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Schubert TJ, Gidding SS, Jones LK. Overcoming the real and imagined barriers to cholesterol screening in pediatrics. J Clin Lipidol 2024:S1933-2874(24)00031-X. [PMID: 38485620 DOI: 10.1016/j.jacl.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/19/2024] [Accepted: 02/21/2024] [Indexed: 03/20/2024]
Abstract
Recent guidance by the United States Preventive Services Task Force has renewed the debate surrounding the benefits of pediatric lipid screening. This commentary reviews the evolution of the pediatric lipid screening recommendations in the United States, followed by an exploration of real and imagined challenges that prevent optimal cholesterol screening rates in children. Real challenges substantively prevent the uptake of these guidelines into practice; imagined challenges, such as identifying the best age to screen, are often context-dependent and can also be surmounted. Experiences from other countries identify potential facilitators to improving screening and additional barriers. Implementation science provides guidance on overcoming the real barriers, translating evidence-based recommendations into clinical practice, and informing the next wave of solutions to overcome these challenges.
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Affiliation(s)
- Tyler J Schubert
- Department of Genomic Health, Geisinger, Danville, PA, USA; Geisinger Commonwealth School of Medicine, Scranton, PA, USA.
| | | | - Laney K Jones
- Department of Genomic Health, Geisinger, Danville, PA, USA; Heart and Vascular Institute, Geisinger, Danville, PA, USA.
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Dickson MA, Zahavich L, Rush J, Hewson S, Chitayat D, McCrindle BW, Chahal N. Exploring Barriers and Facilitators to Indirect Cascade Screening for Familial Hypercholesteraemia in a Paediatric/Parent Population. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:211-218. [PMID: 37970213 PMCID: PMC10642093 DOI: 10.1016/j.cjcpc.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/23/2023] [Indexed: 11/17/2023]
Abstract
Background Familial hypercholesteraemia (FH), an inherited disorder of cholesterol metabolism, has a prevalence of 1:250 and an associated 6- to 22-fold increased risk for cardiovascular disease. Despite the prevalence and availability of effective risk-reduction treatments, 90% of at-risk Canadians are undiagnosed. Indirect cascade screening from an index case is useful but the uptake is low (<4%), suggesting that barriers may exist. Using the Theoretical Domains Framework, we sought to determine barriers and facilitators among parents of children diagnosed with FH that may influence the uptake of cascade screening among families. Methods A qualitative description approach was used for virtual interviews with 10 parents of children with FH, recruited from a regional Lipid Clinic in Toronto, Canada. Semistructured interviews were conducted. The data were analysed using a directed content analysis method. Results Five interconnecting themes were identified that captured both facilitators and barriers of indirect cascade screening: a high level of knowledge about FH after clinic attendance; parents' surprise of their child's diagnosis and ongoing worry; parents' willingness to communicate the need for cholesterol screening; parents' desire for educational materials, dictated by an external vs internal locus of control; and social and societal influences including the lack of awareness about FH in professional and public domains. Conclusions The themes identified will inform next steps in programme development. An urgent need was identified for strategies to educate the public and primary care providers about FH and blood cholesterol/genetic screening.
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Affiliation(s)
- Megan A. Dickson
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
- Department of Genetic Counselling, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Laura Zahavich
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
- Department of Genetic Counselling, Hospital for Sick Children, Toronto, Ontario, Canada
- Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Janet Rush
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Stacy Hewson
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
- Department of Genetic Counselling, Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Chitayat
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- Prenatal Diagnosis and Medical Genetics Program, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Brian W. McCrindle
- Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Nita Chahal
- Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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Khoury M. Cascade Screening in Familial Hypercholesterolemia: Achieving Buy-In and Turning Patients Into Partners. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:219-221. [PMID: 37970215 PMCID: PMC10642102 DOI: 10.1016/j.cjcpc.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/14/2023] [Indexed: 11/17/2023]
Affiliation(s)
- Michael Khoury
- Department of Pediatrics, University of Alberta, Stollery Children’s Hospital, Edmonton, Alberta, Canada
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Perak AM, Baker-Smith C, Hayman LL, Khoury M, Peterson AL, Ware AL, Zachariah JP, Raghuveer G. Toward a Roadmap for Best Practices in Pediatric Preventive Cardiology: A Science Advisory From the American Heart Association. Circ Cardiovasc Qual Outcomes 2023; 16:e000120. [PMID: 37548024 DOI: 10.1161/hcq.0000000000000120] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Cardiovascular disease risk factors are highly prevalent among youth in the United States and Canada. Pediatric preventive cardiology programs have independently developed and proliferated to address cardiovascular risk factors in youth, but there is a general lack of clarity on best practices to optimize and sustain desired outcomes. We conducted surveys of pediatric cardiology division directors and pediatric preventive cardiology clinicians across the United States and Canada to describe the current landscape and perspectives on future directions for the field. We summarize the data and conclude with a call to action for various audiences who seek to improve cardiovascular health in youth, reduce the burden of premature cardiovascular disease, and increase healthy longevity. We call on heart centers, hospitals, payers, and policymakers to invest resources in the important work of pediatric preventive cardiology programs. We urge professional societies to advocate for pediatric preventive cardiology and provide opportunities for training and cross-pollination across programs. We encourage researchers to close evidence gaps. Last, we invite pediatric preventive cardiology clinicians to collaborate and innovate to advance the practice of pediatric preventive cardiology.
