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Appel R, Grush AE, Upadhyaya RM, Mann DG, Buchanan EP. Ethical Implications of Cleft Lip and Palate Repair in Patients with Trisomy 13 and Trisomy 18. Cleft Palate Craniofac J 2024; 61:1383-1388. [PMID: 36945782 DOI: 10.1177/10556656231163722] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Children born with Trisomy 13 or 18 (T13/18) often have multiple congenital anomalies, many of which drastically shorten their lifespan. Among these defects are cleft lip and palate, the repair of which presents an ethical dilemma to the surgeon given the underlying comorbidities associated with T13/18. The authors present an ethical discussion and institutional experience in navigating this dilemma. METHODS The authors analyzed existing literature on T13 and T18 surgery and mortality. A retrospective study over ten years was also conducted to identify pediatric patients who underwent surgical correction of cleft lip and/or palate secondary to a confirmed diagnosis of T13/18. The authors identified two patients and examined their treatment course. RESULTS The authors' review of literature coupled with their institution's experience builds on the published successes of correcting cleft lip and palate in the setting of T13/18. It was found that both patients identified in the case series underwent successful correction with no surgical complications. CONCLUSION A careful balance must be struck between improved quality of life, benefits of treatment, and risks of surgery in children with T13/T18. Careful consideration should be given to the medical status of these complex patients. If the remaining medical comorbidities are well managed and under control, there is an ethical precedent for performing cleft lip and palate surgeries on these children. A diagnosis of T13/T18 alone is not enough to disqualify patients from cleft lip/palate surgery.
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Affiliation(s)
- Richard Appel
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, USA
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Andrew E Grush
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, USA
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Raghave M Upadhyaya
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, USA
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - David G Mann
- Department of Pediatric Anesthesiology, Perioperative, and Pain Medicine, Clinical Ethics, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin Street, Suite A3300, Houston, TX 77030, USA
| | - Edward P Buchanan
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, USA
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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Martinez NCM, de Almeida ST, Rosa RFM, Zen PRG. Prevalence and clinical characterization of oral clefts in patients with chromosome trisomy 18. REVISTA PAULISTA DE PEDIATRIA : ORGAO OFICIAL DA SOCIEDADE DE PEDIATRIA DE SAO PAULO 2024; 42:e2023169. [PMID: 38922187 PMCID: PMC11197772 DOI: 10.1590/1984-0462/2024/42/2023169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 02/18/2024] [Indexed: 06/27/2024]
Abstract
OBJECTIVE To verify the prevalence and perform the clinical characterization of oral clefts in a sample of patients with trisomy of chromosome 18 in Southern Brazil. METHODS This was a retrospective cross-sectional study, performed in a reference clinical genetic service in Southern Brazil. The initial sample consisted of 77 patients diagnosed in the neonatal period with trisomy 18 treated at the Clinical Genetics Service of a referral hospital at Federal University of Health Sciences of Porto Alegre (UFCSPA). The patients' diagnosis was confirmed by karyotype and care was provided during their stay in the intensive care unit (ICU) of the hospital that is a reference in Southern Brazil for care for malformed patients. The period covered was from 1975 to 2020. RESULTS During the study period, 77 patients diagnosed with trisomy 18 were treated, most of them in the ICU. Of these, 13 individuals were excluded due to incomplete data. The final sample consisted of 64 patients with an average age of 2.4 years of life, ranging from one day to 16 years old, the majority of whom were female. Regarding face dysmorphisms identified in the sample, three (4,68%) patients had cleft lip and two (3,11%) had cleft lip and palate. CONCLUSIONS This study contributed to the recognition of the characteristics and prevalence of oral clefts in individuals with trisomy 18 in a sample of patients from Southern Brazil. In addition, we described the clinical alterations found in patients with oral clefts, as well as other associated comorbidities, such as cardiac, neurological and pulmonary comorbidities, as well as cranial and facial dysmorphisms.
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Affiliation(s)
| | - Sheila Tamanini de Almeida
- Universidade Federal de Ciências da Saúde de Porto Alegre – Porto Alegre, RS, Brazil
- Irmandade da Santa Casa de Misericórdia de Porto Alegre – Porto Alegre, RS, Brazil
| | - Rafael Fabiano Machado Rosa
- Universidade Federal de Ciências da Saúde de Porto Alegre – Porto Alegre, RS, Brazil
- Irmandade da Santa Casa de Misericórdia de Porto Alegre – Porto Alegre, RS, Brazil
| | - Paulo Ricardo Gazzola Zen
- Universidade Federal de Ciências da Saúde de Porto Alegre – Porto Alegre, RS, Brazil
- Irmandade da Santa Casa de Misericórdia de Porto Alegre – Porto Alegre, RS, Brazil
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Kim AJH, Marshall M, Gievers L, Tate T, Taub S, Dukhovny S, Ronai C, Madriago EJ. Structured Framework for Multidisciplinary Parent Counseling and Medical Interventions for Fetuses and Infants with Trisomy 13 or Trisomy 18. Am J Perinatol 2024; 41:e2666-e2673. [PMID: 37619598 DOI: 10.1055/s-0043-1772748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
OBJECTIVE Trisomy 13 (T13) and 18 (T18) are aneuploidies associated with multiple structural congenital anomalies and high rates of fetal demise and neonatal mortality. Historically, patients with either one of these diagnoses have been treated similarly with exclusive comfort care rather than invasive interventions or intensive care, despite a wide phenotypic variation and substantial variations in survival length. However, surgical interventions have been on the rise in this population in recent years without clearly elucidated selection criterion. Our objective was to create a standardized approach to counseling expectant persons and parents of newborns with T13/T18 in order to provide collaborative and consistent counseling and thoughtful approach to interventions such as surgery. STUDY DESIGN This article describes our process and presents our resulting clinical care guideline. RESULTS We formed a multi- and interdisciplinary committee. We used published literature when available and otherwise expert opinion to develop an approach to care featuring individualized assessment of the patient to estimate qualitative mortality risk and potential to benefit from intensive care and/or surgeries centered within an ethical framework. CONCLUSION Through multidisciplinary collaboration, we successfully created a patient-centered approach for counseling families facing a diagnosis of T13/T18. Other institutions may use our approach as a model for developing their own standardized approach. KEY POINTS · Trisomy 13 and trisomy 18 are associated with high but variable morbidity and mortality.. · Research on which patients are most likely to benefit from surgery is lacking.. · We present our institution's framework to counsel families with fetal/neonatal T13/T18..
