Ethnic and socioeconomic variation in incidence of congenital heart defects

Socioeconomic Status and Access to Care for Pediatric and Adult Congenital Heart Disease in Universal Health Coverage Models

Congenital heart disease (CHD) is the most common major congenital anomaly, affecting one in every 100 live births. Whereas over 90% of children born with CHD in low- and middle-income countries cannot access the care they need, early detection, advances in management, and financial risk protection have resulted in over 90% of children with CHD in high-income countries surviving into adulthood. Despite the presence of universal health coverage, barriers to accessing high-quality cardiovascular and non-cardiovascular care for CHD remain common. Lower socioeconomic status has been associated with differential access to cardiac care and poorer outcomes across multiple cardiovascular conditions and subspecialties. In this review article, we describe the relationship between socioeconomic status and access to CHD care in countries with universal health coverage models. We further evaluate notable challenges and opportunities to improve equitable, high-quality CHD care in these countries.

Enhancing discharge preparation for parents after complex cardiac surgery: evaluation of an e-learning resource for nurses

Parents need to be appropriately prepared by knowledgeable healthcare professionals before going home with their infant following cardiac surgery for complex congenital heart disease (CHD). A quality improvement project was undertaken between 2018 and 2021 to equip healthcare professionals including children's cardiac nurses with the knowledge required to use the Congenital Heart Assessment Tool (CHAT) to teach parents how to monitor their infant at home. The project involved developing, implementing and evaluating an e-learning resource that included simulated scenarios captured on video. An online survey showed that users perceived the e-learning resource as having a positive effect on their understanding of complex CHD and their practice of preparing parents for discharge and home monitoring.

Racial, ethnic, and socio-economic disparities in neonatal ICU admissions among neonates born with cyanotic CHD in the United States, 2009-2018

INTRODUCTION

Disparities in CHD outcomes exist across the lifespan. However, less is known about disparities for patients with CHD admitted to neonatal ICU. We sought to identify sociodemographic disparities in neonatal ICU admissions among neonates born with cyanotic CHD.

MATERIALS & METHODS

Annual natality files from the US National Center for Health Statistics for years 2009-2018 were obtained. For each neonate, we identified sex, birthweight, pre-term birth, presence of cyanotic CHD, and neonatal ICU admission at time of birth, as well as maternal age, race, ethnicity, comorbidities/risk factors, trimester at start of prenatal care, educational attainment, and two measures of socio-economic status (Special Supplemental Nutrition Program for Women, Infants, and Children [WIC] status and insurance type). Multivariable logistic regression models were fit to determine the association of maternal socio-economic status with neonatal ICU admission. A covariate for race/ethnicity was then added to each model to determine if race/ethnicity attenuate the relationship between socio-economic status and neonatal ICU admission.

RESULTS

Of 22,373 neonates born with cyanotic CHD, 77.2% had a neonatal ICU admission. Receipt of WIC benefits was associated with higher odds of neonatal ICU admission (adjusted odds ratio [aOR] 1.20, 95% CI 1.1-1.29, p < 0.01). Neonates born to non-Hispanic Black mothers had increased odds of neonatal ICU admission (aOR 1.20, 95% CI 1.07-1.35, p < 0.01), whereas neonates born to Hispanic mothers were at lower odds of neonatal ICU admission (aOR 0.84, 95% CI 0.76-0.93, p < 0.01).

CONCLUSION

Maternal Black race and low socio-economic status are associated with increased risk of neonatal ICU admission for neonates born with cyanotic CHD. Further work is needed to identify the underlying causes of these disparities.

Effect of Maternal Race, Residential Rurality, and Social Vulnerability on Critical Congenital Heart Defect Risk

The development of a congenital heart defect (CHD) is multifactorial, with many cases having an unknown etiology. This study explored whether maternal race and lived environment were associated with an infant being born with a critical CHD. A cross-sectional, case-control design was conducted utilizing secondary data analysis. The CHD group (N = 199) consisted of infants diagnosed with a critical CHD within the first year of life identified from hospital databases. The non-CHD group (N = 548) was a random sample of infants selected from the state's vital statistics database. The primary outcome was a critical CHD diagnosis. Maternal race, residential rurality, and the Social Vulnerability Index (SVI) were assessed for associations with a critical CHD using bivariate and multilevel regression models. Bivariate findings reported significance among residential rurality (p < 0.001), SVI ranking overall (p = 0.017), and SVI by theme (theme 1 p =  0.004, theme 2 p < 0.001, theme 3 p = 0.007, and theme 4 p = 0.049) when comparing infants with and without a critical CHD diagnosis. Results of multilevel logistic regression analyses further identified living in a rural residential area compared to urban areas (OR = 7.32; p < 0.001) as a predictor for a critical CHD diagnosis. The findings of lived environmental level associations provides information needed for continued investigation as the burden of a critical CHD continues to impact families, suggesting further research efforts are needed to improve health disparities.

Disparities in resource utilisation by families of children with cardiac conditions

OBJECTIVES

There are limited data documenting sources of medical information that families use to learn about paediatric cardiac conditions. Our study aims to characterise these resources and to identify any disparities in resource utilisation. We hypothesise there are significant variations in the resources utilised by families from different educational and socio-economic backgrounds.

METHODS

A survey evaluating what resources families use (websites, healthcare professionals, social media, etc.) to better understand paediatric cardiac conditions was administered to caretakers and paediatric patients at Morgan Stanley Children's Hospital. Patients with a prior diagnosis of CHD, cardiac arrhythmia, and/or heart failure were included. Caretakers' levels of education (fewer than 16 years vs. 16 years or more) and patients' medical insurance types (public vs. private) were compared with regard to the utilisation of resources.

RESULTS

Surveys completed by 137 (91%) caretakers and 27 (90%) patients were analysed. Websites were utilised by 72% of caretakers and 56% of patients. Both private insurance and higher education were associated with greater reported utilisation of websites, healthcare professionals, and personal networks (by insurance p = 0.009, p = 0.001, p = 0.006; by education p = 0.022, p < 0.001, p = 0.018). They were also more likely to report use of electronic devices (such as a computer) compared to those with public medical insurance and fewer than 16 years of education (p < 0.001, p < 0.001, respectively).

CONCLUSION

Both levels of education and insurance status are associated with the utilisation of informative resources and digital devices by families seeking to learn more about cardiac conditions in children.

Sociodemographic factors associated with paediatric out-of-hospital cardiac arrest: A systematic review

BACKGROUND

Paediatric out-of-hospital cardiac arrest (POHCA) is associated with poor survival and severe neurological sequelae. We conducted a systematic review on the impact of sociodemographic factors across different stages of POHCA.

METHODS

We searched MEDLINE, EMBASE, and Web of Science from database inception to October 2022. We included studies examining the association between sociodemographic factors (i.e., race, ethnicity, migrant status and socioeconomic status [SES]) and POHCA risk, bystander cardiopulmonary resuscitation (CPR) provision, bystander automated external defibrillator (AED) application, survival (at or 30-days post-discharge), and neurological outcome. We synthesized the data qualitatively.

RESULTS

We screened 11,097 citations and included 18 articles (arising from 15 studies). There were 4 articles reporting on POHCA risk, 5 on bystander CPR provision, 3 on bystander AED application, 13 on survival, and 6 on neurological outcome. In all studies on POHCA risk, significant differences were found across racial groups, with minority populations being disproportionately impacted. There were no articles reporting on the association between SES and POHCA risk. Bystander CPR provision was consistently associated with race and ethnicity, with disparities impacting Black and Hispanic children. The association between bystander CPR provision and SES was variable. There was little evidence of socioeconomic or racial disparities in studies on bystander AED application, survival, and neurological outcome, particularly across adjusted analyses.

CONCLUSIONS

Race and ethnicity are likely associated with POHCA risk and bystander CPR provision. These findings highlight the importance of prioritizing at-risk groups in POHCA prevention and intervention efforts. Further research is needed to understand underlying mechanisms.