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Christian S, Ridsdale R, Lin M, Khoury M. Evaluating the prevalence of lipid assessments in children in Alberta, Canada. CMAJ Open 2023; 11:E820-E825. [PMID: 37726114 PMCID: PMC10516684 DOI: 10.9778/cmajo.20220163] [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: 09/21/2023] Open
Abstract
BACKGROUND Familial hypercholesterolemia is a common, inherited, life-threatening and treatable condition that is characterized by marked elevations of low-density lipoprotein cholesterol (LDL-C), resulting in a high risk of cardiovascular disease, but treatment starting in childhood dramatically reduces this risk. We sought to evaluate the prevalence of pediatric lipid assessments among children in Alberta. METHODS We reviewed laboratory and administrative data from Alberta Health between Apr. 1, 2012, and Dec. 31, 2021. We evaluated 2 pediatric cohorts (children aged 2-10 yr and children aged 9-17 yr) to allow for longitudinal assessments throughout the pediatric period. We also reviewed annual frequencies of lipid assessment for all children between 2013 and 2021. RESULTS Pediatric lipid assessments were performed for 1972 (4.3%) of 46 170 children aged 2-10 years and for 8158 (19.9%) of 40 926 children aged 9-17 years. Female children (aged 2-10 yr) and those living in rural communities were significantly less likely to have a lipid assessment, compared with male children and those in nonrural communities. Among those with lipid assessments, 23 (1.2%) and 86 (1.1%) children aged 2-10 years and 9-17 years, respectively, had an LDL-C level suggestive of probable familial hypercholesterolemia (≥ 4.0 mmol/L). Statin therapy was prescribed in 16 children during the study period. The frequency of lipid assessments was relatively stable, with the exception of a decrease in 2020. INTERPRETATION Rates of pediatric lipid assessment in Alberta are suboptimal. These findings highlight the need to increase awareness of the benefits of early diagnosis and treatment of familial hypercholesterolemia with regard to long-term health and identify and overcome barriers to diagnosis and treatment.
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Affiliation(s)
- Susan Christian
- Department of Medical Genetics (Christian, Risdale) and Department of Pediatrics (Khoury), University of Alberta; Alberta SPOR Support Unit and Provincial Research Data Services (Lin), Alberta Health Services, Edmonton, Alta.
| | - Ross Ridsdale
- Department of Medical Genetics (Christian, Risdale) and Department of Pediatrics (Khoury), University of Alberta; Alberta SPOR Support Unit and Provincial Research Data Services (Lin), Alberta Health Services, Edmonton, Alta
| | - Mu Lin
- Department of Medical Genetics (Christian, Risdale) and Department of Pediatrics (Khoury), University of Alberta; Alberta SPOR Support Unit and Provincial Research Data Services (Lin), Alberta Health Services, Edmonton, Alta
| | - Michael Khoury
- Department of Medical Genetics (Christian, Risdale) and Department of Pediatrics (Khoury), University of Alberta; Alberta SPOR Support Unit and Provincial Research Data Services (Lin), Alberta Health Services, Edmonton, Alta
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Kim GK, Yee JK, Bansal N. Algorithms for Treating Dyslipidemia in Youth. Curr Atheroscler Rep 2023; 25:495-507. [PMID: 37523052 DOI: 10.1007/s11883-023-01122-1] [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] [Accepted: 06/16/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE OF REVIEW The goal of this article is to review algorithms for treating dyslipidemia in youth, discuss pitfalls, propose enhanced algorithms to address pitfalls, and consider future directions. RECENT FINDINGS The presence of modifiable and non-modifiable cardiovascular disease (CVD) risk factors during childhood is associated with CVD-related events in adulthood. Recent data has shown that childhood initiation of statin therapy in youth < 18 years of age with familial hypercholesterolemia reduces the risk of adult CVD. However, pediatric dyslipidemia remains undertreated in part due to a lack of primary health care providers with adequate understanding of screening guidelines and pediatric lipidologists with experience in treatment and follow-up of this unique population. Management algorithms have been published by the National Heart, Lung, and Blood Institute and American Heart Association as tools to empower clinicians to manage dyslipidemia. We propose enhanced algorithms, which incorporate recently approved pharmacotherapy to address the management gaps. Future algorithms based upon clinical risk scores may enhance treatment and improve outcomes. Algorithms for dyslipidemia management which target youth < 18 years of age are tools which empower clinicians to manage dyslipidemia in this unique population. Enhanced algorithms may help address pitfalls. We acknowledge the need for further risk assessment tools in pediatrics for tailored dyslipidemia management.
