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Dautzenberg L, van Laake LW, Raijman RC, Lefeber GJ, Knol W, Oerlemans MI, Ramjankhan FZ, Braithwaite SA, Nagtegaal MD, Emmelot-Vonk MH, Koek HL. Impairments identified by comprehensive geriatric assessment in potential candidates for left ventricular assist device and heart transplantation. IJC HEART & VASCULATURE 2024; 50:101318. [PMID: 38169976 PMCID: PMC10758860 DOI: 10.1016/j.ijcha.2023.101318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/17/2023] [Accepted: 11/26/2023] [Indexed: 01/05/2024]
Abstract
Background The aim of this study was to assess the prevalence of frailty and other impairments in potential left ventricular assist device (LVAD) and heart transplantation (HTx) candidates by performing a preoperative comprehensive geriatric assessment (CGA) and reviewing the treatment recommendations resulting from the CGA. Methods and results This cross-sectional study included 73 patients aged ≥40 years who received a CGA as part of the patient selection procedure for LVAD and HTx. In every patient, a conclusion comprising frailty and other impairments was formulated based on the medical, mental, functional, and social domains and recommendations were made. The mean age was 58 years (range 40-71) and 70 % were male. In 97 % of patients, at least one impairment was identified by the CGA. The most common impairments were polypharmacy, high morbidity burden, reduced renal function, osteopenia, depression, poor quality of life, reduced functionality, (risk of) malnutrition, reduced grip strength and high caregiver burden. A small proportion of the potential LVAD and HTx candidates were frail (7 % according to Fried's frailty criteria, 6 % according to the Edmonton Frail Scale) and 39 % were pre-frail. The domains for which most impairments were found and the domains for which most treatment recommendations were given matched well, with the functional domain as the frontrunner. Conclusion This study showed that most of the potential candidates for LVAD or HTx have impairments on at least one domain of the CGA. Impairments and associated risks can contribute to the decision making process for candidacy for LVAD and HTx.
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Affiliation(s)
- Lauren Dautzenberg
- Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Linda W. van Laake
- Department of Cardiology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Renee C.M.A. Raijman
- Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Geert J. Lefeber
- Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Wilma Knol
- Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Marish I.F. Oerlemans
- Department of Cardiology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Faiz Z. Ramjankhan
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Susan A. Braithwaite
- Department of Anesthesiology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Mieke D.J. Nagtegaal
- Department of Cardiology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Marielle H. Emmelot-Vonk
- Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Huiberdina L Koek
- Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
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Tournoy TK, Moons P, Daelman B, De Backer J. Biological Age in Congenital Heart Disease-Exploring the Ticking Clock. J Cardiovasc Dev Dis 2023; 10:492. [PMID: 38132660 PMCID: PMC10743752 DOI: 10.3390/jcdd10120492] [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: 11/14/2023] [Revised: 12/08/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023] Open
Abstract
Over the past 50 years, there has been a major shift in age distribution of patients with congenital heart disease (CHD) thanks to significant advancements in medical and surgical treatment. Patients with CHD are, however, never cured and face unique challenges throughout their lives. In this review, we discuss the growing data suggesting accelerated aging in this population. Adults with CHD are more often and at a younger age confronted with age-related cardiovascular complications such as heart failure, arrhythmia, and coronary artery disease. These can be related to the original birth defect, complications of correction, or any residual defects. In addition, and less deductively, more systemic age-related complications are seen earlier, such as renal dysfunction, lung disease, dementia, stroke, and cancer. The occurrence of these complications at a younger age makes it imperative to further map out the aging process in patients across the spectrum of CHD. We review potential feasible markers to determine biological age and provide an overview of the current data. We provide evidence for an unmet need to further examine the aging paradigm as this stresses the higher need for care and follow-up in this unique, newly aging population. We end by exploring potential approaches to improve lifespan care.