Cardiac findings in newborn twins

AIMS

To evaluate cardiac findings in newborn twins from the general population and investigate if newborn twins may require systematic evaluation of cardiac parameters.

METHODS

Prospective cohort study of newborns with cardiac evaluation performed during the first month of life. Cardiac findings were compared 1:3 with matched singletons.

RESULTS

We included 412 newborn twins (16% monochorionic; 50% boys) and 1236 singletons. Comparing cardiac findings showed twins had an increased prevalence of non-severe structural heart disease (most common: ventricular septal defects in both groups), thinner left ventricular posterior wall in diastole (LVPWd; 1.82 vs. 1.87 mm, p = 0.02), smaller diameter of the left atrium (10.6 vs. 11.1 mm, p = 0.04), higher heart rate (148 vs. 144 bpm, p = 0.04), more left-shifted QRS axis (106 vs. 111°, p < 0.001), and lower maximum R-wave amplitude in V1 (927 vs. 1015 μV, p = 0.02) compared to singletons. After multifactorial adjustment for potential confounders, the effect of twinning on cardiac parameters persisted only for LVPWd (p < 0.05).

CONCLUSION

Despite contemporary surveillance, we found an increased prevalence of non-severe structural heart disease in a population-based cohort of newborn twins. However, the effect of twinning on cardiac parameters was modest and generally did not persist after correction for likely confounding factors.

Characteristics, treatments and survival of pulmonary arterial hypertension associated with congenital heart disease in China: Insights from a national multicenter prospective registry

BACKGROUND

The purpose of this registry was to provide insights into the characteristics, treatments and survival of patients with PAH-CHD in China.

METHODS

Patients diagnosed with PAH-CHD were enrolled in this national multicenter prospective registry. Baseline and follow-up data on clinical characteristics, PAH-targeted treatments and survival were collected.

RESULTS

A total of 1060 PAH-CHD patients (mean age 31 years; 67.9% females) were included, with Eisenmenger syndrome (51.5%) being the most common form and atrial septal defects (37.3%) comprising the most frequent underlying defect. Approximately 33.0% of the patients were in World Health Organization functional class III to IV. The overall mean pulmonary arterial pressure and pulmonary vascular resistance were 67.1 (20.1) mm Hg and 1112.4 (705.9) dyn/s/cm5, respectively. PAH-targeted therapy was utilized in 826 patients (77.9%), and 203 patients (19.1%) received combination therapy. The estimated 1-, 3-, 5-, and 10-year survival rates of the overall cohort were 96.9%, 92.9%, 87.6% and 73.0%, respectively. Patients received combination therapy had significantly better survival than those with monotherapy (p = 0.016). NT-proBNP >1400 pg/ml, SvO2 ≤ 65% and Borg dyspnea index ≥ 3 and PAH-targeted therapy were independent predictors of mortality. Hemoglobin > 160g/L was a unique predictor for mortality in Eisenmenger syndrome.

CONCLUSIONS

Chinese PAH-CHD patients predominantly exhibit Eisenmenger syndrome and have significantly impaired exercise tolerance and right ventricular function at diagnosis, which are closely associated with long-term survival. PAH-targeted therapy including combination therapy showed a favorable effect on survival in PAH-CHD. The long-term survival of Chinese CHD-PAH patients remains to be improved.

Case-control association study of congenital heart disease from a tertiary paediatric cardiac centre from North India

BACKGROUND

Congenital Heart diseases (CHDs) account for 1/3rd of all congenital birth defects. Etiopathogenesis of CHDs remain elusive despite extensive investigations globally. Phenotypic heterogeneity witnessed in this developmental disorder reiterate gene-environment interactions with periconceptional factors as risk conferring; and genetic analysis of both sporadic and familial forms of CHD suggest its multigenic basis. Significant association of de novo and inherited variants have been observed. Approximately 1/5th of CHDs are documented in the ethnically distinct Indian population but genetic insights have been very limited. This pilot case-control based association study was undertaken to investigate the status of Caucasian SNPs in a north Indian cohort.

METHOD

A total of 306 CHD cases sub-classified into n = 198 acyanotic and n = 108 cyanotic types were recruited from a dedicated tertiary paediatric cardiac centre in Palwal, Haryana. 23 SNPs primarily prioritized from Genome-wide association studies (GWAS) on Caucasians were genotyped using Agena MassARRAY Technology and test of association was performed with adequately numbered controls.

RESULTS

Fifty percent of the studied SNPs were substantially associated in either allelic, genotypic or sub-phenotype categories validating their strong correlation with disease manifestation. Of note, strongest allelic association was observed for rs73118372 in CRELD1 (p < 0.0001) on Chr3, rs28711516 in MYH6 (p = 0.00083) and rs735712 in MYH7 (p = 0.0009) both on Chr 14 and were also significantly associated with acyanotic, and cyanotic categories separately. rs28711516 (p = 0.003) and rs735712 (p = 0.002) also showed genotypic association. Strongest association was observed with rs735712(p = 0.003) in VSD and maximum association was observed for ASD sub-phenotypes.

CONCLUSIONS

Caucasian findings were partly replicated in the north Indian population. The findings suggest the contribution of genetic, environmental and sociodemographic factors, warranting continued investigations in this study population.

Association between maternal marginalization and infants born with congenital heart disease in Ontario Canada

BACKGROUND

This study aims to evaluate the impact of socioeconomic status (SES) on the risk of congenital heart disease (CHD) since previous studies have yielded inconsistent results.

METHODS

We conducted a population-based retrospective cohort study, including all singleton live and still births in Ontario hospitals from April 1, 2012, to March 31, 2018. We used linked records from the Better Outcomes Registry & Network Information System, the Canadian Institute for Health Information databases, and the Ontario Marginalization Index (ON_Marg). ON_Marg was estimated at a dissemination area level using Canadian Census 2016 data and categorized into quintiles. Multivariable logistic regression models were performed to examine the relationships between four ON_Marg indices (material deprivation, dependency, ethnic concentration, residential instability), as proxies for maternal SES and the risk of infant CHD. We adjusted for maternal age at birth, assisted reproductive technology, obesity, pre-existing health conditions, substance use during pregnancy, mental health conditions before and during pregnancy, rural residence, and infant's sex in the analysis.

RESULTS

Among the cohort of 776,799 singletons, 9,359 infants had a diagnosis of CHD. Of those, 3,069 were severe CHD and 493 cases were single ventricle CHD. The prevalence of all infant CHD types was higher for males relative to females. Compared to mothers living in neighbourhoods with the lowest material deprivation, mothers with highest material deprivation had a 27% (adjusted OR = 1.27; 95% CI: 1.18-1.37) higher odds of having an infant diagnosed with CHD. Mothers living in neighbourhoods with the highest minority ethnic and immigrant concentration tend to have infants with 11% lower odds of CHD (adjusted OR = 0.89; 95% CI: 0.82-0.97) as compared to those living in the least ethnically diverse communities. Maternal dependency and residential stability quintiles were not significantly associated with the risk of CHD.

CONCLUSION

Higher maternal material deprivation was associated with increasing odds of infant CHD, whereas neighbourhood minority ethnic concentration was inversely associated with the odds of infant CHD. Our study further confirms that poverty is associated with CHD development. Future investigations might focus on the causal pathways between social deprivation, immigrant status, ethnicity, and the risk of infant CHD.

Frequency of Congenital Cardiac Disease in Various Divisions of Khyber Pakhtunkhwa (KPK) Based on a Six-Month Analysis of Inpatients at a Tertiary Care Hospital’s Pediatric Cardiology Unit

OBJECTIVE

To identify the frequency of congenital heart disease (CHD) in various Khyber Pakhtunkhwa (KPK) divisions.

MATERIALS AND METHODS

To perform this research, we reviewed the medical records of pediatric cardiology patients hospitalized between January 2022 and July 2022. Data was taken from the cardiology department's computerized data system between January 1 and July 31, 2022. To prevent any errors in diagnosis and address them during input by the ward clerk, patients' addresses, diagnoses, and gender were verified with the computerized medical record. Data were analyzed, and frequency and percentages were calculated. Per the digital mapping of KPK districts, we stratified and examined the data among various KPK divisions.