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Affiliation(s)
- Amanda J H Kim
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Mayme Marshall
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Ladawna Gievers
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Tyler Tate
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Sara Taub
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Stephanie Dukhovny
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
| | - Christina Ronai
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Erin J Madriago
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
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St Louis JD, Bhat A, Carey JC, Lin AE, Mann PC, Smith LM, Wilfond BS, Kosiv KA, Sorabella RA, Alsoufi B. The American Association for Thoracic Surgery (AATS) 2023 Expert Consensus Document: Recommendation for the care of children with trisomy 13 or trisomy 18 and a congenital heart defect. J Thorac Cardiovasc Surg 2024; 167:1519-1532. [PMID: 38284966 DOI: 10.1016/j.jtcvs.2023.11.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/27/2023] [Accepted: 11/30/2023] [Indexed: 01/30/2024]
Abstract
OBJECTIVES Recommendations for surgical repair of a congenital heart defect in children with trisomy 13 or trisomy 18 remain controversial, are subject to biases, and are largely unsupported with limited empirical data. This has created significant distrust and uncertainty among parents and could potentially lead to suboptimal care for patients. A working group, representing several clinical specialties involved with the care of these children, developed recommendations to assist in the decision-making process for congenital heart defect care in this population. The goal of these recommendations is to provide families and their health care teams with a framework for clinical decision making based on the literature and expert opinions. METHODS This project was performed under the auspices of the AATS Congenital Heart Surgery Evidence-Based Medicine Taskforce. A Patient/Population, Intervention, Comparison/Control, Outcome process was used to generate preliminary statements and recommendations to address various aspects related to cardiac surgery in children with trisomy 13 or trisomy 18. Delphi methodology was then used iteratively to generate consensus among the group using a structured communication process. RESULTS Nine recommendations were developed from a set of initial statements that arose from the Patient/Population, Intervention, Comparison/Control, Outcome process methodology following the groups' review of more than 500 articles. These recommendations were adjudicated by this group of experts using a modified Delphi process in a reproducible fashion and make up the current publication. The Class (strength) of recommendations was usually Class IIa (moderate benefit), and the overall level (quality) of evidence was level C-limited data. CONCLUSIONS This is the first set of recommendations collated by an expert multidisciplinary group to address specific issues around indications for surgical intervention in children with trisomy 13 or trisomy 18 with congenital heart defect. Based on our analysis of recent data, we recommend that decisions should not be based solely on the presence of trisomy but, instead, should be made on a case-by-case basis, considering both the severity of the baby's heart disease as well as the presence of other anomalies. These recommendations offer a framework to assist parents and clinicians in surgical decision making for children who have trisomy 13 or trisomy 18 with congenital heart defect.
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Affiliation(s)
- James D St Louis
- Department of Surgery, Children's Hospital of Georgia, Augusta University, Augusta, Ga.
| | - Aarti Bhat
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Wash
| | - John C Carey
- Department of Pediatrics, University of Utah Health and Primary Children's Hospital, Salt Lake City, Utah
| | - Angela E Lin
- Department of Pediatrics, Mass General Hospital for Children, Boston, Mass
| | - Paul C Mann
- Department of Surgery, Children's Hospital of Georgia, Augusta University, Augusta, Ga
| | - Laura Miller Smith
- Department of Pediatrics, Oregon Health and Science University, Portland, Ore
| | - Benjamin S Wilfond
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Wash
| | - Katherine A Kosiv
- Department of Pediatrics, Yale University School of Medicine, New Haven, Conn
| | - Robert A Sorabella
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | - Bahaaldin Alsoufi
- Department of Surgery, University of Louisville and Norton Children's Hospital, Louisville, Ky
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Greenberg JW, Kulshrestha K, Ramineni A, Winlaw DS, Lehenbauer DG, Zafar F, Cooper DS, Morales DLS. Contemporary Trends in Cardiac Surgical Care for Trisomy 13 and 18 Patients Admitted to Hospitals in the United States. J Pediatr 2024; 268:113955. [PMID: 38340889 DOI: 10.1016/j.jpeds.2024.113955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 01/26/2024] [Accepted: 02/05/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE To assess rates of cardiac surgery and the clinical and demographic features that influence surgical vs nonsurgical treatment of congenital heart disease (CHD) in patients with trisomy 13 (T13) and trisomy 18 (T18) in the United States. STUDY DESIGN A retrospective study was performed using the Pediatric Health Information System. All hospital admissions of children (<18 years of age) with T13 and T18 in the United States were identified from 2003 through 2022. International Classifications of Disease (ICD) codes were used to identify presence of CHD, extracardiac comorbidities/malformations, and performance of cardiac surgery. RESULTS Seven thousand one hundred thirteen patients were identified. CHD was present in 62% (1625/2610) of patients with T13 and 73% (3288/4503) of patients with T18. The most common CHD morphologies were isolated atrial/ventricular septal defects (T13 40%, T18 42%) and aortic hypoplasia/coarctation (T13 21%, T18 23%). Single-ventricle morphologies comprised 6% (100/1625) of the T13 and 5% (167/3288) of the T18 CHD cohorts. Surgery was performed in 12% of patients with T13 plus CHD and 17% of patients with T18 plus CHD. For all cardiac diagnoses, <50% of patients received surgery. Nonsurgical patients were more likely to be born prematurely (P < .05 for T13 and T18). The number of extracardiac comorbidities was similar between surgical/nonsurgical patients with T13 (median 2 vs 2, P = .215) and greater in surgical vs nonsurgical patients with T18 (median 3 vs 2, P < .001). Hospital mortality was <10% for both surgical cohorts. CONCLUSIONS Patients with T13 or T18 and CHD receive surgical palliation, but at a low prevalence (≤17%) nationally. Given operative mortality <10%, opportunity exists perhaps for quality improvement in the performance of cardiac surgery for these vulnerable patient populations.
