarm fatigue levels of respondents in every country. In the Czech Republic, Poland and Slovakia, a statistically significant association (p = 0.039, p = 0.001, p < 0.001) was found between alarm fatigue and sleep quality in medical staff.

Conclusion

Based on our study, alarm fatigue and sleep quality of HCWs are correlated. Therefore, alarm fatigue and sleep hygiene should be monitored.

Noonan syndrome and Noonan-like syndrome with loose anagen hair: rare phenotypes may emerge during follow-up

Background

Noonan syndrome (NS) and Noonan-like syndrome with loose anagen hair (NS/LAH) are neurodevelopmental syndromes resulting from germline mutations in genes that participate in the rat sarcoma/mitogen-activated protein kinases (RAS/MAPK) pathway. The aim of this retrospective study was to describe common and rare manifestations of NS and NS/LAH.

Methods

We collected and analyzed clinical and genetic data from 25 patients with NS and NS/LAH.

Results

The patients' median age was 6.3 years (range, 1-13 years), and the male-to-female ratio was 18:7. In total, 19 patients had NS caused by a mutation in PTPN11. Another causative gene was found in six patients, including two patients with a SHOC2 mutation, one patient with a KRAS mutation, one patient with an LZTR1 mutation, one patient with a BRAF mutation, and one patient with a PPP1CB mutation. Short stature was detected in 100% of the patients. This study provides an overview of the clinical features of NS, including unique facial features, short stature, congenital heart defects, and other manifestations. Notably, systemic lupus erythematosus (SLE) was found in two SHOC2-positive patients. One patient had a posterior urethral valve, which is very rare in NS patients.

Conclusions

Our study identified several clinical features that were previously poorly related to NS, including SLE. We concluded that SHOC2-related NS is associated with a particularly high risk of SLE, which may have a significant impact on quality of life, and a posterior urethral valve is a novel phenotype. These findings could be helpful in enhancing the understanding of the clinical spectrum of NS.

Integrating Heart Rate Monitoring Into a Camp for Children With Neuromotor Disorders: A Case Series

PURPOSE

This case series investigated the implementation fidelity, feasibility, and effectiveness of integrating continuous heart rate monitoring with visual feedback into an established, intensive physical therapy camp for children with neuromotor disorders.

SUMMARY OF KEY POINTS

The provision of continuous visual feedback through color-coded, individually calculated heart rate zones was a feasible and effective intervention, encouraging pediatric gait camp participants to exercise at intensities that produced aerobic and functional gains. The use of technology facilitated participation with peers, an outcome equally as important as their endurance and functional improvements.

CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

Pediatric physical therapists play a crucial role in enhancing the well-being and physical fitness of children with disabilities. Encouraging regular exercise in a social environment fosters enjoyable, inclusive experiences while promoting overall health. It is important for clinicians in various pediatric rehabilitation settings to establish programs that offer such opportunities for children with neuromotor disorders.

Sotalol prophylaxis was efficient and safe for supraventricular tachycardia in early infancy

AIM

There is no consensus on the best prophylaxis for supraventricular tachycardia (SVT) in infancy. We studied the efficacy and safety of sotalol.

METHOD

This retrospective study comprised infants diagnosed with SVT before 1 year of age and treated with sotalol during 2002-2018 in Stockholm, Sweden. The patients' characteristics, comorbidities, sotalol dosages, QT intervals and outcomes were extracted from their medical records.

RESULTS

We studied 85 infants (65% boys) with a median age of eight (range 0-288) days at the time of diagnosis, including 78 with re-entry tachycardia. Sotalol was completely or partially successful in the 67/75 patients who completed the treatment, as well as in four of the seven patients with other tachycardia mechanisms. The 48 infants with postnatal debut had significantly higher success rates than the 27 with foetal debut (96% vs. 78%, p = 0.04). Prolongation of corrected QT (QTc) intervals of ≥450 ms occurred in 16% of the total cohort and two patients with QTc intervals of ≥500 ms had their treatment changed. There were no cases of proarrhythmia after sotalol treatment.

CONCLUSION

Sotalol provided effective and safe prophylaxis for SVT during infancy. QTc prolongation rarely caused treatment discontinuation and there were no cases of proarrhythmia.