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Affiliation(s)
- Tijs K. Tournoy
- Department of Cardiology, Ghent University Hospital, 9000 Ghent, Belgium;
| | - Philip Moons
- KU Leuven Department of Public Health and Primary Care, University of Leuven, 3000 Leuven, Belgium
- Institute of Health and Care Sciences, University of Gothenburg, 405 30 Gothenburg, Sweden
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town 7700, South Africa
| | - Bo Daelman
- KU Leuven Department of Public Health and Primary Care, University of Leuven, 3000 Leuven, Belgium
| | - Julie De Backer
- Department of Cardiology, Ghent University Hospital, 9000 Ghent, Belgium;
- Center for Medical Genetics, Ghent University Hospital, 9000 Ghent, Belgium
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Affiliation(s)
- Sarah Ellison
- Cheshire and Wirral Partnership NHS Foundation Trust, Redesmere, Countess of Chester Health Park, Liverpool Road, Chester, CH2 1BQ, UK
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Vaikunth S, Sundaravel S, Saef J, Ortega-Legaspi J. Novel Therapeutic Strategies in Heart Failure in Adult Congenital Heart Disease: of Medicines and Devices. Curr Heart Fail Rep 2023; 20:401-416. [PMID: 37582901 DOI: 10.1007/s11897-023-00621-1] [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] [Accepted: 07/18/2023] [Indexed: 08/17/2023]
Abstract
PURPOSE OF REVIEW This paper reviews the latest literature on the growing field of heart failure in the adult congenital heart disease population. RECENT FINDINGS After highlighting the increasing prevalence and a few of the unique potential causes, including the concept of early senescence, this review begins with novel medical management strategies such as the angiotensin II receptor blocker and neprilysin inhibitors and sodium glucose cotransporter-2 inhibitors. Then, it addresses the latest applications of percutaneous techniques like implantable hemodynamic monitoring, transcatheter pulmonary and aortic valve replacement, and mitral clips. Cardiac resynchronization therapy and novel lymphatic system imaging and intervention are then described. Finally, the use of mechanical support devices, temporary and durable, is discussed as well as heart and combined heart and liver transplantation. There have been recent exciting advances in the strategies used to manage adult congenital heart disease patients with heart failure. As this population continues to grow, it is likely we will see further rapid evolution in this field.
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Affiliation(s)
- Sumeet Vaikunth
- Philadelphia Adult Congenital Heart Center, Penn Medicine & Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
| | - Swethika Sundaravel
- Advanced Heart Failure Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua Saef
- Philadelphia Adult Congenital Heart Center, Penn Medicine & Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Juan Ortega-Legaspi
- Advanced Heart Failure Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Barcella CA, Christensen DM, Idorn L, Mudalige N, Malmborg M, Folke F, Torp-Pedersen C, Gislason G, El-Chouli M. Outcomes of out-of-hospital cardiac arrest in adult congenital heart disease: a Danish nationwide study. Eur Heart J 2023; 44:3264-3274. [PMID: 37409410 DOI: 10.1093/eurheartj/ehad358] [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: 11/20/2022] [Revised: 03/20/2023] [Accepted: 04/18/2023] [Indexed: 07/07/2023] Open
Abstract
AIMS The risk, characteristics, and outcome of out-of-hospital cardiac arrest (OHCA) in patients with congenital heart disease (CHD) remain scarcely investigated. METHODS AND RESULTS An epidemiological registry-based study was conducted. Using time-dependent Cox regression models fitted with a nested case-control design, hazard ratios (HRs) with 95% confidence intervals of OHCA of presumed cardiac cause (2001-19) associated with simple, moderate, and severe CHD were calculated. Moreover, using multiple logistic regression, we investigated the association between pre-hospital OHCA characteristics and 30-day survival and compared 30-day survival in OHCA patients with and without CHD. Overall, 43 967 cases (105 with simple, 144 with moderate, and 53 with severe CHD) and 219 772 controls (median age 72 years, 68.2% male) were identified. Any type of CHD was found to be associated with higher rates of OHCA compared with the background population [simple CHD: HR 1.37 (1.08-1.70); moderate CHD: HR 1.64 (1.36-1.99); and severe CHD: HR 4.36 (3.01-6.30)]. Pre-hospital cardiopulmonary resuscitation and defibrillation were both associated with improved 30-day survival in patients with CHD, regardless of CHD severity. Among patients with OHCA, simple, moderate, and severe CHD had a similar likelihood of 30-day survival compared with no CHD [odds ratio 0.95 (0.53-1.69), 0.70 (0.43-1.14), and 0.68 (0.33-1.57), respectively]. CONCLUSION A higher risk of OHCA was found throughout the spectrum of CHD. Patients with and without CHD showed the same 30-day survival, which relies on the pre-hospital chain of survival, namely cardiopulmonary resuscitation and defibrillation.