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Affiliation(s)
- Jason W Greenberg
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Kevin Kulshrestha
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Aadhyasri Ramineni
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - David S Winlaw
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - David G Lehenbauer
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - David S Cooper
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
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Marçola L, Zoboli I, Polastrini RTV, Barbosa SMDM, Falcão MC, Gaiolla PDV. Patau and Edwards Syndromes in a University Hospital: beyond palliative care. REVISTA PAULISTA DE PEDIATRIA : ORGAO OFICIAL DA SOCIEDADE DE PEDIATRIA DE SAO PAULO 2023; 42:e2023053. [PMID: 38088680 PMCID: PMC10712940 DOI: 10.1590/1984-0462/2024/42/2023053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 09/15/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE To describe the newborn population with Patau (T13) and Edwards Syndrome (T18) with congenital heart diseases that stayed in the Intensive Care Unit (ICU) of a quaternary care hospital complex, regarding surgical and non-surgical medical procedures, palliative care, and outcomes. METHODS Descriptive case series conducted from January/2014 to December/2018 through analysis of records of patients with positive karyotype for T13 or T18 who stayed in the ICU of a quaternary hospital. Descriptive statistics analysis was applied. RESULTS 33 records of eligible patients were identified: 27 with T18 (82%), and 6 T13 (18%); 64% female and 36% male. Eight were preterm infants with gestational age between 30-36 weeks (24%), and only 4 among the 33 infants had a birth weight >2500 g (12%). Four patients underwent heart surgery and one of them died. Intrahospital mortality was 83% for T13, and 59% for T18. The majority had other malformations and underwent other surgical procedures. Palliative care was offered to 54% of the patients. The median hospitalization time for T18 and T13 was 29 days (range: 2-304) and 25 days (13-58), respectively. CONCLUSIONS Patients with T13 and T18 have high morbidity and mortality, and long hospital and ICU stays. Multicentric studies are needed to allow the analysis of important aspects for creating protocols that, seeking therapeutic proportionality, may bring better quality of life for patients and their families.
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Affiliation(s)
- Ligia Marçola
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Ivete Zoboli
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brazil
| | | | | | - Mário Cícero Falcão
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brazil
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Fox MT, Meyer-Macaulay C, Roberts H, Lipsitz S, Siegel BD, Mastropietro C, Graham RJ, Moynihan KM. Tracheostomy Timing During Pediatric Cardiac Intensive Care: Single Referral Center Retrospective Cohort. Pediatr Crit Care Med 2023; 24:e556-e567. [PMID: 37607094 DOI: 10.1097/pcc.0000000000003345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
OBJECTIVES To describe associations between the timing of tracheostomy and patient characteristics or outcomes in the cardiac ICU (CICU). DESIGN Single-institution retrospective cohort study. SETTING Freestanding academic children's hospital. PATIENTS CICU patients with tracheostomy placed between July 1, 2011, and July 1, 2020. INTERVENTIONS We compared patient characteristics and outcomes between early and late tracheostomy based on the duration of positive pressure ventilation (PPV) before tracheostomy placement, fitting a receiver operating characteristic curve for current survival to define a cutoff. MEASUREMENTS AND MAIN RESULTS Sixty-one patients underwent tracheostomy placement (0.5% of CICU admissions). Median age was 7.8 months. Eighteen patients (30%) had single ventricle physiology and 13 patients (21%) had pulmonary vein stenosis (PVS). Primary indications for tracheostomy were pulmonary/lower airway (41%), upper airway obstruction (UAO) (31%), cardiac (15%), neuromuscular (4%), or neurologic (4%). In-hospital mortality was 26% with 41% survival at the current follow-up (median 7.8 [interquartile range, IQR 2.6-30.0] mo). Late tracheostomy was defined as greater than or equal to 7 weeks of PPV which was equivalent to the median PPV duration pre-tracheostomy. Patients with late tracheostomy were more likely to be younger, have single ventricle physiology, and have greater respiratory severity. Patients with early tracheostomy were more likely to have UAO or genetic comorbidities. In multivariable analysis, late tracheostomy was associated with 4.2 times greater mortality (95% CI, 1.9-9.0). PVS was associated with higher mortality (adjusted hazard ratio [HR] 5.2; 95% CI, 2.5-10.9). UAO was associated with lower mortality (adjusted HR 0.2; 95% CI, 0.1-0.5). Late tracheostomy was also associated with greater cumulative opioid exposure. CONCLUSIONS CICU patients who underwent tracheostomy had high in-hospital and longer-term mortality rates. Tracheostomy timing decisions are influenced by indication, disease, genetic comorbidities, illness severity, and age. Earlier tracheostomy was associated with lower sedative use and improved adjusted survival. Tracheostomy placement is a complex decision demanding individualized consideration of risk-benefit profiles and thoughtful family counseling.