In Vivo Approaches to Understand Arrhythmogenic Cardiomyopathy: Perspectives on Animal Models

Arrhythmogenic cardiomyopathy (AC) is a hereditary cardiac disorder characterized by the gradual replacement of cardiomyocytes with fibrous and adipose tissue, leading to ventricular wall thinning, chamber dilation, arrhythmias, and sudden cardiac death. Despite advances in treatment, disease management remains challenging. Animal models, particularly mice and zebrafish, have become invaluable tools for understanding AC's pathophysiology and testing potential therapies. Mice models, although useful for scientific research, cannot fully replicate the complexity of the human AC. However, they have provided valuable insights into gene involvement, signalling pathways, and disease progression. Zebrafish offer a promising alternative to mammalian models, despite the phylogenetic distance, due to their economic and genetic advantages. By combining animal models with in vitro studies, researchers can comprehensively understand AC, paving the way for more effective treatments and interventions for patients and improving their quality of life and prognosis.

Cardiovascular Sequelae of Bronchopulmonary Dysplasia in Preterm Neonates Born before 32 Weeks of Gestational Age: Impact of Associated Pulmonary and Systemic Hypertension

Bronchopulmonary dysplasia (BPD) remains the most common respiratory disorder of prematurity for infants born before 32 weeks of gestational age (GA). Early and prolonged exposure to chronic hypoxia and inflammation induces pulmonary hypertension (PH) with the characteristic features of a reduced number and increased muscularisation of the pulmonary arteries resulting in an increase in the pulmonary vascular resistance (PVR) and a fall in their compliance. BPD and BPD-associated pulmonary hypertension (BPD-PH) together with systemic hypertension (sHTN) are chronic cardiopulmonary disorders which result in an increased mortality and long-term problems for these infants. Previous studies have predominantly focused on the pulmonary circulation (right ventricle and its function) and developing management strategies accordingly for BPD-PH. However, recent work has drawn attention to the importance of the left-sided cardiac function and its impact on BPD in a subset of infants arising from a unique pathophysiology termed postcapillary PH. BPD infants may have a mechanistic link arising from chronic inflammation, cytokines, oxidative stress, catecholamines, and renin-angiotensin system activation along with systemic arterial stiffness, all of which contribute to the development of BPD-sHTN. The focus for the treatment of BPD-PH has been improvement of the right heart function through pulmonary vasodilators. BPD-sHTN and a subset of postcapillary PH may benefit from afterload reducing agents such as angiotensin converting enzyme inhibitors. Preterm infants with BPD-PH are at risk of later cardiac and respiratory morbidities as young adults. This paper reviews the current knowledge of the pathophysiology, diagnosis, and treatment of BPD-PH and BPD-sHTN. Current knowledge gaps and emerging new therapies will also be discussed.

Absorbable metal stents for vascular use in pediatric cardiology: progress and outlook

The past five years have yielded impressive advancements in fully absorbable metal stent technology. The desired ultimate ability for such devices to treat a vascular stenosis without long-term device-related complications or impeding future treatment continues to evoke excitement in clinicians and engineers alike. Nowhere is the need for fully absorbable metal stents greater than in patients experiencing vascular anomalies associated with congenital heart disease (CHD). Perhaps not surprisingly, commercially available absorbable metal stents have been implanted in pediatric cardiology patients with conditions ranging from pulmonary artery and vein stenosis to coarctation of the aorta and conduit/shunt reconstructions. Despite frequent short term procedural success, device performance has missed the mark with the commercially available devices not achieving degradation benchmarks for given applications. In this review we first provide a general overview detailing the theory of absorbable metal stents, and then review recent clinical use in CHD patients since the release of current-generation absorbable metal stents around 2019. We also discuss the challenges and our center's experience associated with the use of absorbable metal stents in this pediatric population. Lastly, we present potential directions for future engineering endeavors to mitigate existing challenges.

Engineering 3D Scaffold-Free Nanoparticle-Laden Stem Cell Constructs for Piezoelectric Enhancement of Human Neural Tissue Formation and Function