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Affiliation(s)
- Carlo Alberto Barcella
- Department of Cardiology, Copenhagen University Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
- Department of Internal Medicine, Nykøbing Falster Hospital, Fjordvej 15, 4800 Nykøbing Falster, Denmark
| | | | - Lars Idorn
- Department of Pediatric Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Nishan Mudalige
- Health Systems Intelligence Unit, Data Analytics, Reporting and Evaluation, Provincial Health Services Authority, British Columbia, Canada
| | - Morten Malmborg
- Department of Cardiology, Copenhagen University Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Frederik Folke
- Department of Cardiology, Copenhagen University Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
- Emergency Medical Services: The Capital Region of Denmark, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjaellands Hospital, Hillerød, Denmark
- Department of Public Health, University of Copenhagen, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
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Kovacs AH, Lebovic G, Raptis S, Blais S, Caldarone CA, Dahdah N, Dallaire F, Drolet C, Grewal J, Hancock Friesen CL, Hickey E, Karur GR, Khairy P, Leonardi B, Keir M, McCrindle BW, Nadeem SN, Ng MY, Shah AH, Tham EB, Therrien J, Warren AE, Vonder Muhll IF, Van de Bruaene A, Yamamura K, Farkouh ME, Wald RM. Patient-Reported Outcomes After Tetralogy of Fallot Repair. J Am Coll Cardiol 2023; 81:1937-1950. [PMID: 37164527 DOI: 10.1016/j.jacc.2023.03.385] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/01/2023] [Accepted: 03/02/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Comprehensive assessment of tetralogy of Fallot (TOF) outcomes extends beyond morbidity and mortality to incorporate patient-reported outcomes (PROs), including quality of life (QOL) and health status (HS). OBJECTIVES This study explored PROs in adolescents and adults with TOF and delineated variables associated with PROs. METHODS This was a cross-sectional observational study within a larger prospective registry of adolescents and adults with repaired TOF and moderate or greater pulmonary regurgitation from North America, Europe, and Asia. Participants completed PROs, including a QOL linear analogue scale (QOL-LAS) and an HS visual analogue scale (HS-VAS). Scores were classified according to age cohorts: <18, 18 to 25, 26 to 40, and >40 years. RESULTS The study included 607 patients (46.3% female; median age 28.5 years). Median QOL-LAS scores (0-100) were similar across age cohorts (85, 80, 80, 80; P = 0.056). Median HS-VAS scores (0-100) were lowest for the oldest cohort (77) compared with the 3 younger cohorts (85, 80, 80) (P = 0.004). With advancing age, there were increased reports of poor mobility (P < 0.001) and pain or discomfort (P = 0.004); problems in these dimensions were reported by 19.1% and 37.2% of patients aged >40 years, respectively. Of factors associated with superior PROs on multivariable regression modeling (ie, being White, being nonsyndromic, having employment, and having better left ventricular function; P < 0.05), asymptomatic status (functional class I) was the variable associated with the greatest number of QOL and HS measures (P < 0.001). CONCLUSIONS Strategies to improve TOF outcomes should consider PROs alongside conventional clinical variables. Factors associated with poorer PROs represent opportunities to intervene to improve the lives of patients with TOF.
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Affiliation(s)
- Adrienne H Kovacs
- Equilibria Psychological Health, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Gerald Lebovic
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Stavroula Raptis
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Samuel Blais
- Division of Pediatrics, University of Sherbrooke, Sherbrokke, Quebec, Canada; Research Centre of the Sherbrooke University Hospital, Sherbrooke, Quebec, Canada
| | | | - Nagib Dahdah
- Division of Pediatric Cardiology, Sainte-Justine University Hospital Center, Montreal, Quebec, Canada
| | - Frédéric Dallaire
- Division of Pediatrics, University of Sherbrooke, Sherbrokke, Quebec, Canada; Research Centre of the Sherbrooke University Hospital, Sherbrooke, Quebec, Canada
| | - Christian Drolet
- Division of Pediatric and Congenital Cardiology, Department of Pediatrics, Laval University Hospital, Quebec City, Quebec, Canada
| | - Jasmine Grewal
- Yasmin and Amir Virani Provincial Adult Congenital Heart Program, Vancouver, British Columbia, Canada
| | | | - Edward Hickey
- Division of Cardiovascular Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Gauri Rani Karur
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Paul Khairy
- Adult Congenital Center, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Benedetta Leonardi
- Department of Pediatric Cardiology, Cardiac Surgery and Heart Lung Transplantation, Bambino Gesù Hospital and Research Institute, Scientific Institute for Research, Hospitalization, and Health Care, Rome, Italy
| | - Michelle Keir
- Southern Alberta Adult Congenital Heart Disease Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Brian W McCrindle
- Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Syed Najaf Nadeem
- Division of Cardiology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Ming-Yen Ng
- Department of Diagnostic Radiology, School of Clinical Medicine, The University of Hong Kong, Hong Kong; Department of Medical Imaging, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Ashish H Shah
- Division of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Edythe B Tham
- Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Judith Therrien
- MAUDE Unit (McGill University Health Network/Beth Raby Adult Congenital Heart Disease Clinic, Jewish General Hospital), Montreal, Quebec, Canada
| | - Andrew E Warren
- Division of Pediatric Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | | | | | - Michael E Farkouh
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rachel M Wald
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada; Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada; Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel.