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Affiliation(s)
- Grace K Kim
- Division of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin St. Ste 1020, Houston, TX, 77030, USA
| | - Jennifer K Yee
- Division of Endocrinology, Department of Pediatrics, Harbor-UCLA Medical Center, The Lundquist Institute of Biomedical Innovation at Harbor-UCLA, Torrance, CA, 90509, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, 90509, USA
| | - Nidhi Bansal
- Division of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin St. Ste 1020, Houston, TX, 77030, USA.
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Khoury M, Bigras JL, Cummings EA, Harris KC, Hegele RA, Henderson M, Morrison KM, St-Pierre J, Wong PD, McCrindle BW. The Detection, Evaluation, and Management of Dyslipidemia in Children and Adolescents: A Canadian Cardiovascular Society/Canadian Pediatric Cardiology Association Clinical Practice Update. Can J Cardiol 2022; 38:1168-1179. [PMID: 35961755 DOI: 10.1016/j.cjca.2022.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/02/2022] [Accepted: 05/05/2022] [Indexed: 12/20/2022] Open
Abstract
Atherosclerosis begins in youth and is directly linked with the presence and severity of cardiovascular risk factors, including dyslipidemia. Thus, the timely identification and management of dyslipidemia in childhood might slow atherosclerotic progression and decrease the risk of cardiovascular disease in adulthood. This is particularly true for children with genetic disorders resulting in marked dyslipidemia, including familial hypercholesterolemia, which remains frequently undiagnosed. Universal and cascade screening strategies can effectively identify cases of pediatric dyslipidemia. In the clinical evaluation of children with dyslipidemia, evaluating for secondary causes of dyslipidemia, including medications and systemic disorders is essential. The first line therapy generally centres around lifestyle modifications, with dietary changes specific to the dyslipidemia phenotype. Indications for medication depend on the severity of dyslipidemia and an individualized assessment of cardiovascular risk. Despite an expanding evidence base supporting the detection and timely management of pediatric dyslipidemia, numerous knowledge gaps remain, including a sufficient evidence base to support more widespread screening, thresholds for initiation of pharmacotherapy, and treatment targets. Further studies on the most appropriate age for statin initiation and long-term safety studies of statin use in youth are also required. The most pressing matter, however, is the development of knowledge translation strategies to improve the screening and detection of lipid disorders in Canadian youth.
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Affiliation(s)
- Michael Khoury
- Division of Pediatric Cardiology, Department of Pediatrics Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada.
| | - Jean-Luc Bigras
- Division of Pediatric Cardiology, Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Elizabeth A Cummings
- Division of Pediatric Endocrinology, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kevin C Harris
- Children's Heart Centre, BC Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert A Hegele
- Department of Medicine, Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Mélanie Henderson
- Department of Pediatrics, Université de Montréal, Montreal, Quebec, Canada; Centre de Recherche CHU Sainte-Justine, Montreal, Quebec, Canada; School of Public Health, Department of Social and Preventive Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Katherine M Morrison
- Centre for Metabolism, Obesity and Diabetes Research, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Julie St-Pierre
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Peter D Wong
- Division of Pediatric Medicine, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Brian W McCrindle
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Khoury M. Measuring cardiovascular risk across the lifespan: when should we start checking and what should we do about it? Can J Cardiol 2022; 38:1141-1143. [PMID: 35489670 DOI: 10.1016/j.cjca.2022.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/15/2022] [Accepted: 04/21/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Michael Khoury
- Department of Pediatrics. University of Alberta. Stollery Children's Hospital.
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