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Affiliation(s)
- Miriam T Fox
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Pediatrics, Boston Medical Center, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Colin Meyer-Macaulay
- Division of Cardiac Critical Care, Department of Pediatrics, Nemours Children's Health, Delaware Valley, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Hanna Roberts
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Stuart Lipsitz
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Bryan D Siegel
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Chris Mastropietro
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Robert J Graham
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Anesthesia and Critical Care, Boston Children's Hospital, Boston, MA
| | - Katie M Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
- Faculty of Medicine and Health, Children's Hospital at Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia
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Czosek RJ, Baskar S, Mohan S, Anderson JB, Spar DS. Incidence and outcome of arrhythmias and electrical disease in patients with Trisomy 18. Am J Med Genet A 2023; 191:2518-2523. [PMID: 37303261 DOI: 10.1002/ajmg.a.63324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 05/11/2023] [Accepted: 05/26/2023] [Indexed: 06/13/2023]
Abstract
Patients with Trisomy 18 have a high incidence of cardiac anomalies and are associated with early death. Because of early mortality, electrical system disease and arrhythmia has been difficult to delineate and the incidence remain unknown. We sought to describe the association and clinical outcomes of electrical system disease and cardiac tachy-arrhythmias in patients with Trisomy 18. This was a retrospective, single institutional study. All patients with Trisomy 18 were included in the study. Patient characteristics, congenital heart disease (CHD), conduction system and clinical tachy-arrhythmia data were collected on all patients. Outcomes including cardiac surgical interventions, electrical system interventions and death were collected until the time of study. Patients with tachy-arrhythmias/electrical system involvement were compared to those without to identify potential associated variables. A total of 54 patients with Trisomy 18 were included in analysis. The majority of patients was female and had associated CHD. AV nodal conduction system abnormalities with either first or second degree AV block were common (15%) as was QTc prolongation (37%). Tachy-arrhythmias were common with 22% of patients having at least one form of tachy-arrhythmia and associated with concomitant conduction system disease (p = 0.002). Tachy-arrhythmias were typically treatable with monitoring or medication with eventual resolution without need for procedural intervention. Although early death was common, there were no causes of death associated with tachy-arrhythmia or conduction system disease. In conclusion, patients with Trisomy 18 have a high incidence of conduction system abnormalities and burden of clinical tachy-arrhythmias. Although frequent, electrical system disease did not affect patient outcome or difficultly of care delivery.
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Affiliation(s)
- Richard J Czosek
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Shankar Baskar
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Shaun Mohan
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Kentucky Albert B. Chandler Hospital, Lexington, Kentucky, USA
| | - Jeffrey B Anderson
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - David S Spar
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
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9
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Sullivan RT, Raj JU, Austin ED. Recent Advances in Pediatric Pulmonary Hypertension: Implications for Diagnosis and Treatment. Clin Ther 2023; 45:901-912. [PMID: 37517916 DOI: 10.1016/j.clinthera.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE Pediatric pulmonary hypertension (PH) is a condition characterized by elevated pulmonary arterial pressure, which has the potential to be life-limiting. The etiology of pediatric PH varies. When compared with adult cohorts, the etiology is often multifactorial, with contributions from prenatal, genetic, and developmental factors. This review aims to provide an up-to-date overview of the causes and classification of pediatric PH, describe current therapeutics in pediatric PH, and discuss upcoming and necessary research in pediatric PH. METHODS PubMed was searched for articles relating to pediatric pulmonary hypertension, with a particular focus on articles published within the past 10 years. Literature was reviewed for pertinent areas related to this topic. FINDINGS The evaluation and approach to pediatric PH are unique when compared with that of adults, in large part because of the different, often multifactorial, causes of the disease in children. Collaborative registry studies have found that the most common disease causes include developmental lung disease and subsets of pulmonary arterial hypertension, which includes genetic variants and PH associated with congenital heart disease. Treatment with PH-targeted therapies in pediatrics is often guided by extrapolation of adult data, small clinical studies in pediatrics, and/or expert consensus opinion. We review diagnostic considerations and treatment in some of the more common pediatric subpopulations of patients with PH, including developmental lung diseases, congenital heart disease, and trisomy 21. IMPLICATIONS The care of pediatric patients with PH requires consideration of unique pediatric-specific factors. With significant variability in disease etiology, ongoing efforts are needed to optimize treatment strategies based on disease phenotype and guide evidence-based practices.
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Affiliation(s)
- Rachel T Sullivan
- Department of Pediatrics, Division of Cardiology, Vanderbilt University Medical Center, Monroe Carrell Jr Children's Hospital, Nashville, Tennessee.