RESULTS

Out Of the 371 patients with CHD who were admitted, 36.98% (137) were from the Peshawar division, 28.84% (107) from the Malakand division, 16.71% (62) from the Mardan division, 6.1% (23) from the Kohat division, 4.3% (16) from the Bannu division, 3.5% (13) from the Dera Ismail Khan division, and 3.5% (13) from the Hazara division. A total of 371 had CHD, of which 234 (63.07%) were cyanotic and 137 (36.92%) were cyanotic. The most prevalent acynotic congenital heart defect was patent ductus arteriosus (PDA) at 36.32% (85), followed by a ventricular septal defect (VSD) at 35.04 (82). The most frequent acyanotic congenital cardiac abnormality was tetralogy of Fallot (TOF) at 49.63% (68), which was followed by transposition of the great arteries (TGA) at 33.57% (46).

CONCLUSION

In KPK, congenital heart disease is most prevalent in the divisions of Peshawar and Malakand, while it is least prevalent in Hazara.

Research priorities in children and adults with congenital heart disease: a James Lind Alliance Priority Setting Partnership

OBJECTIVE

To bring together patients, parents, charities and clinicians in a Priority Setting Partnership to establish national clinical priorities for research in children and adults with congenital heart disease.

METHODS

The established James Lind Alliance methodology was used to identify and prioritise research on the management of congenital heart disease, focusing on diagnosis, treatment and outcomes. An initial open survey was used to gather potential uncertainties which were filtered, categorised, converted into summary questions and checked against current evidence. In a second survey, respondents identified the unanswered questions most important to them. At two final workshops, patients, parents, charities and healthcare professionals agreed the top 10 lists of priorities for child/antenatal and adult congenital heart disease research.

RESULTS

524 respondents submitted 1373 individual questions, from which 313 out of scope or duplicate questions were removed. The remaining 1060 questions were distilled into summary questions and checked against existing literature, with only three questions deemed entirely answered and removed. 250 respondents completed the child/antenatal survey (56 uncertainties) and 252 completed the adult survey (47 uncertainties). The questions ranked the highest by clinicians and non-clinicians were taken forward to consensus workshops, where two sets of top 10 research priorities were agreed.

CONCLUSIONS

Through an established and equitable process, we determined national clinical priorities for congenital heart disease research. These will be taken forward by specific working groups, a national patient and public involvement group, and through the establishment of a UK and Ireland network for collaborative, multicentre clinical trials in congenital heart disease.

Race in the Reading: A Study of Problematic Uses of Race and Ethnicity in a Prominent Pediatrics Textbook

PURPOSE

Aspects of medical education and clinical practice continue to reflect the antiquated notion that race is a biologically valid distinction among individuals rather than a social construct. The authors analyzed the use of race and ethnicity in a popular pediatrics textbook to determine if these concepts were being used consistently and correctly.

METHOD

In May 2021, using the search function on the American Academy of Pediatrics (AAP) eBooks platform, the authors searched for 29 race- or ethnicity-related terms (e.g., African, Asian, Black, race) in the AAP Textbook of Pediatric Care, 2nd Edition , which was published in 2016. One researcher extracted direct quotes containing at least one of these search terms. Three researchers independently coded each quote as problematic or nonproblematic with respect to the use of the search terms, excluding examples in which the terms were used in irrelevant contexts (e.g., black box warning). The researchers then identified themes based on the quotes that used race and ethnicity problematically.

RESULTS

The search produced 2,167 total results across the search terms, 806 of which were relevant to race or ethnicity and were analyzed. Problematic quotes: (1) used race or ethnicity as a surrogate for social variables, (2) conflated terminology (e.g., conflated socially defined race with genetic ancestry), (3) overgeneralized or made claims based on limited data, (4) lacked clinical relevance, (5) lacked inclusivity, (6) promoted racial stereotypes, or (7) made contradicting claims about race.

CONCLUSIONS

The use of race and ethnicity in the AAP Textbook of Pediatric Care, 2nd Edition was not always appropriate, as demonstrated by examples that reified race as a biological fact and thereby promoted structural racism. Critical evaluation of the use of race and ethnicity in all current medical textbooks and future revisions is warranted.

Health Care Disparities in Congenital Cardiology: Considerations Through the Lens of an Interventional Cardiologist

When resources in a society are dispersed unevenly, generally through allocation standards, distinct patterns emerge along lines of socially defined categories of people. Power, religion, kinship, prestige, race, ethnicity, gender, age, sexual orientation, and class all play a role in determining who has access to social goods in society. In most cases, social inequality refers to a lack of equality of outcome, but it can also refer to a lack of equality of access to opportunity. Unfortunately, health care is not immune to these social disparities and/or inequalities. These health care disparities in interventional cardiology were recently brought to the forefront by the Society for Cardiovascular Angiography and Interventions (SCAI) as a major focus of 2020-2021. In a recent publication, unique factors leading to disparities were reported to exist among the subsections of interventional cardiology. The congenital heart disease council of SCAI created a task force to further investigate the unique challenges and disparities impacting the practice of congenital heart disease and pediatric cardiology.

Evaluating the congenital heart assessment tool: a quality improvement project

BACKGROUND

An early warning tool, the Congenital Heart Assessment Tool (CHAT), was designed in 2012 to support parental preparation before discharge, enhancing understanding of their infant's complex CHD, the signs of deterioration to look out for and to support decision-making at home. Acceptability and feasibility of the tool were tested during 2013-2015 in a single centre.

AIM OF THIS PROJECT

To evaluate the wider implementation across four children's cardiac centres of the CHAT for infants with complex CHD in the community setting.

DESIGN

A four-centre collaborative mixed-methods quality improvement project funded by The Health Foundation, during 2016-2018. A plan, do, study, act cycle of improvement was employed. This article reports on the planning phases, creation of a modified tool (CHATm); and the implementation phases, including retrospective case note review using CHATm; tabletop simulation exercise using CHATm and clinical implementation of CHATm.

RESULTS

Key findings included the benefit of using CHATm simulation for practitioners; the effectiveness of CHATm in predicting amber and red triggers, indicating parental actions and escalation of concerns to professionals. Parents using CHATm found it enhanced knowledge in preparation for going home, supported decision-making, and discussions with health care professionals.

CONCLUSION

Using the CHATm clinically identified the need to develop a structured model of assessment of parental suitability for home-monitoring programmes. A robust and nationally agreed training programme for all staff using CHATm was recommended to ensure successful and complete implementation in practice.

Palliative care for children with complex cardiac conditions: survey results

OBJECTIVE

To explore perspectives of paediatric cardiac and palliative care professionals on providing palliative care to children with complex cardiac conditions.

DESIGN

A national survey including closed-ended and open-ended questions as well as clinical scenarios designed to capture referral practices, attitudes towards palliative care, confidence delivering key components of palliative care and perspectives on for whom to provide palliative care. Responses to closed-ended questions and scenarios were analysed using descriptive statistics. Open-ended responses were analysed thematically.

PARTICIPANTS

Paediatric cardiac and palliative care professionals caring for children with complex cardiac conditions in the UK.

RESULTS

177 professionals (91 cardiac care and 86 palliative care) responded. Aspects of advance care planning were the most common reasons for referral to palliative care. Palliative care professionals reported greater confidence than cardiac colleagues with such discussions. Clinicians agreed that children with no further surgical management options, comorbid genetic disorders, antenatal diagnosis of a single ventricle, ventricular device in situ, symptomatic heart failure and those awaiting heart transplantation would benefit from palliative care involvement.

CONCLUSIONS

Components of palliative care, such as advance care planning, can be provided by cardiac care professionals alongside the disease-directed care of children with complex cardiac conditions. Further research and training are needed to address confidence levels in cardiac care professionals in delivering components of palliative care as well as clarification of professional roles and parent preferences in delivery of family-centred care for children with complex cardiac conditions.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Association of maternal socioeconomic status and race with risk of congenital heart disease: a population-based retrospective cohort study in Ontario, Canada

OBJECTIVE

To investigate the interrelationships between maternal socioeconomic status (SES), race and congenital heart diseases (CHD) among infants.

