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Toni E, Ayatollahi H, Abbaszadeh R, Fotuhi Siahpirani A. Adverse Drug Reactions in Children with Congenital Heart Disease: A Scoping Review. Paediatr Drugs 2024; 26:519-553. [PMID: 39044096 DOI: 10.1007/s40272-024-00644-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2024] [Indexed: 07/25/2024]
Abstract
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.
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Affiliation(s)
- Esmaeel Toni
- Medical Informatics, Student Research Committee, Iran University of Medical Sciences, Tehran, Iran
| | - Haleh Ayatollahi
- Medical Informatics, Health Management and Economics Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran.
| | - Reza Abbaszadeh
- Pediatric Cardiology, Heart Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Fotuhi Siahpirani
- Department of Bioinformatics, Institute of Biochemistry and Biophysics (IBB), University of Tehran, Tehran, Iran
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Hunter S, Crawford H, Ao BT, Grant C. Methods to Reduce Cost of Treatment in Childhood Bone and Joint Infection: A Systematic Review. JBJS Rev 2024; 12:01874474-202405000-00007. [PMID: 38814570 DOI: 10.2106/jbjs.rvw.24.00043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
BACKGROUND Childhood bone and joint infection (BJI) is a potentially severe disease with consequences for growth and development. Critically unwell children may require prolonged hospitalization and multiple surgeries. Acknowledging rising healthcare costs and the financial impact of illness on caregivers, increased efforts are required to optimize treatment. This systematic review aims to characterize existing costs of hospital care and summarize strategies, which reduce treatment expense. METHODS A systematic review of the literature was performed from January 1, 1980, to January 31, 2024. Data were extracted on hospitalization costs for pediatric BJI by decade and global region. Results have been converted to cost per day in US dollars with purchase parity for 2023. Studies reporting innovations in clinical care to reduce length of stay (LOS) and simplify treatment were identified. Studies trialing shorter antibiotic treatment were only included if they specifically reported changes in LOS. RESULTS Twenty-three studies met inclusion criteria; of these, a daily hospitalization cost could be derived from 7 publications. Overall hospitalization cost and inpatient charges rose steeply from the 1990s to the 2020s. By contrast, average LOS seems to have decreased. Cost per day was higher in the United States than in Europe and higher for cases with confirmed methicillin-resistant Staphylococcus aureus. Sixteen studies report innovations to optimize care. For studies where reduced LOS was achieved, early magnetic resonance imaging with immediate transfer to theater when necessary and discharge on oral antibiotics were consistent features. CONCLUSION Rising costs of hospital care and economic consequences for families can be mitigated by simplifying treatment for childhood BJI. Hospitals that adopt protocols for early advanced imaging and oral antibiotic switch may provide satisfactory clinical outcomes at lower cost. LEVEL OF EVIDENCE Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sarah Hunter
- University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
- Orthopaedic Department, Starship Hospital, Auckland, New Zealand
| | - Haemish Crawford
- University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
- Orthopaedic Department, Starship Hospital, Auckland, New Zealand
| | - Braden Te Ao
- University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
- School of Population Health and Health Economics, University of Auckland, Auckland, New Zealand
| | - Cameron Grant
- University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
- Department of Child and Youth Health, Starship Hospital, Auckland, New Zealand
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Kelleher ST, Kyle WB, Penny DJ, Olsen J, Nolke L, Allen HD, McMahon CJ. Twinning International Pediatric Cardiology Fellowship Programs: A Transformative Educational Experience for Trainees with Potential for Global Adoption. Pediatr Cardiol 2024:10.1007/s00246-024-03469-x. [PMID: 38565665 DOI: 10.1007/s00246-024-03469-x] [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: 11/22/2023] [Accepted: 03/07/2024] [Indexed: 04/04/2024]
Abstract
Over the last decade, having endured the COVID-19 pandemic, education and training in pediatric cardiology have undergone a profound disruptive transformation. Trainees experience considerable stress achieving all the competencies required to become a competent pediatric cardiologist. Often the quality of the training experienced by trainees, the approach to patients, and potential institutional preference in management strategy is heavily influenced by the center in which they train. We developed an online live twin program of education between Texas Children's Hospital, Houston, Texas and Children's Health at Crumlin Dublin Ireland in 2019. We explored using grounded theory whether a regular scheduled shared teaching program improved fellow education and training between both centers. Trainees were surveyed to evaluate the benefits and disadvantages of such a twin program. The majority (93%) found the sessions helpful from an educational standpoint with many trainees reporting it to be a transformative experience. Three important learning themes emerged: practice variation between centers, managing uncertainty in clinical practice and cognitive overload. This pedagogical model could be replicated across multiple international pediatric cardiology units and facilitate "collaborative learning" among centers across the globe. Furthermore, this novel educational model could also be adopted by other medical specialties.