| | - J Usha Raj
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois
| | - Eric D Austin
- Department of Pediatrics, Division of Pulmonary Medicine, Vanderbilt University Medical Center, Monroe Carrell Jr Children's Hospital, Nashville, Tennessee
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10
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Glinianaia SV, Rankin J, Tan J, Loane M, Garne E, Cavero-Carbonell C, de Walle HEK, Gatt M, Gissler M, Klungsøyr K, Lelong N, Neville A, Pierini A, Tucker DF, Urhoj SK, Wellesley DG, Morris JK. Ten-year survival of children with trisomy 13 or trisomy 18: a multi-registry European cohort study. Arch Dis Child 2023; 108:461-467. [PMID: 36882305 DOI: 10.1136/archdischild-2022-325068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 02/03/2023] [Indexed: 03/09/2023]
Abstract
OBJECTIVE To investigate the survival to 10 years of age of children with trisomy 13 (T13) and children with trisomy 18 (T18), born 1995-2014. DESIGN Population-based cohort study that linked mortality data to data on children born with T13 or T18, including translocations and mosaicisms, from 13 member registries of EUROCAT, a European network for the surveillance of congenital anomalies. SETTING 13 regions in nine Western European countries. PATIENTS 252 live births with T13 and 602 with T18. MAIN OUTCOME MEASURES Survival at 1 week, 4 weeks and 1, 5 and 10 years of age estimated by random-effects meta-analyses of registry-specific Kaplan-Meier survival estimates. RESULTS Survival estimates of children with T13 were 34% (95% CI 26% to 46%), 17% (95% CI 11% to 29%) and 11% (95% CI 6% to 18%) at 4 weeks, 1 and 10 years, respectively. The corresponding survival estimates were 38% (95% CI 31% to 45%), 13% (95% CI 10% to 17%) and 8% (95% CI 5% to 13%) for children with T18. The 10-year survival conditional on surviving to 4 weeks was 32% (95% CI 23% to 41%) and 21% (95% CI 15% to 28%) for children with T13 and T18, respectively. CONCLUSIONS This multi-registry European study found that despite extremely high neonatal mortality in children with T13 and T18, 32% and 21%, respectively, of those who survived to 4 weeks were likely to survive to age 10 years. These reliable survival estimates are useful to inform counselling of parents after prenatal diagnosis.
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Affiliation(s)
- Svetlana V Glinianaia
- Newcastle University Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Judith Rankin
- Newcastle University Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Joachim Tan
- Population Health Research Institute, St George's University of London, London, UK
| | - Maria Loane
- Centre for Maternal, Fetal and Infant Research, Faculty of Life and Health Sciences, Ulster University, Belfast, UK
| | - Ester Garne
- Department of Paediatrics and Adolescent Medicine, Lillebaelt Hospital - University Hospital of Southern Denmark, Kolding, Denmark
| | - Clara Cavero-Carbonell
- Rare Diseases Research Unit, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region, FISABIO, Valencia, Spain
| | - Hermien E K de Walle
- University Medical Centre Groningen, Department of Genetics, University of Groningen, Groningen, Netherlands
| | - Miriam Gatt
- Malta Congenital Anomalies Registry, Directorate for Health Information and Research, Tal-Pietà, Malta
| | - Mika Gissler
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
- Academic Primary Health Care Centre, Stockholm, Region Stockholm, Sweden
| | - Kari Klungsøyr
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Bergen, Norway
| | - Natalie Lelong
- Université de Paris Cité, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (EPOPé), CRESS, INSERM, Paris, France
| | - Amanda Neville
- IMER Registry (Emilia Romagna Registry of Birth Defects), Centre for Clinical and Epidemiological Research, University of Ferrara, Ferrara, Emilia-Romagna, Italy
| | - Anna Pierini
- Unit of Epidemiology of Rare Diseases and Congenital Anomalies, Institute of Clinical Physiology, National Research Council, Pisa, Toscana, Italy
| | - David F Tucker
- Public Health Wales, Public Health Knowledge and Research, Swansea, Wales, UK
| | - Stine Kjaer Urhoj
- Department of Paediatrics and Adolescent Medicine, Lillebaelt Hospital - University Hospital of Southern Denmark, Kolding, Denmark
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Joan K Morris
- Population Health Research Institute, St George's University of London, London, UK
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11
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Stephens EH, Dearani JA, Connolly HM, Gleich SJ, Deyle DR, Johnson JN. Impact of Genetic Disorders in the Surgical Management of Congenital Heart Disease. World J Pediatr Congenit Heart Surg 2023; 14:201-210. [PMID: 36866650 DOI: 10.1177/21501351221139837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
The congenital heart surgeon frequently encounters patients with various genetic disorders requiring surgical intervention. Although the specifics of the genetics for these patients and their families lie in the purview of specialists in genetics, the surgeon is well-served to be familiar with aspects of specific syndromes that impact surgical management and perioperative care. This aids in counseling families in expectations for the hospital course and recovery as well as can impact intraoperative and surgical management. This review article summarizes key characteristics for the congenital heart surgeon to be familiar with for common genetic disorders as they help coordinate care.
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Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, 6915Mayo Clinic, Rochester, MN, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, 6915Mayo Clinic, Rochester, MN, USA
| | - Stephen J Gleich
- Anesthesiology and Perioperative Medicine, 6915Mayo Clinic, Rochester, MN, USA
| | - David R Deyle
- Department of Clinical Genomics, 6915Mayo Clinic, Rochester, MN, USA
- Department of Pediatric and Adolescent Medicine, 6915Mayo Clinic, Rochester, MN, USA
| | - Jonathan N Johnson
- Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology, 6915Mayo Clinic, Rochester, MN, USA
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12
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Hu RS, Heffernan J, Sims J, Wojcik MH. Trisomy 13: Survival beyond the NICU. Neoreviews 2023; 24:51-56. [PMID: 36587011 PMCID: PMC10184504 DOI: 10.1542/neo.24-1-e51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Trisomy 13 is the third most common autosomal aneuploidy disorder and is associated with a number of congenital malformations. Survival of infants with trisomy 13 has improved over time as life-prolonging technological interventions are more commonly offered. In this article, we describe the course of a child with trisomy 13 who has been followed at our hospital since infancy and explore the changing landscape of care for children with trisomy 13.