DESIGN

Retrospective cohort study.

STUDY SETTING

Ontario, Canada.

STUDY POPULATION

All singleton stillbirths and live births born in hospitals between 1 April 2012 and 31 March 2018 in Ontario, Canada (n=804 292).

OUTCOME

CHD.

ANALYSIS

Multivariable logistic regression models were performed to assess associations between maternal neighbourhood household income, education level, race and CHD while adjusting for maternal age at birth, assisted reproductive technology, obesity, pre-existing health conditions, substance use during pregnancy, maternal rural residence and infant's sex.

RESULTS

Compared with infants whose mothers lived in the highest median household income neighbourhoods, infants whose mothers lived in the lowest median income neighbourhoods had a higher likelihood of having CHD (adjusted OR 1.15, 95% CI 1.06 to 1.24). Compared with infants whose mothers lived in neighbourhoods with more people with a university or higher degree, those infants whose mothers lived in neighbourhoods with less people with a university or higher degree had a higher chance of developing CHD (adjusted OR 1.26, 95% CI 1.16 to 1.36). Compared with white mothers, black mothers had a higher odds of giving birth to a child with CHD (adjusted OR 1.40, 95% CI 1.27 to 1.54). No association was detected between White and Asian mothers and CHD among infants.

CONCLUSIONS

Our study indicates that there are inequities in CHD burden by maternal SES and race in Ontario, Canada. Further investigation is needed to examine racial variation in CHD using more detailed ethnic data.

Differences in ill health and in socioeconomic inequalities in health by ethnic groups: a cross-sectional study using 2011 Scottish census

Objectives: We compare rates of ill health and socioeconomic inequalities in health by ethnic groups in Scotland by age. We focus on ethnic differences in socioeconomic inequalities in health. There is little evidence of how socioeconomic inequalities in health vary by ethnicity, especially in Scotland, where health inequalities are high compared to other European countries.Design: A cross-sectional study using the 2011 Scottish Census (population 5.3 million) was conducted. Directly standardized rates were calculated for two self-rated health outcomes (poor general health and limiting long-term illness) separately by ethnicity, age and small-area deprivation. Slope and relative indices of inequality were calculated to measure socioeconomic inequalities in health.Results: The results show that the White Scottish population tend to have worse health and higher socioeconomic inequalities in health than many other ethnic groups, while White Polish and Chinese people tend to have better health and low socioeconomic inequalities in health. These results are more salient for ages 30-44. The Pakistani population has high rates of poor health similar to the White Scottish for ages 15-44, but at ages 45 and above Pakistani people have the highest rates of poor self-rated health. Compared to other ethnicities, Pakistani people are also more likely to experience poor health in the least deprived areas, particularly at ages 45 and above.Conclusions: There are statistically significant and substantial differences in poor self-rated health and in socioeconomic inequalities in health between ethnicities. Rates of ill health vary between ethnic groups at any age. The better health of the younger minority population should not be taken as evidence of better health outcomes in later life. Since socioeconomic gradients in health vary by ethnicity, policy interventions for health improvement in Scotland that focus only on deprived areas may inadvertently exclude minority populations.

Socioeconomic inequality in congenital heart diseases in Iran

INTRODUCTION

Social-economic factors have an important role in shaping inequality in congenital heart diseases. The current study aimed to assess and decompose the socio-economic inequality in Congenital Heart Diseases (CHDs) in Iran.

METHODS

This is a cross-sectional research conducted at Shahid Rajaie Cardiovascular Medical and Research Center in Tehran, Iran, as one of the largest referral heart hospitals in Asia. Data were collected primarily from 600 mothers who attended in pediatric cardiology department in 2020. The polychoric principal component analysis (PCA) and Errygers corrected CI (ECI) were used to construct household socioeconomic status and to assess inequality in CHDs, respectively. A regression-based decomposition analysis was also applied to explain socioeconomic-related inequalities. To select the explanatory social, medical/biological, and lifestyle variables, the chi-square test was first used.

RESULTS

There was a significant pro-rich inequality in CHDs (ECI = -0.65, 95% CI, - 0.72 to - 0.58). The social, medical/biological, and lifestyle variables accounted for 51.47, 43.25, and 3.92% of inequality in CHDs, respectively. Among the social variables, family SES (about 50%) and mother's occupation (21.05%) contributed the most to CHDs' inequality. Besides, in the medical/biological group, receiving pregnancy care (22.06%) and using acid folic (15.70%) had the highest contribution.

CONCLUSION

We concluded that Iran suffers from substantial socioeconomic inequality in CHDs that can be predominantly explained by social and medical/biological variables. It seems that distributional policies aim to reduce income inequality while increasing access of prenatal care and folic acid for disadvantaged mothers could address this inequality much more strongly in Iran.

Maternal sociodemographic characteristics, early pregnancy behaviours, and livebirth outcomes as congenital heart defects risk factors - Northern Ireland 2010-2014

BACKGROUND

Congenital Heart Defects (CHD) is the most commonly occurring congenital anomaly in Europe and a major paediatric health care concern. Investigations are needed to enable identification of CHD risk factors as studies have given conflicting results. This study aim was to identify maternal sociodemographic characteristics, behaviours, and birth outcomes as risk factors for CHD. This was a population based, data linkage cohort study using anonymised data from Northern Ireland (NI) covering the period 2010-2014. The study cohort composed of 94,067 live births with an outcome of 1162 cases of CHD using the International Statistical Classification of Diseases and Related Health Problems (ICD)-10 codes and based on the European Surveillance of Congenital Anomalies (EUROCAT) grouping system for CHD. CHD cases were obtained from the HeartSuite database (HSD) at the Royal Belfast Hospital for Sick Children (RBHSC), maternal data were extracted from the Northern Ireland Maternity System (NIMATS), and medication data were extracted from the Enhanced Prescribing Database (EPD). STATA version 14 was used for the statistical analysis in this study, Odds Ratio (OR), 95% Confident intervals (CI), P value, and logistic regression were used in the analysis. Ethical approval was granted from the National Health Service (NHS) Research Ethics Committee.

RESULT

In this study, a number of potential risk factors were assessed for statistically significant association with CHD, however only certain risk factors demonstrated a statistically significant association with CHD which included: gestational age at first booking (AOR = 1.21; 95% CI = 1.04-1.41; P < 0.05), family history of CHD or congenital abnormalities and syndromes (AOR = 4.14; 95% CI = 2.47-6.96; P < 0.05), woman's smoking in pregnancy (AOR = 1.22; 95% CI = 1.04-1.43; P < 0.05), preterm birth (AOR = 3.01; 95% CI = 2.44-3.01; P < 0.05), multiple births (AOR = 1.89; 95% CI = 1.58-2.60; P < 0.05), history of abortion (AOR = 1.12; 95% CI = 1.03-1.28; P < 0.05), small for gestational age (SGA) (AOR = 1.44; 95% CI = 1.22-1.78; P < 0.05), and low birth weight (LBW) (AOR = 3.10; 95% CI = 2.22-3.55; P < 0.05). Prescriptions and redemptions of antidiabetic (AOR = 2.68; 95% CI = 1.85-3.98; P < 0.05), antiepileptic (AOR = 1.77; 95% CI = 1.10-2.81; P < 0.05), and dihydrofolate reductase inhibitors (DHFRI) (AOR = 2.13; 95% CI = 1.17-5.85; P < 0.05) in early pregnancy also showed evidence of statistically significant association with CHD.

CONCLUSION

The results of this study suggested that there are certain maternal sociodemographic characteristics, behaviours and birth outcomes that are statistically significantly associated with higher risk of CHD. Appropriate prevention policy to target groups with higher risk for CHD may help to reduce CHD prevalence. These results are important for policy makers, obstetricians, cardiologists, paediatricians, midwives and the public.