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Affiliation(s)
- Sean T Kelleher
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, 12, Ireland
| | - William B Kyle
- Department Pediatric Cardiology, Texas Children's Hospital, 6621 Fannin Houston, Texas, 77030, USA
| | - Daniel J Penny
- Department Pediatric Cardiology, Texas Children's Hospital, 6621 Fannin Houston, Texas, 77030, USA
| | - Jillian Olsen
- Department Pediatric Cardiology, Texas Children's Hospital, 6621 Fannin Houston, Texas, 77030, USA
| | - Lars Nolke
- Department of Congenital Cardiothoracic Surgery, Children's Health Ireland, Crumlin, Dublin, 12, Ireland
| | - Hugh D Allen
- Department Pediatric Cardiology, Texas Children's Hospital, 6621 Fannin Houston, Texas, 77030, USA
| | - Colin J McMahon
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, 12, Ireland.
- UCD School of Medicine, Belfield, Dublin, 4, Ireland.
- Maastricht School of Health Professions Education, Maastricht, Netherlands.
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Eisenstein EL, Hill KD, Wood N, Kirchner JL, Anstrom KJ, Granger CB, Rao SV, Baldwin HS, Jacobs JP, Jacobs ML, Kannankeril PJ, Graham EM, O'Brien SM, Li JS. Evaluating registry-based trial economics: Results from the STRESS clinical trial. Contemp Clin Trials Commun 2024; 38:101257. [PMID: 38298917 PMCID: PMC10826145 DOI: 10.1016/j.conctc.2024.101257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/18/2023] [Accepted: 01/08/2024] [Indexed: 02/02/2024] Open
Abstract
Background Registry-based trials have the potential to reduce randomized clinical trial (RCT) costs. However, observed cost differences also may be achieved through pragmatic trial designs. A systematic comparison of trial costs across different designs has not been previously performed. Methods We conducted a study to compare the current Steroids to Reduce Systemic inflammation after infant heart surgery (STRESS) registry-based RCT vs. two established designs: pragmatic RCT and explanatory RCT. The primary outcome was total RCT design costs. Secondary outcomes included: RCT duration and personnel hours. Costs were estimated using the Duke Clinical Research Institute's pricing model. Results The Registry-Based RCT estimated duration was 31.9 weeks greater than the other designs (259.5 vs. 227.6 weeks). This delay was caused by the Registry-Based design's periodic data harvesting that delayed site closing and statistical reporting. Total personnel hours were greatest for the Explanatory design followed by the Pragmatic design and the Registry-Based design (52,488 vs 29,763 vs. 24,480 h, respectively). Total costs were greatest for the Explanatory design followed by the Pragmatic design and the Registry-Based design ($10,140,263 vs. $4,164,863 vs. $3,268,504, respectively). Thus, Registry-Based total costs were 32 % of the Explanatory and 78 % of the Pragmatic design. Conclusion Total costs for the STRESS RCT with a registry-based design were less than those for a pragmatic design and much less than an explanatory design. Cost savings reflect design elements and leveraging of registry resources to improve cost efficiency, but delays to trial completion should be considered.