Electrical stimulation (ES) of cellular systems can be utilized for biotechnological applications and electroceuticals (bioelectric medicine). Neural cell stimulation especially has a long history in neuroscience research and is increasingly applied for clinical therapies. Application of ES via conventional electrodes requires external connectors and power sources, hindering scientific and therapeutic applications. Here engineering novel 3D scaffold-free human neural stem cell constructs with integrated piezoelectric nanoparticles for enhanced neural tissue induction and function is described. Tetragonal barium titanate (BaTi03) nanoparticles are employed as piezoelectric stimulators prepared as cytocompatible dispersions, incorporated into 3D self-organizing neural spheroids, and activated wirelessly by ultrasound. Ultrasound delivery (low frequency; 40 kHz) is optimized for cell survival, and nanoparticle activation enabled ES throughout the spheroids during differentiation, tissue formation, and maturation. The resultant human neural tissues represent the first example of direct tissue loading with piezoelectric particles for ensuing 3D ultrasound-mediated piezoelectric enhancement of human neuronal induction from stem cells, including augmented neuritogenesis and synaptogenesis. It is anticipated that the platform described will facilitate advanced tissue engineering and in vitro modeling of human neural (and potentially non-neural) tissues, with modeling including tissue development and pathology, and applicable to preclinical testing and prototyping of both electroceuticals and pharmaceuticals.

Developing the green operating room: exploring barriers and opportunities to reducing operating room waste

The Australian health care system contributes 7% of the national greenhouse gas emission footprint and generates massive waste streams annually. Operating rooms are a particular hotspot, generating at least 20% of the total hospital waste. A systematic search of several global academic databases was conducted in mid-2022 (articles from 1992 to 2022) for peer-reviewed research relevant to waste management in the operating rooms. We then used thematic analysis to enumerate and characterise the strategies and barriers to sustainable waste management in the operating room. The waste reduction strategies focused on avoidance of high carbon products; correct waste segregation and reduced overage; reusing, reprocessing, and repurposing devices; and improved recycling. The first barrier identified was a constrained interpretation of the concept of "first do not harm", ingrained in surgeons' practices, in prioritising single-use surgical products. The second barrier was ineffective or insufficient waste education. The third barrier was the immediate cost of implementing waste management compared with the long term realisation of environmental and economic benefits. The last barrier to implementing institutional practice change was the lack of policies and regulations at the local hospital, federal and international levels. We also evaluated the knowledge gaps in current surgical waste research, including lack of benchmarking data and standardised regulations concerning reusable or reprocessed devices, as well as the methods used to promote pro-sustainability behavioural change.

Computational haemodynamics for pulmonary valve replacement by means of a reduced fluid-structure interaction model

Pulmonary valve replacement (PVR) consists of substituting a patient's original valve with a prosthetic one, primarily addressing pulmonary valve insufficiency, which is crucially relevant in Tetralogy of Fallot repairment. While extensive clinical and computational literature on aortic and mitral valve replacements is available, PVR's post-procedural haemodynamics in the pulmonary artery and the impact of prosthetic valve dynamics remain significantly understudied. Addressing this gap, we introduce a reduced Fluid-Structure Interaction (rFSI) model, applied for the first time to the pulmonary valve. This model couples a three-dimensional computational representation of pulmonary artery haemodynamics with a one-degree-of-freedom model to account for valve structural mechanics. Through this approach, we analyse patient-specific haemodynamics pre and post PVR. Patient-specific geometries, reconstructed from CT scans, are virtually equipped with a template valve geometry. Boundary conditions for the model are established using a lumped-parameter model, fine-tuned based on clinical patient data. Our model accurately reproduces patient-specific haemodynamic changes across different scenarios: pre-PVR, six months post-PVR, and a follow-up condition after a decade. It effectively demonstrates the impact of valve implantation on sustaining the diastolic pressure gradient across the valve. The numerical results indicate that our valve model is able to reproduce overall physiological and/or pathological conditions, as preliminary assessed on two different patients. This promising approach provides insights into post-PVR haemodynamics and prosthetic valve effects, shedding light on potential implications for patient-specific outcomes.

Rationale and design of a randomized controlled clinical trial of a resilience-building intervention in adults with congenital heart disease

BACKGROUND

Adults with congenital heart disease (ACHD) are at risk for lower quality of life (QOL) and psychological health. Behavioral interventions to meet their psychosocial needs are lacking. The aim of this study is to evaluate the feasibility of implementing the Promoting Resilience in Stress Management (PRISM) intervention in ACHD and its efficacy in increasing resilience in this population.