Cohort study of intervened functionally univentricular heart in England and Wales (2000-2018)

Objective

Given the paucity of long-term outcome data for complex congenital heart disease (CHD), we aimed to describe the treatment pathways and survival for patients who started interventions for functionally univentricular heart (FUH) conditions, excluding hypoplastic left heart syndrome.

Methods

We performed a retrospective cohort study using all procedure records from the National Congenital Heart Diseases Audit for children born in 2000–2018. The primary outcome was mortality, ascertained from the Office for National Statistics in 2020.

Results

Of 53 615 patients, 1557 had FUH: 55.9% were boys and 67.4% were of White ethnic groups. The largest diagnostic categories were tricuspid atresia (28.9%), double inlet left ventricle (21.0%) and unbalanced atrioventricular septal defect (AVSD) (15.2%). The ages at staged surgery were: initial palliation 11.5 (IQR 5.5–43.5) days, cavopulmonary shunt 9.2 (IQR 6.0–17.1) months and Fontan 56.2 (IQR 45.5–70.3) months. The median follow-up time was 10.8 (IQR 7.0–14.9) years and the 1, 5 and 10-year survival rates after initial palliation were 83.6% (95% CI 81.7% to 85.4%), 79.4% (95% CI 77.3% to 81.4%) and 77.2% (95% CI 75.0% to 79.2%), respectively. Higher hazards were present for unbalanced AVSD HR 2.75 (95% CI 1.82 to 4.17), atrial isomerism HR 1.75 (95% CI 1.14 to 2.70) and low weight HR 1.65 (95% CI 1.13 to 2.41), critical illness HR 2.30 (95% CI 1.67 to 3.18) or acquired comorbidities HR 2.71 (95% CI 1.82 to 4.04) at initial palliation.

Conclusion

Although treatment pathways for FUH are complex and variable, nearly 8 out of 10 children survived to 10 years. Longer-term analyses of outcome based on diagnosis (rather than procedure) can inform parents, patients and clinicians, driving practice improvements for complex CHD.

Association Between Race and COVID-19 Outcomes Among 2.6 Million Children in England

IMPORTANCE

Although children mainly experience mild COVID-19 disease, hospitalization rates are increasing, with limited understanding of underlying factors. There is an established association between race and severe COVID-19 outcomes in adults in England; however, whether a similar association exists in children is unclear.

OBJECTIVE

To investigate the association between race and childhood COVID-19 testing and hospital outcomes.

DESIGN, SETTING, PARTICIPANTS

In this cohort study, children (0-18 years of age) from participating family practices in England were identified in the QResearch database between January 24 and November 30, 2020. The QResearch database has individually linked patients with national SARS-CoV-2 testing, hospital admission, and mortality data.

EXPOSURES

The main characteristic of interest is self-reported race. Other exposures were age, sex, deprivation level, geographic region, household size, and comorbidities (asthma; diabetes; and cardiac, neurologic, and hematologic conditions).

MAIN OUTCOMES AND MEASURES

The primary outcome was hospital admission with confirmed COVID-19. Secondary outcomes were SARS-CoV-2-positive test result and any hospital attendance with confirmed COVID-19 and intensive care admission.

RESULTS

Of 2 576 353 children (mean [SD] age, 9.23 [5.24] years; 48.8% female), 410 726 (15.9%) were tested for SARS-CoV-2 and 26 322 (6.4%) tested positive. A total of 1853 children (0.07%) with confirmed COVID-19 attended hospital, 343 (0.01%) were admitted to the hospital, and 73 (0.002%) required intensive care. Testing varied across race. White children had the highest proportion of SARS-CoV-2 tests (223 701/1 311 041 [17.1%]), whereas Asian children (33 213/243 545 [13.6%]), Black children (7727/93 620 [8.3%]), and children of mixed or other races (18 971/147 529 [12.9%]) had lower proportions. Compared with White children, Asian children were more likely to have COVID-19 hospital admissions (adjusted odds ratio [OR], 1.62; 95% CI, 1.12-2.36), whereas Black children (adjusted OR, 1.44; 95% CI, 0.90-2.31) and children of mixed or other races (adjusted OR, 1.40; 95% CI, 0.93-2.10) had comparable hospital admissions. Asian children were more likely to be admitted to intensive care (adjusted OR, 2.11; 95% CI, 1.07-4.14), and Black children (adjusted OR, 2.31; 95% CI, 1.08-4.94) and children of mixed or other races (adjusted OR, 2.14; 95% CI, 1.25-3.65) had longer hospital admissions (≥36 hours).

CONCLUSIONS AND RELEVANCE

In this large population-based study exploring the association between race and childhood COVID-19 testing and hospital outcomes, several race-specific disparities were observed in severe COVID-19 outcomes. However, ascertainment bias and residual confounding in this cohort study should be considered before drawing any further conclusions. Overall, findings of this study have important public health implications internationally.

Nonmedical Determinants of Congenital Heart Diseases in Children from the Perspective of Mothers: A Qualitative Study in Iran

Introduction

Mortality due to noncommunicable diseases has increased in the world today with the advent of demographic shifts, growing age, and lifestyle patterns in the world, which have been affected by economic and social crises. Congenital heart defects are one of the forms of diseases that have raised infant mortality worldwide. The objective of present study was to identify nonmedical determinants related to this abnormality from the mother's perspectives.

Methods

This research was a qualitative study and the data collection method was a semistructured interview with mothers who had children with congenital heart diseases referring to the Shahid Rajaei Heart Hospital in Tehran, Iran. A thematic analysis approach was employed to analyze transcribed documents assisted by MAXQDA Plus version 12.

Results

Four general themes and ten subthemes including social contexts (social harms, social interactions, and social necessities), psychological contexts (mood disorders and mental well-being), cultural contexts (unhealthy lifestyle, family culture, and poor parental health behaviors), and environmental contexts (living area and polluted air) were extracted from interviews with mothers of children with congenital heart diseases.

Conclusions

Results suggest that factors such as childhood poverty, lack of parental awareness of congenital diseases, lack of proper nutrition and health facilities, education, and lack of medical supervision during pregnancy were most related with the birth of children with congenital heart disease from mothers' prospective. In this regard, targeted and intersectorial collaborations are proposed to address nonmedical determinants related to the incidence of congenital heart diseases.

Clinical utility of fetal echocardiography: an Egyptian center experience

BACKGROUND

The impact of early diagnosis of fetal cardiac abnormalities on the postnatal outcome has been controversial in literature. We aimed to evaluate the role of fetal echocardiography (FE) as a diagnostic tool for early detection and proper management of fetal cardiac abnormalities, study the indications of referral and detect the perinatal outcome in our institution.

RESULTS

This is a cross-sectional observational and descriptive study that included one hundred and one singleton pregnant women (101 fetuses) who were referred for FE over a period of one year. Indications for referral and perinatal risk factors were documented. FE and postnatal transthoracic echocardiography were done. Fetal cardiac abnormalities were detected in 46.5% of cases. Congenital heart defects (CHDs) in 34.6%, fetal arrythmias in 9.9%, cardiomyopathy in 2.9% and cardiac mass (Rhabdomyoma) in 1% (combined structural and rhythm abnormalities were observed in two fetuses). Of the CHDs, complex heart lesions were diagnosed in 57.1%, common atrioventricular canal in 28.6% and conotrunchal anomalies in 14.3%. Of the ten cases with fetal arrythmias, five fetuses had tachyarrhythmias, four had ectopics and one fetus had congenital heart block in association with maternal lupus. The indications for referral were abnormal obstetric ultrasound (52.5%), maternal medical illnesses (23.8%), multiple neonatal deaths (13.9%) and positive family history of CHD (10.9%). The number of fetuses with cardiac abnormalities was significantly higher than those without cardiac abnormalities in mothers not exposed to perinatal risk factors (p = 0.009) and was statistically lower in mothers exposed to perinatal risk factors (p = 0.005). FE showed 100% accuracy in diagnosing complex lesions, common atrio-ventricular canals, cono-truncal anomalies, cardiac masses and fetal arrhythmias. It missed two cases of tiny muscular ventricular septal defects and one case of aortic coarctation. Cases of fetal supraventricular tachycardia were successfully treated in-utero.