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Affiliation(s)
| | - Kevin D. Hill
- Duke Clinical Research Institute, Durham, NC, USA
- Duke Pediatric and Congenital Heart Center, Durham, NC, USA
| | - Nancy Wood
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Kevin J. Anstrom
- Collaborative Studies Coordinating Center, Chapel Hill, NC, USA
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA
| | | | | | - H. Scott Baldwin
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | | | - Eric M. Graham
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Jennifer S. Li
- Duke Clinical Research Institute, Durham, NC, USA
- Duke Pediatric and Congenital Heart Center, Durham, NC, USA
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Amdani S, Auerbach SR, Bansal N, Chen S, Conway J, Silva JPDA, Deshpande SR, Hoover J, Lin KY, Miyamoto SD, Puri K, Price J, Spinner J, White R, Rossano JW, Bearl DW, Cousino MK, Catlin P, Hidalgo NC, Godown J, Kantor P, Masarone D, Peng DM, Rea KE, Schumacher K, Shaddy R, Shea E, Tapia HV, Valikodath N, Zafar F, Hsu D. Research Gaps in Pediatric Heart Failure: Defining the Gaps and Then Closing Them Over the Next Decade. J Card Fail 2024; 30:64-77. [PMID: 38065308 DOI: 10.1016/j.cardfail.2023.08.026] [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: 02/07/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 01/13/2024]
Abstract
Given the numerous opportunities and the wide knowledge gaps in pediatric heart failure, an international group of pediatric heart failure experts with diverse backgrounds were invited and tasked with identifying research gaps in each pediatric heart failure domain that scientists and funding agencies need to focus on over the next decade.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio.
| | - Scott R Auerbach
- Division of Pediatric Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Neha Bansal
- Division of Pediatric Cardiology, Mount Sinai Kravis Children's Hospital, Icahn School of Medicine, New York, New York
| | - Sharon Chen
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Conway
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Julie Pires DA Silva
- Division of Pediatric Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Jessica Hoover
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio
| | - Kimberly Y Lin
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Shelley D Miyamoto
- Division of Pediatric Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kriti Puri
- Department of Pediatrics, Section of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Jack Price
- Department of Pediatrics, Section of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Joseph Spinner
- Department of Pediatrics, Section of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Rachel White
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph W Rossano
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David W Bearl
- Department of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee
| | - Melissa K Cousino
- Department of Pediatrics, University of Michigan, C. S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Perry Catlin
- Department of Psychology, Marquette University, Milwaukee, Wisconsin
| | - Nicolas Corral Hidalgo
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Justin Godown
- Department of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee
| | - Paul Kantor
- Children's Hospital Los Angeles and the Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital Naples, Naples, Italy
| | - David M Peng
- Department of Pediatrics, University of Michigan, C. S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Kelly E Rea
- Department of Pediatrics, University of Michigan, C. S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Kurt Schumacher
- Department of Pediatrics, University of Michigan, C. S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Robert Shaddy
- Children's Hospital Los Angeles and the Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Erin Shea
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital Naples, Naples, Italy
| | - Henry Valora Tapia
- Division of Pediatric Cardiology, University of Utah. Salt Lake City, Utah
| | - Nishma Valikodath
- Department of Pediatrics, Section of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Daphne Hsu
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
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6
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Shao W, Diao S, Zhou L, Cai L. Milrinone for the treatment of heart failure caused by severe Pneumonia in children with congenital heart disease: a meta-analysis. BMC Pediatr 2023; 23:537. [PMID: 37891490 PMCID: PMC10612214 DOI: 10.1186/s12887-023-04360-z] [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: 12/19/2022] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Children with congenital heart disease (CHD) are easily complicated by severe pneumonia and heart failure. We aimed to conduct a meta-analysis to evaluate the effects and safety of milrinone for the treatment of heart failure caused by severe pneumonia in children with CHD to provide evidence for the clinical CHD treatment. METHODS Two authors searched MEDLINE, PubMed, Embase, Science Direct, Cochrane Central Register of Controlled Trials, the Cochrane Library, Wanfang database, Chinese Biomedical Literature Database, China National Knowledge Infrastructure (CNKI) for randomized controlled trials (RCTs) about the application of milrinone in the treatment of heart failure caused by severe pneumonia in children with CHD in children up to December 10, 2022. Two evaluators independently selected the literature, extracted data and evaluated the methodological quality, meta-analysis was carried out with RevMan 5.3 software. RESULTS Eight RCTs involving 680 CHD children complicated by severe pneumonia and heart failure were included in this meta-analysis. Meta-analysis indicated that total effective rate of the milrinone group was higher than that of control group (RR = 1.25, 95%CI: 1.17 ~ 1.34, P < 0.001), the time to stable heart rate of the milrinone group was less than that of control group (RR=-0.88, 95%CI: -1.09~ -0.67, P < 0.001). The time to stable respiration of the milrinone group was less than that of control group (RR=-0.98, 95%CI: -1.17~ -0.78, P < 0.001). The LVEF of the milrinone group was higher than that of control group (RR = 6.46, 95%CI: 5.30 ~ 7.62, P < 0.001). There was no significant difference in the incidence of adverse reactions between the milrinone group and control group (RR = 0.85, 95%CI: 0.47 ~ 1.56, P = 0.061). Funnel plots and Egger regression test results indicated that there were no statistical publication bias amongst the synthesized outcomes (all P > 0.05). CONCLUSIONS Milrinone is beneficial to improve clinical symptoms and cardiac function and increase the therapeutic effect and safety in children with CHD complicated by severe pneumonia and heart failure. However, more RCTs with large samples and rigorous design are needed to verify this finding.