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Affiliation(s)
- Rachel S Hu
- Divisions of Newborn Medicine, Boston Children’s Hospital and Harvard Medical School
| | - Jody Heffernan
- Divisions of Newborn Medicine, Boston Children’s Hospital and Harvard Medical School
| | - Jessica Sims
- Divisions of Newborn Medicine, Boston Children’s Hospital and Harvard Medical School
| | - Monica H Wojcik
- Divisions of Newborn Medicine, Boston Children’s Hospital and Harvard Medical School
- Genetics and Genomics, Department of Pediatrics, Boston Children’s Hospital and Harvard Medical School
- Maternal Fetal Care Center, Boston Children’s Hospital, Boston, MA
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13
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Geddes GC, Hafezi N, Gray BW. Misdiagnosis of trisomy 13 and trisomy 18 is more common than anticipated. Am J Med Genet A 2022; 188:3126-3129. [PMID: 35924647 PMCID: PMC9541165 DOI: 10.1002/ajmg.a.62937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/08/2022] [Accepted: 06/21/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Gabrielle C. Geddes
- Department of Medical and Molecular GeneticsIndiana University School of MedicineIndianapolisIndianaUSA
| | - Niloufar Hafezi
- Department of SurgeryIndiana University School of MedicineIndianapolisIndianaUSA
| | - Brian W. Gray
- Department of SurgeryIndiana University School of MedicineIndianapolisIndianaUSA
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14
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Rosenblum JM, Kanter KR, Shashidharan S, Shaw FR, Chai PJ. Cardiac surgery in children with trisomy 13 or trisomy 18: How safe is it? JTCVS OPEN 2022; 12:364-371. [PMID: 36590710 PMCID: PMC9801274 DOI: 10.1016/j.xjon.2022.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 08/04/2022] [Accepted: 09/21/2022] [Indexed: 01/04/2023]
Abstract
Objective Surgery for heart defects in children with trisomy 13 or 18 is controversial. We analyzed our 20-year experience. Methods Since 2002, we performed 21 operations in 19 children with trisomy 13 (n = 8) or trisomy 18 (n = 11). Age at operation was 4 days to 12 years (median, 154 days). Principal diagnosis was ventricular septal defect in 10 patients, tetralogy of Fallot in 7 patients, arch hypoplasia in 1 patient, and patent ductus arteriosus in 1 patient. Results The initial operation was ventricular septal defect closure in 9 patients, tetralogy of Fallot repair in 7 patients, pulmonary artery banding in 1 patient, patent ductus arteriosus ligation in 1 patient, and aortic arch/coarctation repair in 1 patient. There were no operative or hospital deaths. Median postoperative intensive care and hospital stays were 189 hours (interquartile range, 70-548) and 14 days (interquartile range, 8.0-37.0), respectively, compared with median hospital stays in our center for ventricular septal defect repair of 4.0 days and tetralogy of Fallot repair of 5.0 days. On median follow-up of 17.4 months (interquartile range, 6.0-68), 1 patient was lost to follow-up after 5 months. Two patients had reoperation without mortality. There have been 5 late deaths (4 with trisomy 18, 1 with trisomy 13) predominately due to respiratory failure from 4 months to 9.4 years postoperatively. Five-year survival was 66.6% compared with 24% in a group of unoperated patients with trisomy 13 or 18. Conclusions Cardiac operation with an emphasis on complete repair can be performed safely in carefully selected children with trisomy 13 or trisomy 18. Hospital resource use measured by postoperative intensive care and hospital stays is considerably greater compared with nontrisomy 13 and 18.
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Affiliation(s)
- Joshua M. Rosenblum
- Address for reprints: Joshua M. Rosenblum, MD, PhD, Pediatric Cardiac Surgery, Emory University School of Medicine, 1405 Clifton Rd, NE, Atlanta, GA 30322.
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15
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Torbert N, Neumann M, Birge N, Perkins D, Ehrhardt E, Weaver MS. Discipline-Specific Perspectives on Caring for Babies with Trisomy 13 or 18 in the Neonatal Intensive Care Unit. Am J Perinatol 2022; 39:1074-1082. [PMID: 33285605 DOI: 10.1055/s-0040-1721496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Care offerings vary across medical settings and between families for babies with trisomy 13 or 18. The purpose of this qualitative descriptive study was to explore nurse, advanced practice practitioner, and neonatologist perspectives on care for babies with trisomy 13 or 18 in the intensive care unit. STUDY DESIGN Voice-recorded qualitative interviews occurred with 64 participants (41 bedside nurses, 14 advance practice practitioners, and 9 neonatologists) from two neonatal intensive care units (NICU) in the midwestern United States. Consolidated Criteria for Reporting Qualitative Research guidelines were followed. Content analyses occurred utilizing MAXQDA (VERBI Software, 2020). RESULTS Over half of NICU staff perceived care for babies with trisomy 13 or 18 as different from care for other babies with critical chronic illness. Qualitative themes included internal conflict, variable presentation and prognosis, grappling with uncertainty, family experiences, and provision of meaningful care. Neonatologists emphasized the variability of presentation and prognosis, while nurses emphasized provision of meaningful care. Phrases "hard/difficult" were spoken 31 times; primarily describing the comorbidities, complexities, and prognostic uncertainty. CONCLUSION Care for babies with these genetic diagnoses reveals need for a shared dialogue not only with families but also across staff disciplines. While perspectives differ, participants depicted striving to offer compassionate, family-centered care while also balancing biomedical uncertainty about interventions for children with trisomy 13 and 18. KEY POINTS · Care for babies with trisomy 13 or 18 has been recognized as shifting.. · Controversy exists across the diverse and changing range of care models.. · This study describes perspectives of bedside neonatal nurses, advanced practitioners, and neonatologists.. · Differences in perspectives warrant attentiveness to insights and dialogue across disciplines..