CONCLUSIONS

CHDs exist in fetuses with no underlying perinatal risk factors. FE can accurately diagnose most of the cardiac anomalies though few errors remain challenging (aortic coarctation). It also offers a good chance for successful early life-saving management of some types of fetal arrhythmia.

Racial and ethnic disparities in coronary, vascular, structural, and congenital heart disease

Cardiovascular disease (CVD) remains the leading cause of death in the United States. However, percutaneous interventional cardiovascular therapies are often underutilized in Blacks, Hispanics, and women and may contribute to excess morbidity and mortality in these vulnerable populations. The Society for Cardiovascular Angiography and Interventions (SCAI) is committed to reducing racial, ethnic, and sex-based treatment disparities in interventional cardiology patients. Accordingly, each of the SCAI Clinical Interest Councils (coronary, peripheral, structural, and congenital heart disease [CHD]) participated in the development of this whitepaper addressing disparities in diagnosis, treatment, and outcomes in underserved populations. The councils were charged with summarizing the available data on prevalence, treatment, and outcomes and elucidating potential reasons for any disparities. Given the huge changes in racial and ethnic composition by age in the United States (Figure 1), it was difficult to determine disparities in rates of diagnosis and we expected to find some racial differences in prevalence of disease. For example, since the average age of patients undergoing transcatheter aortic valve replacement (TAVR) is 80 years, one may expect 80% of TAVR patients to be non-Hispanic White. Conversely, only 50% of congenital heart interventions would be expected to be performed in non-Hispanic Whites. Finally, we identified opportunities for SCAI to advance clinical care and equity for our patients, regardless of sex, ethnicity, or race.

Racial and socioeconomic disparities in congenital heart surgery: A research article

BACKGROUND

Though the modern era has proven to be reassuring with the advancement of perioperative care leading to improved survival, congenital heart disease (CHD) continues to underscore its significance in the lives of newborns and families worldwide. Particularly, CHD has disproportionately afflicted vulnerable minorities such as Black and Hispanic populations from the standpoint of ethnic disparities in mortality following heart surgery, increased resource utilization, and longer durations of stay. This study aims to identify and provide insight regarding the relationships between the aforementioned factors to develop targeted strategies of intervention to mitigate the outcomes for patients of these specific populations.

METHODS

Free, current peer-reviewed literature from databases such as the American Heart Association, The European Heart Journal, Science Direct, and PubMed regarding CHD, racial disparities, and socioeconomic variances were accessed. The study was narrowed to a patient population including only infants without chromosomal anomalies or those that passed away before hospital discharge.

RESULTS

Having private insurance and maternal education showed positive correlations with positive outcomes of patients post congenital heart surgery. Teaching hospitals were linked with increased mortality and complications. Male infants showed higher rates of complications. Hispanics had increased odds of complications. Black patients had increased risk for failures in being rescued.

CONCLUSIONS

Race plays a major role in the disparities in CHD, it is imperative to evaluate the socioeconomic contributors, surgical efforts, and provisions in place regarding minority patients. The apparency of these disparities, and willingness to invoke changes in practice has the potential for improvements in outcomes for these patients.

Neurodevelopmental status and follow-up in preschool children with heart disease in London, UK

OBJECTIVE

To describe neurodevelopment and follow-up services in preschool children with heart disease (HD).

DESIGN

Secondary analysis of a prospectively collected multicentre dataset.

SETTING

Three London tertiary cardiac centres.

PATIENTS

Preschool children<5 years of age: both inpatients and outpatients.

METHODS

We analysed results of Mullen Scales of Early Learning (MSEL) and parental report of follow-up services in a representative convenience sample evaluated between January 2014 and July 2015 within a previous study.

RESULTS

Of 971 preschool children: 577 (59.4%) had ≥1 heart operation, 236 (24.3%) had a known diagnosis linked to developmental delay (DD) ('known group') and 130 (13.4%) had history of clinical event linked to DD. On MSEL assessment, 643 (66.2%) had normal development, 181 (18.6%) had borderline scores and 147 (15.1%) had scores indicative of DD. Of 971 children, 609 (62.7%) were not receiving follow-up linked to child development and were more likely to be under these services with a known group diagnosis, history of clinical event linked to DD and DD (defined by MSEL). Of 236 in known group, parents of 77 (32.6%) and of 48 children not in a known group but with DD 29 (60.4%), reported no child development related follow-up. DD defined by MSEL assessment was more likely with a known group and older age at assessment.

CONCLUSIONS

Our findings indicate that a 'structured neurodevelopmental follow-up pathway' in preschool children with HD should be considered for development and evaluation as children get older, with particular focus on those at higher risk.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Race and Genetics in Congenital Heart Disease: Application of iPSCs, Omics, and Machine Learning Technologies

Congenital heart disease (CHD) is a multifaceted cardiovascular anomaly that occurs when there are structural abnormalities in the heart before birth. Although various risk factors are known to influence the development of this disease, a full comprehension of the etiology and treatment for different patient populations remains elusive. For instance, racial minorities are disproportionally affected by this disease and typically have worse prognosis, possibly due to environmental and genetic disparities. Although research into CHD has highlighted a wide range of causal factors, the reasons for these differences seen in different patient populations are not fully known. Cardiovascular disease modeling using induced pluripotent stem cells (iPSCs) is a novel approach for investigating possible genetic variants in CHD that may be race specific, making it a valuable tool to help solve the mystery of higher incidence and mortality rates among minorities. Herein, we first review the prevalence, risk factors, and genetics of CHD and then discuss the use of iPSCs, omics, and machine learning technologies to investigate the etiology of CHD and its connection to racial disparities. We also explore the translational potential of iPSC-based disease modeling combined with genome editing and high throughput drug screening platforms.

Chinese Parents' Perceptions, Attitudes, and Treatment-Seeking Intentions Toward Congenital Heart Disease with Charitable Assistance: A Cross-Sectional Study in a Congenital Heart Center in Southern China

OBJECTIVE

To investigate the perceptions, attitudes and treatment-seeking intentions of Chinese parents toward charitable assistance for congenital heart disease (CHD).

METHODS

This was a cross-sectional study, and different questionnaires were used. Data on Chinese parents' perceptions, attitudes, and treatment-seeking intentions toward charitable assistance for CHD were collected and analyzed.

RESULTS

A total of 220 parents of children with CHD were included in the survey, and 201 completed the survey. The results showed that the perception rate of charity assistance for CHD was only 44.8%, and the channels of understanding were narrow. The majority of participants (98.0%) approved of charitable assistance. A total of 79.1% of the parents thought that charity assistance would improve their treatment-seeking intentions, and 62.7% of the parents answered that it would affect their medical institutions' choice. The results also showed that higher treatment-seeking intention was significantly correlated with higher income and charitable assistance but not with the parents' education level. Correlation analysis found that parents with different monthly incomes and charitable assistance had statistically significant treatment-seeking intentions. Analyzing the factors of surgical treatment in our hospital, it was found that charitable assistance was an essential factor influencing them to choose treatment.

CONCLUSION

Many Chinese parents of patients with CHD did not know about charity assistance, but most of them approved the project. Charitable assistance could improve parents' treatment-seeking intentions.

Mutations in the tail domain of MYH3 contributes to atrial septal defect

Atrial septal defect (ASD) is one of the most common congenital heart defects diagnosed in children. Sarcomeric genes has been attributed to ASD and knockdown of MYH3 functionally homologues gene in chick models indicated abnormal atrial septal development. Here, we report for the first time, a case-control study investigating the role of MYH3 among non-syndromic ASD patients in contributing to septal development. Four amplicons which will amplifies the 40 kb MYH3 were designed and amplified using long range-PCR. The amplicons were then sequenced using indexed paired-end libraries on the MiSeq platform. The STREGA guidelines were applied for planning and reporting. The non-synonymous c. 3574G>A (p.Ala1192Thr) [p = 0.001, OR = 2.30 (1.36-3.87)] located within the tail domain indicated a highly conserved protein region. The mutant model of c. 3574G>A (p.Ala1192Thr) showed high root mean square deviation (RMSD) values compared to the wild model. To our knowledge, this is the first study to provide compelling evidence on the pathogenesis of MYH3 variants towards ASD hence, suggesting the crucial role of non-synonymous variants in the tail domain of MYH3 towards atrial septal development. It is hoped that this gene can be used as panel for diagnosis of ASD in future.