METHODS

We designed a phase II randomized controlled clinical trial of patients with moderate or complex ACHD, physiological stages C or D. Enrolled participants will be randomized to receive PRISM or usual care. PRISM is a manualized, skills-based behavioral intervention comprised of four one-on-one sessions targeting resilience resources (stress-management, goal-setting, cognitive reframing, meaning making), an optional session on advance care planning, and a facilitated family meeting. Participants in both groups will complete study questionnaires at enrollment and 3-months later. The primary aim is to describe feasibility, namely the proportions of patients who a) enroll in the study among those eligible, and b) complete the PRISM intervention among those randomized to that arm. We will also evaluate PRISM's efficacy by using linear regression models to compare changes in mean resilience scores between assigned groups. In exploratory analyses, we will evaluate effects on QOL, psychological distress, perceived competence for health care management, and comfort with advance care planning.

DISCUSSION

This study will provide rigorous evidence to determine the feasibility and efficacy of a brief intervention to promote resilience and psychosocial health in ACHD. Findings may guide the development of a future multi-site effectiveness study.

CLINICAL TRIAL REGISTRATION

NCT04738474.

Cypher/ZASP drives cardiomyocyte maturation via actin-mediated MRTFA-SRF signalling

Rationale: Cardiomyocytes (CMs) undergo dramatic structural and functional changes in postnatal maturation; however, the regulatory mechanisms remain greatly unclear. Cypher/Z-band alternatively spliced PDZ-motif protein (ZASP) is an essential sarcomere component maintaining Z-disc stability. Deletion of mouse Cypher and mutation in human ZASP result in dilated cardiomyopathy (DCM). Whether Cypher/ZASP participates in CM maturation and thereby affects cardiac function has not been answered. Methods: Immunofluorescence, transmission electron microscopy, real-time quantitative PCR, and Western blot were utilized to identify the role of Cypher in CM maturation. Subsequently, RNA sequencing and bioinformatics analysis predicted serum response factor (SRF) as the key regulator. Rescue experiments were conducted using adenovirus or adeno-associated viruses encoding SRF, both in vitro and in vivo. The molecular mechanisms were elucidated through G-actin/F-actin fractionation, nuclear-cytoplasmic extraction, actin disassembly assays, and co-sedimentation assays. Results: Cypher deletion led to impaired sarcomere isoform switch and morphological abnormalities in mitochondria, transverse-tubules, and intercalated discs. RNA-sequencing analysis revealed significant dysregulation of crucial genes related to sarcomere assembly, mitochondrial metabolism, and electrophysiology in the absence of Cypher. Furthermore, SRF was predicted as key transcription factor mediating the transcriptional differences. Subsequent rescue experiments showed that SRF re-expression during the critical postnatal period effectively rectified CM maturation defects and notably improved cardiac function in Cypher-depleted mice. Mechanistically, Cypher deficiency resulted in the destabilization of F-actin and a notable increase in G-actin levels, thereby impeding the nuclear localisation of myocardin-related transcription factor A (MRTFA) and subsequently initiating SRF transcription. Conclusion: Cypher/ZASP plays a crucial role in CM maturation through actin-mediated MRTFA-SRF signalling. The linkage between CM maturation abnormalities and the late-onset of DCM is suggested, providing further insights into the pathogenesis of DCM and potential treatment strategies.

Advancing Cardiovascular Drug Screening Using Human Pluripotent Stem Cell-Derived Cardiomyocytes

Human pluripotent stem cell-derived cardiomyocytes (hPSC-CMs) have emerged as a promising tool for studying cardiac physiology and drug responses. However, their use is largely limited by an immature phenotype and lack of high-throughput analytical methodology. In this study, we developed a high-throughput testing platform utilizing hPSC-CMs to assess the cardiotoxicity and effectiveness of drugs. Following an optimized differentiation and maturation protocol, hPSC-CMs exhibited mature CM morphology, phenotype, and functionality, making them suitable for drug testing applications. We monitored intracellular calcium dynamics using calcium imaging techniques to measure spontaneous calcium oscillations in hPSC-CMs in the presence or absence of test compounds. For the cardiotoxicity test, hPSC-CMs were treated with various compounds, and calcium flux was measured to evaluate their effects on calcium dynamics. We found that cardiotoxic drugs withdrawn due to adverse drug reactions, including encainide, mibefradil, and cetirizine, exhibited toxicity in hPSC-CMs but not in HEK293-hERG cells. Additionally, in the effectiveness test, hPSC-CMs were exposed to ATX-II, a sodium current inducer for mimicking long QT syndrome type 3, followed by exposure to test compounds. The observed changes in calcium dynamics following drug exposure demonstrated the utility of hPSC-CMs as a versatile model system for assessing both cardiotoxicity and drug efficacy. Overall, our findings highlight the potential of hPSC-CMs in advancing drug discovery and development, which offer a physiologically relevant platform for the preclinical screening of novel therapeutics.