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Transcatheter Interventions for Atrioventricular Dysfunction in Patients with Adult Congenital Heart Disease: An International Case Series. J Clin Med 2023; 12:jcm12020521. [PMID: 36675450 PMCID: PMC9864755 DOI: 10.3390/jcm12020521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 12/28/2022] [Accepted: 01/05/2023] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION A substantial proportion of patients with adult congenital heart disease (ACHD) suffer from worsening valvular dysfunction in adulthood. Transcatheter valve interventions can offer a therapeutic alternative to surgery for those at high surgical risk. There is emerging but limited data on transcatheter interventions for atrioventricular (AV) valve dysfunction in patients with ACHD. METHODS We compiled an international collaborative multi-center registry focusing on adult patients with congenital heart disease undergoing transcatheter AV valve interventions (repair or replacement). Included were patients from three international centers who underwent procedures between 2016 and 2022. Demographic, clinical, and procedural data were compiled. RESULTS Nine patients with ACHD underwent AV valve interventions. The median age was 48 years (IQR (37; 56), 55% women). At baseline, seven patients (78%) were in NYHA functional class III and two (22%) were in NYHA functional class II. The diagnosis of ACHD varied. Three valve interventions were performed on the subpulmonary AV valve and six on the systemic AV valve. The primary valvular pathology was regurgitation (six patients, 78%). Five procedures were valve-in-valve interventions, and four procedures were transcatheter edge-to-edge repair procedures. There were no major complications or peri-procedural complications or peri-procedural mortality. One patient developed a suspected non-obstructive thrombus on the valve that was medically treated. One patient did not improve clinically following the procedure and underwent a heart transplant, one patient died 6 months following the procedure due to a cardiovascular implantable electronic device infection. At one year, six patients were in NYHA functional class I, and one patient was in NYHA functional class III. In conclusion, transcatheter AV heart valve interventions are feasible and safe procedures in carefully selected ACHD patients. These procedures can offer an effective treatment option in these younger patients with high surgical risk.
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Steiner JM, Kirkpatrick JN. A view from the end: what the last year of life can teach us about palliative care on the adult congenital heart disease journey. Eur Heart J 2022; 43:4493-4495. [PMID: 36030412 DOI: 10.1093/eurheartj/ehac492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Jill M Steiner
- Division of Cardiology, Department of Medicine & Cambia Palliative Care Center of Excellence, University of Washington, 1959 NE Pacific St., HSB C502, Box 356422 Seattle, WA 98195, USA
| | - James N Kirkpatrick
- Division of Cardiology, Department of Medicine & Department of Bioethics and Humanities, University of Washington, 1959 NE Pacific St., Seattle, WA 98195, USA
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Arvanitaki A. Dyslipidemia in Adult Congenital Heart Disease: Highly Prevalent Although Underdiagnosed. JACC. ADVANCES 2022; 1:100082. [PMID: 38939711 PMCID: PMC11198415 DOI: 10.1016/j.jacadv.2022.100082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Alexandra Arvanitaki
- First Department of Cardiology, Faculty of Health Sciences, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’s NHS Foundation Trust, Imperial College, London, United Kingdom
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10
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Iacobazzi D, Alvino VV, Caputo M, Madeddu P. Accelerated Cardiac Aging in Patients With Congenital Heart Disease. Front Cardiovasc Med 2022; 9:892861. [PMID: 35694664 PMCID: PMC9177956 DOI: 10.3389/fcvm.2022.892861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 04/11/2022] [Indexed: 01/03/2023] Open
Abstract
An increasing number of patients with congenital heart disease (CHD) survive into adulthood but develop long-term complications including heart failure (HF). Cellular senescence, classically defined as stable cell cycle arrest, is implicated in biological processes such as embryogenesis, wound healing, and aging. Senescent cells have a complex senescence-associated secretory phenotype (SASP), involving a range of pro-inflammatory factors with important paracrine and autocrine effects on cell and tissue biology. While senescence has been mainly considered as a cause of diseases in the adulthood, it may be also implicated in some of the poor outcomes seen in patients with complex CHD. We propose that patients with CHD suffer from multiple repeated stress from an early stage of the life, which wear out homeostatic mechanisms and cause premature cardiac aging, with this term referring to the time-related irreversible deterioration of the organ physiological functions and integrity. In this review article, we gathered evidence from the literature indicating that growing up with CHD leads to abnormal inflammatory response, loss of proteostasis, and precocious age in cardiac cells. Novel research on this topic may inspire new therapies preventing HF in adult CHD patients.
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Affiliation(s)
| | | | | | - Paolo Madeddu
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
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