Environmental and Socioeconomic Factors Influence the Live-Born Incidence of Congenital Heart Disease: A Population-Based Study in California

BACKGROUND

The development of congenital heart disease (CHD) is multifactorial with genetic and environmental influences. We sought to determine the relationship between socioeconomic and environmental factors with the incidence of CHD among live‐born infants in California and to determine whether maternal comorbidities are in the causal pathway.

METHODS AND RESULTS

This was a population‐based cohort study in California (2007–2012). The primary outcome was having significant CHD. Predictors included socioeconomic status and environmental exposure to pollutants determined by U.S. Census data. A social deprivation index and environmental exposure index was assigned based on neighborhood socioeconomic variables, categorized into 4 quartiles. Quartile 1 was the best with the least exposure to pollutants and social deprivation, and quartile 4 was the worst. Multivariate logistic regression and mediation analyses were performed. Among 2 419 651 live‐born infants, the incidence of CHD was 3.2 per 1000 live births. The incidence of CHD was significantly higher among those in quartile 4 compared with quartile 1 (social deprivation index: 0.35% versus 0.29%; odds ratio [OR], 1.31; 95% CI, 1.21–1.41; environmental exposure index: 0.35% versus 0.29%; OR, 1.23; 95% CI, 1.15–1.31) after adjusting for maternal race/ethnicity and age and accounting for the relationship between the 2 primary predictors. Maternal comorbidities explained 13% (95% CI, 10%–20%) of the relationship between social deprivation index and environmental exposure index with the incidence of CHD.

CONCLUSIONS

Increased social deprivation and exposure to environmental pollutants are associated with the incidence of live‐born CHD in California. Maternal comorbidities explain some, but not all, of this relationship. These findings identify targets for social policy initiatives to minimize health disparities.

Analysis of Congenital Heart Defects in Mouse Embryos Using Qualitative and Quantitative Histological Methods

Congenital heart defects (CHD) are the most common type of birth defect in humans, affecting up to 1% of all live births. However, the underlying causes for CHD are still poorly understood. The developing mouse constitutes a valuable model for the study of CHD, because cardiac developmental programs between mice and humans are highly conserved. The protocol describes in detail how to produce mouse embryos of the desired gestational stage, methods to isolate and preserve the heart for downstream processing, quantitative methods to identify common types of CHD by histology (e.g., ventricular septal defects, atrial septal defects, patent ductus arteriosus), and quantitative histomorphometry methods to measure common muscular compaction phenotypes. These methods articulate all the steps involved in sample preparation, collection, and analysis, allowing scientists to correctly and reproducibly measure CHD.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

5-year experience of a tertiary center in major congenital abnormalities in singleton pregnancies

OBJECTIVE

To demonstrate major congenital abnormalities delivered or terminated at our institution between 2014 and 2018.

MATERIALS AND METHODS

Necessary information was retrieved from the registries of the delivery room and electronic database of Hacettepe University Hospital, Ankara.

RESULTS

This study was consisted of 307 major congenital anomalies. The incidence of major congenital anomalies was 2.9 per 1,000 live births, while the majority of the cases were related to cardiovascular, central nervous system, and diaphragmatic hernia with 97, 87, and 25 cases at each group, respectively. Rate of termination of pregnancy (TOP) and live birth were 35.1 and 59.2%, respectively. The overall infant mortality rate was 28.9% in cases with live birth, while this rate was highest in cardiovascular system abnormalities and diaphragmatic hernia. Out of 182 newborns, 92.8% admitted to the neonatal intensive care unit after the delivery. Median gestational week at TOP was 21(20).

CONCLUSION

We have shown that TOP and infant mortality rates were 35.1 and 28.9%, respectively in pregnancies with fetal malformations. Detailed multidisciplinary counseling must be provided for parents in pregnancies with major congenital abnormalities.

Association of maternal ethnicity and urbanicity on severe pediatric disease: a nationwide cohort study

BACKGROUND

A healthy migrant effect on birth outcomes has been reported, however, whether this protective effect persists throughout childhood is unknown. The effect of urbanicity on child health among an immigrant population is unclear. The objective of this study was to compare the incidence rate and cumulative incidence of severe diseases among urban children of Taiwan-born mothers, rural children of Taiwan-born mothers, urban children of foreign-born mothers, and rural children of foreign-born mothers.

METHODS

A nationwide cohort study was conducted for children born in Taiwan during 2004-2011 and follow-up till age 4 to 11 years old by linkage the Taiwan Birth Registry 2004-2011, Taiwan Death Registry 2004-2015, and National Health Insurance Research Database 2004-2015. Cox proportional hazards model (multivariable) was used to examine differences among the four study groups.

RESULTS

There were 682,982 urban children of Taiwan-born mothers, 662,818 rural children of Taiwan-born mothers, 61,570 urban children of foreign-born mothers, 87,473 rural children of foreign-born mothers. Children of foreign-born mothers had a lower incidence of vasculitis, mainly Kawasaki disease. The incidences of congenital disorders did not differ between children of foreign-born mothers and children of Taiwan-born mothers. The incidence of psychotic disorders was higher in urban children. However, children in rural areas had a higher incidence of major trauma/burn and a higher mortality rate.

CONCLUSIONS

A healthy migrant effect was only seen for Kawasaki disease. The mental health of urban children born to immigrant mothers warrants concern.

Ethnic-specific mortality of infants undergoing congenital heart surgery in England and Wales

PURPOSE

To investigate ethnic differences in mortality for infants with congenital heart defects (CHDs) undergoing cardiac surgery or interventional catheterisation.

DESIGN

Observational study of survival to age 1 year using linked records from routine national paediatric cardiac surgery and intensive care audits. Mortality risk was investigated using multivariable Poisson models with multiple imputation. Predictors included sex, ethnicity, preterm birth, deprivation, comorbidities, prenatal diagnosis, age and weight at surgery, preprocedure deterioration and cardiac diagnosis.

SETTING

All paediatric cardiac surgery centres in England and Wales.

PATIENTS

5350 infants with CHDs born from 2006 to 2009.

MAIN OUTCOME MEASURE

Survival at age 1 year.

RESULTS

Mortality was 83.9 (95% CI 76.3 to 92.1) per 1000 infants, with variation by ethnic group. Compared with those of white ethnicity, infants in British Asian (Indian, Pakistani and Bangladeshi) and 'all other' (Chinese, mixed and other) categories experienced significantly higher mortality by age 1 year (relative risk [RR] 1.52[95% CI 1.19 to 1.95]; 1.62[95% CI 1.20 to 2.20], respectively), specifically during index hospital admission (RR 1.55 [95% CI 1.07 to 2.26]; 1.64 [95% CI 1.05 to 2.57], respectively). Further predictors of mortality included non-cardiac comorbidities, prenatal diagnosis, older age at surgery, preprocedure deterioration and cardiac diagnosis. British Asian infants had higher mortality risk during elective hospital readmission (RR 1.86 [95% CI 1.02 to 3.39]).

CONCLUSIONS

Infants of British Asian and 'all other' non-white ethnicity experienced higher postoperative mortality risk, which was only partly explained by socioeconomic deprivation and access to care. Further investigation of case-mix and timing of risk may provide important insights into potential mechanisms underlying ethnic disparities.

Socio-economic inequalities in mortality in children with congenital heart disease: A systematic review and meta-analysis

BACKGROUND

The impact of socio-economic status (SES) on congenital heart disease (CHD)-related mortality in children is not well established.

OBJECTIVES

We aimed to systematically review and appraise the existing evidence on the association between SES (including poverty, parental education, health insurance, and income) and mortality among children with CHD.