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Affiliation(s)
- Nicholas Torbert
- Division of Neonatology, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska
| | - Marie Neumann
- Division of Palliative Care, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska
| | - Nicole Birge
- Division of Neonatology, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska
| | - Donnetta Perkins
- Division of Neonatology, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska
| | - Elizabeth Ehrhardt
- Division of Neonatology, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska
| | - Meaghann S Weaver
- Division of Palliative Care, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska
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16
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Cleary JP, Janvier A, Farlow B, Weaver M, Hammel J, Lantos J. Cardiac Interventions for Patients With Trisomy 13 and Trisomy 18: Experience, Ethical Issues, Communication, and the Case for Individualized Family-Centered Care. World J Pediatr Congenit Heart Surg 2021; 13:72-76. [PMID: 34919485 DOI: 10.1177/21501351211044132] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This report is informed by the themes of the session Trisomy 13/18, Exploring the Changing Landscape of Interventions at NeoHeart 2020-The Fifth International Conference of the Neonatal Heart Society. The faculty reviewed the present evidence in the management of patients and the support of families in the setting of trisomy 13 and trisomy 18 with congenital heart disease. Until recently medical professionals were taught that T13 and 18 were "lethal conditions" that were "incompatible with life" for which measures to prolong life are therefore ethically questionable and likely futile. While the medical literature painted one picture, family support groups shared stories of the long-term survival of children who displayed happiness and brought joy along with challenges to families. Data generated from such care shows that surgery can, in some cases, prolong survival and increase the likelihood of time at home. The authors caution against a change from never performing heart surgery to always-we suggest that the pendulum of intervention find a balanced position where all therapies including comfort care and surgery can be reviewed. Families and clinicians should typically be supported and empowered to define the best care for their children and patients. Key concepts in communication and case vignettes are reviewed including the importance of supportive relationships and the fact that palliative care may serve as an additional layer of support for decision-making and quality of life interventions. While cardiac surgery may be beneficial in some cases, surgery should not be the primary focus of initial family education and support.
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Affiliation(s)
- John P Cleary
- 20209Children's Hospital of Orange County, Orange, CA, USA.,University of California Irvine, Irvine, CA, USA
| | - Annie Janvier
- 5622Université de Montréal, Montréal, QC, Canada.,CHU Sainte-Justine, Clinical Ethics Unit, Unité de recherche en éthique et partenariat famille, Montreal, QC, Canada
| | - Barbara Farlow
- The deVeber Institute for Bioethics and Social Research, North York, ON, Canada
| | - Meaghann Weaver
- 20635Children's Hospital and Medical Center Omaha, Omaha, NE, USA
| | - James Hammel
- 20635Children's Hospital and Medical Center Omaha, Omaha, NE, USA
| | - John Lantos
- 4204Children's Mercy Kansas City and University of Missouri School of Medicine, Kansas City, MO, USA
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17
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Gibelli MABC, de Carvalho WB, Krebs VLJ. Limits of therapeutic intervention in a tertiary neonatal intensive care unit in patients with major congenital anomalies in Brazil. J Paediatr Child Health 2021; 57:1966-1970. [PMID: 34223685 DOI: 10.1111/jpc.15630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/10/2021] [Accepted: 06/16/2021] [Indexed: 11/28/2022]
Abstract
AIM Major congenital anomalies are an important cause of death in the neonatal intensive care unit (NICU). Therapeutic interventions and the suspension of those already in place often raise ethical dilemmas in neonatal care. METHODS We analysed treatments-such as ventilatory support, vasoactive drugs, antibiotics, sedation/or analgesia, central venous access and other invasive procedures-offered up to 48 h before death to all newborns with major congenital anomalies over a 3-year period in a NICU in Brazil. We also gathered information contained in medical records concerning conversations with the families and decisions to limit therapeutic interventions. RESULTS We enrolled 74 newborns who were hospitalised from 1 January 2015 to 31 December 2017. A total of 81.1% had central venous access, 74.3% were on ventilatory support, 56.8% received antibiotics and 43.2% used some sedative/analgesic drugs in their final moments. Conversations were registered in medical records in 76% of cases, and 46% of the families chose therapeutic intervention limits. Those who chose to limit therapeutic interventions asked for less exposure to vasoactive drugs (P = 0.003) and antibiotics (P = 0.003), as well as fewer invasive procedures (P = 0.046). There was no change in ventilatory support (P = 0.66), and palliative extubation was not performed for any patient. CONCLUSIONS The therapeutic intervention was mainly characterised by maintenance of the current treatment when a terminal situation was identified with no introduction of new treatments that could increase suffering. The families' approach proved to be essential for making difficult decisions in the NICU.