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Affiliation(s)
- Wenshen Shao
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Shuangshuang Diao
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Lu Zhou
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Lina Cai
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China.
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Yadav S, Ramakrishnan S. Pediatric cardiology: In search for evidence. Ann Pediatr Cardiol 2023; 16:311-315. [PMID: 38766456 PMCID: PMC11098287 DOI: 10.4103/apc.apc_47_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/01/2024] [Accepted: 03/15/2024] [Indexed: 05/22/2024] Open
Affiliation(s)
- Satyavir Yadav
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
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Smeets NJL, Raaijmakers LPM, van der Zanden TM, Male C, de Wildt SN. Guiding future paediatric drug studies based on existing pharmacokinetic and efficacy data: Cardiovascular drugs as a proof of concept. Br J Clin Pharmacol 2023; 89:2888-2901. [PMID: 37160686 DOI: 10.1111/bcp.15781] [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] [Received: 09/13/2022] [Revised: 03/29/2023] [Accepted: 04/13/2023] [Indexed: 05/11/2023] Open
Abstract
INTRODUCTION Off-label drug use in the paediatric population is common, and the lack of high-quality efficacy studies poses patients at risk for failing pharmacotherapy. Next to efficacy studies, pharmacokinetic (PK) studies are increasingly used to inform paediatric dose selection. As resources for paediatric trials are limited, we aimed to summarize existing PK and efficacy studies to identify knowledge gaps in available evidence supporting paediatric dosing recommendations, thereby taking paediatric cardiovascular drugs as proof of concept. METHODS For each cardiovascular drug, paediatric indication and prespecified age group, together comprising one record, the authorized state was assessed. Next, for off-label records, the highest level of evidence was scored. High-quality efficacy studies were defined as meta-analysis or randomized controlled trials. Other comparative research, noncomparative research or consensus-based expert opinions were considered low quality. The level of evidence for PK studies was scored per drug and per age group, but regardless of indication. RESULTS A total of 58 drugs included 417 records, of which 279 (67%) were off-label. Of all off-label records, the majority (81%) were not supported by high-quality efficacy studies, but for 140 of these records (62%) high-quality PK studies were available. CONCLUSION We demonstrated that for the majority of off-label cardiovascular drugs, only low-quality efficacy studies were available. However, high-quality PK studies were frequently available. Combining these PK data with extrapolation of efficacy data from adults may help to close the current information gap and prioritize the drugs for which clinical studies and safety data are urgently needed.
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Affiliation(s)
- Nori J L Smeets
- Department of Pharmacology and Toxicology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Lieke P M Raaijmakers
- Department of Pharmacology and Toxicology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tjitske M van der Zanden
- Department of Pharmacology and Toxicology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Dutch Knowledge Center Pharmacotherapy for Children, The Hague, The Netherlands
| | - Christoph Male
- Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Saskia N de Wildt
- Department of Pharmacology and Toxicology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Dutch Knowledge Center Pharmacotherapy for Children, The Hague, The Netherlands
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Littman E, Hsiao D, Gautham KS. The paucity of high-level evidence for therapy in pediatric cardiology. Ann Pediatr Cardiol 2023; 16:316-321. [PMID: 38766450 PMCID: PMC11098293 DOI: 10.4103/apc.apc_120_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/24/2023] [Accepted: 01/11/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction Clinical practice should be based on the highest quality of evidence available. Therefore, we aimed to classify publications in the field of pediatric cardiology in the year 2021 based on the level of scientific evidence. Materials and Methods A PubMed search was performed to identify pediatric cardiology articles published in the calendar year 2021. The abstract or manuscript of each study was reviewed. Each study was categorized as high, medium, or low level of evidence based on the study design. Disease investigated, treatment studied, and country of publication were recorded. Randomized control trials (RCTs) in similar fields of neonatology and adult cardiology were identified for comparison. Descriptive statistics were performed on the level of evidence, type of disease, country of publication, and therapeutic intervention. Results In 2021, 731 studies were identified. A decrease in prevalence for the level of evidence as a function of low, medium, and high was found (50.1%, 44.2%, and 5.8%, respectively). A low level of evidence studies was the majority for all types of cardiac disease identified, including acquired heart disease, arrhythmias, congenital heart disease, and heart failure, and for treatment modalities, including circulatory support, defibrillator, percutaneous intervention, medicine, and surgery. In a subgroup analysis, most high-level evidence studies were from the USA (31%), followed by China (26.2%) and India (14.3%). Comparing RCTs, 21 RCTs were identified in pediatric cardiology compared to 178 in neonatology and 413 in adult ischemic heart disease. Conclusions There is a great need for the conduct of studies that offer a high level of evidence in the discipline of pediatric cardiology.