DATA SOURCES

Seven electronic databases (Medline, Embase, Scopus, PsycINFO, CINAHL, ProQuest Natural, and Biological Science Collections), reference lists, citations, and key journals were searched.

STUDY SELECTION AND DATA EXTRACTION

We included articles reporting original research on the association between SES and mortality in children with CHD if they were full papers published in the English language and regardless of (a) timing of mortality; (b) individual or area-based measures of SES; (c) CHD subtype; (d) age at ascertainment; (e) study period examined. Screening for eligibility, data extraction, and quality appraisal were performed in duplicate.

SYNTHESIS

Meta-analyses were performed to estimate pooled ORs for in-hospital mortality according to health insurance status.

RESULTS

Of 1388 identified articles, 28 met the inclusion criteria. Increased area-based poverty was associated with increased odds/risk of postoperative (n = 1), neonatal (n = 1), post-discharge (n = 1), infant (n = 1), and long-term mortality (n = 2). Higher parental education was associated with decreased odds/risk of neonatal (n = 1) and infant mortality (n = 5), but not with long-term mortality (n = 1). A meta-analysis of four US articles showed increased unadjusted odds of in-hospital mortality in those with government/public versus private health insurance (OR 1.40, 95% CI 1.24, 1.56). The association between area-based income and CHD-related mortality was conflicting, with three of eight articles reporting significant associations.

CONCLUSION

This systematic review provides evidence that children of lower SES are at increased risk of CHD-related mortality. As these children are over-represented in the CHD population, interventions targeting socio-economic inequalities could have a large impact on improving CHD survival.

Prospective paediatric intensive care registry in Latvia: one year outcomes

Background

In Latvia, there is a single eight-bed paediatric intensive care unit (PICU) where all critically ill children are admitted. A recent retrospective audit of the outcomes of paediatric critical care in this unit revealed a high number of unplanned extubations and excess crude mortality. In 2017, our centre joined the UK and Ireland based Paediatric Intensive Care Audit Network (PICANet) as a pilot project to investigate the feasibility of developing a paediatric critical care registry in Latvia and in the Baltic states.

Methods

Riga Stradins University Ethics Committee approved the study. Anonymized data on all patients admitted to our unit from 1 June, 2017 to 31 May 2018 were prospectively entered onto the PICANet database.

Results

A total of 774 PICU admissions were analysed; 45% of admissions were elective. The median age was 59 months (IQR: 14-149). The highest admission rate was on Wednesdays representing the flow of elective surgical patients. The median length of stay was 0.95 days (IQR: 0.79-1.98). Twenty-five percent required respiratory support. The expected number of deaths estimated using the Paediatric Index of Mortality 3 (PIM 3) 15.16; 15 patients (1.94%) died resulting in Standartized Mortality Ratio (SMR) of 0.99 (95% CI 0.57-1.60). The emergency readmission rate within 48 hours after PICU discharge was 0.9%. There were 1.8 unplanned extubations per 100 invasive ventilation days. Other paediatric intensive care audit networks reported similar adjusted mortality rates but lower rates of unplanned extubations. Thirty days after PICU discharge, 653 (84.36%) patients were alive and outside hospital, 98 (12.66%) were inpatients, six (0.78%) had died, two (0.26%) were lost to the follow-up. We observed a marked peak of infant emergency respiratory admissions in February.

Conclusions

This project explored the possibility of prospective paediatric critical care audit in Latvia by joining an established international network. This allowed direct comparison of outcomes between the countries. Excess mortality was not observed during one-year data collection period, however a high rate of unplanned extubations was revealed. The results allowed a better planning of elective patient flow by spreading elective cases over the week to avoid "rush hours".

Parental stress and resilience in CHD: a new frontier for health disparities research

Parental stress is a universal experience for parents who have children diagnosed with CHD and has been studied within the context of the child's illness, but not through a broader health disparity lens. This paper provides a thorough synthesis of the current literature on parental stress addressing disparities in parents of children with CHD. Several theories and models from within this literature are described and a new comprehensive framework, the Parental Stress and Resilience in CHD Model, is presented. Future research and clinical implications are discussed.

Issues facing families of infants discharged after cardiac surgery: the perceptions of charity helpline staff

AIM

To elicit the perceptions of helpline staff who talk to parents of children discharged after cardiac surgery in infancy about parents' key concerns.

METHODS

A qualitative study involving semistructured interviews with 10 staff at four heart charities. Interviews were recorded, transcribed and analysed using Framework analysis.

RESULTS

Staff identified the knowledge, communication and support needs of parents which they described in terms of the impact of patient and family factors, sources of support and systems. Staff perceptions of helplines, in terms of the function of a helpline and the roles of its staff, together with staff's personal views based on their experience of multiple encounters with many families, influenced how they viewed families' needs and responded to their requests.

CONCLUSION

Helpline staff provided important, previously uncaptured evidence about the challenges faced by parents of children discharged after cardiac surgery in infancy. Staff have an important role in supporting communication, in terms of speaking to families about how to talk to professionals and talking to professionals directly to get or give information when parents are unable to do so. Capturing the perspective of helpline staff about communication issues has highlighted the need for interventions with professionals as well as parents.

Respiratory virus prophylaxis in congenital heart disease

Respiratory syncytial virus (RSV) is the leading cause of acute lower respiratory tract infections and causes up to 200,000 infant deaths a year worldwide. The average rate of hospitalization for severe RSV infection is 5 per 1000 children, and the rate is three-times higher in those with congenital heart disease (CHD). Palivizumab, a monoclonal antibody, reduces hospitalization rates and intensive care admissions. It is used prophylactically and is administered as monthly doses during the RSV season. Hemodynamically unstable CHD is the most susceptible CHD to a severe episode of RSV infection. This review explores current evidence surrounding therapies, patterns of infection and identifies groups which may still be vulnerable to severe RSV infection.

Parents' Experiences of Caring for Their Child at the Time of Discharge After Cardiac Surgery and During the Postdischarge Period: Qualitative Study Using an Online Forum

Background

Congenital heart disease (CHD) is the most common class of birth defects, which encompasses a broad spectrum of severity ranging from relatively minor to extremely complex. Improvements in surgery and intensive care have resulted in an increasing number of infants with the most complex lesions surviving after surgery until the time of discharge from the hospital, but there remain concerns about out-of-hospital mortality, variability in how services are provided at the time of discharge and beyond, and difficulties experienced by some families in accessing care.

Objective

As part of a mixed-methods program of research, this study aimed to elicit parental experiences of caring for a child with CHD after hospital discharge following a cardiac surgery and collect information to inform interviews for a subsequent stage of the project.

Methods

A closed online discussion group was set up via the main Facebook page of the Children’s Heart Federation (CHF), a national charity offering support to children with heart disease and their families. The discussion group was advertised through the charity’s webpage, and interested participants were directed to the charity’s Facebook page from where they could access the closed Facebook group and respond to questions posted. The CHF moderated the forum, and the research team provided questions to be posted on the forum. Responses were collated into a single transcript and subjected to thematic analysis.

Results

The forum was open for 4 months, and 91 participants (mean age 35 years, range 23-58 years, 89 females, 89 parents, and 2 grandparents) submitted demographic information and were given access to the closed forum group. A common experience of isolation emerged from the data, with descriptions of how that isolation was experienced (physical, social, knowledge) and its psychological impact, together with the factors that made it worse or better. Woven through this theme was the notion that parents developed expertise over time.

Conclusions

The use of an online forum provided a means for eliciting data from a large number of parents regarding their experiences of caring for their child after hospital discharge following cardiac surgery. Parents engaged with the forum and were able to articulate what went well and what went less well, together with sharing their stories and supporting each other through doing so. Some parents clearly found participating in the forum a positive experience in itself, demonstrating the potential of social media as a mechanism for providing support and reducing isolation. Information gained from the forum was used to shape questions for interviews with parents in a subsequent phase of the study. Furthermore, the themes identified in the online forum have contributed to identifying ways of improving the provision of care and support for parents of high-risk babies following discharge after cardiac surgery.