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Affiliation(s)
- Maria A B C Gibelli
- Child and Adolescent Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Werther B de Carvalho
- Child and Adolescent Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Vera L J Krebs
- Child and Adolescent Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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18
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Fick TA, Sexson Tejtel SK. Trisomy 18 Trends over the Last 20 Years. J Pediatr 2021; 239:206-211.e1. [PMID: 34363815 DOI: 10.1016/j.jpeds.2021.07.062] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/26/2021] [Accepted: 07/29/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the trends in hospitalizations for children with trisomy 18 over time and to determine the rate of invasive procedures on these children, using a large inpatient database. STUDY DESIGN A retrospective analysis using the Kids' Inpatient Database from 1997 to 2016 was performed for trisomy 18. We evaluated survival to discharge as well as the presence of pulmonary, skeletal, neurologic, gastrointestinal, renal, and hematologic/bleeding problems. We also searched for the following interventions, if performed: gastrostomy tube placement, tracheostomy, or cardiac procedure. RESULTS Over this period 10 151 admissions occurred in children with a diagnosis of trisomy 18. Between 1997 and 2016, the number of children admitted annually with trisomy 18 increased 74% from 1036 to 1798. The proportion of patients born prematurely remained stable at 14%-16% throughout the study. Gastrostomy tube placement increased 12-fold during the study period, tracheostomy increased 11-fold, and cardiac intervention increased 5-fold. The overall mortality rate decreased in those with trisomy 18 from 32% in 1997 to 21% in 2016. CONCLUSIONS We highlight a decreased inpatient mortality rate during the study period. The number of children undergoing interventions such as gastrostomy tube and tracheostomy increased, as did the number of children undergoing cardiac intervention. Although the number of procedures has increased with the mortality rate decreasing, it is unclear at present whether the 2 are related.
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19
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Findley TO, Northrup H. The current state of prenatal detection of genetic conditions in congenital heart defects. Transl Pediatr 2021; 10:2157-2170. [PMID: 34584888 PMCID: PMC8429866 DOI: 10.21037/tp-20-315] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/05/2020] [Indexed: 11/06/2022] Open
Abstract
The incidence of congenital heart defect (CHD) has increased over the past fifty years, partly attributed to routine fetal anatomical examination by sonography during obstetric care and improvements in ultrasound technology and technique. Fetal findings on ultrasound in addition to maternal biomarkers are the backbone of first- and second-trimester screening for common genetic conditions, namely aneuploidy. Since the introduction of non-invasive prenatal testing (NIPT) using next-generation sequencing to sequence cell-free fetal DNA, the detection rate of common trisomies as well as sex chromosomal aneuploidies have markedly increased. As the use of NIPT continues to broaden, the best means of incorporating NIPT into prenatal care is less clear and complicated by misunderstanding of the limitations and non-diagnostic role of NIPT by clinicians and families. In other advancements in prenatal genetic testing, recommendations on the role of chromosomal microarray (CMA) for prenatal diagnosis has led to its increasing use to identify genetic conditions in fetuses diagnosed with CHD. Lastly, as whole exome sequencing (WES) becomes more available and affordable, the next clinical application of next-generation sequencing in prenatal diagnostic testing is on the horizon. While newer genetic tests may provide answers in terms of genetic diagnosis, even more questions will likely ensue for clinicians, researchers, and parents. The objective of this review is to provide the perspective of the evolution of maternal and fetal obstetric care against the backdrop of advancing genetic technology and its impact on families and clinicians.
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Affiliation(s)
- Tina O Findley
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Hope Northrup
- Division of Medical Genetics, Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
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20
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Abstract
This case report shares the story of a family who sought care elsewhere after their daughter was denied cardiac surgery in their home state because she had trisomy 18. This case report recommends case-by-case assessment of cardiac surgical interventions for children with trisomy 13 or 18 as informed by review of goals, assessment of comorbidities, and literature-informed practice. Coordinated care planning and interdisciplinary communication are relevant in cardiac surgical considerations for children with these underlying genetic conditions.
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21
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Weaver MS, Anderson V, Beck J, Delaney JW, Ellis C, Fletcher S, Hammel J, Haney S, Macfadyen A, Norton B, Rickard M, Robinson JA, Sewell R, Starr L, Birge ND. Interdisciplinary care of children with trisomy 13 and 18. Am J Med Genet A 2020; 185:966-977. [PMID: 33381915 DOI: 10.1002/ajmg.a.62051] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 11/21/2020] [Accepted: 12/12/2020] [Indexed: 01/20/2023]
Abstract
Children with trisomy 13 and 18 (previously deemed "incompatible with life") are living longer, warranting a comprehensive overview of their unique comorbidities and complex care needs. This Review Article provides a summation of the recent literature, informed by the study team's Interdisciplinary Trisomy Translational Program consisting of representatives from: cardiology, cardiothoracic surgery, neonatology, otolaryngology, intensive care, neurology, social work, chaplaincy, nursing, and palliative care. Medical interventions are discussed in the context of decisional-paradigms and whole-family considerations. The communication format, educational endeavors, and lessons learned from the study team's interdisciplinary care processes are shared with recognition of the potential for replication and implementation in other care settings.
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Affiliation(s)
- Meaghann S Weaver
- Division of Palliative Care, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Venus Anderson
- Division of Cardiology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jill Beck
- Division of Oncology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jeffrey W Delaney
- Division of Cardiology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Cynthia Ellis
- Division of Developmental Pediatrics, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA.,Munroe-Meyer Institute for Genetics and Rehabilitation, Omaha, Nebraska, USA
| | - Scott Fletcher
- Division of Cardiology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA.,Division of Cardiology, Department of Pediatrics, Creighton University, Omaha, Nebraska, USA
| | - James Hammel
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Suzanne Haney
- Division of Child Advocacy, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Andrew Macfadyen
- Division of Critical Care, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Bridget Norton
- Division of Critical Care, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Mary Rickard
- Division of Neurology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jeffrey A Robinson
- Division of Cardiology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Ryan Sewell
- Division of Otolaryngology, Department of Pediatrics, Children's Hospital and Medical Center and ENT Specialists PC, Omaha, Nebraska, USA
| | - Lois Starr
- Munroe-Meyer Institute for Genetics and Rehabilitation, Omaha, Nebraska, USA.,Division of Genetics, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Nicole D Birge
- Division of Neonatology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
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