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Affiliation(s)
- Emily Littman
- Department of Medicine, University of Central Florida College of Medicine, Orlando, FL, USA
| | - Diana Hsiao
- Department of Medicine, University of Central Florida College of Medicine, Orlando, FL, USA
| | - Kanekal S. Gautham
- Department of Medicine, University of Central Florida College of Medicine, Orlando, FL, USA
- Department of Pediatrics, Nemours Children’s Health System, Orlando, FL, USA
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10
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Schwartz BN, Pearson GD, Burns KM. Multicenter Clinical Research in Congenital Heart Disease: Leveraging Research Networks to Investigate Important Unanswered Questions. Neoreviews 2023; 24:e504-e510. [PMID: 37525311 PMCID: PMC10615178 DOI: 10.1542/neo.24-8-e504] [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: 08/02/2023]
Abstract
Congenital heart disease (CHD) is the most common birth defect in the United States. Neonates with CHD are often cared for by neonatologists in addition to cardiologists. However, there is a paucity of rigorous evidence and limited clinical trials regarding the management of neonates with CHD. In this review, we will describe some of the challenges of research in this field. The Pediatric Heart Network serves as an example of how a research network can effectively overcome barriers to conduct and execute well-designed multicenter studies.
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Affiliation(s)
- Bryanna N Schwartz
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Division of Cardiology, Children's National Hospital, Washington, DC
| | - Gail D Pearson
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Kristin M Burns
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Division of Cardiology, Children's National Hospital, Washington, DC
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Bogle C, Colan SD, Miyamoto SD, Choudhry S, Baez-Hernandez N, Brickler MM, Feingold B, Lal AK, Lee TM, Canter CE, Lipshultz SE. Treatment Strategies for Cardiomyopathy in Children: A Scientific Statement From the American Heart Association. Circulation 2023; 148:174-195. [PMID: 37288568 DOI: 10.1161/cir.0000000000001151] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
This scientific statement from the American Heart Association focuses on treatment strategies and modalities for cardiomyopathy (heart muscle disease) in children and serves as a companion scientific statement for the recent statement on the classification and diagnosis of cardiomyopathy in children. We propose that the foundation of treatment of pediatric cardiomyopathies is based on these principles applied as personalized therapy for children with cardiomyopathy: (1) identification of the specific cardiac pathophysiology; (2) determination of the root cause of the cardiomyopathy so that, if applicable, cause-specific treatment can occur (precision medicine); and (3) application of therapies based on the associated clinical milieu of the patient. These clinical milieus include patients at risk for developing cardiomyopathy (cardiomyopathy phenotype negative), asymptomatic patients with cardiomyopathy (phenotype positive), patients with symptomatic cardiomyopathy, and patients with end-stage cardiomyopathy. This scientific statement focuses primarily on the most frequent phenotypes, dilated and hypertrophic, that occur in children. Other less frequent cardiomyopathies, including left ventricular noncompaction, restrictive cardiomyopathy, and arrhythmogenic cardiomyopathy, are discussed in less detail. Suggestions are based on previous clinical and investigational experience, extrapolating therapies for cardiomyopathies in adults to children and noting the problems and challenges that have arisen in this experience. These likely underscore the increasingly apparent differences in pathogenesis and even pathophysiology in childhood cardiomyopathies compared with adult disease. These differences will likely affect the utility of some adult therapy strategies. Therefore, special emphasis has been placed on cause-specific therapies in children for prevention and attenuation of their cardiomyopathy in addition to symptomatic treatments. Current investigational strategies and treatments not in wide clinical practice, including future direction for investigational management strategies, trial designs, and collaborative networks, are also discussed because they have the potential to further refine and improve the health and outcomes of children with cardiomyopathy in the future.