Neonatal hyperoxia exposure leads to developmental programming of cardiovascular and renal disease in adult rats

Premature infants are often exposed to hyperoxia. However, there is limited data regarding the mechanistic underpinnings linking neonatal hyperoxia exposure and its contribution to cardio-renal dysfunction in adults born preterm. Our objective was to determine whether neonatal hyperoxia induces systemic vascular stiffness and cardio-renal dysfunction in adulthood. Newborn rats were randomly assigned to room air (RA) or hyperoxia (85% O2) from postnatal day 1 to 14, then recovered in RA until 1 year of life. Arterial stiffness, cardio-renal histomorphometry, and fibrosis in the aorta, heart, and kidney were assessed. RNA-sequencing (RNA-seq) of the aorta and kidney was also done. Adult rats exposed to neonatal hyperoxia had increased aortic and mesenteric artery stiffness as demonstrated by wire and pressure myography. They also had cardiomyocyte hypertrophy, glomerulomegaly, and tubular injury. Hyperoxia exposure altered the transcriptome profile associated with fibrosis and matrix remodeling in the aorta and kidney. There was also increased TGF-β1 levels and fibrosis in the aorta, left ventricle, and kidney. In conclusion, neonatal hyperoxia exposure was associated with systemic vascular and cardio-renal alterations in 1-year-old rats. Further studies to determine how targeted therapies could reprogram cardio-renal injury after neonatal hyperoxia exposure are indicated.

Comparison of Morbidity and Mortality Outcomes between Hybrid Palliation and Norwood Palliation Procedures for Hypoplastic Left Heart Syndrome: Meta-Analysis and Systematic Review

Background/Objectives: Hybrid palliation (HP) procedures for hypoplastic left heart syndrome (HLHS) are increasing. Our objective was to compare mortality and morbidity following HP and NP (Norwood palliation) procedures. Methods: Systematic review and meta-analysis of HLHS patients of peer-reviewed literature between 2000 and 2023. Mortality and/or heart transplantation in HP versus NP in the neonatal period, interstage period, and at 1, 3 and 5 years of age, and morbidity including completion of Stage II and Stage III palliation, unexpected interventions, pulmonary artery pressures, right ventricle function, neurodevelopmental outcomes and length of hospital stay were evaluated. Results: Twenty-one (meta-analysis: 16; qualitative synthesis: 5) studies evaluating 1182 HLHS patients included. HP patients had higher interstage mortality (RR = 1.61; 95% CI: 1.10-2.33; p = 0.01) and 1-year mortality (RR = 1.22; 95% CI: 1.03-1.43; p = 0.02) compared to NP patients without differences in 3- and 5-years mortality. HP procedure in high-risk HLHS patients had lower mortality (RR = 0.48; 95% CI: 0.27-0.87; p = 0.01) only in the neonatal period. HP patients underwent fewer Stage II (RR = 0.90; 95% CI: 0.81-1.00; p = 0.05) and Stage III palliation (RR = 0.78; 95% CI: 0.69-0.90; p < 0.01), had more unplanned interventions (RR = 3.38; 95% CI: 2.04-5.59; p < 0.01), and longer hospital stay after Stage I palliation (weighted mean difference = 12.88; 95% CI: 1.15-24.62; p = 0.03) compared to NP patients. Conclusions: Our study reveals that HP, compared to NP for HLHS, is associated with increased morbidity risk without an improved survival rate.

Antiarrhythmic therapy for narrow QRS supraventricular tachyarrhythmias in newborns and infants in the first year of life: Potent tools to be handled with care

Supraventricular tachyarrhythmias pose a significant challenge in neonates and infants, particularly within the first year of life, where prompt and effective management is crucial. By synthesizing available evidence and clinical experience, this review aims to provide a comprehensive overview of antiarrhythmic therapy in this vulnerable population, with a focus on narrow QRS supraventricular tachyarrhythmias. This review examines the current understanding of supraventricular tachyarrhythmia management and discusses the challenges associated with antiarrhythmic therapy in newborns and infants during the critical first year of life, evaluating the efficacy and safety of various antiarrhythmic agents commonly utilized in this population, including dosing considerations, adverse effects, and strategies for acute management and prophylactic long-term antiarrhythmic treatment.