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Harahsheh AS, Portman MA, Khoury M, Elias MD, Lee S, Lin J, McCrindle BW. Management of Multisystem Inflammatory Syndrome in Children: Decision-Making Regarding a New Condition in the Absence of Clinical Trial Data. Can J Cardiol 2023; 39:803-814. [PMID: 36455760 PMCID: PMC9705008 DOI: 10.1016/j.cjca.2022.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022] Open
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is a new illness that evolved during the COVID-19 pandemic with initial reports of severe disease including use of extracorporeal membrane oxygenation and death. Institutions rapidly assembled task forces to develop treatment algorithms. At the national/international levels, collaboratives and associations assembled consensus writing groups to draft guidelines. These guidelines and algorithms were initially on the basis of expert opinion and small case series. Some groups used the Delphi approach, and the resultant guidelines often mimicked those for other conditions that resembled MIS-C, like Kawasaki disease (KD). For instance, intravenous immunoglobulin (IVIG), a known effective treatment for KD, was recommended for MIS-C. Early in the pandemic many favoured IVIG over steroids as first-line therapy. As evidence evolved so did some guidelines, which now endorse the dual use of IVIG with steroids as first-line therapy. In contrast, withholding immunotherapy became an option for some MIS-C patients with mild symptoms. Herein, we review guidelines and discuss the evidence informing early recommendations, how this has evolved, the role and limitations of expert opinion and observational data, and the importance of leveraging existing research infrastructures, such as the intensive care unit collaborative (Overcoming COVID-19 surveillance registry), and the International Kawasaki Disease Registry. Finally, we discuss strategies to rapidly develop, deploy, and adapt clinical trials evaluating the treatment of such rare conditions in children, which might include alternatives to conventional clinical trial design. The emergence of MIS-C during the COVID-19 pandemic has highlighted unmet needs regarding research of a new condition.
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Affiliation(s)
- Ashraf S Harahsheh
- Division of Cardiology, Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | | | - Michael Khoury
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew D Elias
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Simon Lee
- The Heart Center at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Justin Lin
- Labatt Family Heart Centre, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Brian W McCrindle
- Labatt Family Heart Centre, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
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Zhaori G. A new column in this journal - Forum on Clinical Investigation. Pediatr Investig 2023; 7:147-149. [PMID: 37324597 PMCID: PMC10262868 DOI: 10.1002/ped4.12378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 04/19/2023] [Indexed: 06/17/2023] Open
Affiliation(s)
- Getu Zhaori
- Editorial OfficePediatric InvestigationBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
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Fite EL, Rivera BK, McNabb R, Smith CV, Hill KD, Katheria A, Maitre N, Backes CH. Umbilical cord clamping among infants with a prenatal diagnosis of congenital heart disease. Semin Perinatol 2023; 47:151747. [PMID: 37002126 DOI: 10.1016/j.semperi.2023.151747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Elliott L Fite
- Ohio Perinatal Research Network (OPRN), The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Brian K Rivera
- Ohio Perinatal Research Network (OPRN), The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Riley McNabb
- Ohio Perinatal Research Network (OPRN), The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Charles V Smith
- Center for Integrated Brain Research, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA, USA
| | - Kevin D Hill
- Duke University Pediatric and Congenital Heart Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Anup Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA
| | - Nathalie Maitre
- Emory University School of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Carl H Backes
- Ohio Perinatal Research Network (OPRN), The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Departments of Pediatrics and Obstetrics & Gynecology, The Ohio State University, Columbus, OH, USA.
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Pediatric Heart Network Trial of Losartan vs. Atenolol in Children and Young Adults with Marfan Syndrome: Impact on Prescription Practices. Pediatr Cardiol 2023; 44:618-623. [PMID: 35902413 DOI: 10.1007/s00246-022-02976-z] [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: 04/04/2022] [Accepted: 07/11/2022] [Indexed: 10/16/2022]
Abstract
The Pediatric Heart Network (PHN) trial showed similar efficacy of β-blockers (BB) and angiotensin receptor blockers (ARB) for aortic root dilation in Marfan syndrome, but the impact on prescription practices is unknown. We hypothesized BB and ARB prescriptions would increase after the trial results were published (2014). Prescription data (2007-2016) were obtained from outpatient encounters (IBM Marketscan) for Marfan syndrome patients (6 months-25 years old). Excluding 2014 as a washout period, we analyzed two intervals: 2007-2013 and 2015-2016. Medication categories included BB, ARB, angiotensin converting enzyme inhibitors (ACEI), combination (BB/ARB and/or BB/ACEI), and no drug. Interrupted time-series analysis assessed immediate level change after publication and change in slope for the trend pre- and post-publication. Odds ratios (OR) and 95% confidence intervals from logistic regressions and generalized estimating equation methods accounted for correlation of prescriptions within patients. In 1499 patients (age 14.1 ± 6.1 years, 59% female) seen 2007-2013, BB trended lower [OR 0.91 (0.89, 0.93), p < 0.001] and ARB trended higher [OR 1.12 (1.07, 1.18), p < 0.001], while combination, ACEI, and no drug remained stable. This trend persisted, but was not significant, for BB [OR 0.54 (0.27, 1.08), p = 0.37] and ARB [OR 1.91 (0.55, 6.69), p = 0.31] in 2015-2016. Combination, ACEI, and no drug remained similar. In short term follow-up, changes in prescription practices following publication of the PHN trial were not statistically significant. This may be due to a change seen prior to publication with early adoption of ARBs that was maintained after confirmation of their effectiveness.
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Van den Eynde J, Manlhiot C, Van De Bruaene A, Diller GP, Frangi AF, Budts W, Kutty S. Medicine-Based Evidence in Congenital Heart Disease: How Artificial Intelligence Can Guide Treatment Decisions for Individual Patients. Front Cardiovasc Med 2021; 8:798215. [PMID: 34926630 PMCID: PMC8674499 DOI: 10.3389/fcvm.2021.798215] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 11/09/2021] [Indexed: 01/06/2023] Open
Abstract
Built on the foundation of the randomized controlled trial (RCT), Evidence Based Medicine (EBM) is at its best when optimizing outcomes for homogeneous cohorts of patients like those participating in an RCT. Its weakness is a failure to resolve a clinical quandary: patients appear for care individually, each may differ in important ways from an RCT cohort, and the physician will wonder each time if following EBM will provide best guidance for this unique patient. In an effort to overcome this weakness, and promote higher quality care through a more personalized approach, a new framework has been proposed: Medicine-Based Evidence (MBE). In this approach, big data and deep learning techniques are embraced to interrogate treatment responses among patients in real-world clinical practice. Such statistical models are then integrated with mechanistic disease models to construct a “digital twin,” which serves as the real-time digital counterpart of a patient. MBE is thereby capable of dynamically modeling the effects of various treatment decisions in the context of an individual's specific characteristics. In this article, we discuss how MBE could benefit patients with congenital heart disease, a field where RCTs are difficult to conduct and often fail to provide definitive solutions because of a small number of subjects, their clinical complexity, and heterogeneity. We will also highlight the challenges that must be addressed before MBE can be embraced in clinical practice and its full potential can be realized.
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Affiliation(s)
- Jef Van den Eynde
- Department of Cardiovascular Sciences, KU Leuven and Congenital and Structural Cardiology, UZ Leuven, Leuven, Belgium.,Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, The Johns Hopkins Hospital and School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Cedric Manlhiot
- Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, The Johns Hopkins Hospital and School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Alexander Van De Bruaene
- Department of Cardiovascular Sciences, KU Leuven and Congenital and Structural Cardiology, UZ Leuven, Leuven, Belgium
| | - Gerhard-Paul Diller
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - Alejandro F Frangi
- Department of Cardiovascular Sciences, KU Leuven and Congenital and Structural Cardiology, UZ Leuven, Leuven, Belgium.,Centre for Computational Imaging and Simulation Technologies in Biomedicine (CISTIB), School of Computing and Medicine, University of Leeds, Leeds, United Kingdom.,Leeds Institute for Cardiovascular and Metabolic Medicine, Schools of Medicine, University of Leeds, Leeds, United Kingdom
| | - Werner Budts
- Department of Cardiovascular Sciences, KU Leuven and Congenital and Structural Cardiology, UZ Leuven, Leuven, Belgium
| | - Shelby Kutty
- Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, The Johns Hopkins Hospital and School of Medicine, Johns Hopkins University, Baltimore, MD, United States
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